Episode 955: Cardiac Effects of COVID-19
Emergency Medical Minute
Contributor: Ricky Dhaliwal, MD Educational Pearls: What factors are considered in a COVID-19 infection? The viral load: Understood as the impact of SARS-CoV-2 viral particles infecting host cell tissue itself (utilizing ACE-2 receptors). Pro-Inflammatory Response: Post-infection, the body's downstream systemic cytokine release (can be both normal or hyperactive, aka “cytokine storm”). What cardiac impacts have been observed with COVID-19? Arrhythmias: The mechanism of COVID-19 infection and arrhythmias is believed to be multifactorial. However, evidence suggests T-cell-mediated...
info_outline
Episode 954: Combo Rescue Inhalers - New Guidelines
Emergency Medical Minute
Contributor: Aaron Lessen, MD Educational Pearls: What is a Rescue Inhaler? A rescue inhaler is a medication for people with asthma to quickly reverse the symptoms of an asthma attack. Historically albuterol (Short Acting Beta Agonist (SABA)) monotherapy has been the mainstay rescue inhaler. This is because albuterol works fast and is relatively cheap. \n\n What are Combination Rescue Inhalers? Combination rescue inhalers contain a fast-acting bronchodilator as well as an inhaled corticosteroid (ICS) The steroid helps to reduce some of the chronic airway inflammation that is...
info_outline
Episode 953: Penicillin Allergies
Emergency Medical Minute
Contributor: Geoff Hogan MD Educational Pearls: Penicillin allergies are relatively uncommon despite their frequent reports 10% of the population reports a penicillin allergy but only 5% of these cases are clinically significant 90-95% of patients may tolerate a rechallenge after appropriate allergy evaluation Penicillin Allergy Decision Rule (PEN-FAST) on MD Calc Useful tool to assess patients for penicillin allergies Five years or less since reaction = 2 points (even if unknown) Anaphylaxis or angioedema OR Severe cutaneous reaction = 2 points Treatment required for...
info_outline
Episode 952: Heart Transplants
Emergency Medical Minute
Contributor: Travis Barlock, MD Educational Pearls: Key clinical considerations when managing heart transplant patients due to their unique pathophysiology 1. Arrhythmias A transplanted heart is denervated, meaning it lacks autonomic nervous system innervation The lack of vagal tone results in an increased resting heart rate Adenosine can be used since it primarily slows conduction through the AV node Atropine is ineffective in treating transplant bradyarrhythmia because its mechanism is to inhibit the vagus nerve - but the heart lacks vagal tone Allograft rejection can...
info_outline
Episode 951: Pediatric Febrile Seizures
Emergency Medical Minute
Contributor: Taylor Lynch, MD Educational Pearls: Pediatric febrile seizures are defined as seizures that occur between the ages of six months to five years in the presence of a fever greater than or equal to 38.0 ºC (100.4 ºF). It is the most common pediatric convulsive disorder, with an incidence between 2-5% What are the types of seizures? Simple: Tonic-clonic seizure, duration <15 minutes, only one occurrence in a 24-hour period, ABSENCE of focal features, ABSENCE of Todd’s paralysis Complex: Duration >15 minutes, requires medication to stop the seizing, multiple...
info_outline
Episode 950: Ultrasound Pulse Check During Cardiac Arrest
Emergency Medical Minute
Contributor: Aaron Lessen, MD Educational Pearls: Point-of-care ultrasound (POCUS) is used to assess cardiac activity during cardiac arrest and can identify potential reversible causes such as pericardial tamponade Ultrasound could be beneficial in another way during cardiac arrest as well: pulse checks Manual palpation for detecting pulses is imperfect, with false positives and negatives Doppler ultrasound can be used as an adjunct or replacement to manual palpation for improved accuracy Options for Doppler ultrasound of carotid or femoral pulses during cardiac arrest: ...
info_outline
Episode 949: Hoover's Sign
Emergency Medical Minute
Contributor: Travis Barlock, MD Educational Pearls: What is Hoover’s sign used to identify? This physical exam maneuver differentiates between organic vs. functional (previously known as psychogenic) leg weakness. Organic causes include disease processes such as stroke, MS, spinal cord compression, guillain-barre, ALS, and sciatica, among others In Functional Neurologic Disorder, the dysfunction is in brain signaling, and treatment relies on more of a psychiatric approach How is Hoover's Sign performed? Place your hand under the heel of the unaffected leg and ask the patient to...
info_outline
Episode 948: CYP Inducers and Inhibitors
Emergency Medical Minute
Contributor: Jorge Chalit-Hernandez, OMS3 Educational Pearls: CYP enzymes are responsible for the metabolism of many medications, drugs, and other substances CYP3A4 is responsible for the majority Other common ones include CYP2D6 (antidepressants), CYP2E1 (alcohol), and CYP1A2 (cigarettes) CYP inducers lead to reduced concentrations of a particular medication CYP inhibitors effectively increase concentrations of certain medications in the body Examples of CYP inducers Phenobarbital Rifampin Cigarettes St. John’s Wort Examples of CYP inhibitors -azole...
info_outline
Episode 947: Hypercapnia
Emergency Medical Minute
Educational Pearls: Physiologic stimulation of ventilation occurs through changes in levels of: Arterial carbon dioxide (PaCO2) Arterial oxygen (PaO2) Hypercapnia is an elevated level of CO2 in the blood - this primarily drives ventilation Hypoxia is a decreased level of O2 in the body’s tissues - the backup drive for ventilation Patients at risk of hypercapnia should maintain an O2 saturation between 88-92% Normal O2 saturation is 95-100% In patients who chronically retain CO2, their main drive for ventilation becomes hypoxia An audit was performed of SpO2 observations...
info_outline
Episode 946: Time to Defibrillation
Emergency Medical Minute
Contributor: Aaron Lessen, MD Educational Pearls: Quick background info Cardiac arrest is when the heart stops pumping blood for any reason. This is different from a heart attack in which the heart is still working but the muscle itself is starting to die. One cause of cardiac arrest is when the electrical signals are very disrupted in the heart and start following chaotic patterns such as Ventricular tachycardia (VTach) and Ventricular fibrillation (VFib) One of the only ways to save a person whose heart is in VFib or VTach is to jolt the heart with electricity and terminate the...
info_outlineContributors:
-
Kalen Abbott, MD - EM Physician and Medical Director for AirLife Denver
-
Brendan Reiss - Flight Nurse AirLife Denver
-
Matt Spoon - Flight Paramedic AirLife Denver
-
Jordan Ourada - EMS Coordinator at Swedish Medical Center and Paramedic
Summary:
In this episode, hosted by Jordan Ourada, Brendan Reiss and Matt Spoon present a first-hand experience case of hydrofluoric acid exposure in a pediatric patient. Commentary and educational pearls are provided by EM Physician, Kalen Abbott.
The case:
-
The patient was a male infant who had spilled a large amount of heavy-duty acid aluminum wheel cleaner on himself while playing in his parent's garage. Unclear if he had ingested any fluid. The cleaning fluid contained a large percentage of hydrofluoric acid.
-
He was brought by EMS to his local hospital, who quickly decided to transport the infant by helicopter to a large Denver hospital.
-
Initial labs were unremarkable and the EKG was normal. Heart rate was in the 140s. Blood pressure was 110/73. Respirations were around 30 and non-labored. Chest and abdominal x-rays were unremarkable.
-
The patient had received a water-based decontamination and 1 gram of calcium gluconate IV.
Complications:
-
Immediately before leaving a nurse informed Brendan and Matt that the serum calcium was 6.8 mg/dl (normal range: 8.5 to 10.2).
-
During the flight, the patient went into cardiac arrest.
-
The patient achieved ROSC after CPR was administered in the helicopter.
-
Once on the ground, an I/O line was started and calcium chloride, sodium bicarb, and normal saline were administered.
-
Within the first 2 hours that patient received the equivalent of 310 mg/kg of calcium (the pediatric dose is 20 mg/kg)
Care resolution:
-
The patient ended up having a several-week stay in the pediatric ICU. There were some complications such as pulmonary hemorrhage. Calcium gluconate was continued via nebulization for several days. Ultimately, the child was weaned off the ventilator and spontaneous respirations resumed. They were able to wean the child off vasopressors and sedation over the course of several days. A gastric lavage with calcium gluconate was completed as well during the inpatient stay. The child was able to leave the hospital, neurologically intact after about 14 days.
Pearls:
-
Lower concentrations of acids can be more dangerous because they don’t immediately burn but rather can be absorbed systemically through the skin.
-
Calcium is the antidote to hydrofluoric acid exposure.
-
Calcium chloride has 3 times the elemental calcium as calcium gluconate.
-
The maximum infusion rate of calcium chloride through a peripheral line is 1 gram every 10 minutes, calcium gluconate can be infused at 1 gram every 5 minutes.
-
When intubating a patient with acid exposure, avoid succinylcholine because of the risk of hyperkalemia.
References
-
Caravati EM. Acute hydrofluoric acid exposure. Am J Emerg Med. 1988 Mar;6(2):143-50. doi: 10.1016/0735-6757(88)90053-8. PMID: 3281684.
-
Pepe J, Colangelo L, Biamonte F, Sonato C, Danese VC, Cecchetti V, Occhiuto M, Piazzolla V, De Martino V, Ferrone F, Minisola S, Cipriani C. Diagnosis and management of hypocalcemia. Endocrine. 2020 Sep;69(3):485-495. doi: 10.1007/s12020-020-02324-2. Epub 2020 May 4. PMID: 32367335.
-
Strayer RJ. Succinylcholine, rocuronium, and hyperkalemia. Am J Emerg Med. 2016 Aug;34(8):1705-6. doi: 10.1016/j.ajem.2016.05.039. Epub 2016 May 19. PMID: 27241569.
-
Vallentin MF, Granfeldt A, Meilandt C, Povlsen AL, Sindberg B, Holmberg MJ, Iversen BN, Mærkedahl R, Mortensen LR, Nyboe R, Vandborg MP, Tarpgaard M, Runge C, Christiansen CF, Dissing TH, Terkelsen CJ, Christensen S, Kirkegaard H, Andersen LW. Effect of Intravenous or Intraosseous Calcium vs Saline on Return of Spontaneous Circulation in Adults With Out-of-Hospital Cardiac Arrest: A Randomized Clinical Trial. JAMA. 2021 Dec 14;326(22):2268-2276. doi: 10.1001/jama.2021.20929. PMID: 34847226; PMCID: PMC8634154.
Summarized by Jeffrey Olson MS2 | Edited by Jeffrey Olson, Meg Joyce, & Jorge Chalit, OMSII