Episode 983: Head-of-Bed Position in Large Vessel Occlusion Strokes
Emergency Medical Minute
Contributor: Aaron Lessen MD Educational Pearls: Recent prospective randomized clinical trial assessed optimal head-of-bed positioning in patients with LVO 0º vs. 30º elevation Objective was to determine superiority of the two angles in stability prior to thrombectomy for LVO patients 45 patients randomized to the group with 0° head positioning and 47 patients randomized to the group with 30° head positioning Patients in the 30º group experienced worsening of NIHSS by 2 points or more Patients with head position at 0° showed score stability Hazard ratio 34.40; 95% CI,...
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Episode 982: Epistaxis Management
Emergency Medical Minute
Contributor: Meghan Hurley, MD Educational Pearls: 1. Initial Assessment Start with a physical examination: Determine if the bleed is anterior or posterior. Perform a primary survey: assess airway, breathing, and circulation (ABCs). Airway compromise = intubation immediately. If the patient is stable, have them blow out any clots, then re-examine the nares. 2. Topical Medications Anesthetics: provide local anesthesia and pain relief. Lidocaine Tetracaine Vasoconstrictors: reduce bleeding. LET (Lidocaine, Epinephrine, Tetracaine) is ideal because it provides...
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Episode 981: Electrical Burns
Emergency Medical Minute
Contributor: Travis Barlock, MD Educational Pearls: Quick Statistics on Electrical Burns: Electrical burns compose roughly 2 to 9% of all burns that come into emergency departments. The majority of patients who receive electrical burns are male, typically aged 20’s to 30’s, accounting for 80 to 90% of all electrical burn victims. The majority of burns are linked to occupational exposure. The upper extremities are more commonly impacted by electrical burns, accounting for 70 to 90% of entry points into the body during an exposure. What are some of the key considerations in electrical...
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Tox Talks 2025 Recap 1, Digoxin and Beta Blockers
Emergency Medical Minute
Contributors: Preeya Prakash MD, Adam Greenhaw PharmD, Travis Barlock MD, and Jeffrey Olson MS4 In this episode, cardiologist Preeya Prakash and medical student Jeffrey Olson listen in as two cases are presented from EMM’s recent event, Tox Talk 2025. Talk 1- Digoxin Overdose Dr. Adam Greenhaw presents a case of a Digoxin overdose along with many pearls. During the studio listen in, Dr. Prakash helps to answer the questions of: How does digoxin work? Why might a patient still be on digoxin in 2025? What are the EKG findings of digoxin toxicity? Is there any utility in atropine...
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Episode 980: Brain Injury Guidelines (BIG)
Emergency Medical Minute
Contributor: Aaron Lessen, MD Educational Pearls: Traumatic Brain Injuries are a frequent complaint in the Emergency Department and have increased in recent years. The American Association for Surgery of Trauma (AAST) has created Brain Injury Guidelines (BIG), in an attempt to categorize brain injuries and the level of treatment they require. They are… BIG 1 Normal neuro exam Not intoxicated Not on anticoagulation or antiplatelet medications Minimal findings on head CT No fracture <4 mm bleed (subdural, epidural, intraparenchymal (max one location)) Maximum of “trace” subarachnoid...
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Episode 979: Oral vs Temporal Thermometers
Emergency Medical Minute
Contributor: Taylor Lynch, MD Educational Pearls: A recent study published in a pediatric journal in April 2025 compared temporal and oral thermometers Paired temperature measurements (temporal and oral temperature within 30 minutes) were obtained from 1,412 pediatric patients 26% of patients had statistically different temporal and oral temperatures The temporal reading was always lower than the oral reading Children less than 12 years old were 2-3x more likely to actually have that statistical difference in temperatures The study also evaluated 1,000 adult patients 36% had a temporal...
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Episode 978: Delusional Parasitosis
Emergency Medical Minute
Contributor: Taylor Lynch, MD Educational Pearls: Delusional parasitosis is a subtype of the psychiatric condition delusional disorder Defined as a fixed, false belief of infestation by parasites or other organisms A somatic type of delusional disorder Primary delusional parasitosis Occurs in the absence of other psychiatric or medical conditions Secondary delusional parasitosis Causes include methamphetamine use disorder, schizophrenia, neurologic diseases, or medical conditions such as thyroid disease Pathophysiology Poorly understood Upregulation of striatal dopamine system is...
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Episode 977: Amyloid Therapy and Stroke-like Events
Emergency Medical Minute
Contributor: Aaron Lessen, MD Educational Pearls: The cause of Alzheimer’s disease is multifactorial, but the most widely suspected mechanism is the amyloid cascade hypothesis: Beta-amyloid proteins accumulate in the central nervous system, forming plaques that impair neuronal function. In recent years, advances have led to the development of targeted therapies with monoclonal antibodies. These drugs: Work by degrading amyloid plaques Slow the rate of cognitive decline and disease progression Have major side effects, most notably the development of amyloid-related imaging abnormalities...
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Episode 976: Improvised Burr Hole in an Epidural Hematoma
Emergency Medical Minute
Contributor: Alec Coston, MD Case Report Summary: A 17-year-old female involved in a motor vehicle collision presented to a rural emergency facility via personally operated vehicle. During workup and initial CT scan, the patient began rapidly decompensating with CT revealing a 1.5cm epidural hematoma with 7mm of midline shift. The patient went from being able to walk and talk to being obtunded with a blown left pupil and unresponsive. Following intubation, the patient was being prepared for transport but potential delays required immediate emergency evacuation of the hematoma via a Burr Hole....
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Episode 975: Nursemaid's Elbow
Emergency Medical Minute
Contributor: Aaron Lessen, MD Educational Pearls: What is a Nursemaid's Elbow? A condition in which an elbow gets partially pulled out of place (a radial head subluxation) Usually happens in kids under 5 because the ligaments around their elbow are still loose. A common situation is when an adult pulls a child up by the hand or swings them by the arms. The sudden tug causes the radius to slip out of its normal spot at the elbow joint. How are they identified? These don’t normally need an xray The child will often hold their arm close to their side and refuse to use it There’s usually no...
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Kalen Abbott, MD - EM Physician and Medical Director for AirLife Denver
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Brendan Reiss - Flight Nurse AirLife Denver
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Matt Spoon - Flight Paramedic AirLife Denver
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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:
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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.
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He was brought by EMS to his local hospital, who quickly decided to transport the infant by helicopter to a large Denver hospital.
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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.
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The patient had received a water-based decontamination and 1 gram of calcium gluconate IV.
Complications:
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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).
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During the flight, the patient went into cardiac arrest.
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The patient achieved ROSC after CPR was administered in the helicopter.
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Once on the ground, an I/O line was started and calcium chloride, sodium bicarb, and normal saline were administered.
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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:
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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:
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Lower concentrations of acids can be more dangerous because they don’t immediately burn but rather can be absorbed systemically through the skin.
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Calcium is the antidote to hydrofluoric acid exposure.
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Calcium chloride has 3 times the elemental calcium as calcium gluconate.
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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.
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When intubating a patient with acid exposure, avoid succinylcholine because of the risk of hyperkalemia.
References
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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.
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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.
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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.
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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