Podcast 992: Fentanyl for Asthma
Emergency Medical Minute
Contributor: Alec Coston, MD Educational Pearls: BiPAP is often effective in severe asthma, but many patients struggle with mask tolerance due to intense air hunger–driven anxiety, often compounded by hypoxia. Benzodiazepines are commonly used for anxiety, but they can depress respiratory drive, making clinical improvement difficult to interpret (a lower RR may reflect sedation rather than true physiologic improvement). Low-dose fentanyl is a useful alternative when patients cannot tolerate BiPAP despite coaching. Opioids blunt the perception of dyspnea and are well established for...
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Episode 991: BRASH
Emergency Medical Minute
Contributor: Aaron Lessen, MD Educational Pearls BRASH Syndrome: Bradycardia Renal Failure AV Nodal Blockade Shock Hyperkalemia Clinical Features: Profound bradycardia and shock in patients on AV nodal blockers: Commonly, Beta Blockers or Calcium Channel Blockers Etiology: Caused by an inciting kidney injury: Common triggers include precipitating illness, dehydration, or medications Results in hyperkalemia The enhanced effect of the combination of AV nodal blockade and hyperkalemia leads to a more profound presentation of shock. ...
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Episode 990: Tramadol, or rather, Trama-don’t
Emergency Medical Minute
Contributor: Taylor Lynch, MD Educational Pearls: What is tramadol and how does it work? Tramadol is a Schedule IV opioid analgesic used for moderate pain and is often perceived as safer than other opioids due to lower abuse potential. It is a prodrug with weak direct μ-opioid receptor activity. The parent compound also inhibits serotonin and norepinephrine reuptake, giving it SSRI/SNRI-like properties. Tramadol is metabolized by CYP2D6 into O-desmethyltramadol (ODT), which has significantly stronger μ-opioid receptor agonism than the parent drug. What are the concerns with...
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Episode 989: Young Strokes
Emergency Medical Minute
Contributor: Aaron Lessen, MD Educational Pearls: The Case 24F brought in for anxiety. Patient is tearful, not talking, and potentially hyperventilating. History from boyfriend is that she suddenly stopped talking and started crying and it was hard to understand what she was saying. On exam, patient appears anxious and has a gaze preference for the right side and is still having difficulty speaking. Decision is made to stroke alert patient. CT shows early MCA stroke and M2 occlusion. Patient is treated by IR with mechanical thrombectomy. What are the risk factors for strokes in young...
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Episode 988: Infant Botulism
Emergency Medical Minute
Contributor: Aaron Lessen, MD Educational Pearls: A 2025 multistate outbreak of infant botulism has been linked to ByHeart infant formula As of December 10-17th, there have been at least 51 infants with suspected or confirmed botulism who were exposed to this formula across 19 states All reported cases resulted in hospitalization but no deaths reported to date Infant botulism Occurs when C. botulinum spores germinate in the infant’s intestine, producing toxin Spores are classically found in honey but can also be in dirt or contaminated in infant formula Infants are...
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Carepoint Journal Club: Trauma Discussion
Emergency Medical Minute
Carepoint Journal Club is a quarterly series with discussions about a medical topic, brought to you by Carepoint's Emergency Physicians.
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Episode 987: Cough Suppressants
Emergency Medical Minute
Contributor: Meghan Hurley, MD Educational Pearls: OTC Medications Dextromethorphan (DM) Most common OTC cough suppressant Minimal efficacy: Little evidence that it shortens the duration or severity of cough. Potential side effects: At recommended doses: Mild dizziness, drowsiness, GI symptoms Higher doses: Decreased consciousness, dissociative effects Guaifenesin Found in Mucinex and other severe cough/cold products Thins secretions and loosens mucus in airways No more effective than increasing oral fluid intake Prescription Medications Codeine-containing products ...
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Episode 986: Lateral Canthotomy in Emergency Settings
Emergency Medical Minute
Contributor: Taylor Lynch, MD Educational Pearls: What is orbital compartment syndrome, and how is it assessed in the emergency room? Orbital compartment syndrome (OCS) is an emergent ophthalmic condition in which intraorbital pressure in the orbital compartment rises dramatically, compromising perfusion of the optic nerve and retina, leading to risk of irreversible vision loss. OCS occurs in the context of traumatic lesions with retrobulbar hemorrhage. Intraocular pressures (IOP) are measured via tonometry as a surrogate for intraorbital pressures, with emergent pathology being present when...
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Episode 985: Amiodarone vs. Lidocaine
Emergency Medical Minute
Contributor: Aaron Lessen, MD Educational Pearls: How do amiodarone and lidocaine work on the heart? Amiodarone Blocks potassium channels (Class III effect). Also blocks sodium and calcium channels. Additional noncompetitive beta-blocker effects. Stabilizes cardiac tissue, slows heart rate, and suppresses both atrial and ventricular arrhythmias. Lidocaine Blocks fast sodium channels in ventricular tissue (Class Ib). Shortens the action potential in ventricular myocardium, especially in ischemic tissue. Suppresses abnormal automaticity in damaged/irritable myocardium. Which one should...
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Episode 984: Fish Hooks
Emergency Medical Minute
Contributor: Megan Hurley, MD Educational Pearls: Assess first: confirm the hook isn’t near vital structures. Automatic subspecialty consult for eye involvement or proximity to carotid artery, radial artery, peritoneum, testicle, or urethra Barbed hook: cannot be pulled back through the entry without disengaging the barb Removal Techniques String-Pull: best for superficial, single-barbed hooks Depress shank and eye of hook to disengage barb and then pull string taut and jerk suddenly along the long axis Can only be used when the hook is in a body part that can be firmly secured so it...
info_outlineContributor: Meghan Hurley MD
Educational Pearls:
What is Cellulitis?
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A common and potentially serious bacterial skin infection.
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Caused by various types of bacteria, with Streptococcus and Staphylococcus species being the most common.
What is Preseptal Cellulitis and why is it more serious than facial cellulitis?
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Preseptal Cellulitis, also known as Periorbital Cellulitis, is a bacterial infection of the soft tissues in the eyelid and the surrounding area.
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This requires prompt and aggressive treatment to avoid progression into Orbital Cellulitis.
How is Preseptal Cellulitis treated?
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Oral antibiotics for five to seven days.
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In the setting of trauma (scratching bug bites) Clindamycin or TMP-SMX (for MRSA coverage) and Amoxicillin-clavulanic acid or Cefpodoxime or Cefdinir.
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If there is no trauma, monotherapy with amoxicillin-clavulanic acid is appropriate.
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Check immunization status against H.influenzae and adjust appropriately.
What is Orbital Cellulitis, how is it diagnosed, and why is it more serious than Preseptal Cellulitis?
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Orbital cellulitis involves the tissues behind the eyeball and within the eye socket itself.
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Key features include:
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Eye pain.
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Proptosis (Bulging of the eye out of its normal position).
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Impaired eye movement.
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Blurred or double vision.
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This can lead to three very serious complications:
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Orbital Compartment Syndrome. This can push eye forward, stretch optic nerve, and threaten vision.
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Meningitis given that the meninges of the brain are continuous with optic nerve.
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Endophthalmitis, which is inflammation of the inner coats of the eye. This can also threaten vision.
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If suspected, get a CT of the orbits and/or an MRI to look for an abscess behind the eyes.
How is Orbital Cellulitis treated?
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IV antibiotics. Cover for meningitis with Ceftriaxone and Vancomycin.
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Add Metronidazole until intracranial involvement has been ruled out.
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Drain the abscess surgically. Usually this is performed by an ophthalmologist or an otolaryngologist.
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Admit to the hospital.
References
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Bae C, Bourget D. Periorbital Cellulitis. 2023 Jul 17. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan–. PMID: 29261970.
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Chaudhry IA, Shamsi FA, Elzaridi E, Al-Rashed W, Al-Amri A, Al-Anezi F, Arat YO, Holck DE. Outcome of treated orbital cellulitis in a tertiary eye care center in the middle East. Ophthalmology. 2007 Feb;114(2):345-54. doi: 10.1016/j.ophtha.2006.07.059. PMID: 17270683.
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Seltz LB, Smith J, Durairaj VD, Enzenauer R, Todd J. Microbiology and antibiotic management of orbital cellulitis. Pediatrics. 2011 Mar;127(3):e566-72. doi: 10.1542/peds.2010-2117. Epub 2011 Feb 14. PMID: 21321025.
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Wong SJ, Levi J. Management of pediatric orbital cellulitis: A systematic review. Int J Pediatr Otorhinolaryngol. 2018 Jul;110:123-129. doi: 10.1016/j.ijporl.2018.05.006. Epub 2018 May 8. PMID: 29859573.
Summarized by Jeffrey Olson MS2 | Edited by Meg Joyce & Jorge Chalit, OMSII