Episode 936: Etomidate vs. Ketamine for Rapid Sequence Intubation
Emergency Medical Minute
Contributor: Ricky Dhaliwal MD Educational Pearls: Etomidate was previously the drug of choice for rapid sequence intubation (RSI) However, it carries a risk of adrenal insufficiency as an adverse effect through inhibition of mitochondrial 11-β-hydroxylase activity A recent meta-analysis analyzing etomidate as an induction agent showed the following: 11 randomized-controlled trials with 2704 patients Number needed to harm is 31; i.e. for every 31 patients that receive etomidate for induction, there is one death The probability of any mortality increase was 98.1% ...
info_outline
Episode 935: Pregnancy Extremis - TOLDD
Emergency Medical Minute
Contributor: Aaron Lessen MD Educational Pearls: Pregnant patients at high risk of cardiac arrest, in cardiac arrest, or in extremis require special care A useful mnemonic to recall the appropriate management of critically ill pregnant patients is TOLDD T: Tilt the patient to the left lateral decubitus position This position relieves pressure exerted from the uterus onto the inferior vena cava, which reduces cardiac preload If the patient is receiving CPR, an assistant should displace the uterus manually from the IVC towards the patient’s left side O: Administer high-flow...
info_outline
Episode 934: Subendocardial Ischemia
Emergency Medical Minute
Contributor: Travis Barlock MD Educational Pearls: What is the ST segment? The ST segment on an ECG represents the interval between the end of ventricular depolarization (QRS) and the beginning of ventricular repolarization (T-wave). It should appear isoelectric (flat) in a normal ECG. What if the ST segment is elevated? This is evidence that there is an injury that goes all the way through the muscular wall of the heart (transmural) This is very concerning for a heart attack (STEMI) but can be occasionally caused by other pathology, such as pericarditis What if the ST...
info_outline
Episode 933: Benign Convulsions with Gastroenteritis
Emergency Medical Minute
Contributor: Alec Coston MD Educational Pearls: Causes of seizures in a fairly well-appearing child with diarrhea: Electrolyte abnormalities: hypocalcemia, hyponatremia Also hyperkalemia which causes arrhythmias and syncope - can appear like seizures Hypoglycemia If the child has diarrhea and appears very sick, differential diagnosis may include: Hemolytic uremic syndrome (HUS): simultaneous occurrence of microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury Typically caused by Shiga-like toxin producing Escherichia coli (also known as EHEC, or...
info_outline
Episode 932: Induction Agent Hypotension
Emergency Medical Minute
Contributor: Aaron Lessen MD Educational Pearls: Induction agent selection during rapid sequence intubation involves accounting for hemodynamic stability in the post-intubation setting Many emergency departments use ketamine or etomidate A recent study sought to explore the rates of post-induction hypotension of ketamine compared with propofol Single center retrospective cohort study of patients between 2018-2021 Ketamine and propofol were both significantly associated with post-induction hypotension Ketamine adjusted odds ratio = 4.50 Propofol adjusted odds ratio = 4.88 50%...
info_outline
Episode 931: Naloxone in Cardiac Arrest
Emergency Medical Minute
Contributor: Aaron Lessen MD Educational Pearls: Can opioids cause cardiac arrest? Opioids can cause respiratory suppression and the subsequent low oxygen levels can lead to arrhythmias and eventually cardiac arrest. In 2023, 17% of out-of-hospital cardiac arrests (OHCA) were attributable to opioids. Given that this is a rising cause of cardiac arrest, should we just treat all cardiac arrest with naloxone (Narcan)? Naloxone is correlated with an increased chance of return of spontaneous circulation (ROSC) Additionally, a wide variety of individuals can be exposed to opioids and...
info_outline
Episode 930: Holding Costs
Emergency Medical Minute
Contributor: Aaron Lessen MD Educational Pearls: A study evaluated the patient-care impact and financial costs of holding patients in the ED, a nationwide issue Prospective, observational study of acute stroke management Conducted at a large urban, comprehensive stroke center The study evaluated patients in multiple categories: admitted to med/surg admitted to med/surg but held in the ED admitted to the ICU Admitted to ICU but held in the ED Examined the amount of time nurses and providers spent with each patient This was analyzed in conjunction with the...
info_outline
Episode 929: Traumatic Aortic Injury
Emergency Medical Minute
Contributor: Aaron Lessen MD Educational Pearls: Aortic injury occurs in 1.5-2% of patients who sustain blunt thoracic trauma Majority are caused by automobile collisions or motorcycle accidents Due to sudden deceleration mechanism accidents Clinical manifestations Signs of hypovolemic shock including tachycardia and hypotension, though not always present Patients may have altered mental status Imaging Widened mediastinum on chest x-ray, though not highly sensitive CT is more sensitive and specific, and signs of thoracic injury include an intimal flap, aortic wall...
info_outline
Laboring Under Pressure Episode 4: Obstetric Emergency in South Africa with Dr. Meghan Hurley
Emergency Medical Minute
Laboring Under Pressure Episode 4: Obstetric Emergency in South Africa with Dr. Meghan Hurley Contributors: Meghan Hurley MD, Travis Barlock MD, Jeffrey Olson MS3 Show Pearls Map of South Africa Referenced South Africa Geography Lesson There is a big disparity between Cape Town and its neighbor Khayelitsha. Cape Town is the legislative capital and economic hub of South Africa, known for its infrastructure, tourist attractions, and developed urban areas. Khayelitsha Township is a large informal settlement on the outskirts of Cape Town, with limited infrastructure and services compared to...
info_outline
Episode 928: Neutropenic Fever
Emergency Medical Minute
Contributor: Taylor Lynch, MD Educational Pearls: What is neutropenic fever? Specific type of fever that is seen in cancer patients and other patients with impaired immune systems These patients are highly susceptible to infection Typically occurs 7-10 days after the last chemotherapy dose, this is when the immune system is the weakest It is useful to know the specific type of malignancy. For example, heme malignancies (ALL, AML, etc.) have more intense chemo and are at higher risk of neutropenic fever To qualify as a neutropenic fever, a patient must have one recorded temperature...
info_outlineContributor: Jared Scott MD
Educational Pearls:
Should we use opioids to treat low back and neck pain? The OPAL Trial, published in The Lancet, in June 2023, attempted to answer this very question.
-
Objective: Investigate the efficacy and safety of a short course of opioid analgesic (oxycodone-naloxone) for acute low back pain and neck pain.
-
Trial Design: Triple-blinded, placebo-controlled randomized trial, conducted in Emergency and Primary Care in Sydney, Australia, involving adults with 12 weeks or less of low back or neck pain.
-
Participants: 347 recruited adults (174 in the opioid group, 173 in the placebo group) with at least moderate pain severity.
-
Intervention: Participants were assigned to receive either an opioid or a placebo for up to 6 weeks.
-
Primary Outcome: Pain severity at 6 weeks measured with the pain severity subscale of the Brief Pain Inventory (10-point scale).
-
Results: No significant difference in pain severity at 6 weeks between the opioid group (mean score 2.78) and placebo group (mean score 2.25).
-
Adverse events were reported by 35% in the opioid group and 30% in the placebo group, with more opioid-related adverse events in the opioid group (e.g., constipation).
-
Conclusion: Opioids should not be recommended for acute non-specific low back pain or neck pain, as there was no significant difference in pain severity compared with the placebo. The study calls for a change in the frequent use of opioids for these conditions.
Pharmacy Pearl: Why was naloxone mixed with oxycodone?
-
Naloxone is an opioid receptor antagonist, meaning it can block the effects of opioids. When combined with oxycodone, naloxone's presence discourages certain forms of opioid misuse.
-
Additionally, naloxone can bind to opioid receptors in the gut and improve symptoms of Opioid Induced Constipation (OIC).
-
This is the same idea behind Suboxone (buprenorphine/naloxone).
References
-
Jones CMP, Day RO, Koes BW, Latimer J, Maher CG, McLachlan AJ, Billot L, Shan S, Lin CC; OPAL Investigators Coordinators. Opioid analgesia for acute low back pain and neck pain (the OPAL trial): a randomised placebo-controlled trial. Lancet. 2023 Jul 22;402(10398):304-312. doi: 10.1016/S0140-6736(23)00404-X. Epub 2023 Jun 28. Erratum in: Lancet. 2023 Aug 19;402(10402):612. PMID: 37392748.
-
Camilleri M, Lembo A, Katzka DA. Opioids in Gastroenterology: Treating Adverse Effects and Creating Therapeutic Benefits. Clin Gastroenterol Hepatol. 2017 Sep;15(9):1338-1349. doi: 10.1016/j.cgh.2017.05.014. Epub 2017 May 19. PMID: 28529168; PMCID: PMC5565678.
Summarized by Jeffrey Olson MS2 | Edited by Jorge Chalit, OMSII