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...
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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...
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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...
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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...
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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...
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Episode 927: Functional Gallbladder Syndrome
Emergency Medical Minute
Contributor: Jorge Chalit-Hernandez, OMS3 Typically presents with biliary colic Right upper quadrant abdominal pain lasting more than 30 minutes and subsiding over several hours Often associated with fatty meals but not always Must rule out other causes of pain Peptic ulcer disease - typically presents with epigastric pain Pancreatitis - pain that radiates to the back or family history of pancreatitis Laboratory workup LFTs including ALT, AST, and alkaline phosphatase are within the reference range Lipase and amylase within the reference range Imaging workup ...
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Episode 926: Supraventricular Tachycardia
Emergency Medical Minute
Contributor: Taylor Lynch MD Supraventricular tachycardias (SVTs) arise above the bundle of His The term SVT includes AV nodal reentrant tachycardia (AVNRT), atrioventricular reentrant tachycardia (AVRT), atrial tachycardia, atrial fibrillation, atrial flutter, and multifocal atrial tachycardia AVNRT is the most common form of SVT Paroxysmal Spontaneous or provoked by exertion, coffee, alcohol, or thyroid disease More common in women (3:1 women:men ratio) HR 160-240 Narrow complex with a normal QRS Unstable patients receive synchronized cardioversion at 0.5-1 J/kg ...
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Episode 925: Table Sugar for Tongue Entrapment
Emergency Medical Minute
Contributor: Aaron Lessen, MD Educational Pearls: Pediatric case study where the child’s tongue was stuck in the opening of a hard plastic drink lid Entrapment restricts circulation which causes fluid to build and the tongue becomes more edematous with time There is a risk of ischemia with prolonged entrapment Initially tried 2% viscous lidocaine for analgesia and lubricant The ER recognized that this mucosal, edematous tongue could benefit from the trick for ostomies and rectal prolapses → table sugar! Sugar granules absorb water which decreases tissue edema This option...
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Episode 924: Pregnancy Cold Remedies
Emergency Medical Minute
Contributor: Megan Hurley, MD Educational Pearls: Fevers Tylenol Up until 20 weeks NSAIDs are ok but after 20 weeks they are contraindicated Can limit the amount of amniotic fluid produced Can lead to growth restriction Can cause premature closure of the ductus arteriosus Cough Cough drops Humidifier Guafenesine and dextromethorphan (Mucinex) is not well studied but is probably ok with caution in certain circumstances such as post-tussive emesis causing poor PO intake and weight loss Congestion Flonase (Fluticasone nasal spray) Nasal rinses Humidifier 1st...
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Episode 923: Blunt Cerebrovascular Injury
Emergency Medical Minute
Contributor: Travis Barlock MD Educational Pearls: Assessment of head and neck vascular injury due to blunt trauma Symptomatic patients require screening head and neck CT angiography EAST guidelines include the following criteria for a screening CT angiography in blunt head trauma: Unexplained neurological deficits Arterial nosebleed GCS < 6 Petrous bone fracture Cervical spine fracture Any size fracture through the transverse foramen LeFort fractures type II or type III EAST guidelines include a grading scale for vascular injury: Grade I: Luminal irregularity...
info_outlineContributor: Taylor Lynch MD
Educational Pearls:
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Anticholinergics are found in many medications, including over-the-counter remedies
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Medications include:
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Diphenhydramine
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Tricyclic antidepressants like amitriptyline
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Atropine
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Antipsychotics like olanzapine
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Antispasmodics - dicyclomine
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Jimsonweed
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Muscaria mushrooms
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Mechanism of action involves competitive antagonism of the muscarinic receptor
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Symptomatic presentation is easily remembered via the mnemonic:
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Dry as a bone - anhidrosis due to cholinergic antagonism at sweat glands
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Red as a beet - cutaneous vasodilation leads to skin flushing
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Hot as a hare - anhidrotic hyperthermia
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Blind as a bat - pupillary dilation and ineffective accommodation
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Mad as a hatter - anxiety, agitation, dysarthria, hallucinations, and others
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Clinical management
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ABCs
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Benzodiazepines for supportive care, agitation, and seizures
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Sodium bicarbonate for TCA toxicity due to widened QRS
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Activated charcoal if patient present < 1 hour after ingestion
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Temperature monitoring
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Contact poison control with questions
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Physostigmine controversy
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Physostigmine is a reversible cholinesterase inhibitor that can cross the blood-brain barrier so in theory it would be a useful antidote BUT…
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There is a black box warning for asystole and seizures when physostigmine is used this way
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Therefore it is contraindicated in TCA overdoses
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However, it is still indicated in certain anticholinergic overdoses with delirium
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Disposition
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Admission criteria include: symptoms >6 hours, CNS findings, QRS prolongation, hyperthermia, and rhabdomyolysis
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ICU admission criteria include: delirium, dysrhythmias, seizures, coma, or requirement for physostigmine drip
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References
1. Arens AM, Shah K, Al-Abri S, Olson KR, Kearney T. Safety and effectiveness of physostigmine: a 10-year retrospective review<sup/>. Clin Toxicol (Phila). 2018;56(2):101-107. doi:10.1080/15563650.2017.1342828
2. Nguyen TT, Armengol C, Wilhoite G, Cumpston KL, Wills BK. Adverse events from physostigmine: An observational study. Am J Emerg Med. 2018;36(1):141-142. doi:10.1016/j.ajem.2017.07.006
3. Scharman E, Erdman A, Wax P, et al. Diphenhydramine and dimenhydrinate poisoning: An evidence-based consensus guideline for out-of-hospital management. Clin Toxicol. 2006;44(3):205-223. doi:10.1080/15563650600585920
4. Shervette RE 3rd, Schydlower M, Lampe RM, Fearnow RG. Jimson "loco" weed abuse in adolescents. Pediatrics. 1979;63(4):520-523.
5. Woolf AD, Erdman AR, Nelson LS, et al. Tricyclic antidepressant poisoning: An evidence-based consensus guideline for out-of-hospital management. Clin Toxicol. 2007;45(3):203-233. doi:10.1080/15563650701226192
Summarized by Jorge Chalit, OMSIII | Edited by Jorge Chalit