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: Taylor Lynch, MD
Educational Pearls:
Opioid Epidemic- quick facts
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Drug overdoses, primarily driven by opioids, have become the leading cause of accidental death in the U.S. for individuals aged 18-45.
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In 2021, opioids were involved in nearly 75% of all drug overdose deaths
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The rise of synthetic opioids like fentanyl, which is much more potent than heroin or prescription opioids, has played a major role in the increase in overdose deaths
What is Narcan AKA Naloxone?
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Competitive opioid antagonist. It sits on the receptor but doesn’t activate it.
When do we give Narcan?
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Respiratory rate less than 8-10 breaths per minute
Should you check the pupils?
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An opioid overdose classically presents with pinpoint pupils BUT…
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Hypercapnia from bradypnea can normalize the pupils
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Taking other drugs at the same time like cocaine or meth can counteract the pupillary effects
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Basilar stroke could also cause small pupils, so don’t anchor on an opioid overdose
How does Narcan affect the body?
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Relatively safe even if the patient is not experiencing an opioid overdose. So when in doubt, give the Narcan.
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What if the patient is opioid naive and overdosing?
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Use a large dose given that this patient is unlikely to withdraw
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0.4-2 mg every 3-5 minutes
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What if the patient is a chronic opioid user
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Use a smaller dose such as 0.04-0.4 mg to avoid precipitated withdrawal
How fast does Narcan work?
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Given intravenously (IV), onset is 1-2 min
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Given intranasal (IN), onset is 3-4 min
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Given intramuscularly (IM), onset is ~6 min
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Duration of action is 60 mins, with a range of 20-90 minutes
How does that compare to the duration of action of common opioids?
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Heroine lasts 60 min
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Fentanyl lasts 30-60 min, depending on route
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Carfentanyl lasts ~5 hrs
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Methadone lasts 12-24 hrs
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So we really need to be conscious about redosing
How do you monitor someone treated with Narcan?
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Pay close attention to the end-tidal CO2 to ensure that are ventilating appropriately
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Be cautious with giving O2 as it might mask hypoventilation
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Watch the respiratory rate
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Give Narcan as needed
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Observe for at least 2-4 hours after the last Narcan dose
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Larger the dose, longer the observation period
Who gets a drip?
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If they have gotten ~3 doses, time to start the drip
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Start at 2/3rds last effective wake-up dose
Complications
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Flash pulm edema
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0.2-3.6% complication rate
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Might be from the catecholamine surge from abrupt wake-up
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Might also be from large inspiratory effort against a partially closed glottis which creates too much negative pressure
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Treat with BIPAP if awake and intubation if not awake
Should you give Narcan in cardiac arrest?
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Short answer no. During ACLS you take over breathing for the patient and that is pretty much the only way that Narcan can help
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Just focus on high quality CPR
References
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Elkattawy, S., Alyacoub, R., Ejikeme, C., Noori, M. A. M., & Remolina, C. (2021). Naloxone induced pulmonary edema. Journal of community hospital internal medicine perspectives, 11(1), 139–142. https://doi.org/10.1080/20009666.2020.1854417
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van Lemmen, M., Florian, J., Li, Z., van Velzen, M., van Dorp, E., Niesters, M., Sarton, E., Olofsen, E., van der Schrier, R., Strauss, D. G., & Dahan, A. (2023). Opioid Overdose: Limitations in Naloxone Reversal of Respiratory Depression and Prevention of Cardiac Arrest. Anesthesiology, 139(3), 342–353. https://doi.org/10.1097/ALN.0000000000004622
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Yousefifard, M., Vazirizadeh-Mahabadi, M. H., Neishaboori, A. M., Alavi, S. N. R., Amiri, M., Baratloo, A., & Saberian, P. (2019). Intranasal versus Intramuscular/Intravenous Naloxone for Pre-hospital Opioid Overdose: A Systematic Review and Meta-analysis. Advanced journal of emergency medicine, 4(2), e27. https://doi.org/10.22114/ajem.v0i0.279
Summarized by Jeffrey Olson MS2 | Edited by Meg Joyce & Jorge Chalit, OMSII