Episode 974: ACE Inhibitor Angioedema
Emergency Medical Minute
Contributor: Ricky Dhaliwal, MD Educational Pearls: Angioedema in anaphylaxis Histamine and mast cell-mediated pathway Treatment: First line: epinephrine for vasoconstriction and bronchodilation Second line: H1 and H2 antihistamines such as Benadryl and famotidine ACE inhibitor-induced angioedema Different pathway from anaphylaxis ACE inhibitor-induced angioedema is mediated by bradykinins Therefore, anaphylaxis medications are not beneficial in patients with ACE inhibitor-induced angioedema Leading cause of drug-induced angioedema in the US Patients most commonly present with...
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Emergency Medicine Cases with Dr. Barlock
Emergency Medical Minute
Contributors: Travis Barlock MD, Jeffrey Olson MS4 Feel free to use the cases below for your own practice. All of the scenarios are completely made up and designed to hit several teaching points. Case 1 25 M, presents to the ED with chest pain. Stabbing, started a few hours ago, substernal. Thinks it is GERD. After 2-3 minutes, pain worsens and radiates to the back. VS: BP 125/50 (Right arm 190/110). HR 120. RR of 18. Sat 98% on RA. Additional VS: Temp of 37.2, height of 6’5”, BMI of 18. PMH: None, doesn’t see a doctor. Meds: None FH: Weird heart thing (Mitral Valve Prolapse), weird lung...
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Episode 973: Meningitis Retention Syndrome
Emergency Medical Minute
Contributor: Travis Barlock MD Educational Pearls: Meningitis retention syndrome is a relatively novel and rare clinical condition Aseptic meningitis + acute urinary retention One study reports an incidence of about 8% in patients with acute aseptic meningitis Clinical presentation Typical meningeal symptoms including fever, stiff neck, and headache Urinary retention occurs about one week after initial symptoms Potential pathophysiology Immune-mediated dysfunction of the central nervous system Detrusor muscle underactivity from inflammation of the spinal cord Management Supportive...
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Episode 972: Hepatic Encephalopathy
Emergency Medical Minute
Contributor: Alec Coston, MD Educational Pearls: Hepatic encephalopathy (HE) is defined as a disruption in brain function that results from impaired liver function or portosystemic shunting. Manifests as various neurologic and psychiatric symptoms such as confusion, inattention, and cognitive dysfunction Although ammonia levels have historically been recognized as important criteria for HE, the diagnosis is ultimately made clinically. An elevated ammonia level lacks sensitivity and specificity for HE Trends in ammonia levels do not correlate with disease improvement or resolution A 2020...
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Episode 971: Calcium Pretreatment for Diltiazem in AFib with RVR
Emergency Medical Minute
Contributor: Taylor Lynch, MD Educational Pearls: What is atrial fibrillation with rapid ventricular response (AFib with RVR) and how does it differ from atrial fibrillation (AFib)? AFib is an abnormal heart rhythm in which the heart has disorganized atrial electrical activity. This causes the atria to quiver with only select signals being conducted through the Atrioventricular (AV) Node to reach the ventricles and result in ventricular contraction. Often described as “irregularly irregular”, a patient's EKG will present with no discernible P-waves, and irregular R-R intervals. AFib with...
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Episode 970: Fever Management
Emergency Medical Minute
Contributor: Aaron Lessen, MD Educational Pearls: Recorded March 2025 What is the best treatment for a fever? Tylenol? Ibuprofen? Combined? Alternating the two? The journal Pediatrics aimed to answer this question with a meta-analysis of 31 randomized controlled trials including 5,009 febrile children. Results showed that both combined and alternating acetaminophen/ibuprofen regimens were significantly more effective at reducing fever at 4 and 6 hours compared with acetaminophen alone, with numbers needed to treat (NNT) of 3 and 4, respectively. High-dose ibuprofen alone also offered modest...
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Episode 969: Shoulder Reduction
Emergency Medical Minute
Contributor: Aaron Lessen, MD Educational Pearls: There are many techniques for reducing a shoulder dislocation A recent study discussed a new variation of closed reduction technique: wrist-clamping shoulder-lifting The patient is in a sitting position The provider holds the wrist of the injured arm with both hands and slowly rotates the arm to 90 degrees of abduction and 60 degrees of external rotation After this traction, the arm is slowly moved to 45 degrees of abduction and 60 degrees of external rotation The provider then secures the patient’s wrist between the provider’s knees and...
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Episode 968: Heavy Metals
Emergency Medical Minute
Contributor: Megan Hurley MD Educational Pearls: Acute toxicity of heavy metals: Gastrointestinal upset is the most common presentation Chronic toxicity of heavy metals: Symptoms depend on the metal ingested Increased risk of cancer Altered mentation Developmental delays (in children) Kidney failure Four heavy metals that are tested for in a general panel and their sources: Lead Old paint (homes built before 1977) or some older toys Pipes of older homes or those with corrosive agents May obtain testing kits from home improvement stores to test water supply Mercury Previously in...
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Episode 967: Dilutional Hyponatremia
Emergency Medical Minute
Contributor: Taylor Lynch, MD Educational Pearls: Dilutional Hyponatremia: Occurs when there is an excess of free water relative to sodium in the body. Causes a falsely low sodium concentration without a true change in total body sodium. Commonly seen in DKA: Hyperglycemia raises plasma osmolality. Water shifts from the intracellular to extracellular space. This dilutes serum sodium, creating apparent hyponatremia. Corrected sodium calculation: Use tools like MDCALC, or apply this formula: Add 1.6 mEq/L to the measured sodium for every 100 mg/dL increase in glucose above 100. Clinical...
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EMSAC 2024
Emergency Medical Minute
Contributors: Col. (Dr.) Stacy Shackelford Dr. Sean Keenan Paramedic Alan Moreland Dr. Chris Tems Kara Napolitano From military-inspired trauma protocols to behavioral health alternatives and cardiac resuscitation, EMS is evolving fast. Our Medical Minutes from EMSAC highlight the growing need for prehospital providers to think critically, act quickly, and adapt to new approaches in trauma, crisis response, and patient advocacy. Educational Pearls: What was covered & recorded at EMSAC 2024 by EMM? Col. (Dr.) Stacy Shackelford, U.S. Air Force trauma surgeon and Director of the Joint Trauma...
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