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...
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Episode 922: Chest Tube Irrigation
Emergency Medical Minute
Contributor: Aaron Lessen, MD Educational Pearls: Hemothorax: blood in the pleural cavity, most commonly due to chest trauma Treatment: thoracostomy tube for blood drainage helps to avoid clotting, scarring, and infection A recent study looked at patients with hemothorax who either received or did not receive thoracic irrigation with saline Evaluated incidence of secondary intervention, such as video-assisted thoracoscopic surgery (VATS), for persistent hemothorax Patients who received irrigation had a slight decrease in secondary intervention frequency Multi-center study -...
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Episode 921: Pediatric Hypoglycemia
Emergency Medical Minute
Contributor: Taylor Lynch, MD Educational Pearls: When it comes to hypoglycemia, the age dictates possible causes Neonate: Hormonal deficiency Congenital Adrenal Hyperplasia (21-hydroxylase deficiency, 11β-hydroxylase deficiency) Primary or Secondary Adrenal Insufficiency leading to cortisol deficiency Hypopituitarism Inborn errors of metabolism Systemic infection (Under 30 days old should trigger a full infectious workup) Toddler Accidental ingestions Sulfonylureas such as glipizide or glyburide Older children Addison’s Disease (Hypocortisolism) ...
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Laboring Under Pressure Episode 3: Hypertensive Disorders of Pregnancy with Dr. Kiersten Williams
Emergency Medical Minute
Contributor: Kiersten Williams MD, Travis Barlock MD, Jeffrey Olson MS3 Show Pearls Hypertensive disorders of pregnancy are one of the leading causes of maternal mortality worldwide. Hypertension (HTN) complicates 2-8% of pregnancies The definition of HTN in pregnancy is a systolic >140 or diastolic >90, measured 4 hours apart There is a range of HTN disorders Chronic HTN which could have superimposed preeclampsia (preE) on top Gestational HTN in which there are no lab abnormalities PreE w/o severe features Protein in urine Urine protein >300 mg in 24 hours Urine...
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Episode 920: Pediatric Growth Estimates
Emergency Medical Minute
Contributor: Sean Fox, MD Educational Pearls: Newborns may lose up to 10% of their birth weight in the first week of life Weight loss is greatest in exclusively breastfed infants Should regain birth weight by age 2 weeks Newborns should gain an average of 30g (1 oz) per day in the first 3 months of life Some will gain more and some will gain less Infants double their birth weight by 6 months of life and triple their weight by 12 months A 1-year-old should weigh on average 10 kg (22 lbs) A 3-year-old should weigh on average 15 kg (33 lbs) 2-year-olds are between 10-15 kg...
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Episode 919: EKG Criteria for Adenosine
Emergency Medical Minute
Contributor: Travis Barlock, MD Educational Pearls: SVT: supraventricular tachycardia Pharmacotherapy for SVT includes drugs that block the AV node, such as adenosine EKG criteria before adenosine administration in SVT Regular rhythm Monomorphic: all QRS complexes are identical If the EKG is polymorphic, with QRS complexes displaying changing morphologies, it is unsafe to administer adenosine Adenosine can worsen polymorphic VTach and lead to VFib References Ganz, Leonard I., and Peter L. Friedman. “Supraventricular Tachycardia.” New England Journal of...
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Episode 918: Automated Blood Pressure Cuffs
Emergency Medical Minute
Contributor: Aaron Lessen, MD Educational Pearls: How does an automated blood pressure cuff work? Automated blood pressure cuffs work differently than taking a manual blood pressure. While taking a manual blood pressure, one typically listens for Korotkoff sounds (turbulent flow) while slowly deflating the cuff. An automatic blood pressure cuff only senses the pressure in the cuff itself and specifically pays attention to oscillations in the pressure caused by when the pressure of the cuff is between the systolic (heart squeezing) and diastolic (heart relaxed) pressures. These...
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Episode 917: Heat-Related Illnesses
Emergency Medical Minute
Contributor: Megan Hurley, MD Educational Pearls: Heat cramps Occur due to electrolyte disturbances Most common electrolyte abnormalities are hyponatremia and hypokalemia Heat edema Caused by vasodilation with pooling of interstitial fluid in the extremities Heat rash (miliaria) Common in newborns and elderly Due to accumulation of sweat beneath eccrine ducts Heat syncope Lightheadedness, hypotension, and/or syncope in patients with peripheral vasodilation due to heat exposure Treatment is removal from the heat source and rehydration (IV fluids or Gatorade) ...
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Episode 916: Central Cord Syndrome
Emergency Medical Minute
Contributor: Taylor Lynch, MD Educational Pearls: What is Central Cord Syndrome (CCS)? Incomplete spinal cord injury caused by trauma that compresses the center of the cord More common in hyperextension injuries like falling and hitting the chin Usually happens only in individuals with preexisting neck and spinal cord conditions like cervical spondylosis (age-related wear and tear of the cervical spine) Anatomy of spinal cord Motor tracts The signals the brain sends for the muscles to move travel in the corticospinal tracts of the spinal cord The tracts that control the...
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Episode 915: Severe Burn Injuries
Emergency Medical Minute
Contributor: Megan Hurley, MD Educational Pearls: Initial assessment of patients with severe burn injuries begins with ABCs Airway: consider inhalation injury Breathing: circumferential burns of the trunk region can reduce respiratory muscle movement Circulation: circumferential burns compromise circulation Exposure: Important to assess the affected surface area Escharotomy: emergency procedure to release the tourniquet-ing effects of the eschar Differs from a fasciotomy in that it does not breach the deep fascial layer PEEP = positive end-expiratory pressure ...
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