Episode 983: Head-of-Bed Position in Large Vessel Occlusion Strokes
Emergency Medical Minute
Contributor: Aaron Lessen MD Educational Pearls: Recent prospective randomized clinical trial assessed optimal head-of-bed positioning in patients with LVO 0º vs. 30º elevation Objective was to determine superiority of the two angles in stability prior to thrombectomy for LVO patients 45 patients randomized to the group with 0° head positioning and 47 patients randomized to the group with 30° head positioning Patients in the 30º group experienced worsening of NIHSS by 2 points or more Patients with head position at 0° showed score stability Hazard ratio 34.40; 95% CI,...
info_outline
Episode 982: Epistaxis Management
Emergency Medical Minute
Contributor: Meghan Hurley, MD Educational Pearls: 1. Initial Assessment Start with a physical examination: Determine if the bleed is anterior or posterior. Perform a primary survey: assess airway, breathing, and circulation (ABCs). Airway compromise = intubation immediately. If the patient is stable, have them blow out any clots, then re-examine the nares. 2. Topical Medications Anesthetics: provide local anesthesia and pain relief. Lidocaine Tetracaine Vasoconstrictors: reduce bleeding. LET (Lidocaine, Epinephrine, Tetracaine) is ideal because it provides...
info_outline
Episode 981: Electrical Burns
Emergency Medical Minute
Contributor: Travis Barlock, MD Educational Pearls: Quick Statistics on Electrical Burns: Electrical burns compose roughly 2 to 9% of all burns that come into emergency departments. The majority of patients who receive electrical burns are male, typically aged 20’s to 30’s, accounting for 80 to 90% of all electrical burn victims. The majority of burns are linked to occupational exposure. The upper extremities are more commonly impacted by electrical burns, accounting for 70 to 90% of entry points into the body during an exposure. What are some of the key considerations in electrical...
info_outline
Tox Talks 2025 Recap 1, Digoxin and Beta Blockers
Emergency Medical Minute
Contributors: Preeya Prakash MD, Adam Greenhaw PharmD, Travis Barlock MD, and Jeffrey Olson MS4 In this episode, cardiologist Preeya Prakash and medical student Jeffrey Olson listen in as two cases are presented from EMM’s recent event, Tox Talk 2025. Talk 1- Digoxin Overdose Dr. Adam Greenhaw presents a case of a Digoxin overdose along with many pearls. During the studio listen in, Dr. Prakash helps to answer the questions of: How does digoxin work? Why might a patient still be on digoxin in 2025? What are the EKG findings of digoxin toxicity? Is there any utility in atropine...
info_outline
Episode 980: Brain Injury Guidelines (BIG)
Emergency Medical Minute
Contributor: Aaron Lessen, MD Educational Pearls: Traumatic Brain Injuries are a frequent complaint in the Emergency Department and have increased in recent years. The American Association for Surgery of Trauma (AAST) has created Brain Injury Guidelines (BIG), in an attempt to categorize brain injuries and the level of treatment they require. They are… BIG 1 Normal neuro exam Not intoxicated Not on anticoagulation or antiplatelet medications Minimal findings on head CT No fracture <4 mm bleed (subdural, epidural, intraparenchymal (max one location)) Maximum of “trace” subarachnoid...
info_outline
Episode 979: Oral vs Temporal Thermometers
Emergency Medical Minute
Contributor: Taylor Lynch, MD Educational Pearls: A recent study published in a pediatric journal in April 2025 compared temporal and oral thermometers Paired temperature measurements (temporal and oral temperature within 30 minutes) were obtained from 1,412 pediatric patients 26% of patients had statistically different temporal and oral temperatures The temporal reading was always lower than the oral reading Children less than 12 years old were 2-3x more likely to actually have that statistical difference in temperatures The study also evaluated 1,000 adult patients 36% had a temporal...
info_outline
Episode 978: Delusional Parasitosis
Emergency Medical Minute
Contributor: Taylor Lynch, MD Educational Pearls: Delusional parasitosis is a subtype of the psychiatric condition delusional disorder Defined as a fixed, false belief of infestation by parasites or other organisms A somatic type of delusional disorder Primary delusional parasitosis Occurs in the absence of other psychiatric or medical conditions Secondary delusional parasitosis Causes include methamphetamine use disorder, schizophrenia, neurologic diseases, or medical conditions such as thyroid disease Pathophysiology Poorly understood Upregulation of striatal dopamine system is...
info_outline
Episode 977: Amyloid Therapy and Stroke-like Events
Emergency Medical Minute
Contributor: Aaron Lessen, MD Educational Pearls: The cause of Alzheimer’s disease is multifactorial, but the most widely suspected mechanism is the amyloid cascade hypothesis: Beta-amyloid proteins accumulate in the central nervous system, forming plaques that impair neuronal function. In recent years, advances have led to the development of targeted therapies with monoclonal antibodies. These drugs: Work by degrading amyloid plaques Slow the rate of cognitive decline and disease progression Have major side effects, most notably the development of amyloid-related imaging abnormalities...
info_outline
Episode 976: Improvised Burr Hole in an Epidural Hematoma
Emergency Medical Minute
Contributor: Alec Coston, MD Case Report Summary: A 17-year-old female involved in a motor vehicle collision presented to a rural emergency facility via personally operated vehicle. During workup and initial CT scan, the patient began rapidly decompensating with CT revealing a 1.5cm epidural hematoma with 7mm of midline shift. The patient went from being able to walk and talk to being obtunded with a blown left pupil and unresponsive. Following intubation, the patient was being prepared for transport but potential delays required immediate emergency evacuation of the hematoma via a Burr Hole....
info_outline
Episode 975: Nursemaid's Elbow
Emergency Medical Minute
Contributor: Aaron Lessen, MD Educational Pearls: What is a Nursemaid's Elbow? A condition in which an elbow gets partially pulled out of place (a radial head subluxation) Usually happens in kids under 5 because the ligaments around their elbow are still loose. A common situation is when an adult pulls a child up by the hand or swings them by the arms. The sudden tug causes the radius to slip out of its normal spot at the elbow joint. How are they identified? These don’t normally need an xray The child will often hold their arm close to their side and refuse to use it There’s usually no...
info_outlineContributor: Taylor Lynch, MD
Educational Pearls:
What is NMS?
-
Neuroleptic Malignant Syndrome
-
Caused by anti-dopamine medication or rapid withdrawal of pro-dopamenergic medications
-
Mechanism is poorly understood
-
Life threatening
What medications can cause it?
-
Typical antipsychotics
-
Haloperidol, chlorpromazine, prochlorperazine, fluphenazine, trifluoperazine
-
Atypical antipsychotics
-
Less risk
-
Risperidone, clozapine, quetiapine, olanzapine, aripiprazole, ziprasidone
-
Anti-emetic agents with anti dopamine activity
-
Metoclopramide, promethazine, haloperidol
-
Not ondansetron
-
Abrupt withdrawal of levodopa
How does it present?
-
Slowly over 1-3 days (unlike serotonin syndrome which has a more acute onset)
-
Altered mental status, 82% of patients, typically agitated delirium with confusion
-
Peripheral muscle rigidity and decreased reflexes. AKA lead pipe rigidity. (As opposed to clonus and hyperreflexia in serotonin syndrome)
-
Hyperthermia (>38C seen in 87% of patients)
-
Can also have tachycardia, labile blood pressures, tachypnea, and tremor
How is it diagnosed?
-
Clinical diagnosis, focus on the timing of symptoms
-
No confirmatory lab test but can see possible elevated CK levels and WBC of 10-40k with a left shift
What else might be on the differential?
-
Sepsis
-
CNS infections
-
Heat stroke
-
Agitated delirium
-
Status eptilepticus
-
Drug induced extrapyramidal symptoms
-
Serotonin syndrome
-
Malignant hyperthermia
What is the treatment?
-
Start with ABC’s
-
Stop all anti-dopaminergic meds and restart pro-dopamine meds if recently stopped
-
Maintain urine output with IV fluids if needed to avoid rhabdomyolysis
-
Active or passive cooling if needed
-
Benzodiazapines, such as lorazepam 1-2 mg IV q 4hrs
What are active medical therapies?
-
Controversial treatments
-
Bromocriptine, dopamine agonist
-
Dantrolene, classically used for malignant hyperthermia
-
Amantadine, increases dopamine release
-
Use as a last resort
Dispo?
-
Mortality is around 10% if not recognized and treated
-
Most patients recover in 2-14 days
-
Must wait 2 weeks before restarting any medications
References
-
Oruch, R., Pryme, I. F., Engelsen, B. A., & Lund, A. (2017). Neuroleptic malignant syndrome: an easily overlooked neurologic emergency. Neuropsychiatric disease and treatment, 13, 161–175. https://doi.org/10.2147/NDT.S118438
-
Tormoehlen, L. M., & Rusyniak, D. E. (2018). Neuroleptic malignant syndrome and serotonin syndrome. Handbook of clinical neurology, 157, 663–675. https://doi.org/10.1016/B978-0-444-64074-1.00039-2
-
Velamoor, V. R., Norman, R. M., Caroff, S. N., Mann, S. C., Sullivan, K. A., & Antelo, R. E. (1994). Progression of symptoms in neuroleptic malignant syndrome. The Journal of nervous and mental disease, 182(3), 168–173. https://doi.org/10.1097/00005053-199403000-00007
-
Ware, M. R., Feller, D. B., & Hall, K. L. (2018). Neuroleptic Malignant Syndrome: Diagnosis and Management. The primary care companion for CNS disorders, 20(1), 17r02185. https://doi.org/10.4088/PCC.17r02185
Summarized by Jeffrey Olson MS2 | Edited by Meg Joyce & Jorge Chalit, OMSIII