Episode 942: Acute Mountain Sickness and High Altitude Cerebral Edema
Emergency Medical Minute
Contributor: Jorge Chalit-Hernandez, OMS3 Educational Pearls: Acute mountain sickness (AMS) is the term given to what is otherwise colloquially known as altitude sickness High altitude cerebral edema (HACE) is a severe form of AMS marked by encephalopathic changes Symptoms begin at elevations as low as 6500 feet above sea level for people who ascend rapidly May develop more severe symptoms at higher altitudes The pathophysiology involves cerebral vasodilation Occurs in everyone ascending to high altitudes but is more pronounces in those that develop symptoms The reduced...
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Episode 941: Rehydration in Pediatric Gastroenteritis
Emergency Medical Minute
Contributor: Meghan Hurley, MD Educational Pearls: Gastroenteritis clinical diagnoses: Diarrhea with or without vomiting and fever Vomiting in the absence of diarrhea has a large list of differential diagnoses, so the combination of diarrhea and vomiting in a patient is helpful to indicate the gastroenteritis diagnosis Symptom timeline is usually 1-3 days, but can last up to 14 days – diarrhea persists the longest Treatment for mild to moderate dehydration: oral or IV rehydration Begin orally to avoid unnecessary IV in a pediatric patient Administer ODT Ondansetron...
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Episode 940: Laceration Repair Methods
Emergency Medical Minute
Contributor: Aaron Lessen, MD Educational Pearls: If a patient sustains a cut, the provider has several options on how to close the wound. If they choose to suture the wound closed, it involves needles both in the form of injecting numbing medication (lidocaine) as well as with the suture itself. Other techniques are “needleless,” like closing the wound with adhesive strips (Steri-Strips) or skin adhesive (Dermabond). But which method is best? A recent study looked to compare guardian-perceived cosmetic outcomes of pediatric lacerations repaired with absorbable sutures, Dermabond, and...
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Episode 939: Serotonin Syndrome
Emergency Medical Minute
Contributor: Jorge Chalit-Hernandez, OMS3 Educational Pearls: Serotonin syndrome occurs most commonly due to the combination of monoamine oxidase inhibition with concomitant serotonergic medications like SSRIs Examples of unexpected monoamine oxidase inhibitors Linezolid - a last-line antibiotic reserved for patients with true anaphylaxis to penicillins and cephalosporins Methylene blue - not mentioned in the podcast due to its uncommon usage for methemoglobinemia Other medications that can interact with SSRIs to cause serotonin syndrome Dextromethorphan - primarily an...
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Episode 938: AHA Policy on Management of Elevated Blood Pressure (BP) in the Acute Care Setting
Emergency Medical Minute
Contributor: Aaron Lessen, MD Educational Pearls: Many patients present to the ED with elevated BP Many are referred from outpatient surgery centers or present after an elevated measurement at home Persistent questions on the best way to treat these patients The AHA published a scientific statement on the management of elevated BP in the acute care setting Hypertensive emergencies: SBP/DBP >180/110–120 mm Hg with evidence of new or worsening target-organ damage Includes aortic dissection or subarachnoid hemorrhage Require aggressive treatment Asymptomatic...
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Episode 937: Pneumomediastinum
Emergency Medical Minute
Contributor: Megan Hurley MD Educational Pearls: What is the mediastinum? The thoracic cavity is separated into different compartments by membranes The lungs exist in their own pleural cavities, and the mediastinum is everything in between The mediastinum extends from the sternum to the thoracic vertebrae and includes the heart, the aorta, the trachea, the esophagus, the thymus, as well as many lymph nodes and nerves. What is a pneumomediastinum? Air in the mediastinum How can pneumomediastinum be categorized? Traumatic Ex. Stab wound to the trachea Ex. Boerhaave’s...
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Episode 936: Etomidate vs. Ketamine for Rapid Sequence Intubation
Emergency Medical Minute
Contributor: Ricky Dhaliwal MD Educational Pearls: Etomidate was previously the drug of choice for rapid sequence intubation (RSI) However, it carries a risk of adrenal insufficiency as an adverse effect through inhibition of mitochondrial 11-β-hydroxylase activity A recent meta-analysis analyzing etomidate as an induction agent showed the following: 11 randomized-controlled trials with 2704 patients Number needed to harm is 31; i.e. for every 31 patients that receive etomidate for induction, there is one death The probability of any mortality increase was 98.1% ...
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Episode 935: Pregnancy Extremis - TOLDD
Emergency Medical Minute
Contributor: Aaron Lessen MD Educational Pearls: Pregnant patients at high risk of cardiac arrest, in cardiac arrest, or in extremis require special care A useful mnemonic to recall the appropriate management of critically ill pregnant patients is TOLDD T: Tilt the patient to the left lateral decubitus position This position relieves pressure exerted from the uterus onto the inferior vena cava, which reduces cardiac preload If the patient is receiving CPR, an assistant should displace the uterus manually from the IVC towards the patient’s left side O: Administer high-flow...
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Episode 934: Subendocardial Ischemia
Emergency Medical Minute
Contributor: Travis Barlock MD Educational Pearls: What is the ST segment? The ST segment on an ECG represents the interval between the end of ventricular depolarization (QRS) and the beginning of ventricular repolarization (T-wave). It should appear isoelectric (flat) in a normal ECG. What if the ST segment is elevated? This is evidence that there is an injury that goes all the way through the muscular wall of the heart (transmural) This is very concerning for a heart attack (STEMI) but can be occasionally caused by other pathology, such as pericarditis What if the ST...
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Episode 933: Benign Convulsions with Gastroenteritis
Emergency Medical Minute
Contributor: Alec Coston MD Educational Pearls: Causes of seizures in a fairly well-appearing child with diarrhea: Electrolyte abnormalities: hypocalcemia, hyponatremia Also hyperkalemia which causes arrhythmias and syncope - can appear like seizures Hypoglycemia If the child has diarrhea and appears very sick, differential diagnosis may include: Hemolytic uremic syndrome (HUS): simultaneous occurrence of microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury Typically caused by Shiga-like toxin producing Escherichia coli (also known as EHEC, or...
info_outlineContributor: Aaron Lessen, MD
Educational Pearls:
How does an automated blood pressure cuff work?
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Automated blood pressure cuffs work differently than taking a manual blood pressure.
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While taking a manual blood pressure, one typically listens for Korotkoff sounds (turbulent flow) while slowly deflating the cuff.
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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.
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These oscillations are at a maximum when the pressure in the cuff matches the mean arterial pressure (MAP) and therefore the machines are most accurate at reporting the MAP.
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The machines then use the MAP and other information about the oscillations to estimate the systolic and diastolic pressures, which are less accurate.
What should you do if you need more accurate systolic and diastolic blood pressures?
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Take a manual blood pressure.
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Get an arterial-line (a-line), which provides continuous data for the blood pressure at the end of a catheter.
What happens if the cuff is too big or too small for the patient?
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If the cuff is too small it will overestimate the pressure.
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If the cuff is too large it will underestimate the pressure.
What should you do if the cuff cycles a bunch of times before reporting a blood pressure?
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It probably isn’t very accurate so consider another method.
Bonus fact!
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The MAP is not directly in the middle of the systolic and diastolic pressures but is weighted towards the diastolic pressure. The MAP can be calculated by adding two-thirds of the diastolic pressure to one third of the systolic pressure. For example if the BP is 120/90 the MAP is 100 mmHg.
References
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Benmira, A., Perez-Martin, A., Schuster, I., Aichoun, I., Coudray, S., Bereksi-Reguig, F., & Dauzat, M. (2016). From Korotkoff and Marey to automatic non-invasive oscillometric blood pressure measurement: does easiness come with reliability?. Expert review of medical devices, 13(2), 179–189. https://doi.org/10.1586/17434440.2016.1128821
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Liu, J., Li, Y., Li, J., Zheng, D., & Liu, C. (2022). Sources of automatic office blood pressure measurement error: a systematic review. Physiological measurement, 43(9), 10.1088/1361-6579/ac890e. https://doi.org/10.1088/1361-6579/ac890e
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Vilaplana J. M. (2006). Blood pressure measurement. Journal of renal care, 32(4), 210–213. https://doi.org/10.1111/j.1755-6686.2006.tb00025.x
Summarized by Jeffrey Olson, MS3 | Edited by Meg Joyce, MS1 & Jorge Chalit, OMS3
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