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...
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Episode 966: Acetaminophen Toxicity
Emergency Medical Minute
Contributor: Jorge Chalit-Hernandez, OMS4 Educational Pearls: What is the toxic dose of acetaminophen? 7.5 grams, in an adult. The safe daily limit is 4 grams in an adult with a normally functioning liver. This is equivalent to fifteen 500mg pills. What are the symptoms of acetaminophen toxicity? First 24 hours, symptoms are non-specific e.g. nausea, vomiting, lack of appetite. Can also be asymptomatic. 24-72 hours, hepatotoxicity occurs (causing yellow skin, pruritus, abdominal pain, bleeding, and confusion) Fulminant liver failure at 72-96 hours Liver function tests (LFTs) peak at 72-96...
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Episode 965: Oxygen Administration in Trauma Patients
Emergency Medical Minute
Contributor: Aaron Lessen, MD Educational Pearls: Many trauma patients are placed on oxygen via non-rebreather A large, multicenter, controlled trial evaluated the outcomes of oxygen administration in trauma patients Patients were randomized to two groups 1. 8-hour restrictive oxygen strategy: only receiving oxygen when the patient’s saturation dropped below 94% 2. 8-hour liberal oxygen strategy: 12-15 liters of oxygen per minute or fraction of inspired oxygen of 0.6-1.0 The study evaluated rates of death or major respiratory complications at 30 days There was no statistical difference...
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Episode 964: Ketamine & Midazolam for Prehospital Seizure Management
Emergency Medical Minute
Contributor: Aaron Lessen, MD Educational Pearls: Prehospital seizures are typically managed with intramuscular midazolam (Versed) Seizures theoretically involve the NMDA pathway, and ketamine is a potent NMDA antagonist A recent retrospective cohort study analyzed a Florida EMS protocol that uses ketamine in seizures refractory to midazolam One group received two doses of midazolam for seizure control The other group received a dose of midazolam followed by a dose of ketamine After matching, 82% of the midazolam-only group patients had resolution of convulsions prior to ED arrival 94.4%...
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Episode 963: Antihypertensives and Emergency Room Considerations
Emergency Medical Minute
Contributor: Alec Coston, MD Educational Pearls: For patients presenting to the emergency room with hypertension, clinicians should determine if it is isolated and uncomplicated, or involves comorbidities with more complex underlying pathophysiology. For uncomplicated and isolated hypertension, first-line treatment is thiazide diuretics. How do thiazide diuretics work to treat hypertension? Thiazide diuretics work by blocking sodium and chloride resorption in the kidneys. “Where sodium goes, water follows,” thus promoting diuresis and lowering blood pressure. Examples...
info_outlineContributor: Travis Barlock, MD
Educational Pearls:
What is Portal Vein Thrombosis?
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The formation of a blood clot within the portal vein, which carries blood from the gastrointestinal tract, pancreas, and spleen to the liver
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Not only can this cause problems downstream in the liver, but the backup of venous blood can cause ischemia in the bowels
How does it present?
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Similar to acute mesenteric ischemia: Sudden onset of abdominal pain, nausea, vomiting, and fever
How is it diagnosed?
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Abdominal CT or MRI with contrast
What causes it?
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Cirrhosis
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Coagulopathy (Factor V Leiden mutation, Prothrombin gene mutation, Antiphospholipid syndrome, Protein C, protein S, antithrombin III deficiency, etc.)
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Oral Contraceptive Pills (OCPs)
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Cancer such as hepatocellular carcinoma
How is it treated?
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Aggressive fluid resuscitation
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Antibiotics. Be sure to cover enteric gram-negative bacteria and anaerobes
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Heparin, same dosing as a bolus for a DVT
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Endovascular treatment, such as a thrombectomy with IR
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Surgical evaluation if there has been tissue death in the mesentery
References
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Hilscher, M. B., Wysokinski, W. E., Andrews, J. C., Simonetto, D. A., Law, R. J., & Kamath, P. S. (2024). Portal Vein Thrombosis in the Setting of Cirrhosis: Evaluation and Management Strategies. Gastroenterology, 167(4), 664–672. https://doi.org/10.1053/j.gastro.2024.05.017
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Intagliata, N. M., Caldwell, S. H., & Tripodi, A. (2019). Diagnosis, Development, and Treatment of Portal Vein Thrombosis in Patients With and Without Cirrhosis. Gastroenterology, 156(6), 1582–1599.e1. https://doi.org/10.1053/j.gastro.2019.01.265
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Ju, C., Li, X., Gadani, S., Kapoor, B., & Partovi, S. (2022). Portal Vein Thrombosis: Diagnosis and Endovascular Management. Pfortaderthrombose: Diagnose und endovaskuläres Management. RoFo : Fortschritte auf dem Gebiete der Rontgenstrahlen und der Nuklearmedizin, 194(2), 169–180. https://doi.org/10.1055/a-1642-0990
Summarized by Jeffrey Olson MS3 | Edited by Jorge Chalit, OMS3
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