Episode 954: Combo Rescue Inhalers - New Guidelines
Release Date: 04/30/2025
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: Aaron Lessen, MD
Educational Pearls:
What is a Rescue Inhaler?
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A rescue inhaler is a medication for people with asthma to quickly reverse the symptoms of an asthma attack.
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Historically albuterol (Short Acting Beta Agonist (SABA)) monotherapy has been the mainstay rescue inhaler. This is because albuterol works fast and is relatively cheap. \n\n
What are Combination Rescue Inhalers?
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Combination rescue inhalers contain a fast-acting bronchodilator as well as an inhaled corticosteroid (ICS)
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The steroid helps to reduce some of the chronic airway inflammation that is worsening the asthma attack and can help to prevent future attacks
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Examples include budesonide-formoterol and albuterol-budesonide
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Global Initiative for Asthma (GINA), states that combination therapy is now the preferred reliever for adults and adolescents with mild asthma
What are the drawbacks of Combination Rescue Inhalers?
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These inhalers are generally more expensive than just using a SABA inhaler which can be a barrier for some people \n\n
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Improper use can also lead to conditions like thrush due to the addition of the steroid
References
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Krings JG, Beasley R. The Role of ICS-Containing Rescue Therapy Versus SABA Alone in Asthma Management Today. J Allergy Clin Immunol Pract. 2024 Apr;12(4):870-879. doi: 10.1016/j.jaip.2024.01.011. Epub 2024 Jan 17. PMID: 38237858; PMCID: PMC10999356.
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Papi A, Chipps BE, Beasley R, Panettieri RA Jr, Israel E, Cooper M, Dunsire L, Jeynes-Ellis A, Johnsson E, Rees R, Cappelletti C, Albers FC. Albuterol-Budesonide Fixed-Dose Combination Rescue Inhaler for Asthma. N Engl J Med. 2022 Jun 2;386(22):2071-2083. doi: 10.1056/NEJMoa2203163. Epub 2022 May 15. PMID: 35569035.
Summarized by Jeffrey Olson, MS3 | Edited by Jorge Chalit, OMS3 \n\n
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