Podcast 1013: Thoracotomy Indications
Emergency Medical Minute
Contributor; Taylor Lynch, MD Educational Pearls: Thoracotomy Thoracotomy is used in traumatic cardiac arrest to replace conventional CPR with direct access to the chest. Goals include identifying and controlling reversible causes of bleeding, prioritizing blood flow to the heart and brain, and performing open cardiac massage. Trauma categories Penetrating trauma: Gunshot wounds and stab wounds. Has a higher chance of survival because the injury may be localized and directly repairable. Cardiac stab wounds may have the highest survivability because the defect can be...
info_outline
Podcast 1012: Meth Sedation
Emergency Medical Minute
Contributor: Aaron Lessen, MD Educational Pearls: Agitated patients who are intoxicated with methamphetamine pose a unique challenge when selecting a sedative to counter their symptoms. Is there a superior medication? A recent study compared the efficacy of commonly used medications for methamphetamine-induced agitation in the emergency department. The study compared IM Droperidol 5mg, IM Olanzapine 10mg, IM Midazolam 5mg, and IM Lorazepam 2mg. The study concluded that Droperidol, Olanzapine, and Midazolam performed similarly, with a median time to adequate sedation of...
info_outline
Podcast 1011: Creepy Crawlies
Emergency Medical Minute
Contributor: Meghan Hurley, MD Educational Pearls: What animal is the most lethal to humans? Depending on how we define lethal, and animal, this answer is actually not straight forward. Globally and in the U.S. the most lethal animal is humans, accounting for ~436,000 to ~20,000 deaths (homicides) per year on average respectively. In the United States the most lethal animal is of the Hymenoptera order (bees, wasps, and hornets). It accounts for approximately ~60 deaths per year from anaphylaxis. Globally the number is harder to track, but is estimated between...
info_outline
Podcast 1010: First Pass Intubation Success
Emergency Medical Minute
Contributor: Travis Barlock, MD Educational Pearls: First-pass success is critical to limit complications from apnea, hypoxia, and airway trauma. Complication rate for patients intubated on the first pass is 14% Complication rates increase to 47% after two attempts, 64% after three, and 71% after the fourth attempt How to improve likelihood of first-pass success: Use Video laryngoscopy (VL). VL increases chance of first-pass success to 85% from 71% Use a bougie, especially in patients with anatomically difficult or otherwise obstructed airways. The BEAM study...
info_outline
On the Streets- Zero to Rodeo
Emergency Medical Minute
Dan Orbidan, OMS-II and Dr. Travis Barlock, MD discuss a real out of hospital call. This episode covers the implications of a pharmacologically abnormal patient presentation and the pre and post hospital considerations for patient management and care.
info_outline
Carepoint Journal Club- Neurology
Emergency Medical Minute
Carepoint Journal Club is a quarterly series with discussions about a medical topic, brought to you by Carepoint's Emergency Physicians.
info_outline
Podcast 1009: Prevention for Recurrent UTI
Emergency Medical Minute
Contributor: Aaron Lessen, MD Educational Pearls: UTIs are commonly seen in older women We often see them taking long-term prophylactic antibiotics because of common recurrence. Around 20-30% of older women who develop a UTI have a recurrence due to either diagnostic failure, treatment failure or non-compliance with treatment. UTI signs and symptoms Burning sensation when urinating Strong urge to urinate Urinating often and passing small amounts of urine. Pelvic pain There are currently more guidelines and studies on treatments to prevent these...
info_outline
Podcast 1008: Acupuncture for Low Back Pain in Older Adults
Emergency Medical Minute
Contributor: Aaron Lessen, MD Educational Pearls: Back pain is a common presenting complaint in the emergency department. Challenges arise when tailoring care to elderly populations using standard medical therapy: Muscle relaxants carry the risk of CNS depression or anticholinergic effects such as urinary retention and confusion. Pain medications such as opiates have side effects including constipation, respiratory depression, and hypotension. NSAIDs carry a risk of GI bleeding and worsening kidney function with chronic use. A randomized clinical trial assessing the effects...
info_outline
Podcast 1007: Caffeine Pharmacology
Emergency Medical Minute
Contributor: Travis Barlock, MD Educational Pearls: Caffeine Geography and Types: Caffeine is found throughout the world and has evolved independently in various plants that are not evolutionarily related through direct lineage, but rather demonstrate convergent evolution (i.e. different species evolve the same traits). These plants use caffeine as an insecticide. Examples of caffeine sources include coffee, tea, yerba-mate, guaraná, cacao, and yaupon holly. Roughly 85% of Americans are estimated to consume caffeine daily. Caffeine Pharmacology in...
info_outline
Podcast 1006: Cannabinoid Pharmacology
Emergency Medical Minute
Contributor: Travis Barlock, MD Educational Pearls: Endocannabinoid System: THC binds CB1 and CB2 receptors in neurons and immune cells Δ9-Tetrahydrocannabinol (THC) is the main psychoactive compound in cannabis CB1 and CB2 receptors typically bind endogenously-produced 2-arachidonoylglycerol (2-AG) and anandamide (AEA) to regulate pain, stress, and inflammation THC similarly binds CB1 and CB2, leading to the cannabinoid high: euphoria, paranoia, anxiety, analgesia, anti-inflammation, and appetite, among a variety of others Ingestion via edibles, vice inhalation via smoking,...
info_outlineContributors: 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 thing (spontaneous pneumothorax), tall family members with long fingers and toes
Physical Exam:
Cards: Diastolic decrescendo at the RUSB, diminished S2. UE pulses are asymmetric, LE pulses are asymmetric, carotid pulses are asymmetric, BP is asymmetric
MSK: Knees, elbows, and wrists are hypermobile.
Imaging: CXR #1 normal, #2 widened mediastinum (no read yet but shows widened mediastinum), POCUS shows small effusion
CTA/MRA doesn’t come back until after the case.
ECG: Sinus Tach
Labs:
NT-proBNP 500 pg/mL
D-Dimer: 7000 ng/L
CBC: Hemoglobin: 13.5 g/dL, WBC: 20,000/µL, Platelets: 250,000/µL
Chem 7: Na 138, K, 5.7, Cl 102, Bicarb 17, BUN 45, Creatinine: 3.5 mg/dL, Glucose: 180
LFTs: Albumin 2.4, Total protein 5.5, ALP: 140, AST: 3500, ALT: 2800, TBili: 3.2, DirectBili: 2.4,
Ca: 7.8
LDH: 2200
PT: 20.5, INR: 2.2, Fibrinogen: 170
5th gen High-Sensitivity Troponin: <3
Lactate: 7 mmol/L
VBG: pH 7.22, paCO2 28, bicarb 15
Notes: Can have patient crash somewhere in middle and show 2nd xray
Case 2:
A 67-year-old female is brought to the ED by her daughter due to progressive weakness, confusion, and fatigue that have worsened over the past week.
Unable to get out of bed and has become increasingly lethargic. Also having some nausea, constipation. The daughter denies any preceding illness, recent trauma, or travel. Does not know her meds but will head home to get them after talking with you.
VS: BP 88/55 mmHg, HR 110, RR 20, O2 Sat 98% on room air.
Additional VS: Temp 36.8°C.
PMH: Hypertension, osteoarthritis, and depression.
Physical exam:
General: Thin, somnolent but arousable.
HENT: Dry mucous membranes
Neuro: Confused, A&Ox1 (self), hyporeflexia
Labs (Includes many that would not return in the ED in case you want to take this case forward to the floor)
CBC: WBC 9,500, Hb 16.5, Hct: 50%, Platelets 220,000
Chem7: Na 129, K 2.1, Cl 95, HCO3 34, Creatinine 1.6, BUN 40, Glucose 115
LFTs: normal
Magnesium: 1.1
Calcium: 10.8 mg/dL (corrects to 12.8)
iCal: 3.2
Phosphate: 2.3 mg/dL
Albumin: 2
BUN:Cr ratio: 25
VBG: pH: 7.49, PaCO2 45, HCO3: 34
Lactate: 2.8
Serum Osmolality: 276 mOsm/kg (Osmolal gap of 2)
Urine Osmolality: 550 mOsm/kg
Urine Sodium (UNa): 10 mEq/L (low). Urine Potassium (UK): 25 mEq/L (elevated). Urine Chloride (UCl): 12 mEq/L (low). Urine Magnesium (UMg): 20 (Elevated). Urine Calcium (UCa): 50 in 24 hrs (Low)
100 cc of urine with foley
FeNa <1%
Plasma renin activity: 15 mg/mL/hr (elevated), Aldosterone: 25 ng/dL (Elevated), ADH: Elevated, Diuretic screen: Positive for thiazides
PTH: 8 (low), HsTrop: 32, Cortisol and ACTH: Normal.
EKG: Hypokalemia features
CXR: Normal
Renal US: shows stones
Improves with fluids
Note: Can have daughter return with med list at some point including HCTZ, ibuprofen, and sertraline
Case 3:
Patient Presentation
EMS Report: A 27-year-old male involved in a high-speed motorcycle collision is brought to the emergency department by EMS. The patient was found unconscious at the scene with evidence of severe thoracic and extremity trauma. He was intubated en route for airway protection due to altered mental status (GCS 7).
VS: HR 130, BP 90/60, RR: bagging at 12 bpm, satting 88% on 100% FiO2
Primary Survey
Airway: Endotracheal tube in place.
Breathing: Decreased breath sounds on the left side with visible chest asymmetry and paradoxical chest wall movement.
Circulation: Mottled extremities noted, with significant deformity of the right thigh. Pulses are diminished in the right leg
Disability: GCS remains 7 (E1 V2 M4). Pupils equal and reactive.
Exposure: Full-body examination reveals an open fracture of the right femur, multiple abrasions, and bruising over the chest wall.
Vent alarms
Peak Inspiratory Pressure (PIP) 40 cm H₂O (elevated)
Plateau Pressure (Pplat) 35 cm H₂O (elevated)
EtCO₂ (End-Tidal CO₂) 55 mmHg
High-Pressure Alarm Triggering frequently
Glucose 120
CBC: Hgb 8.9, Hct 27, WBC 14.2, platelets 220,000
VBG: pH 7.28, pCO2 33, bicarb 18, lactate 4.5
CXR with tension pneumothorax
Patient improves after chest tube, pigtail catheter, or needle decompression.
Ready to be transferred upstairs and O2 starts tanking again
Vent alarms- second episode
Peak Inspiratory Pressure (PIP) 35 cm H₂O (elevated)
Plateau Pressure (Pplat) 30 cm H₂O (elevated)
EtCO₂ (End-Tidal CO₂) 20 mmHg
HR: 140, satting 84%, temp 38.5,
ABG: pH 7.32, pCO₂ 30 mmHg, pO₂ 60 mmHg on 100% FiO₂, HCO₃⁻ 18 mmol/L (hypoxemia and metabolic acidosis).
D-dimer: Elevated
Thrombocytopenia: Platelets 90,000/µL.
US shows blown right ventricle
ECG shows new RBBB
CT PE: Ground glass opacities, consolidation, centrilobular nodules, septal thickening, and fat-attenuating lesions.
Note: Management is largely supportive care so once the diagnosis is made, end the case.
References
-
Carroll MF, Schade DS. A practical approach to hypercalcemia. Am Fam Physician. 2003 May 1;67(9):1959-66. PMID: 12751658.
-
Coelho SG, Almeida AG. Marfan syndrome revisited: From genetics to the clinic. Rev Port Cardiol (Engl Ed). 2020 Apr;39(4):215-226. English, Portuguese. doi: 10.1016/j.repc.2019.09.008. Epub 2020 May 18. PMID: 32439107.
-
Palmer BF. Metabolic complications associated with use of diuretics. Semin Nephrol. 2011 Nov;31(6):542-52. doi: 10.1016/j.semnephrol.2011.09.009. PMID: 22099511.
-
Reed MJ. Diagnosis and management of acute aortic dissection in the emergency department. Br J Hosp Med (Lond). 2024 Apr 30;85(4):1-9. doi: 10.12968/hmed.2023.0366. PMID: 38708978.
-
Roberts DJ, Leigh-Smith S, Faris PD, Blackmore C, Ball CG, Robertson HL, Dixon E, James MT, Kirkpatrick AW, Kortbeek JB, Stelfox HT. Clinical Presentation of Patients With Tension Pneumothorax: A Systematic Review. Ann Surg. 2015 Jun;261(6):1068-78. doi: 10.1097/SLA.0000000000001073. PMID: 25563887.
-
Rothberg DL, Makarewich CA. Fat Embolism and Fat Embolism Syndrome. J Am Acad Orthop Surg. 2019 Apr 15;27(8):e346-e355. doi: 10.5435/JAAOS-D-17-00571. PMID: 30958807.
Produced by Jeffrey Olson, MS4
Special thanks to Evan Fisch MD
Get your tickets to Tox Talks Event, Sept 11, 2025: https://emergencymedicalminute.org/events-2/