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...
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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...
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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...
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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...
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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...
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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...
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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...
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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....
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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...
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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...
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
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Carroll MF, Schade DS. A practical approach to hypercalcemia. Am Fam Physician. 2003 May 1;67(9):1959-66. PMID: 12751658.
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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.
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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.
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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.
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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.
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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
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