Podcast 1021: Pulmonary Edema From Naloxone Administration
Emergency Medical Minute
Contributor: Travis Barlock, MD Educational Pearls: What is pulmonary edema? Pulmonary edema is the accumulation of fluid initially in the interstitium of the lungs, that when severe enough can also accumulate in the alveolar air sacs. It develops when the rate of fluid filtration through the pulmonary vasculature out-paces the lymphatics ability to drain the fluid. There are 2 theories for what causes pulmonary edema in the setting of naloxone administration: catecholamine surge vs negative pressure/barotrauma Catecholamine Surge : Naloxone administration precipitates an...
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Podcast 1020: Benign Paroxysmal Positional Vertigo (BPPV)
Emergency Medical Minute
Contributor: Alec Coston, MD Educational Pearls: Benign Paroxysmal Positional Vertigo (BPPV) Common inner ear condition that can cause dizziness Diagnosis of BPPV can help to avoid admissions and extra imaging Three categories: positional, horizontal, and anterior Positional is the most common Dizziness is not a positive indicator, a torsional nystagmus must be induced Dix's hallpike maneuver is done to diagnose and an epley maneuver is then used for treatment Horizontal Usually determined to be the case if the vertigo seems positional and the dix...
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Podcast 1019: Trauma Blunt Cardiovascular Injuries (BCVI)
Emergency Medical Minute
Contributor: Aaron Lessen, MD Educational Pearls: Blunt cerebrovascular injury (BCVI) BCVI is a traumatic injury to the carotid or vertebral arteries Patients may initially have no neurologic symptoms In some cases, a thrombus can form at the site of the injury and later cause ischemic stroke, sometimes hours after the original trauma CT angiography (CTA) of the neck is a useful screening tool for BCVI HIstorically, CTA was reserved for patients with high-risk mechanisms or neurologic symptoms CTA screening has expanded as understanding of BCVIs and their prevention...
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Podcast 1018: Occult Ventricular Fibrillation on Echocardiography
Emergency Medical Minute
Contributor: Aaron Lessen, MD Educational Pearls: Big question in cardiac arrest: is the rhythm shockable? Shockable: ventricular fibrillation (VF) and pulseless ventricular tachycardia Non-shockable: asystole and pulseless electrical activity (PEA) Rhythm classification is typically based on ECG, but echocardiography can directly visualize myocardial fibrillation Occult VF: a rhythm that appears non-shockable on ECG but demonstrates VF on echocardiography A 2025 multicenter prospective study looked at 811 patients with out-of-hospital cardiac arrest 5.3% had occult VF...
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Podcast 1017: CPR Hand Placement
Emergency Medical Minute
Contributor: Taylor Lynch, MD Educational Pearls: CPR is an important life-saving measure designed for anyone to perform. Chest compressions works by two mechanisms: Cardiac pump: Direct squeezing of the heart Thoracic pump: Increasing intrathoracic pressure, causing increased blood flow Proper hand placement per current AHA guidelines: Hands are placed in the center of the chest, on the lower half of the sternum A recent study challenged this approach, using TEE during chest compressions to visualize the cardiac structures being compressed. They found...
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Podcast 1016: Hypokalemia
Emergency Medical Minute
Contributor: Meghan Hurley, MD Educational Pearls: What is hypokalemia? Hypokalemia is when the measured blood level of potassium falls below 3.5 mEq/L (normal 3.5 - 5.2 mEq/L). Can generally be considered in mild (3.0 - 3.5 mEq/L); moderate (2.5 - 2.9 mEq/L); and severe (<2.5 mEq/L) categories with differing treatment goals based on levels. Should be noted that blood levels of potassium can be low while total body potassium is normal due to intracellular shift by certain agents like β-2 agonists (e.g. Albuterol) or insulin. There is no appreciable loss of insulin despite...
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Podcast 1015: Calcium in Hyperkalemia
Emergency Medical Minute
Contributor: Meghan Hurley, MD Educational Pearls: What is hyperkalemia? Hyperkalemia is when the measured blood level of potassium reaches above 5.2 - 5.5 mEq/L (normal 3.5 - 5.2 mEq/L). What are common causes of hyperkalemia? Chronic or acute kidney disease. Medications that impact the Renin-Angiotensin-Aldosterone-System (RAAS). Hypoaldosteronism and primary adrenal insufficiency (Addison’s Disease). What are concerns of hyperkalemia? The biggest concern with hyperkalemia is the impact on the cardiac conduction system. At differing levels of...
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Podcast 1014: Eating and Drinking on Shift
Emergency Medical Minute
Contributor; Aaron Lessen, MD Educational Pearls: A 2026 survey asked Canadian emergency medicine (EM) physicians about their eating and drinking habits while on shift. Among 527 respondents, 35% reported that they never or hardly ever ate during shifts, and 37% said the same about drinking water. Lack of time was the most commonly cited barrier, reported by 91% of respondents. Lack of available food, personal health goals, perceived mental clarity, and emergency department culture were also commonly identified factors. Physicians who did not eat or drink on shift often reported...
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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...
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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_outlineContributor: Meghan Hurley, MD
Educational Pearls:
What is hyperkalemia?
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Hyperkalemia is when the measured blood level of potassium reaches above 5.2 - 5.5 mEq/L (normal 3.5 - 5.2 mEq/L).
What are common causes of hyperkalemia?
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Chronic or acute kidney disease.
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Medications that impact the Renin-Angiotensin-Aldosterone-System (RAAS).
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Hypoaldosteronism and primary adrenal insufficiency (Addison’s Disease).
What are concerns of hyperkalemia?
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The biggest concern with hyperkalemia is the impact on the cardiac conduction system.
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At differing levels of hyperkalemia, the patient may initially have peaked T waves, that then progress into a widening of the QRS complex which may eventually lead to a sine wave pattern.
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This increases risk for cardiac arrest with ventricular fibrillation, PEA, and asystole.
What is the treatment algorithm for hyperkalemia?
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Works through a three-tier approach.
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First tier treatment is with a calcium agent (calcium gluconate or chloride).
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Thought for the longest time to “stabilize the cardiac membrane/action potential”. Recent research shows the true mechanism of action is likely through acting on calcium dependent channels.
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Does not fix underlying hyperkalemia, but buys time for the heart.
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Second tier treatment is inducing intracellular potassium shift.
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Can be achieved through agents such as insulin (which may need to be bolused with glucose to prevent hypoglycemia), albuterol, or sodium bicarbonate.
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Third tier is potassium elimination
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If the patient is producing urine, loop or thiazide diuretics can be considered.
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Hemodialysis may also be considered based on patient condition.
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Long term (and slowest method of elimination) through fecal excretion. Unlikely to see benefits in emergency management.
Key Takeaways?
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Hyperkalemia is a condition that can be brought on by primarily renal conditions and medication side effects. Careful attention must be paid to the patient's cardiac status, and urgent cardiac stabilization (though now we may know that calcium doesn’t truly “stabilize” the cardiac membrane) must be performed to prevent deadly arrhythmias. Definitive management involves addressing the offending agent, offloading potassium, and stabilizing the patient long term.
References:
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Geldermann N, Dzimiera J, Fischer H, Christ M. Acute hyperkalaemia in emergency care: evidence-based approaches. Emerg Med J. 2026;43(5):305-311. doi:10.1136/emermed-2025-215469
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Piktel JS, Wan X, Kouk S, Laurita KR, Wilson LD. Beneficial Effect of Calcium Treatment for Hyperkalemia is Not Due to “Membrane Stabilization.” Crit Care Med. 2024;52(10):1499-1508. doi:10.1097/CCM.0000000000006376
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Hunter RW, Bailey MA. Hyperkalemia: pathophysiology, risk factors and consequences. Nephrol Dial Transplant. 2019;34(Suppl 3):iii2-iii11. doi:10.1093/ndt/gfz206
Summarized by Dan Orbidan, OMS3 | Edited by Dan Orbidan & Ahmed Abdel-Hafiz, NREMT-P
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