Emergency Medical Minute

Emergency Medical Minute is medicine's most prolific podcast. Geared towards physicians, nurses and paramedics! Tune in weekly for real, raw and relevant medical education.

Episode 913: Vasopressors after ROSC 07/23/2024

Podcast 912: Narcan (Naloxone) 07/15/2024

Podcast 912: Narcan (Naloxone) Contributor: Taylor Lynch, MD Educational Pearls: Opioid Epidemic- quick facts Drug overdoses, primarily driven by opioids, have become the leading cause of accidental death in the U.S. for individuals aged 18-45. In 2021, opioids were involved in nearly 75% of all drug overdose deaths The rise of synthetic opioids like fentanyl, which is much more potent than heroin or prescription opioids, has played a major role in the increase in overdose deaths What is Narcan AKA Naloxone? Competitive opioid antagonist. It sits on the receptor but doesn’t activate it. When do we give Narcan? Respiratory rate less than 8-10 breaths per minute Should you check the pupils? An opioid overdose classically presents with pinpoint pupils BUT… Hypercapnia from bradypnea can normalize the pupils Taking other drugs at the same time like cocaine or meth can counteract the pupillary effects Basilar stroke could also cause small pupils, so don’t anchor on an opioid overdose How does Narcan affect the body? Relatively safe even if the patient is not experiencing an opioid overdose. So when in doubt, give the Narcan. What if the patient is opioid naive and overdosing? Use a large dose given that this patient is unlikely to withdraw 0.4-2 mg every 3-5 minutes What if the patient is a chronic opioid user Use a smaller dose such as 0.04-0.4 mg to avoid precipitated withdrawal How fast does Narcan work? Given intravenously (IV), onset is 1-2 min Given intranasal (IN), onset is 3-4 min Given intramuscularly (IM), onset is ~6 min Duration of action is 60 mins, with a range of 20-90 minutes How does that compare to the duration of action of common opioids? Heroine lasts 60 min Fentanyl lasts 30-60 min, depending on route Carfentanyl lasts ~5 hrs Methadone lasts 12-24 hrs So we really need to be conscious about redosing How do you monitor someone treated with Narcan? Pay close attention to the end-tidal CO2 to ensure that are ventilating appropriately Be cautious with giving O2 as it might mask hypoventilation Watch the respiratory rate Give Narcan as needed Observe for at least 2-4 hours after the last Narcan dose Larger the dose, longer the observation period Who gets a drip? If they have gotten ~3 doses, time to start the drip Start at 2/3rds last effective wake-up dose Complications Flash pulm edema 0.2-3.6% complication rate Might be from the catecholamine surge from abrupt wake-up Might also be from large inspiratory effort against a partially closed glottis which creates too much negative pressure Treat with BIPAP if awake and intubation if not awake Should you give Narcan in cardiac arrest? Short answer no. During ACLS you take over breathing for the patient and that is pretty much the only way that Narcan can help Just focus on high quality CPR References . Elkattawy, S., Alyacoub, R., Ejikeme, C., Noori, M. A. M., & Remolina, C. (2021). Naloxone induced pulmonary edema. Journal of community hospital internal medicine perspectives, 11(1), 139–142. van Lemmen, M., Florian, J., Li, Z., van Velzen, M., van Dorp, E., Niesters, M., Sarton, E., Olofsen, E., van der Schrier, R., Strauss, D. G., & Dahan, A. (2023). Opioid Overdose: Limitations in Naloxone Reversal of Respiratory Depression and Prevention of Cardiac Arrest. Anesthesiology, 139(3), 342–353. Yousefifard, M., Vazirizadeh-Mahabadi, M. H., Neishaboori, A. M., Alavi, S. N. R., Amiri, M., Baratloo, A., & Saberian, P. (2019). Intranasal versus Intramuscular/Intravenous Naloxone for Pre-hospital Opioid Overdose: A Systematic Review and Meta-analysis. Advanced journal of emergency medicine, 4(2), e27. Summarized by Jeffrey Olson MS2 | Edited by Meg Joyce & Jorge Chalit, OMSII /episode/index/show/emergencymedicalminute/id/32134707

Episode 911: Anticholinergic Toxicity 07/08/2024

Episode 911: Anticholinergic Toxicity Contributor: Taylor Lynch MD Educational Pearls: Anticholinergics are found in many medications, including over-the-counter remedies Medications include: Diphenhydramine Tricyclic antidepressants like amitriptyline Atropine Antipsychotics like olanzapine Antispasmodics - dicyclomine Jimsonweed Muscaria mushrooms Mechanism of action involves competitive antagonism of the muscarinic receptor Symptomatic presentation is easily remembered via the mnemonic: Dry as a bone - anhidrosis due to cholinergic antagonism at sweat glands Red as a beet - cutaneous vasodilation leads to skin flushing Hot as a hare - anhidrotic hyperthermia Blind as a bat - pupillary dilation and ineffective accommodation Mad as a hatter - anxiety, agitation, dysarthria, hallucinations, and others Clinical management ABCs Benzodiazepines for supportive care, agitation, and seizures Sodium bicarbonate for TCA toxicity due to widened QRS Activated charcoal if patient present < 1 hour after ingestion Temperature monitoring Contact poison control with questions Physostigmine controversy Physostigmine is a reversible cholinesterase inhibitor that can cross the blood-brain barrier so in theory it would be a useful antidote BUT… There is a black box warning for asystole and seizures when physostigmine is used this way Therefore it is contraindicated in TCA overdoses However, it is still indicated in certain anticholinergic overdoses with delirium Disposition Admission criteria include: symptoms >6 hours, CNS findings, QRS prolongation, hyperthermia, and rhabdomyolysis ICU admission criteria include: delirium, dysrhythmias, seizures, coma, or requirement for physostigmine drip References 1. Arens AM, Shah K, Al-Abri S, Olson KR, Kearney T. Safety and effectiveness of physostigmine: a 10-year retrospective review<sup/>. Clin Toxicol (Phila). 2018;56(2):101-107. doi:10.1080/15563650.2017.1342828 2. Nguyen TT, Armengol C, Wilhoite G, Cumpston KL, Wills BK. Adverse events from physostigmine: An observational study. Am J Emerg Med. 2018;36(1):141-142. doi:10.1016/j.ajem.2017.07.006 3. Scharman E, Erdman A, Wax P, et al. Diphenhydramine and dimenhydrinate poisoning: An evidence-based consensus guideline for out-of-hospital management. Clin Toxicol. 2006;44(3):205-223. doi:10.1080/15563650600585920 4. Shervette RE 3rd, Schydlower M, Lampe RM, Fearnow RG. Jimson "loco" weed abuse in adolescents. Pediatrics. 1979;63(4):520-523. 5. Woolf AD, Erdman AR, Nelson LS, et al. Tricyclic antidepressant poisoning: An evidence-based consensus guideline for out-of-hospital management. Clin Toxicol. 2007;45(3):203-233. doi:10.1080/15563650701226192 Summarized by Jorge Chalit, OMSIII | Edited by Jorge Chalit /episode/index/show/emergencymedicalminute/id/32042752

Episode 910: Cellulitis Recovery Timeline 07/02/2024

Episode 909: Prehospital Blood Pressure Management in Suspected Stroke 06/24/2024

Episode 908: Sympathomimetic Drugs 06/17/2024

Episode 908: Sympathomimetic Drugs Contributor: Taylor Lynch MD Educational Pearls: Overview: Sympathomimetic drugs mimic the fight or flight response, affecting monoamines such as dopamine, norepinephrine, and epinephrine Limited therapeutic use, often abused. Types: Amphetamines: Methamphetamine, Adderall, Ritalin, Vyvanse MDMA (Ecstasy) Cocaine (Both hydrochloride salt & free based crack cocaine) Theophylline (Asthma treatment) Ephedrine (For low blood pressure) BZP, Oxymetazoline (Afrin), Pseudoephedrine (Sudafed) MAO Inhibitors (treatment-resistant depression) Mechanisms: Act on adrenergic and dopaminergic receptors. Cocaine blocks dopamine and serotonin reuptake. Methamphetamines increase stimulatory neurotransmitter release MAO Inhibitors prevent neurotransmitter breakdown. Symptoms: Agitation, tachycardia, hypertension, hyperactive bowel sounds, diuresis, hyperthermia. Severe cases: Angina, seizures, cardiovascular collapse. Diagnosis: Clinical examination and history. Differentiate from anticholinergic toxidrome by diaphoresis and hyperactive bowel sounds. Tests: EKG, cardiac biomarkers, chest X-ray, blood gas, BMP, CK, coagulation studies, U-tox screen. Treatment: Stabilize ABCs, IV hydration, temperature monitoring, benzodiazepines. Avoid beta-blockers due to unopposed alpha agonism. Whole bowel irrigation for body packers; surgical removal if packets rupture. IV hydration for high CK levels. Observation period often necessary. Recap: Mimic sympathetic nervous system. Key symptoms: Diaphoresis, hyperactive bowel sounds. Treatment: Supportive care, benzodiazepines. Use poison control as a resource. References: Costa VM, Grazziotin Rossato Grando L, Milandri E, Nardi J, Teixeira P, Mladěnka P, Remião F. Natural Sympathomimetic Drugs: From Pharmacology to Toxicology. Biomolecules. 2022;12(12):1793. doi:10.3390/biom12121793 Kolecki P. Sympathomimetic Toxicity From Emergency Medicine. Medscape. Updated March 11, 2024. Williams RH, Erickson T, Broussard LA. Evaluating Sympathomimetic Intoxication in an Emergency Setting. Lab Med. 2000;31(9):497-508. https://doi.org/10.1309/WVX1-6FPV-E2LC-B6YG Summarized by Steven Fujaros | Edited by Jorge Chalit, OMSIII /episode/index/show/emergencymedicalminute/id/31768701

Episode 907: Wide-Complex Tachycardia 06/12/2024

Episode 906: Case Study of Hypernatremia 06/03/2024

Episode 906: Case Study of Hypernatremia Contributor: Aaron Lessen MD Educational Pearls: The case: A gentleman came in from a nursing home with symptoms concerning for sepsis. He was hypotensive, hypoxic, febrile, and mentally altered. His past medical history included previous strokes which had left him with deficits for which he required a feeding tube. Initial workup included some point of care labs which revealed a sodium of 165 mEq/L (normal range 135-145) Hypernatremia What causes it? Dehydration, from insufficient fluid intake. This might happen in individuals who cannot drink water independently, such as infants, elderly, or disabled people, as was the case for this patient. Other causes of dehydration/hypernatremia include excessive sweating; diabetes insipidus; diuretic use; kidney dysfunction; and severe burns which can lead to fluid loss through the damaged skin. How do you correct it? Need to correct slowly, not more than 10 to 12 meq/L in 24 hours Can do normal saline (0.9%) or half saline (0.45%) and D5, at 150-200 mL per hour. Check the sodium frequently (every 2-3 hours) Will likely need ICU-level monitoring What happens if you correct it too quickly? Cerebral edema Seizures Bonus fact: Correction of hyponatremia too quickly causes osmotic demyelination syndrome (ODS). References Chauhan, K., Pattharanitima, P., Patel, N., Duffy, A., Saha, A., Chaudhary, K., Debnath, N., Van Vleck, T., Chan, L., Nadkarni, G. N., & Coca, S. G. (2019). Rate of Correction of Hypernatremia and Health Outcomes in Critically Ill Patients. Clinical journal of the American Society of Nephrology : CJASN, 14(5), 656–663. https://doi.org/10.2215/CJN.10640918 Lindner, G., & Funk, G. C. (2013). Hypernatremia in critically ill patients. Journal of critical care, 28(2), 216.e11–216.e2.16E20. https://doi.org/10.1016/j.jcrc.2012.05.001 Muhsin, S. A., & Mount, D. B. (2016). Diagnosis and treatment of hypernatremia. Best practice & research. Clinical endocrinology & metabolism, 30(2), 189–203. Summarized by Jeffrey Olson MS2 | Edited by Meg Joyce & Jorge Chalit, OMSIII /episode/index/show/emergencymedicalminute/id/31573767

Episode 905: Oseltamivir (Tamiflu) for Influenza 05/27/2024

Episode 904: Cardiovascular Risks of Epinephrine 05/20/2024

Episode 904: Cardiovascular Risks of Epinephrine Contributor: Aaron Lessen MD Educational Pearls: Epinephrine is essential in the treatment of anaphylaxis, but is epinephrine dangerous from a cardiovascular perspective? A 2024 study in the Journal of the American College of Emergency Physicians Open sought to answer this question. Methods: Retrospective observational study at a Tennessee quaternary care academic ED that analyzed ED visits from 2017 to 2021 involving anaphylaxis treated with IM epinephrine. The primary outcome was cardiotoxicity Results: Out of 338 patients, 16 (4.7%) experienced cardiotoxicity. Events included ischemic EKG changes (2.4%), elevated troponin (1.8%), atrial arrhythmias (1.5%), ventricular arrhythmia (0.3%), and depressed ejection fraction (0.3%). Affected patients were older, had more comorbidities, and often received multiple epinephrine doses. Bottom line: All adults presenting with anaphylaxis should be rapidly treated with epinephrine but monitored closely for cardiotoxicity, especially in patients with a history of hypertension and those who receive multiple doses. These results are supported by a 2017 study that found that 9% (4/44) of older patients who received epinephrine for anaphylaxis had cardiovascular complications. References Kawano, T., Scheuermeyer, F. X., Stenstrom, R., Rowe, B. H., Grafstein, E., & Grunau, B. (2017). Epinephrine use in older patients with anaphylaxis: Clinical outcomes and cardiovascular complications. Resuscitation, 112, 53–58. https://doi.org/10.1016/j.resuscitation.2016.12.020 Pauw, E. K., Stubblefield, W. B., Wrenn, J. O., Brown, S. K., Cosse, M. S., Curry, Z. S., Darcy, T. P., James, T. E., Koetter, P. E., Nicholson, C. E., Parisi, F. N., Shepherd, L. G., Soppet, S. L., Stocker, M. D., Walston, B. M., Self, W. H., Han, J. H., & Ward, M. J. (2024). Frequency of cardiotoxicity following intramuscular administration of epinephrine in emergency department patients with anaphylaxis. Journal of the American College of Emergency Physicians open, 5(1), e13095. https://doi.org/10.1002/emp2.13095 Summarized by Jeffrey Olson MS2 | Edited by Meg Joyce & Jorge Chalit OMS II /episode/index/show/emergencymedicalminute/id/31376687

Episode 903: Treating Precipitated Opioid Withdrawal 05/13/2024

Episode 902: Liver Failure and Cirrhosis 05/06/2024

Episode 902: Liver Failure and Cirrhosis Contributor: Travis Barlock MD Educational Pearls: How do you differentiate between compensated and decompensated cirrhosis? Use the acronym VIBE to look for signs of being decompensated. V-Volume Cirrhosis can cause volume overload through a variety of mechanisms such as by increasing pressure in the portal vein system and the decreased production of albumin. Look for pulmonary edema (dyspnea, orthopnea, wheezing/crackles, coughing up frothy pink sputum, etc.) or a tense abdomen. I-Infection The ascitic fluid can become infected with bacteria, a complication called Spontaneous Bacterial Peritonitis (SBP). Look for abdominal pain, fever, hypotension, and tachycardia. Diagnosis is made with ascitic fluid cell analyses (polymorphonuclear neutrophils >250/mm3) B-Bleeding Another consequence of increased portal pressure is that blood backs up into smaller blood vessels, including those in the esophagus. Over time, this increased pressure can result in the development of dilated, fragile veins called esophageal varices, which are prone to bleeding. Look for hematemesis, melena, lightheadedness, and pale skin. E-Encephalopathy A failing liver also does not clear toxins which can affect the brain. Look for asterixis (flapping motion of the hands when you tell the patient to hold their hands up like they are going to stop a bus) Other complications to look out for. Hepatorenal syndrome Hepatopulmonary syndrome References Engelmann, C., Clària, J., Szabo, G., Bosch, J., & Bernardi, M. (2021). Pathophysiology of decompensated cirrhosis: Portal hypertension, circulatory dysfunction, inflammation, metabolism and mitochondrial dysfunction. Journal of hepatology, 75 Suppl 1(Suppl 1), S49–S66. https://doi.org/10.1016/j.jhep.2021.01.002 Enomoto, H., Inoue, S., Matsuhisa, A., & Nishiguchi, S. (2014). Diagnosis of spontaneous bacterial peritonitis and an in situ hybridization approach to detect an "unidentified" pathogen. International journal of hepatology, 2014, 634617. Mansour, D., & McPherson, S. (2018). Management of decompensated cirrhosis. Clinical medicine (London, England), 18(Suppl 2), s60–s65. https://doi.org/10.7861/clinmedicine.18-2-s60 Summarized by Jeffrey Olson MS2 | Edited by Meg Joyce & Jorge Chalit, OMS II /episode/index/show/emergencymedicalminute/id/31137958

Episode 901: Underdosing in Status Epilepticus 04/29/2024

Episode 900: Ketamine Dosing 04/22/2024

Episode 899: Thrombolytic Contraindications 04/15/2024

Episode 898: Takotsubo Cardiomyopathy 04/10/2024

Episode 897: Adrenal Crisis 04/01/2024

Episode 897: Adrenal Crisis Contributor: Ricky Dhaliwal MD Educational Pearls: Primary adrenal insufficiency (most common risk factor for adrenal crises) An autoimmune condition commonly known as Addison's Disease Defects in the cells of the adrenal glomerulosa and fasciculata result in deficient glucocorticoids and mineralocorticoids Mineralocorticoid deficiency leads to hyponatremia and hypovolemia Lack of aldosterone downregulates Endothelial Sodium Channels (ENaCs) at the renal tubules Water follows sodium and generates a hypovolemic state Glucocorticoid deficiency contributes further to hypotension and hyponatremia Decreased vascular responsiveness to angiotensin II Increased secretion of vasopressin (ADH) from the posterior pituitary An adrenal crisis is defined as a sudden worsening of adrenal insufficiency Presents with non-specific symptoms including nausea, vomiting, fatigue, confusion, and fevers Fevers may be the result of underlying infection Work-up in the ED includes labs looking for infection and adding cortisol + ACTH levels Emergent treatment is required 100 mg hydrocortisone bolus followed by 50 mg every 6 hours Immediate IV fluid repletion with 1L normal saline The most common cause of an adrenal crisis is an acute infection in patients with baseline adrenal insufficiency Often due to a gastrointestinal infection References 1. Bancos I, Hahner S, Tomlinson J, Arlt W. Diagnosis and management of adrenal insufficiency. Lancet Diabetes Endocrinol. 2015;3(3):216-226. doi:10.1016/S2213-8587(14)70142-1 2. Bornstein SR, Allolio B, Arlt W, et al. Diagnosis and Treatment of Primary Adrenal Insufficiency: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2016;101(2):364-389. doi:10.1210/jc.2015-1710 3. Cronin CC, Callaghan N, Kearney PJ, Murnaghan DJ, Shanahan F. Addison disease in patients treated with glucocorticoid therapy. Arch Intern Med. 1997;157(4):456-458. 4. Feldman RD, Gros R. Vascular effects of aldosterone: sorting out the receptors and the ligands. Clin Exp Pharmacol Physiol. 2013;40(12):916-921. doi:10.1111/1440-1681.12157 5. Hahner S, Loeffler M, Bleicken B, et al. Epidemiology of adrenal crisis in chronic adrenal insufficiency: the need for new prevention strategies. Eur J Endocrinol. 2010;162(3):597-602. doi:10.1530/EJE-09-0884 Summarized by Jorge Chalit, OMSII | Edited by Meg Joyce & Jorge Chalit /episode/index/show/emergencymedicalminute/id/30619008

Podcast 896: Cancer-Related Emergencies 03/25/2024

Podcast 896: Cancer-Related Emergencies Contributor: Travis Barlock, MD Educational Pearls: Cancer-related emergencies can be sorted into a few buckets: Infection Cancer itself and the treatments (chemotherapy/radiation) can be immunosuppressive. Look out for conditions such as sepsis and neutropenic fever. Obstruction Cancer causes a hypercoagulable state. Look out for blood clots which can cause emergencies such as a pulmonary embolism, stroke, superior vena cava (SVC) syndrome, and cardiac tamponade. Metabolic Cancer can affect the metabolic system in a variety of ways. For example, certain cancers like bone cancers can stimulate the bones to release large amounts of calcium leading to hypercalcemia. Tumor lysis syndrome is another consideration in which either spontaneously or due to treatment, tumor cells will release large amounts of electrolytes into the bloodstream causing hyperuricemia, hyperkalemia, hyperphosphatemia, and hypocalcemia. Medication side effect Immunomodulators can have strange side effects. A common one to know is Keytruda (pembrolizumab), which can cause inflammation in any organ. So if you have a cancer patient on immunomodulators with any inflammatory changes (cystitis, colitis, pneumonitis, etc), talk to oncology about whether steroids are indicated. Chemotherapy can cause tumor lysis syndrome (see above), and multiple chemotherapeutics are known to cause heart failure (doxorubicin, trastuzumab), kidney failure (cisplatin), and pulmonary toxicity (bleomycin). References Campello, E., Ilich, A., Simioni, P., & Key, N. S. (2019). The relationship between pancreatic cancer and hypercoagulability: a comprehensive review on epidemiological and biological issues. British journal of cancer, 121(5), 359–371. Gyamfi, J., Kim, J., & Choi, J. (2022). Cancer as a Metabolic Disorder. International journal of molecular sciences, 23(3), 1155. Kwok, G., Yau, T. C., Chiu, J. W., Tse, E., & Kwong, Y. L. (2016). Pembrolizumab (Keytruda). Human vaccines & immunotherapeutics, 12(11), 2777–2789. Wang, S. J., Dougan, S. K., & Dougan, M. (2023). Immune mechanisms of toxicity from checkpoint inhibitors. Trends in cancer, 9(7), 543–553. Zimmer, A. J., & Freifeld, A. G. (2019). Optimal Management of Neutropenic Fever in Patients With Cancer. Journal of oncology practice, 15(1), 19–24. Summarized by Jeffrey Olson MS2 | Edited by Meg Joyce & Jorge Chalit, OMSII /episode/index/show/emergencymedicalminute/id/30523718

Episode 895: Indications for Exogenous Albumin 03/18/2024

Episode 895: Indications for Exogenous Albumin Contributor: Travis Barlock MD Educational Pearls: There are three indications for IV albumin in the ED Spontaneous bacterial peritonitis (SBP) Patients with SBP develop renal failure from volume depletion Albumin repletes volume stores and reduces renal impairment Albumin binds inflammatory cytokines and expands plasma volume Reduced all-cause mortality if IV albumin is given with antibiotics Hepatorenal syndrome Cirrhosis of the liver causes the release of endogenous vasodilators The renin-angiotensin-aldosterone system (RAAS) fails systemically but maintains vasoconstriction at the kidneys, leading to decreased renal perfusion IV albumin expands plasma volume and prevents failure of the RAAS Large volume paracentesis Large-volume removal may lead to circulatory dysfunction IV albumin is associated with a reduced risk of paracentesis-associated circulatory dysfunction There are many other FDA-approved conditions for which to use exogenous albumin but the data are conflicted about the benefits on mortality References 1. Arroyo V, Fernandez J. Pathophysiological basis of albumin use in cirrhosis. Ann Hepatol. 2011;10(SUPPL. 1):S6-S14. doi:10.1016/s1665-2681(19)31600-x 2. Bai Z, Wang L, Wang R, et al. Use of human albumin infusion in cirrhotic patients: a systematic review and meta-analysis of randomized controlled trials. Hepatol Int. 2022;16(6):1468-1483. doi:10.1007/s12072-022-10374-z 3. Batool S, Waheed MD, Vuthaluru K, et al. Efficacy of Intravenous Albumin for Spontaneous Bacterial Peritonitis Infection Among Patients With Cirrhosis: A Meta-Analysis of Randomized Control Trials. Cureus. 2022;14(12). doi:10.7759/cureus.33124 4. Kwok CS, Krupa L, Mahtani A, et al. Albumin reduces paracentesis-induced circulatory dysfunction and reduces death and renal impairment among patients with cirrhosis and infection: A systematic review and meta-analysis. Biomed Res Int. 2013;2013. doi:10.1155/2013/295153 5. Sort P, Navasa M, Arroyo V, et al. Effect of Intravenous Albumin on Renal Impairment and Mortality in Patients with Cirrhosis and Spontaneous Bacterial Peritonitis. N Engl J Med. 1999;341(6):403-409. Summarized by Jorge Chalit, OMSII | Edited by Meg Joyce & Jorge Chalit /episode/index/show/emergencymedicalminute/id/30415578

Episode 894: DKA and HHS 03/11/2024

Episode 894: DKA and HHS Contributor: Ricky Dhaliwal, MD Educational Pearls: What are DKA and HHS? DKA (Diabetic Ketoacidosis) and HHS (Hyperosmolar Hyperglycemic State) are both acute hyperglycemic states. DKA More common in type 1 diabetes. Triggered by decreased circulating insulin. The body needs energy but cannot use glucose because it can’t get it into the cells. This leads to increased metabolism of free fatty acids and the increased production of ketones. The buildup of ketones causes acidosis. The kidneys attempt to compensate for the acidosis by increasing diuresis. These patients present as dry and altered, with sweet-smelling breath and Kussmaul (fast and deep) respirations. HSS More common in type 2 diabetes. In this condition there is still enough circulating insulin to avoid the breakdown of fats for energy but not enough insulin to prevent hyperglycemia. Serum glucose levels are very high – around 600 to 1200 mg/dl. Also presents similarly to DKA with the patient being dry and altered. Important labs to monitor Serum glucose Potassium Phosphorus Magnesium Anion gap (Na - Cl - HCO3) Renal function (Creatinine and BUN) ABG/VBG for pH Urinalysis and urine ketones by dipstick Treatment Identify the cause, i.e. Has the patient stopped taking their insulin? Aggressive hydration with isotonic fluids. Normal Saline (NS) vs Lactated Ringers (LR)? LR might resolve the DKA/HHS faster with less risk of hypernatremia. Should you bolus with insulin? No, just start a drip. 0.1-0.14 units per kg of insulin. Make sure you have your potassium back before starting insulin as the insulin can shift the potassium into the cells and lead to dangerous hypokalemia. Should you treat hyponatremia? Make sure to correct for hyperglycemia before treating. This artificially depresses the sodium. Should you give bicarb? Replace if the pH < 6.9. Otherwise, it won’t do anything to help. Don’t intubate, if the patient is breathing fast it is because they are compensating for their acidosis. References Andrade-Castellanos, C. A., Colunga-Lozano, L. E., Delgado-Figueroa, N., & Gonzalez-Padilla, D. A. (2016). Subcutaneous rapid-acting insulin analogues for diabetic ketoacidosis. The Cochrane database of systematic reviews, 2016(1), CD011281. Chaithongdi, N., Subauste, J. S., Koch, C. A., & Geraci, S. A. (2011). Diagnosis and management of hyperglycemic emergencies. Hormones (Athens, Greece), 10(4), 250–260. Dhatariya, K. K., Glaser, N. S., Codner, E., & Umpierrez, G. E. (2020). Diabetic ketoacidosis. Nature reviews. Disease primers, 6(1), 40. Duhon, B., Attridge, R. L., Franco-Martinez, A. C., Maxwell, P. R., & Hughes, D. W. (2013). Intravenous sodium bicarbonate therapy in severely acidotic diabetic ketoacidosis. The Annals of pharmacotherapy, 47(7-8), 970–975. Modi, A., Agrawal, A., & Morgan, F. (2017). Euglycemic Diabetic Ketoacidosis: A Review. Current diabetes reviews, 13(3), 315–321. Self, W. H., Evans, C. S., Jenkins, C. A., Brown, R. M., Casey, J. D., Collins, S. P., Coston, T. D., Felbinger, M., Flemmons, L. N., Hellervik, S. M., Lindsell, C. J., Liu, D., McCoin, N. S., Niswender, K. D., Slovis, C. M., Stollings, J. L., Wang, L., Rice, T. W., Semler, M. W., & Pragmatic Critical Care Research Group (2020). Clinical Effects of Balanced Crystalloids vs Saline in Adults With Diabetic Ketoacidosis: A Subgroup Analysis of Cluster Randomized Clinical Trials. JAMA network open, 3(11), e2024596. Summarized by Jeffrey Olson MS2 | Edited by Meg Joyce & Jorge Chalit, OMSII /episode/index/show/emergencymedicalminute/id/30315938

Episode 893: Home Treatments for Button Battery Ingestion 03/04/2024

Episode 892: Tourniquets 02/27/2024

Episode 892: Tourniquets Contributor: Ricky Dhaliwal, MD Educational Pearls: What can you do to control bleeding in a penetrating wound? Apply direct pinpoint pressure on the wound as well as proximal to the wound. Build a compression dressing. How do you build a compression dressing? Think about building an upside-down pyramid with the gauze. Consider coagulation agents such as an absorbent gelatin sponge material, microporous polysaccharide hemispheres, oxidized cellulose, fibrin sealants, topical thrombin, or tranexamic acid. What are the indications to use a tourniquet? The Stop The Bleed campaign recommends looking for the following features of “life-threatening” bleeding. Pulsatile bleeding. Blood is pooling on the ground. The overlying clothes are soaked. Bandages are ineffective. Partial or full amputation. And if the patient is in shock. How do you put on a tourniquet? If using a Combat Application Tourniquet (C-A-T) tourniquet, apply it proximal to the wound, then rotate the plastic rod until the bleeding stops. Then secure the plastic rod with a clip and make sure the Velcro is in place. Mark the time - generally, there is a spot on the tourniquet to write. Have a plan for the next steps. Does the patient need emergent surgery? Do they need to be transfered? How long can you leave a tourniquet on? Less than 90 minutes. What are the risks? Nerve injury. Ischemia. References Latina R, Iacorossi L, Fauci AJ, Biffi A, Castellini G, Coclite D, D'Angelo D, Gianola S, Mari V, Napoletano A, Porcu G, Ruggeri M, Iannone P, Chiara O, On Behalf Of Inih-Major Trauma. Effectiveness of Pre-Hospital Tourniquet in Emergency Patients with Major Trauma and Uncontrolled Haemorrhage: A Systematic Review and Meta-Analysis. Int J Environ Res Public Health. 2021 Dec 6;18(23):12861. doi: 10.3390/ijerph182312861. PMID: 34886586; PMCID: PMC8657739. Martinson J, Park H, Butler FK Jr, Hammesfahr R, DuBose JJ, Scalea TM. Tourniquets USA: A Review of the Current Literature for Commercially Available Alternative Tourniquets for Use in the Prehospital Civilian Environment. J Spec Oper Med. 2020 Summer;20(2):116-122. doi: 10.55460/CT9D-TMZE. PMID: 32573747. Resources poster booklet. (n.d.). Stop the Bleed. Summarized by Jeffrey Olson MS2 | Edited by Meg Joyce & Jorge Chalit, OMSII /episode/index/show/emergencymedicalminute/id/30129148

Pharmacy Phriday #11: Riddles, Medical Jargon, NNT, and Time Travel 02/23/2024

Pharmacy Phriday #11: Riddles, Medical Jargon, NNT, and Time Travel Contributors: Kali Olson PharmD, Travis Barlock MD, Jeffrey Olson MS2 Summary: In this episode of Pharmacy Phriday, Dr. Kali Olson joins Dr. Travis Barlock and Jeffrey Olson in studio to discuss a variety of interesting topics in the form of a segment show. Dr. Kali Olson earned her Doctorate of Pharmacy from the University of Colorado, Skaggs School of Pharmacy and completed a PGY1 residency at Detroit Receiving Hospital and a PGY2 residency in Emergency Medicine at Denver Health. She now works as an Emergency Medicine Pharmacist at Denver Health. In segment one of the show, Kali and Travis answer the Get-To-Know-You questionnaire. In segment two, they work together to answer a series of pharmacy-based riddles. In segment three they play a “Balderdash” like game in which they guess the definitions of medical jargon. In segment four they play the Number Needed to Treat game, invented by the AFP podcast. And in segment five they work together to answer a question about a far-out scenario involving medications and time travel! References · American Family Physician Podcast, https://www.aafp.org/pubs/afp/multimedia/podcast.html · Gragnolati, A. (2022, May 5). The Yuzpe method of emergency contraception. GoodRx. https://www.goodrx.com/conditions/emergency-contraceptive/yuzpe-method · Manikandan S, Vani NI. Holiday reading: Learning medicine through riddles. CMAJ. 2010 Dec 14;182(18):E863-4. doi: 10.1503/cmaj.100466. PMID: 21149530; PMCID: PMC3001539. · Riddle Me This: Mixing Medicine, https://peimpact.com/riddle-me-this-mixing-medicine/ · https://thennt.com/nnt/corticosteroids-treatment-kawasaki-disease-children/ · https://thennt.com/nnt/aspirin-acute-ischemic-stroke/ · https://thennt.com/nnt/tranexamic-acid-treatment-epistaxis/ · https://thennt.com/nnt/antibiotics-culture%e2%80%90positive-asymptomatic-bacteriuria-pregnant-women/ Produced, Hosted, Edited, and Summarized by Jeffrey Olson MS2 | Additional editing by Jorge Chalit, OMSII /episode/index/show/emergencymedicalminute/id/30076258

Episode 891: Hypothermia 02/19/2024

Episode 891: Hypothermia Contributor: Taylor Lynch MD Educational Pearls Hypothermia is defined as a core body temperature less than 35 degrees Celsius or less than 95 degrees Fahrenheit Mild Hypothermia: 32-35 degrees Celsius Presentation: alert, shivering, tachycardic, and cold diuresis Management: Passive rewarming i.e. remove wet clothing and cover the patient with blankets or other insulation Moderate Hypothermia: 28-32 degrees Celsius Presentation: Drowsiness, lack of shivering, bradycardia, hypotension Management: Active external rewarming Severe Hypothermia: 24-28 degrees Celsius Presentation: Heart block, cardiogenic shock, no shivering Management: Active external and internal rewarming Less than 24 degrees Celsius Presentation: Pulseless, ventricular arrhythmia Active External Rewarming Warm fluids are insufficient for warming due to a minimal temperature difference (warmed fluids are maintained at 40 degrees vs. a patient at 30 degrees is not a large enough thermodynamic difference) External: Bear hugger, warm blankets Active Internal Rewarming Thoracic lavage (preferably on the patient’s right side) Place 2 chest tubes (anteriorly and posteriorly); infuse warm IVF anteriorly and hook up the posterior tube to a Pleur-evac Warms the patient 3-6 Celsius per hour Bladder lavage Continuous bladder irrigation with 3-way foley or 300 cc warm fluid Less effective than thoracic lavage due to less surface area Pulseless patients ACLS does not work until patients are rewarmed to 30 degrees High-quality CPR until 30 degrees (longest CPR in a hypothermic patient was 6 hours and 30 minutes) Give epinephrine once you reach 35 degrees, spaced out every 6 minutes ECMO is the best way to warm these patients up (10 degrees per hour) Pronouncing death must occur at 32 degrees or must have potassium > 12 References 1. 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care - Part 1: Introduction. Circulation. 2005;112(24 SUPPL.). doi:10.1161/CIRCULATIONAHA.105.166550 2. Brown DJA, Burgger H, Boyd J, Paal P. Accidental Hypothermia. N Engl J Med. 2012;367:1930-1938. doi:10.1136/bmj.2.5543.51-c 3. Dow J, Giesbrecht GG, Danzl DF, et al. Wilderness Medical Society Clinical Practice Guidelines for the Out-of-Hospital Evaluation and Treatment of Accidental Hypothermia: 2019 Update. Wilderness Environ Med. 2019;30(4S):S47-S69. doi:10.1016/j.wem.2019.10.002 4. Kjærgaard B, Bach P. Warming of patients with accidental hypothermia using warm water pleural lavage. Resuscitation. 2006;68(2):203-207. doi:10.1016/j.resuscitation.2005.06.019 5. Lott C, Truhlář A, Alfonzo A, et al. European Resuscitation Council Guidelines 2021: Cardiac arrest in special circumstances. Resuscitation. 2021;161:152-219. doi:10.1016/j.resuscitation.2021.02.011 6. Plaisier BR. Thoracic lavage in accidental hypothermia with cardiac arrest - Report of a case and review of the literature. Resuscitation. 2005;66(1):99-104. doi:10.1016/j.resuscitation.2004.12.024 Summarized by Jorge Chalit, OMSII | Edited by Meg Joyce & Jorge Chalit, OMSII /episode/index/show/emergencymedicalminute/id/30011533

Podcast 890: Outdoor Cold Air for Croup 02/14/2024

Podcast 889: Blood Pressure Cuff Size 02/05/2024

Podcast 888: Low GCS and Intubation 01/29/2024

Podcast 888: Low GCS and Intubation Contributor: Aaron Lessen MD Educational Pearls: Is the adage, “GCS of 8, you’ve got to intubate” accurate? A recent study published in the November 2023 issue of JAMA attempted to answer this question. Design Multicenter, randomized trial, in France from 2021 to 2023. 225 patients experiencing comatose in the setting of acute poisoning were randomly assigned to either a conservative airway strategy of withholding intubation or “routine practice” of much more frequent intubation. The primary outcome was a composite endpoint including in-hospital death, length of intensive care unit stay, and length of hospital stay. Secondary outcomes included adverse events from intubation and pneumonia within 48 hours. Results Results showed that in the intervention group (with intubation withholding), only 16% of patients were intubated, compared to 58% in the control group. No in-hospital deaths occurred in either group. The intervention group demonstrated a significant clinical benefit for the primary endpoint, with a win ratio of 1.85 (95% CI, 1.33 to 2.58). The conservative airway management strategy also saw a statistically significant decrease in adverse events from intubation and pneumonia. Conclusion Among comatose patients with suspected acute poisoning, a conservative strategy of withholding intubation was associated with a greater clinical benefit. This suggests that a judicious approach to intubation is appropriate in many other settings and clinicians should rely on more than the GCS to make this decision. References Freund Y, Viglino D, Cachanado M, Cassard C, Montassier E, Douay B, Guenezan J, Le Borgne P, Yordanov Y, Severin A, Roussel M, Daniel M, Marteau A, Peschanski N, Teissandier D, Macrez R, Morere J, Chouihed T, Roux D, Adnet F, Bloom B, Chauvin A, Simon T. Effect of Noninvasive Airway Management of Comatose Patients With Acute Poisoning: A Randomized Clinical Trial. JAMA. 2023 Dec 19;330(23):2267-2274. doi: 10.1001/jama.2023.24391. PMID: 38019968; PMCID: PMC10687712. Summarized by Jeffrey Olson MS2 | Edited by Meg Joyce & Jorge Chalit, OMSII /episode/index/show/emergencymedicalminute/id/29689538

Podcast 887: Family Presence in Cardiac Resuscitation 01/22/2024

Podcast 886: Cough in Kids 01/15/2024

Podcast 886: Cough in Kids Contributor: Ricky Dhaliwal, MD Educational Pearls: Croup Caused by: Parainfluenza, Adenovirus, RSV, Enterovirus (big right now) Age range: 6 months to 3 years Symptoms: Barky cough Inspiratory stridor (Severe = stidor at rest) Use the Westley Croup Score to gauge the severity Treatment: High flow, humidified, cool oxygen Dexamethasone 0.6 mg/kg oral, max 16mg Severe: Racemic Epinephrine 0.5 mL/kg Consider heliox, a mixture of helium and oxygen Very severe: be ready to intubate Bronchiolitis Caused by: RSV, Rhinovirus Symptoms are driven by secretions Symptoms: Cough Wheezing Dehydration (often the symptom that makes them look the worst) Age range: 2 to 6 months Treatment: Suctioning Oxygen IV fluids Nebulized hypertonic saline DuoNebs? No. Asthma Caused by: Environmental factors Viral illness with a predisposition Treatment: Beta agonists Steroids Ipratropium Magnesium (relaxes smooth muscle) References Dalziel SR, Haskell L, O'Brien S, Borland ML, Plint AC, Babl FE, Oakley E. Bronchiolitis. Lancet. 2022 Jul 30;400(10349):392-406. doi: 10.1016/S0140-6736(22)01016-9. Epub 2022 Jul 1. PMID: 35785792. Hoch HE, Houin PR, Stillwell PC. Asthma in Children: A Brief Review for Primary Care Providers. Pediatr Ann. 2019 Mar 1;48(3):e103-e109. doi: 10.3928/19382359-20190219-01. PMID: 30874817. Midulla F, Petrarca L, Frassanito A, Di Mattia G, Zicari AM, Nenna R. Bronchiolitis clinics and medical treatment. Minerva Pediatr. 2018 Dec;70(6):600-611. doi: 10.23736/S0026-4946.18.05334-3. Epub 2018 Oct 18. PMID: 30334624. Smith DK, McDermott AJ, Sullivan JF. Croup: Diagnosis and Management. Am Fam Physician. 2018 May 1;97(9):575-580. PMID: 29763253. Westley CR, Cotton EK, Brooks JG. Nebulized racemic epinephrine by IPPB for the treatment of croup: a double-blind study. Am J Dis Child. 1978 May;132(5):484-7. doi: 10.1001/archpedi.1978.02120300044008. PMID: 347921. https://www.mdcalc.com/calc/677/westley-croup-score Summarized by Jeffrey Olson | Edited by Meg Joyce & Jorge Chalit, OMSII /episode/index/show/emergencymedicalminute/id/29488738

Podcast 885: Penetrating Neck Injuries 01/10/2024

Podcast 885: Penetrating Neck Injuries Contributor: Ricky Dhaliwal MD Educational Pearls: Three zones of the neck with different structures and risks for injuries: Zone 1 is the most caudal region from the clavicle to the cricoid cartilage Zone 2 is from the cricoid cartilage to the angle of the mandible Zone 3 is superior to the angle of the mandible Zone 1 contains the thoracic outlet vasculature (subclavian arteries and veins, internal jugular veins), carotid arteries, vertebral artery, apices of the lungs, trachea, esophagus, spinal cord, thoracic duct, thyroid gland, jugular veins, and the vagus nerve. Zone 2 contains the common carotid arteries, internal and external branches of carotid arteries, vertebral arteries, jugular veins, trachea, esophagus, larynx, pharynx, spinal cord, and vagus and recurrent laryngeal nerves Lower risk than Zone 1 or Zone 3 Zone 3 contains the distal carotid arteries, vertebral arteries, jugular veins, pharynx, spinal cord, cranial nerves IX, X, XI, XII, the sympathetic chain, and the salivary and parotid glands Hard signs that indicate direct transfer to OR: Airway compromise Active, brisk bleeding Pulsatile hematomas Hematemesis Massive subcutaneous emphysema Soft signs that may obtain imaging to determine further interventions: Hemoptysis Oropharyngeal bleeding Dysphagia Dysphonia Expanding hematomas Soft sign management includes ABCs, type & screen, and airway interventions followed by imaging of the head & neck area Patients with dysphonia or dysphagia with subsequent negative CTAs may get further work-up via swallow studies References Asensio JA, Chahwan S, Forno W, et al. Penetrating esophageal injuries: multicenter study of the American Association for the Surgery of Trauma. J Trauma. 2001;50(2):289-296. doi:10.1097/00005373-200102000-00015 Azuaje RE, Jacobson LE, Glover J, et al. Reliability of physical examination as a predictor of vascular injury after penetrating neck trauma. Am Surg. 2003;69(9):804-807. Ibraheem K, Wong S, Smith A, et al. Computed tomography angiography in the "no-zone" approach era for penetrating neck trauma: A systematic review. J Trauma Acute Care Surg. 2020;89(6):1233-1238. doi:10.1097/TA.0000000000002919 Nowicki JL, Stew B, Ooi E. Penetrating neck injuries: A guide to evaluation and managementx. Ann R Coll Surg Engl. 2018;100(1):6-11. doi:10.1308/rcsann.2017.0191 Summarized by Jorge Chalit, OMSII | Edited by Meg Joyce & Jorge Chalit, OMSII /episode/index/show/emergencymedicalminute/id/29382538

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