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 959: The KLM Flight Disaster and Lessons in Healthcare Communication 06/02/2025

Episode 959: The KLM Flight Disaster and Lessons in Healthcare Communication Contributor: Taylor Lynch, MD Educational Pearls: The KLM Flight Disaster, also known as the Tenerife Airport Disaster, occurred on 27 March 1977. It involved the collision of two Boeing 747 passenger jets from KLM and Pan Am Airlines, resulting in 583 fatalities. What fell through the cracks to cause this incident? The captain of the KLM flight believed he had received clearance from air traffic control to take off, when in fact he had not. This captain was one of the most senior pilots in the organization, and the culture often saw senior pilots as infallible and not to be questioned. The co-pilot, who noticed improper communication resulting from power dynamics, did not assertively speak up. What lessons can be taken from the tragedy and applied to healthcare? Aviation and healthcare are both high-stakes industries that require extensive communication for the safety of passengers and patients. Within medicine, an inherent hierarchy exists, and it is crucial not to let this hierarchy and perceived power imbalance prevent people from speaking up. In healthcare, providers such as nurses, paramedics, and technicians may spend more time with patients and thus may notice warning signs earlier. It is imperative to foster a culture where they can speak up freely and without hesitation if something concerning is caught in a patient. When might mistakes happen most often? Hanna et al. found that radiological interpretation errors were more likely to occur later in shifts, peaking around the 10-to-12-hour mark. Leviatan et al. found that medication prescription errors were more likely to occur by physicians working on 2nd and 3rd consecutive shifts. Hendey et al. found medication ordering errors were higher on overnight and post-call shifts. Gatz et al. found that surgical procedural complication rates are higher during the last 4 hours of a 12-hour shift. In Short, Ends of shifts are when mistakes are most likely to occur. Overall takeaway? In a healthcare team, it is critical to look after each other regardless of years of experience or post-nominal letters, and speak up for patient safety. Making a special note that we may need to do so more towards the end of shifts, where we might not be at our sharpest. References Gatz JD, Gingold DB, Lemkin DL, Wilkerson RG. Association of Resident Shift Length with Procedural Complications. Journal of Emergency Medicine. 2021 Aug 1;61(2):189–97. Hanna TN, Lamoureux C, Krupinski EA, Weber S, Johnson JO. Effect of Shift, Schedule, and Volume on Interpretive Accuracy: A Retrospective Analysis of 2.9 Million Radiologic Examinations. Radiology. 2018 Apr;287(1):205–12. Hendey GW, Barth BE, Soliz T. Overnight and postcall errors in medication orders. Acad Emerg Med. 2005 Jul;12(7):629–34. Leviatan I, Oberman B, Zimlichman E, Stein GY. Associations of physicians’ prescribing experience, work hours, and workload with prescription errors. J Am Med Inform Assoc. 2021 Jun 12;28(6):1074–80. Summarized by Dan Orbidan, OMS2 | Edited by Dan Orbidan & Jorge Chalit, OMS4 Donate: https://emergencymedicalminute.org/donate/ /episode/index/show/emergencymedicalminute/id/36813460

Episode 958: Intranasal Fentanyl 05/26/2025

Episode 958: Intranasal Fentanyl Contributor: Aaron Lessen, MD Educational Pearls: How do we take care of kids in severe pain? There are many non-pharmacologic options for pain (i.e. ice, elevation) as well as more conventional medication options (i.e. acetaminophen, NSAIDS) but in severe pain stronger medications might be indicated. These stronger medications include options such as IV morphine, a subdissociative dose of ketamine, as well as intranasal fentanyl. Intranasal fentanyl has many advantages: Studies have shown it might be more effective early on in controlling pain, as in the first 15-20 minutes after administration, and then becomes equivalent to other pain control options Total adverse effects were also lower with IN fentanyl, including low rates of nausea and vomiting To administer, use the IV formulation with an atomizer and spray into the nose; therefore, you do not need an IV line Dose is 1-2 micrograms per kilogram, can be redosed once at 10 minutes. Don’t forget about gabapentinoids for neuropathic pain, muscle relaxants for muscle spasms, and nerve blocks when appropriate. (Disclaimer: muscle relaxers have not been well studied in children) References Alsabri M, Hafez AH, Singer E, Elhady MM, Waqar M, Gill P. Efficacy and Safety of Intranasal Fentanyl in Pediatric Emergencies: A Systematic Review and Meta-analysis. Pediatr Emerg Care. 2024 Oct 1;40(10):748-752. doi: 10.1097/PEC.0000000000003187. Epub 2024 Apr 11. PMID: 38713846. Bailey B, Trottier ED. Managing Pediatric Pain in the Emergency Department. Paediatr Drugs. 2016 Aug;18(4):287-301. doi: 10.1007/s40272-016-0181-5. PMID: 27260499. Hadland SE, Agarwal R, Raman SR, Smith MJ, Bryl A, Michel J, Kelley-Quon LI, Raval MV, Renny MH, Larson-Steckler B, Wexelblatt S, Wilder RT, Flinn SK. Opioid Prescribing for Acute Pain Management in Children and Adolescents in Outpatient Settings: Clinical Practice Guideline. Pediatrics. 2024 Sep 30:e2024068752. doi: 10.1542/peds.2024-068752. Epub ahead of print. PMID: 39344439. Summarized by Jeffrey Olson, MS4 | Edited by Jorge Chalit, OMS4 Donate: https://emergencymedicalminute.org/donate/ /episode/index/show/emergencymedicalminute/id/36711145

Episode 957: Cardiac Asthma 05/19/2025

Episode 956: Psychedelics and Risk of Schizophrenia 05/12/2025

Episode 956: Psychedelics and Risk of Schizophrenia Contributor: Jorge Chalit-Hernandez, OMS3 Educational Pearls: Psychedelics are being studied for their therapeutic effects in mental illnesses, including major depressive disorder, post-traumatic stress disorder, anxiety, and many others Classic psychedelics include compounds like psilocybin, LSD, and ayahuasca MDMA and ketamine are often included in psychedelic research, but have a different mechanism of action than the others Their mechanism of action involves agonism of the 5HT2A receptor, among others Given their resurgence, there is an increase in recreational use of these substances A recent study assessed the risks of recreational users developing subsequent psychotic disorders Individuals who visited the ED for hallucinogen use had a greater risk of being diagnosed with a schizophrenia spectrum disorder in the following 3 years Hazard ratio (HR) of 21.32 After adjustment for comorbid substance use and other mental illness, the hazard ratio was 3.53 - still a significant increase compared with the general population They also found an elevated risk for psychedelics when compared to alcohol (HR 4.66) and cannabis (HR 1.47) The study did not assess whether patients received antipsychotics or other treatments in the ED References Lieberman JA. Back to the Future - The Therapeutic Potential of Psychedelic Drugs. N Engl J Med. 2021;384(15):1460-1461. doi:10.1056/NEJMe2102835 Livne O, Shmulewitz D, Walsh C, Hasin DS. Adolescent and adult time trends in US hallucinogen use, 2002-19: any use, and use of ecstasy, LSD and PCP. Addiction. 2022;117(12):3099-3109. doi:10.1111/add.15987 Myran DT, Pugliese M, Xiao J, et al. Emergency Department Visits Involving Hallucinogen Use and Risk of Schizophrenia Spectrum Disorder. JAMA Psychiatry. 2025;82(2):142-150. doi:10.1001/jamapsychiatry.2024.3532 Summarized & Edited by Jorge Chalit, OMS3 Donate: /episode/index/show/emergencymedicalminute/id/36528945

Episode 955: Cardiac Effects of COVID-19 05/05/2025

Episode 955: Cardiac Effects of COVID-19 Contributor: Ricky Dhaliwal, MD Educational Pearls: What factors are considered in a COVID-19 infection? The viral load: Understood as the impact of SARS-CoV-2 viral particles infecting host cell tissue itself (utilizing ACE-2 receptors). Pro-Inflammatory Response: Post-infection, the body's downstream systemic cytokine release (can be both normal or hyperactive, aka “cytokine storm”). What cardiac impacts have been observed with COVID-19? Arrhythmias: The mechanism of COVID-19 infection and arrhythmias is believed to be multifactorial. However, evidence suggests T-cell-mediated toxicity and cytokine storm may contribute to cardiac myocyte damage, precipitating proarrhythmias instead of direct viral entry. Bradycardia: Increased prevalence in patients with severe COVID-19 infection, but not associated with increased adverse outcomes. Atrial Fibrillation: Most common cardiac complication and risk factor for worsened outcomes in patients with COVID-19. Biggest associated risk is strokes, and may require heightened monitoring and anticoagulation therapy to mitigate stroke risk. Fibrosis of Cardiac Tissue: Similar to arrhythmias, believed to be inflammation-mediated in COVID-19. Fibrosis of cardiac tissue increases the risk that any arrhythmias that develop during infection may persist after the infection has resolved. Ventricular damage: Also inflammation mediated by an active infection and contributes to myocarditis. No evidence suggests that COVID-19 vaccination contributes to myocarditis. Sinus node dysfunction induced by inflammation that may lead to or be similar to Postural Orthostatic Tachycardia Syndrome (POTS). Big takeaway? Patients who have had or currently have COVID-19 are at an increased risk of developing arrhythmias and sustaining them post-infection. However, a majority of patients will recover. Due to atrial fibrillation being the most prevalent arrhythmia associated with COVID-19 infection, increased monitoring and potential anticoagulation therapy are required. References Gopinathannair R, Olshansky B, Chung MK, Gordon S, Joglar JA, Marcus GM, et al. Cardiac Arrhythmias and Autonomic Dysfunction Associated With COVID-19: A Scientific Statement From the American Heart Association. Circulation. 2024 Nov 19;150(21):e449–65. Khan Z, Pabani UK, Gul A, Muhammad SA, Yousif Y, Abumedian M, et al. COVID-19 Vaccine-Induced Myocarditis: A Systemic Review and Literature Search. Cureus. 14(7):e27408. Summarized by Dan Orbidan, OMS1 | Edited by Dan Orbidan & Jorge Chalit, OMS3 Donate: /episode/index/show/emergencymedicalminute/id/36433575

Episode 954: Combo Rescue Inhalers - New Guidelines 04/30/2025

Episode 953: Penicillin Allergies 04/21/2025

Episode 953: Penicillin Allergies Contributor: Geoff Hogan MD Educational Pearls: Penicillin allergies are relatively uncommon despite their frequent reports 10% of the population reports a penicillin allergy but only 5% of these cases are clinically significant 90-95% of patients may tolerate a rechallenge after appropriate allergy evaluation Penicillin Allergy Decision Rule (PEN-FAST) on MD Calc Useful tool to assess patients for penicillin allergies Five years or less since reaction = 2 points (even if unknown) Anaphylaxis or angioedema OR Severe cutaneous reaction = 2 points Treatment required for reaction (e.g. epinephrine) = 1 point (even if unknown) A score of 0 on PEN-FAST indicates a less than 1% risk of a positive penicillin allergy test A score of 1 or 2 indicates a 5% risk of a positive penicillin allergy test A low score on PEN-FAST should prompt clinicians to proceed with the best empiric antibiotic for the patient’s infection References Broyles AD, Banerji A, Barmettler S, et al. Practical Guidance for the Evaluation and Management of Drug Hypersensitivity: Specific Drugs [published correction appears in J Allergy Clin Immunol Pract. 2021 Jan;9(1):603. doi: 10.1016/j.jaip.2020.10.025.] [published correction appears in J Allergy Clin Immunol Pract. 2021 Jan;9(1):605. doi: 10.1016/j.jaip.2020.11.036.]. J Allergy Clin Immunol Pract. 2020;8(9S):S16-S116. doi:10.1016/j.jaip.2020.08.006 Piotin A, Godet J, Trubiano JA, et al. Predictive factors of amoxicillin immediate hypersensitivity and validation of PEN-FAST clinical decision rule [published correction appears in Ann Allergy Asthma Immunol. 2022 Jun;128(6):740. doi: 10.1016/j.anai.2022.04.005.]. Ann Allergy Asthma Immunol. 2022;128(1):27-32. doi:10.1016/j.anai.2021.07.005 Shenoy ES, Macy E, Rowe T, Blumenthal KG. Evaluation and Management of Penicillin Allergy: A Review. JAMA. 2019;321(2):188-199. doi:10.1001/jama.2018.19283 Trubiano JA, Vogrin S, Chua KYL, et al. Development and Validation of a Penicillin Allergy Clinical Decision Rule. JAMA Intern Med. 2020;180(5):745-752. doi:10.1001/jamainternmed.2020.0403 Summarized & edited by Jorge Chalit, OMS3 Donate: /episode/index/show/emergencymedicalminute/id/36241015

Episode 952: Heart Transplants 04/14/2025

Episode 952: Heart Transplants Contributor: Travis Barlock, MD Educational Pearls: Key clinical considerations when managing heart transplant patients due to their unique pathophysiology 1. Arrhythmias A transplanted heart is denervated, meaning it lacks autonomic nervous system innervation The lack of vagal tone results in an increased resting heart rate Adenosine can be used since it primarily slows conduction through the AV node Atropine is ineffective in treating transplant bradyarrhythmia because its mechanism is to inhibit the vagus nerve - but the heart lacks vagal tone Allograft rejection can also cause tachycardia Consult transplant surgery - treatment is usually 500 mg methylprednisolone 2. Rejection Transplant patients are administered immunosuppressants Clinical presentation of acute rejection looks similar to heart failure with increased BNP, increased troponin, and pulmonary edema Cardiac allograft vasculopathy is a form of chronic rejection Patients will not report chest pain due to denervated heart Symptoms are usually weakness and fatigue 3. High risk of infection due to immunosuppression Increased risk of infections which includes CMV, legionella, tuberculosis, etc Immunosuppressants have side effects such as acute kidney injury or pancytopenia 4. Radiographic Cardiomegaly A study found that radiographic cardiomegaly does not connote heart failure They hypothesized it is instead the result of a mismatch between the size of the transplanted heart and the space in the thoracic cavity References Murphy JD, Mergo PJ, Taylor HM, Fields R, Mills RM Jr. Significance of radiographic cardiomegaly in orthotopic heart transplant recipients. AJR Am J Roentgenol. 1998 Aug;171(2):371-4. doi: 10.2214/ajr.171.2.9694454. PMID: 9694454. Park MH, Starling RC, Ratliff NB, McCarthy PM, Smedira NS, Pelegrin D, Young JB. Oral steroid pulse without taper for the treatment of asymptomatic moderate cardiac allograft rejection. J Heart Lung Transplant. 1999 Dec;18(12):1224-7. doi: 10.1016/s1053-2498(99)00098-4. PMID: 10612382. Pethig K, Heublein B, Wahlers T, Dannenberg O, Oppelt P, Haverich A. Mycophenolate mofetil for secondary prevention of cardiac allograft vasculopathy: influence on inflammation and progression of intimal hyperplasia. J Heart Lung Transplant. 2004 Jan;23(1):61-6. doi: 10.1016/s1053-2498(03)00097-4. PMID: 14734128. Summarized by Meg Joyce, MS1 | Edited by Meg Joyce & Jorge Chalit, OMS3 Donate: /episode/index/show/emergencymedicalminute/id/36123475

Episode 951: Pediatric Febrile Seizures 04/07/2025

Episode 951: Pediatric Febrile Seizures Contributor: Taylor Lynch, MD Educational Pearls: Pediatric febrile seizures are defined as seizures that occur between the ages of six months to five years in the presence of a fever greater than or equal to 38.0 ºC (100.4 ºF). It is the most common pediatric convulsive disorder, with an incidence between 2-5% What are the types of seizures? Simple: Tonic-clonic seizure, duration <15 minutes, only one occurrence in a 24-hour period, ABSENCE of focal features, ABSENCE of Todd’s paralysis Complex: Duration >15 minutes, requires medication to stop the seizing, multiple occurrences in a 24-hour period, PRESENCE of focal features, PRESENCE of Todd’s paralysis What are the causes? Caused by infectious agents leading to fever. Seen with common childhood infections. It is debated whether the absolute temperature of the fever or the rate of change of temperature incites the seizure, but current evidence points to the rate of change of the temperature being the primary catalyst What are the treatment considerations? For simple febrile seizures, work-up is similar to any pediatric patient presenting with a fever between the ages of six months and five years Thorough physical exam to rule out any potential of meningeal or intracranial infections Prophylactic antipyretics are not believed to prevent the occurrence of febrile seizures Disposition? If the patient has returned to normal baseline behavior following a simple febrile seizure, and the physical exam is reassuring, the patient can be discharged home. Additional labs, electroencephalogram, or lumbar punctures are not indicated in simple febrile seizures as long as the physical exam is completely normal Any evidence of a complex seizure requires further workup Fast Facts: Patients with a familial history of febrile seizures and developmental delays have a higher risk of developing febrile seizures If a child has one febrile seizure, there is a 30-40% chance of another febrile seizure by age 5 Only 2-7% of children with febrile seizures go on to develop epilepsy References: 1. Berg AT, Shinnar S, Hauser WA, Alemany M, Shapiro ED, Salomon ME, et al. A prospective study of recurrent febrile seizures. N Engl J Med. 1992 Oct 15;327(16):1122–7. 2. Schuchmann S, Vanhatalo S, Kaila K. Neurobiological and physiological mechanisms of fever-related epileptiform syndromes. Brain Dev. 2009 May;31(5):378–82. 3. Nilsson G, Westerlund J, Fernell E, Billstedt E, Miniscalco C, Arvidsson T, et al. Neurodevelopmental problems should be considered in children with febrile seizures. Acta Paediatr. 2019 Aug;108(8):1507–14. 4. Subcommittee on Febrile Seizures, American Academy of Pediatrics. Neurodiagnostic evaluation of the child with a simple febrile seizure. Pediatrics. 2011 Feb;127(2):389–94. 5. Pavlidou E, Panteliadis C. Prognostic factors for subsequent epilepsy in children with febrile seizures. Epilepsia. 2013 Dec;54(12):2101–7. 6. Huang CC, Wang ST, Chang YC, Huang MC, Chi YC, Tsai JJ. Risk factors for a first febrile convulsion in children: a population study in southern Taiwan. Epilepsia. 1999 Jun;40(6):719–25. 7. Hashimoto R, Suto M, Tsuji M, Sasaki H, Takehara K, Ishiguro A, et al. Use of antipyretics for preventing febrile seizure recurrence in children: a systematic review and meta-analysis. Eur J Pediatr. 2021 Apr;180(4):987–97. Summarized by Dan Orbidan, OMS1 | Edited by Dan Orbidan & Jorge Chalit, OMS3 Donate: /episode/index/show/emergencymedicalminute/id/36032040

Episode 950: Ultrasound Pulse Check During Cardiac Arrest 03/31/2025

Episode 949: Hoover's Sign 03/24/2025

Episode 948: CYP Inducers and Inhibitors 03/17/2025

Episode 948: CYP Inducers and Inhibitors Contributor: Jorge Chalit-Hernandez, OMS3 Educational Pearls: CYP enzymes are responsible for the metabolism of many medications, drugs, and other substances CYP3A4 is responsible for the majority Other common ones include CYP2D6 (antidepressants), CYP2E1 (alcohol), and CYP1A2 (cigarettes) CYP inducers lead to reduced concentrations of a particular medication CYP inhibitors effectively increase concentrations of certain medications in the body Examples of CYP inducers Phenobarbital Rifampin Cigarettes St. John’s Wort Examples of CYP inhibitors -azole antifungals like itraconazole and ketoconazole Bactrim (trimethoprim-sulfamethoxazole) Ritonavir (found in Paxlovid) Grapefruit juice Clinical relevance Drug-drug interactions happen frequently and often go unrecognized or underrecognized in patients with significant polypharmacy A study conducted on patients receiving Bactrim and other antibiotics found increased rates of anticoagulation in patients receiving Bactrim Currently, Paxlovid is prescribed to patients with COVID-19, many of whom have multiple comorbidities and are on multiple medications Paxlovid contains ritonavir, a powerful CYP inhibitor that can increase concentrations of many other medications A complete list of clinically relevant CYP inhibitors can be found on the FDA website: https://www.fda.gov/drugs/drug-interactions-labeling/drug-development-and-drug-interactions-table-substrates-inhibitors-and-inducers References Glasheen JJ, Fugit RV, Prochazka AV. The risk of overanticoagulation with antibiotic use in outpatients on stable warfarin regimens. J Gen Intern Med. 2005;20(7):653-656. doi:10.1111/j.1525-1497.2005.0136.x Lynch T, Price A. The effect of cytochrome P450 metabolism on drug response, interactions, and adverse effects. Am Fam Physician. 2007;76(3):391-396. PAXLOVID™. Drug interactions. PAXLOVIDHCP. Accessed March 16, 2025. https://www.paxlovidhcp.com/drug-interactions Summarized & Edited by Jorge Chalit, OMS3 Donate: /episode/index/show/emergencymedicalminute/id/35719855

Episode 947: Hypercapnia 03/10/2025

Episode 946: Time to Defibrillation 03/03/2025

Episode 945: Ketorolac vs. Ibuprofen 02/24/2025

Episode 944: Colchicine Overdose 02/17/2025

Episode 943: Portal Vein Thrombosis 02/10/2025

Episode 943: Portal Vein Thrombosis Contributor: Travis Barlock, MD Educational Pearls: What is Portal Vein Thrombosis? The formation of a blood clot within the portal vein, which carries blood from the gastrointestinal tract, pancreas, and spleen to the liver Not only can this cause problems downstream in the liver, but the backup of venous blood can cause ischemia in the bowels How does it present? Similar to acute mesenteric ischemia: Sudden onset of abdominal pain, nausea, vomiting, and fever How is it diagnosed? Abdominal CT or MRI with contrast What causes it? Cirrhosis Coagulopathy (Factor V Leiden mutation, Prothrombin gene mutation, Antiphospholipid syndrome, Protein C, protein S, antithrombin III deficiency, etc.) Oral Contraceptive Pills (OCPs) Cancer such as hepatocellular carcinoma How is it treated? Aggressive fluid resuscitation Antibiotics. Be sure to cover enteric gram-negative bacteria and anaerobes Heparin, same dosing as a bolus for a DVT Endovascular treatment, such as a thrombectomy with IR Surgical evaluation if there has been tissue death in the mesentery References Hilscher, M. B., Wysokinski, W. E., Andrews, J. C., Simonetto, D. A., Law, R. J., & Kamath, P. S. (2024). Portal Vein Thrombosis in the Setting of Cirrhosis: Evaluation and Management Strategies. Gastroenterology, 167(4), 664–672. Intagliata, N. M., Caldwell, S. H., & Tripodi, A. (2019). Diagnosis, Development, and Treatment of Portal Vein Thrombosis in Patients With and Without Cirrhosis. Gastroenterology, 156(6), 1582–1599.e1. https://doi.org/10.1053/j.gastro.2019.01.265 Ju, C., Li, X., Gadani, S., Kapoor, B., & Partovi, S. (2022). Portal Vein Thrombosis: Diagnosis and Endovascular Management. Pfortaderthrombose: Diagnose und endovaskuläres Management. RoFo : Fortschritte auf dem Gebiete der Rontgenstrahlen und der Nuklearmedizin, 194(2), 169–180. Summarized by Jeffrey Olson MS3 | Edited by Jorge Chalit, OMS3 Donate: https://emergencymedicalminute.org/donate/ /episode/index/show/emergencymedicalminute/id/35217350

Episode 942: Acute Mountain Sickness and High Altitude Cerebral Edema 02/03/2025

Episode 942: Acute Mountain Sickness and High Altitude Cerebral Edema Contributor: Jorge Chalit-Hernandez, OMS3 Educational Pearls: Acute mountain sickness (AMS) is the term given to what is otherwise colloquially known as altitude sickness High altitude cerebral edema (HACE) is a severe form of AMS marked by encephalopathic changes Symptoms begin at elevations as low as 6500 feet above sea level for people who ascend rapidly May develop more severe symptoms at higher altitudes The pathophysiology involves cerebral vasodilation Occurs in everyone ascending to high altitudes but is more pronounces in those that develop symptoms The reduced partial pressure of oxygen induces hypoxic vasodilation in the brain, which results in edema and, ultimately, HACE in some patients Symptomatic presentation Headache, nausea, and sleeping difficulties occur within 2-24 hours of arrival at altitude HACE may occur between 12-72 hours after AMS and presents with ataxia, confusion, irritability, and ultimately results in coma if left untreated Clinical presentation may be mistaken for simple exhaustion, so clinicians should maintain a high index of suspicion Notably, if symptoms occur more than 2 days after arrival at altitude, clinicians should seek an alternative diagnosis but maintain AMS/HACE on the differential Treatment and management AMS Adjunctive oxygen and descent to lower altitude Acetazolamide is used as a preventive measure but is not helpful in acute treatment +/- dexamethasone HACE Patients with HACE should receive dexamethasone to help reduce cerebral edema Immediate descent to a lower altitude References Burtscher M, Wille M, Menz V, Faulhaber M, Gatterer H. Symptom progression in acute mountain sickness during a 12-hour exposure to normobaric hypoxia equivalent to 4500 m. High Alt Med Biol. 2014;15(4):446-451. doi:10.1089/ham.2014.1039 Levine BD, Yoshimura K, Kobayashi T, Fukushima M, Shibamoto T, Ueda G. Dexamethasone in the treatment of acute mountain sickness. N Engl J Med. 1989;321(25):1707-1713. doi:10.1056/NEJM198912213212504 Luks AM, Beidleman BA, Freer L, et al. Wilderness Medical Society Clinical Practice Guidelines for the Prevention, Diagnosis, and Treatment of Acute Altitude Illness: 2024 Update. Wilderness Environ Med. 2024;35(1_suppl):2S-19S. doi:10.1016/j.wem.2023.05.013 Summarized & Edited by Jorge Chalit, OMS3 Donate: /episode/index/show/emergencymedicalminute/id/35124375

Episode 941: Rehydration in Pediatric Gastroenteritis 01/27/2025

Episode 940: Laceration Repair Methods 01/20/2025

Episode 939: Serotonin Syndrome 01/13/2025

Episode 939: Serotonin Syndrome Contributor: Jorge Chalit-Hernandez, OMS3 Educational Pearls: Serotonin syndrome occurs most commonly due to the combination of monoamine oxidase inhibition with concomitant serotonergic medications like SSRIs Examples of unexpected monoamine oxidase inhibitors Linezolid - a last-line antibiotic reserved for patients with true anaphylaxis to penicillins and cephalosporins Methylene blue - not mentioned in the podcast due to its uncommon usage for methemoglobinemia Other medications that can interact with SSRIs to cause serotonin syndrome Dextromethorphan - primarily an anti-tussive at sigma opioid receptors that also has serotonin reuptake inhibition Clinical presentation of serotonin syndrome Altered mental status Autonomic dysregulation leading to hypertension (most common), hypotension, and tachycardia Hyperthermia Neuromuscular hyperactivity - tremors, myoclonus, and hyperreflexia Hunter Criteria (high sensitivity and specificity for serotonin syndrome): Spontaneous clonus Inducible clonus + agitation or diaphoresis Ocular clonus + agitation or diaphoresis Tremor + hyperreflexia Hypertonia, temperature > 38º C, and ocular or inducible clonus Management of serotonin syndrome Primarily supportive - benzodiazepines can help treat hypertension, agitation, and hyperthermia. Patients often require repeated and higher dosing of benzodiazepines Avoid antipyretics to treat hyperthermia since the elevated temperature is due to sustained muscle contraction and not central temperature dysregulation In refractory patients, cyproheptadine (a 5HT2 antagonist) may be used as a second-line treatment Patients with temperatures > 41.1º C or 106º F require medically induced paralysis and intubation to control their temperature References Boyer EW, Shannon M. The serotonin syndrome [published correction appears in N Engl J Med. 2007 Jun 7;356(23):2437] [published correction appears in N Engl J Med. 2009 Oct 22;361(17):1714]. N Engl J Med. 2005;352(11):1112-1120. doi:10.1056/NEJMra041867 Dunkley EJ, Isbister GK, Sibbritt D, Dawson AH, Whyte IM. The Hunter Serotonin Toxicity Criteria: simple and accurate diagnostic decision rules for serotonin toxicity. QJM. 2003;96(9):635-642. doi:10.1093/qjmed/hcg109 Ramsay RR, Dunford C, Gillman PK. Methylene blue and serotonin toxicity: inhibition of monoamine oxidase A (MAO A) confirms a theoretical prediction. Br J Pharmacol. 2007;152(6):946-951. doi:10.1038/sj.bjp.0707430 Schwartz AR, Pizon AF, Brooks DE. Dextromethorphan-induced serotonin syndrome. Clin Toxicol (Phila). 2008;46(8):771-773. doi:10.1080/15563650701668625 Thomas CR, Rosenberg M, Blythe V, Meyer WJ 3rd. Serotonin syndrome and linezolid. J Am Acad Child Adolesc Psychiatry. 2004;43(7):790. doi:10.1097/01.chi.0000128830.13997.aa Summarized & Edited by Jorge Chalit, OMS3 Donate: /episode/index/show/emergencymedicalminute/id/34827955

Episode 938: AHA Policy on Management of Elevated Blood Pressure (BP) in the Acute Care Setting 01/06/2025

Episode 937: Pneumomediastinum 12/30/2024

Episode 937: Pneumomediastinum Contributor: Megan Hurley MD Educational Pearls: What is the mediastinum? The thoracic cavity is separated into different compartments by membranes The lungs exist in their own pleural cavities, and the mediastinum is everything in between The mediastinum extends from the sternum to the thoracic vertebrae and includes the heart, the aorta, the trachea, the esophagus, the thymus, as well as many lymph nodes and nerves. What is a pneumomediastinum? Air in the mediastinum How can pneumomediastinum be categorized? Traumatic Ex. Stab wound to the trachea Ex. Boerhaave’s Syndrome of the esophagus, possibly from an endoscopic procedure. This mechanism in particular is a higher risk of infection because not only air but food can accumulate in the mediastinum Ex. Intubation with a bougie These will likely need surgical repair Nontraumatic Ex. Forceful inhalation causing microperforations in the trachea. Possibly while inhaling something like drugs Ex. Bad asthma for similar reasons Ex. Gas forming bacteria What happens if you use positive pressure ventilation on a patient with a hole in their trachea? The positive pressure will force extra air into the mediastinum The air will move between the layers of subcutaneous tissue and can track up into the neck and face regions recognized as crepitus on exam This can also cause a tension pneumomediastinum in which the air pressure in the compartment constricts the heart, impeding its ability to fill during diastole These patients can undergo bronchoscopy because that procedure does not require positive pressure and will not worsen the condition. Endoscopies do require positive pressure so endoscopies are not an option How is a tension pneumomediastinum treated? By inserting a needle into the space from below the xiphoid process to allow the air to escape, similar to a pericardiocentesis As a temporizing measure, if the hole is high enough in the trachea, the intubation can be continued by deliberately pushing the endotracheal tube into the right main bronchus, creating a seal, and only ventilating the right lung while the patient heads to surgery. This is called right-mainstemming. References Clancy DJ, Lane AS, Flynn PW, Seppelt IM. Tension pneumomediastinum: A literal form of chest tightness. J Intensive Care Soc. 2017 Feb;18(1):52-56. doi: 10.1177/1751143716662665. Epub 2016 Aug 3. PMID: 28979537; PMCID: PMC5606356. Grewal, J., & Gillaspie, E. A. (2024). Pneumomediastinum. Thoracic surgery clinics, 34(4), 309–319. Underner, M., Perriot, J., & Peiffer, G. (2017). Pneumomédiastin et consommation de cocaïne [Pneumomediastinum and cocaine use]. Presse medicale (Paris, France : 1983), 46(3), 249–262. Summarized by Jeffrey Olson, MS3 | Edited by Meg Joyce & Jorge Chalit, OMS3 Donate: https://emergencymedicalminute.org/donate/ /episode/index/show/emergencymedicalminute/id/34651935

Episode 936: Etomidate vs. Ketamine for Rapid Sequence Intubation 12/23/2024

Episode 936: Etomidate vs. Ketamine for Rapid Sequence Intubation Contributor: Ricky Dhaliwal MD Educational Pearls: Etomidate was previously the drug of choice for rapid sequence intubation (RSI) However, it carries a risk of adrenal insufficiency as an adverse effect through inhibition of mitochondrial 11-β-hydroxylase activity A recent meta-analysis analyzing etomidate as an induction agent showed the following: 11 randomized-controlled trials with 2704 patients Number needed to harm is 31; i.e. for every 31 patients that receive etomidate for induction, there is one death The probability of any mortality increase was 98.1% Ketamine is preferable due to a better adverse effect profile Laryngeal spasms and bronchorrhea are the most common adverse effects after IV push Beneficial effects on hemodynamics via catecholamine surge, albeit not as pronounced in shock patients 2023 meta-analysis compared ketamine and etomidate for RSI Ketamine’s probability of reducing mortality is cited as 83.2% Overall, induction with ketamine demonstrates a reduced risk of mortality compared with etomidate The dosage of each medication for induction Etomidate: 20 mg based on 0.3 mg/kg for a 70 kg adult Ketamine: 1-2 mg/kg (or 0.5-1 mg/kg in patients with shock) Patients with asthma and/or COPD also benefit from ketamine induction due to putative bronchodilatory properties References Goyal S, Agrawal A. Ketamine in status asthmaticus: A review. Indian J Crit Care Med. 2013;17(3):154-161. doi:10.4103/0972-5229.117048 Koroki T, Kotani Y, Yaguchi T, et al. Ketamine versus etomidate as an induction agent for tracheal intubation in critically ill adults: a Bayesian meta-analysis. Crit Care. 2024;28(1):1-9. doi:10.1186/s13054-024-04831-4 Kotani Y, Piersanti G, Maiucci G, et al. Etomidate as an induction agent for endotracheal intubation in critically ill patients: A meta-analysis of randomized trials. J Crit Care. 2023;77(April 2023):154317. doi:10.1016/j.jcrc.2023.154317 Summarized & Edited by Jorge Chalit, OMS3 Donate: https://emergencymedicalminute.org/donate/ /episode/index/show/emergencymedicalminute/id/34573135

Episode 935: Pregnancy Extremis - TOLDD 12/16/2024

Episode 935: Pregnancy Extremis - TOLDD Contributor: Aaron Lessen MD Educational Pearls: Pregnant patients at high risk of cardiac arrest, in cardiac arrest, or in extremis require special care A useful mnemonic to recall the appropriate management of critically ill pregnant patients is TOLDD T: Tilt the patient to the left lateral decubitus position This position relieves pressure exerted from the uterus onto the inferior vena cava, which reduces cardiac preload If the patient is receiving CPR, an assistant should displace the uterus manually from the IVC towards the patient’s left side O: Administer high-flow adjunctive oxygen L: Lines should be placed above the diaphragm Lines below the diaphragm are ineffective due to uterine compression of the IVC May consider humeral interosseous line vs. internal jugular or subclavian central line D: Dates should be estimated > 20 weeks, can consider a resuscitative hysterotomy (previously known as perimortem c-section) to improve chances of survival The uterus is palpable at the umbilicus at 20 weeks and 1 cm superior to the umbilicus for every week thereafter D: Call the labor and delivery unit for additional help References ACOG Practice Bulletin No. 211 Summary: Critical Care in Pregnancy. Obstetrics & Gynecology. 2019;133(5) Fujita N, Higuchi H, Sakuma S, Takagi S, Latif MAHM, Ozaki M. Effect of Right-Lateral Versus Left-Lateral Tilt Position on Compression of the Inferior Vena Cava in Pregnant Women Determined by Magnetic Resonance Imaging. Anesth Analg. 2019;128(6):1217-1222. doi:10.1213/ANE.0000000000004166 Jeejeebhoy FM, Zelop CM, Lipman S, et al. Cardiac Arrest in Pregnancy. Circulation. 2015;132(18):1747-1773. doi:doi:10.1161/CIR.0000000000000300 Singh, Ajay; Dhir, Ankita; Jain, Kajal; Trikha, Anjan1. Role of High Flow Nasal Cannula (HFNC) for Pre-Oxygenation Among Pregnant Patients: Current Evidence and Review of Literature. Journal of Obstetric Anaesthesia and Critical Care 12(2):p 99-104, Jul–Dec 2022. | DOI: 10.4103/JOACC.JOACC_18_22 Summarized & Edited by Jorge Chalit, OMS3 Donate: https://emergencymedicalminute.org/donate/ /episode/index/show/emergencymedicalminute/id/34462155

Episode 934: Subendocardial Ischemia 12/09/2024

Episode 934: Subendocardial Ischemia Contributor: Travis Barlock MD Educational Pearls: What is the ST segment? The ST segment on an ECG represents the interval between the end of ventricular depolarization (QRS) and the beginning of ventricular repolarization (T-wave). It should appear isoelectric (flat) in a normal ECG. What if the ST segment is elevated? This is evidence that there is an injury that goes all the way through the muscular wall of the heart (transmural) This is very concerning for a heart attack (STEMI) but can be occasionally caused by other pathology, such as pericarditis What if the ST segment is depressed? This is evidence that only the innermost part of the muscular wall of the heart is becoming ischemic This has a much broader differential and includes a partial occlusion of a coronary artery but also any other stress on the body that could cause a supply-and-demand mismatch between the oxygen the coronaries can deliver and the oxygen the heart needs This is called subendocardial ischemia What else should you look for in the ECG to identify subendocardial ischemia? The ST-depressions should be at least 1 mm The ST depressions should be present in leads I, II, V4-6 and a variable number of additional leads. There is often reciprocal ST elevation in aVR > 1 mm The most important thing to remember when you see subendocardial ischemia is…history Still, keep all cardiac causes on your differential, such as unstable angina, stable angina, Prinzmetal angina, etc. Also consider a wide array of non-cardiac causes such as severe anemia, severe hypertension, pulmonary embolism, COPD, severe pneumonia, sepsis, shock, thyrotoxicosis, stimulant use, DKA, or any other state that lead to reduced oxygen supply to the subendocardium and/or increased myocardial oxygen demand. References Birnbaum, Y., Wilson, J. M., Fiol, M., de Luna, A. B., Eskola, M., & Nikus, K. (2014). ECG diagnosis and classification of acute coronary syndromes. Annals of noninvasive electrocardiology : the official journal of the International Society for Holter and Noninvasive Electrocardiology, Inc, 19(1), 4–14. Buttà, C., Zappia, L., Laterra, G., & Roberto, M. (2020). Diagnostic and prognostic role of electrocardiogram in acute myocarditis: A comprehensive review. Annals of noninvasive electrocardiology : the official journal of the International Society for Holter and Noninvasive Electrocardiology, Inc, 25(3), e12726. Cadogan, E. B. a. M. (2024, October 8). Myocardial Ischaemia. Life in the Fast Lane • LITFL. Retrieved December 7, 2024, from . Summarized by Jeffrey Olson, MS3 | Edited by Meg Joyce & Jorge Chalit, OMS3 Donate: https://emergencymedicalminute.org/donate/ /episode/index/show/emergencymedicalminute/id/34339540

Episode 933: Benign Convulsions with Gastroenteritis 12/02/2024

Episode 933: Benign Convulsions with Gastroenteritis Contributor: Alec Coston MD Educational Pearls: Causes of seizures in a fairly well-appearing child with diarrhea: Electrolyte abnormalities: hypocalcemia, hyponatremia Also hyperkalemia which causes arrhythmias and syncope - can appear like seizures Hypoglycemia If the child has diarrhea and appears very sick, differential diagnosis may include: Hemolytic uremic syndrome (HUS): simultaneous occurrence of microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury Typically caused by Shiga-like toxin producing Escherichia coli (also known as EHEC, or enterohemorragic E. coli) One of the main causes of acute kidney injury in children Toxic ingestions such as salicylates, lead, or iron In this case, the child had a seizure but appeared well and was afebrile: Consult with neurology led to a diagnosis of benign convulsions with mild gastroenteritis (CwG) First identified in 1982 in Japan Viral gastroenteritis with diarrhea and convulsions but does not include fever, severe dehydration, or electrolyte abnormalities Uncommon illness caused by rotavirus and norovirus pathogens Criteria for discharge is similar to a febrile seizure - the patient had one seizure that lasted less than 15 minutes and he quickly returned to his baseline, so he was able to be safely discharged home This diagnosis does not predispose him to epilepsy later in life References Lee YS, Lee GH, Kwon YS. Update on benign convulsions with mild gastroenteritis. Clin Exp Pediatr. 2022 Oct;65(10):469-475. doi: 10.3345/cep.2021.00997. Epub 2021 Dec 27. PMID: 34961297; PMCID: PMC9561189. Mauritz M, Hirsch LJ, Camfield P, et al. Acute symptomatic seizures: an educational, evidence-based review. Epileptic Disorders. 2200;1(1). doi:https://doi.org/10.1684/epd.2021.1376 ‌Noris, Marina*; Remuzzi, Giuseppe*, †. Hemolytic Uremic Syndrome. Journal of the American Society of Nephrology 16(4):p 1035-1050, April 2005. | DOI: 10.1681/ASN.2004100861 Summarized by Meg Joyce, MS1 | Edited by Meg Joyce & Jorge Chalit, OMS3 Donate: https://emergencymedicalminute.org/donate/ /episode/index/show/emergencymedicalminute/id/34223440

Episode 932: Induction Agent Hypotension 11/25/2024

Episode 931: Naloxone in Cardiac Arrest 11/18/2024

Episode 930: Holding Costs 11/15/2024

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