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.
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Podcast 644: Covid Outcomes
03/01/2021
Podcast 644: Covid Outcomes
Contributor: Aaron Lessen, MD Educational Pearls: Meta-analysis of 57,420 COVID+ patients evaluated mortality after intubation 45% mortality rate for all patients in the study 84.4% mortality in patients over 80 years old POSITIONED Trail assessed need for intubation in patients awake self-proning compared to not Risk of intubation and mortality was lower for those self-proning 0.3 hazard ratio for intubation in those self-proning References Lim ZJ, Subramaniam A, Ponnapa Reddy M, et al. Case Fatality Rates for Patients with COVID-19 Requiring Invasive Mechanical Ventilation. A Meta-analysis. Am J Respir Crit Care Med. 2021;203(1):54-66. doi:10.1164/rccm.202006-2405OC Jagan N, Morrow LE, Walters RW, Klein LP, Wallen TJ, Chung J, Plambeck RW. The POSITIONED Study: Prone Positioning in Nonventilated Coronavirus Disease 2019 Patients-A Retrospective Analysis. Crit Care Explor. 2020 Oct 1;2(10):e0229. doi: 10.1097/CCE.0000000000000229. PMID: 33063033; PMCID: PMC7531752. Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD
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Podcast 643: Convulsions with Gastroenteritis
02/23/2021
Podcast 643: Convulsions with Gastroenteritis
Contributor: Jared Scott, MD Educational Pearls: Differential Diagnosis: non-accidental trauma, febrile seizure, meningitis, hyponatremia, epilepsy Convulsions with gastroenteritis is a known entity to cause seizures in infancy Predominantly occurs in ages 6 months to 3 years Occur with diarrheal episodes No electrolyte abnormalities associated with the seizure nor severe dehydration Seizures tend to come in clusters Most have a normal EEG and do not develop epilepsy Reported incidence in gastroenteritis of 1-2% of gastroenteritis Treatment addresses the seizures but long term anti-epileptic drugs are typically not needed References Kang B, Kwon YS. Benign convulsion with mild gastroenteritis. Korean J Pediatr. 2014;57(7):304-309. doi:10.3345/kjp.2014.57.7.304 Ma X, Luan S, Zhao Y, Lv X, Zhang R. Clinical characteristics and follow-up of benign convulsions with mild gastroenteritis among children. Medicine (Baltimore). 2019;98(2):e14082. doi:10.1097/MD.0000000000014082 Image credit: Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD
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Podcast 642: Vasopressors
02/22/2021
Podcast 642: Vasopressors
Contributor: Nick Tsipis, MD Educational Pearls: Epinephrine: alpha-1, alpha-2, beta-1, and beta 2 agonist - used in cardiac arrest with positive effects on ROSC in prehospital and peri-hopsital setting Norepinephrine: alpha-1 and beta-1 agonist - used in septic shock to increase cardiac output and peripheral vasoconstriction Phenylephrine: alpha-1 adrenergic agonist - used in spinal/neurogenic shock as well as medication-induced peri-procedural hypotension (propofol for RSI) as it only helps with vasoconstriction Dopamine: alpha-1, alpha-2, beta-1, beta 2, and dopamine agonist - used for sepsis in the past, but not recommended due to dysrhythmias Vasopressin: V1 agonist (vasoconstricts) - used when maxed out of norepinephrine for septic shock Milrenone: phosphodiesterase inhibitor - used in heart failure to drop preload and afterload Dobutamine: beta-2 (with minimal beta-1) adrenergic agonist - used in heart failure and cardiogenic shock to reduce afterload References Shields SH, Holland RM. Pharmacology of Vasopressors and Inotropes. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7e. McGraw-Hill; Accessed February 14, 2021. Episode 31 - Vasopressors. FOAMcast: An Emergency Medicine Podcast. 25 July 2015. https://foamcast.org/tag/vasopressors/ Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD
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Podcast 641: Leadless Intracardiac Pacemaker
02/16/2021
Podcast 641: Leadless Intracardiac Pacemaker
Contributor: Jared Scott, MD Educational Pearls: Small capsule pacemaker (2.5 cm, 1 ml volume) resides in the heart without any associated wires or leads like a traditional pacemaker The new version has a 6 year battery life, after which it can be deactivated and a traditional pacemaker put in place Cost is around 2-4 times that of a traditional pacemaker NEJM study from 2015 showed it met the primary efficacy endpoint in 90% of patients and the primary safety endpoint in 93.3% of patients Follow up study showed 3% complication with the intracardiac pacemaker compared to 9% in traditional References Groner, Ashley PA-C; Grippe, Kristen PA-C The leadless pacemaker, Journal of the American Academy of Physician Assistants: June 2019 - Volume 32 - Issue 6 - p 48-50 doi: 10.1097/01.JAA.0000554750.85170.d4 Reddy VY, Exner DV, Cantillon DJ, Doshi R, Bunch TJ, Tomassoni GF, Friedman PA, Estes NA 3rd, Ip J, Niazi I, Plunkitt K, Banker R, Porterfield J, Ip JE, Dukkipati SR; LEADLESS II Study Investigators. Percutaneous Implantation of an Entirely Intracardiac Leadless Pacemaker. N Engl J Med. 2015 Sep 17;373(12):1125-35. doi: 10.1056/NEJMoa1507192. Epub 2015 Aug 30. PMID: 26321198. Chan KH, McGrady M, Wilcox I. A Leadless Intracardiac Transcatheter Pacing System. N Engl J Med. 2016 Jun 30;374(26):2604. doi: 10.1056/NEJMc1604852. PMID: 27355553. Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD
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Podcast 640: Kawasaki’s Disease
02/15/2021
Podcast 640: Kawasaki’s Disease
Contributor: Peter Bakes , MD Educational Pearls: Pediatric Fever + Rash Differential: scarlet fever, measles, rubella, chicken pox, fifth’s disease, HHV-6, adenovirus, anaphylaxis, Kawasaki’s disease Kawasaki’s is diagnosed clinically with prolonged fever (>7 days fever in <6 months > 5 days of fever >6 months with 4 of the following: Strawberry tongue/fissured lips Bilateral conjunctival injection Cervical lymphadenopathy Hand/foot edema Maculopapular rash Can develop life threatening coronary artery aneurysms Treated with aspirin/IVIG References Modesti AM, Plewa MC. Kawasaki Disease. [Updated 2020 Jul 2]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: Ramphul K, Mejias SG. Kawasaki disease: a comprehensive review. Arch Med Sci Atheroscler Dis. 2018;3:e41-e45. Published 2018 Mar 21. doi:10.5114/amsad.2018.74522 Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD
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Pharmacy Phriday #9: Xofluza (Baloxavir marboxil) for Influenza
02/12/2021
Pharmacy Phriday #9: Xofluza (Baloxavir marboxil) for Influenza
Contributor: Rachael Duncan, PharmD BCPS Educational Pearls: According to the Department of Public Health and Environment who puts out a weekly report on the influenza virus in Colorado, there appears to be less influenza in Colorado than previous years A milder influenza outbreak is likely due to mask wearing and social distancing practices There have only been 22 hospitalizations for influenza in Colorado since the start of the flu season back in September and 0 outbreaks in long-term care facilities Xofluza (baloxavir marboxil) is an antiviral PA endonuclease inhibitor and was approved by the FDA in 2018 for uncomplicated influenza in patients 12 years and older that have been symptomatic for less than 48 hours Patient’s getting Xofluza must be otherwise healthy or at risk of developing influenza-related complications Due to limited data, Xofluza would not be a good option for those that are inpatient or critically ill and is best utilized for patients who are being seen in the emergency department and will be sent home Currently Xofluza is not approved for complicated patients, pregnant patients or those that are breast-feeding which limits its use When compared with Tamiflu in phase 3 studies, Xofluza was superior to placebo and similar to Tamiflu in shortening the duration of illness Xofluza is a single dose that is weight based and appears to be very well tolerated with some adverse effects including headache, nausea and diarrhea Xofluza showed a quicker recovery compared to Tamiflu by 8 hours which could be related to its one-time dosing Cost is a limiting factor for the use of Xofluza. Tamiflu costs around $25 where as Xofluza (only available as brand name currently) is $156 at the cheapest Pharmacists are still encouraging everyone to get their influenza vaccines despite less influenza cases this year References: Cdphe.colorado.gov. 2021. Influenza (flu) | Department of Public Health & Environment. [online] Available at: <https://cdphe.colorado.gov/influenza> [Accessed 11 February 2021]. Ison, M., Portsmouth, S., Yoshida, Y., Shishido, T., Mitchener, M., Tsuchiya, K., Uehara, T. and Hayden, F., 2020. Early treatment with baloxavir marboxil in high-risk adolescent and adult outpatients with uncomplicated influenza (CAPSTONE-2): a randomised, placebo-controlled, phase 3 trial. The Lancet Infectious Diseases, 20(10), pp.1204-1214. Hayden, F., Sugaya, N., Hirotsu, N., Lee, N., de Jong, M., Hurt, A., Ishida, T., Sekino, H., Yamada, K., Portsmouth, S., Kawaguchi, K., Shishido, T., Arai, M., Tsuchiya, K., Uehara, T. and Watanabe, A., 2018. Baloxavir Marboxil for Uncomplicated Influenza in Adults and Adolescents. New England Journal of Medicine, 379(10), pp.913-923. Summarized by Emily Mack OMSIII The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at and create an account.
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Mental Health Monthly #7: Urine Toxicology in the ED
02/10/2021
Mental Health Monthly #7: Urine Toxicology in the ED
This episode of Mental Health Monthly we will be discussing drugs screens in the Emergency Department with Dr. Justin Romano and Eddie Carillo. Dr. Justin Romano is a current psychiatry resident and Eddie Carillo is a licensed mental health therapist. Check out their podcast on all major podcast platforms. Shout out to Dr. Dave Marshall whose grand round presentation this was based on. Key Points: Try not to judge your patient based on the results of their drug screen Drug screens are used a lot; they are not always accurate Based on one study there was no significant change in outcome, treatment, disposition or psychiatric course when a drug screen was obtained Specific good uses for drug screens include new onset of psychiatric symptoms Educational Pearls: 1 in 8 ED visits are due to psychiatric complaints which is up 44% since mid 2000’s 63% of new psychiatric complaints had a medical cause Physicians use drug screens commonly in the Emergency Department, but often do not understand their limitations and are often not using them in the most clinically effective manner Urine is by far the most commonly used in the Emergency Department UA drug screens are notorious for having false positives and false negatives Length of clearance from the urine: Alcohol 12 hours Methamphetamines/Amphetamines 48 hours Benzodiazepines 3 days Opiates 2-3 days Cocaine 2-4 days Marijuana dependent on use: 3- 15 days Phencyclidine (PCP) 8 days Urine drug screens have a false positive rate of 5-10 % and a false negative rate of 10-15% False Positive; urine drug screen positive, but drug is not in their body False positives for amphetamines: bupropion, trazodone, metformin, promethazine, pseudoephedrine, phentermine and atomoxetine False positives for benzodiazepines: sertraline False positives for cannabis: ibuprofen, naproxen, proton pump inhibitors False positives for opiates: poppy seeds, antibiotics, Benadryl False positives for PCP: venlafaxine, ibuprofen and Ambien False positives for cocaine: amoxicillin False Negative; urine drug screen negative, but drug is in the body Benzodiazepines: such as alprazolam, clonazepam, lorazepam or triazolam Cannabinoids: CBD, synthetic marijuana such as K2 Opiates: oxycodone, fentanyl, methadone and tramadol If you get a test that you don’t think is accurate you can always send off for a confirmatory test Summarized by Emily Mack OMSIII | Edited by Mason Tuttle The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at and create an account.
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Podcast 639: Rib Fractures in the Elderly
02/09/2021
Podcast 639: Rib Fractures in the Elderly
Contributor: Aaron Lessen, MD Educational Pearls: Retrospective review of 5,021 patients over 65 with 2 or more rib fractures recently published 3577 (78 %) were admitted to non-ICU setting 1.1% of these patients had unexpected intubation or ICU transfer Findings raise questions regarding current guidelines for ICU admission in elderly patients with isolated rib fractures References Naar L, El Hechi MW, van Erp IA, Mashbari HNA, Fawley J, Parks JJ, Fagenholz PJ, King DR, Mendoza AE, Velmahos GC, Kaafarani HMA, Saillant NN. Isolated rib cage fractures in the elderly: Do all patients belong to the intensive care unit? A retrospective nationwide analysis. J Trauma Acute Care Surg. 2020 Dec;89(6):1039-1045. doi: 10.1097/TA.0000000000002891. PMID: 32697447. Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD
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Podcast 638: Pyogenic Liver Abscess
02/08/2021
Podcast 638: Pyogenic Liver Abscess
Contributor: Aaron Lessen, MD Educational Pearls: Pyogenic liver abscesses can be caused by Intra-abdominal infection progressing to peritonitis which then drains into liver Bacteremia leading to hematogenous spead and seeding Local biliary infection with contiguous spread Patients typically present with signs of sepsis or septic shock and the abscess can be diagnosed using ultrasound or CT Treat with IV fluids, broad spectrum antibiotics, and consultation for drainage References Kurland JE, Brann OS. Pyogenic and amebic liver abscesses. Curr Gastroenterol Rep. 2004 Aug;6(4):273-9. doi: 10.1007/s11894-004-0078-2. PMID: 15245694. Rahimian J, Wilson T, Oram V, Holzman RS. Pyogenic liver abscess: recent trends in etiology and mortality. Clin Infect Dis. 2004 Dec 1;39(11):1654-9. doi: 10.1086/425616. Epub 2004 Nov 9. PMID: 15578367. Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD
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Podcast 637: LSD
02/02/2021
Podcast 637: LSD
Contributor: Katie Sprinkel, MD Educational Pearls: Commonly known as “acid,” LSD is seeing a resurgence in the population as a recreational hallucination Onset is about 30 minutes with peak pharmacologic effects at 2-4 hours, the drug’s half life is 3 hours resulting in some prolonged effects While there is not an significant addictive component of LSD, tolerance for LSD does occur and prolonged usage is associated with increased incidence of schizophreniform disorders Hallucinations and pseudo-hallucinations (sensory misperceptions) are typical of LSD intoxication, other common signs of intoxication include nausea, diaphoresis, tachycardia, mydriasis, and hypertension More serious effects can be coma, hyperthermia, seizures, cardiac arrest, serotonin syndrome (with concomitant SSRI use) and coagulopathy, although the dose to cause these effects is very high Treatment is decreasing sensory stimulation, benzodiazepines in some cases, and symptomatic treatment - no specific antidote exists References Blaho K, Merigian K, Winbery S, Geraci SA, Smartt C. Clinical pharmacology of lysergic acid diethylamide: case reports and review of the treatment of intoxication. Am J Ther. 1997 May-Jun;4(5-6):211-21. doi: 10.1097/00045391-199705000-00008. PMID: 10423613. Klock JC, Boerner U, Becker CE. Coma, hyperthermia and bleeding associated with massive LSD overdose. A report of eight cases. West J Med. 1974;120(3):183-188. Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD
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Podcast 636: May-Thurner Syndrome
02/01/2021
Podcast 636: May-Thurner Syndrome
Contributor: Sam Killian, MD Educational Pearls: iliac vein compression syndrome is also called May-Thurner Syndrome The left leg more frequently develops deep venous thrombosis (DVT) in part because about 1/4 of the population has May-Thurner May-Thurner syndrome anatomic variant results in a right iliac artery compresses the left iliac vein against the spine, which can promote DVT formation This is thought to be the cause of 2-3% of DVTs in patients seen in the ED and suspicion for this disease should increased in those with recurrent DVT Diagnosis is made with MRV/MRA and will typically not be seen on duplex ultrasound Typical anticoagulation treatment fails to address the underlying structural cause References Demir MC, Kucur D, Çakır E, Aksu NM, Onur MR, Sabuncu T, Akkaş M. May-Thurner syndrome: A curious syndrome in the ED. Am J Emerg Med. 2016 Sep;34(9):1920.e1-3. doi: 10.1016/j.ajem.2016.02.045. Epub 2016 Feb 19. PMID: 26971822. Sharafi S, Farsad K. Variant May-Thurner syndrome: Compression of the left common iliac vein by the ipsilateral internal iliac artery. Radiol Case Rep. 2018;13(2):419-423. Published 2018 Feb 20. doi:10.1016/j.radcr.2018.01.001 Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD
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Pharmacy Phriday #8: Atropine with Ketamine for Conscious Sedation of Pediatrics
01/29/2021
Pharmacy Phriday #8: Atropine with Ketamine for Conscious Sedation of Pediatrics
Educational Pearls: Atropine has been shown to reduce hypersalivation as well as nausea and vomiting induced by ketamine sedation. Atropine can increase the occurrence of a transient rash, as well as tachycardia. There are no guidelines that recommend for or against atropine use in pediatric patients undergoing ketamine induced sedation. Ultimately, it is the providers decision to include atropine when performing ketamine sedation. Pediatric dosing for atropine is 0.01mg/kg IM. References Heinz P, Geelhoed GC, Wee C, Pascoe EM. Is atropine needed with ketamine sedation? A prospective, randomised, double blind study. Emerg Med J. 2006 Mar;23(3):206-9. doi: 10.1136/emj.2005.028969. PMID: 16498158; PMCID: PMC2464444. Chong JH, Chew SP, Ang AS. Is prophylactic atropine necessary during ketamine sedation in children? J Paediatr Child Health. 2013 Apr;49(4):309-12. doi: 10.1111/jpc.12149. Epub 2013 Mar 15. PMID: 23495827. Shi J, Li A, Wei Z, Liu Y, Xing C, Shi H, Ding H, Pan D, Ning G, Feng S. Ketamine versus ketamine pluses atropine for pediatric sedation: A meta-analysis. Am J Emerg Med. 2018 Jul;36(7):1280-1286. doi: 10.1016/j.ajem.2018.04.010. Epub 2018 Apr 5. PMID: 29656945. Presented and Summarized by Devan Naughton, 4th year pharmacy student | Edited by Ruben Marrero-Vasquez
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Podcast 635: Wide Complex Tachycardias
01/26/2021
Podcast 635: Wide Complex Tachycardias
Contributor: Peter Bakes, MD Educational Pearls: Two main differentials for wide complex tachycardia (WCT) include ventricular tachycardia (most common) and supraventricular tachycardia with aberrancy Brugada syndrome and Wolff-Parkinson White are potential causes Arrhythmogenic right ventricular dysplasia is a rare congenital cause of WCT that should be considered in younger patients presenting with WCT References B Garner J, M Miller J. . Arrhythm Electrophysiol Rev. 2013;2(1):23-29. doi:10.15420/aer.2013.2.1.23 Katritsis DG, Brugada J. . Arrhythm Electrophysiol Rev. 2020;9(3):155-160. doi:10.15420/aer.2020.20 Li KHC, Bazoukis G, Liu T, et al. . J Arrhythm. 2017;34(1):11-22. Published 2017 Dec 21. doi:10.1002/joa3.12021 Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD
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Podcast 634: D10 for Hypoglycemia
01/25/2021
Podcast 634: D10 for Hypoglycemia
Contributor: Dylan Luyten, MD Educational Pearls: D10 may be a better alternative to D50 in correcting hypoglycemia Risks of D50: Can cause extravasation injury Risk of rebound hypoglycemia D10 does not have the same risks and has no significant difference in reversal time of hypoglycemia compared to D50 References Kiefer MV, Gene Hern H, Alter HJ, Barger JB. . Prehosp Disaster Med. 2014 Apr;29(2):190-4. doi: 10.1017/S1049023X14000284. Epub 2014 Apr 15. PMID: 24735872. Moore C, Woollard M. . Emerg Med J. 2005 Jul;22(7):512-5. doi: 10.1136/emj.2004.020693. PMID: 15983093; PMCID: PMC1726850. Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at and create an account.
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Podcast 633: Pathologic Femur Fractures
01/19/2021
Podcast 633: Pathologic Femur Fractures
Contributor: Jared Scott, MD Educational Pearls: Pathologic bone fractures occur due to weakened bones from chronic disease and with less force when compared to non-pathologic fractures Can be due to bone tumors, bone cysts, infections (osteomyelitis), osteogenesis imperfecta, Paget's disease of bone, and multiple myeloma Have moth bitten or lytic appearance and you can sometimes see the periosteum peeling away from the bone References Angelini A, Trovarelli G, Berizzi A, Pala E, Breda A, Maraldi M, Ruggieri P. Injury. 2018 Nov;49 Suppl 3:S77-S83. doi: 10.1016/j.injury.2018.09.044. PMID: 30415673. Marshall RA, Mandell JC, Weaver MJ, Ferrone M, Sodickson A, Khurana B. I. Radiographics. 2018 Nov-Dec;38(7):2173-2192. doi: 10.1148/rg.2018180073. PMID: 30422769. Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at and create an account.
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Podcast 632: Neonatal Jaundice
01/18/2021
Podcast 632: Neonatal Jaundice
Contributor: Jared Scott, MD Educational Pearls: Bilirubin is natural breakdown product of red blood cells but can be neurotoxic if levels become too high Fetal red blood cells are fragile and break down easier, leading to higher bilirubin levels in neonates Immature livers and increased intestinal absorption from sterile bowels also contribute to elevated levels and jaundice in all neonates Other risk factors for neonatal jaundice include: temperature instability, poor feeding, hypoxia at birth, and being of East Asian descent Neonatal bilirubin levels are referenced to time since birth using a nomogram to determine the need for light therapy (or exchange transfusion) References Mitra S, Rennie J. Br J Hosp Med (Lond). 2017 Dec 2;78(12):699-704. doi: 10.12968/hmed.2017.78.12.699. PMID: 29240507. Woodgate P, Jardine LA. . BMJ Clin Evid. 2015 May 22;2015:0319. PMID: 25998618; PMCID: PMC4440981. Colletti JE, Kothari S, Jackson DM, Kilgore KP, Barringer K. . Emerg Med Clin North Am. 2007 Nov;25(4):1117-35, vii. doi: 10.1016/j.emc.2007.07.007. Erratum in: Emerg Med Clin North Am. 2008 Feb;26(1):xi. Kothori, Samip [corrected to Kothari, Samip]. PMID: 17950138. Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at and create an account.
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Pharmacy Phriday #7: Bactrim Adverse Events
01/15/2021
Pharmacy Phriday #7: Bactrim Adverse Events
Contributor: Cheyenne Bean, PharmD Educational Pearls: Bactrim (TMP-SMX) is a sulfa antibiotic used for a number of infections but can have untoward effects. Hypoglycemia can be induced by the sulfa component of Bactrim, which binds receptors in the pancreas causing insulin to be secreted, dropping blood sugar levels. Oral diabetic medications, specifically sulfonylureas, when taken with Bactrim most often lead to these hypoglycemic episodes. Hyperkalemia can be induced by Trimethoprim by blocking potassium excretion in the kidney, so Bactrim in combination with ACE inhibitors/ARBs/spironolactone can induce high potassium. When prescribing Bactrim, remember to check home medications and if a patient is taking an above medication, check a baseline BGL and potassium. References 1) Khorvash F, Moeinzadeh F, Saffaei A, Hakamifard A. . Iran J Kidney Dis. 2019 Jul;13(4):277-280. PMID: 31422395. 2) Kennedy KE, Teng C, Patek TM, Frei CR. . Drug Saf. 2020 Apr;43(4):363-369. doi: 10.1007/s40264-019-00901-7. PMID: 31863282; PMCID: PMC7117991. Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at and create an account.
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Podcast 631: UK COVID-19 Mutation
01/13/2021
Podcast 631: UK COVID-19 Mutation
Contributor: Gretchen Hinson, MD Educational Pearls: Viruses mutate frequently and a new variant of COVID has been found in the United Kingdom. Mutations typically occur due to transcription errors during virus replication leading to slight changes in the virus which can alter its virulence, and this UK mutation has shown more infectivity. The UK variant was first identified on 9/20/20 and sequenced in October The variant has a mutation of the spike protein with increased receptor binding capacity, making it more efficient at infecting cells Children seem to be more susceptible to this variant as compared to the prior COVID strains. References 1) Tang JW, Tambyah PA, Hui DS. J Infect. 2020 Dec 28:S0163-4453(20)30786-6. doi: 10.1016/j.jinf.2020.12.024. Epub ahead of print. PMID: 33383088. Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at and create an account.
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Podcast 630: Evolution of an STEMI
01/12/2021
Podcast 630: Evolution of an STEMI
Contributor: Peter Bakes, MD Educational Pearls: Hyperacute T waves can occur immediately and typical last less than an hour Hyperacute T waves are typically broader than peaked T-waves, which are associated with hyperkalemia ST elevation which usually starts within an hour of the inciting event and can last up to a few days, and often follows the hyperacute T-waves Q waves can begin at the time ST elevation begins and can remain permanently T waves can invert before normalizing again days later References Levis JT. . Perm J. 2015;19(3):79. doi:10.7812/TPP/14-243 Vogel B, Claessen BE, Arnold SV, Chan D, Cohen DJ, Giannitsis E, Gibson CM, Goto S, Katus HA, Kerneis M, Kimura T, Kunadian V, Pinto DS, Shiomi H, Spertus JA, Steg PG, Mehran R. Nat Rev Dis Primers. 2019 Jun 6;5(1):39. doi: 10.1038/s41572-019-0090-3. PMID: 31171787. Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at and create an account.
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Podcast 629: Inferior STEMI
01/11/2021
Podcast 629: Inferior STEMI
Contributor: Jared Scott, MD Educational Pearls: EKGs look at different angles, or vectors, of the heart’s electrical conduction as it travels through the heart. Knowing how to read these vectors is essential in diagnosing locations of cardiac pathologies Leads II, III, and aVF follow an inferior path, so ST elevation in those leads indicates inferior involvement Major complications more common with inferior STEMIs can include: hypotension which can be made worse by nitroglycerin Severe bradycardia due to SA/AV node involvement Inferior STEMI, barring no hypotension or bradycardia, have better mortality than other types References Warner MJ, Tivakaran VS. . 2020 Aug 8. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan–. PMID: 29262146. Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at and create an account.
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Podcast 628: ST Elevation
01/05/2021
Podcast 628: ST Elevation
Contributor: Peter Bakes, MD Educational Pearls: STEMI criteria is not just 1mm elevation in contiguous leads 1.5 mm in V2-V3 for women 2.0 mm in V2-V3 for men 2.5 mm in V2-V3 for men under 40 Inferior MI typically have ST elevation in leads II, III and aVF Usually inferior MI’s show reciprocal changes (ST depression) in the lateral leads. Lateral MI typically elevation in V5, V6, I, and aVL Anterior MI show elevation in leads V1-4 Right sided MIs have mixed pattern, showing elevation in V1-V2 and V4 along with the inferior leads. Right sided MI’s are very sensitive to nitrates, especially if they become intubated because this combination can drop pre-load significantly leading to profound hypotension References Akbar H, Foth C, Kahloon RA, et al. . [Updated 2020 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK532281/ Namana V, Gupta SS, Abbasi AA, Raheja H, Shani J, Hollander G. Cardiovasc Revasc Med. 2018 Jan;19(1 Pt A):43-50. doi: 10.1016/j.carrev.2017.07.009. Epub 2017 Jul 14. PMID: 28822687. Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at and create an account.
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Podcast 627: Oxygen Like It’s Hot
01/04/2021
Podcast 627: Oxygen Like It’s Hot
Contributor: Aaron Lessen, MD Educational Pearls: High flow nasal cannula (HFNC) has become more utilized with COVID pandemic Multiple studies have shown this method improves both oxygenation and ventilation Newer studies have shown the respiratory benefit of HFNC vs normal oxygen in patients suffering from CHF and those with do not intubate orders who are experiencing respiratory distress. Heated high flow is another option to provide ventilator and oxygen support to patients who either do not need or do not want to be intubated References Kang MG, Kim K, Ju S, et al. . J Thorac Dis. 2019;11(2):410-417. doi:10.21037/jtd.2019.01.51 Peters SG, Holets SR, Gay PC. Respir Care. 2013 Apr;58(4):597-600. doi: 10.4187/respcare.01887. PMID: 22781059. Sharma S, Danckers M, Sanghavi D, et al. [Updated 2020 Jul 2]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at and create an account.
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Pharmacy Phriday #6: Tik Tok Benadryl Challenge and Diphenhydramine Toxicity
01/01/2021
Pharmacy Phriday #6: Tik Tok Benadryl Challenge and Diphenhydramine Toxicity
Contributor: Ruben Marrero-Vasquez, PharmD Educational Pearls: ACEP and FDA have both issued warnings about the viral Tik Tok Benadryl (diphenhydramine) challenge where individuals voluntarily overdose on diphenhydramine which can cause fatal toxicity Diphenhydramine is typically dosed at 0.5-1 mg/kg in pediatric patients Q4-6 PRN and carries a fatal dose of 20-40 mg/kg but anywhere from 3-5x recommended dose does can cause toxicity Diphenhydramine toxicity causes both central and peripheral anticholinergic toxicity Central anticholinergic toxicity symptoms: delirium, agitation, combativeness, confusion, restlessness, hallucinations, ataxia, tremor and seizures Peripheral anticholinergic toxicity symptoms: tachycardia, dry flushed skin, dry mucus membranes, thick secretions, dilation of pupils, urinary retention, and decreased bowel sounds Pneumatic to help you remember anticholinergic toxidrome: Red as a beet Dry as a bone Blind as a bat Mad as a hatter Hot as a hare Full as a flask Management typically only requires supportive care, agitation from central anticholinergic delirium can be hardest aspect to treat, IV benzodiapines are first line treatment to control and may require large doses to prevent rhabdomyolysis and hyperthermia Diphenhydramine toxicity has been associated with blockade of sodium and potentially potassium channels increasing risk of arrhythmia and seizures. Cardiac changes can include: QRS widening, myocardial depression, QT prolongation and torasades-type ventricular tachycardia. Wide QRS complexes indicate delayed ventricular depolarization caused by sodium channel blockade, bolus of sodium bicarbonate can be used dosed 1-2 mEq/kg followed by continuous infusion Prolonged QT: restoration of low serum potassium and magnesium to high normal range Benzodiazipines should be used as first line therapy for toxin induced seizures Don’t use fosphenytoin or phenytoin sodium channel blockers as they can worsen cardiac conduction References Olson KR, Anderson IB, Benowitz NL, Blanc PD, Clark RF, Kearney TE, Kim-Katz SY, Wu AH. Diphenhydramine. In: Poisoning & Drug Overdose. 7th ed.McGraw Hll; 2018: 544-545. FDA Warns About Serious Problems With High Doses Of The Allergy Medicine Diphenhydramine (Benadryl).(09/24/2020). CDC website. Accessed December 01, 2020. https://www.fda.gov/drugs/drug-safety-and-availability/fda-warns-about-serious-problems-high-doses-allergy-medicine-diphenhydramine-benadryl. Su M, Goldman M. Anticholinergic Poisoning. UpToDate. https://www.uptodate.com/contents/anticholinergic-poisoning?search=diphenhydramine overdose&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1. Published October 6, 2020. Accessed December 26, 2020. Summarized by Mason Tuttle
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Mental Health Monthly #6: Suicide Assessment
12/30/2020
Mental Health Monthly #6: Suicide Assessment
EMM is excited to welcome back the hosts of Millennial Mental Health Channel podcast to explain the key points of a robust suicide assessment in the ED. Dr. Justin Romano is a third year psychiatry resident in Omaha, Nebraska and Eddie Carrillo is a licensed mental health therapist currently working at partial hospitalization and IOP eating disorder program in Portland, Oregon. Their podcast Millennial Mental Health Channel seeks to explore the world of mental health from their two professional perspectives. You can listen to their podcast on all major streaming platforms including , and Follow them on and @millennialmhc Contributors: Dr. Justin Romano and Eddie Carrillo, M.A., LPC Educational Pearls: Suicide is 10th most common cause in U.S. and the rate rose by 30% from 2000-2016 and the CDC reports that there was a 25% increase in ED visits for SI from January 2017 - December 2018 Use an objective screening tool like Columbia-Suicide Severity Rating Scale (C-SSRS) when assessing patients as they can help detect SI although ultimately it is up to your clinical impression to make a decision Suicide reduction measures and strategies work! Take advantage of social workers when setting up outpatient resources for patients i.e. gun locks Risk Factors include: prior attempts, substance use/abuse, mental disorders (especially depression and bipolar disorder), access to lethal means (most modifiable by risk reduction strategies), knowing someone who has died by suicide, social isolation, chronic disease or disability, lack of access to mental health resources, recent changes in social status and being a member of a high risk demographic (older caucasian men, LGBTQ+, Native Americans and Alaskan Natives) Protective Factors include: good followup as an outpatient, good social support, life skills, purpose in life, cultural beliefs, children and sense of responsibility in the family Sober up and reassess suicidality If not medically cleared, admit to hospital to address these complaints and then address suicidality If they have suicidal thoughts, plan and are reaching out for help because they don’t want to do it then send to inpatient facility Consult psychiatry to explain inpatient psych or when you’re worried about patient safety to have them weigh in Get collateral by talking to a family member to verify that the patient is telling the truth At the end of the day, thorough documentation of risk and protective factors and results of screening tool in Assessment and Plan is essential to protecting yourself as a professional References Betz ME, Boudreaux ED. Managing Suicidal Patients in the Emergency Department. Ann Emerg Med. 2016;67(2):276-282. doi:10.1016/j.annemergmed.2015.09.001 Suicide. National Institute of Mental Health. https://www.nimh.nih.gov/health/statistics/suicide.shtml. Published September 2020. Accessed December 30, 2020. Zwald ML, Holland KM, Annor FB, et al. Syndromic Surveillance of Suicidal Ideation and Self-Directed Violence — United States, January 2017–December 2018. MMWR Morb Mortal Wkly Rep 2020;69:103–108. DOI: Summarized by Mason Tuttle
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Podcast 626: Updated Gonorrhea Treatment
12/29/2020
Podcast 626: Updated Gonorrhea Treatment
Educational Pearls: The CDC has made new formal recommendations for treating Gonorrhea due to increasing resistance to Rocephin and Azithromycin. New recommendations: Confirmed gonorrhea: Ceftriaxone 500 mg once Empiric treatment: Ceftriaxone 500 mg once followed by 7 days Doxycycline 100 mg BID No longer using Azithromycin due to high resistance Second line: Gentamycin IM Cefixime 800 mg oral Pharyngeal involvement has high resistance rates to second line agents and ceftriaxone is strongly preferred References St. Cyr S, Barbee L, Workowski KA, et al. Update to CDC’s Treatment Guidelines for Gonococcal Infection, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1911–1916. DOI: Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at and create an account.
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Podcast 625: High Altitude Cerebral Edema (HACE)
12/28/2020
Podcast 625: High Altitude Cerebral Edema (HACE)
Contributor: Tom Seibert, MD Educational Pearls: High altitude cerebral edema (HACE) is the end stage of acute mountain sickness and is diagnosed when patients develop neurologic dysfunction, ataxia, and altered mental status. The pathophysiology of HACE is thought to be due to increased cerebral blood flow and increased capillary permeability causing vasogenic edema and brain swelling HACE is linked to extreme altitude Rapid descent should be done as soon as possible for this potentially fatal condition Oxygen can be supportive Dexamethasone is also typically indicated (8mg initially followed by 4 mg every 6 hours) Editor's note: HACE can occur at altitudes as low as 8000 feet so don’t automatically assume it can’t/doesn’t happen in the US References Jensen JD, Vincent AL. . 2020 Aug 26. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan–. PMID: 28613666. Hackett PH, Yarnell PR, Weiland DA, Reynard KB. AJNR Am J Neuroradiol. 2019 Mar;40(3):464-469. doi: 10.3174/ajnr.A5897. Epub 2019 Jan 24. PMID: 30679208; PMCID: PMC7028681. Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at and create an account.
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Podcast 624: Timing and Tips on Sepsis
12/22/2020
Podcast 624: Timing and Tips on Sepsis
Contributor: Don Stader, MD Educational Pearls: Time can be an important factor in outcomes regarding sepsis including mortality Emphasis has grown on early administration of antibiotics and IV fluids in sepsis However, early initiation of vasopressors for hypotensive patients may have significant mortality benefit as well References Hayden GE, Tuuri RE, Scott R, et al. Am J Emerg Med. 2016;34(1):1-9. doi:10.1016/j.ajem.2015.08.039 Colling KP, Banton KL, Beilman GJ. . Surg Infect (Larchmt). 2018;19(2):202-207. doi:10.1089/sur.2017.255 Colon Hidalgo D, Patel J, Masic D, Park D, Rech MA. J Crit Care. 2020 Feb;55:145-148. doi: 10.1016/j.jcrc.2019.11.004. Epub 2019 Nov 9. PMID: 31731173. Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at and create an account.
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Podcast 623: Acute Mountain Sickness
12/21/2020
Podcast 623: Acute Mountain Sickness
Contributor: Tom Seibert, MD Educational Pearls: Acute Mountain sickness (AMS) can cause headache along with fatigue, nausea, vomiting, insomnia Typically occurs above 6500 feet (not 65,000) in elevation Acclimation to altitude can help prevent symptoms if not treated, AMS can advance to severe illness involving cerebral or pulmonary edema. Mild symptoms can be managed with rest but more severe symptoms will require descent, oxygen, acetazolamide and steroids Acetazolamide can be used as both a preventative and therapeutic drug References Davis C, Hackett P. . Emerg Med Clin North Am. 2017 May;35(2):241-260. doi: 10.1016/j.emc.2017.01.002. PMID: 28411926. Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at and create an account.
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Podcast 622: High Altitude Pulmonary Edema (HAPE)
12/15/2020
Podcast 622: High Altitude Pulmonary Edema (HAPE)
Contributor: Thomas Seibert, MD Educational Pearls: High Altitude Pulmonary Edema (HAPE) typically occurs 2-4 days after arriving at elevation Symptoms include: Fatigue Dyspnea Cough Treatment includes: Descent to lower elevation Oxygen supplementation Nifedipine Caused by sympathetic stimulation from hypobaric hypoxic exposure, causing uneven pulmonary vasculature constriction and when paired with a leaky endothelium, pulmonary edema. #science References Swenson ER, Bärtsch P. Compr Physiol. 2012 Oct;2(4):2753-73. doi: 10.1002/cphy.c100029. PMID: 23720264. Johnson NJ, Luks AM. . Med Clin North Am. 2016 Mar;100(2):357-69. doi: 10.1016/j.mcna.2015.09.002. PMID: 26900119. Hultgren HN. . Annu Rev Med. 1996;47:267-84. doi: 10.1146/annurev.med.47.1.267. PMID: 8712781. Summarized by Jackson Roos, MSIV | Edited by Erik Verzemnieks, MD The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at and create an account.
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Podcast 621: Pediatric Psychosis
12/14/2020
Podcast 621: Pediatric Psychosis
Contributor: Aaron Lessen, MD Educational Pearls: Schizophrenia typically doesn’t present until age 13 and has a prodrome Prodrome includes months of gradual changes in behavior, starting with negative symptoms and progressing to positive symptoms Negative symptoms include losing concentration, poor memory, poor school performance, and personality changes Positive symptoms include hallucinations, which tend to be more visual in children Sudden changes mimicking psychiatric illness should raise concern for alternative causes References Kendhari J, Shankar R, Young-Walker L. Focus (Am Psychiatr Publ). 2016 Jul;14(3):328-332. doi: 10.1176/appi.focus.20160007. Epub 2016 Jul 8. PMID: 31975813; PMCID: PMC6526799. Staal M, Panis B, Schieveld JNM. Eur Child Adolesc Psychiatry. 2019 Sep;28(9):1159-1167. doi: 10.1007/s00787-018-1208-y. Epub 2018 Jul 27. PMID: 30054738. Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at and create an account.
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