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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Pediatric Emergencies Brewcast: Common Respiratory Conditions in Pediatric Patients
10/21/2020
Pediatric Emergencies Brewcast: Common Respiratory Conditions in Pediatric Patients
Emergency Medical Minute collaborated with CarePoint Health in early March for a night of education on Pediatric Emergencies geared towards mid-level providers at a local Denver brewery for our latest Brewcast. Pediatric patients require special considerations compared to adults when receiving medical care, and that remains true when dealing with respiratory illnesses across different age ranges. Dr. Parisa Jamshidi, Pediatric Emergency Physician, reviews common respiratory illnesses including bronchiolitis, croup and bacterial tracheitis in pediatric patients covering their presentation on exam and via diagnostics, treatment plans and special considerations. Her lecture is complete with a case review of a patient presenting with croup and its management, differentiation of airway sounds and high flow oxygen delivery recommendations. Listen to brush up on on your knowledge of pediatric respiratory emergencies. 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. Photo by on
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Podcast 606: The Oxygen Wars
10/20/2020
Podcast 606: The Oxygen Wars
Contributor: Aaron Lessen, MD Educational Pearls: The use of oxygen is controversial when treating patients with certain conditions, like MI’s, stokes, or ARDS because adverse outcomes have been demonstrated with using high oxygen concentrations. The Oxygen ICU trial looked at using higher and lower oxygen levels in treating intubated ARDS patients and found that mortality was improved when less oxygen was given allowing oxygen saturations to sit around 95% versus using high oxygen levels to obtain 100% blood oxygen saturation. The LOCO trial tested using even lower oxygen concentrations allowing patients to have oxygen saturations around 88% compared to more oxygen with saturation goals of 96%. They found a 15% increase in mortality in the lower saturation group and had some incidences of mesenteric ischemia leading to a premature termination of the trial due to the detrimental outcomes. This means a blood oxygen saturation rate of around 94% is probably a safe bet for patients to reduce episodes of hypoxia but limit over oxygenation injuries, especially in patients requiring longer term oxygen therapy. References 1) Girardis M, Busani S, Damiani E, Donati A, Rinaldi L, Marudi A, Morelli A, Antonelli M, Singer M. JAMA. 2016 Oct 18;316(15):1583-1589. doi: 10.1001/jama.2016.11993. PMID: 27706466. 2) Barrot L, Asfar P, Mauny F, Winiszewski H, Montini F, Badie J, Quenot JP, Pili-Floury S, Bouhemad B, Louis G, Souweine B, Collange O, Pottecher J, Levy B, Puyraveau M, Vettoretti L, Constantin JM, Capellier G; LOCO2 Investigators and REVA Research Network. N Engl J Med. 2020 Mar 12;382(11):999-1008. doi: 10.1056/NEJMoa1916431. PMID: 32160661. 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 605: Acute Limb Ischemia
10/19/2020
Podcast 605: Acute Limb Ischemia
Contributor: Peter Bakes, MD Educational Pearls: Classically presents with the 6Ps: Pain, pallor, paresthesia, pulseless, poikilothermia (cold), and paralysis Acute limb ischemia occurs by embolic or thrombotic causes Thrombotic causes are now more common due to aging populations and advancements in vascular surgery like stents which can be a nidus for thrombosis. Sudden onset of pain without prior symptoms is more typical of embolic causes Preceding symptoms leading to acute ischemia are more often from thrombosis Diagnosis can be clinical based on absent pulses, ultrasound or CT angiogram Definitive treatment includes thrombectomy, stenting, or bypass surgery to restore the blood flow to the distal limb References McNally MM, Univers J. . Surg Clin North Am. 2018 Oct;98(5):1081-1096. doi: 10.1016/j.suc.2018.05.002. PMID: 30243449. Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD
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On the Streets #9: Advanced Applications of Capnography
10/14/2020
On the Streets #9: Advanced Applications of Capnography
Capnography is the measurement of the partial pressure of exhaled CO2 and is an indirect measurement of your cellular respiration. It is displayed visually as a block-like waveform during the exhalation phase of respiration and monitors ventilation in real-time. Capnography is the gold standard for monitoring sedated and intubated patients in the hospital and the field and can be used in many other situations to discern more information about your patient. Our host Jordan Ourada is joined by Dr. Eric Hill who is a board certified Emergency Physician, EMS Director for 9 agencies around Colorado, a retired military physician with the Army, former paramedic firefighter and combat veteran to discuss advanced applications of capnography to monitor a range of different patients in the pre-hospital setting. Tune in to learn how to apply capnography to monitor your patients and detect serious conditions like sepsis and DKA and initiate time-sensitive interventions that reduce mortality in patients. Quick Educational Pearls: Normal range is between 35 - 45 mmHg Low capnography indicates they are blowing off CO2 High capnography indicates they are retaining CO2 Normal waveform morphology is box-like with gradual expiratory plateau after expiratory upstroke Monitor your patient’s status and interpret the capnography numbers, rate and waveforms accordingly Time Stamps 1:32 Capnography definition 6:36 Normal range 7:40 Reading capnography waveforms 12:36 Capnography monitoring in sedated/intubated patients 13:36 Intubation monitoring 18:03 VQ match vs mismatch 21:42 Asthmatic patients 24:30 Capnography cannula 26:24 Cardiac arrest uses 31:28 Acid-base physiology 37:28 Diabetic patients 40:15 COPD patients 41:42 CHF patients 45:18 Head injury patients 52:07 Sepsis detection and subsequent prehospital management 1:08:15 Closing thoughts on using capnography in the field REFERENCES Brandt, P. “Current Capnography Field Uses.” JEMS. 2010, Nov. DiCorpo,P.,etal.“CapnographyProvidesBiggerPhysiological Picture to Maximize Patient Care.” JEMS. 2015, Nov. Eckstein,M.,etal.“End-tidalCO2asapredictorofsurvivalinout-of- hospital cardiac arrest.” Prehosp Disaster Med. 2011 Jun;26(3):148-50 Kodali,B.“Physicsofcapnography.”2014 Poste,J.,etal.“Airmedicaltransportofseverelyhead-injured patients undergoing paramedic rapid sequence intubation.” Air Med J. 2004 Jul-Aug;23(4):36-40 Davis, D., et al. “Predictors of Intubation Success and Therapeutic Value of Paramedic Airway Management in a Large, Urban EMS System.” Prehospital Emergency Care. 2006: Vol. 10, Iss. 3. Grmec, S. “Comparison of three different methods to confirm endotracheal tube placement in emergency intubation.” Intensive Care Medicine. 2002; 28: 701-4. Silvestri, et al. “The Effectiveness of out of hospital use of continuous end-tidal carbon dioxide monitoring on the rate of unrecognized misplaced intubation within a regional emergency medical services system.” Ann Emerg Med. 2005; 45: 497- 503. Hartman, et al. “Systematic Review and Meta- Analysis of End-Tidal Carbon Dioxide Values Associated With Return of Spontaneous Circulation During Cardiopulmonary Resuscitation.” Journal Intensive Care Med. 2015, Oct;30 (7) 426-35. Levine, et al. “End-tidal carbon dioxide and outcome of out-of-hospital cardiac arrest.” N England J Med. 1997, Jul 31; 337(5): 301-6. AHA 2015 Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Hunter CL, et al. “A prehospital screening tool utilizing end-tidal carbon dioxide predicts sepsis and severe sepsis.” American Journal of Emergency Medicine. 2016 May; 34(5):813-819. Bou Chebi, R, et al. “Diagnostic value of end tidal capnography in patients with hyperglycemia in the emergency department.” BMC Emerg Med. 2016 Jan 29; 16:7 Soleimanpour, H, et al. “Predictive value of capnography for suspected diabetic ketoacidosis in the emergency department.” West J Emerg Med. 2013;14(6): 590-4. 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 604: Baclofen Withdrawal
10/13/2020
Podcast 604: Baclofen Withdrawal
Contributor: Erik Verzemnieks, MD Educational Pearls: Baclofen is used to treat muscle spasms or spasticity. Baclofen comes in two forms: oral and intrathecal Withdrawal is much more common with those receiving intrathecal administration from a Baclofen pump, which is typically spinal cord patients Withdrawal symptoms usually start within 1-3 days after stopping baclofen Symptoms include altered mental status, muscle rigidity, and fevers, which can mimic other severe illnesses It is nearly impossible to reverse withdrawal symptoms with oral baclofen if a patient is receiving it intrathecally, so solving the pump problem is key References Ross JC, Cook AM, Stewart GL, Fahy BG. Neurocrit Care. 2011 Feb;14(1):103-8. doi: 10.1007/s12028-010-9422-6. PMID: 20717751. 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 603: Don't Sedate. Block.
10/12/2020
Podcast 603: Don't Sedate. Block.
Contributor: Don Stader, MD Educational Pearls: Fractures and dislocations that require reduction do not necessarily require sedation Nerve blocks are an effective alternative that can provide analgesia to reduce fractures and dislocations and provide sustained pain relief after the reduction is completed Hematoma blocks are effective for distal radius and various ankle fractures Shoulder dislocations can be reduced by performing a scapular nerve block References Tezel O, Kaldirim U, Bilgic S, Deniz S, Eyi YE, Ozyurek S, Durusu M, Tezel N. Am J Emerg Med. 2014 Jun;32(6):549-52. doi: 10.1016/j.ajem.2014.02.014. Epub 2014 Feb 17. PMID: 24721024. Tseng PT, Leu TH, Chen YW, Chen YP. J Orthop Surg Res. 2018 Mar 27;13(1):62. doi: 10.1186/s13018-018-0772-7. PMID: 29580286; PMCID: PMC5869786. 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 602: Post-Narcan Observation
10/06/2020
Podcast 602: Post-Narcan Observation
Contributor: Donald Stader, MD Educational Pearls: Not uncommon for patients presenting after opiate overdose and narcan administration to be observed for 4-6 hours This has been based more on tradition than evidence Observation periods for overdose may vary based on the opiate(s) used Fentanyl and heroin have half lives of about 2 hours, while oxycodone and methadone have significantly longer half lives. HOUR trial attempted to externally validate a scoring tool for stratification of low risk patients appropriate for discharge after 1 hour References Clemency BM, Eggleston W, Shaw EW, Cheung M, Pokoj NS, Manka MA, Giordano DJ, Serafin L, Yu H, Lindstrom HA, Hostler D. Acad Emerg Med. 2019 Jan;26(1):7-15. doi: 10.1111/acem.13567. Epub 2018 Dec 28. PMID: 30592101. Summarized by Will Dewispelaere, MD | Edited by Erik Verzemnieks, MD
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Podcast 601: Droperidol
10/05/2020
Podcast 601: Droperidol
Contributor: Sam Killian, MD Educational Pearls: Droperidol (Inapsine) is an antipsychotic drug with efficacy for nausea, vomiting, headaches, and treating agitation In the early 2000’s, Droperidol received a black box warning for QT prolongation This caused a precipitous drop of in administration and ultimately led to a stop in production More careful analysis since has called into question the true incidence of QT prolongation in typical dosing Retrospective review published this year looked at 15,374 non-critical and 1,172 critical patients who received droperidol with only a single episode of Torsades des pointes (which was attributed to multiple other risk factors) Of the 2,431 non-critical patients, and 396 critical patients, who received an ECG before and after administration, there were no changes to the mean QTc Droperidol is being manufactured again and the prior black box warning being called into question, so it will likely begin to become more widely available for use References Cole JB, Lee SC, Martel ML, Smith SW, Biros MH, Miner JR. West J Emerg Med. 2020 Jul 2;21(4):728-736. doi: 10.5811/westjem.2020.4.47036. PMID: 32726229; PMCID: PMC7390553. Perkins J, Ho JD, Vilke GM, DeMers G. J Emerg Med. 2015 Jul;49(1):91-7. doi: 10.1016/j.jemermed.2014.12.024. Epub 2015 Mar 30. PMID: 25837231. Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD
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Pediatric Emergencies Brewcast: Pediatric Fever
09/30/2020
Pediatric Emergencies Brewcast: Pediatric Fever
Emergency Medical Minute collaborated with CarePoint Health in early March for a night of education on Pediatric Emergencies geared towards mid-level providers at a local Denver brewery for our latest Brewcast. Pediatric patients require special considerations compared to adults when receiving medical care, and that remains true when dealing with fevers across different age ranges. With flu season around the corner, now is a good time to brush up on your knowledge surrounding pediatric fevers. Dr. Leslie Tourangeau, Pediatric Emergency Medicine Physician, breaks down what qualifies as a fever and how they should be managed for different development ranges of pediatric patients. It's important to consider the timeline of the patient's fever and the patient's vaccination history to inform your differential diagnoses and guide your workup. Tune in for a full run-down on how to proceed with pediatric fever patients you may encounter in the Emergency Department, complete with workup, consultation and disposition recommendations. References: Up To Date
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Podcast 600: Penicillin Allergy?
09/29/2020
Podcast 600: Penicillin Allergy?
Contributor: Aaron Lessen, MD Educational Pearls: True allergies to penicillin compared to reported allergies from patients ranges around 10% Recent study took patients undergoing sensitivity tests and developed the PEN(icillin)-FAST score to address reported penicillin allergies PEN-FAST has four components for a total score of 0-4: o F = five years or less since prior reaction. o A = Angioedema/Anaphylaxis. o S = Severe cutaneous reaction (rash). o T = Treatment, did they require treatment for a reaction? Patients with a score of 0 had <1% incidence of penicillin allergy Even a score of 1-2 points had around 5% incidence of a true allergy References Trubiano JA, Vogrin S, Chua KYL, Bourke J, Yun J, Douglas A, Stone CA, Yu R, Groenendijk L, Holmes NE, Phillips EJ. JAMA Intern Med. 2020 May 1;180(5):745-752. doi: 10.1001/jamainternmed.2020.0403. PMID: 32176248; PMCID: PMC7076536. Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD
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Podcast 599: Facial Blocks for the Win
09/28/2020
Podcast 599: Facial Blocks for the Win
Contributor: Don Stader, MD Educational Pearls: Local anesthetics injected directly into wounds can cause distortion - especially important in facial lacerations Several blocks can be helpful to help numb branches of the trigeminal nerve (CN V) which innervates the face: Supraorbital nerve block: blocks distribution of V1 (most of the forehead) through injection above the eyebrow External nasal nerve block: blocks superficial innervation of nose through injection along the nasal dorsum Infraorbital nerve block: blocks innervation to lip and cheek by injection below the eye Mental nerve block: blocks innervation to chin and lower lip by injection at the mandible Zygomatic nerve block: blocks innervation to temporal scalp and lateral aspect of forehead by injection at the temple Greater auricular nerve block: blocks innervation to on and around the lower ear by injection across the sternocleidomastoid References Moskovitz JB, Sabatino F. . Emerg Med Clin North Am. 2013 May;31(2):517-27. doi: 10.1016/j.emc.2013.01.003. Epub 2013 Feb 18. PMID: 23601486. Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD
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UnfilterED #10: Debi Smith
09/23/2020
UnfilterED #10: Debi Smith
General Counsel attorney, Debi Smith, joins Dr. Nick Tsipis to discuss the ins and outs of healthcare law. Many people forget that a subpoena only compels attendance to a court date, it does not compel one to provide any information on a case without a specific HIPAA compliant authorization for use and disclosure of protected health information. Tune in for more details, perspective on the intricacies of the legal world as it pertains to medicine and for tips on how to navigate different general situations from contracts to litigation. Time Stamps 0:47 Legal Disclaimer 3:14 Evolution of healthcare law 5:00 Contracts 9:36 Independent medical decision making without influence from a corporation 11:00 Importance of protecting your ideas 12:30 How to navigate litigation 15:09 Choosing to be an expert witness 15:56 Malpractice 17:22 common mistakes with subpoenas 18:56 COVID 22:01 Advice to getting involved in healthcare law
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Podcast 598: Sepsis, Round One
09/22/2020
Podcast 598: Sepsis, Round One
Contributor: Aaron Lessen, MD Educational Pearls: Early antibiotics have been shown to improve outcomes in septic patients time after time Emerging evidence challenges the concept of one-size-fits-all large fluid boluses for septic shock patients and fluid may worsen patients who have underlying sepsis-induced pulmonary capillary leak Starting peripheral vasopressors early, and relaxing if fluid resuscitation is successful, is appearing to be a more appropriate strategy than fluids first, then vasopressors References CLASSIC Trial Group; Scandinavian Critical Care Trials Group. Intensive Care Med. 2016 Nov;42(11):1695-1705. doi: 10.1007/s00134-016-4500-7. Epub 2016 Sep 30. PMID: 27686349. Permpikul C, Tongyoo S, Viarasilpa T, Trainarongsakul T, Chakorn T, Udompanturak S. Am J Respir Crit Care Med. 2019 May 1;199(9):1097-1105. doi: 10.1164/rccm.201806-1034OC. PMID: 30704260. Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD
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Podcast 597: Weather Can be a Headache
09/21/2020
Podcast 597: Weather Can be a Headache
Contributor: Sam Killian, MD Educational Pearls: One study found that patients presented with headaches more frequently when there was high temperatures and low humidity, while higher humidity is correlated to lower incidence of headache. Moon phases had no effect on headache frequency. A Canadian study looking at over 100,000 ED visits for headaches found increased incidence of headaches when there were higher levels of air pollution/particulates, like smoke. References Yilmaz M, Gurger M, Atescelik M, Yildiz M, Gurbuz S. Am J Emerg Med. 2015;33(3):409-413. doi:10.1016/j.ajem.2014.12.056 Szyszkowicz M, Stieb DM, Rowe BH. Am J Emerg Med. 2009;27(4):391-396. doi:10.1016/j.ajem.2008.03.013 Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD
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Pediatric Emergencies Brewcast: Pediatric Trauma
09/16/2020
Pediatric Emergencies Brewcast: Pediatric Trauma
Emergency Medical Minute collaborated with CarePoint Health in early March for a night of education on Pediatric Emergencies at a local Denver brewery for our latest Brewcast. Pediatric patients require special considerations compared to adults when receiving medical care, and that remains true for traumatic injuries dealt with in the ED and pre-hospital settings. Dr. Christine Darr, Pediatric Emergency Medicine Physician, discusses a range of traumatic injuries in pediatric patients and how to appropriately perform a physical exam, order radiographic diagnostics to further assess and identify injuries and key steps for management. She reviews growth plate injuries as well as considerations at different developmental stages that can mask the presence of more serious injuries like blunt internal organ trauma without rib fractures and SCIWORA (spinal cord injury without radiographic abnormality). Common injuries associated with abuse at different ages are also addressed to help you identify concerning signs of maltreatment of pediatric patients. Listen for a deep dive into the intricacies of pediatric trauma!
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Podcast 596: Peripheral Vasopressors
09/15/2020
Podcast 596: Peripheral Vasopressors
Contributor: Aaron Lessen, MD Educational Pearls: Traditional teaching has shied away from using vasopressors through peripheral IVs Tissue necrosis from extravasation is cited as a risk of use of vasopressors through a peripheral site However, risk of extravasation is low (2-4%) and even more rarely results in significant complications Using an IV that is more proximal and larger bore with monitoring can further minimize these risks Starting with peripheral vasopressors in a critically ill patient appears to be without significant increased cutaneous complications compared to using a central line alone References Loubani OM, Green RS. J Crit Care. 2015;30(3):653.e9-653.e6.53E17. doi:10.1016/j.jcrc.2015.01.014 Cardenas-Garcia J, Schaub KF, Belchikov YG, Narasimhan M, Koenig SJ, Mayo PH. J Hosp Med. 2015;10(9):581-585. doi:10.1002/jhm.2394 Lewis T, Merchan C, Altshuler D, Papadopoulos J. . 2019;34(1):26-33. doi:10.1177/0885066616686035 Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD
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Podcast 595: Smoking. Still Bad
09/14/2020
Podcast 595: Smoking. Still Bad
Contributor: Don Stader, MD Educational Pearls: On average, smoking reduces life expectancy by 13.2 years for men and for 14.5 years for women Nicotine is highly addictive and has both stimulant and calming effects Having a newborn can be a strong motivator to quit so take advantage and educate new (or expecting) parents to the risks of smoking and benefits of quitting Smoking has been associated with sudden infant death Biggest predictor of children smoking is seeing their parents smoking Side effects of smoking that can be discussed with patients are cataracts/blindness, cancers (lung and throat), coronary artery disease, early menopause, osteoporosis/fractures, and impotency References Haug S, Schaub MP, Schmid H. Patient Educ Couns. 2014;95(3):378-383. doi:10.1016/j.pec.2014.03.004 Mays D, Gilman SE, Rende R, Luta G, Tercyak KP, Niaura RS. . Pediatrics. 2014;133(6):983-991. doi:10.1542/peds.2013-3003 Anderson TM, Lavista Ferres JM, Ren SY, et al. . Pediatrics. 2019;143(4):e20183325. doi:10.1542/peds.2018-3325 Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD
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On The Streets #8: Limb Injury and Preservation
09/09/2020
On The Streets #8: Limb Injury and Preservation
Dr. Glenda Quan, esteemed Trauma Surgeon at Swedish Medical Center, discusses cases related to limb injury and reviews their management. Topics include proper tourniquet application as well as alternatives to commercially available devices how to manage pain or a difficult patient with significant limb injury. We also explore the use of new “hybrid ORs” where multiple surgical teams can care for various injuries simultaneously and briefly chat about the use of blood products in the prehospital setting. Thought we were done? Nope. We finish with pearls on temperature management as part of trauma resuscitation and find the answer to when you consider reduction of a joint or mid-shaft fracture?
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Podcast 594: Topicalization for Awake Intubations
09/08/2020
Podcast 594: Topicalization for Awake Intubations
Contributor: Ricky Dhaliwal, MD, JD Educational Pearls: Topical anesthetization can allow for an awake intubation, which substantially decreases chance of loss of airway or respiratory drive because sedatives/paralytics are not necessary Lidocaine treatments like URO-JET (2% lidocaine jelly) can be applied through the nare followed by LMX cream (4% lidocaine) which should be applied to the back of the tongue to anesthetize the tongue and larynx. Good topicalization can be confirmed by testing for lack of a gag reflex References Simmons ST, Schleich AR. Reg Anesth Pain Med. 2002;27(2):180-192. doi:10.1053/rapm.2002.30659 Ducharme J, Matheson K. J Emerg Nurs. 2003;29(5):427-430. doi:10.1016/s0099-1767(03)00295-2 Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD
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Podcast 593: TXA for GIB
09/07/2020
Podcast 593: TXA for GIB
Contributor: Ricky Dhaliwal, MD, JD Educational Pearls: Tranexamic acid (TXA) as shown to have mortality benefit to patients with traumatic GI hemorrhage but should it be used to achieve hemostasis in atraumatic GI bleeding? HALT-IT study looked at TXA for the treatment of upper and lower GI hemorrhage and found no 5 day mortality benefit Patients given TXA also had higher occurrences of DVT and PE References Roberts I, Coats T, Edwards P, et al. Trials. 2014;15:450. Published 2014 Nov 19. doi:10.1186/1745-6215-15-450 Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD
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Podcast 592: Rapid Antihypertensives
09/01/2020
Podcast 592: Rapid Antihypertensives
Contributor: Ramnik Dhaliwal, MD, JD Educational Pearls: Nitrates Nitroprusside: becomes effective in under a minute, and becomes ineffective 10 minutes after stopping it. Nitroprusside can metabolize into cyanide leading to toxicity, however this is rare. Nitroglycerin: predominately causes vasodilation but some arterial dilation as well; preferred agent in patients with volume overload/CHF Adrenergic Blocking Agents Labetalol: alpha/beta-blocking agent with a rapid onset of 5 minutes or less given as bolus or intravenous drip Esmolol: cardioselective beta blocker with rapid onset and short duration of action making it easily titratable Hydralazine: direct arterial dilator; patient dependent response that can be unpredictable. Use with caution in patients with CAD or an aortic dissection because there will be a reflexive increase in heart rate to combat the arteriolar dilation. Calcium Channel Blockers Nicardipine: Given as an IV infusion starting at 5g/hr up to 15g/hr. This drug has a slower onset of action making it difficult to titrate and it has a longer serum elimination half-life (3-6 hours) Clevidipine: rapid onset and short duration of action; Reduces BP without affecting cardiac filling pressures but can cause reflex tachycardia References )Wani-Parekh P, Blanco-Garcia C, Mendez M, Mukherjee D. Cardiovasc Hematol Disord Drug Targets. 2017;17(1):52-57. doi:10.2174/1871529X16666161220142020 Suneja M, Sanders ML. Med Clin North Am. 2017;101(3):465-478. doi:10.1016/j.mcna.2016.12.007 Maloberti A, Cassano G, Capsoni N, et al. High Blood Press Cardiovasc Prev. 2018;25(2):177-189. doi:10.1007/s40292-018-0261-4 Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD
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Podcast 591: Pediatric Documentation Pearls
08/31/2020
Podcast 591: Pediatric Documentation Pearls
Emergency Medical Minute collaborated with CarePoint Health in early March for a night of education on Pediatric Emergencies at a local Denver brewery for our latest Brewcast. Pediatric patients require special considerations compared to adults when receiving medical care, and that remains true in the ED and pre-hospital settings. As such, it's important to be careful with the documentation of these patients to maintain accuracy and avoid inclusion of common normal findings that may populate in "normal patient" macros that are inappropriate for pediatric patients. Dr. Karen Woolf, Pediatric Emergency Medicine Physician, shares some key areas to be wary of in your documentation for pediatric patients. Some examples include the description of vital signs and whether they fall within normal ranges, general appearance descriptors as well as developmental stage specific findings i.e AAOx3, normal gait and fontanelle description etc. Listen for a rundown of the key pointers for keeping pediatric documentation accurate and informative.
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Pharmacy Phriday #2: Penicillin and Cephalosporin Allergies
08/28/2020
Pharmacy Phriday #2: Penicillin and Cephalosporin Allergies
The penicillin and cephalosporin drug classes include many first line drug options for infectious disease although high rates of self-reported allergies may cause physicians to seek alternative options. In part two of our dive into antibiotics use for infectious disease, listen as Dr. Rachael Duncan, Emergency Medicine Clinical Pharmacist, addresses the need to investigate the validity of these reported allergies and their severity to avoid us elf riskier alternatives, like fluoroquinolones. Cross-reactivity between cephalosporins is most often dictated by side chain of cephalosporins rather than the beta-lactam ring. Refer to the chart included for cross-reactivity tips. References: Li M, Krishna MT, Razaq S, Pillay D. A real-time prospective evaluation of clinical pharmaco-economic impact of diagnostic label of 'penicillin allergy' in a UK teaching hospital. J Clin Pathol 2014; 67(12): 1088-92. Romano A, Gueant-Rodriguez RM, Viola M, Pettinato R, Gueant JL. Cross-reactivity and tolerability of cephalosporins in patients with immediate hypersensitivity to penicillins. Ann Intern Med 2004; 141(1): 16-22. Macy E, Contreras R. Health care use and serious infection prevalence associated with penicillin "allergy" in hospitalized patients: A cohort study. J Allergy Clin Immunol 2014; 133(3): 790-6
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Mental Health Monthly #4: Trauma, Loss and Grief in First Responders Heightened by COVID-19
08/26/2020
Mental Health Monthly #4: Trauma, Loss and Grief in First Responders Heightened by COVID-19
Trauma and loss are common issues faced by emergency personnel and first responders. These challenges have since been heightened by the COVID-19 pandemic. On this installment of Mental Health Monthly, Anat ‘Nati’ Geva, PsyD, LP joins us to discuss the stages of grief in response to loss and trauma and how they pertain to first responders and frontline workers in particular. Each of the five stages of grief: denial, anger, bargaining, despair and acceptance are addressed and explained so you can expand your understanding of the natural process of grieving, identify signs and symptoms and take steps towards moving forward. If you or a love one is struggling through the grieving process and need more support, we encourage you to utilize the resources below: My Strengths - passcode: TMCAProfessional Responder Strong - Jason’s Foundation - Rocky Mountain Crisis Partners (also known as “the crisis line”) – 1-844-493-8255 (TALK) HCAT – 1-844-556-2012 Anat ‘Nati’ Geva, PsyD, LP If you are interested in taking part in a personalized experiential application of the content, there will be a Webex webinar session tomorrow, August 27th from 10 - 11 am MST. The focus group follow-up is a complimentary experiential component for individuals who want to deepen their understanding of the material from this podcast. It will benefit those who want to take the opportunity to make the content personal to their situation. In this session, participants will discuss the prominent experiences for participants, have more extended time for Q&A, and then explore (a facet of) the primary model used. Time allowing, participants will be invited to join and share insights for the benefit of all participants. Details for joining: Join from a video system or application Dial 1453267047@hcameeting.webex.com Tap to join from a mobile device (attendees only) +1-415-655-0003,,1453267047## United States TOLL Join by phone +1-415-655-0003 United States TOLL Access code: 145 326 7047 Meeting password: Meeting password: mVx3rt6Kwb
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Podcast 590: Esophageal Food Impactions
08/25/2020
Podcast 590: Esophageal Food Impactions
Contributor: Aaron Lessen, MD Educational Pearls: Carbonated beverages have shown efficacy in helping patients spontaneously pass esophageal food impactions Glucagon, while historically used for treatment, has been shown to have significant side effects without any clinical benefit Definitive treatment is with endoscopy performed typically by a gastroenterologist References Long B, Koyfman A, Gottlieb M. J Emerg Med. 2019;56(5):499-511. doi:10.1016/j.jemermed.2019.01.025 Peksa GD, DeMott JM, Slocum GW, Burkins J, Gottlieb M. Pharmacotherapy. 2019;39(4):463-472. doi:10.1002/phar.2236 Akram J, Amin FM, Toft JG, Rømeling F. Håndtering af fremmedlegeme i øsofagus med synkestop . Ugeskr Laeger. 2013;175(10):640-643. Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD
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Podcast 589: Management of Dental Trauma
08/24/2020
Podcast 589: Management of Dental Trauma
Contributor: Peter Bakes, MD Educational Pearls: Dental fractures are described by the Ellis classifications, which are based on the involvement of layers of the teeth: Ellis I: involvement of the enamel Ellis II: involvement of the enamel and dentin Ellis III: involvement of the enamel, dentin, and pulp While Ellis I injuries can be sent for dental follow up without intervention, Ellis II/III injuries require covering of the exposed dental layers, particularly because bacteria can more easily enter into the pulp Calcium hydroxide (Dycal) is used to cover teeth until patients can get to a dentist. Dental avulsions, or displacement of the tooth from the socket, are time sensitive. Every minute the tooth is not put back in place carries an increased risk of permanent loss. After the tooth is replanted, it requires fixation or bracing Dental subluxations can also be secured or braced with dental follow up References Marte, D, and B Robinson. . Core EM, 7 Oct. 2019, coreem.net/core/dental-trauma/#ellis-classification-system-for-dental-fractures. Rosenberg H, Rosenberg H, Hickey M. . Ann Emerg Med. 2011;57(4):375-377. Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD
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Pharmacy Friday #1: Antibiotic Alternatives to Fluoroquinolones for Infectious Disease
08/21/2020
Pharmacy Friday #1: Antibiotic Alternatives to Fluoroquinolones for Infectious Disease
Welcome to EMM’s first Pharmacy Friday where we dive deeper on a certain pharmacological topic as it pertains to emergency medicine. Dr. Rachael Duncan, emergency medicine clinical Pharmacist, joins us today to talk about antibiotics use for infectious disease, specifically fluoroquinolones. Special thanks to Dr. Nichole Neville, infectious disease pharmacist, for much of the information presented in this podcast. Educational Pearls: Levofloxacin and other fluoroquinolones used to be relied upon heavily due to key upsides including ease of use and wide spectrum coverage of common bacteria. Overuse over the past decade has resulted in the discovery of 3 concerns that have led to their use being advised against in most patients These concerns are patient adverse reactions, safety concerns and drug resistance. Patient adverse reactions include potential QTc prolongation, neurologic symptoms including worsening of myasthenia gravis or peripheral neuropathy and severe hypoglycemia. Due to these adverse effects, a new term was coined: fluoroquinolone-associated disability. In an FDA report, they looked at the percentage of disability reports among all serious outcome reports of selected antibiotics and found that the top 5 antibiotics that led to disability reports were fluoroquinolones. Safety concerns have led to several black box warnings as well. Drug resistance due to overuse has also severely decreased the susceptibility rates of fluoroquinolones at many institutions. Check out your facility’s antibiograms to get an idea of what susceptibility rates are for different drugs. Common infections that are inappropriately given fluoroquinolones when other options would be better suited are PNA, UTI and intra-abdominal infections. Tune in next week for more on cross-reactivity of cephalosporins and penicillins References: Fda.gov. 2017. Fluoroquinolone Safety Labeling Changes. [online] Available at: <> [Accessed 21 August 2020]. Idsociety.org. 2018. Practice Guidelines. [online] Available at: <> [Accessed 18 August 2020]. U.S. Food and Drug Administration. 2018. FDA Updates Warnings For Oral And Injectable Fluoroquinolone. [online] Available at: <> [Accessed 18 August 2020].
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Buprenorphine after Naloxone
08/19/2020
Buprenorphine after Naloxone
EMM would like to extend a large thank you to the Pain Management and Addiction Medicine section of the American College of Emergency Physicians for allowing us to post their webinar panel discussion facilitated by EMM’s own Don Stader, MD, FACEP on Buprenorphine use after Naloxone. This episode discusses the nuances of emergency physicians inducing patients on Buprenorphine following an opioid overdose and covers key considerations including dosing, precipitated withdrawal and contraindications to Buprenorphine administration. Panelists include: Rachel Haroz, MD - EM physician boarded in Medical Toxicology and Addiction working in Camden, NJ Andrew Herring, MD - EM physician boarded in Pain and Addiction working in Oakland, CA and leads California’s Bridge program that helps hospitals start Buprenorphine programs Eric Ketcham, MD, FACEP - EM physician who is a cofounder and chair of ACEP’s Pain Management and Addiction Medicine section working in New Mexico
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Podcast 588: Esmolol for Refractory Ventricular Fibrillation
08/18/2020
Podcast 588: Esmolol for Refractory Ventricular Fibrillation
Contributor: Ricky Dhaliwal, MD, JD Educational Pearls: Ventricular Fibrillation (VF) is a potentially fatal cardiac arrhythmia; Refractory VF even more so Epinephrine stimulates alpha and beta receptors which increase sympathetic tone, thereby increasing cardiac oxygen demand and myocardial calcium levels which can cause new arrhythmias, particularly a problem during resuscitation Esmolol (or any beta blocker) can be used in VF refractory to defibrillation, epinephrine and amiodarone in a last-ditch effort. Esmolol in the setting of epinephrine can help prevent some of these known effects from repeated beta stimulation Dosing esmolol for refractory VF: 500mcg/kg bolus, followed by drip (max typically 1000 mcg/kg/min) Esmolol is associated with improved mortality in ACLS care in refractory VF References Long DA, Long B, April MD. . Ann Emerg Med. 2020;76(1):42-45. doi:10.1016/j.annemergmed.2020.01.025 Lee YH, Lee KJ, Min YH, et al. Resuscitation. 2016;107:150-155. doi:10.1016/j.resuscitation.2016.07.243 Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD
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Podcast 587: Puppies Preventing Burnout?
08/17/2020
Podcast 587: Puppies Preventing Burnout?
Contributor: Jared Scott, MD Educational Pearls: Burnout happens. This study reminds us to take a few minutes on shift to take care of yourself. A new study looked at burnout in ER nurses, residents, and attending physicians where they were asked to take a 5-minute break on shift to color or play with a therapy dog. Researchers measured stress levels and checked salivary cortisol levels after the breaks to see if the therapies were working against a control group who did not have the breaks. Those who colored reported increased stress levels at the end of their shifts, while those who played with dogs reported decreased stress. Cortisol levels dropped in both coloring and pet therapy groups. Interestingly, patients couldn’t see any difference in their providers' stress level. Those who conducted the study believe maybe coloring increased stress only because those who colored were denied the chance to play with a dog. Go figure. References 1) Kline JA, VanRyzin K, Davis JC, et al. Acad Emerg Med. 2020; doi:10.1111/acem.13939
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