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.
info_outline
Episode 967: Dilutional Hyponatremia
07/28/2025
Episode 967: Dilutional Hyponatremia
Contributor: Taylor Lynch, MD Educational Pearls: Dilutional Hyponatremia: Occurs when there is an excess of free water relative to sodium in the body. Causes a falsely low sodium concentration without a true change in total body sodium. Commonly seen in DKA: Hyperglycemia raises plasma osmolality. Water shifts from the intracellular to extracellular space. This dilutes serum sodium, creating apparent hyponatremia. Corrected sodium calculation: Use tools like MDCALC, or apply this formula: Add 1.6 mEq/L to the measured sodium for every 100 mg/dL increase in glucose above 100. Clinical relevance: Considering corrected sodium in DKA is crucial, as the lab value may not be reflective of actual sodium depletion. True severe hyponatremia can lead to complications like seizures May require treatment with hypertonic saline. References: Fulop M. Acid–base problems in diabetic ketoacidosis. Am J Med Sci. 2008;336(4):274-276. doi:10.1097/MAJ.0b013e318180f478 Palmer BF, Clegg DJ. Electrolyte and Acid–Base Disturbances in Patients with Diabetes Mellitus. N Engl J Med. 2015;373(6):548-559. doi:10.1056/NEJMra1503102 Spasovski G, Vanholder R, Allolio B, et al. Diagnosis and management of hyponatremia: a review. JAMA. 2014;312(24):2640–2650. doi:10.1001/jama.2014.13773 Summarized by Ashley Lyons, OMS3 | Edited by Ashley Lyons & Jorge Chalit, OMS4 Donate:
/episode/index/show/emergencymedicalminute/id/37573400
info_outline
EMSAC 2024
07/26/2025
EMSAC 2024
Contributors: Col. (Dr.) Stacy Shackelford Dr. Sean Keenan Paramedic Alan Moreland Dr. Chris Tems Kara Napolitano From military-inspired trauma protocols to behavioral health alternatives and cardiac resuscitation, EMS is evolving fast. Our Medical Minutes from EMSAC highlight the growing need for prehospital providers to think critically, act quickly, and adapt to new approaches in trauma, crisis response, and patient advocacy. Educational Pearls: What was covered & recorded at EMSAC 2024 by EMM? Col. (Dr.) Stacy Shackelford, U.S. Air Force trauma surgeon and Director of the Joint Trauma System, emphasized the critical importance of early hemorrhage control and timely transfusions in prehospital trauma care. She highlighted military studies showing that interventions within 30 minutes can dramatically increase survival, underscoring the value of rapid response and frontline readiness. Dr. Sean Keenan, retired Army emergency physician and EMS doctor, introduced the concept of prolonged field care—managing critically injured patients in environments where evacuation is delayed. He discussed how this model, developed in the military, is now being taught to civilian EMS providers in rural areas. Paramedic Alan Moreland from Denver’s STAR Program (Support Team Assisted Response) explained how alternative response teams, pairing paramedics with clinical social workers, are reshaping how we respond to behavioral health emergencies, reducing reliance on police or ambulance transport and focusing on trauma-informed care. Dr. Chris Tems, an emergency physician working with ECMO (extracorporeal membrane oxygenation), shared data on using ECMO for refractory cardiac arrest. With a survival rate of 87.5% in select emergency department cases, he highlighted ECMO’s growing role in cardiac resuscitation for patients not responding to CPR. Kara Napolitano, of the Laboratory to Combat Human Trafficking, outlined the role EMS plays in recognizing human trafficking. She offered key indicators to look for and encouraged providers to stay alert to the signs of exploitation, emphasizing EMS’s role in early intervention. Recorded by: Steven Fujaros, Brian Parga, & Ahmed Abdel-Hafiz Summarized by: Steven Fujaros
/episode/index/show/emergencymedicalminute/id/37551600
info_outline
Episode 966: Acetaminophen Toxicity
07/21/2025
Episode 966: Acetaminophen Toxicity
Contributor: Jorge Chalit-Hernandez, OMS4 Educational Pearls: What is the toxic dose of acetaminophen? 7.5 grams, in an adult. The safe daily limit is 4 grams in an adult with a normally functioning liver. This is equivalent to fifteen 500mg pills. What are the symptoms of acetaminophen toxicity? First 24 hours, symptoms are non-specific e.g. nausea, vomiting, lack of appetite. Can also be asymptomatic. 24-72 hours, hepatotoxicity occurs (causing yellow skin, pruritus, abdominal pain, bleeding, and confusion) Fulminant liver failure at 72-96 hours Liver function tests (LFTs) peak at 72-96 hours. When would you give activated charcoal? Within 4 hours of ingestion. The risk of activated charcoal is that it can be very dangerous if aspirated so use with caution with a poorly mentating patient When would you give N-acetylcysteine (NAC)? The peak absorption of acetaminophen occurs at about 4 hours with acute ingestions Use the Rumack–Matthew nomogram to plot the serum level of acetaminophen versus the time since ingestion to see if you are above the treatment line. If the ingestion time is unknown then just give it. How do you dose NAC? 3 bag system: First, a 150 mg/kg bolus is administered IV over 15-60 minutes (Bag 1), then a 50 mg/kg drip is administered over 4 hours (Bag 2), then a 100 mg/kg drip is administered over the following 16 hours (Bag 3). This is the Prescott Protocol that requires three bag of IV fluids 2 bag system: There is a simplified protocol that only requires 2 bags, 200mg/kg IV over 4 hours (Bag 1) followed by 100mg/kg over 16 hours (Bag 2) Less risk of anaphylactoid reactions with a 2-bag system due to the high rate of IV NAC given in the 3 bag system. What are the endpoints for stopping NAC? If the INR is <1.5 If the acetaminophen level is < 10 mcg/mL or undetectable References Hodgman MJ, Garrard AR. A review of acetaminophen poisoning. Crit Care Clin. 2012 Oct;28(4):499-516. doi: 10.1016/j.ccc.2012.07.006. PMID: 22998987. Rumack BH, Matthew H. Acetaminophen poisoning and toxicity. Pediatrics. 1975 Jun;55(6):871-6. PMID: 1134886. Sudanagunta S, Camarena-Michel A, Pennington S, Leonard J, Hoyte C, Wang GS. Comparison of Two-Bag Versus Three-Bag N-Acetylcysteine Regimens for Pediatric Acetaminophen Toxicity. Ann Pharmacother. 2023 Jan;57(1):36-43. doi: 10.1177/10600280221097700. Epub 2022 May 19. PMID: 35587124. Summarized by Jeffrey Olson, MS4 | Edited by Jeffrey Olson and Jorge Chalit, OMS4 Donate:
/episode/index/show/emergencymedicalminute/id/37476760
info_outline
Episode 965: Oxygen Administration in Trauma Patients
07/14/2025
Episode 965: Oxygen Administration in Trauma Patients
Contributor: Aaron Lessen, MD Educational Pearls: Many trauma patients are placed on oxygen via non-rebreather A large, multicenter, controlled trial evaluated the outcomes of oxygen administration in trauma patients Patients were randomized to two groups 1. 8-hour restrictive oxygen strategy: only receiving oxygen when the patient’s saturation dropped below 94% 2. 8-hour liberal oxygen strategy: 12-15 liters of oxygen per minute or fraction of inspired oxygen of 0.6-1.0 The study evaluated rates of death or major respiratory complications at 30 days There was no statistical difference between the two groups Therefore, there is no clear benefit to administering liberal amounts of oxygen to trauma patients, but there is also no clear harm Ultimately, trauma patients do not need to be on oxygen via non-rebreather unless they are hypoxic or short of breath References Arleth T, Baekgaard J, Siersma V, et al. Early Restrictive vs Liberal Oxygen for Trauma Patients: The TRAUMOX2 Randomized Clinical Trial. JAMA. 2025;333(6):479-489. doi:10.1001/jama.2024.25786 Summarized by Meg Joyce, MS2 | Edited by Meg Joyce & Jorge Chalit, OMS4 Donate:
/episode/index/show/emergencymedicalminute/id/37395055
info_outline
Episode 964: Ketamine & Midazolam for Prehospital Seizure Management
07/07/2025
Episode 964: Ketamine & Midazolam for Prehospital Seizure Management
Contributor: Aaron Lessen, MD Educational Pearls: Prehospital seizures are typically managed with intramuscular midazolam (Versed) Seizures theoretically involve the NMDA pathway, and ketamine is a potent NMDA antagonist A recent retrospective cohort study analyzed a Florida EMS protocol that uses ketamine in seizures refractory to midazolam One group received two doses of midazolam for seizure control The other group received a dose of midazolam followed by a dose of ketamine After matching, 82% of the midazolam-only group patients had resolution of convulsions prior to ED arrival 94.4% of patients in the midazolam + ketamine group experienced resolution Absolute difference between groups was 12.4% (95% CI 3.1% to 21.7%) Limitations to the study include its prehospital setting and limited long-term follow-up References Zitek T, Scheppke KA, Antevy P, et al. Midazolam and Ketamine for Convulsive Status Epilepticus in the Out-of-Hospital Setting. Ann Emerg Med. 2025;85(4):305-312. doi:10.1016/j.annemergmed.2024.11.002 Summarized & Edited by Jorge Chalit, OMS4 Donate:
/episode/index/show/emergencymedicalminute/id/37302495
info_outline
Episode 963: Antihypertensives and Emergency Room Considerations
06/30/2025
Episode 963: Antihypertensives and Emergency Room Considerations
Contributor: Alec Coston, MD Educational Pearls: For patients presenting to the emergency room with hypertension, clinicians should determine if it is isolated and uncomplicated, or involves comorbidities with more complex underlying pathophysiology. For uncomplicated and isolated hypertension, first-line treatment is thiazide diuretics. How do thiazide diuretics work to treat hypertension? Thiazide diuretics work by blocking sodium and chloride resorption in the kidneys. “Where sodium goes, water follows,” thus promoting diuresis and lowering blood pressure. Examples of thiazide diuretics and their benefits? Hydrochlorothiazide (HCTZ): First-line medication in uncomplicated and chronic hypertensive states. Cheaper and fewer significant adverse effects compared to chlorthalidone. HCTZ can be associated with decreased risk of stroke and myocardial infarction. However, for more complicated hypertension, especially in the setting of heart failure, Angiotensin Converting Enzyme (ACE) Inhibitors should be considered. How do ACE Inhibitors manage blood pressure? The body’s kidneys drive the Renin-Angiotensin-Aldosterone-System (RAAS) to regulate blood pressure. It is easiest to understand RAAS as being pro-hypertensive as a response to decreased renal perfusion. As renal perfusion decreases, renin is released and activates angiotensin I, which is converted by ACE to Angiotensin II, which causes release of aldosterone. ACE Inhibitors prevent the conversion of Angiotensin I to Angiotensin II, thus decreasing the kidneys' production of Angiotensin II and Aldosterone levels. Why, in the context of heart failure, are ACE Inhibitors preferred? In heart failure, especially left-sided or left-ventricular heart failure, a vicious cycle can develop wherein the left ventricle fails to perfuse the kidneys due to over-dilation. The kidneys are hypoperfused and activate RAAS to try to retain volume and increase peripheral vasoconstriction, promoting renal perfusion. The increase in blood pressure puts further strain on the heart, thereby further decreasing cardiac output. The cycle develops, and extremely elevated blood pressures can develop. ACE Inhibitors can directly block this cycle, hence their preference in heart failure. Big takeaway? In uncomplicated hypertensive patients, consider thiazide diuretics. When comorbidities, especially heart failure, are introduced, then consider ACE Inhibitors. References Carey RM, Moran AE, Whelton PK. Treatment of Hypertension: A Review. JAMA. 2022;328(18):1849-1861. doi:10.1001/jama.2022.19590 Fan M, Zhang J, Lee CL, Zhang J, Feng L. Structure and thiazide inhibition mechanism of the human Na-Cl cotransporter. Nature. 2023;614(7949):788-793. doi:10.1038/s41586-023-05718-0 Hripcsak G, Suchard MA, Shea S, et al. Comparison of Cardiovascular and Safety Outcomes of Chlorthalidone vs Hydrochlorothiazide to Treat Hypertension. JAMA Internal Medicine. 2020;180(4):542-551. doi:10.1001/jamainternmed.2019.7454 Yu D, Li JX, Cheng Y, et al. Comparative efficacy of different antihypertensive drug classes for stroke prevention: A network meta-analysis of randomized controlled trials. PLoS One. 2025;20(2):e0313309. doi:10.1371/journal.pone.0313309 Summarized by Dan Orbidan, OMS2 | Edited by Dan Orbidan & Jorge Chalit, OMS4 Donate:
/episode/index/show/emergencymedicalminute/id/37214390
info_outline
Episode 962: HEART Score
06/23/2025
Episode 962: HEART Score
Contributor: Taylor Lynch, MD Educational Pearls: How do we risk-stratify chest-pain patients? One option is the HEART score This score predicts a patient’s 6-week risk of a major adverse cardiac event. Ex. Cath procedure, CABG, PCI, death H stands for History Ask 1) Was the patient diaphoretic? 2) Did they have nausea and/or vomiting? 3) Did the pain radiate down the right or left arm? 4) Was it exertional? Yes to one = one point. Two or more = two points. E stands for EKG One point for left ventricular hypertrophy, t-wave inversions, new bundle-branch blocks. No points for first degree AV block, benign early repolarization, or QT-prolongation Two points for ST-depression A stands for Age >65 gets two points 45-64 gets one point R stands for Risk factors Hypertension, hyperlipidemia, diabetes, obesity, family history, smoking, previous MI, previous CABG, stroke, peripheral arterial disease 1-2 risk factors get 1 point More than two risk factors gets two points T stands for Troponin 1-3x upper limit of normal gets one point >3x upper limit of normal gets two points This gives you a score between zero and ten 0-3 points, patients have a ~2% chance of an adverse event These patients likely go home 4-6 points, patients have a ~20% chance of an adverse event These patients get admitted or expedited outpatient stress test/echo 7-10 points, patients have a ~60% chance of an adverse event Admit and call cardiology. These patients likely get catheterized References Backus BE, Six AJ, Kelder JC, Bosschaert MA, Mast EG, Mosterd A, Veldkamp RF, Wardeh AJ, Tio R, Braam R, Monnink SH, van Tooren R, Mast TP, van den Akker F, Cramer MJ, Poldervaart JM, Hoes AW, Doevendans PA. A prospective validation of the HEART score for chest pain patients at the emergency department. Int J Cardiol. 2013 Oct 3;168(3):2153-8. doi: 10.1016/j.ijcard.2013.01.255. Epub 2013 Mar 7. PMID: 23465250. Laureano-Phillips J, Robinson RD, Aryal S, Blair S, Wilson D, Boyd K, Schrader CD, Zenarosa NR, Wang H. HEART Score Risk Stratification of Low-Risk Chest Pain Patients in the Emergency Department: A Systematic Review and Meta-Analysis. Ann Emerg Med. 2019 Aug;74(2):187-203. doi: 10.1016/j.annemergmed.2018.12.010. Epub 2019 Feb 2. PMID: 30718010. Summarized by Jeffrey Olson, MS4 | Edited by Jorge Chalit, OMS4 Donate: https://emergencymedicalminute.org/donate/
/episode/index/show/emergencymedicalminute/id/37109650
info_outline
Episode 961: Cell Phone Sign
06/16/2025
Episode 961: Cell Phone Sign
Contributor: Aaron Lessen, MD Educational Pearls: A prospective study at the Mayo Clinic Rochester was conducted to examine whether patients actively using their phones on initial assessment in the ED was associated with higher discharge rates The study included 292 patients, and only about 15% of patients were on their phone The patients on their phone tended to be a younger demographic Scribes were trained to record the data during their shifts The results did show that patients on their phone have a higher rate of discharge 94% chance of discharge if the patient is on their phone 64% chance of discharge if the patient is not on their phone This concept can potentially contribute to improving triage decisions References Garcia SI, Jacobson A, Moore GP, Frank J, Gifford W, Johnson S, Lazaro-Paulina D, Mullan A, Finch AS. Airway, breathing, cellphone: a new vital sign? Int J Emerg Med. 2024 Nov 22;17(1):177. doi: 10.1186/s12245-024-00769-0. PMID: 39578750; PMCID: PMC11583604. Summarized by Meg Joyce, MS2 | Edited by Meg Joyce & Jorge Chalit, OMS4 Donate:
/episode/index/show/emergencymedicalminute/id/37021140
info_outline
Episode 960: Frank's Sign - A Marker for Coronary Artery Disease
06/09/2025
Episode 960: Frank's Sign - A Marker for Coronary Artery Disease
Contributor: Travis Barlock MD Educational Pearls Frank’s sign is a curious physical exam finding first described in the literature in 1973 Bilateral earlobe creases are recognized as a marker of coronary artery disease and cerebrovascular disease Some studies have found an increase in all-cause mortality in patients with bilateral diagonal earlobe creases The pathophysiology is still not fully understood One 2020 study found histopathological changes associated with diagonal earlobe creases, potentially linking them via a model of hypoxia/reoxygenation References Elliott WJ, Karrison T. Increased all-cause and cardiac morbidity and mortality associated with the diagonal earlobe crease: a prospective cohort study. Am J Med. 1991;91(3):247-254. doi:10.1016/0002-9343(91)90123-f Nazzal S, Hijazi B, Khalila L, Blum A. Diagonal Earlobe Crease (Frank's Sign): A Predictor of Cerebral Vascular Events. Am J Med. 2017;130(11):1324.e1-1324.e5. doi:10.1016/j.amjmed.2017.03.059 Stoyanov GS, Dzhenkov D, Petkova L, Sapundzhiev N, Georgiev S. The Histological Basis of Frank's Sign. Head Neck Pathol. 2021;15(2):402-407. doi:10.1007/s12105-020-01205-4 Summarized & Edited by Jorge Chalit, OMS4 Donate: https://emergencymedicalminute.org/donate/
/episode/index/show/emergencymedicalminute/id/36908365
info_outline
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
info_outline
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
info_outline
Episode 957: Cardiac Asthma
05/19/2025
Episode 957: Cardiac Asthma
Contributor: Travis Barlock, MD Educational Pearls: Wheezing is classically heard in asthma and COPD, but it can be the result of a wide range of processes that cause airflow limitation Narrowed bronchioles lead to turbulent airflow → creates the wheezing Crackles (rales) suggest pulmonary edema which is often due to heart failure Approximately 35% of heart failure patients have bronchial edema, which can also produce wheezing COPD and heart failure can coexist in a patient, and both of these diseases can cause wheezing It’s vital to differentiate whether the wheezing is due to the patient’s COPD or their heart failure because the treatment differs Diagnosing wheezing due to heart failure (cardiac asthma): Symptoms: orthopnea, paroxysmal nocturnal dyspnea Diagnostic tools: bedside ultrasound Treatment: diuresis and BiPAP for respiratory support Not all wheezing is asthma Consider heart failure in the differential and tailor treatment accordingly References 1. Buckner K. Cardiac asthma. Immunol Allergy Clin North Am. 2013 Feb;33(1):35-44. doi: 10.1016/j.iac.2012.10.012. Epub 2012 Dec 23. PMID: 23337063. 2. Hollingsworth HM. Wheezing and stridor. Clin Chest Med. 1987 Jun;8(2):231-40. PMID: 3304813. Summarized by Meg Joyce, MS1 | Edited by Meg Joyce & Jorge Chalit, OMS3 Donate:
/episode/index/show/emergencymedicalminute/id/36620785
info_outline
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
info_outline
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
info_outline
Episode 954: Combo Rescue Inhalers - New Guidelines
04/30/2025
Episode 954: Combo Rescue Inhalers - New Guidelines
Contributor: Aaron Lessen, MD Educational Pearls: What is a Rescue Inhaler? A rescue inhaler is a medication for people with asthma to quickly reverse the symptoms of an asthma attack. Historically albuterol (Short Acting Beta Agonist (SABA)) monotherapy has been the mainstay rescue inhaler. This is because albuterol works fast and is relatively cheap. \n\n What are Combination Rescue Inhalers? Combination rescue inhalers contain a fast-acting bronchodilator as well as an inhaled corticosteroid (ICS) The steroid helps to reduce some of the chronic airway inflammation that is worsening the asthma attack and can help to prevent future attacks Examples include budesonide-formoterol and albuterol-budesonide Global Initiative for Asthma (GINA), states that combination therapy is now the preferred reliever for adults and adolescents with mild asthma What are the drawbacks of Combination Rescue Inhalers? These inhalers are generally more expensive than just using a SABA inhaler which can be a barrier for some people \n\n Improper use can also lead to conditions like thrush due to the addition of the steroid References Krings JG, Beasley R. The Role of ICS-Containing Rescue Therapy Versus SABA Alone in Asthma Management Today. J Allergy Clin Immunol Pract. 2024 Apr;12(4):870-879. doi: 10.1016/j.jaip.2024.01.011. Epub 2024 Jan 17. PMID: 38237858; PMCID: PMC10999356. Papi A, Chipps BE, Beasley R, Panettieri RA Jr, Israel E, Cooper M, Dunsire L, Jeynes-Ellis A, Johnsson E, Rees R, Cappelletti C, Albers FC. Albuterol-Budesonide Fixed-Dose Combination Rescue Inhaler for Asthma. N Engl J Med. 2022 Jun 2;386(22):2071-2083. doi: 10.1056/NEJMoa2203163. Epub 2022 May 15. PMID: 35569035. Summarized by Jeffrey Olson, MS3 | Edited by Jorge Chalit, OMS3 \n\n Donate:
/episode/index/show/emergencymedicalminute/id/36334105
info_outline
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
info_outline
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
info_outline
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
info_outline
Episode 950: Ultrasound Pulse Check During Cardiac Arrest
03/31/2025
Episode 950: Ultrasound Pulse Check During Cardiac Arrest
Contributor: Aaron Lessen, MD Educational Pearls: Point-of-care ultrasound (POCUS) is used to assess cardiac activity during cardiac arrest and can identify potential reversible causes such as pericardial tamponade Ultrasound could be beneficial in another way during cardiac arrest as well: pulse checks Manual palpation for detecting pulses is imperfect, with false positives and negatives Doppler ultrasound can be used as an adjunct or replacement to manual palpation for improved accuracy Options for Doppler ultrasound of carotid or femoral pulses during cardiac arrest: Visualize arterial pulsation Use color doppler Numerically quantify the flow and correlate this to a BP reading - slightly more complex Doppler ultrasound is much faster than manual palpation for pulse check Can provide information almost instantaneously without waiting the full 10 seconds for a manual pulse check The main priority during cardiac arrest resuscitation is to maintain quality compressions If pulses are unable to be obtained through Doppler within the 10-second window, resume compressions and try again during the next pulse check References Cohen AL, Li T, Becker LB, Owens C, Singh N, Gold A, Nelson MJ, Jafari D, Haddad G, Nello AV, Rolston DM; Northwell Health Biostatistics Unit. Femoral artery Doppler ultrasound is more accurate than manual palpation for pulse detection in cardiac arrest. Resuscitation. 2022 Apr;173:156-165. doi: 10.1016/j.resuscitation.2022.01.030. Epub 2022 Feb 4. PMID: 35131404. Summarized by Meg Joyce, MS1 | Edited by Meg Joyce & Jorge Chalit, OMS3 Donate:
/episode/index/show/emergencymedicalminute/id/35930050
info_outline
Episode 949: Hoover's Sign
03/24/2025
Episode 949: Hoover's Sign
Contributor: Travis Barlock, MD Educational Pearls: What is Hoover’s sign used to identify? This physical exam maneuver differentiates between organic vs. functional (previously known as psychogenic) leg weakness. Organic causes include disease processes such as stroke, MS, spinal cord compression, guillain-barre, ALS, and sciatica, among others In Functional Neurologic Disorder, the dysfunction is in brain signaling, and treatment relies on more of a psychiatric approach How is Hoover's Sign performed? Place your hand under the heel of the unaffected leg and ask the patient to attempt to lift the paralyzed leg. If the paralysis is due to an organic cause, then you should feel the unaffected leg push down. This is due to the crossed-extensor reflex mechanism, an unconscious motor control function mediated by the corticospinal tract. If you don’t feel the opposite heel push down, that is a positive Hoover’s Sign. How sensitive/specific is it? An unblinded cohort study in patients with suspected stroke found a sensitivity of 63% and a specificity of 100% Fun Fact There’s also a pulmonary Hoover’s sign, named after the same doctor, Charles Franklin Hoover, which refers to paradoxical inward movement of the lower ribs during inspiration due to diaphragmatic flattening in COPD. References McWhirter L, Stone J, Sandercock P, Whiteley W. Hoover's sign for the diagnosis of functional weakness: a prospective unblinded cohort study in patients with suspected stroke. J Psychosom Res. 2011 Dec;71(6):384-6. doi: 10.1016/j.jpsychores.2011.09.003. Epub 2011 Oct 6. PMID: 22118379. Stone J, Aybek S. Functional limb weakness and paralysis. Handb Clin Neurol. 2016;139:213-228. doi: 10.1016/B978-0-12-801772-2.00018-7. PMID: 27719840. Summarized by Jeffrey Olson, MS3 | Edited by Jorge Chalit, OMS3 Donate:
/episode/index/show/emergencymedicalminute/id/35832805
info_outline
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
info_outline
Episode 947: Hypercapnia
03/10/2025
Episode 947: Hypercapnia
Educational Pearls: Physiologic stimulation of ventilation occurs through changes in levels of: Arterial carbon dioxide (PaCO2) Arterial oxygen (PaO2) Hypercapnia is an elevated level of CO2 in the blood - this primarily drives ventilation Hypoxia is a decreased level of O2 in the body’s tissues - the backup drive for ventilation Patients at risk of hypercapnia should maintain an O2 saturation between 88-92% Normal O2 saturation is 95-100% In patients who chronically retain CO2, their main drive for ventilation becomes hypoxia An audit was performed of SpO2 observations of all patients with a target range of 88–92% at a single hospital over a four-year period This found that excessive oxygen administration was more common than insufficient oxygen and is associated with an increased risk of harm Individuals at risk of hypercapnia include but are not limited to patients with COPD, hypoventilation syndrome, or altered mental status References Homayoun Kazemi, Douglas C. Johnson, Respiration, Editor(s): V.S. Ramachandran, Encyclopedia of the Human Brain, Academic Press, 2002, Pages 209-216, ISBN 9780122272103, https://doi.org/10.1016/B0-12-227210-2/00302-2. O'Driscoll BR, Bakerly ND. Are we giving too much oxygen to patients at risk of hypercapnia? Real world data from a large teaching hospital. Respir Med. 2025 Mar;238:107965. doi: 10.1016/j.rmed.2025.107965. Epub 2025 Jan 30. PMID: 39892771. Summarized by Meg Joyce, MS1 | Edited by Meg Joyce & Jorge Chalit, OMS3 Donate:
/episode/index/show/emergencymedicalminute/id/35602200
info_outline
Episode 946: Time to Defibrillation
03/03/2025
Episode 946: Time to Defibrillation
Contributor: Aaron Lessen, MD Educational Pearls: Quick background info Cardiac arrest is when the heart stops pumping blood for any reason. This is different from a heart attack in which the heart is still working but the muscle itself is starting to die. One cause of cardiac arrest is when the electrical signals are very disrupted in the heart and start following chaotic patterns such as Ventricular tachycardia (VTach) and Ventricular fibrillation (VFib) One of the only ways to save a person whose heart is in VFib or VTach is to jolt the heart with electricity and terminate the dangerous arrhythmia. A recent study in the Netherlands looked at how important the time delay is from when cardiac arrest is first identified to when a defibrillation shock from an Automated External Defibrillator (AED) is actually given. Their main take-away: each minute defibrillation is delayed drops the survival rate by 6%! These findings reinforce the importance of rapid AED deployment and early defibrillation strategies in prehospital cardiac arrest response. References Stieglis, R., Verkaik, B. J., Tan, H. L., Koster, R. W., van Schuppen, H., & van der Werf, C. (2025). Association Between Delay to First Shock and Successful First-Shock Ventricular Fibrillation Termination in Patients With Witnessed Out-of-Hospital Cardiac Arrest. Circulation, 151(3), 235–244. https://doi.org/10.1161/CIRCULATIONAHA.124.069834 Summarized by Jeffrey Olson, MS3 | Edited by Meg Joyce, MS1 & Jorge Chalit, OMS3 Donate:
/episode/index/show/emergencymedicalminute/id/35507490
info_outline
Episode 945: Ketorolac vs. Ibuprofen
02/24/2025
Episode 945: Ketorolac vs. Ibuprofen
Contributor: Ricky Dhaliwal, MD Educational Pearls: Ketorolac and ibuprofen are NSAIDs with equivalent efficacy for pain in the emergency department Oral ibuprofen provides the same relief as intramuscular ketorolac IM ketorolac is associated with the adverse effect of a painful injection IM ketorolac is slightly faster in onset but not significant Studies have assessed the two medications in head-to-head randomized-controlled trials and found no significant difference in pain scores IM ketorolac takes longer to administer and has a higher cost Ketorolac dosing Commonly given in 10 mg, 15 mg, and 30 mg doses However, higher doses are associated with more adverse effects Gastrointestinal upset, nausea, and bleeding risk Studies have demonstrated equal efficacy in pain reduction with lower doses References Motov S, Yasavolian M, Likourezos A, et al. Comparison of Intravenous Ketorolac at Three Single-Dose Regimens for Treating Acute Pain in the Emergency Department: A Randomized Controlled Trial. Ann Emerg Med. 2017;70(2):177-184. doi:10.1016/j.annemergmed.2016.10.014 Neighbor ML, Puntillo KA. Intramuscular ketorolac vs oral ibuprofen in emergency department patients with acute pain. Acad Emerg Med. 1998;5(2):118-122. doi:10.1111/j.1553-2712.1998.tb02595.x Summarized & Edited by Jorge Chalit, OMS3 Donate:
/episode/index/show/emergencymedicalminute/id/35402870
info_outline
Episode 944: Colchicine Overdose
02/17/2025
Episode 944: Colchicine Overdose
Contributor: Aaron Lessen, MD Educational Pearls: Colchicine is most commonly used for the prevention and treatment of gout There is research investigating the anti-inflammatory and cardioprotective effects of colchicine This drug has a narrow therapeutic index: a small margin between effective dose and toxic dose Colchicine overdoses can be unintentional or intentional and are associated with poor outcomes Phase 1: 10 - 24 hours after ingestion Patient looks well but may have mild symptoms mimicking gastroenteritis Phase 2: 24 hours - 7 days after ingestion Multiple organ dysfunction syndrome (MODS) Phase 3: recovery is usually within a few weeks of ingestion Treatment for colchicine overdose Treat early and aggressively Gastrointestinal decontamination with activated charcoal and orogastric lavage Dialysis and ECMO for MODS treatment References Finkelstein Y, Aks SE, Hutson JR, Juurlink DN, Nguyen P, Dubnov-Raz G, Pollak U, Koren G, Bentur Y. Colchicine poisoning: the dark side of an ancient drug. Clin Toxicol (Phila). 2010 Jun;48(5):407-14. doi: 10.3109/15563650.2010.495348. PMID: 20586571. Gasparyan AY, Ayvazyan L, Yessirkepov M, Kitas GD. Colchicine as an anti-inflammatory and cardioprotective agent. Expert Opin Drug Metab Toxicol. 2015;11(11):1781-94. doi: 10.1517/17425255.2015.1076391. Epub 2015 Aug 4. PMID: 26239119. Summarized by Meg Joyce, MS1 | Edited by Meg Joyce & Jorge Chalit, OMS3 Donate:
/episode/index/show/emergencymedicalminute/id/35309445
info_outline
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
info_outline
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
info_outline
Episode 941: Rehydration in Pediatric Gastroenteritis
01/27/2025
Episode 941: Rehydration in Pediatric Gastroenteritis
Contributor: Meghan Hurley, MD Educational Pearls: Gastroenteritis clinical diagnoses: Diarrhea with or without vomiting and fever Vomiting in the absence of diarrhea has a large list of differential diagnoses, so the combination of diarrhea and vomiting in a patient is helpful to indicate the gastroenteritis diagnosis Symptom timeline is usually 1-3 days, but can last up to 14 days – diarrhea persists the longest Treatment for mild to moderate dehydration: oral or IV rehydration Begin orally to avoid unnecessary IV in a pediatric patient Administer ODT Ondansetron (Zofran) to prevent vomiting Meta-analysis showed that 2-8 mg orally, based on body weight, decreased vomiting quickly Wait 15-20 minutes for the medication to take effect Use streamlined method for oral rehydration: Fluids such as over-the-counter Pedialyte, Infalyte, Rehydrate, Resol, and Naturalyte may be used If patient weighs less than 10kg: administer 5mL of fluid per minute for 20 minutes If patient weighs 10kg or more: administer 10mL of fluid for 20 minutes If the patient can keep the fluid down, double the fluid volume and repeat If the patient once again keeps the fluid down, double the fluid volume and repeat If successful with each attempt, the patient may be discharged home Can prescribe ODT Zofran for 1-2 days at home If the patient vomits more than once during this oral rehydration process, intravenous rehydration must be initiated References Churgay CA, Aftab Z. Gastroenteritis in children: Part II. Prevention and management. Am Fam Physician. 2012 Jun 1;85(11):1066-70. PMID: 22962878. Summarized by Meg Joyce, MS1 | Edited by Meg Joyce & Jorge Chalit, OMS3 Donate:
/episode/index/show/emergencymedicalminute/id/35023895
info_outline
Episode 940: Laceration Repair Methods
01/20/2025
Episode 940: Laceration Repair Methods
Contributor: Aaron Lessen, MD Educational Pearls: If a patient sustains a cut, the provider has several options on how to close the wound. If they choose to suture the wound closed, it involves needles both in the form of injecting numbing medication (lidocaine) as well as with the suture itself. Other techniques are “needleless,” like closing the wound with adhesive strips (Steri-Strips) or skin adhesive (Dermabond). But which method is best? A recent study looked to compare guardian-perceived cosmetic outcomes of pediatric lacerations repaired with absorbable sutures, Dermabond, and Steri-Strips. It also assessed pain and satisfaction with the procedure from both guardian and provider perspectives. Participants: 55 patients were enrolled; 30 completed the 3-month follow-up. Cosmetic Ratings (Median and IQR): Sutures: 70.5 (59.8–76.8) Dermabond: 85 (73–90) Steri-Strips: 67 (55–78) (P = 0.254, no statistically significant difference) Satisfaction and Pain: No significant differences in guardian or provider satisfaction Pain levels were comparable across all methods Even though there was no statistically significant difference in guardian-perceived cosmetic outcomes, the Dermabond did have the highest ratings at the end of the study. References Barton, M. S., Chaumet, M. S. G., Hayes, J., Hennessy, C., Lindsell, C., Wormer, B. A., Kassis, S. A., Ciener, D., & Hanson, H. (2024). A Randomized Controlled Comparison of Guardian-Perceived Cosmetic Outcome of Simple Lacerations Repaired With Either Dermabond, Steri-Strips, or Absorbable Sutures. Pediatric emergency care, 40(10), 700–704. https://doi.org/10.1097/PEC.0000000000003244 Summarized by Jeffrey Olson MS3 | Edited by Meg Joyce, MS1 & Jorge Chalit, OMS3 Donate: https://emergencymedicalminute.org/donate/
/episode/index/show/emergencymedicalminute/id/34918770
info_outline
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