Contributor: Aaron Lessen MD
Educational Pearls:
Induction agent selection during rapid sequence intubation involves accounting for hemodynamic stability in the post-intubation setting
Many emergency departments use ketamine or etomidate
A recent study sought to explore the rates of post-induction hypotension of ketamine compared with propofol
Single center retrospective cohort study of patients between 2018-2021
Ketamine and propofol were both significantly associated with post-induction hypotension
Ketamine adjusted odds ratio = 4.50
Propofol adjusted odds ratio = 4.88
50% of patients became hypotensive after induction with either propofol or ketamine
References
Tamsett Z, Douglas N, King C, et al. Does the choice of induction agent in rapid sequence intubation in the emergency department influence the incidence of post-induction hypotension?. Emerg Med Australas. 2024;36(3):340-347. doi:10.1111/1742-6723.14355
Summarized & Edited by Jorge Chalit, OMS3
Donate: https://emergencymedicalminute.org/donate/
Contributor: Aaron Lessen MD
Educational Pearls:
Can opioids cause cardiac arrest?
Opioids can cause respiratory suppression and the subsequent low oxygen levels can lead to arrhythmias and eventually cardiac arrest.
In 2023, 17% of out-of-hospital cardiac arrests (OHCA) were attributable to opioids.
Given that this is a rising cause of cardiac arrest, should we just treat all cardiac arrest with naloxone (Narcan)?
Naloxone is correlated with an increased chance of return of spontaneous circulation (ROSC)
Additionally, a wide variety of individuals can be exposed to opioids and therefore opioid overdose should be considered in all cases of OHCA
But does naloxone improve neurologic outcomes?
Yes, naloxone, especially when given early on in the resuscitation can improve neuro outcomes
What is the dose?
2-4 mg IN/IV depending on access.
High suspicion for opioid overdose consider going with an even higher dose such as 4-8 mg IN/IV
References
Orkin, A. M., & Dezfulian, C. (2024). Recognizing the fastest growing cause of out-of-hospital cardiac arrest. Resuscitation, 198, 110206. https://doi.org/10.1016/j.resuscitation.2024.110206
Quinn, E., & Du Pont, D. (2024). Naloxone administration in out-of-hospital cardiac arrest: What's next?. Resuscitation, 201, 110307. https://doi.org/10.1016/j.resuscitation.2024.110307
Saybolt, M. D., Alter, S. M., Dos Santos, F., Calello, D. P., Rynn, K. O., Nelson, D. A., & Merlin, M. A. (2010). Naloxone in cardiac arrest with suspected opioid overdoses. Resuscitation, 81(1), 42–46. https://doi.org/10.1016/j.resuscitation.2009.09.016
Wampler D. A. (2024). Naloxone in Out-of-Hospital Cardiac Arrest-More Than Just Opioid Reversal. JAMA network open, 7(8), e2429131. https://doi.org/10.1001/jamanetworkopen.2024.29131
Summarized by Jeffrey Olson, MS3 | Edited by Meg Joyce MS1 & Jorge Chalit, OMS3
Contributor: Aaron Lessen MD
Educational Pearls:
A study evaluated the patient-care impact and financial costs of holding patients in the ED, a nationwide issue
Prospective, observational study of acute stroke management
Conducted at a large urban, comprehensive stroke center
The study evaluated patients in multiple categories:
admitted to med/surg
admitted to med/surg but held in the ED
admitted to the ICU
Admitted to ICU but held in the ED
Examined the amount of time nurses and providers spent with each patient
This was analyzed in conjunction with the knowledge of each providers’ salaries and the overhead costs of the med/surg unit, ICU, and ED
Conclusions:
Patients who required med/surg inpatient care but who were held in the ED resulted in a doubled daily cost
$1856 for med/surg inpatient boarding vs $993 for med/surg inpatient care
Patients who required ICU care but who were held in the ED also resulted in an increased daily cost, but this difference was not as large
$2267 for ICU inpatient boarding vs $2165 for ICU care
Holding in the ED negatively impacts patients since they receive less time from providers
Holding also results in increased financial costs
References
Canellas MM, Jewell M, Edwards JL, Olivier D, Jun-O’Connell AH, Reznek MA. Measurement of Cost of Boarding in the Emergency Department Using Time-Driven Activity-Based Costing. Annals of emergency medicine. Published online May 1, 2024. doi:https://doi.org/10.1016/j.annemergmed.2024.04.012
Summarized by Meg Joyce, MS1 | Edited by Meg Joyce & Jorge Chalit, OMS3
Donate: https://emergencymedicalminute.org/donate/
Contributor: Aaron Lessen MD
Educational Pearls:
Aortic injury occurs in 1.5-2% of patients who sustain blunt thoracic trauma
Majority are caused by automobile collisions or motorcycle accidents
Due to sudden deceleration mechanism accidents
Clinical manifestations
Signs of hypovolemic shock including tachycardia and hypotension, though not always present
Patients may have altered mental status
Imaging
Widened mediastinum on chest x-ray, though not highly sensitive
CT is more sensitive and specific, and signs of thoracic injury include an intimal flap, aortic wall outpouching, and aortic contour abnormalities
In hemodynamically unstable or otherwise unfit for CT patients, transesophageal echocardiogram may be used
Four types of aortic injury (in order of ascending severity)
I: Intimal tear or flap
II: Intramural hematoma
III: Pseudoaneurysm
IV: Rupture
Management
Hemodynamically unstable: immediate OR for exploratory laparotomy and repair
Hemodynamically stable: heart rate and blood pressure control with beta-blockers
Minor injuries are treated with observation and hemodynamic control
Severe injuries may receive surgical management
Some patients benefit from delayed repair
An endovascular aortic graft is a surgical option
Mortality
80-85% of patients die before hospital arrival
50% of patients that make it to the hospital do not survive
References
Fox N, Schwartz D, Salazar JH, et al. Evaluation and management of blunt traumatic aortic injury: a practice management guideline from the Eastern Association for the Surgery of Trauma [published correction appears in J Trauma Acute Care Surg. 2015 Feb;78(2):447]. J Trauma Acute Care Surg. 2015;78(1):136-146. doi:10.1097/TA.0000000000000470
Lee WA, Matsumura JS, Mitchell RS, et al. Endovascular repair of traumatic thoracic aortic injury: clinical practice guidelines of the Society for Vascular Surgery. J Vasc Surg. 2011;53(1):187-192. doi:10.1016/j.jvs.2010.08.027
Osgood MJ, Heck JM, Rellinger EJ, et al. Natural history of grade I-II blunt traumatic aortic injury. J Vasc Surg. 2014;59(2):334-341. doi:10.1016/j.jvs.2013.09.007
Osman A, Fong CP, Wahab SFA, Panebianco N, Teran F. Transesophageal Echocardiography at the Golden Hour: Identification of Blunt Traumatic Aortic Injuries in the Emergency Department. J Emerg Med. 2020;59(3):418-423. doi:10.1016/j.jemermed.2020.05.003
Steenburg SD, Ravenel JG, Ikonomidis JS, Schönholz C, Reeves S. Acute traumatic aortic injury: imaging evaluation and management. Radiology. 2008;248(3):748-762. doi:10.1148/radiol.2483071416
Summarized by Jorge Chalit, OMS3 | Edited by Meg Joyce & Jorge Chalit
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Laboring Under Pressure Episode 4: Obstetric Emergency in South Africa with Dr. Meghan Hurley
Contributors: Meghan Hurley MD, Travis Barlock MD, Jeffrey Olson MS3
Show Pearls
Map of South Africa Referenced
South Africa Geography Lesson
There is a big disparity between Cape Town and its neighbor Khayelitsha.
Cape Town is the legislative capital and economic hub of South Africa, known for its infrastructure, tourist attractions, and developed urban areas.
Khayelitsha Township is a large informal settlement on the outskirts of Cape Town, with limited infrastructure and services compared to the city center. Many residents live in informal housing.
This disparity is the lasting effect of how land was divided up and populations were moved around during Apartheid.
Apartheid was a policy of segregation that lasted from 1948 to 1994.
How does medical education work in South Africa?
Medical education in South Africa typically follows a 6-year undergraduate program directly after high school
Registrars our the equivalent of Resident in America. They are graduated doctors who work in hospitals under the supervision of senior doctors as they progress toward becoming specialists.
Pearls from the case and the discussion afterward
Whole blood from a draw can be used instead of urine on a POC pregnancy test. Wait a little bit longer before making a determination because blood is more viscous. Although the casettes are not approved for whole blood several studies have shown this to be efficacious.
Free fluid in the abdomen and a pregnancy of unknown location is a rupture ectopic until proven otherwise.
Appendicitis can present on the left side. Most commonly from an extra appendix, but can also result from situs inversus or mid-gut malrotation. This presentation can also be the result of an atypically large appendix.
Fever is common in appendicitis (~40%) and becomes less common with older patients.
Don’t be falsely reassured by a normal hemoglobin in acute bleeding because patients bleed whole blood and the hemoglobin concentration is not affected. These patients should be resuscitated with whole blood.
Give rhesus factor negative blood to female patients of childbearing age to prevent them from developing antibodies to the rhesus factor which can lead to Rh disease in future pregnancies.
Rhogam can be given in cases of ruptured ectopic pregnancies to lower the risk of alloimmunization.
Blood transfusions carry the risk of lung and heart injury from the extra volume. The treatment for this condition is to diurese the patient.
Other topics discussed include the complications of working in a South African township hospital at night, the epidemiology of burns, and the importance of global health.
References
Akbulut S, Ulku A, Senol A, Tas M, Yagmur Y. Left-sided appendicitis: review of 95 published cases and a case report. World J Gastroenterol. 2010 Nov 28;16(44):5598-602. doi: 10.3748/wjg.v16.i44.5598. PMID: 21105193; PMCID: PMC2992678.
Barash, J. H., Buchanan, E. M., & Hillson, C. (2014). Diagnosis and management of ectopic pregnancy. American family physician, 90(1), 34–40.
Fromm C, Likourezos A, Haines L, Khan AN, Williams J, Berezow J. Substituting whole blood for urine in a bedside pregnancy test. J Emerg Med. 2012 Sep;43(3):478-82. doi: 10.1016/j.jemermed.2011.05.028. Epub 2011 Aug 27. PMID: 21875776.
Moris, D., Paulson, E. K., & Pappas, T. N. (2021). Diagnosis and Management of Acute Appendicitis in Adults: A Review. JAMA, 326(22), 2299–2311. https://doi.org/10.1001/jama.2021.20502
Sowder AM, Yarbrough ML, Nerenz RD, Mitsios JV, Mortensen R, Gronowski AM, Grenache DG. Analytical performance evaluation of the i-STAT Total β-human chorionic gonadotropin immunoassay. Clin Chim Acta. 2015 Jun 15;446:165-70. doi: 10.1016/j.cca.2015.04.025. Epub 2015 Apr 25. PMID: 25916696.
Produced by Jeffrey Olson, MS3 | Edited by Jeffrey Olson and Jorge Chalit, OMSIII
Contributor: Taylor Lynch, MD
Educational Pearls:
What is neutropenic fever?
Specific type of fever that is seen in cancer patients and other patients with impaired immune systems
These patients are highly susceptible to infection
Typically occurs 7-10 days after the last chemotherapy dose, this is when the immune system is the weakest
It is useful to know the specific type of malignancy. For example, heme malignancies (ALL, AML, etc.) have more intense chemo and are at higher risk of neutropenic fever
To qualify as a neutropenic fever, a patient must have one recorded temperature greater than 38.3 degrees C or be over 38 degrees C for one hour.
The severity of the neutropenic fever is established by the absolute neutrophil count. Abs neutrophil count under 1500 is mild, less than 1000 is moderate, less than 500 is severe.
Also look at monocytes (cell that becomes a macrophage). Less than 200 is very concerning
What is the workup and treatment?
Obtain a panculture (culture blood from both arms and all indwelling lines), obtain urine culture, and get a chest x-ray.
Do not preform a rectal exam or obtain a rectal core temperature. This could cause bacteremia.
Treat with Cefepime (broad range and includes pseudomonas but not MRSA). If there is concern for MRSA add vancomycin.
Admit with Neutropenic precautions (gowns, gloves, mask, positive pressure room)
References
Peseski, A. M., McClean, M., Green, S. D., Beeler, C., & Konig, H. (2021). Management of fever and neutropenia in the adult patient with acute myeloid leukemia. Expert review of anti-infective therapy, 19(3), 359–378. https://doi.org/10.1080/14787210.2020.1820863
Zimmer, A. J., & Freifeld, A. G. (2019). Optimal Management of Neutropenic Fever in Patients With Cancer. Journal of oncology practice, 15(1), 19–24. https://doi.org/10.1200/JOP.18.00269
Summarized by Jeffrey Olson, MS3 | Edited by Meg Joyce & Jorge Chalit, OMS3
Contributor: Jorge Chalit-Hernandez, OMS3
Typically presents with biliary colic
Right upper quadrant abdominal pain lasting more than 30 minutes and subsiding over several hours
Often associated with fatty meals but not always
Must rule out other causes of pain
Peptic ulcer disease - typically presents with epigastric pain
Pancreatitis - pain that radiates to the back or family history of pancreatitis
Laboratory workup
LFTs including ALT, AST, and alkaline phosphatase are within the reference range
Lipase and amylase within the reference range
Imaging workup
RUQ ultrasound is unremarkable
Upper endoscopy with ultrasound can help rule out peptic ulcer disease and small stones
HIDA scan may show a reduced gallbladder ejection fraction below 30-35% or it may be normal
Opiates may give false-positive results
Opiates can sometimes make biliary colic worse due to their contractile effect on the sphincter of Oddi
Some patients may benefit from surgical intervention i.e. cholecystectomy
Classic biliary-type pain (best predictor of response to cholecystectomy)
Pain for > 3 months duration
Positive HIDA scan
References
Alhayo S, Eslick GD, Cox MR. Cholescintigraphy may have a role in selecting patients with biliary dyskinesia for cholecystectomy: a systematic review. ANZ J Surg. 2020;90(9):1647-1652. doi:10.1111/ans.16003
Arshi J, Layfield LJ, Esebua M. Mast cell infiltration and activation in the gallbladder wall: Implications for the pathogenesis of functional gallbladder disorder in adult patients. Ann Diagn Pathol. 2021;54:151798. doi:10.1016/j.anndiagpath.2021.151798
Carr JA, Walls J, Bryan LJ, Snider DL. The treatment of gallbladder dyskinesia based upon symptoms: results of a 2-year, prospective, nonrandomized, concurrent cohort study. Surg Laparosc Endosc Percutan Tech. 2009;19(3):222-226. doi:10.1097/SLE.0b013e3181a74690
Joehl RJ, Koch KL, Nahrwold DL. Opioid drugs cause bile duct obstruction during hepatobiliary scans. Am J Surg. 1984;147(1):134-138. doi:10.1016/0002-9610(84)90047-3
Mahid SS, Jafri NS, Brangers BC, Minor KS, Hornung CA, Galandiuk S. Meta-analysis of cholecystectomy in symptomatic patients with positive hepatobiliary iminodiacetic acid scan results without gallstones. Arch Surg. 2009;144(2):180-187. doi:10.1001/archsurg.2008.543
Summarized & Edited by Jorge Chalit, OMS3
Donate: https://emergencymedicalminute.org/donate/
Contributor: Taylor Lynch MD
Supraventricular tachycardias (SVTs) arise above the bundle of His
The term SVT includes AV nodal reentrant tachycardia (AVNRT), atrioventricular reentrant tachycardia (AVRT), atrial tachycardia, atrial fibrillation, atrial flutter, and multifocal atrial tachycardia
AVNRT is the most common form of SVT
Paroxysmal
Spontaneous or provoked by exertion, coffee, alcohol, or thyroid disease
More common in women (3:1 women:men ratio)
HR 160-240
Narrow complex with a normal QRS
Unstable patients receive synchronized cardioversion at 0.5-1 J/kg
Valsalva maneuver is attempted before pharmaceutical interventions
Increases vagal tone at the AV node to slow conduction and prolongs its refractory period to normalize the conduction
Traditionally, patients are asked to bear down, but this only works in 17% of patients
REVERT trial assessed a modified valsalva that worked in 43% of patients
Adenosine
Slows conduction at the AV node by activating potassium channels and inhibiting calcium influx
Extremely uncomfortable for most patients
Not commonly used anymore
Nondihydropyridine calcium-channel blockers are preferred
A 2009 RCT investigated low-infusion CCBs compared with adenosine bolus
The study found a conversion rate of 98% in the CCB group vs. adenosine group at 86.5%
The main adverse effect of CCB is hypotension, which a slow infusion rate can mitigate
Diltiazem dose is 0.25 mg/kg/2min and repeat at 0.35 mg/kg/15 minutes or slow infusion at 2.5 mg/min up to a conversion or 50 mg total
References
1. Appelboam A, Reuben A, Mann C, et al. Postural modification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): A randomised controlled trial. Lancet. 2015;386(10005):1747-1753. doi:10.1016/S0140-6736(15)61485-4
Belz MK, Stambler BS, Wood MA, Pherson C, Ellenbogen KA. Effects of enhanced parasympathetic tone on atrioventricular nodal conduction during atrioventricular nodal reentrant tachycardia. Am J Cardiol. 1997;80(7):878-882. doi:10.1016/s0002-9149(97)00539-0
Lim SH, Anantharaman V, Teo WS, Chan YH. Slow infusion of calcium channel blockers compared with intravenous adenosine in the emergency treatment of supraventricular tachycardia. Resuscitation. 2009;80(5):523-528. doi:10.1016/j.resuscitation.2009.01.017
Page RL, Joglar JA, Caldwell MA, et al. 2015 ACC/AHA/HRS Guideline for the Management of Adult Patients With Supraventricular Tachycardia: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society [published correction appears in Circulation. 2016 Sep 13;134(11):e234-5. doi: 10.1161/CIR.0000000000000448]. Circulation. 2016;133(14):e506-e574. doi:10.1161/CIR.0000000000000311
Summarized & Edited by Jorge Chalit, OMS3
Donate: https://emergencymedicalminute.org/donate/
Contributor: Aaron Lessen, MD
Educational Pearls:
Pediatric case study where the child’s tongue was stuck in the opening of a hard plastic drink lid
Entrapment restricts circulation which causes fluid to build and the tongue becomes more edematous with time
There is a risk of ischemia with prolonged entrapment
Initially tried 2% viscous lidocaine for analgesia and lubricant
The ER recognized that this mucosal, edematous tongue could benefit from the trick for ostomies and rectal prolapses → table sugar!
Sugar granules absorb water which decreases tissue edema
This option avoids sedation and aggressive treatment
References
A Young Girl with Tongue Swelling Jarjour, Jane et al. Annals of Emergency Medicine, Volume 84, Issue 3, 317 - 318
Summarized by Meg Joyce, MS1 | Edited by Meg Joyce & Jorge Chalit, OMS3
Donate: https://emergencymedicalminute.org/donate/
Contributor: Megan Hurley, MD
Educational Pearls:
Fevers
Tylenol
Up until 20 weeks NSAIDs are ok but after 20 weeks they are contraindicated
Can limit the amount of amniotic fluid produced
Can lead to growth restriction
Can cause premature closure of the ductus arteriosus
Cough
Cough drops
Humidifier
Guafenesine and dextromethorphan (Mucinex) is not well studied but is probably ok with caution in certain circumstances such as post-tussive emesis causing poor PO intake and weight loss
Congestion
Flonase (Fluticasone nasal spray)
Nasal rinses
Humidifier
1st generation anti-histamines (Diphenhydramine, Doxylamine, etc.)
However, these tend to have more side effects such as fatigue, drowsiness, and dizziness
Concider switching to a 2nd generation (Cetirizine, Loratidine, etc.) during the day
Disease specific treatments
Flu (A and B) gets tamiflu (Oseltamivir)
Covid gets paxlovid (Nirmatrelvir/ritonavir)
Antibiotics for suspected pneumonia
Additional recommendations
Elevating the head of bed
Nasal strips
Stay well hydrated
Tea
Ice chips
Echinacea
Zinc
Rest
Avoid
NSAIDs
Pseudophedrine
Afrin (Oxymetazoline)
Combined meds in general
References
Antonucci, R., Zaffanello, M., Puxeddu, E., Porcella, A., Cuzzolin, L., Pilloni, M. D., & Fanos, V. (2012). Use of non-steroidal anti-inflammatory drugs in pregnancy: impact on the fetus and newborn. Current drug metabolism, 13(4), 474–490. https://doi.org/10.2174/138920012800166607
Black, E., Khor, K. E., Kennedy, D., Chutatape, A., Sharma, S., Vancaillie, T., & Demirkol, A. (2019). Medication Use and Pain Management in Pregnancy: A Critical Review. Pain practice : the official journal of World Institute of Pain, 19(8), 875–899. https://doi.org/10.1111/papr.12814
D'Ambrosio, V., Vena, F., Scopelliti, A., D'Aniello, D., Savastano, G., Brunelli, R., & Giancotti, A. (2023). Use of non-steroidal anti-inflammatory drugs in pregnancy and oligohydramnios: a review. The journal of maternal-fetal & neonatal medicine : the official journal of the European Association of Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International Society of Perinatal Obstetricians, 36(2), 2253956. https://doi.org/10.1080/14767058.2023.2253956
Summarized by Jeffrey Olson MS3 | Edited by Meg Joyce, MS1 & Jorge Chalit, OMS3
Contributor: Travis Barlock MD
Educational Pearls:
Assessment of head and neck vascular injury due to blunt trauma
Symptomatic patients require screening head and neck CT angiography
EAST guidelines include the following criteria for a screening CT angiography in blunt head trauma:
Unexplained neurological deficits
Arterial nosebleed
GCS < 6
Petrous bone fracture
Cervical spine fracture
Any size fracture through the transverse foramen
LeFort fractures type II or type III
EAST guidelines include a grading scale for vascular injury:
Grade I: Luminal irregularity or dissection with 25% luminal narrowing, intraluminal thrombus, or raised intimal flap
Grade III: Pseudoaneurysm
Grade IV: Occlusion
Grade V: Transection with free extravasation
References
Bensch FV, Varjonen EA, Pyhältö TT, Koskinen SK. Augmenting Denver criteria yields increased BCVI detection, with screening showing markedly increased risk for subsequent ischemic stroke. Emerg Radiol. 2019;26(4):365-372. doi:10.1007/s10140-019-01677-0
Biffl WL, Moore EE, Offner PJ, et al. Optimizing screening for blunt cerebrovascular injuries. Am J Surg. 1999;178(6):517-522. doi:10.1016/s0002-9610(99)00245-7
Kim DY, Biffl W, Bokhari F, et al. Evaluation and management of blunt cerebrovascular injury: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2020;88(6):875-887. doi:10.1097/TA.0000000000002668
Summarized & Edited by Jorge Chalit, OMS3
Donate: https://emergencymedicalminute.org/donate/
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