Emergency Medical Minute

Contributor: Travis Barlock MD Educational Pearls: Common sedatives used in the Emergency Department and a few pearls for each. Propofol Type: Non-barbiturate sedative hypnotic agonizing GABA receptors. Benefit: Quick on and quick off (duration of action is approximately 2-7 minutes), helpful for suspected neurologic injury so the patient can wake up and be re-evaluated. Also has the benefit of reducing intracranial pressure (ICP). Downsides: Hypotension, bradycardia, respiratory depression. What should you do if a patient is getting hypotensive on propofol? Do not stop the propofol. Start pressors. May have to reduce the propofol dose if delay in pressors. Dexmedetomidine (Precedex) Type: Alpha 2 agonist - causes central sedation Uses: Patients are more alert and responsive and therefore can be on BiPAP instead of being intubated. Does not cause respiratory depression. Downsides: Hypotension and Bradycardia. Caution in using this for head injuries, its side effects can mask the Cus

Contributor: Meghan Hurley MD Educational Pearls: Pericarditis is inflammation of the pericardial sac, which can arise from infectious or non-infectious etiologies Myocarditis is inflammation of the myocardium, which may accompany pericarditis Pericarditis clinical findings include: Diffuse concave ST elevation, classic for acute pericarditis with myocardial involvement. More common in younger male patients Elevated high-sensitivity troponin - higher levels may occur in young healthy patients Ultrasound may show pericardial effusions POCUS may be helpful in assessing left ventricular ejection fraction (LVEF) via E-point septal separation (EPSS) Elevation in EPSS correlates with decreased LVEF Treatments: Anti-inflammatories including NSAIDs and colchicine Monitor inflammation Repeat ultrasounds Risk factors in this patient’s case: mRNA COVID vaccine - the risk of myocarditis from vaccination is significantly lower than that from COVID-19 infection Preceding infection Re

Contributor: Dylan Luyten MD Educational Pearls: What is a Bradyarrhythmia? Also known as a bradyarrhythmia, it is an irregular heart rate that is also slow (below 60 beats per minute). What can cause it? Complete heart block AKA third-degree AV block; identified on ECG by a wide QRS, and complete dissociation between the atrial and ventricular rhythms with the ventricular being much slower. Treat with a pacemaker. Medication overdose, especially beta blockers. Many other drugs can slow the heart as well including: opioids, clonidine, digitalis, amiodarone, diltiazem, and verapamil to name a few. Electrolyte abnormalities, specifically hyperkalemia. Hypokalemia, hypocalcemia, and hypomagnesemia can also cause bradyarrhythmias. Myocardial infarction. Either by damaging the AV node or the conduction system itself or by triggering a process called Reperfusion Bradycardia. Hypothermia. Bradycardia is generally a sign of severe or advanced hypothermia. References Jurkovicová O, Cagán S. Reperfúzn

Contributor: Aaron Lessen MD Educational Pearls: Tranexamic acid (TXA) is a common medication to achieve hemostasis in a variety of conditions Patients visiting the ED for gross hematuria (between March 2022 and September 2022) were treated with intravesical TXA 1 g tranexamic acid in 100 mL NS via Foley catheter Clamped Foley for 15 minutes Subsequent continuous bladder irrigation, as is standard in most EDs Compared with a cohort of patients visiting the ED for a similar concern between March 2021 and September 2021, the TXA patients had: A shorter median length of stay in the ED (274 min vs. 411 mins, P < 0.001). A shorter median duration of Foley catheter placement (145 min vs. 308 mins, P < 0.001) Fewer revisits after ED discharge (2.3% vs. 12.3%, P = 0.031) References 1. Choi H, Kim DW, Jung E, et al. Impact of intravesical administration of tranexamic acid on gross hematuria in the emergency department: A before-and-after study. Am J Emerg Med. 2023;68:68-72. doi:10.1016/j.ajem.

Contributor: Meghan Hurley MD Educational Pearls: What is Cellulitis? A common and potentially serious bacterial skin infection. Caused by various types of bacteria, with Streptococcus and Staphylococcus species being the most common. What is Preseptal Cellulitis and why is it more serious than facial cellulitis? Preseptal Cellulitis, also known as Periorbital Cellulitis, is a bacterial infection of the soft tissues in the eyelid and the surrounding area. This requires prompt and aggressive treatment to avoid progression into Orbital Cellulitis. How is Preseptal Cellulitis treated? Oral antibiotics for five to seven days. In the setting of trauma (scratching bug bites) Clindamycin or TMP-SMX (for MRSA coverage) and Amoxicillin-clavulanic acid or Cefpodoxime or Cefdinir. If there is no trauma, monotherapy with amoxicillin-clavulanic acid is appropriate. Check immunization status against H.influenzae and adjust appropriately. What is Orbital Cellulitis, how is it diagnosed, and why is it m

Contributors: Andrew White MD - Outpatient Psychiatrist; Fellowship Trained in Addiction Psychiatry; Denver Health Travis Barlock MD - Emergency Medicine Physician; Swedish Medical Center Summary In this episode of Mental Health Monthly, Dr. Travis Barlock hosts Dr. Andrew White to discuss the elements of mania that may be encountered in the emergency department. The discussion includes a helpful mnemonic to assess mania, work-up and treatment in the ED, underlying causes of mania, mental health holds, inpatient treatment, and the role of sleep in mania. Educational Pearls Initial assessment of suspected mania can be done via DIGFAST: Distractibility - Individual that is unable to carry a linear, goal-directed conversation Impulsivity - Executive functioning is impaired and patients are unable to control their behaviors Grandiosity - Elevated mood and sense of self to delusions of grandeur Flight of ideas - Usually described as racing thoughts Agitation - Increase in psychomotor activity; start s

Contributor: Travis Barlock MD Education Pearls: The Cushing Reflex is a physiologic response to elevated intracranial pressure (ICP) Cushing’s Triad: widened pulse pressure (systolic hypertension), bradycardia, and irregular respirations Increased ICP results from systolic hypertension, which causes a parasympathetic reflex to drop heart rate, leading to Cushing’s Triad.  The Cushing Reflex is a sign of herniation Treatment includes: Hypertonic saline is comparable to mannitol and preferable in patients with hypovolemia or hyponatremia Give 250-500mL of 3%NaCl 20% Mannitol - given at a dose of 0.5-1 g/kg Each additional dose of 0.1 g/kg reduces ICP by 1 mm Hg 23.4% hypertonic saline is more often given in the neuro ICU 8.4% Sodium bicarbonate lowers ICP for 6 hours without causing metabolic acidosis Non-pharmacological interventions: Raise the head of the bed to 30-45 degrees Remove the c-collar to improve blood flow to the head Hyperventilation induces hypocapnia, whic

Contributors: Kalen Abbott, MD - EM Physician and Medical Director for AirLife Denver Brendan Reiss - Flight Nurse AirLife Denver Matt Spoon - Flight Paramedic AirLife Denver Jordan Ourada - EMS Coordinator at Swedish Medical Center and Paramedic Summary: In this episode, hosted by Jordan Ourada, Brendan Reiss and Matt Spoon present a first-hand experience case of hydrofluoric acid exposure in a pediatric patient. Commentary and educational pearls are provided by EM Physician, Kalen Abbott. The case:  The patient was a male infant who had spilled a large amount of heavy-duty acid aluminum wheel cleaner on himself while playing in his parent's garage. Unclear if he had ingested any fluid. The cleaning fluid contained a large percentage of hydrofluoric acid. He was brought by EMS to his local hospital, who quickly decided to transport the infant by helicopter to a large Denver hospital. Initial labs were unremarkable and the EKG was normal. Heart rate was in the 140s. Blood pressure was 110/73.

Contributor: Meghan Hurley MD Educational Pearls: What is ATLS? Advanced Trauma Life Support (ATLS) is a systematic and comprehensive approach to the evaluation and management of trauma patients It was developed by the American College of Surgeons (ACS) The key components include the Primary Survey ("ABCDE"), the Secondary Survey, Definitive Care, and Special Considerations What are the issues with ATLS? ATLS relies on many algorithms and rules-of-thumb, which might be helpful for individuals with basic skills and training but might actually present obstacles for those with higher levels of training. Dr. Hurley cites several examples. Example 1: ABC approach to trauma patients ABC stands for Airway, Breathing, and Circulation but focusing on the airway first is not always the best decision. Immediate attention may need to be applied to massive hemorrhage. Intubating a patient that is hemodynamically unstable may cause cardiac arrest. A more helpful phrase might be “Resuscitate before you i

Contributor: Meghan Hurley MD Educational Pearls: Shift work is defined as anything that takes place outside of a 9-5 schedule, not exempting day-shift medical workers Various ill effects of shift work on overall health: Increased all-cause mortality Increased number of accidents Glucose metabolism dysregulation Increased BMI Fertility impacts for men and women Increased breast cancer risk Decreased cognitive functioning Mitigation strategies Work at the same time every day Anchor Sleep - always try to be asleep at the same time of day Progressive shifts: day- into swing- into night shift instead of the other way around Three days off after a stretch of nights can help reset sleep schedule Shorter night shifts Morning shifts should start no earlier than 8 AM Sleep hygiene Ensure an ideal sleep environment; cool, dark, and damp Avoid bright lights when going to sleep Exposure to bright lights when waking up Hydration throughout your shift Stop caffeine at midnig

Contributor: Aaron Lessen MD Educational Pearls: Why is airway management more difficult in obesity? Larger body habitus causes the chest to be above the head when the patient is lying supine, creating difficult angles for intubation. Reduced Functional Residual Capacity (FRC) causes these patients to deoxygenate much more quickly, reducing the amount of time during which the intubation can take place. What special considerations need to be made? Positioning. The auditory canal and sternal notch should be aligned in a horizontal plane. Do this by stacking blankets to lift the neck and head. Also, try to make the head itself parallel to the ceiling. Pre-oxygenation. Use Bi-level Positive Airway Pressure (BiPAP) with Positive End Expiratory Pressure (PEEP) or a Bag-Valve-Mask (BVM) with a PEEP valve. PEEP helps prevent alveoli from collapsing after every breath and improves oxygenation. Dosing of paralytics. Succinylcholine is dosed on total body weight so the dose will be much larger for the obese

Contributor: Nick Tsipis MD Educational Pearls: The scaphoid bone is the most proximal carpal bone just distal to the radius Fractures of the scaphoid bone are sometimes missed by plain X-rays A 2020 review found a 21.8% incidence of missed scaphoid fractures later diagnosed by advanced imaging modalities Only MRI has a sensitivity above 90% for diagnosing scaphoid fractures Sensitivity of plain-film radiography is low unless it is a displaced fracture Physical examination techniques fail to definitively rule out scaphoid fractures A 2023 systematic review assessed the sensitivity and specificity of several common physical exam maneuvers: Tenderness of the anatomical snuffbox has a sensitivity of 92.1% and specificity of 48.4%; i.e. absence reduces the likelihood of an occult scaphoid fracture but does not rule it out Another common physical exam maneuver is pain with ulnar deviation, which carries a sensitivity of 55.2% and specificity of 76.4%. Elicitation of pain with supination agains

Contributor: Aaron Lessen MD Educational Pearls: What is Carbamazepine (Tegretol)? Carbamazepine is an anti-epileptic drug with mood-stabilizing properties that is used to treat bipolar disorder, epilepsy, and neuropathic pain. It functions primarily by blocking sodium channels which can prevent repetitive action potential firing. What are the symptoms of an overdose? Common initial signs include diminished conscious state, nystagmus, ataxia, hyperreflexia, CNS depression, dystonia, and tachycardia Severe toxicity can cause seizures, respiratory depression, decreased myocardial contractility, pulmonary edema, hypotension, and dysrhythmias. How is an overdose treated? An overdose is treated with large doses of activated charcoal and correction of electrolyte disturbances. Be ready to intubate given the potential for respiratory depression. Carbamazepine is moderately dialyzable and dialysis is recommended in severe overdoses. Additional educational pearl: Individuals in correctional facilit

Contributor: Jason Papazian MD, Travis Barlock MD, Jeffrey Olson Summary: In this episode, Dr. Travis Barlock and Jeffrey Olson meet in the studio to discuss several clips from Dr. Jason Papazian’s talk at the event “Laboring Under Pressure, Managing Obstetric Emergencies in a Global Setting” from May 2023. This event was hosted at the University of Denver and was organized with the help of Joe Parker as a fundraiser for the organization Health Outreach Latin America (HOLA).   Dr. Jason Papazian practices Obstetric Anesthesiology for the Maternal Fetal Care Unit at Children's Hospital Colorado. He is the Assistant Program Director of Didactics for the Anesthesiology Residency at the University of Colorado, as well as the Faculty Advisor to Residents and Obstetric Anesthesiology Fellows.   During his talk, Dr. Papazian walks the audience through the steps of a maternal cardiac arrest from initial rapid response, to intubation, CPR, ACLS, and eventually emergency cesarean section.   Some important take-away poi

Contributor: Aaron Lessen MD Educational Pearls: A recent randomized controlled trial compared ondansetron 8 mg IV with droperidol 2.5 mg IV for the treatment of nausea & vomiting in the emergency department.  Overall, droperidol and ondansetron had similar primary outcomes in acute nausea control  Symptom improvement in 93% of patients receiving droperidol vs. 87% receiving ondansetron (P = 0.362) Secondary measures were, however, statistically significantly different between groups Patients needed fewer rescue/additional antiemetics in the droperidol group (16%) compared with the ondansetron group (37%); p = 0.016 Similarly, more patients in the droperidol group reported they achieved the desired effect of the medication (85% vs. 63%; p = 0.006) Patients receiving droperidol did experience increased drowsiness 40% in the droperidol group vs. 11% in the ondansetron group The trial did not assess the length of stay in the ED after administering medications, which is a potential ave

Contributor: Aaron Lessen MD Educational Pearls: What is measured in an ABG/VBG? Blood values for oxygen tension (pO2), carbon dioxide tension (pCO2), acidity (pH), oxyhemoglobin saturation, and bicarbonate (HCO3) in either arterial or venous blood Other tests can measure methemoglobin, carboxyhemoglobin, hemoglobin levels, base excess, and lactate What are they used for? Identification of ventilation/acid-base disturbances. For example: if a patient is in septic shock, oxyhemoglobin saturation can be used to guide resuscitation efforts (early goal- directed therapy) What's the difference between an ABG and VBG? One of the main differences is how the blood samples are collected. Venous blood gas is normally collected from existing venous access such as a central venous catheter. Arterial blood gases must be drawn from an artery, such as the radial artery. Arterial blood draws can be difficult, painful, and contraindicated in many situations. ABGs have traditionally provided more accurate measu

Contributor: Aaron Lessen MD Educational Pearls: Patients with alcohol use disorder are frequently discharged from the ED without further resources Pharmacological treatments to reduce cravings in AUD exist Naltrexone  Effective at reducing alcohol cravings and heavy drinking  Gabapentin Reduces the percentage of heavy drinking days in AUD Patients being discharged from the ED should be asked if they feel their alcohol use is a problem, which can further direct appropriate pharmacological interventions References 1. Kranzler M.D. HR, Feinn Ph.D. R, Morris B.A. P, Hartwell Ph.D. EE. A Meta-analysis of the Efficacy of Gabapentin for Treating Alcohol Use Disorder Henry. Addiction. 2019;114(9):1547-1555. doi:10.1111/add.14655 2. Maisel NC, Blodgett JC, Wilbourne PL, Humphreys K, Finney JW. Meta-analysis of naltrexone and acamprosate for treating alcohol use disorders: When are these medications most helpful? Addiction. 2013;108(2):275-293. doi:10.1111/j.1360-0443.2012.04054.x 3. Mariani JJ, Pa

Contributor: Travis Barlock MD Educational Pearls: When might you need to apply a painful stimulus in a medical setting? The main reason is to assess the patient's level of consciousness, such as when they are waking up from anesthesia or have potentially suffered a brain injury. It can be part of the Glasgow Coma Scale (GCS) if patients are not responding to auditory stimuli. Possible levels of consciousness include Alert, Lethargic, Obtunded, and Comatose (ALOC) What are the approved ways to apply a painful stimulus to assess central nervous system function? Trapezius squeeze. Grab the trapezius muscle and twist (contraindicated in clavicle fractures). Supraorbital rim pressure. Find the notch in the supraorbital rim of the patient and push hard with your thumb (contraindicated in facial fractures). Mandibular pressure (not mentioned). Press hard at the angle of the jaw on the mandibular nerve (contraindicated in mandible fractures). Sternal rub. Push down with your knuckles into the patient

Contributor: Travis Barlock MD Educational Pearls: Alcohol binds the GABA receptor, which produces an inhibitory response, hence the “depressive” effects of ethanol beverages. Over time, alcohol downregulates the GABA receptors, leading to unopposed glutamate activity. Given that glutamate is excitatory, this can lead to seizures. Alcohol also suppresses REM sleep; in patients with chronically suppressed REM sleep, the brain starves for dream sleep and it spills over into the wakeful state, inducing a dream-like state when someone is awake. The awake dream-like state of delirium tremens (DT) differs from alcohol hallucinosis Alcohol hallucinosis presents with visual hallucinations in a wakeful state DT presents with a generalized clouding of the sensorium and a dream-like state Treatment for DT is better achieved with phenobarbital due to predictable pharmacology Phenobarbital acts on GABA and NMDA receptors References 1. Davies M. The role of GABAA receptors in mediating the effects of

Contributors: David Young MD, John Hesling MD, Travis Barlock MD, Jeffrey Olson Summary: In this episode, Dr. Travis Barlock and Jeffrey Olson meet in the studio to discuss several clips from the event “Ukraine Brewtalk” from October 2022. This event was hosted by the University of Colorado’s Center for COMBAT Research and Emergency Medical Minute assisted in the audio recording of the speakers. The first clip is of a brief talk by Dr. John Hesling who was presenting some of his research about Pediatric Supermassive Transfusions. The second and third clips are from the keynote speaker, Dr. Dave Young, an Emergency Medicine Physician at the University of Colorado Hospital, talking about his experience of serving with USA’s Team Rubicon providing medical aid in war-torn Ukraine. Medical topics discussed include Pediatric trauma, blood transfusions, tourniquet use, refugee care, and blast injuries. References Hesling JD, Paulson MW, McKay JT, Bebarta VS, Flarity K, Keenan S, Fisher AD, Borgman MA, April MD, Sc