Emergency Medical Minute

Author: Sam Killian, M.D. Educational Pearls: Defined as fracture of neck (distal segment) of 5th metacarpal. Intrinsic muscles of hand pull segment to palmar aspect of hand. 30 degrees of angulation is allowed. Any more increases risk of chronic pain, grip strength and grasping deficits, and rotational deformities. Reduce fracture if more than 30 degrees of angulation or if rotation is present. Splint fracture in "ulnar gutter" with goal being flexion at MCP and extension at DIP and PIP. References: http://www.emedicinehealth.com/boxers_fracture/article_em.htm

Author: Jared Scott, M.D. Educational Pearls: DDx for blood at urethral meatus includes: pelvic fracture, ruptured bladder, kidney laceration, penile trauma. Retrograde Urethrogram (RUG) must be performed before placing foley and is critical for diagnosis. References: https://www.ncbi.nlm.nih.gov/pubmed/16488282

Author: Michael Hunt, M.D. Educational Pearls: Research has shown that the higher temperatures post-cardiac arrests may lead to poorer outcomes. Initially, 33 deg C was the target temp. However, more research is being done to find therapeutic temperature levels. New studies have shown that the cooling protocol differs for inpatient cardiac arrests vs. outpatient cardiac arrests. The results show that it may not be necessary to cool inpatient cardiac arrests. References: http://www.hopkinsmedicine.org/healthlibrary/test_procedures/cardiovascular/therapeutic_hypothermia_after_cardiac_arrest_135,393/

Authors: Rebecca van Vliet MS, APN; Michelle Whaley MSN, CNS, CCNS, ANVP-VC The Stroke Team at Swedish Medical Center gives us a taste of how they are breaking records with door-to-needle time in management of acute cerebrovascular accidents.

Author: Aaron Lessen M.D. Educational Pearls: Thoracotomy is a potentially life-saving procedure. However, outcomes are often poor and the procedure itself poses many risks to provider and patient. Chance of surviving a thoracotomy when there is no cardiac activity on ultrasound is 0%. Performing a thoracotomy is unlikely to benefit patients with no cardiac activity on ultrasound or patients that lost vital signs greater than 10 minutes before starting the procedure. A thoracotomy is maximally beneficial in patients with a penetrating chest injury that occurred less than 10 minutes before the procedure. References: K. Inaba et al, "FAST Ultrasound Examination as a Predictor of Outcomes After Resuscitative Thoracotomy: A Prospective Evaluation" Ann. of Surgery, 2015. https://www.ncbi.nlm.nih.gov/pubmed/26258320

Author: Dave Rosenberg M.D. Educational Pearls: Louis Pasteur developed the technique that is now known as pasteurization. It was first used in the wine-producing regions of France, and eventually in dairy products like milk. Pasteur also investigated infectious disease. During one experiment, Pasteur's lab assistant accidentally infected chickens with a weakened form of cholera. When none of the chickens died, Pasteur re-infected them with a stronger strain. This time, none of the chickens became sick because they had been inoculated against the disease. This experiment paved the way for modern vaccination. References: Smith KA. Louis Pasteur, the Father of Immunology? Frontiers in Immunology. 2012;3:68. doi:10.3389/fimmu.2012.00068.

Author: Susan Brion M.D. Educational Pearls: Laundry and dishwasher detergent pods resemble candy and can be ingested by children. These tide pods are very highly concentrated and can cause chemical burns of the lips, airway, eyes, mouth and esophagus. The strong bases in detergent pods (pH>12) can cause liquefactive necrosis, which can cause immediate perforation of the esophagus. Common symptoms associated with ingestion of detergent pods include pain, dysphagia, drooling, mediastinal pain, upper airway inflammation. The presence or absence of symptoms does not indicate severity - suspected ingestions should be admitted and undergo bronchoscopy. Mental status should be assessed rapidly because detergent ingestion can lead to CNS depression and aspiration. References: Bonney AG, Mazor S, Goldman RD. Laundry detergent capsules and pediatric poisoning. Canadian Family Physician. 2013;59(12):1295-1296.

Author: Mark Kozlowski M.D. Educational Pearls: Humans cannot "multitask" effectively - a more accurate term is "task interruption." When doing more than one task at once, we are more likely to forget key details and perform both tasks more slowly overall. Do not interrupt people who are focusing on critical tasks - programming a pump or drawing up doses. Think about ways to reduce task interruption in your hospital for a better clinical practice. References: Westbrook JI, Woods A, Rob MI, Dunsmuir WTM, Day RO. Association of Interruptions With an Increased Risk and Severity of Medication Administration Errors. Arch Intern Med. 2010;170(8):683-690. doi:10.1001/archinternmed.2010.65

Author: Don Stader M.D. Educational Pearls: Non-traumatic back pain is a very common complaint in the Emergency Department. Conditions that can manifest with back pain include: ruptured abdominal aortic aneurysm, retroperitoneal bleeding, cauda equina syndrome, epidural abscess or cancer. Patients with cauda equina syndrome or epidural abscess prefer to sit forward, while people with disc issues tend to sit upright. References: https://emergencymedicinecases.com/episode-26-low-back-pain-emergencies/

Author: Arthur Lessen M.D. Educational Pearls: Zofran (ondansetron) is generally safe to use for the treatment of nausea and vomiting. However, it can prolong the QT interval and increase the chance for torsades. Low doses of Zofran are not likely to be an issue. However, when multiple doses are given, especially in the setting of a preexisting LQTS, clinical concern should be raised. When giving Zofran to a patient with an increased risk for torsades, consider continuous cardiac monitoring or an alternate anti-emetic. References: https://www.fda.gov/Drugs/DrugSafety/ucm310190.htm

Author: Aaron Lessen M.D. Educational Pearls: Imodium (loperamide) is a mu-opioid receptor agonist. Traditionally, it is used as an anti-diarrheal. It is also abused recreationally for an opioid high and to self-treat opioid withdrawal. 40 or more pills are often ingested. People often co-ingest with cimetidine to potentiate the desired effects. Patients will present with opioid overdose symptoms (narrow pupils, respiratory depression). Narcan is effective in reversing an overdose of Imodium. Imodium prolongs QT and predisposes to Torsades, so monitor rhythm and then treat like any other opioid OD. References: http://www.tandfonline.com/doi/abs/10.3109/15563650.2016.1159310

Author: Dylan Luyten M.D. Educational Pearls: Ashman's Phenomenon occurs in the setting atrial fibrillation and mimics ventricular tachycardia, but is harmless. On ECG, the pattern of Ashman Phenomenon is a long cycle, followed a short cycle, followed by a complex wide complex beat. The wide complex beats have right BBB morphology. The long R-R followed by a short R-R leads to conduction down the left bundle branch while the right bundle branch is still in a refractory period. References: https://lifeinthefastlane.com/ecg-library/atrial-fibrillation/

Author: Samuel Killian M.D. Educational Pearls: Lower extremity DVTs are extremely common. There are more left lower extremity DVT due to anatomical variation. May-Thurner Syndrome is a form of anatomical variation in which the left iliac artery compresses the left iliac vein. Anticoagulation may not be sufficient to treat those with May-Thurner syndrome - endovascular stenting may be needed Patients with with recurrent LLE DVT, especially those in whom anticoagulation fails, should be referred to a specialist. References: Peters M, Syed RK, Katz M, et al. May-Thurner syndrome: a not so uncommon cause of a common condition. Proceedings (Baylor University Medical Center). 2012;25(3):231-233. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3377287/

Author: Don Stader, M.D Educational Pearls: It is important for providers to know how to use IV drugs properly so that they can instruct their patients on how to avoid injury. Heroin use is increasing. Hepatitis, HIV and infection are possible complications of improper IV drug use The first step of heroin use is to dissolve the solid heroin in water using heat - a spoon and lighter are often used for this step. Next, the heroin is drawn into the syringe through a filter (cotton is often used). Heroin concentration often varies widely - counsel patients to test their heroin first. Sterility of the needle, water, cooker, cotton and syringe is paramount. Refer patients to a needle exchange program where they can get clean supplies. Hepatitis C can live outside the body for 4 days - NEVER share ANY supplies. Sterile procedure is important - needles should not be licked. References: http://drugsense.org/flyers/10_tips_for_safer_use.pdf

Author: Peter Bakes, M.D Educational Pearls Intracerebral hemorrhage is an intracranial bleed within the brain tissue or ventricles. Subarachnoid aneurysm causes about 50% of all ICH. Amyloid deposition can lead to ICH in elderly patients. Hypertension is another common cause of atraumatic ICH, commonly leading to pontine, cerebellar, or basal ganglial bleeding. Bleeding in other locations is suggestive of a different etiology. ICH will often present with depressed mental status, but specifically a patient with a systolic BP > 220 is suggestive of hypertensive ICH. CT is the first diagnostic step. CTA should be considered when the bleeding is in an atypical area. Significant edema on imaging can be suggestive of a tumor. Treatment should include hemostatic measures and BP control. Transfuse platelets if necessary and reverse any anticoagulation. BP target is References: Sahni R, Weinberger J. Management of intracerebral hemorrhage. Vascular Health and Risk Management. 2007;3(5):701-709. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2291314/

Author: JP Brewer M.D. Educational Pearls: The "Quick Wee" was a method to get urine out of infants who need to have a UA in the Emergency Department. A randomized-controlled experiment was done with 350 infants between the ages of 1 to 12 months. The "Quick Wee" method is taking a sterile saline gauze with cool saline and rubbing it over the suprapubic abdomen for five minutes. The results were significant, with 31% in the treatment group voided after five minutes, 12% in the control group voided after five minutes. References: http://www.bmj.com/content/357/bmj.j1341

Author: Jared Scott M.D. Educational Pearls: There are two anatomical triangles on the back, the inferior lumbar triangle and the superior lumbar triangle. Herniation occurs whenever something moves to a place where it is not supposed to be, often through a fascial weakness. A "back hernia" can happen when the contents of of the abdominal cavity herniate into the back, usually through the superior lumbar triangle. This is also known as a Grynfeltt-Lesshaft hernia. Back hernias can be traumatic or congenital. These hernias are typically treated surgically. References: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3959346/

Author: Chris Holmes M.D. Educational Pearls: Mechanism of injury involves hyperextension/hyperflexion Pathophysiology: inside of the arteries in the neck becomes disrupted, similar to a dissection. This is thrombogenic and leads to cerebral infarction Neurologic deficit is common. Other risk factors include facial fracture and cervical-spine fracture. Treat with anticoagulation - aspirin or other antiplatelet agents are appropriate. Increase clinical suspicion when patient presents with neurological deficit and has a negative CT. References: https://www.east.org/education/practice-management-guidelines/blunt-cerebrovascular-injury

Author: Michael Hunt M.D. Dr. Hunt shares his wealth of experience with biological terrorism over the course of his career.

Author: Rachel Duncan, PharmD BCPS Educational Pearls: Toradol (Ketorolac) is an NSAID used for its anti-inflammatory properties In practice, the common dosages are 30mg IV or 60mg IM. Clinical concerns arise in patients with renal insufficiency or bleeding, but the risks are small ( Studies have found that doses over 7.5mg have the same efficacy in pain control as higher doses. Consider lower-dose Toradol (15mg) and decrease dose in the elderly and those with a CrCl 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 2016. http://www.annemergmed.com/article/S0196-0644(16)31244-6/fulltext

Author: Donald Stader M.D. Educational Pearls: Coffee originates from Ethiopia. Its "active ingredient" is caffeine. Caffeine is a xanthine alkaloid used in medicine to control headache and as a neonatal stimulant. Studies have shown that coffee may increase lifespan. Overdose can be encountered in those using diet pills or concentrated caffeine pills and is treated with dialysis. References: Juliano, LM et al. "A critical review of caffeine withdrawal: empirical validation of symptoms and signs, incidence, severity, and associated features." Psychopharmacology, 2004. https://www.ncbi.nlm.nih.gov/pubmed?term=15448977

Author: Peter Bakes M.D. Educational Pearls: Some common causes of monoarticular arthritis include: crystal arthropathies (gout and pseudogout), infection (septic joint), reactive arthritis and acute presentations of chronic arthritides. Lyme disease usually presents with a targetoid lesion associated with constitutional symptoms. The common triad of symptoms associated with reactive arthritis (aka Reiter's Syndrome) consists of conjunctivitis, urethritis, and arthritis. Reactive arthritis commonly presents with a history of a GU infection (often chlamydia) or GI infection (Shigella, Campylobacter, Yersinia, Salmonella). It is more common in men and those between 20 and 40 years old. Treatment for reactive arthritis is usually supportive. References: www.emedicine.medscape.com/article/331347-overview

Author: Gretchen Hinson M.D. Educational Pearls: The key imaging of a mumps patient is "chipmunk cheeks" or parotitis. The swelling can extend almost to the ears and can be extremely painful - in about 25% of cases the swelling is unilateral. Other organs can be involved as well including: testicles, ovaries, breast tissue, other salivary glands, and the brain/spinal cord. Mumps is transmitted through droplets in the air. Two immunizations will get you 88% probability immunity and one immunization will get you 78% probability of immunity. Yet, immunity can wane and there can be viral strains not covered by the immunization. Mumps outbreaks are common in the winter season because of close quarters. You can test for Mumps using an IGM blood test, (more likely to see a spike in this if the patient is not vaccinated) Buckle swabs, & Urine test. References: https://www.cdc.gov/mumps/index.html

Author: Aaron Lessen M.D. Educational Pearls: Regularly a patient's creatinine level is an important factor in determining whether a patient will receive IV contrast with a CT because it is thought that contrast can harm the kidneys and could worsen underlying kidney disease. A recent retrospective study compared the rates of worsening kidney problems between patients who received a CT scan with contrast, a CT without contrast, and no CT. The study even included patients with creatinines of up to 4 before excluding patients. The study suggested that there is no difference in the rate of worsening kidney problems between the three groups. References: http://www.annemergmed.com/article/S0196-0644(16)31388-9/fulltext

Author: Peter Bakes M.D. Dr. Peter Bakes takes us through how he developed his interest in travel medicine as well as some of the more interesting aspects of the specialty.

Author: Peter Bakes Educational Pearls: The Neuromuscular Junction (NMJ) is a neuronal synapse in skeletal muscle mediated by nicotinic acetylcholine receptors. Paralytic agents, commonly used in the ED for intubation, include succinylcholine and rocuronium/vecuronium. Succinylcholine is a depolarizing paralytic while rocuronium is a non-depolarizing agent. A newly developed reversing agent, sugammadex, can be used to counter the effects of curonium based paralytics. This is especially helpful due to the long duration of action of rocuronium (45 minutes to 1 hour) as compared to succinylcholine ( References: https://www.acep.org/Physician-Resources/Clinical/Thoracic-Respiratory/Rocuronium-vs--Succinylcholine--Which-Is-Best-/

There are many causes of syncope and a pulmonary embolism may be a commonly missed reason.

Electrolytes it's what your bodies crave.

What's the difference between an Aortic Dissection and an Aortic Aneurysm?

New information about concussion precautions for patients

A case presentation of an abnormal rhythm in a younger patient with Lupus.

Probably not what Def Leppard were thinking about when they wrote "Pour Some Sugar on Me".

Learning about football injuries may not make you a pro bowl player, but it can help you treat patients like one.

A discussion on the clinical features and testing for preeclampsia in the ER.

Are cervical collars disappearing? Probably not soon, but there are a few reasons why collars may not be as helpful as we think.

A few quick tips to help increase the success of defibrillating a patient in persistent ventricular fibrillation.

A permutation of the Cincinnati pre-hospital stroke scale to help EMS decide when to take patients to a comprehensive stroke center.

A unique disease with a bizarre presentation is discussed.

Learn about the dangers of synthetic marijuana and why it is a huge problem for emergency rooms.

What are the symptoms of Lyme and why is it becoming a more frequent occurrence in the New England and upper Midwest.

A case of neurogenic shock in patient with a GSW of the spine is discussed.

Some of the possible side effects of suppressing or completely removing the adrenal glands.

A discussion about the presentation and treatments for SDH, both chronic and acute.

The clinical presentation of a critical illness that can become fatal if not treated properly.

Need a drug to convert a stable wide complex tachycardia patient? Why not procainamide?

We all know what a dollar is right? But what about a gray? Let Dr. Scott explain how to approach radiation in pregnancy.

Ludwig's Angina, what it presents as and what to be prepared for.

Some interested questions and comments from some lovely folks.

From our friend, the famed Mark Rosenberg MD.

From our fearless leader Donald Stader MD.