Episoder
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Contributor: Travis Barlock MD
Educational Pearls:
Thrombolytic therapy (tPA or TNK) is often used in the ED for strokes
Use of anticoagulants with INR > 1.7 or PT >15
Warfarin will reliably increase the INR
Current use of Direct thrombin inhibitor or Factor Xa inhibitor
aPTT/PT/INR are insufficient to assess the degree of anticoagulant effect of Factor Xa inhibitors like apixaban (Eliquis) and rivaroxaban (Xarelto)
Intracranial or intraspinal surgery in the last 3 months
Intracranial neoplasms or arteriovenous malformations also increase the risk of bleeding
Current intracranial or subarachnoid hemorrhage
History of intracranial hemorrhage from thrombolytic therapy also contraindicates tPA/TNK
Recent (within 21 days) or active gastrointestinal bleed
Hypertension
BP >185 systolic or >110 diastolic
Administer labetalol before thrombolytics to lower blood pressure
Timing of symptoms
Onset > 4.5 hours contraindicates tPA
Platelet count < 100,000
BGL < 50
Potential alternative explanation for stroke-like symptoms obviating need for thrombolytics
References
1. Fugate JE, Rabinstein AA. Absolute and Relative Contraindications to IV rt-PA for Acute Ischemic Stroke. The Neurohospitalist. 2015;5(3):110-121. doi:10.1177/1941874415578532
2. Powers WJ, Rabinstein AA, Ackerson T, et al. Guidelines for the Early Management of Patients with Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke a Guideline for Healthcare Professionals from the American Heart Association/American Stroke Association. Vol 50.; 2019. doi:10.1161/STR.0000000000000211
Summarized by Jorge Chalit, OMSII | Edited by Jorge Chalit
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Contributor: Ricky Dhaliwal, MD
Educational Pearls:
Takotsubo cardiomyopathy, also known as "broken heart syndrome,â is a temporary heart condition that can mimic the symptoms of a heart attack, including troponin elevations and mimic STEMI on ECG.
The exact cause is not fully understood, but it is often triggered by severe emotional or physical stress. The stress can lead to a surge of catecholamines which affects the heart (multivessel spasm/paralysed myocardium).
The name "Takotsubo" comes from the Japanese term for a type of octopus trap, as the left ventricle takes on a distinctive shape resembling this trap during systole. The LV is dilated and part of the wall becomes akenetic. These changes can be seen on ultrasound.
The population most at risk for Takotsubo are post-menopausal women.
Coronary angiography is one of the only ways to differentiate Takotsubo from other acute coronary syndromes.
Most people with Takotsubo cardiomyopathy recover fully.
References
Amin, H. Z., Amin, L. Z., & Pradipta, A. (2020). Takotsubo Cardiomyopathy: A Brief Review. Journal of medicine and life, 13(1), 3â7. https://doi.org/10.25122/jml-2018-0067
Bossone, E., Savarese, G., Ferrara, F., Citro, R., Mosca, S., Musella, F., Limongelli, G., Manfredini, R., Cittadini, A., & Perrone Filardi, P. (2013). Takotsubo cardiomyopathy: overview. Heart failure clinics, 9(2), 249âx. https://doi.org/10.1016/j.hfc.2012.12.015
Dawson D. K. (2018). Acute stress-induced (takotsubo) cardiomyopathy. Heart (British Cardiac Society), 104(2), 96â102. https://doi.org/10.1136/heartjnl-2017-311579
Kida, K., Akashi, Y. J., Fazio, G., & Novo, S. (2010). Takotsubo cardiomyopathy. Current pharmaceutical design, 16(26), 2910â2917. https://doi.org/10.2174/138161210793176509
Summarized by Jeffrey Olson MS2 | Edited by Jorge Chalit, OMSII
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Manglende episoder?
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Contributor: Ricky Dhaliwal MD
Educational Pearls:
Primary adrenal insufficiency (most common risk factor for adrenal crises)
An autoimmune condition commonly known as Addison's Disease
Defects in the cells of the adrenal glomerulosa and fasciculata result in deficient glucocorticoids and mineralocorticoids
Mineralocorticoid deficiency leads to hyponatremia and hypovolemia
Lack of aldosterone downregulates Endothelial Sodium Channels (ENaCs) at the renal tubules
Water follows sodium and generates a hypovolemic state
Glucocorticoid deficiency contributes further to hypotension and hyponatremia
Decreased vascular responsiveness to angiotensin II
Increased secretion of vasopressin (ADH) from the posterior pituitary
An adrenal crisis is defined as a sudden worsening of adrenal insufficiency
Presents with non-specific symptoms including nausea, vomiting, fatigue, confusion, and fevers
Fevers may be the result of underlying infection
Work-up in the ED includes labs looking for infection and adding cortisol + ACTH levels
Emergent treatment is required
100 mg hydrocortisone bolus followed by 50 mg every 6 hours
Immediate IV fluid repletion with 1L normal saline
The most common cause of an adrenal crisis is an acute infection in patients with baseline adrenal insufficiency
Often due to a gastrointestinal infection
References
1. Bancos I, Hahner S, Tomlinson J, Arlt W. Diagnosis and management of adrenal insufficiency. Lancet Diabetes Endocrinol. 2015;3(3):216-226. doi:10.1016/S2213-8587(14)70142-1
2. Bornstein SR, Allolio B, Arlt W, et al. Diagnosis and Treatment of Primary Adrenal Insufficiency: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2016;101(2):364-389. doi:10.1210/jc.2015-1710
3. Cronin CC, Callaghan N, Kearney PJ, Murnaghan DJ, Shanahan F. Addison disease in patients treated with glucocorticoid therapy. Arch Intern Med. 1997;157(4):456-458.
4. Feldman RD, Gros R. Vascular effects of aldosterone: sorting out the receptors and the ligands. Clin Exp Pharmacol Physiol. 2013;40(12):916-921. doi:10.1111/1440-1681.12157
5. Hahner S, Loeffler M, Bleicken B, et al. Epidemiology of adrenal crisis in chronic adrenal insufficiency: the need for new prevention strategies. Eur J Endocrinol. 2010;162(3):597-602. doi:10.1530/EJE-09-0884
Summarized by Jorge Chalit, OMSII | Edited by Meg Joyce & Jorge Chalit
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Contributor: Travis Barlock, MD
Educational Pearls:
Cancer-related emergencies can be sorted into a few buckets:
Infection
Cancer itself and the treatments (chemotherapy/radiation) can be immunosuppressive. Look out for conditions such as sepsis and neutropenic fever.
Obstruction
Cancer causes a hypercoagulable state. Look out for blood clots which can cause emergencies such as a pulmonary embolism, stroke, superior vena cava (SVC) syndrome, and cardiac tamponade.
Metabolic
Cancer can affect the metabolic system in a variety of ways. For example, certain cancers like bone cancers can stimulate the bones to release large amounts of calcium leading to hypercalcemia. Tumor lysis syndrome is another consideration in which either spontaneously or due to treatment, tumor cells will release large amounts of electrolytes into the bloodstream causing hyperuricemia, hyperkalemia, hyperphosphatemia, and hypocalcemia.
Medication side effect
Immunomodulators can have strange side effects. A common one to know is Keytruda (pembrolizumab), which can cause inflammation in any organ. So if you have a cancer patient on immunomodulators with any inflammatory changes (cystitis, colitis, pneumonitis, etc), talk to oncology about whether steroids are indicated.
Chemotherapy can cause tumor lysis syndrome (see above), and multiple chemotherapeutics are known to cause heart failure (doxorubicin, trastuzumab), kidney failure (cisplatin), and pulmonary toxicity (bleomycin).
References
Campello, E., Ilich, A., Simioni, P., & Key, N. S. (2019). The relationship between pancreatic cancer and hypercoagulability: a comprehensive review on epidemiological and biological issues. British journal of cancer, 121(5), 359â371. https://doi.org/10.1038/s41416-019-0510-x
Gyamfi, J., Kim, J., & Choi, J. (2022). Cancer as a Metabolic Disorder. International journal of molecular sciences, 23(3), 1155. https://doi.org/10.3390/ijms23031155
Kwok, G., Yau, T. C., Chiu, J. W., Tse, E., & Kwong, Y. L. (2016). Pembrolizumab (Keytruda). Human vaccines & immunotherapeutics, 12(11), 2777â2789. https://doi.org/10.1080/21645515.2016.1199310
Wang, S. J., Dougan, S. K., & Dougan, M. (2023). Immune mechanisms of toxicity from checkpoint inhibitors. Trends in cancer, 9(7), 543â553. https://doi.org/10.1016/j.trecan.2023.04.002
Zimmer, A. J., & Freifeld, A. G. (2019). Optimal Management of Neutropenic Fever in Patients With Cancer. Journal of oncology practice, 15(1), 19â24. https://doi.org/10.1200/JOP.18.00269
Summarized by Jeffrey Olson MS2 | Edited by Meg Joyce & Jorge Chalit, OMSII
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Contributor: Travis Barlock MD
Educational Pearls:
There are three indications for IV albumin in the ED
Spontaneous bacterial peritonitis (SBP)
Patients with SBP develop renal failure from volume depletion
Albumin repletes volume stores and reduces renal impairment
Albumin binds inflammatory cytokines and expands plasma volume
Reduced all-cause mortality if IV albumin is given with antibiotics
Hepatorenal syndrome
Cirrhosis of the liver causes the release of endogenous vasodilators
The renin-angiotensin-aldosterone system (RAAS) fails systemically but maintains vasoconstriction at the kidneys, leading to decreased renal perfusion
IV albumin expands plasma volume and prevents failure of the RAAS
Large volume paracentesis
Large-volume removal may lead to circulatory dysfunction
IV albumin is associated with a reduced risk of paracentesis-associated circulatory dysfunction
There are many other FDA-approved conditions for which to use exogenous albumin but the data are conflicted about the benefits on mortality
References
1. Arroyo V, Fernandez J. Pathophysiological basis of albumin use in cirrhosis. Ann Hepatol. 2011;10(SUPPL. 1):S6-S14. doi:10.1016/s1665-2681(19)31600-x
2. Bai Z, Wang L, Wang R, et al. Use of human albumin infusion in cirrhotic patients: a systematic review and meta-analysis of randomized controlled trials. Hepatol Int. 2022;16(6):1468-1483. doi:10.1007/s12072-022-10374-z
3. Batool S, Waheed MD, Vuthaluru K, et al. Efficacy of Intravenous Albumin for Spontaneous Bacterial Peritonitis Infection Among Patients With Cirrhosis: A Meta-Analysis of Randomized Control Trials. Cureus. 2022;14(12). doi:10.7759/cureus.33124
4. Kwok CS, Krupa L, Mahtani A, et al. Albumin reduces paracentesis-induced circulatory dysfunction and reduces death and renal impairment among patients with cirrhosis and infection: A systematic review and meta-analysis. Biomed Res Int. 2013;2013. doi:10.1155/2013/295153
5. Sort P, Navasa M, Arroyo V, et al. Effect of Intravenous Albumin on Renal Impairment and Mortality in Patients with Cirrhosis and Spontaneous Bacterial Peritonitis. N Engl J Med. 1999;341(6):403-409.
Summarized by Jorge Chalit, OMSII | Edited by Meg Joyce & Jorge Chalit
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Contributor: Ricky Dhaliwal, MD
Educational Pearls:
What are DKA and HHS?
DKA (Diabetic Ketoacidosis) and HHS (Hyperosmolar Hyperglycemic State) are both acute hyperglycemic states.
DKA
More common in type 1 diabetes.
Triggered by decreased circulating insulin.
The body needs energy but cannot use glucose because it canât get it into the cells.
This leads to increased metabolism of free fatty acids and the increased production of ketones.
The buildup of ketones causes acidosis.
The kidneys attempt to compensate for the acidosis by increasing diuresis.
These patients present as dry and altered, with sweet-smelling breath and Kussmaul (fast and deep) respirations.
HSS
More common in type 2 diabetes.
In this condition there is still enough circulating insulin to avoid the breakdown of fats for energy but not enough insulin to prevent hyperglycemia.
Serum glucose levels are very high â around 600 to 1200 mg/dl.
Also presents similarly to DKA with the patient being dry and altered.
Important labs to monitor
Serum glucose
Potassium
Phosphorus
Magnesium
Anion gap (Na - Cl - HCO3)
Renal function (Creatinine and BUN)
ABG/VBG for pH
Urinalysis and urine ketones by dipstick
Treatment
Identify the cause, i.e. Has the patient stopped taking their insulin?
Aggressive hydration with isotonic fluids.
Normal Saline (NS) vs Lactated Ringers (LR)?
LR might resolve the DKA/HHS faster with less risk of hypernatremia.
Should you bolus with insulin?
No, just start a drip.
0.1-0.14 units per kg of insulin.
Make sure you have your potassium back before starting insulin as the insulin can shift the potassium into the cells and lead to dangerous hypokalemia.
Should you treat hyponatremia?
Make sure to correct for hyperglycemia before treating. This artificially depresses the sodium.
Should you give bicarb?
Replace if the pH < 6.9. Otherwise, it wonât do anything to help.
Donât intubate, if the patient is breathing fast it is because they are compensating for their acidosis.
References
Andrade-Castellanos, C. A., Colunga-Lozano, L. E., Delgado-Figueroa, N., & Gonzalez-Padilla, D. A. (2016). Subcutaneous rapid-acting insulin analogues for diabetic ketoacidosis. The Cochrane database of systematic reviews, 2016(1), CD011281. https://doi.org/10.1002/14651858.CD011281.pub2
Chaithongdi, N., Subauste, J. S., Koch, C. A., & Geraci, S. A. (2011). Diagnosis and management of hyperglycemic emergencies. Hormones (Athens, Greece), 10(4), 250â260. https://doi.org/10.14310/horm.2002.1316
Dhatariya, K. K., Glaser, N. S., Codner, E., & Umpierrez, G. E. (2020). Diabetic ketoacidosis. Nature reviews. Disease primers, 6(1), 40. https://doi.org/10.1038/s41572-020-0165-1
Duhon, B., Attridge, R. L., Franco-Martinez, A. C., Maxwell, P. R., & Hughes, D. W. (2013). Intravenous sodium bicarbonate therapy in severely acidotic diabetic ketoacidosis. The Annals of pharmacotherapy, 47(7-8), 970â975. https://doi.org/10.1345/aph.1S014
Modi, A., Agrawal, A., & Morgan, F. (2017). Euglycemic Diabetic Ketoacidosis: A Review. Current diabetes reviews, 13(3), 315â321. https://doi.org/10.2174/1573399812666160421121307
Self, W. H., Evans, C. S., Jenkins, C. A., Brown, R. M., Casey, J. D., Collins, S. P., Coston, T. D., Felbinger, M., Flemmons, L. N., Hellervik, S. M., Lindsell, C. J., Liu, D., McCoin, N. S., Niswender, K. D., Slovis, C. M., Stollings, J. L., Wang, L., Rice, T. W., Semler, M. W., & Pragmatic Critical Care Research Group (2020). Clinical Effects of Balanced Crystalloids vs Saline in Adults With Diabetic Ketoacidosis: A Subgroup Analysis of Cluster Randomized Clinical Trials. JAMA network open, 3(11), e2024596. https://doi.org/10.1001/jamanetworkopen.2020.24596
Summarized by Jeffrey Olson MS2 | Edited by Meg Joyce & Jorge Chalit, OMSII
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Contributor: Aaron Lessen MD
Educational Pearls:
Button batteries cause alkaline corrosion and erosion of the esophagus when swallowed
Children swallow button batteries, which create a medical emergency as they can perforate the esophagus
A recent study compared various home remedies as first-aid therapy for button battery ingestion
Honey, jam, normal saline, Coca-Cola, orange juice, milk, and yogurt
The study used a porcine esophageal model to assess resistance to alkalinization with the different home remedies
Honey and jam demonstrated a significantly lower esophageal tissue pH compared with normal saline
Histologic changes in the tissue samples appeared 60 minutes later with honey and jam compared with normal saline
These treatments do not preclude medical intervention and battery removal
References
1. Chiew AL, Lin CS, Nguyen DT, Sinclair FAW, Chan BS, Solinas A. Home Therapies to Neutralize Button Battery Injury in a Porcine Esophageal Model. Ann Emerg Med. 2023:1-9. doi:10.1016/j.annemergmed.2023.08.018
Summarized by Jorge Chalit, OMSII | Edited by Meg Joyce & Jorge Chalit
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Contributor: Ricky Dhaliwal, MD
Educational Pearls:
What can you do to control bleeding in a penetrating wound?
Apply direct pinpoint pressure on the wound as well as proximal to the wound.
Build a compression dressing.
How do you build a compression dressing?
Think about building an upside-down pyramid with the gauze.
Consider coagulation agents such as an absorbent gelatin sponge material, microporous polysaccharide hemispheres, oxidized cellulose, fibrin sealants, topical thrombin, or tranexamic acid.
What are the indications to use a tourniquet?
The Stop The Bleed campaign recommends looking for the following features of âlife-threateningâ bleeding.
Pulsatile bleeding.
Blood is pooling on the ground.
The overlying clothes are soaked.
Bandages are ineffective.
Partial or full amputation.
And if the patient is in shock.
How do you put on a tourniquet?
If using a Combat Application Tourniquet (C-A-T) tourniquet, apply it proximal to the wound, then rotate the plastic rod until the bleeding stops. Then secure the plastic rod with a clip and make sure the Velcro is in place.
Mark the time - generally, there is a spot on the tourniquet to write.
Have a plan for the next steps. Does the patient need emergent surgery? Do they need to be transfered?
How long can you leave a tourniquet on?
Less than 90 minutes.
What are the risks?
Nerve injury.
Ischemia.
References
Latina R, Iacorossi L, Fauci AJ, Biffi A, Castellini G, Coclite D, D'Angelo D, Gianola S, Mari V, Napoletano A, Porcu G, Ruggeri M, Iannone P, Chiara O, On Behalf Of Inih-Major Trauma. Effectiveness of Pre-Hospital Tourniquet in Emergency Patients with Major Trauma and Uncontrolled Haemorrhage: A Systematic Review and Meta-Analysis. Int J Environ Res Public Health. 2021 Dec 6;18(23):12861. doi: 10.3390/ijerph182312861. PMID: 34886586; PMCID: PMC8657739.
Martinson J, Park H, Butler FK Jr, Hammesfahr R, DuBose JJ, Scalea TM. Tourniquets USA: A Review of the Current Literature for Commercially Available Alternative Tourniquets for Use in the Prehospital Civilian Environment. J Spec Oper Med. 2020 Summer;20(2):116-122. doi: 10.55460/CT9D-TMZE. PMID: 32573747.
Resources poster booklet. (n.d.). Stop the Bleed. https://www.stopthebleed.org/resources-poster-booklet/
Summarized by Jeffrey Olson MS2 | Edited by Meg Joyce & Jorge Chalit, OMSII
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Contributors: Kali Olson PharmD, Travis Barlock MD, Jeffrey Olson MS2
Summary:
In this episode of Pharmacy Phriday, Dr. Kali Olson joins Dr. Travis Barlock and Jeffrey Olson in studio to discuss a variety of interesting topics in the form of a segment show. Dr. Kali Olson earned her Doctorate of Pharmacy from the University of Colorado, Skaggs School of Pharmacy and completed a PGY1 residency at Detroit Receiving Hospital and a PGY2 residency in Emergency Medicine at Denver Health. She now works as an Emergency Medicine Pharmacist at Denver Health.
In segment one of the show, Kali and Travis answer the Get-To-Know-You questionnaire. In segment two, they work together to answer a series of pharmacy-based riddles. In segment three they play a âBalderdashâ like game in which they guess the definitions of medical jargon. In segment four they play the Number Needed to Treat game, invented by the AFP podcast. And in segment five they work together to answer a question about a far-out scenario involving medications and time travel!
References
· American Family Physician Podcast, https://www.aafp.org/pubs/afp/multimedia/podcast.html
· Gragnolati, A. (2022, May 5). The Yuzpe method of emergency contraception. GoodRx. https://www.goodrx.com/conditions/emergency-contraceptive/yuzpe-method
· Manikandan S, Vani NI. Holiday reading: Learning medicine through riddles. CMAJ. 2010 Dec 14;182(18):E863-4. doi: 10.1503/cmaj.100466. PMID: 21149530; PMCID: PMC3001539.
· Riddle Me This: Mixing Medicine, https://peimpact.com/riddle-me-this-mixing-medicine/
· https://thennt.com/nnt/corticosteroids-treatment-kawasaki-disease-children/
· https://thennt.com/nnt/aspirin-acute-ischemic-stroke/
· https://thennt.com/nnt/tranexamic-acid-treatment-epistaxis/
· https://thennt.com/nnt/antibiotics-culture%e2%80%90positive-asymptomatic-bacteriuria-pregnant-women/
Produced, Hosted, Edited, and Summarized by Jeffrey Olson MS2 | Additional editing by Jorge Chalit, OMSII
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Contributor: Taylor Lynch MD
Educational Pearls
Hypothermia is defined as a core body temperature less than 35 degrees Celsius or less than 95 degrees Fahrenheit
Mild Hypothermia: 32-35 degrees Celsius
Presentation: alert, shivering, tachycardic, and cold diuresis
Management: Passive rewarming i.e. remove wet clothing and cover the patient with blankets or other insulation
Moderate Hypothermia: 28-32 degrees Celsius
Presentation: Drowsiness, lack of shivering, bradycardia, hypotension
Management: Active external rewarming
Severe Hypothermia: 24-28 degrees Celsius
Presentation: Heart block, cardiogenic shock, no shivering
Management: Active external and internal rewarming
Less than 24 degrees Celsius
Presentation: Pulseless, ventricular arrhythmia
Active External Rewarming
Warm fluids are insufficient for warming due to a minimal temperature difference (warmed fluids are maintained at 40 degrees vs. a patient at 30 degrees is not a large enough thermodynamic difference)
External: Bear hugger, warm blankets
Active Internal Rewarming
Thoracic lavage (preferably on the patientâs right side)
Place 2 chest tubes (anteriorly and posteriorly); infuse warm IVF anteriorly and hook up the posterior tube to a Pleur-evac
Warms the patient 3-6 Celsius per hour
Bladder lavage
Continuous bladder irrigation with 3-way foley or 300 cc warm fluid
Less effective than thoracic lavage due to less surface area
Pulseless patients
ACLS does not work until patients are rewarmed to 30 degrees
High-quality CPR until 30 degrees (longest CPR in a hypothermic patient was 6 hours and 30 minutes)
Give epinephrine once you reach 35 degrees, spaced out every 6 minutes
ECMO is the best way to warm these patients up (10 degrees per hour)
Pronouncing death must occur at 32 degrees or must have potassium > 12
References
1. 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care - Part 1: Introduction. Circulation. 2005;112(24 SUPPL.). doi:10.1161/CIRCULATIONAHA.105.166550
2. Brown DJA, Burgger H, Boyd J, Paal P. Accidental Hypothermia. N Engl J Med. 2012;367:1930-1938. doi:10.1136/bmj.2.5543.51-c
3. Dow J, Giesbrecht GG, Danzl DF, et al. Wilderness Medical Society Clinical Practice Guidelines for the Out-of-Hospital Evaluation and Treatment of Accidental Hypothermia: 2019 Update. Wilderness Environ Med. 2019;30(4S):S47-S69. doi:10.1016/j.wem.2019.10.002
4. KjĂŠrgaard B, Bach P. Warming of patients with accidental hypothermia using warm water pleural lavage. Resuscitation. 2006;68(2):203-207. doi:10.1016/j.resuscitation.2005.06.019
5. Lott C, TruhlĂĄĆ A, Alfonzo A, et al. European Resuscitation Council Guidelines 2021: Cardiac arrest in special circumstances. Resuscitation. 2021;161:152-219. doi:10.1016/j.resuscitation.2021.02.011
6. Plaisier BR. Thoracic lavage in accidental hypothermia with cardiac arrest - Report of a case and review of the literature. Resuscitation. 2005;66(1):99-104. doi:10.1016/j.resuscitation.2004.12.024
Summarized by Jorge Chalit, OMSII | Edited by Meg Joyce & Jorge Chalit, OMSII
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Contributor: Jared Scott MD
Educational Pearls:
Croup is a respiratory condition typically caused by a viral infection (e.g., parainfluenza). The disease is characterized by inflammation of the larynx and trachea, which often leads to a distinctive barking cough.
A common treatment for croup is the powerful steroid dexamethasone, but it can take up to 30 minutes to start working.
A folk remedy for croup is to take the afflicted child outside in the cold to help them breathe better, but does it really work?
A 2023 study in Switzerland, published in the Journal of Pediatrics, investigated whether a 30-minute exposure to outdoor cold air could improve mild to moderate croup symptoms before the onset of steroid effects.
The randomized controlled trial included children aged 3 months to 10 years with croup.
After receiving a single-dose oral dexamethasone, participants were exposed to either outdoor cold air or indoor room air. The primary outcome was a decrease in the Westley Croup Score (WCS) by at least 2 points at 30 minutes.
The results indicated that exposure to outdoor cold air, in addition to dexamethasone, significantly reduced symptoms in children with croup, especially in those with moderate cases.
References
Siebert JN, Salomon C, Taddeo I, Gervaix A, Combescure C, Lacroix L. Outdoor Cold Air Versus Room Temperature Exposure for Croup Symptoms: A Randomized Controlled Trial. Pediatrics. 2023 Sep 1;152(3):e2023061365. doi: 10.1542/peds.2023-061365. PMID: 37525974.
Summarized by Jeffrey Olson, MS2 | Edited by Meg Joyce & Jorge Chalit, OMSII
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Contributor: Aaron Lessen MD
Educational Pearls:
Does the size of a blood pressure (BP) cuff matter?
A recent randomized crossover trial revealed that, indeed, cuff size can affect blood pressure readings
Design
195 adults with varying mid-upper arm circumferences were randomized to the order of BP cuff application:
Appropriate
Too small
Too large
Individuals had their mid-upper arm circumference measured to determine the appropriate cuff size
Participants underwent 4 sets of triplicate blood pressure measurements, the last of which was always with the appropriately sized cuff
Results
In individuals requiring a small cuff, the use of a regular cuff resulted in blood pressure readings 3.6 mm Hg lower than with the small cuff
In individuals requiring large cuffs, the use of a regular cuff resulted in pressures 4.8 mm Hg higher than with the large cuffs
In individuals requiring extra-large cuffs, the use of a regular cuff resulted in pressures 19.5 mm Hg higher than with extra-large cuffs
Conclusion
Miscuffing results in significantly inaccurate blood pressure measurements
It is important to emphasize individualized BP cuff selection
References
1. Ishigami J, Charleston J, Miller ER, Matsushita K, Appel LJ, Brady TM. Effects of Cuff Size on the Accuracy of Blood Pressure Readings: The Cuff(SZ) Randomized Crossover Trial. JAMA Intern Med. 2023;183(10):1061-1068. doi:10.1001/jamainternmed.2023.3264
Summarized by Jorge Chalit, OMSII | Edited by Jorge Chalit
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Contributor: Aaron Lessen MD
Educational Pearls:
Is the adage, âGCS of 8, youâve got to intubateâ accurate? A recent study published in the November 2023 issue of JAMA attempted to answer this question.
Design
Multicenter, randomized trial, in France from 2021 to 2023.
225 patients experiencing comatose in the setting of acute poisoning were randomly assigned to either a conservative airway strategy of withholding intubation or âroutine practiceâ of much more frequent intubation.
The primary outcome was a composite endpoint including in-hospital death, length of intensive care unit stay, and length of hospital stay.
Secondary outcomes included adverse events from intubation and pneumonia within 48 hours.
Results
Results showed that in the intervention group (with intubation withholding), only 16% of patients were intubated, compared to 58% in the control group.
No in-hospital deaths occurred in either group.
The intervention group demonstrated a significant clinical benefit for the primary endpoint, with a win ratio of 1.85 (95% CI, 1.33 to 2.58).
The conservative airway management strategy also saw a statistically significant decrease in adverse events from intubation and pneumonia.
Conclusion
Among comatose patients with suspected acute poisoning, a conservative strategy of withholding intubation was associated with a greater clinical benefit.
This suggests that a judicious approach to intubation is appropriate in many other settings and clinicians should rely on more than the GCS to make this decision.
References
Freund Y, Viglino D, Cachanado M, Cassard C, Montassier E, Douay B, Guenezan J, Le Borgne P, Yordanov Y, Severin A, Roussel M, Daniel M, Marteau A, Peschanski N, Teissandier D, Macrez R, Morere J, Chouihed T, Roux D, Adnet F, Bloom B, Chauvin A, Simon T. Effect of Noninvasive Airway Management of Comatose Patients With Acute Poisoning: A Randomized Clinical Trial. JAMA. 2023 Dec 19;330(23):2267-2274. doi: 10.1001/jama.2023.24391. PMID: 38019968; PMCID: PMC10687712.
Summarized by Jeffrey Olson MS2 | Edited by Meg Joyce & Jorge Chalit, OMSII
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Contributor: Aaron Lessen MD
Educational Pearls:
A 2013 study randomized families of those in cardiac arrest into two groups:
Actively offered patientsâ families the opportunity to observe CPR
Follow standard practice regarding family presence (control group)
Of the 266 relatives that received offers to observe CPR, 211 (79%) accepted vs. 43% in the control group observed CPR
The study assessed a primary end-point of PTSD-related symptoms 90 days after the event
Secondary end-points included depression, anxiety, medicolegal claims, medical efforts at resuscitation, and the well-being of the healthcare team
The frequency of PTSD-related symptoms was significantly higher in the control group
Lower rates of anxiety and depression for the families who witnessed CPR
There were no effects on resuscitation efforts, patient survival, medicolegal claims, or stress on the healthcare team
If families choose to witness CPR, itâs beneficial to have someone with the family to explain the process
References
1. Jabre P, Belpomme V, Azoulay E, et al. Family Presence during Cardiopulmonary Resuscitation. N Engl J Med. 2013;368(11):1008-1018. doi:10.1056/NEJMoa1203366
Summarized by Jorge Chalit, OMSII | Edited by Jorge Chalit
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Contributor: Ricky Dhaliwal, MD
Educational Pearls:
Croup
Caused by:
Parainfluenza, Adenovirus, RSV, Enterovirus (big right now)
Age range:
6 months to 3 years
Symptoms:
Barky cough
Inspiratory stridor (Severe = stidor at rest)
Use the Westley Croup Score to gauge the severity
Treatment:
High flow, humidified, cool oxygen
Dexamethasone 0.6 mg/kg oral, max 16mg
Severe: Racemic Epinephrine 0.5 mL/kg
Consider heliox, a mixture of helium and oxygen
Very severe: be ready to intubate
Bronchiolitis
Caused by:
RSV, Rhinovirus
Symptoms are driven by secretions
Symptoms:
Cough
Wheezing
Dehydration (often the symptom that makes them look the worst)
Age range:
2 to 6 months
Treatment:
Suctioning
Oxygen
IV fluids
Nebulized hypertonic saline
DuoNebs? No.
Asthma
Caused by:
Environmental factors
Viral illness with a predisposition
Treatment:
Beta agonists
Steroids
Ipratropium
Magnesium (relaxes smooth muscle)
References
Dalziel SR, Haskell L, O'Brien S, Borland ML, Plint AC, Babl FE, Oakley E. Bronchiolitis. Lancet. 2022 Jul 30;400(10349):392-406. doi: 10.1016/S0140-6736(22)01016-9. Epub 2022 Jul 1. PMID: 35785792.
Hoch HE, Houin PR, Stillwell PC. Asthma in Children: A Brief Review for Primary Care Providers. Pediatr Ann. 2019 Mar 1;48(3):e103-e109. doi: 10.3928/19382359-20190219-01. PMID: 30874817.
Midulla F, Petrarca L, Frassanito A, Di Mattia G, Zicari AM, Nenna R. Bronchiolitis clinics and medical treatment. Minerva Pediatr. 2018 Dec;70(6):600-611. doi: 10.23736/S0026-4946.18.05334-3. Epub 2018 Oct 18. PMID: 30334624.
Smith DK, McDermott AJ, Sullivan JF. Croup: Diagnosis and Management. Am Fam Physician. 2018 May 1;97(9):575-580. PMID: 29763253.
Westley CR, Cotton EK, Brooks JG. Nebulized racemic epinephrine by IPPB for the treatment of croup: a double-blind study. Am J Dis Child. 1978 May;132(5):484-7. doi: 10.1001/archpedi.1978.02120300044008. PMID: 347921.
https://www.mdcalc.com/calc/677/westley-croup-score
Summarized by Jeffrey Olson | Edited by Meg Joyce & Jorge Chalit, OMSII
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Contributor: Ricky Dhaliwal MD
Educational Pearls:
Three zones of the neck with different structures and risks for injuries:
Zone 1 is the most caudal region from the clavicle to the cricoid cartilage
Zone 2 is from the cricoid cartilage to the angle of the mandible
Zone 3 is superior to the angle of the mandible
Zone 1 contains the thoracic outlet vasculature (subclavian arteries and veins, internal jugular veins), carotid arteries, vertebral artery, apices of the lungs, trachea, esophagus, spinal cord, thoracic duct, thyroid gland, jugular veins, and the vagus nerve.
Zone 2 contains the common carotid arteries, internal and external branches of carotid arteries, vertebral arteries, jugular veins, trachea, esophagus, larynx, pharynx, spinal cord, and vagus and recurrent laryngeal nerves
Lower risk than Zone 1 or Zone 3
Zone 3 contains the distal carotid arteries, vertebral arteries, jugular veins, pharynx, spinal cord, cranial nerves IX, X, XI, XII, the sympathetic chain, and the salivary and parotid glands
Hard signs that indicate direct transfer to OR:
Airway compromise
Active, brisk bleeding
Pulsatile hematomas
Hematemesis
Massive subcutaneous emphysema
Soft signs that may obtain imaging to determine further interventions:
Hemoptysis
Oropharyngeal bleeding
Dysphagia
Dysphonia
Expanding hematomas
Soft sign management includes ABCs, type & screen, and airway interventions followed by imaging of the head & neck area
Patients with dysphonia or dysphagia with subsequent negative CTAs may get further work-up via swallow studies
References
Asensio JA, Chahwan S, Forno W, et al. Penetrating esophageal injuries: multicenter study of the American Association for the Surgery of Trauma. J Trauma. 2001;50(2):289-296. doi:10.1097/00005373-200102000-00015
Azuaje RE, Jacobson LE, Glover J, et al. Reliability of physical examination as a predictor of vascular injury after penetrating neck trauma. Am Surg. 2003;69(9):804-807.
Ibraheem K, Wong S, Smith A, et al. Computed tomography angiography in the "no-zone" approach era for penetrating neck trauma: A systematic review. J Trauma Acute Care Surg. 2020;89(6):1233-1238. doi:10.1097/TA.0000000000002919
Nowicki JL, Stew B, Ooi E. Penetrating neck injuries: A guide to evaluation and managementx. Ann R Coll Surg Engl. 2018;100(1):6-11. doi:10.1308/rcsann.2017.0191
Summarized by Jorge Chalit, OMSII | Edited by Meg Joyce & Jorge Chalit, OMSII
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Contributor: Kiersten Williams MD, Travis Barlock MD, Jeffrey Olson MS2
Summary:
In this episode, Dr. Travis Barlock and Jeffrey Olson meet in the studio to discuss a clip from Dr. Williamsâ talk at the âLaboring Under Pressure, Managing Obstetric Emergencies in a Global Settingâ event 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. Kiersten Williams completed her OBGYN residency at Bay State Medical Center and practices as an Obstetric Hospitalist at Presbyterian/St. Lukeâs Medical Center in Denver, Colorado.
During her talk, Dr. Williams walks the audience through the common causes and treatments for post-partum hemorrhage (PPH).
Some important take-away points from this talk are:
The most common causes of PPH can be remembered by the 4 Tâs. Tone (atony), Trauma, Tissue (retained placenta), and Thrombin (coagulopathies).
AV malformations of the uterus are probably underdiagnosed.
Quantitative blood loss is much more accurate than estimated blood loss (EBL).
The ideal fibrinogen for an obstetric patient about to deliver is above 400 mg/dl - under 200 is certain to cause bleeding.
Do not deliver oxytocin via IV push dose, it can cause significant hypotension.
Tranexamic Acid is available in both IV and PO and can be administered in the field. The dose is 1 gram and can be run over 10 minutes if administered via IV. It is best if used within 3 hours of delivery.
When performing a uterine massage, place one hand inside the vagina and one hand on the lower abdomen. Then rub the lower abdomen like mad.
A new option for treating PPH is called the JADA System which is slimmer than a Bakri Balloon and uses vacuum suction to help the uterus clamp down.*
Another option for a small uterus is to insert a 60 cc Foley catheter.
In an operating room, a B-Lynch suture can be put in place, uterine artery ligation can be performed, and as a last resort, a hysterectomy can be done.
*EMM is not sponsored by JADA system or the Bakri balloon.
References
Andrikopoulou M, D'Alton ME. Postpartum hemorrhage: early identification challenges. Semin Perinatol. 2019 Feb;43(1):11-17. doi: 10.1053/j.semperi.2018.11.003. Epub 2018 Nov 14. PMID: 30503400.
Committee on Practice Bulletins-Obstetrics. Practice Bulletin No. 183: Postpartum Hemorrhage. Obstet Gynecol. 2017 Oct;130(4):e168-e186. doi: 10.1097/AOG.0000000000002351. PMID: 28937571.
Federspiel JJ, Eke AC, Eppes CS. Postpartum hemorrhage protocols and benchmarks: improving care through standardization. Am J Obstet Gynecol MFM. 2023 Feb;5(2S):100740. doi: 10.1016/j.ajogmf.2022.100740. Epub 2022 Sep 2. PMID: 36058518; PMCID: PMC9941009.
Health Outreach for Latin America Foundation - HOLA Foundation. (n.d.). http://www.hola-foundation.org/
Kumaraswami S, Butwick A. Latest advances in postpartum hemorrhage management. Best Pract Res Clin Anaesthesiol. 2022 May;36(1):123-134. doi: 10.1016/j.bpa.2022.02.004. Epub 2022 Feb 24. PMID: 35659949.
Pacheco LD, Saade GR, Hankins GDV. Medical management of postpartum hemorrhage: An update. Semin Perinatol. 2019 Feb;43(1):22-26. doi: 10.1053/j.semperi.2018.11.005. Epub 2018 Nov 14. PMID: 30503399.
Produced by Jeffrey Olson, MS2 | Edited by Jeffrey Olson and Jorge Chalit, OMSII
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Contributor: Meghan Hurley MD
Educational Pearls:
What is a nerve block?
A nerve block is the medical procedure of injecting anesthetic into the area around a nerve to block pain signals.
They are typically done with ultrasound guidance.
Are nerve blocks effective?
Most of the information we have about nerve blocks is extrapolated from fascia iliaca blocks. This nerve block targets the fascia iliaca compartment, which contains the femoral, lateral femoral cutaneous, and obturator nerves. These blocks are commonly done for hip fractures to help stabilize the patient while awaiting surgical repair.
The data for these types of injections is strong. They decrease pain, they decrease total morphine equivalents needed while a patient is in the hospital, they help mobilize patients earlier and start physical therapy earlier, and they help patients leave the hospital about a day earlier.
What is an example of an agent that can be used?
Bupivacaine. A long acting amide-type local anesthetic. It works best when paired with epinephrine which causes local vasoconstriction and allows the bupivaciaine to bathe the nerve for longer. It gives 5-15 hours of anesthesia (complete sensation loss), and up to 30 hours of analgesia (pain loss).
Whatâs an example of another block that can be done?
An Erector Spinae Plane (ESP) block is performed in the paraspinal fascial plane in the back. This can be used for pain around the ribs and before a variety of medical procedures including a Nuss procedure, thoracotomies, percutaneous nephrolithotomies, ventral hernia repairs, and even lumbar fusions.
What is one potential complication of a nerve block?
Local Anesthetic Systemic Toxicity (LAST).
There are three ways this can happen:
1) Using too much total anesthetic (Maximum dose of bupivacaine is 2.5 mg/kg).
2) Too much anesthetic is injected into a confined space which then gets absorbed into the venous system.
3) Injecting directly into the vasculature by mistake.
What are the signs that this complication has occurred?
Perioral tingling
Stupor
Coma
Seizures
What can that cause?
Cardiovascular collapse
How is that treated?
Intralipid AKA Soybean Oil, or âlipid emulsionâ should be given as a bolus followed by a drip. These patients need to be admitted.
Bolus 1.5 ml/kg (lean body mass) intravenously over 1 min (max ~100 ml).
Continuous infusion at 0.25 mL/kg/min. Max dosing in the first 30 minutes is around 100 ml/kg.
Fun fact: Patients being treated for LAST with intralipid cannot undergo general anesthesia because the intralipid will impact the anesthesia drugs.
References
Long B, Chavez S, Gottlieb M, Montrief T, Brady WJ. Local anesthetic systemic toxicity: A narrative review for emergency clinicians. Am J Emerg Med. 2022 Sep;59:42-48. doi: 10.1016/j.ajem.2022.06.017. Epub 2022 Jun 13. PMID: 35777259.
Carvalho JĂșnior LH, Temponi EF, Paganini VO, Costa LP, Soares LF, Gonçalves MB. Reducing the length of hospital stay after total knee arthroplasty: influence of femoral and sciatic nerve block. Rev Assoc Med Bras (1992). 2015 Jan-Feb;61(1):40-3. doi: 10.1590/1806-9282.61.01.040. Epub 2015 Jan 1. PMID: 25909207.
Jain N, Kotulski C, Al-Hilli A, Yeung-Lai-Wah P, Pluta J, Heegeman D. Fascia Iliaca Block in Hip and Femur Fractures to Reduce Opioid Use. J Emerg Med. 2022 Jul;63(1):1-9. doi: 10.1016/j.jemermed.2022.04.018. Epub 2022 Aug 4. PMID: 35933265.
Kot P, Rodriguez P, Granell M, Cano B, Rovira L, Morales J, Broseta A, Andrés J. The erector spinae plane block: a narrative review. Korean J Anesthesiol. 2019 Jun;72(3):209-220. doi: 10.4097/kja.d.19.00012. Epub 2019 Mar 19. PMID: 30886130; PMCID: PMC6547235.
Lee SH, Sohn JT. Mechanisms underlying lipid emulsion resuscitation for drug toxicity: a narrative review. Korean J Anesthesiol. 2023 Jun;76(3):171-182. doi: 10.4097/kja.23031. Epub 2023 Jan 26. PMID: 36704816; PMCID: PMC10244607.
Weinberg, Guy. LipidRescueâą Resuscitation. http://www.lipidrescue.org/
Summarized by Jeffrey Olson MS2 | Edited by Jorge Chalit, OMSII
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Contributor: Jorge Chalit, OMS II
Educational Pearls:
Migraine pathophysiology
Primarily mediated through the trigeminovascular system
Serotonin, dopamine, and calcitonin gene-related peptide (CGRP)
Trigeminovascular system is linked to the trigeminal nucleus caudalis, which relays pain to the hypothalamus and cerebral cortex
One effective treatment for acute migraines is -triptan medications
5-HT1D/1B agonists such as sumatriptan
Often combined with NSAIDs and dopamine antagonists (as antiemetics) in migraine cocktails
Diphenhydramine (Benadryl) was shown to be ineffective in a randomized controlled trial comparing it with placebo and a dopamine antagonist antiemetic.
The -triptan medications carry significant risk for peripheral vasoconstriction and are therefore avoided in cardiovascular disease
One serotonin agonist specifically approved for use in vascular disease
Lasmiditan - 5-HT1F agonist
Slightly different mechanism of action avoids peripheral vasoconstriction
CGRP antagonists are also used in patients who are unresponsive to -triptans
References
1. Friedman WB, Cabral L, Adewunmi V, et al. Diphenhydramine as adjuvant therapy for acute migraine. An ED-based randomized clinical trial. Ann Emerg Med. 2016;67(1):32-39.e3. doi:doi:10.1016/j.annemergmed.2015.07.495
2. Lasmiditan (Reyvow) and ubrogepant (Ubrelvy) for acute treatment of migraine. (2020). The Medical letter on drugs and therapeutics, 62(1593), 35â39.
3. Robbins MS. Diagnosis and Management of Headache: A Review. JAMA - J Am Med Assoc. 2021;325(18):1874-1885. doi:10.1001/jama.2021.1640
4. Vanderpluym JH, Halker Singh RB, Urtecho M, et al. Acute Treatments for Episodic Migraine in Adults: A Systematic Review and Meta-analysis. JAMA - J Am Med Assoc. 2021;325(23):2357-2369. doi:10.1001/jama.2021.7939
Summarized by Jorge Chalit, OMSII | Edited by Meg Joyce & Jorge Chalit, OMSII
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Contributor: Aaron Lessen MD
Educational Pearls:
How is the severity of a stroke assessed?
Strokes are assessed by the NIH Stroke Scale (NIHSS), this scale has different tasks, such as asking the person to repeat words, move their arms, or follow simple instructions. The maximum score is 42 but any score over 21 is considered severe.
What would qualify as a minor storke?
NIH
- Vis mere
