Episodes
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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
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Missing episodes?
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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
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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
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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
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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 - 318Summarized by Meg Joyce, MS1 | Edited by Meg Joyce & Jorge Chalit, OMS3
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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
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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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Contributor: Aaron Lessen, MD
Educational Pearls:
Hemothorax: blood in the pleural cavity, most commonly due to chest trauma
Treatment: thoracostomy tube for blood drainage
helps to avoid clotting, scarring, and infection
A recent study looked at patients with hemothorax who either received or did not receive thoracic irrigation with saline
Evaluated incidence of secondary intervention, such as video-assisted thoracoscopic surgery (VATS), for persistent hemothorax
Patients who received irrigation had a slight decrease in secondary intervention frequency
Multi-center study - all patients who had the irrigation procedure were at two centers
Study limitation: variability in approaches at each location could be a confounder
Technique that could potentially prevent future complications
References
Carver TW, Berndtson AE, McNickle AG, et al. Thoracic irrigation for prevention of secondary intervention after thoracostomy tube drainage for hemothorax: A Western Trauma Association multi-center study. J Trauma Acute Care Surg. Published online May 20, 2024. doi:10.1097/TA.0000000000004364
Yi JH, Liu HB, Zhang M, et al. Management of traumatic hemothorax by closed thoracic drainage using a central venous catheter. J Zhejiang Univ Sci B. 2012;13(1):43-48. doi:10.1631/jzus.B1100161
Summarized by Meg Joyce, MS | Edited by Meg Joyce & Jorge Chalit, OMS3
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Contributor: Taylor Lynch, MD
Educational Pearls:
When it comes to hypoglycemia, the age dictates possible causes
Neonate:
Hormonal deficiency
Congenital Adrenal Hyperplasia (21-hydroxylase deficiency, 11β-hydroxylase deficiency)
Primary or Secondary Adrenal Insufficiency leading to cortisol deficiency
Hypopituitarism
Inborn errors of metabolism
Systemic infection (Under 30 days old should trigger a full infectious workup)
Toddler
Accidental ingestions
Sulfonylureas such as glipizide or glyburide
Older children
Addison’s Disease (Hypocortisolism)
Accidential or intentional ingestions
Exogenous insulin
How is it diagnosed?
Child or infant
Glucose
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Contributor: Kiersten Williams MD, Travis Barlock MD, Jeffrey Olson MS3
Show Pearls
Hypertensive disorders of pregnancy are one of the leading causes of maternal mortality worldwide.
Hypertension (HTN) complicates 2-8% of pregnancies
The definition of HTN in pregnancy is a systolic >140 or diastolic >90, measured 4 hours apart
There is a range of HTN disorders
Chronic HTN which could have superimposed preeclampsia (preE) on top
Gestational HTN in which there are no lab abnormalities
PreE w/o severe features
Protein in urine
Urine protein >300 mg in 24 hours
Urine Protein to Creatinine ratio of .3
+2 Protein on urine dipstick
PreE w/ severe features
Systolics above 160 mmHg
Diastolics above 110 mmHg
Headache, especially not going away with meds, or different than previous headaches
Visual changes, anything that lasts more than a few minutes
RUQ pain, which could present as heartburn
Pulmonary edema
Low platelets, if
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Contributor: Sean Fox, MD
Educational Pearls:
Newborns may lose up to 10% of their birth weight in the first week of life
Weight loss is greatest in exclusively breastfed infants
Should regain birth weight by age 2 weeks
Newborns should gain an average of 30g (1 oz) per day in the first 3 months of life
Some will gain more and some will gain less
Infants double their birth weight by 6 months of life and triple their weight by 12 months
A 1-year-old should weigh on average 10 kg (22 lbs)
A 3-year-old should weigh on average 15 kg (33 lbs)
2-year-olds are between 10-15 kg on average
Weight assessment can help determine causes of forceful vomiting
Not all “projectile” vomiting is due to pyloric stenosis
Some infants may experience vigorous vomiting from overfeeding
Weight estimates can also provide information for quick decisions on medical management for children coming via EMS
Helps to prepare medications and dosages based on predicted average weight
References
Crossland DS, Richmond S, Hudson M, Smith K, Abu-Harb M. Weight change in the term baby in the first 2 weeks of life. Acta Paediatr. 2008;97(4):425-429. doi:10.1111/j.1651-2227.2008.00685.x
Grummer-Strawn LM, Reinold C, Krebs NF; Centers for Disease Control and Prevention (CDC). Use of World Health Organization and CDC growth charts for children aged 0-59 months in the United States [published correction appears in MMWR Recomm Rep. 2010 Sep 17;59(36):1184]. MMWR Recomm Rep. 2010;59(RR-9):1-15.
Macdonald PD, Ross SR, Grant L, Young D. Neonatal weight loss in breast and formula fed infants. Arch Dis Child Fetal Neonatal Ed. 2003;88(6):F472-F476. doi:10.1136/fn.88.6.f472
Paul IM, Schaefer EW, Miller JR, et al. Weight Change Nomograms for the First Month After Birth. Pediatrics. 2016;138(6):e20162625. doi:10.1542/peds.2016-2625
Summarized & Edited by Jorge Chalit, OMS3
Special thanks to the Carolinas Medical Center for their contribution to this episode
Donate: https://emergencymedicalminute.org/donate/
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Contributor: Travis Barlock, MD
Educational Pearls:
SVT: supraventricular tachycardia
Pharmacotherapy for SVT includes drugs that block the AV node, such as adenosine
EKG criteria before adenosine administration in SVT
Regular rhythm
Monomorphic: all QRS complexes are identical
If the EKG is polymorphic, with QRS complexes displaying changing morphologies, it is unsafe to administer adenosine
Adenosine can worsen polymorphic VTach and lead to VFib
References
Ganz, Leonard I., and Peter L. Friedman. “Supraventricular Tachycardia.” New England Journal of Medicine, vol. 332, no. 3, 19 Jan. 1995, pp. 162–173, https://doi.org/10.1056/nejm199501193320307.
Smith JR, Goldberger JJ, Kadish AH. Adenosine induced polymorphic ventricular tachycardia in adults without structural heart disease. Pacing Clin Electrophysiol. 1997;20(3 Pt 1):743-745. doi:10.1111/j.1540-8159.1997.tb03897.x
Viskin, Sami, et al. “Polymorphic Ventricular Tachycardia: Terminology, Mechanism, Diagnosis, and Emergency Therapy.” Circulation, vol. 144, no. 10, 7 Sept. 2021, pp. 823–839, https://doi.org/10.1161/circulationaha.121.055783.
Summarized by Meg Joyce, MS1 | Edited by Meg Joyce & Jorge Chalit, OMS3
Donate: https://emergencymedicalminute.org/donate/
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Contributor: Aaron Lessen, MD
Educational Pearls:
How does an automated blood pressure cuff work?
Automated blood pressure cuffs work differently than taking a manual blood pressure.
While taking a manual blood pressure, one typically listens for Korotkoff sounds (turbulent flow) while slowly deflating the cuff.
An automatic blood pressure cuff only senses the pressure in the cuff itself and specifically pays attention to oscillations in the pressure caused by when the pressure of the cuff is between the systolic (heart squeezing) and diastolic (heart relaxed) pressures.
These oscillations are at a maximum when the pressure in the cuff matches the mean arterial pressure (MAP) and therefore the machines are most accurate at reporting the MAP.
The machines then use the MAP and other information about the oscillations to estimate the systolic and diastolic pressures, which are less accurate.
What should you do if you need more accurate systolic and diastolic blood pressures?
Take a manual blood pressure.
Get an arterial-line (a-line), which provides continuous data for the blood pressure at the end of a catheter.
What happens if the cuff is too big or too small for the patient?
If the cuff is too small it will overestimate the pressure.
If the cuff is too large it will underestimate the pressure.
What should you do if the cuff cycles a bunch of times before reporting a blood pressure?
It probably isn’t very accurate so consider another method.
Bonus fact!
The MAP is not directly in the middle of the systolic and diastolic pressures but is weighted towards the diastolic pressure. The MAP can be calculated by adding two-thirds of the diastolic pressure to one third of the systolic pressure. For example if the BP is 120/90 the MAP is 100 mmHg.
References
Benmira, A., Perez-Martin, A., Schuster, I., Aichoun, I., Coudray, S., Bereksi-Reguig, F., & Dauzat, M. (2016). From Korotkoff and Marey to automatic non-invasive oscillometric blood pressure measurement: does easiness come with reliability?. Expert review of medical devices, 13(2), 179–189. https://doi.org/10.1586/17434440.2016.1128821
Liu, J., Li, Y., Li, J., Zheng, D., & Liu, C. (2022). Sources of automatic office blood pressure measurement error: a systematic review. Physiological measurement, 43(9), 10.1088/1361-6579/ac890e. https://doi.org/10.1088/1361-6579/ac890e
Vilaplana J. M. (2006). Blood pressure measurement. Journal of renal care, 32(4), 210–213. https://doi.org/10.1111/j.1755-6686.2006.tb00025.x
Summarized by Jeffrey Olson, MS3 | Edited by Meg Joyce, MS1 & Jorge Chalit, OMS3
Donate: https://emergencymedicalminute.org/donate/
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Contributor: Megan Hurley, MD
Educational Pearls:
Heat cramps
Occur due to electrolyte disturbances
Most common electrolyte abnormalities are hyponatremia and hypokalemia
Heat edema
Caused by vasodilation with pooling of interstitial fluid in the extremities
Heat rash (miliaria)
Common in newborns and elderly
Due to accumulation of sweat beneath eccrine ducts
Heat syncope
Lightheadedness, hypotension, and/or syncope in patients with peripheral vasodilation due to heat exposure
Treatment is removal from the heat source and rehydration (IV fluids or Gatorade)
Heat exhaustion
Patients have elevated body temperature (greater than 38º C but less than 40º C)
Symptoms include nausea, tachycardia, headache, sweating, and others
Normal mental status or mild confusion that improves with cooling
Treatment is removal from the heat source and hydration
Classic heat stroke
From prolonged exposure to heat
Defined as a core body temperature > 40.5º C, though not required for diagnosis or treatment
Presentation is similar to heat exhaustion with the addition of neurological deficits including ataxia
Patients present “dry”
Exertional heat stroke
Prolonged exposure to heat during exercise
Similar to classic heat stroke but the patients present “wet” due to antecedent treatment in ice baths or other field treatments
Management of heat-related illnesses includes:
Cooling
Rehydration
Evaluation of electrolytes
Antipyretics are not helpful because heat-induced illnesses are not due to hypothalamic dysregulation
References
Casa DJ, McDermott BP, Lee EC, et al. Cold water immersion: the gold standard for exertional heatstroke treatment. Exerc Sport Sci Rev 2007; 35:141.
Ebi KL, Capon A, Berry P, et al. Hot weather and heat extremes: health risks. Lancet 2021; 398:698.
Epstein Y, Yanovich R. Heatstroke. N Engl J Med 2019; 380:2449.
Gardner JW, JA K. Clinical diagnosis, management, and surveillance of exertional heat illness. In: Textbook of Military Medicine, Zajitchuk R (Ed), Army Medical Center Borden Institute, Washington, DC 2001.
Khosla R, Guntupalli KK. Heat-related illnesses. Crit Care Clin 1999; 15:251.
Lipman GS, Gaudio FG, Eifling KP, et al. Wilderness Medical Society Clinical Practice Guidelines for the Prevention and Treatment of Heat Illness: 2019 Update. Wilderness Environ Med 2019; 30:S33.
Summarized by Jorge Chalit, OMSIII | Edited by Meg Joyce, MS1
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Contributor: Taylor Lynch, MD
Educational Pearls:
What is Central Cord Syndrome (CCS)?
Incomplete spinal cord injury caused by trauma that compresses the center of the cord
More common in hyperextension injuries like falling and hitting the chin
Usually happens only in individuals with preexisting neck and spinal cord conditions like cervical spondylosis (age-related wear and tear of the cervical spine)
Anatomy of spinal cord
Motor tracts
The signals the brain sends for the muscles to move travel in the corticospinal tracts of the spinal cord
The tracts that control the upper limbs are more central than the ones that control the lower limbs
The tracts that control the hands are more central than the ones that control the upper arm/shoulder
Fine touch, vibration, and proprioception (body position) tracts
These sensations travel in separate tracts in the spinal cord than the sensation of pain and temperature
Their pathway is called the dorsal column-medial lemniscus (DCML) pathway
This information travels in the most posterior aspect of the spinal cord
Pain, crude touch, pressure, and temperature tracts
These sensations travel in the spinothalamic tract, which is more centrally located
These signals also cross one side of the body to the other within the spinal cord near the level that they enter
How does this anatomy affect the presentation of CCS?
Patients typically experience more pronounced weakness or paralysis in their upper extremities as compared to their lower extremities with their hands being weaker than more proximal muscle groups
Sensation of pain, crude touch, pressure, and temperature are much morelikely to be diminished while the sensation of fine touch, vibration, and proprioception are spared
What happens with reflexes?
Deep tendon reflexes become exaggerated in CCS
This is because the disruption in the corticospinal tract removes inhibitory control over reflex arcs
What happens to bladder control?
The neural signals that coordinate bladder emptying are disrupted, therefore patients can present with urinary retention and/or urge incontinence
What is a Babinski’s Sign?
When the sole of the foot is stimulated a normal response in adults is for the toes to flex downward (plantar flexion)
If there is an upper motor neuron injury like in CCS, the toes will flex upwards (dorsiflexion)
How is CCS diagnosed?
CCS is mostly a clinical diagnosis
These patient also need an MRI to see the extent of the damage which will show increased signal intensity within the central part of the spinal cord on T2-weighted images
How is CCS treated?
Strict c-spine precautions
Neurogenic shock precautions. Maintain a mean arterial pressure (MAP) of 85-90 to ensure profusion of the spinal cord
Levophed (norepinephrine bitartrate) and/or phenylephrine can be used to support their blood pressure to support spinal perfusion
Consider intubation for injuries above C5 (C3, 4, and 5 keep the diaphragm alive)
Consult neurosurgery for possible decompression surgery
Physical Therapy
References
Avila, M. J., & Hurlbert, R. J. (2021). Central Cord Syndrome Redefined. Neurosurgery clinics of North America, 32(3), 353–363. https://doi.org/10.1016/j.nec.2021.03.007
Brooks N. P. (2017). Central Cord Syndrome. Neurosurgery clinics of North America, 28(1), 41–47. https://doi.org/10.1016/j.nec.2016.08.002
Engel-Haber, E., Snider, B., & Kirshblum, S. (2023). Central cord syndrome definitions, variations and limitations. Spinal cord, 61(11), 579–586. https://doi.org/10.1038/s41393-023-00894-2
Summarized by Jeffrey Olson, MS3 | Edited by Jorge Chalit, OMS3
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Contributor: Megan Hurley, MD
Educational Pearls:
Initial assessment of patients with severe burn injuries begins with ABCs
Airway: consider inhalation injury
Breathing: circumferential burns of the trunk region can reduce respiratory muscle movement
Circulation: circumferential burns compromise circulation
Exposure: Important to assess the affected surface area
Escharotomy: emergency procedure to release the tourniquet-ing effects of the eschar
Differs from a fasciotomy in that it does not breach the deep fascial layer
PEEP = positive end-expiratory pressure
The positive pressure remaining in the airway after exhalation
Keeps airway pressure higher than atmospheric pressure
Common formulas for initial fluid rate in burn shock resuscitation
Parkland formula: 4 mL/kg body weight/% TBSA burns (lactated Ringer's solution)
Modified Brooke formula: 2 mL/kg/% (also lactated Ringer's solution)
Less fluid = lower risk of intra-abdominal compartment syndrome
Lactated Ringer’s solution is preferred over normal saline in burn injuries
Normal saline is avoided in large quantities due to the possibility of it leading to hyperchloremic acidosis
References
Acosta P, Santisbon E, Varon J. “The Use of Positive End-Expiratory Pressure in Mechanical Ventilation.” Critical Care Clinics. 2007;23(2):251-261. doi:10.1016/j.ccc.2006.12.012
Orgill DP, Piccolo N. Escharotomy and decompressive therapies in burns. J Burn Care Res. 2009;30(5):759-768. doi:10.1097/BCR.0b013e3181b47cd3
Snell JA, Loh NH, Mahambrey T, Shokrollahi K. Clinical review: the critical care management of the burn patient. Crit Care. 2013;17(5):241. Published 2013 Oct 7. doi:10.1186/cc12706
Summarized by Meg Joyce, MS1 | Edited by Meg Joyce & Jorge Chalit
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Contributor: Taylor Lynch, MD
Educational Pearls:
What is NMS?
Neuroleptic Malignant Syndrome
Caused by anti-dopamine medication or rapid withdrawal of pro-dopamenergic medications
Mechanism is poorly understood
Life threatening
What medications can cause it?
Typical antipsychotics
Haloperidol, chlorpromazine, prochlorperazine, fluphenazine, trifluoperazine
Atypical antipsychotics
Less risk
Risperidone, clozapine, quetiapine, olanzapine, aripiprazole, ziprasidone
Anti-emetic agents with anti dopamine activity
Metoclopramide, promethazine, haloperidol
Not ondansetron
Abrupt withdrawal of levodopa
How does it present?
Slowly over 1-3 days (unlike serotonin syndrome which has a more acute onset)
Altered mental status, 82% of patients, typically agitated delirium with confusion
Peripheral muscle rigidity and decreased reflexes. AKA lead pipe rigidity. (As opposed to clonus and hyperreflexia in serotonin syndrome)
Hyperthermia (>38C seen in 87% of patients)
Can also have tachycardia, labile blood pressures, tachypnea, and tremor
How is it diagnosed?
Clinical diagnosis, focus on the timing of symptoms
No confirmatory lab test but can see possible elevated CK levels and WBC of 10-40k with a left shift
What else might be on the differential?
Sepsis
CNS infections
Heat stroke
Agitated delirium
Status eptilepticus
Drug induced extrapyramidal symptoms
Serotonin syndrome
Malignant hyperthermia
What is the treatment?
Start with ABC’s
Stop all anti-dopaminergic meds and restart pro-dopamine meds if recently stopped
Maintain urine output with IV fluids if needed to avoid rhabdomyolysis
Active or passive cooling if needed
Benzodiazapines, such as lorazepam 1-2 mg IV q 4hrs
What are active medical therapies?
Controversial treatments
Bromocriptine, dopamine agonist
Dantrolene, classically used for malignant hyperthermia
Amantadine, increases dopamine release
Use as a last resort
Dispo?
Mortality is around 10% if not recognized and treated
Most patients recover in 2-14 days
Must wait 2 weeks before restarting any medications
References
Oruch, R., Pryme, I. F., Engelsen, B. A., & Lund, A. (2017). Neuroleptic malignant syndrome: an easily overlooked neurologic emergency. Neuropsychiatric disease and treatment, 13, 161–175. https://doi.org/10.2147/NDT.S118438
Tormoehlen, L. M., & Rusyniak, D. E. (2018). Neuroleptic malignant syndrome and serotonin syndrome. Handbook of clinical neurology, 157, 663–675. https://doi.org/10.1016/B978-0-444-64074-1.00039-2
Velamoor, V. R., Norman, R. M., Caroff, S. N., Mann, S. C., Sullivan, K. A., & Antelo, R. E. (1994). Progression of symptoms in neuroleptic malignant syndrome. The Journal of nervous and mental disease, 182(3), 168–173. https://doi.org/10.1097/00005053-199403000-00007
Ware, M. R., Feller, D. B., & Hall, K. L. (2018). Neuroleptic Malignant Syndrome: Diagnosis and Management. The primary care companion for CNS disorders, 20(1), 17r02185. https://doi.org/10.4088/PCC.17r02185
Summarized by Jeffrey Olson MS2 | Edited by Meg Joyce & Jorge Chalit, OMSIII
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Contributor: Travis Barlock MD
Educational Pearls:
Recent study assessed outcomes after ROSC with epinephrine vs. norepinephrine
Observational multicenter study from 2011-2018
285 patients received epineprhine and 481 received norepinephrine
Epinephrine was associated with an increase in all-cause mortality (primary outcome)
Odds ratio 2.6; 95%CI 1.4-4.7; P = 0.002
Higher cardiovascular mortality (secondary outcome)
Higher proportion of unfavorable neurological outcome (secondary outcome)
Norepinephrine is the vasopressor of choice in post-cardiac arrest care
References
Bougouin W, Slimani K, Renaudier M, et al. Epinephrine versus norepinephrine in cardiac arrest patients with post-resuscitation shock. Intensive Care Med. 2022;48(3):300-310. doi:10.1007/s00134-021-06608-7
Summarized by Jorge Chalit, OMSIII | Edited by Meg Joyce & Jorge Chalit
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Contributor: Taylor Lynch, MD
Educational Pearls:
Opioid Epidemic- quick facts
Drug overdoses, primarily driven by opioids, have become the leading cause of accidental death in the U.S. for individuals aged 18-45.
In 2021, opioids were involved in nearly 75% of all drug overdose deaths
The rise of synthetic opioids like fentanyl, which is much more potent than heroin or prescription opioids, has played a major role in the increase in overdose deaths
What is Narcan AKA Naloxone?
Competitive opioid antagonist. It sits on the receptor but doesn’t activate it.
When do we give Narcan?
Respiratory rate less than 8-10 breaths per minute
Should you check the pupils?
An opioid overdose classically presents with pinpoint pupils BUT…
Hypercapnia from bradypnea can normalize the pupils
Taking other drugs at the same time like cocaine or meth can counteract the pupillary effects
Basilar stroke could also cause small pupils, so don’t anchor on an opioid overdose
How does Narcan affect the body?
Relatively safe even if the patient is not experiencing an opioid overdose. So when in doubt, give the Narcan.
What if the patient is opioid naive and overdosing?
Use a large dose given that this patient is unlikely to withdraw
0.4-2 mg every 3-5 minutes
What if the patient is a chronic opioid user
Use a smaller dose such as 0.04-0.4 mg to avoid precipitated withdrawal
How fast does Narcan work?
Given intravenously (IV), onset is 1-2 min
Given intranasal (IN), onset is 3-4 min
Given intramuscularly (IM), onset is ~6 min
Duration of action is 60 mins, with a range of 20-90 minutes
How does that compare to the duration of action of common opioids?
Heroine lasts 60 min
Fentanyl lasts 30-60 min, depending on route
Carfentanyl lasts ~5 hrs
Methadone lasts 12-24 hrs
So we really need to be conscious about redosing
How do you monitor someone treated with Narcan?
Pay close attention to the end-tidal CO2 to ensure that are ventilating appropriately
Be cautious with giving O2 as it might mask hypoventilation
Watch the respiratory rate
Give Narcan as needed
Observe for at least 2-4 hours after the last Narcan dose
Larger the dose, longer the observation period
Who gets a drip?
If they have gotten ~3 doses, time to start the drip
Start at 2/3rds last effective wake-up dose
Complications
Flash pulm edema
0.2-3.6% complication rate
Might be from the catecholamine surge from abrupt wake-up
Might also be from large inspiratory effort against a partially closed glottis which creates too much negative pressure
Treat with BIPAP if awake and intubation if not awake
Should you give Narcan in cardiac arrest?
Short answer no. During ACLS you take over breathing for the patient and that is pretty much the only way that Narcan can help
Just focus on high quality CPR
References
https://nida.nih.gov/research-topics/trends-statistics/overdose-death-rates#:~:text=Drug%20overdose%20deaths%20involving%20prescription,of%20deaths%20declined%20to%2014%2C716.
Elkattawy, S., Alyacoub, R., Ejikeme, C., Noori, M. A. M., & Remolina, C. (2021). Naloxone induced pulmonary edema. Journal of community hospital internal medicine perspectives, 11(1), 139–142. https://doi.org/10.1080/20009666.2020.1854417
van Lemmen, M., Florian, J., Li, Z., van Velzen, M., van Dorp, E., Niesters, M., Sarton, E., Olofsen, E., van der Schrier, R., Strauss, D. G., & Dahan, A. (2023). Opioid Overdose: Limitations in Naloxone Reversal of Respiratory Depression and Prevention of Cardiac Arrest. Anesthesiology, 139(3), 342–353. https://doi.org/10.1097/ALN.0000000000004622
Yousefifard, M., Vazirizadeh-Mahabadi, M. H., Neishaboori, A. M., Alavi, S. N. R., Amiri, M., Baratloo, A., & Saberian, P. (2019). Intranasal versus Intramuscular/Intravenous Naloxone for Pre-hospital Opioid Overdose: A Systematic Review and Meta-analysis. Advanced journal of emergency medicine, 4(2), e27. https://doi.org/10.22114/ajem.v0i0.279
Summarized by Jeffrey Olson MS2 | Edited by Meg Joyce & Jorge Chalit, OMSII
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