Avsnitt
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Contributor: Ricky Dhaliwal MD
Educational Pearls:
Etomidate was previously the drug of choice for rapid sequence intubation (RSI)
However, it carries a risk of adrenal insufficiency as an adverse effect through inhibition of mitochondrial 11-β-hydroxylase activity
A recent meta-analysis analyzing etomidate as an induction agent showed the following:
11 randomized-controlled trials with 2704 patients
Number needed to harm is 31; i.e. for every 31 patients that receive etomidate for induction, there is one death
The probability of any mortality increase was 98.1%
Ketamine is preferable due to a better adverse effect profile
Laryngeal spasms and bronchorrhea are the most common adverse effects after IV push
Beneficial effects on hemodynamics via catecholamine surge, albeit not as pronounced in shock patients
2023 meta-analysis compared ketamine and etomidate for RSI
Ketamine’s probability of reducing mortality is cited as 83.2%
Overall, induction with ketamine demonstrates a reduced risk of mortality compared with etomidate
The dosage of each medication for induction
Etomidate: 20 mg based on 0.3 mg/kg for a 70 kg adult
Ketamine: 1-2 mg/kg (or 0.5-1 mg/kg in patients with shock)
Patients with asthma and/or COPD also benefit from ketamine induction due to putative bronchodilatory properties
References
Goyal S, Agrawal A. Ketamine in status asthmaticus: A review. Indian J Crit Care Med. 2013;17(3):154-161. doi:10.4103/0972-5229.117048
Koroki T, Kotani Y, Yaguchi T, et al. Ketamine versus etomidate as an induction agent for tracheal intubation in critically ill adults: a Bayesian meta-analysis. Crit Care. 2024;28(1):1-9. doi:10.1186/s13054-024-04831-4
Kotani Y, Piersanti G, Maiucci G, et al. Etomidate as an induction agent for endotracheal intubation in critically ill patients: A meta-analysis of randomized trials. J Crit Care. 2023;77(April 2023):154317. doi:10.1016/j.jcrc.2023.154317
Summarized & Edited by Jorge Chalit, OMS3
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Contributor: Aaron Lessen MD
Educational Pearls:
Pregnant patients at high risk of cardiac arrest, in cardiac arrest, or in extremis require special care
A useful mnemonic to recall the appropriate management of critically ill pregnant patients is TOLDD
T: Tilt the patient to the left lateral decubitus position
This position relieves pressure exerted from the uterus onto the inferior vena cava, which reduces cardiac preload
If the patient is receiving CPR, an assistant should displace the uterus manually from the IVC towards the patient’s left side
O: Administer high-flow adjunctive oxygen
L: Lines should be placed above the diaphragm
Lines below the diaphragm are ineffective due to uterine compression of the IVC
May consider humeral interosseous line vs. internal jugular or subclavian central line
D: Dates should be estimated
> 20 weeks, can consider a resuscitative hysterotomy (previously known as perimortem c-section) to improve chances of survival
The uterus is palpable at the umbilicus at 20 weeks and 1 cm superior to the umbilicus for every week thereafter
D: Call the labor and delivery unit for additional help
References
ACOG Practice Bulletin No. 211 Summary: Critical Care in Pregnancy. Obstetrics & Gynecology. 2019;133(5)
Fujita N, Higuchi H, Sakuma S, Takagi S, Latif MAHM, Ozaki M. Effect of Right-Lateral Versus Left-Lateral Tilt Position on Compression of the Inferior Vena Cava in Pregnant Women Determined by Magnetic Resonance Imaging. Anesth Analg. 2019;128(6):1217-1222. doi:10.1213/ANE.0000000000004166
Jeejeebhoy FM, Zelop CM, Lipman S, et al. Cardiac Arrest in Pregnancy. Circulation. 2015;132(18):1747-1773. doi:doi:10.1161/CIR.0000000000000300
Singh, Ajay; Dhir, Ankita; Jain, Kajal; Trikha, Anjan1. Role of High Flow Nasal Cannula (HFNC) for Pre-Oxygenation Among Pregnant Patients: Current Evidence and Review of Literature. Journal of Obstetric Anaesthesia and Critical Care 12(2):p 99-104, Jul–Dec 2022. | DOI: 10.4103/JOACC.JOACC_18_22
Summarized & Edited by Jorge Chalit, OMS3
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Saknas det avsnitt?
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Contributor: Travis Barlock MD
Educational Pearls:
What is the ST segment?
The ST segment on an ECG represents the interval between the end of ventricular depolarization (QRS) and the beginning of ventricular repolarization (T-wave).
It should appear isoelectric (flat) in a normal ECG.
What if the ST segment is elevated?
This is evidence that there is an injury that goes all the way through the muscular wall of the heart (transmural)
This is very concerning for a heart attack (STEMI) but can be occasionally caused by other pathology, such as pericarditis
What if the ST segment is depressed?
This is evidence that only the innermost part of the muscular wall of the heart is becoming ischemic
This has a much broader differential and includes a partial occlusion of a coronary artery but also any other stress on the body that could cause a supply-and-demand mismatch between the oxygen the coronaries can deliver and the oxygen the heart needs
This is called subendocardial ischemia
What else should you look for in the ECG to identify subendocardial ischemia?
The ST-depressions should be at least 1 mm
The ST depressions should be present in leads I, II, V4-6 and a variable number of additional leads.
There is often reciprocal ST elevation in aVR > 1 mm
The most important thing to remember when you see subendocardial ischemia is…history
Still, keep all cardiac causes on your differential, such as unstable angina, stable angina, Prinzmetal angina, etc.
Also consider a wide array of non-cardiac causes such as severe anemia, severe hypertension, pulmonary embolism, COPD, severe pneumonia, sepsis, shock, thyrotoxicosis, stimulant use, DKA, or any other state that lead to reduced oxygen supply to the subendocardium and/or increased myocardial oxygen demand.
References
Birnbaum, Y., Wilson, J. M., Fiol, M., de Luna, A. B., Eskola, M., & Nikus, K. (2014). ECG diagnosis and classification of acute coronary syndromes. Annals of noninvasive electrocardiology : the official journal of the International Society for Holter and Noninvasive Electrocardiology, Inc, 19(1), 4–14. https://doi.org/10.1111/anec.12130
Buttà, C., Zappia, L., Laterra, G., & Roberto, M. (2020). Diagnostic and prognostic role of electrocardiogram in acute myocarditis: A comprehensive review. Annals of noninvasive electrocardiology : the official journal of the International Society for Holter and Noninvasive Electrocardiology, Inc, 25(3), e12726. https://doi.org/10.1111/anec.12726
Cadogan, E. B. a. M. (2024, October 8). Myocardial Ischaemia. Life in the Fast Lane • LITFL. Retrieved December 7, 2024, from https://litfl.com/myocardial-ischaemia-ecg-library/#:~:text=ST%20depression%20due%20to%20subendocardial,left%20main%20coronary%20artery%20occlusion.
Summarized by Jeffrey Olson, MS3 | Edited by Meg Joyce & Jorge Chalit, OMS3
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Contributor: Alec Coston MD
Educational Pearls:
Causes of seizures in a fairly well-appearing child with diarrhea:
Electrolyte abnormalities: hypocalcemia, hyponatremia
Also hyperkalemia which causes arrhythmias and syncope - can appear like seizures
Hypoglycemia
If the child has diarrhea and appears very sick, differential diagnosis may include:
Hemolytic uremic syndrome (HUS):
simultaneous occurrence of microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury
Typically caused by Shiga-like toxin producing Escherichia coli (also known as EHEC, or enterohemorragic E. coli)
One of the main causes of acute kidney injury in children
Toxic ingestions such as salicylates, lead, or iron
In this case, the child had a seizure but appeared well and was afebrile:
Consult with neurology led to a diagnosis of benign convulsions with mild gastroenteritis (CwG)
First identified in 1982 in Japan
Viral gastroenteritis with diarrhea and convulsions but does not include fever, severe dehydration, or electrolyte abnormalities
Uncommon illness caused by rotavirus and norovirus pathogens
Criteria for discharge is similar to a febrile seizure - the patient had one seizure that lasted less than 15 minutes and he quickly returned to his baseline, so he was able to be safely discharged home
This diagnosis does not predispose him to epilepsy later in life
References
Lee YS, Lee GH, Kwon YS. Update on benign convulsions with mild gastroenteritis. Clin Exp Pediatr. 2022 Oct;65(10):469-475. doi: 10.3345/cep.2021.00997. Epub 2021 Dec 27. PMID: 34961297; PMCID: PMC9561189.
Mauritz M, Hirsch LJ, Camfield P, et al. Acute symptomatic seizures: an educational, evidence-based review. Epileptic Disorders. 2200;1(1). doi:https://doi.org/10.1684/epd.2021.1376
Noris, Marina*; Remuzzi, Giuseppe*, †. Hemolytic Uremic Syndrome. Journal of the American Society of Nephrology 16(4):p 1035-1050, April 2005. | DOI: 10.1681/ASN.2004100861
Summarized by Meg Joyce, MS1 | Edited by Meg Joyce & Jorge Chalit, OMS3
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Contributor: Aaron Lessen MD
Educational Pearls:
Induction agent selection during rapid sequence intubation involves accounting for hemodynamic stability in the post-intubation setting
Many emergency departments use ketamine or etomidate
A recent study sought to explore the rates of post-induction hypotension of ketamine compared with propofol
Single center retrospective cohort study of patients between 2018-2021
Ketamine and propofol were both significantly associated with post-induction hypotension
Ketamine adjusted odds ratio = 4.50
Propofol adjusted odds ratio = 4.88
50% of patients became hypotensive after induction with either propofol or ketamine
These findings suggest post-induction hypotension is mainly due to sympatholysis rather than the choice of agent itselfReferences
Tamsett Z, Douglas N, King C, et al. Does the choice of induction agent in rapid sequence intubation in the emergency department influence the incidence of post-induction hypotension?. Emerg Med Australas. 2024;36(3):340-347. doi:10.1111/1742-6723.14355
Summarized & Edited by Jorge Chalit, OMS3
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Contributor: Aaron Lessen MD
Educational Pearls:
Can opioids cause cardiac arrest?
Opioids can cause respiratory suppression and the subsequent low oxygen levels can lead to arrhythmias and eventually cardiac arrest.
In 2023, 17% of out-of-hospital cardiac arrests (OHCA) were attributable to opioids.
Given that this is a rising cause of cardiac arrest, should we just treat all cardiac arrest with naloxone (Narcan)?
Naloxone is correlated with an increased chance of return of spontaneous circulation (ROSC)
Additionally, a wide variety of individuals can be exposed to opioids and therefore opioid overdose should be considered in all cases of OHCA
But does naloxone improve neurologic outcomes?
Yes, naloxone, especially when given early on in the resuscitation can improve neuro outcomes
What is the dose?
2-4 mg IN/IV depending on access.
High suspicion for opioid overdose consider going with an even higher dose such as 4-8 mg IN/IV
References
Orkin, A. M., & Dezfulian, C. (2024). Recognizing the fastest growing cause of out-of-hospital cardiac arrest. Resuscitation, 198, 110206. https://doi.org/10.1016/j.resuscitation.2024.110206
Quinn, E., & Du Pont, D. (2024). Naloxone administration in out-of-hospital cardiac arrest: What's next?. Resuscitation, 201, 110307. https://doi.org/10.1016/j.resuscitation.2024.110307
Saybolt, M. D., Alter, S. M., Dos Santos, F., Calello, D. P., Rynn, K. O., Nelson, D. A., & Merlin, M. A. (2010). Naloxone in cardiac arrest with suspected opioid overdoses. Resuscitation, 81(1), 42–46. https://doi.org/10.1016/j.resuscitation.2009.09.016
Wampler D. A. (2024). Naloxone in Out-of-Hospital Cardiac Arrest-More Than Just Opioid Reversal. JAMA network open, 7(8), e2429131. https://doi.org/10.1001/jamanetworkopen.2024.29131
Summarized by Jeffrey Olson, MS3 | Edited by Meg Joyce MS1 & Jorge Chalit, OMS3
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Contributor: Aaron Lessen MD
Educational Pearls:
A study evaluated the patient-care impact and financial costs of holding patients in the ED, a nationwide issue
Prospective, observational study of acute stroke management
Conducted at a large urban, comprehensive stroke center
The study evaluated patients in multiple categories:
admitted to med/surg
admitted to med/surg but held in the ED
admitted to the ICU
Admitted to ICU but held in the ED
Examined the amount of time nurses and providers spent with each patient
This was analyzed in conjunction with the knowledge of each providers’ salaries and the overhead costs of the med/surg unit, ICU, and ED
Conclusions:
Patients who required med/surg inpatient care but who were held in the ED resulted in a doubled daily cost
$1856 for med/surg inpatient boarding vs $993 for med/surg inpatient care
Patients who required ICU care but who were held in the ED also resulted in an increased daily cost, but this difference was not as large
$2267 for ICU inpatient boarding vs $2165 for ICU care
Holding in the ED negatively impacts patients since they receive less time from providers
Holding also results in increased financial costs
References
Canellas MM, Jewell M, Edwards JL, Olivier D, Jun-O’Connell AH, Reznek MA. Measurement of Cost of Boarding in the Emergency Department Using Time-Driven Activity-Based Costing. Annals of emergency medicine. Published online May 1, 2024. doi:https://doi.org/10.1016/j.annemergmed.2024.04.012
Summarized by Meg Joyce, MS1 | Edited by Meg Joyce & Jorge Chalit, OMS3
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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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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
Donate: https://emergencymedicalminute.org/donate/
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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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