Contributor: Travis Barlock MD Educational Pearls: Ketamine is an NMDA receptor antagonist with a wide variety of uses in the emergency department. To dose ketamine remember the numbers 0.3, 1, and 3. Pain dose For acute pain relief administer 0.3 mg/kg of ketamine IV over 10-20 minutes (max of 30 mg). Note: There is evidence that a lower dose of 0.1-0.15 mg/kg can be just as effective. Dissociative dose To use ketamine as an induction agent for intubation or for procedural...

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...

Contributor: Ricky Dhaliwal, MD Educational Pearls: Takotsubo cardiomyopathy, also known as "broken heart syndrome,” 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...

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...

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. ...

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...

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 can’t 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...

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...

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...

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...

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,...

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,...

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...

Contributor: Aaron Lessen MD Educational Pearls: Is the adage, “GCS of 8, you’ve got to intubate” 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 “routine practice” of much more frequent intubation. ...

Contributor: Aaron Lessen MD Educational Pearls: A 2013 study randomized families of those in cardiac arrest into two groups: Actively offered patients’ 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 ...

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 ...

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,...

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. Williams’ talk at the “Laboring Under Pressure, Managing Obstetric Emergencies in a Global Setting” 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...

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...

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...

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 This could be achieved with minor symptoms such as numbness Should patients with minor strokes be given...

Contributor: Nick Tsipis MD Educational Pearls: The review article assessed 16.3 million patients across six states to identify those at high-risk for critical revisit Criteria for critical revisit was ICU admission or death within three days of discharge from the ED Critical revisits are extremely rare  0.1% of patients have a critical revisit after discharge 0.00001% die after revisit Of the patients that do experience critical revisits, the two major risk factors...

Contributor: Meghan Hurley MD Educational Pearls: Pearls about labor: Labor is split into 3 stages. Stage 1 starts when the first persistent contractions are felt and goes up until the cervix is fully dilated and the mother starts pushing. Stage 1 is split into two phases: the latent phase (cervix is dilated from 0-4 cm), and the active phase (cervix dilates from 4-10 cm). The latent phase can take between 6 and 12 hours with contractions happening every 5 to 15 minutes. The active...

Contributor: Dr. Taylor Lynch Educational Pearls: Time of arrival until intubation was 26 minutes but nobody tried anterior neck access like a cricothyrotomy until his dad arrived Traditional ACLS protocol is not enough for anaphylactic respiratory arrest Circulating O2 from compressions alone is not enough to sustain the brain Patients need a definitive airway and endotracheal tube is the best method BVM ventilation is not enough to get patients the oxygen they need Time...