Podcast # 345: Snake Bites

Educational Pearls:

 

  • Snake bites commonly occur between April and October.
  • Rattlesnake bites are the most common.
  • Venom contains proteins/enzymes that cause local inflammation, coagulopathy, and systemic effects (hypotension, angioedema, renal failure, etc.) along with neurotoxins may cause fasciculations, ptosis, drooling, or hyporeflexia.
  • Management:
  • Mark site for swelling.
  • Monitor progression.
  • Elevate and immobilize injured limb and treat pain.
  • Check basic labs including coagulation studies, and update tetanus.
  • Antidote is CroFab and use if patient has systemic symptoms.  Anaphylaxis is a known complication of CroFab
  • Avoid: ice, tourniquets, and incision and drainage.

 

References

Hifumi T et. al.. Venomous snake bites: clinical diagnosis and treatment. J Intensive Care. 2015 Apr 1;3(1):16. doi: 10.1186/s40560-015-0081-8.

Warrell DA. Snake bite. Lancet. 2010. 375(9708):77-88. doi: 10.1016/S0140-6736(09)61754-2.

Warrell DA. Envenoming and injuries by venomous and nonvenomous reptiles worldwide. In: Wilderness Medicine, 6th Edition, Auerbach PS (Ed), Elsevier Mosby, Philadelphia 2012. p.1040.

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Podcast # 342: Scombroid

Author: Jared Scott, MD

Educational Pearls:

  • Scombroid is a type of food poisoning associated with dark fish (i.e. tuna, salmon, mackerel) that mimics anaphylaxis.
  • Occurs through conversion of histidine to histamine by bacteria in the fish.
  • Symptoms include flushing, lips swelling, nausea, diarrhea in setting of recent fish consumption.
  • Treat with antihistamines.

 

References

Ridolo E, Martignago I, Senna G, Ricci G. Scombroid syndrome: it seems to be fish allergy but… it isn’t. Curr Opin Allergy Clin Immunol. 2016. 16(5):516-21. doi: 10.1097/ACI.0000000000000297.

Patterson R, Little B, Tolan J, Sweeney C. How to manage a urinary catheter balloon that will not deflate. Int Urol Nephrol. 2006;38(1):57-61. Review. PubMed PMID: 16502053

Podcast # 341: Tenecteplase vs. Alteplase

Author: Rachel Beham, PharmD

Educational Pearls:

  • Tenecteplase is more specific for fibrin and has a longer half-life than alteplase.
  • In setting of ischemic stroke, tenecteplase before thrombectomy was associated with a statistically higher incidence of reperfusion and better functional outcome than alteplase.

 

References

Bruce C.V. Campbell B et al (2018). Tenecteplase versus Alteplase before Thrombectomy for Ischemic Stroke. New England Journal of Medicine. 378:1573-1582

Podcast # 340: Drowning

Author: Chris Holmes, MD

Educational Pearls:

  • Epidemiology: 80% male, ages 1-4 at greatest risk, African-American > Caucasian.
  • Freshwater and ocean water may have more bacteria than pool water.
  • Salt water is hyperosmolar, which theoretically increases risk of pulmonary edema.
  • Greatest physiologic insult is from hypoxia secondary to fluid aspiration or laryngeal spasm. Patient survival is related to presentation on arrival.
  • Workup includes CXR and ABG; consider C-spine immobilization/imaging when cervical injury is strongly suspected (i.e. diving injury).
  • Treatment consists of supplemental oxygen therapy. Consider CPAP or intubation.

References

Szpilman D, Bierens JJ, Handley AJ, Orlowski JP. Drowning. N Engl J Med. 2012. 366(22):2102-10. doi: 10.1056/NEJMra1013317.

Schmidt A, Sempsrott J. Drowning In The Adult Population: Emergency Department Resuscitation And Treatment. Emerg Med Pract. 2015. 17(5):1-18.

Podcast # 339: Ectopic Pregnancy Risk Factors

Author: Jared Scott, MD

Educational Pearls:

  • Data is mixed, but some studies show 1-2% of pregnancies are ectopic.
  • Risk factors for ectopic pregnancies include: pelvic inflammatory disease, prior ectopic pregnancy, prior abdominal surgery, prior abortion, advanced maternal age, IUD, tubal blockage, and smoking (including spouse).
  • Greatest risk factor is a prior ectopic pregnancy, which carries a 17x higher risk.
  • Patients with histories of PID and cigarette smoking present educational opportunities.

References

Moini, A., Hosseini, R., Jahangiri, N., Shiva, M., & Akhoond, M. R. (2014). Risk factors for ectopic pregnancy: A case?control study. Journal of Research in Medical Sciences?: The Official Journal of Isfahan University of Medical Sciences, 19(9), 844?849.

Rana, P; Kazmi, I; Singh, R; Afzal, M; Al-Abbasi, FA; Aseeri, A; Singh, R; Khan, R; Anwar, F (2013). “Ectopic pregnancy: a review”. Archives of Gynecology and Obstetrics. 288 (4): 747?57. doi: 10.1007/s00404-013-2929-2.

Podcast # 338: Mononucleosis Predictors

Author: Chris Holmes, MD

Educational Pearls:

  • Symptoms commonly seen with mononucleosis are palatal petechiae, posterior cervical lymphadenopathy, inguinal/axillary lymphadenopathy, splenomegaly, and/or atypical lymphocytes > 10% on CBC.
  • Among these, posterior cervical lymphadenopathy and atypical lymphocytes > 10% were the most sensitive (sensitivities of 0.64 and 0.66 respectively).

References

Welch, JL et al. What Elements Suggest Infectious Mononucleosis? Annals of Emergency Medicine. 2018. 71(4): 521-522. Doi: 10.1016/j.annemergmed.2017.06.014

Podcast # 337: Airway Burn Inhalation

Author: John Winkler, MD

Educational Pearls:

  • Singed nasal hairs, soot around mouth, hoarse voice, drooling, and burns to head/face are signs suggestive of inhalation injury.
  • Early intubation is critical for these patients as the airway changes rapidly.
  • With inhalation injuries, the upper airway is burned while the lower airway is damaged by inhaled chemicals in the soot and can cause ARDS.
  • Carbon monoxide (CO) and cyanide (CN) poisoning can occur with inhalation injuries.
  • Treatment for CO poisoning is 100% oxygen and possible hyperbarics. Treatment for CN poisoning is cyanocobalamin.

 

References

Rehberg S, Maybauer MO, Enkhbaatar P, et al. Pathophysiology, management and treatment of smoke inhalation injury. Expert Rev Respir Med 2009; 3:283.

Woodson CL. Diagnosis and treatment of inhalation injury. In: Total Burn Care, 4 ed, Herndon DN (Ed), 2009.

Podcast # 336: Hypokalemia

Author: Dylan Luyten, MD

Educational Pearls:

  • Most important questions to answer with low potassium are 1. What are their symptoms? 2. Can they take potassium by mouth?
  • Oral repletion is faster, cheaper, and more effective than IV repletion.
  • Give IV potassium when patients have K < 2.5 mmol/L or present with arrhythmias and/or characteristic EKG changes (flattened T waves).
  • Most patients who are hypokalemic are hypomagnesemic and require magnesium supplementation. ┬áChecking a level is unnecessary.

References

Ashurst J, Sergent SR, Wagner BJ, Kim J. Evidence-based management of potassium disorders in the emergency department. Emerg Med Pract. 2016 Nov 22;18(Suppl Points & Pearls):S1-S2

 

Whang R, Flink EB, Dyckner T, et al. Magnesium depletion as a cause of refractory potassium repletion. Arch Intern Med 1985; 145:1686.

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Podcast # 335: Blunt Head Trauma

Author: Peter Bakes, M.D.

Educational Pearls:

  • Epidural hematomas have a characteristic convex appearance on CT while a subdural hematoma will have a concave appearance.
  • Indications for operative intervention for subdural hematoma may include: >5 mm midline shift, over 10 mm in thickness, comatose with ICP >20, or patient neurologic deterioration.

 

References

Bullock, M. R. et. al. . Surgical management of acute subdural hematomas. 2006. Neurosurgery, 58(SUPPL. 3). DOI: 10.1227/01.NEU.0000210364.29290.C9.

Huang KT, Bi WL, Abd-El-Barr M, Yan SC, Tafel IJ, Dunn IF, Gormley WB. The Neurocritical and Neurosurgical Care of Subdural Hematomas. Neurocrit Care. 2016. 24(2):294-307. doi: 10.1007/s12028-015-0194-x.