Podcast #239: Tetanus in the ED

Author: Rachel Beham, PharmD, Advanced Clinical Pharmacist – Emergency Medicine

Educational Pearls

  • Tetanus Ig is indicated in those who have no or unknown tetanus vaccination history who present with contaminated cuts that or dirty puncture wounds
  • The tetanus vaccine is a 5 shot series (DTAP) for children, TDAP is used for adults
  • There is no harm is receiving the TDAP more than once if vaccination history is unknown

References: https://www.cdc.gov/features/tetanus/index.html

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Podcast #238: Ultrasound in Cardiac Arrest

Author: Aaron Lessen M.D.

Educational Pearls

  • Ultrasound  is helpful in the setting of cardiac arrest for finding a cause like cardiac tamponade or PE, but also for predicting outcomes for non-shockable rhythms.
  • One study showed that in those that presented with asystole or PEA and cardiac activity on US had a 4% survival rate, while those without cardiac activity had almost no chance.

References:  Philip Salen, Larry Melniker, Carolyn Chooljian, John S. Rose, Janet Alteveer, James Reed, Michael Heller, Does the presence or absence of sonographically identified cardiac activity predict resuscitation outcomes of cardiac arrest patients?, The American Journal of Emergency Medicine, Volume 23, Issue 4, 2005, Pages 459-462, ISSN 0735-6757, http://dx.doi.org/10.1016/j.ajem.2004.11.007.

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Podcast #237: Phimosis vs. Paraphimosis

Author: Sam Killian, M.D.

Educational Pearls

  • Phimosis refers to the inability to retract the distal foreskin over the glans penis in uncircumcised males. Paraphimosis is the entrapment of the foreskin proximal to the glans penis in these patients.
  • Phimosis is rarely a medical emergency, but requires follow up with urology. Paraphimosis, on the other hand, can cause venous and lymphatic insufficiency, leading to infarction, necrosis and autoamputation. Therefore, paraphimosis requires emergent treatment with manual reduction of the foreskin or surgery.

References:

Aaron Vunda, M.D., Laurence E. Lacroix, M.D., Franck Schneider, Sergio Manzano, M.D., and Alain Gervaix, M.D. Reduction of Paraphimosis in Boys. N Engl J Med 2013; 368:e16

Podcast #236: Peripheral IJ Access

Author: Nick Hatch, M.D.

Educational Pearls

  • When peripheral or central IV access is difficult, sometimes providers will try to use a peripheral IV setup at an IJ site using US guidance.
  • Case studies have shown that this method is often successful, with the most common complication being the loss of access.

References: Ash AJ, Raio C. Seldinger Technique for Placement of “Peripheral” Internal Jugular Line: Novel Approach for Emergent Vascular Access. Western Journal of Emergency Medicine. 2016;17(1):81-83. doi:10.5811/westjem.2015.11.28726.

Podcast #235: ER Discharge and Mortality

Author: Pete Bakes, M.D.

Educational Pearls

  • One of the roles of the ER provider is to discharge patients only after life-threatening conditions have been ruled out. However, some patients that are discharged from the ED die within days of their discharge. One recent study sought to investigate the factors and diagnoses associated with death within 7 days of discharge.
  • This study was a retrospective study in 10 million medicare recipients that presented to the ER over 10 years. They excluded palliative, hospice and SNF patients.
  • 0.12% of these patients died within 7 days of ER discharge. Signs and symptoms such as altered mental status, general malaise and fatigue, and nonspecific dyspnea had relative risks of 3-5 for death following discharge.
  • Think carefully before discharge in patients with the signs/symptoms above.  

References: Obermeyer Ziad, Cohn Brent, Wilson Michael, JenaAnupam B, Cutler David M. Early death after discharge from emergency departments: analysis of national US insurance claims data BMJ 2017;356 :j239

Podcast #234: CIN AEM Study

Author: Dylan Luyten, M.D.

Educational Pearls

  • Around 30% of patients in the ER receive CT imaging, and the sensitivity of CT imaging may be improved with IV contrast. However, contrast is often withheld for fear of contrast-induced nephropathy.
  • A recent, single-center, retrospective cohort study compared the rates of nephropathy between contrast CT, non-contrast CT, and no CT control patients, and found no differences.
  • This study confirms what many have believed to be true – that the dangers of modern contrast may be overstated. However, the results should be interpreted with caution, as this was a retrospective, single-center study.

References: Hinson, Jeremiah S. et al.. Risk of Acute Kidney Injury After Intravenous Contrast Media Administration. Annals of Emergency Medicine , Volume 69 , Issue 5 , 577 – 586.e4

Podcast #233: Carfentanil

Author: Don Stader, M.D. and Rachael Duncan, PharmD BCPS BCCCP

Educational Pearls

  • Carfentanil is an opioid elephant tranquilizer that can be used recreationally.  It is 1000 times stronger than fentanyl, and looks like a white powder.
  • Healthcare workers must be cautious when carfentanil overdose is suspected, as the drug can be absorbed through caregivers’ skin if it is present on the patient’s clothes.
  • Overdose may require large amounts of naloxone, and a drip may be started at a rate equivalent to the bolus dose that the patient responded to. For example, if the patient responded to a 10mg bolus dose of naloxone, he would then be started on a 10mg/hr naloxone drip.

References: https://www.dea.gov/divisions/hq/2016/hq092216.shtml

Podcast #232: HAPE

Author: Gretchen Hinson, M.D.

Educational Pearls

  • High-Altitude Pulmonary Edema (HAPE) is caused when hypoxemia due to low ambient pO2 leads to breakdown and constriction of the pulmonary vasculature leading to edema.
  • HAPE is very rare under 8000 ft, but common over 10000 ft (6%). Over 18,000 ft the incidence is very high (12-15%).
  • Symptoms include dyspnea, cough, weakness and chest tightness.
  • Signs include hypoxemia, crackles, wheezing, central cyanosis, tachypnea and tachycardia.
  • Drugs that reduce pulmonary resistance have been shown to help, but increased oxygenation and descent are the best treatments.

References: http://emedicine.medscape.com/article/300716-overview

Podcast #231: Esophageal Tearing

Author: Jared Scott, M.D.

Educational Pearls

  • Boerhaave syndrome (aka effort rupture of the esophagus) accounts for 10% of esophageal ruptures and is usually caused by strain during vomiting episodes. It can also be caused by childbirth, seizure, or prolonged coughing or laughing.  
  • Food and water swallowed after the tear end up in the mediastinum, eventually causing infection. Therefore, Boerhaave syndrome is a surgical emergency.
  • Best diagnostic techniques are CT or endoscopy.
  • Mallory-Weiss syndrome may present similarly, however it is less serious since it involves only a small tear through the mucosa at the gastroesophageal junction. This can be managed on an outpatient basis with PPI’s.

References: https://radiopaedia.org/articles/boerhaave-syndrome