Podcast #280: Isolated Aphasia in Stroke

Author: Aaron Lessen, M.D.

Educational Pearls

  • Patients with an ischemic stroke from occlusion of the left middle cerebral artery often present with aphasia in addition to other neurological deficits.
  • A recent study looked at patients presenting with suspected stroke. Of the 700 patients recruited, 3% had isolated aphasia on exam.  On follow-up, none of the 3% had evidence of stroke on imaging. Underlying causes of the isolated aphasia in these patients included syncope, infections, seizures were the underlying cause.  

References: Gabriel Casella, Rafael H. Llinas, Elisabeth B. Marsh, Isolated aphasia in the emergency department: The likelihood of ischemia is low, Clinical Neurology and Neurosurgery, Volume 163, 2017, Pages 24-26, ISSN 0303-8467, https://doi.org/10.1016/j.clineuro.2017.10.013.

Podcast #279: Sedation After Intubation

Author: Aaron Lessen, M.D.

Educational Pearls

  • Post-intubation care should always include pain control and adequate sedation.
  • Commonly used sedation agents include propofol, ketamine and versed.
  • However, too much sedation is harmful. Deep sedation (RASS -4 to -5)  is associated with worse long-term outcomes. RASS of 0 to -2 is ideal, as long as the patient is comfortable.

References: https://coreem.net/core/post-intubation/

Podcast #278: Subdural Hematomas

Educational Pearls

  • Subdural hematomas can happen in the elderly because of brain atrophy, and can manifest with neurological deficit.
  • Subdural hematomas are caused by rupture of the bridging veins of the brain. This can be caused by trauma, brain atrophy, or possibly by anticoagulant use. They are crescent-shaped on head CT.  
  • Epidural hematomas, in contrast, are caused by rupture of meningeal arteries secondary to trauma. They are usually lens-shaped on head CT.
  • Subdurals are difficult to pick up on head CT because they may be isodense to brain tissue.

References: Management of Recurrent Subdural Hematomas Desai, Virendra R. et al. Neurosurgery Clinics , Volume 28 , Issue 2 , 279 – 286

Podcast #277: Mucor

Author: Don Stader, M.D.

Educational Pearls

  • Mucor/Rhizopus fungal infections usually present in diabetic or immunocompromised patients as a black, necrotic lesion on the face.
  • The fungus invades the vasculature of the face, causing tissue ischemia and necrosis.
  • The infection is more common in the diabetic population because the fungus prefers more acidic and glucose-rich environments.
  • This is a surgical emergency since it is cured only with excision of the affected tissue

References: Vijayabala GS, Annigeri RG, Sudarshan R. Mucormycosis in a diabetic ketoacidosis patient. Asian Pacific Journal of Tropical Biomedicine. 2013;3(10):830-833. doi:10.1016/S2221-1691(13)60164-1.

Podcast #276: Angioedema

Author: John Winkler, M.D.

Educational Pearls

  • Angioedema is immediately life-threatening due to airway obstruction.
  • Mechanisms include allergic reaction (histamine-related) or bradykinin-related (ACE-inhibitor, C1 esterase inhibitor deficiency).
  • The bradykinin-related mechanism will not respond to the traditional meds used for anaphylaxis. Instead, use FFP to replace depleted factors.
  • If a patient displays signs of respiratory compromise, intubation is indicated. Anesthesia should be consulted as this will be a very difficult airway.

References: https://emcrit.org/pulmcrit/treatment-of-acei-induced-angioedema/

Podcast #275: Battery Ingestions

Author: Nick Hatch, M.D.

Educational Pearls

  • Unlike coin ingestions, button batteries can cause necrosis of the GI tract.
  • If lodged in the esophagus, removal within 2 hours is important, because they can cause problems such as strictures or esophago-aortic fistula.
  • If the battery is in the stomach or beyond, it may be ok to let it pass but give strict return precautions.
  • Small hearing aid batteries are not as dangerous, but still require close follow-up to ensure the battery passes.
  • Delayed effects (after passage of the battery) are possible.

References: https://www.poison.org/battery/guideline

Podcast #274: Pediatric Sedation

Author: Aaron Lessen, M.D.

Educational Pearls

  • A recent prospective observational study was performed to examine the safety of different sedation medications in the pediatric ED.
  • This study included 6000 children, and looked at the rate of serious adverse events following administration of different sedatives.
  • Overall, the safest drug to use was ketamine alone, with an adverse event rate of about 1%.
  • Propofol, BZDs, and opiates had increased rates of adverse events.

References: https://lifeinthefastlane.com/pediatric-procedural-sedation-with-ketamine/

Podcast #272: More on Temperature in Sepsis

Author: David Rosenberg, M.D.

Educational Pearls

  • A study of 20,000 subjects found that reducing fever in sepsis did not improve outcomes such as morbidity, mortality, or length of stay.
  • However, correcting fever may help for patient comfort.

References: Zhang Z, Chen L, Ni H. Antipyretic Therapy in Critically Ill Patients with Sepsis: An Interaction with Body Temperature. Azevedo LCP, ed. PLoS ONE. 2015;10(3):e0121919. doi:10.1371/journal.pone.0121919.

Podcast #271: Nexus Chest CT Scan Guidelines

Author: Chris Holmes, M.D.

Educational Pearls

  • The nexus chest CT scan rule is based on an 11,000 subject, multicenter study that looked for signs following a trauma that predicted significant findings on subsequent chest CT.
  • Findings that were associated with abnormal chest CT included: abnormal CXR, distracting injury, chest wall, sternal, thoracic spine or scapular tenderness. Furthermore, a mechanism of injury that includes rapid deceleration was also associated.
  • If a patient has none of the above findings, then there is only a small chance that there will be an abnormal chest CT.

References: https://www.mdcalc.com/nexus-chest-ct-decision-instrument-ct-imaging