Medical Minute

Podcast 509: Circadian Rhythm and Shift Work, From Z to Z

Contributor: Jared Scott, MD

Educational Pearls:

  • Sleep deprivation and disturbed sleep cycles increases the risk of many acute and chronic medical issues such as motor vehicle accidents, diabetes, cardiovascular disease, psychiatric disease,  and shift work sleep disorder (difficulty sleeping, fatigue, interference with daily activities)
  • Stages of sleep 
    • Stage 1: 5-10 minutes (light sleep, may not recognize). 
    • Stage 2: Spindle waves, mostly unstudied 
    • Stage 3: Restorative sleep
    • Stage 4 (REM): Paralysis, memory consolidation
  • One sleep cycle takes about 120 minutes
  • Light is critical for regulating sleep cycles. Exposure to light (especially blue light) inhibits melatonin release from the pineal gland, which influences the suprachiasmatic nucleus (master sleep controller in the brain)
  • How can you optimize sleep before your night shifts? On the day of your first night shift, sleep until you wake naturally, then take a 90min nap between 2-6pm before you start your shift 
  • Sleepy on shift? A 5 minute nap is helpful to increase your attention span and thinking. A 30 minute nap is good for achieving more restorative sleep. Naps between 30 and 60 minutes are not recommended due to increased sleep inertia 
  • How do I optimize myself on shift? Keep active and take a 5 minute nap if needed. Do not use caffeine within the last 4 hours of your shift (it will interfere with your sleep!). More than 200-300mg a caffeine are not recommended, if you do use it.Use built in checks to reduce errors, as errors are increased during night shifts! 
  • Leaving your shift, reduce exposure to light by wearing sunglasses, avoid screens and alcohol, and get to sleep ASAP
  • Got things to do? Remember that some sleep is better than none! 

References

Kuhn G et al. Circadian rhythm, shift work, and emergency medicine. Ann Emerg Med. (2001) 37:1, 88-98.

McKenna Helen, Wilkes Matt. Optimising sleep for night shifts BMJ (2018). 360:j5637

Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

Music credit: “Smooth Lovin” by Kevin MacLoed (incompetech.com). Licensed under Creative Commons By Attribution 3.0 License. http://creativecommons.org/licenses/by/3.0/

Podcast 508: Are you with child?

Contributor: Chris Holmes, MD

Educational Pearls:

  • In ancient Egypt, pregnant women would urinate over barley and wheat seeds to help determine the sex of thier fetus, as well as if they were pregnant. Amazingly, this has 70% accuracy (!!) for determining pregnancy (not sex).
  • Piss Prophets in the middle ages would examine urine for changes in color to determine if a woman was pregnant or not. 
  • In the early 1900’s, after discovering progesterone, and it’s associated with pregnancy, the A-Z pregnancy urine test was created. Urine was collected from the woman of interest and injected into an immature rat or rabbit. If the urine put the animal into heat (due to the presence of progesterone in the urine), this was interpreted as a positive test. 

References

https://history.nih.gov/exhibits/thinblueline/timeline.html

Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

Music credit: “Smooth Lovin” by Kevin MacLoed (incompetech.com). Licensed under Creative Commons By Attribution 3.0 License. http://creativecommons.org/licenses/by/3.0/

Podcast 507: Who gonna crump?

Contributor: Nick Tsipis, MD

Educational Pearls:

  • Communication proves time and time again to be most helpful in preventing surprises after patient admission
  • Frequent re-evaluations and repeat vital signs can be important to evaluating a patient’s risk for deterioration once admitted as well as selecting the proper level of care at admission
  • Broad categories of patients who most commonly have a change in condition after admission are septic patients and those admitted for respiratory complaints

References

Kennedy M, Joyce N, Howell MD, et al. Identifying infected ED patients admitted to the hospital ward at risk of clinical deterioration and intensive care unit transfer. Acad Emerg Med. 2010;17(10):1080–1085. 

Caterino JM, Jalbuena T, Bogucki B. Predictors of acute decompensation after admission in ED patients with sepsis. Am J Emerg Med. 2010;28(5):631–636. doi: 10.1016/j.ajem.2009.04.020.

Wardi G, Wali AR, Villar J, et al. Unexpected intensive care transfer of admitted patients with severe sepsis. J Intensive Care. 2017;5:43. Published 2017 Jul 12. doi:10.1186/s40560-017-0239-7

Boerma LM, Reijners EPJ, Hessels RAPA, V Hooft MAA. Risk factors for unplanned transfer to the intensive care unit after emergency department admission. Am J Emerg Med. 2017;35(8):1154–1158.

Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

UnfilterED #1: Dr. Michael Hunt

On the first installment of this new series, Dr. Michael Hunt shares stories, lessons and advice as he reflects on his 35 year career as an emergency physician.

 

Intro Music:

Backbay Lounge Kevin MacLeod (incompetech.com)
Licensed under Creative Commons: By Attribution 3.0 License
http://creativecommons.org/licenses/by/3.0/

Check out this episode!

Podcast 506: Seymour Fracture

Contributor:  Don Stader, MD

Educational Pearls:

  • Seymour fracture is an eponym for a Salter-Harris I/II fracture of the distal phalanx of the finger or toe in children, associated with a nailbed injury
  • These may present and subtle as a subungal hematoma with a fracture on x-ray but carry a significant risk of complications
  • While in adults a hammer-finger deformity indicates an avulsion injury of the extensor tendon, in children it can indicate disruption of the growth plate. This is coupled with disruption of the proximal nail bed. 
  • Because these fractures affect the growth plate, they can lead to arrest of the growth plate or chronic osteomyelitis
  • These injuries require orthopedic consultation for possible debridement and fixation

Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

Check out this episode!

Podcast 505: Sleep on Strep Throat 

Contributor: Don Stader, MD

Educational Pearls:

  • Only 10% of patients receiving antibiotics for strep throat actually have the diesease
  • Treatment of strep with antibiotics only slightly reduces the duration of illness. Most studies say the reduction is between 16 and 24 hours
  • Antibiotic treatment may reduce complications such as peritonsilar abscess and otitis media but antibiotics also increase the risk of diarrhea and yeast infection
  • Rheumatic fever is caused by a specific serotype of strep that is no longer prevalent in the United States, so treating strep throat likely has no effect on preventing this complication 

References

Anand Swaminathan, “Do Patients with Strep Throat Need to Be Treated with Antibiotics?”, REBEL EM blog, January 5, 2015. Available at: https://rebelem.com/patients-strep-throat-need-treated-antibiotics/. 

Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

Check out this episode!

Podcast 504: Ocular Compartment Syndrome

Contributor: Don Stader, MD

Educational Pearls:

  • The eye is surrounded by relatively inflexible tissues such as the bone of the orbit and the fibrous tissue of the eye. This makes it relatively susceptible to damage from outside compression, which is most common from trauma. This phenomenon is called ocular compartment syndrome (OCS) 
  • Look for OCS when patients have face, head or direct eye trauma 
  • OCS will present with a swollen, bulging eye associated with pain and blurry vision. Typically diagnosed with an elevated intraocular pressure (>40)
  • OCS needs to be treated with a lateral canthotomy to help expand the area around the eye, reducing the pressure.
  • Can’t see the eye due to swelling? Use paper clips to make eyelid retractors!

References

Lima V, Burt B, Leibovitch I, Prabhakaran V, Goldberg RA, Selva D. Orbital compartment syndrome: the ophthalmic surgical emergency. Surv Ophthalmol. 2009 Jul-Aug;54(4):441-9. doi: 10.1016/j.survophthal.2009.04.005. Review. PubMed PMID: 19539832.

Rowh AD, Ufberg JW, Chan TC, Vilke GM, Harrigan RA. Lateral canthotomy and cantholysis: emergency management of orbital compartment syndrome. J Emerg Med. 2015 Mar;48(3):325-30. doi: 10.1016/j.jemermed.2014.11.002. Epub 2014 Dec 16. PubMed PMID: 25524455.

Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

Podcast 503: Magical Magnesium 

Contributor: Dylan Luyten, MD

Educational Pearls:

  • Those that are hypokalemic are often hypomagnesemic, and should receive magnesium (Mg) supplementation if repleting potassium
  • Mg levels are typically not necessary – if someone is suspect to have hypomagnesemia, just given them Mg
  • Mg increases the AV node refractory period and therefore may be helpful as an adjunct to those in atrial fibrillation with a rapid ventricular response
  • Mg is the preferred treatment for seizure prophylaxis in preeclampsia. All patients with suspected preeclampsia should get 4g Mg IV over 20 min
  • Mg may reduce hospital admissions in those with severe asthma, though it has not shown to have mortality or other benefits in acute exacerbations

Editor’s note: and we didn’t even touch on magnesium in headaches

References

Huang CL, Kuo E. Mechanism of hypokalemia in magnesium deficiency. J Am Soc Nephrol. 2007 Oct;18(10):2649-52. doi: 10.1681/ASN.2007070792. Epub 2007 Sep 5. Review. PubMed PMID: 17804670.

Ismail Y, Ismail AA, Ismail AA. The underestimated problem of using serum magnesium measurements to exclude magnesium deficiency in adults; a health warning is needed for “normal” results. Clin Chem Lab Med. 2010 Mar;48(3):323-7. doi: 10.1515/CCLM.2010.077. PubMed PMID: 20170394.

Heitz C, Morgenstern J, Bond C, Milne WK. Hot Off the Press: Low-dose Magnesium Sulfate Versus High Dose in the Early Management of Rapid Atrial Fibrillation: Randomized Controlled Double-blind Study. Acad Emerg Med. 2019 Sep;26(9):1093-1095. doi: 10.1111/acem.13720. Epub 2019 Mar 18. PubMed PMID: 30815951.

Levy Z, Slesinger TL. Does intravenous magnesium reduce the need for hospital admission among adult patients with acute asthma exacerbations?. Ann Emerg Med.2015 Jun;65(6):702-3. doi: 10.1016/j.annemergmed.2014.07.019. Epub 2014 Aug 13. PubMed PMID: 25128007.

Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

Podcast 502: EMS Psych Clearance

Contributor: Aaron Lessen, MD

Educational Pearls:

  • Patients with psychiatric complaints are often complicated to disposition from the main ED, and many will require inpatient psychiatric stays
  • Some health systems have dedicated psychiatric ED’s that are specialized in taking care of these patients
  • For example, in Oakland, CA, EMS are permitted to “clear” a patient for transport to a psych-only facility.
  • 5-year retrospective study of this system showed 40% of psych patients were cleared by EMS for transfer directly to a psychiatric facility
    • Only 0.3% of these patients “bounced back” and required an emergency department visit
  • This technique could be used elsewhere to provide the most appropriate care for psych patients 

References

Trivedi TK, Glenn M, Hern G, Schriger DL, Sporer KA. Emergency Medical Services Use Among Patients Receiving Involuntary Psychiatric Holds and the Safety of an Out-of-Hospital Screening Protocol to “Medically Clear” Psychiatric Emergencies in the Field, 2011 to 2016. Ann Emerg Med. 2019 Jan;73(1):42-51. doi: 10.1016/j.annemergmed.2018.08.422. Epub 2018 Sep 28. PubMed PMID: 30274946.

Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

Check out this episode!

Podcast # 501: Take Down Potions 

Author: Jared Scott, MD

Educational Pearls:

  • Study from Hennepin County EM studied the efficacy of different drugs for agitation, which included 737 patients
  • Most patients in this study were male and *surprise* drunk
  • Compared doses of common sedatives with primary outcome of sedation at 15 minutes (all intramuscular)
    • haloperidol 5 mg
    • ziprasidone 20 mg
    • olanzapine 10 mg
    • midazolam 5 mg
    • haloperidol 10 mg with the main outcome of agitation at 15 minutes
  • Intramuscular midazolam resulted in the lowest level of agitation at 15 minutes, followed by ziprasidone. There were no differences in adverse effects.

References

Klein LR, Driver BE, Miner JR, Martel ML, Hessel M, Collins JD, Horton GB, Fagerstrom E, Satpathy R, Cole JB. Intramuscular Midazolam, Olanzapine, Ziprasidone, or Haloperidol for Treating Acute Agitation in the Emergency Department. Ann Emerg Med. 2018 Oct;72(4):374-385. doi: 10.1016/j.annemergmed.2018.04.027. Epub 2018 Jun 7. PubMed PMID: 29885904.

Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

Check out this episode!

 

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