Podcast #403: Meniscus Lock

Author: Mark Hinton, MD

Educational Pearls:

 

  • Meniscus lock can occur with a tear leading to inability to extend the knee
  • Treatment can include an intra-articular joint block followed by straightening
  • Medial meniscus injuries are more common

 

References:

Allum RL, Jones JR. The locked knee. Injury. 1986 Jul;17(4):256-8. PubMed PMID: 3770920.

Critchley IJ, Bracey DJ. The acutely locked knee–is a manipulation worth while? Injury. 1985 Jan;16(4):281-3. PubMed PMID: 3967919.

Summary by Travis Barlock, MS4  | Edited by Erik Verzemnieks, MD

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Podcast #402: Rapid sequence intubation medications

Educational Pearls:

  • RSI includes induction agent (sedative) and a paralytic
  • Succinylcholine is a depolarizing paralytic of rapid onset and short duration with contraindications in hyperkalemic states and muscular dystrophy
  • Rocuronium and vecuronium are longer acting, non-depolarizing paralytic, more commonly
  • Common induction agents are etomidate and ketamine
  • Ketamine can be particularly beneficial for bronchodilator effects in those with reactive airway disease

References:

 

Stollings JL, Diedrich DA, Oyen LJ, Brown DR. Rapid-sequence intubation: a review of the process and considerations when choosing medications. Ann Pharmacother. 2014 Jan;48(1):62-76. doi: 10.1177/1060028013510488. Epub 2013 Nov 4. Review. PubMed PMID: 24259635.

Summary by Travis Barlock, MS4  | Edited by Erik Verzemnieks, MD

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Podcast #401: Foreign Body Aspiration

Author: Gretchen Hinson, MD

Educational Pearls:

  • Diagnosis can be difficult and often delayed
  • Asymmetric breath sounds, choking, stridor may be present, but children also present asymptomatically
  • Peak incidence around one to two years of age
  • Hot dogs, nuts, popcorn – round and smooth objects are most commonly aspirated

References:

Green SS. Ingested and Aspirated Foreign Bodies. Pediatr Rev. 2015 Oct;36(10):430-6. doi: 10.1542/pir.36-10-430. Review. PubMed PMID: 26430203.

Sink JR, Kitsko DJ, Georg MW, Winger DG, Simons JP. Predictors of Foreign Body Aspiration in Children. Otolaryngol Head Neck Surg. 2016 Sep;155(3):501-7. doi: 10.1177/0194599816644410. Epub 2016 Apr 12. PubMed PMID: 27071446.

 

Summary by Travis Barlock, MS4  | Edited by Erik Verzemnieks, MD

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Podcast #400: ECMO

Author: Dylan Luyten, MD

Educational Pearls:

 

  • Extracorporeal membrane oxygenation (ECMO) is similar to bypass
  • ECMO is being utilized routinely at some centers and even prehospital in cardiac arrest
  • There are two general types of ECMO:
    • Venovenous (VV-ECMO) is useful when the patient cannot oxygenate but has adequate heart function.
    • Venoarterial (VA-ECMO) is more like typical bypass and can be used in a pulseless patient

 

References:

Ouweneel DM, Schotborgh JV, Limpens J, Sjauw KD, Engström AE, Lagrand WK, Cherpanath TGV, Driessen AHG, de Mol BAJM, Henriques JPS. Extracorporeal life support during cardiac arrest and cardiogenic shock: a systematic review and meta-analysis. Intensive Care Med. 2016 Dec;42(12):1922-1934. doi: 10.1007/s00134-016-4536-8. Epub 2016 Sep 19. Review. PubMed PMID: 27647331; PubMed Central PMCID: PMC5106498.

Tonna JE, Johnson NJ, Greenwood J, Gaieski DF, Shinar Z, Bellezo JM, Becker L, Shah AP, Youngquist ST, Mallin MP, Fair JF 3rd, Gunnerson KJ, Weng C, McKellar S; Extracorporeal REsuscitation ConsorTium (ERECT) Research Group.. Practice characteristics of Emergency Department extracorporeal cardiopulmonary resuscitation (eCPR) programs in the United States: The current state of the art of Emergency Department extracorporeal membrane oxygenation (ED ECMO). Resuscitation. 2016 Oct;107:38-46. doi: 10.1016/j.resuscitation.2016.07.237. Epub 2016 Aug 11. PubMed PMID: 27523953; PubMed Central PMCID: PMC5475402.

 

Summary by Travis Barlock, MS4  | Edited by Erik Verzemnieks, MD

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Podcast #399: Hunting for pancreatitis

Author: Michael Hunt, MD

Educational Pearls:

  • Alcohol and gallstones are most common causes of pancreatitis
  • Diagnosis is not simply based on lipase alone – must have at least two the the three criteria:
    • Elevated lipase (greater than 3x upper limit of reference range)
    • Typical pain (epigastric pain, radiating to back, etc.)
    • Radiographic findings suggestive of pancreatitis (CT, MRI, US)
  • BISAP criteria can help risk stratify mortality in pancreatitis. You get 1 point for each of the following:
    • BNP > 25
    • Impaired mental status
    • SIRS criteria, more than 2
    • AGE > 60
    • Pleural effusion
  • BISAP score of 0 has < 1% mortality

Editor’s note: The severity of pancreatitis does not correlate with serum lipase levels – notice how it is not used in the BISAP criteria, as an example. Even a mild elevation in serum testing can result in severe pancreatitis.

References:

Banks PA, Bollen TL, Dervenis C, Gooszen HG, Johnson CD, Sarr MG, Tsiotos GG, Vege SS; Acute Pancreatitis Classification Working Group.. Classification of acute pancreatitis–2012: revision of the Atlanta classification and definitions by international consensus. Gut. 2013 Jan;62(1):102-11. doi: 10.1136/gutjnl-2012-302779. Epub 2012 Oct 25. PubMed PMID: 23100216.

Papachristou GI, Muddana V, Yadav D, O’Connell M, Sanders MK, Slivka A, Whitcomb DC. Comparison of BISAP, Ranson’s, APACHE-II, and CTSI scores in predicting organ failure, complications, and mortality in acute pancreatitis. Am J Gastroenterol. 2010 Feb;105(2):435-41; quiz 442. doi: 10.1038/ajg.2009.622. Epub 2009 Oct 27. PubMed PMID: 19861954.

Wu BU, Johannes RS, Sun X, Tabak Y, Conwell DL, Banks PA. The early prediction of mortality in acute pancreatitis: a large population-based study. Gut. 2008 Dec;57(12):1698-703. doi: 10.1136/gut.2008.152702. Epub 2008 Jun 2. PubMed PMID: 18519429.

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Podcast #398: Who is gonna fail your antibiotic plan?

Author: Erik Verzemnieks, MD

Educational Pearls:

  • Recent study provides at least some evidence to help predict antibiotic failure for cellulitis, which is not necessarily straight forward
  • Intuitive risk factors such as recent cellulitis, chronic ulcers, history of MRSA are associated with antibiotic treatment failure
  • Oddly, tachypnea at triage was associated with the highest odds ratio for treatment failure

References:

Yadav K, Suh KN, Eagles D, MacIsaac J, Ritchie D, Bernick J, Thiruganasambandamoorthy V, Wells G, Stiell IG. Predictors of Oral Antibiotic Treatment Failure for Nonpurulent Skin and Soft Tissue Infections in the Emergency Department. Acad Emerg Med. 2018 Jun 5. doi: 10.1111/acem.13492.

Summarized and edited by Erik Verzemnieks, MD

 

 

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Podcast # 370:  Rapid Fire Neonatal Resuscitation

Author:  Erik Verzemnieks, MD

Educational Pearls:

  • In the panic of a precipitous ED delivery, remember: Warm. Dry. Stim.  It will solve most of your problems in most scenarios
  • Start compressions if heart rate is less than 60
  • Put the pulse ox on the right hand – it may make a difference as it is preductal

Editor’s note: detecting a heart rate can be tough in a newborn – you can feel the umbilical stump or just listen with your stethoscope

 

References

Gary Weiner & Jeanette Zaichkin. Textbook of Neonatal Resuscitation (NRP), 7th Ed, 2016. American Academy of Pediatrics & American Heart Association.

Podcast #286: Coronary Vascular Conditions that aren’t STEMI

Author: Don Stader, M.D.

Educational Pearls

  • While we usually associate the coronary vasculature with STEMIs, there are other pathologies that can affect the heart’s blood supply.
  • Kounis syndrome: an allergic vasospasm of the coronary arteries. This can happen post anaphylaxis or be caused by a stent allergy. It is best treated with aggressive management of the allergic reaction.
  • Kawasaki disease: An autoimmune condition that presents in kids as conjunctivitis, lymphadenopathy, hand/foot swelling, rash, and fever. It can also cause coronary aneurysms, which can rupture and be rapidly fatal.  
  • Prinzmetal angina: Caused by coronary vasospasm. Presents with transient chest pain at rest. Treat with CCBs.
  • Cocaine: Causes coronary vasospasm. Cocaine-induced vasospasm is best treated with BZDs.
  • Coronary artery dissection: increased risk in pregnant women and those with connective tissue disorders.

References:  Memon S, Chhabra L, Masrur S, Parker MW. Allergic acute coronary syndrome (Kounis syndrome). Proceedings (Baylor University Medical Center). 2015;28(3):358-362.