Episode Archives

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!

Interesting Presentation of DKA

Interesting presentation of dka

Chief Complaint:

Abdominal Pain 

HPI:

41-year-old female presenting with reported elevated blood sugars in the 200s, 3 days of vomiting and diarrhea.  She states that she vomited twice today without any blood. She states that about 2 weeks ago she was started on a new medication called Farxiga.  She has no known sick contacts, no travel out of the country and no new antibiotics. She has not consumed non-potable water. No diarrhea today.

Pertinent Exam Findings:

  • Dry mucous moist membranes

  • Tachycardic

  • LUQ and tenderness at the epigastric area

 

Diagnostic Studies:

BMP: AG 21/ bicarb 7 /glucose 168 K 4.8/ normal renal function

VBG: pH 7.22/ HCO3 5

Beta hydroxybutyrate:  6.7

ED Course:

Patient was given IV insulin bolus and drip. She was given IVF with D5 and supplemental potassium and admitted to the ICU for further medical management.

Explanation:

Diabetic ketoacidosis (DKA) is traditionally defined as hyperglycemia (>250 mg/dL), anion gap acidosis, and  plasma ketones. Euglycemic DKA (euDKA), is essentially DKA with a serum glucose <200 mg/dL. Euglycemic DKA is a rare entity that mostly occurs in patients with type 1 diabetes, but can possibly occur in type 2 diabetes as well. The exact mechanism of euDKA is not entirely known, but has been associated with partial treatment of diabetes, carbohydrate food restriction, alcohol intake, and inhibition of gluconeogenesis. euDKA, can also be associated with sodium-glucose cotransporter 2 (SGLT-2) inhibitor medications.  These medications first came onto the market in 2013 and are FDA approved for the treatment of type 2 diabetes, however many physicians use them off-label for type I diabetes due to their ability to improve average glucose levels, reduce glycemic variability without increasing hypoglycemia, and finally promote weight loss.

Does euDKA Exist even in Patients not Using SGLT-2 Inhibitors?

  • The short answer is YES. Munro JF et al [5] reviewed a case series of 37 episodes of euDKA in a publication from 1973.  Although, dated and not robust evidence there are some take home messages:

    • All but one episode was in insulin dependent diabetics

    • Vomiting was the most frequent symptom of euDKA in 32% of patients

    • Management in most cases consisted of: Intravenous fluids and electrolyte replacement.

    • No deaths occurred in this case series

    What are the Names of the SGLT-2 Inhibitors?

    • Ipragliflozin (Suglat) – Approved in Japan

    • Dapagliflozin (Farxiga) – 1st SGLT2 Inhibitor Approved; Approved in US

    • Luseogliflozin (Lusefi) – Approved in Japan

    • Tofogliflozin (Apleway; Deberza) – Approved in Japan

    • Canagliflozin (Invokana) – Approved in US & Canada

    • Empagliflozin (Jardiance) – Approved in US

    How do SGLT-2 Inhibitors Cause euDKA?

 Euglycemic DKA Mechanism

 

High Yield Points:

*In patients with diabetes mellitus, on a SGLT-2 inhibitor and/or carbohydrate food restriction, who present with nausea/vomiting, fatigue, or the development of a metabolic acidosis, checking a urine and/or serum ketones is critical to not miss a case of euDKA.

 

*The treatment of euDKA will be nearly identical to DKA:

  • IVF: Treat dehydration; In addition to balanced crystalloids, start fluids with dextrose , due to the serum blood glucose already being low (i.e. <200mg/dL),

  • IV Insulin:  Close the anion gap and reverse the metabolic acidosis

References

Taken from http://rebelem.com/euglycemic-dka-not-myth/

 

  1. Peters AL et al. Euglycemic Diabetic Ketoacidosis: A Potential Complication of Treatment with Sodium-Glucose Cotransporter 2 Inhibition. Diabetes Care 2015; 38 (9): 1687 – 93. PMID: 26078479

  2. Ogawa W and Sakaguchi K. Euglycemic Diabetic Ketoacidosis Induced by SGLT2 Inhibitors: Possible Mechanism and Contributing Factors. J Diabetes Investig 2016; 7 (2): 135 – 8. PMID: 27042263

  3. Hine J et al. SGLT Inhibition and Euglycemic Diabetic Ketoacidosis. Lancet Diabetes Endocrinal 2015; 3: 503 – 504. PMID: 26025388

  4. Hayami T et al. Case of Ketoacidosis by a Sodium-Glucose Cotransporter 2 Inhibitor in a Diabetic Patient with a Low-Carbohydrate Diet. J Diabetes Investig 2015; 6: 587 – 590. PMCID: PMC4578500

  5. Munro JF et al. Euglycemic Diabetic Ketoacidosis. BMJ 1973; 2 (5866: 578 – 80. PMID: 4197425

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!

PREVIEW: UnfilterED

…coming October 2019

 

Music:

emotional by Barradeen | https://soundcloud.com/barradeen
Music promoted by https://www.free-stock-music.com
Creative Commons Attribution-ShareAlike 3.0 Unported
https://creativecommons.org/licenses/by-sa/3.0/deed.en_US

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

Do Opioids Cause Chronic Pain?!

Untitled presentation (1)

The Emergency Medical Minute Proudly Presents its BREW-CAST Series. Recorded Live in Tasty Brew Pubs across the state!

 

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