Podcast # 373: Legionnaires Disease

Author:  Gretchen Hinson, MD

Educational Pearls:

  • Legionnaires disease refers to a severe pneumonia caused by Legionella pneumophilia and occurs typically at the extremes of age
  • Associated gastrointestinal symptoms (nausea/vomiting/diarrhea) may be present
  • Hyponatremia is a common laboratory finding
  • Legionella urinary antigen can be a convenient test to identify the infection
  • Treatment is with fluoroquinolones, macrolides and/or tetracyclines




Pierre DM, Baron J, Yu VL, Stout JE. Diagnostic testing for Legionnaires’ disease. Annals of Clinical Microbiology and Antimicrobials. 2017;16:59. doi:10.1186/s12941-017-0229-6.

Cunha BA, Cunha CB. Legionnaire’s Disease and its Mimics: A Clinical Perspective. Infect Dis Clin North Am. 2017 Mar;31(1):95-109. doi: 10.1016/j.idc.2016.10.008. Review.

Podcast # 372: The Latest on Epinephrine in Cardiac Arrest

Author:  Don Stader, MD

Educational Pearls:

  • 8014 patients with out-of-hospital cardiac arrest randomized to epinephrine vs placebo
  • 30-day survival was not dramatically better between groups (3.2%in the epinephrine group and 2.4% in the placebo group)
  • Functional neurological outcome was nearly identical at 2.2% and 1.9% of patients
  • Adds to literature that epinephrine provides little important benefit in cardiac arrest – focus on chest compressions and early defibrillation


Editor’s note: NNT for epinephrine to prevent one death in this study was 115 – compared to bystander CPR (NNT 15) and defibrillation (NNT 5) from prior studies.



Perkins GD et. al. . A Randomized Trial of Epinephrine in Out-of-Hospital Cardiac Arrest.    N Engl J Med. 2018 Aug 23;379(8):711-721. doi: 10.1056/NEJMoa1806842. Epub 2018 Jul 18.

Kitamura T, Kiyohara K, Sakai T, et al. Public-access defibrillation and out-of-hospital cardiac arrest in Japan. N Engl J Med 2016;375:1649-1659.

Hasselqvist-Ax I, Riva G, Herlitz J, et al. Early cardiopulmonary resuscitation in out-of-hospital cardiac arrest. N Engl J Med 2015;372:2307-2315.

Hagihara A, Hasegawa M, Abe T, Nagata T, Wakata Y, Miyazaki S. Prehospital epinephrine use and survival among patients with out-of-hospital cardiac arrest. JAMA. 2012 Mar 21;307(11):1161-8. doi: 10.1001/jama.2012.294. PubMed PMID: 22436956.

Sanghavi P, Jena AB, Newhouse JP, Zaslavsky AM. Outcomes after out-of-hospital cardiac arrest treated by basic vs advanced life support. JAMA Intern Med. 2015 Feb;175(2):196-204. doi: 10.1001/jamainternmed.2014.5420.

Podcast # 371: EKG changes of Hyperkalemia

Author:  Jared Scott, MD

Educational Pearls:

  • EKG changes do not necessarily correlate to degree of hyperkalemia
  • Traditional progression through peaked T-waves, flattened p-waves, QRS widening, and then sine-waves before asystole


Mattu A, Brady WJ, Robinson DA. Electrocardiographic manifestations of hyperkalemia. Am J Emerg Med. 2000;18:721–729.

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



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

Podcast # 369: Five powerful toxins – the definitive list?

Author: Michael Hunt, MD

Educational Pearls:

Here is a list of some very toxic natural substances:

#5: Tetrodotoxin: Found in pufferfish and other aquatic species

#4: Ricin: made from castor beans

#3: Mercury: natural element absorbable through skin and gloves

#2: Batrachotoxin: found on poison dart frogs

#1: Botulinum toxin: produced by Clostridium botulinum and causes a descending paralysis

Editor’s note: batrachotoxin is thought to be accumulated by the beatles and other insects dart frogs eat – those in captivity therefore are not poisonous




Podcast # 368: Prehospital Plasma

Author: Aaron Lessen, MD

Educational Pearls:

  • Non-blinded randomized study assessing 30-day mortality benefit from plasma-first resuscitation in patients at risk hemorrhagic shock
  • Study involved aeromedical transport of trauma patients
  • 30-day mortality 23.2 % in intervention group vs. 33.0% in standard care group

Editor’s note: a similar study published in Lancet at the same time showed no mortality benefit from prehospital administration of plasma in a slightly different population which had much shorter ground transport times a major trauma center


Sperry JL, Guyette FX, Brown JB, Yazer MH, Triulzi DJ, Early-Young BJ, Adams PW, Daley BJ, Miller RS, Harbrecht BG, Claridge JA, Phelan HA, Witham WR, Putnam AT, Duane TM, Alarcon LH, Callaway CW, Zuckerbraun BS, Neal MD, Rosengart MR, Forsythe RM, Billiar TR, Yealy DM, Peitzman AB, Zenati MS; PAMPer Study Group.. Prehospital Plasma during Air Medical Transport in Trauma Patients at Risk for Hemorrhagic Shock. N Engl J Med. 2018 Jul 26;379(4):315-326. doi: 10.1056/NEJMoa1802345.

Podcast # 367: Digital Necrosis after Epi Drip

Author: Jared Scott, MD.

Educational Pearls:

  • Make sure to monitor for limb ischemia in all patients on vasopressors
  • Good reminder that vasopressors are not risk free – use them only on patients that need them!


Daroca-Pérez, R., & Carrascosa, M. F. . Digital necrosis: a potential risk of high-dose norepinephrine. Therapeutic Advances in Drug Safety. 2017. 8(8), 259–261. http://doi.org/10.1177/2042098617712669.

Podcast # 366: Ehlers Danlos

Podcast # 366: Ehlers Danlos

Author: Gretchen Hinson, MD.

Educational Pearls:

  • Heritable mutation in collagen synthesis and expression commonly resulting in joint hyperextension and skin elasticity.
  • Vascular type can result in aneurysm formation and rupture in young patients.
  • Patients are also at risk for spontaneous bowel rupture.
  • Pregnant women can present with uterine rupture.



Byers PH, Murray ML (2012). “Heritable collagen disorders: the paradigm of Ehlers?Danlos syndrome”. Journal of Investigative Dermatology. 132 (E1): E6?11.

Pepin MG, Byers PH. Ehlers-Danlos Syndrome Type IV. In: Pagon RA, Bird TD, Dolan CR, et al., eds. GeneReviews [Internet]. Seattle (WA): University of Washington, Seattle; 1993-.

Yoneda, A., Okada, K., Okubo, H., Matsuo, M., Kishikawa, H., Naing, B. T., ? Shimada, T. (2014). Spontaneous Colon Perforations Associated with a Vascular Type of Ehlers-Danlos Syndrome. Case Reports in Gastroenterology, 8(2), 175?181. http://doi.org/10.1159/000363373

Podcast # 365: Renal Trigger Point Injections

Author: Erik Verzemnieks, MD

Educational Pearls:

  • Single study in Japan demonstrated possible effectiveness of renal colic trigger point
  • Patients had injection at the area of maximal tenderness on palpation of the flank
  • Compared to a muscle relaxer, injection of local anesthetic at the trigger point had faster time to pain relief and fewer rescue therapies


Iguchi, M et al. Randomized trial of trigger point injection for renal colic. International Journal of Urology. 2002. 9(9): 475-479

Podcast # 364: Other causes of ST elevation

Author: Peter Bakes, MD

Educational Pearls:

  • Pericarditis, LBBB, LVH and left ventricular aneurysms can all present with ST elevation.
  • Ventricular aneurysm will present days after a cardiac event with ST elevation and Q waves in the affected leads.
  • Ventricular aneurysms may cause papillary muscle dysfunction with a resultant holosystolic murmur and even heart failure.



Victor F. Froelicher; Jonathan Myers (2006). Exercise and the heart. Elsevier Health Sciences. pp. 138?. ISBN 978-1-4160-0311-3.

Nagle RE, Williams DO. (1974) Proceedings: Natural history of ventricular aneurysm without surgical treatment. British Heart Journal, 36:1037.