Emergency Medical Minute

Discover the intricate details of portal vein thrombosis, a rare yet critical condition characterized by blood clots in a vital vein. Delve into how it mimics acute mesenteric ischemia, presenting with sudden abdominal pain and other alarming symptoms. Learn about the diverse causes, from liver cirrhosis to coagulopathy and even oral contraceptives. Treatment approaches reveal the importance of aggressive fluid resuscitation, antibiotics, and possible endovascular interventions. A compelling exploration of a medical emergency that demands swift action!

Contributor: Jorge Chalit-Hernandez, OMS3 Educational Pearls: Acute mountain sickness (AMS) is the term given to what is otherwise colloquially known as altitude sickness High altitude cerebral edema (HACE) is a severe form of AMS marked by encephalopathic changes Symptoms begin at elevations as low as 6500 feet above sea level for people who ascend rapidly May develop more severe symptoms at higher altitudes The pathophysiology involves cerebral vasodilation Occurs in everyone ascending to high altitudes but is more pronounces in those that develop symptoms The reduced partial pressure of oxygen induces hypoxic vasodilation in the brain, which results in edema and, ultimately, HACE in some patients Symptomatic presentation Headache, nausea, and sleeping difficulties occur within 2-24 hours of arrival at altitude HACE may occur between 12-72 hours after AMS and presents with ataxia, confusion, irritability, and ultimately results in coma if left untreated Clinical presentation may be mistaken for simple exhaustion, so clinicians should maintain a high index of suspicion Notably, if symptoms occur more than 2 days after arrival at altitude, clinicians should seek an alternative diagnosis but maintain AMS/HACE on the differential Treatment and management AMS Adjunctive oxygen and descent to lower altitude Acetazolamide is used as a preventive measure but is not helpful in acute treatment +/- dexamethasone HACE Patients with HACE should receive dexamethasone to help reduce cerebral edema Immediate descent to a lower altitude References Burtscher M, Wille M, Menz V, Faulhaber M, Gatterer H. Symptom progression in acute mountain sickness during a 12-hour exposure to normobaric hypoxia equivalent to 4500 m. High Alt Med Biol. 2014;15(4):446-451. doi:10.1089/ham.2014.1039 Levine BD, Yoshimura K, Kobayashi T, Fukushima M, Shibamoto T, Ueda G. Dexamethasone in the treatment of acute mountain sickness. N Engl J Med. 1989;321(25):1707-1713. doi:10.1056/NEJM198912213212504 Luks AM, Beidleman BA, Freer L, et al. Wilderness Medical Society Clinical Practice Guidelines for the Prevention, Diagnosis, and Treatment of Acute Altitude Illness: 2024 Update. Wilderness Environ Med. 2024;35(1_suppl):2S-19S. doi:10.1016/j.wem.2023.05.013 Summarized & Edited by Jorge Chalit, OMS3 Donate: https://emergencymedicalminute.org/donate/  

Contributor: Meghan Hurley, MD Educational Pearls: Gastroenteritis clinical diagnoses: Diarrhea with or without vomiting and fever Vomiting in the absence of diarrhea has a large list of differential diagnoses, so the combination of diarrhea and vomiting in a patient is helpful to indicate the gastroenteritis diagnosis Symptom timeline is usually 1-3 days, but can last up to 14 days – diarrhea persists the longest Treatment for mild to moderate dehydration: oral or IV rehydration Begin orally to avoid unnecessary IV in a pediatric patient Administer ODT Ondansetron (Zofran) to prevent vomiting Meta-analysis showed that 2-8 mg orally, based on body weight, decreased vomiting quickly Wait 15-20 minutes for the medication to take effect Use streamlined method for oral rehydration: Fluids such as over-the-counter Pedialyte, Infalyte, Rehydrate, Resol, and Naturalyte may be used If patient weighs less than 10kg: administer 5mL of fluid per minute for 20 minutes If patient weighs 10kg or more: administer 10mL of fluid for 20 minutes If the patient can keep the fluid down, double the fluid volume and repeat If the patient once again keeps the fluid down, double the fluid volume and repeat If successful with each attempt, the patient may be discharged home Can prescribe ODT Zofran for 1-2 days at home If the patient vomits more than once during this oral rehydration process, intravenous rehydration must be initiated References Churgay CA, Aftab Z. Gastroenteritis in children: Part II. Prevention and management. Am Fam Physician. 2012 Jun 1;85(11):1066-70. PMID: 22962878. Summarized by Meg Joyce, MS1 | Edited by Meg Joyce & Jorge Chalit, OMS3 Donate: https://emergencymedicalminute.org/donate/  

Ever wondered how to best close a cut? Discover the battle between sutures, skin adhesive, and adhesive strips in laceration repair. A recent study reveals surprising insights into cosmetic outcomes perceived by parents. Skin adhesive scores the highest for aesthetics, while pain levels remain comparable across methods. Learn which technique might lead to happier faces—both kids and parents—in the ER!

Contributor: Jorge Chalit-Hernandez, OMS3 Educational Pearls: Serotonin syndrome occurs most commonly due to the combination of monoamine oxidase inhibition with concomitant serotonergic medications like SSRIs Examples of unexpected monoamine oxidase inhibitors Linezolid - a last-line antibiotic reserved for patients with true anaphylaxis to penicillins and cephalosporins Methylene blue - not mentioned in the podcast due to its uncommon usage for methemoglobinemia Other medications that can interact with SSRIs to cause serotonin syndrome Dextromethorphan - primarily an anti-tussive at sigma opioid receptors that also has serotonin reuptake inhibition Clinical presentation of serotonin syndrome Altered mental status Autonomic dysregulation leading to hypertension (most common), hypotension, and tachycardia Hyperthermia Neuromuscular hyperactivity - tremors, myoclonus, and hyperreflexia Hunter Criteria (high sensitivity and specificity for serotonin syndrome): Spontaneous clonus Inducible clonus + agitation or diaphoresis Ocular clonus + agitation or diaphoresis Tremor + hyperreflexia Hypertonia, temperature > 38º C, and ocular or inducible clonus Management of serotonin syndrome Primarily supportive - benzodiazepines can help treat hypertension, agitation, and hyperthermia. Patients often require repeated and higher dosing of benzodiazepines Avoid antipyretics to treat hyperthermia since the elevated temperature is due to sustained muscle contraction and not central temperature dysregulation In refractory patients, cyproheptadine (a 5HT2 antagonist) may be used as a second-line treatment Patients with temperatures > 41.1º C or 106º F require medically induced paralysis and intubation to control their temperature References Boyer EW, Shannon M. The serotonin syndrome [published correction appears in N Engl J Med. 2007 Jun 7;356(23):2437] [published correction appears in N Engl J Med. 2009 Oct 22;361(17):1714]. N Engl J Med. 2005;352(11):1112-1120. doi:10.1056/NEJMra041867 Dunkley EJ, Isbister GK, Sibbritt D, Dawson AH, Whyte IM. The Hunter Serotonin Toxicity Criteria: simple and accurate diagnostic decision rules for serotonin toxicity. QJM. 2003;96(9):635-642. doi:10.1093/qjmed/hcg109 Ramsay RR, Dunford C, Gillman PK. Methylene blue and serotonin toxicity: inhibition of monoamine oxidase A (MAO A) confirms a theoretical prediction. Br J Pharmacol. 2007;152(6):946-951. doi:10.1038/sj.bjp.0707430 Schwartz AR, Pizon AF, Brooks DE. Dextromethorphan-induced serotonin syndrome. Clin Toxicol (Phila). 2008;46(8):771-773. doi:10.1080/15563650701668625 Thomas CR, Rosenberg M, Blythe V, Meyer WJ 3rd. Serotonin syndrome and linezolid. J Am Acad Child Adolesc Psychiatry. 2004;43(7):790. doi:10.1097/01.chi.0000128830.13997.aa Summarized & Edited by Jorge Chalit, OMS3 Donate: https://emergencymedicalminute.org/donate/

Contributor: Aaron Lessen, MD Educational Pearls: Many patients present to the ED with elevated BP Many are referred from outpatient surgery centers or present after an elevated measurement at home Persistent questions on the best way to treat these patients The AHA published a scientific statement on the management of elevated BP in the acute care setting Hypertensive emergencies: SBP/DBP >180/110–120 mm Hg with evidence of new or worsening target-organ damage Includes aortic dissection or subarachnoid hemorrhage  Require aggressive treatment Asymptomatic markedly elevated inpatient BP: SBP/DBP >180/110–120 mm Hg without evidence of new or worsening target-organ damage AND asymptomatic elevated inpatient BP: SBP/DBP ≥130/80 mm Hg without evidence of new or worsening target-organ damage No benefits to urgent treatment in the ED, but there are harms to treating patients in this manner These patients do not require IV medications  Provide reassurance and instructions on following up with their PCP to manage their BP in the outpatient setting Removed the term “hypertensive urgency” References Bress AP, Anderson TS, Flack JM, et al. The Management of Elevated Blood Pressure in the Acute Care Setting: A Scientific Statement From the American Heart Association. Hypertension. 2024;81(8). doi:https://doi.org/10.1161/hyp.0000000000000238 Summarized by Meg Joyce, MS1 | Edited by Meg Joyce & Jorge Chalit, OMS3  Donate: https://emergencymedicalminute.org/donate/  

Contributor: Megan Hurley MD Educational Pearls: What is the mediastinum? The thoracic cavity is separated into different compartments by membranes The lungs exist in their own pleural cavities, and the mediastinum is everything in between The mediastinum extends from the sternum to the thoracic vertebrae and includes the heart, the aorta, the trachea, the esophagus, the thymus, as well as many lymph nodes and nerves. What is a pneumomediastinum? Air in the mediastinum How can pneumomediastinum be categorized? Traumatic Ex. Stab wound to the trachea Ex. Boerhaave’s Syndrome of the esophagus, possibly from an endoscopic procedure. This mechanism in particular is a higher risk of infection because not only air but food can accumulate in the mediastinum Ex. Intubation with a bougie These will likely need surgical repair Nontraumatic Ex. Forceful inhalation causing microperforations in the trachea. Possibly while inhaling something like drugs Ex. Bad asthma for similar reasons Ex. Gas forming bacteria What happens if you use positive pressure ventilation on a patient with a hole in their trachea? The positive pressure will force extra air into the mediastinum The air will move between the layers of subcutaneous tissue and can track up into the neck and face regions recognized as crepitus on exam This can also cause a tension pneumomediastinum in which the air pressure in the compartment constricts the heart, impeding its ability to fill during diastole These patients can undergo bronchoscopy because that procedure does not require positive pressure and will not worsen the condition. Endoscopies do require positive pressure so endoscopies are not an option How is a tension pneumomediastinum treated? By inserting a needle into the space from below the xiphoid process to allow the air to escape, similar to a pericardiocentesis As a temporizing measure, if the hole is high enough in the trachea, the intubation can be continued by deliberately pushing the endotracheal tube into the right main bronchus, creating a seal, and only ventilating the right lung while the patient heads to surgery. This is called right-mainstemming. References Clancy DJ, Lane AS, Flynn PW, Seppelt IM. Tension pneumomediastinum: A literal form of chest tightness. J Intensive Care Soc. 2017 Feb;18(1):52-56. doi: 10.1177/1751143716662665. Epub 2016 Aug 3. PMID: 28979537; PMCID: PMC5606356. Grewal, J., & Gillaspie, E. A. (2024). Pneumomediastinum. Thoracic surgery clinics, 34(4), 309–319. https://doi.org/10.1016/j.thorsurg.2024.06.001 Underner, M., Perriot, J., & Peiffer, G. (2017). Pneumomédiastin et consommation de cocaïne [Pneumomediastinum and cocaine use]. Presse medicale (Paris, France : 1983), 46(3), 249–262. https://doi.org/10.1016/j.lpm.2017.01.002 Summarized by Jeffrey Olson, MS3 | Edited by Meg Joyce & Jorge Chalit, OMS3 Donate: https://emergencymedicalminute.org/donate/  

Contributor: Ricky Dhaliwal MD Educational Pearls:  Etomidate was previously the drug of choice for rapid sequence intubation (RSI) However, it carries a risk of adrenal insufficiency as an adverse effect through inhibition of mitochondrial 11-β-hydroxylase activity A recent meta-analysis analyzing etomidate as an induction agent showed the following: 11 randomized-controlled trials with 2704 patients Number needed to harm is 31; i.e. for every 31 patients that receive etomidate for induction, there is one death The probability of any mortality increase was 98.1% Ketamine is preferable due to a better adverse effect profile Laryngeal spasms and bronchorrhea are the most common adverse effects after IV push Beneficial effects on hemodynamics via catecholamine surge, albeit not as pronounced in shock patients 2023 meta-analysis compared ketamine and etomidate for RSI Ketamine’s probability of reducing mortality is cited as 83.2% Overall, induction with ketamine demonstrates a reduced risk of mortality compared with etomidate The dosage of each medication for induction Etomidate: 20 mg based on 0.3 mg/kg for a 70 kg adult Ketamine: 1-2 mg/kg (or 0.5-1 mg/kg in patients with shock) Patients with asthma and/or COPD also benefit from ketamine induction due to putative bronchodilatory properties References  Goyal S, Agrawal A. Ketamine in status asthmaticus: A review. Indian J Crit Care Med. 2013;17(3):154-161. doi:10.4103/0972-5229.117048 Koroki T, Kotani Y, Yaguchi T, et al. Ketamine versus etomidate as an induction agent for tracheal intubation in critically ill adults: a Bayesian meta-analysis. Crit Care. 2024;28(1):1-9. doi:10.1186/s13054-024-04831-4 Kotani Y, Piersanti G, Maiucci G, et al. Etomidate as an induction agent for endotracheal intubation in critically ill patients: A meta-analysis of randomized trials. J Crit Care. 2023;77(April 2023):154317. doi:10.1016/j.jcrc.2023.154317 Summarized & Edited by Jorge Chalit, OMS3 Donate: https://emergencymedicalminute.org/donate/  

Contributor: Aaron Lessen MD Educational Pearls: Pregnant patients at high risk of cardiac arrest, in cardiac arrest, or in extremis require special care A useful mnemonic to recall the appropriate management of critically ill pregnant patients is TOLDD T: Tilt the patient to the left lateral decubitus position This position relieves pressure exerted from the uterus onto the inferior vena cava, which reduces cardiac preload If the patient is receiving CPR, an assistant should displace the uterus manually from the IVC towards the patient’s left side O: Administer high-flow adjunctive oxygen  L: Lines should be placed above the diaphragm Lines below the diaphragm are ineffective due to uterine compression of the IVC May consider humeral interosseous line vs. internal jugular or subclavian central line D: Dates should be estimated > 20 weeks, can consider a resuscitative hysterotomy (previously known as perimortem c-section) to improve chances of survival The uterus is palpable at the umbilicus at 20 weeks and 1 cm superior to the umbilicus for every week thereafter D: Call the labor and delivery unit for additional help References ACOG Practice Bulletin No. 211 Summary: Critical Care in Pregnancy. Obstetrics & Gynecology. 2019;133(5) Fujita N, Higuchi H, Sakuma S, Takagi S, Latif MAHM, Ozaki M. Effect of Right-Lateral Versus Left-Lateral Tilt Position on Compression of the Inferior Vena Cava in Pregnant Women Determined by Magnetic Resonance Imaging. Anesth Analg. 2019;128(6):1217-1222. doi:10.1213/ANE.0000000000004166 Jeejeebhoy FM, Zelop CM, Lipman S, et al. Cardiac Arrest in Pregnancy. Circulation. 2015;132(18):1747-1773. doi:doi:10.1161/CIR.0000000000000300 Singh, Ajay; Dhir, Ankita; Jain, Kajal; Trikha, Anjan1. Role of High Flow Nasal Cannula (HFNC) for Pre-Oxygenation Among Pregnant Patients: Current Evidence and Review of Literature. Journal of Obstetric Anaesthesia and Critical Care 12(2):p 99-104, Jul–Dec 2022. | DOI: 10.4103/JOACC.JOACC_18_22  Summarized & Edited by Jorge Chalit, OMS3 Donate: https://emergencymedicalminute.org/donate/  

Explore the intriguing world of EKG interpretation with insights on subendocardial ischemia. Discover what the ST segment represents and learn about its significance in recognizing heart conditions. Elevated ST segments may indicate a serious injury, while depressed segments reveal ischemic issues. The importance of patient history is emphasized as a vital component in diagnosing various cardiovascular conditions. Delve into the nuanced details of EKG patterns and their implications for heart health.