Emergency Medical Minute

Dr. Steven Bradley is an active duty U.S. Naval officer practicing as a Staff Anesthesiologist in Virginia where also resides on the Medical Ethics Committee for his hospital. He serves as the Anesthesiology Residency Simulation Coordinator there and enjoys the opportunity to teach residents drawing from his experiences as a student. He just recently started The Black Doctors Podcast where he strives to tell stories of Black physicians who overcame adversity to attain their goals so that young individuals in the minority can listen and learn. Tune in to hear Dr. Bradley discuss his experience as a minority in medicine and how systemic racism can manifest in various aspects of medicine. Check out The Black Doctors Podcast on Apple Podcasts, Spotify, and all major streaming platforms. Instagram: @theblackdoctorspodcast Twitter: @StevenBradleyMD

Author: Charlene Gnisci Melton, PharmD Educational Pearls: Status Epilepticus is defined as continuous seizure activity for >5 minutes, or 2 or more seizures without full return to consciousness between events Status epilepticus is a true neurologic emergency with significant morbidity and mortality Aggressive, early treatment of status epilepticus is essential as GABA receptors will regress over time and make benzodiazepines less effective as time elapses Go large with doses of benzodiazepines and repeat doses if necessary: In adults this means lorazepam 4 mg IV push or Midazolam 10 mg intramuscular if no IV access Second line agents include: Levetiracetam (Keppra) 60 mg/kg up to 4500mg Valproic Acid (40 mg/kg up to 3000 mg) Keppra has an arguably better side effect profile and compatibility compared to other second-line agents Third line agents include intubation and sedation with propofol, benzodiazepines, or even ketamine Editor's note: from a time management perspective, call for your second-line treatment early to get it from pharmacy while you slam the benzodiazepines, then it will be arriving hopefully when you need it, and no harm if you don't. Oh, and don't forget a fingerstick glucose. References Glauser T, Shinnar S, Gloss D, et al. Evidence-Based Guideline: Treatment of Convulsive Status Epilepticus in Children and Adults: Report of the Guideline Committee of the American Epilepsy Society. Epilepsy Curr. 2016;16(1):48–61. doi:10.5698/1535-7597-16.1.48 Walker, M.C. Pathophysiology of status epilepticus. Neuroscience Letters. 2018:667:84-91. https://doi.org/10.1016/j.neulet.2016.12.044 Summarized by Jackson Roos, MS3 | Edited by Erik Verzemnieks, MD

This limited series will investigate how the nation's opioid epidemic has been impacted by the COVID-19 pandemic. Over the course of this series, we will hear from a harm reductionist, an addiction medicine physician, a Denver Police narcotics sergeant and two people currently in recovery. Unfortunately, the opioid epidemic and the COVID-19 pandemic are likely not going anywhere soon. Emergency Medical Minute remains committed to providing education to help combat these health crises. In the final episode of this series, we are fortunate enough to speak with Chris Espinoza and Ashley Parsons, two individuals currently in recovery. Chris and Ashley bravely share the origins of their substance use disorders, the challenges that COVID has presented during their recovery process as well as their current life goals and hopes for the future. ______________________________________ Illustration by Kelly Caminero/The Daily Beast/Shutterstock

Contributor: Aaron Lessen, MD Educational Pearls: Studies have shown that patients who are under deeper sedation in the ICU have worse outcomes. Recent study compared lighter vs heavier sedation of patients in the emergency department receiving mechanical ventilation Patients receiving lighter sedation in the ED were often continued in the ICU Patients who had lighter sedation also tended to do better, meaning less days on the ventilator, less days in the ICU, and lower mortality supporting prior observations. Though purely observational, interesting suggestion that lighter sedation starting in the emergency department could have significant impact on important clinical outcomes References Fuller BM, Roberts BW, Mohr NM, et al. The ED-SED Study: A Multicenter, Prospective Cohort Study of Practice Patterns and Clinical Outcomes Associated With Emergency Department SEDation for Mechanically Ventilated Patients. Crit Care Med. 2019;47(11):1539‐1548. doi:10.1097/CCM.0000000000003928 Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

This limited series will investigate how the nation's opioid epidemic has been impacted by the COVID-19 pandemic. Over the course of this series, we will hear from a harm reductionist, an addiction medicine physician, a Denver Police narcotics sergeant and two people currently in recovery. Unfortunately, the opioid epidemic and the COVID-19 pandemic are likely not going anywhere soon. Emergency Medical Minute remains committed to providing education to help combat these health crises. In this episode, we speak with Lex Jorge -- a Denver Police Narcotics Sergeant -- to gain insight into how drug trafficking has been impacted by COVID. We also discuss law enforcement's role in the recovery process and touch on social issues currently afflicting the country. ______________________________________ Illustration by Kelly Caminero/The Daily Beast/Shutterstock

This limited series will investigate how the nation's opioid epidemic has been impacted by the COVID-19 pandemic. Over the course of this series, we will hear from a harm reductionist, an addiction medicine physician, a Denver Police narcotics sergeant and two people currently in recovery. Unfortunately, the opioid epidemic and the COVID-19 pandemic are likely not going anywhere soon. Emergency Medical Minute remains committed to providing education to help combat these health crises. In this episode, we talk to Dr. Steven Young -- board certified emergency physician and addiction medicine physician -- to discover how his clinic has had to adapt and overcome the challenges presented by COVID. Resources: https://www.cotreatment.com/ https://www.samhsa.gov/medication-assisted-treatment https://www.ernaloxone.org/ https://cha.com/opioid-safety/coloradomat/ ______________________________________ Illustration by Kelly Caminero/The Daily Beast/Shutterstock

This limited series will investigate how the nation's opioid epidemic has been impacted by the COVID-19 pandemic. Over the course of this series, we will hear from a harm reductionist, an addiction medicine physician, a Denver Police narcotics sergeant and two people currently in recovery. Unfortunately, both the opioid epidemic and the COVID-19 pandemic are likely not going anywhere soon. Emergency Medical Minute remains committed to providing education to help combat these health crises. In the first episode, we catch up with Lisa Raville -- executive director of the Harm Reduction Action Center in Denver -- to learn how COVID has impacted her facility's daily operations as well as the lives of her clients. For more information about HRAC: http://harmreductionactioncenter.org/ Get In touch with HRAC: Email: HRAC.Denver@gmail.com Facebook: @harmreductionactioncenter Twitter: @HRAC_Denver Instagram: @harmreductionactioncenter ______________________________________ Illustration by Kelly Caminero/The Daily Beast/Shutterstock

Taken from 'UnfilterED #8: Dr. Christopher Hoyte'. "This current sars-coV-2 / COVID-19 situation should really be a wake-up call for not just a pandemic, but for a biological attack...One of the things I would like to do when we bring our attention back from COVID and get through this pandemic is to really start to prepare for disaster preparedness on the level and scale that we need to for a biological attack and get our hospitals ready, my poison center ready, state and local governments ready so that we can meet that challenge when it happens." - Dr. Chris Hoyte Dr. Chris Hoyte is an ED physician, toxicologist and researcher based in Denver, CO. He was featured in Bring Em' All: Chaos. Care. Stories from Medicine's Front Line, a book celebrating emergency physicians through personal testimonies and photography on the frontlines captured by legendary photographer, Eugene RIchards. Photo © courtesy Eugene Richards

Dr. Chris Hoyte is an ED physician, toxicologist and researcher based in Denver, CO. He was featured in Bring Em' All: Chaos. Care. Stories from Medicine's Front Line, a book celebrating emergency physicians through personal testimonies and photography on the frontlines captured by legendary photographer, Eugene RIchards. Time Stamps: 01:25 - Dr. Hoyte's Origin Story 05:01 - What Drew Dr. Hoyte to Medical Toxicology? 08:22 - Dr. Hoyte's Most Interesting Toxicology Cases 08:52 - King Cobra Bite 13:31 - Verapamil Overdose 16:47 - Mass Cyanide Poisoning 19:16 - The Looming Threat of Biological Warfare and the Need for Emergency Preparedness 25:07 - How COVID-19 Affected Dr. Hoyte's Job as a Toxicologist 30:19 - How Does the Rocky Mountain Poison and Drug Center Handle Its Large Workload 35:56 - Cannabinoid Exposures 42:05 - The Future of Toxicology Publications from Dr. Hoyte: A Characterization of Synthetic Cannabinoid Exposures Reported to the National Poison Data System in 2010 https://pubmed.ncbi.nlm.nih.gov/22575211/ An Outbreak of Exposure to a Novel Synthetic Cannabinoid https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3983965/ The Continued Impact of Marijuana Legalization on Unintentional Pediatric Exposures in Colorado https://pubmed.ncbi.nlm.nih.gov/30288992/ Pediatric Death Due to Myocarditis After Exposure to Cannabis https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5965161/ Anaphylaxis to Black Widow Spider Antivenom https://pubmed.ncbi.nlm.nih.gov/21641165/ Intro Music: Backbay Lounge Kevin MacLeod (incompetech.com) Licensed under Creative Commons: By Attribution 3.0 License http://creativecommons.org/licenses/by/3.0/

Contributor: Nick Tsipis, MD Educational Pearls: Significant cyanide exposure most commonly occurs from fire/smoke exposure particularly when plastics are involved Cyanide binds to cytochrome oxidase leading to the use of anaerobic metabolism which causes a profound lactic acidosis Classic toxicity includes a rapid loss of consciousness, hypotension, bradycardia, respiratory depression, and seizures Mild exposures can lead to nausea/vomiting, headaches, and other nonspecific symptoms. Sometimes patients will complain of an almond taste. Cyanide toxicity will manifest on labs by a profound anion gap acidosis with elevated lactate (but don't wait for them to ponder the diagnosis) Antidote is hydroxocobalamin and sodium thiosulfate Severe cyanide exposure will likely need ICU level care until the blood gas levels return to their baselines and the lactic acidosis resolves References Nickson Chris C, Australian Centre for Health Innovation at Alfred Health. Cyanide Poisoning • LITFL • CCC Toxicology. Life in the Fast Lane • LITFL • Medical Blog. https://litfl.com/cyanide-poisoning-ccc/. Published April 2, 2019. Accessed June 11, 2020. Parker-Cote JL, Rizer J, Vakkalanka JP, Rege SV, Holstege CP. Challenges in the diagnosis of acute cyanide poisoning. Clin Toxicol (Phila). 2018;56(7):609‐617. doi:10.1080/15563650.2018.1435886 MacLennan L, Moiemen N. Management of cyanide toxicity in patients with burns. Burns. 2015;41(1):18‐24. doi:10.1016/j.burns.2014.06.001 Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD