Emergency Medical Minute

Author: Aaron Lessen, M.D. Educational Pearls Post-intubation care should always include pain control and adequate sedation. Commonly used sedation agents include propofol, ketamine and versed. However, too much sedation is harmful. Deep sedation (RASS -4 to -5) is associated with worse long-term outcomes. RASS of 0 to -2 is ideal, as long as the patient is comfortable. References: https://coreem.net/core/post-intubation/

Educational Pearls Subdural hematomas can happen in the elderly because of brain atrophy, and can manifest with neurological deficit. Subdural hematomas are caused by rupture of the bridging veins of the brain. This can be caused by trauma, brain atrophy, or possibly by anticoagulant use. They are crescent-shaped on head CT. Epidural hematomas, in contrast, are caused by rupture of meningeal arteries secondary to trauma. They are usually lens-shaped on head CT. Subdurals are difficult to pick up on head CT because they may be isodense to brain tissue. References: Management of Recurrent Subdural Hematomas Desai, Virendra R. et al. Neurosurgery Clinics , Volume 28 , Issue 2 , 279 - 286

Author: Don Stader, M.D. Educational Pearls Mucor/Rhizopus fungal infections usually present in diabetic or immunocompromised patients as a black, necrotic lesion on the face. The fungus invades the vasculature of the face, causing tissue ischemia and necrosis. The infection is more common in the diabetic population because the fungus prefers more acidic and glucose-rich environments. This is a surgical emergency since it is cured only with excision of the affected tissue References: Vijayabala GS, Annigeri RG, Sudarshan R. Mucormycosis in a diabetic ketoacidosis patient. Asian Pacific Journal of Tropical Biomedicine. 2013;3(10):830-833. doi:10.1016/S2221-1691(13)60164-1.

Author: John Winkler, M.D. Educational Pearls Angioedema is immediately life-threatening due to airway obstruction. Mechanisms include allergic reaction (histamine-related) or bradykinin-related (ACE-inhibitor, C1 esterase inhibitor deficiency). The bradykinin-related mechanism will not respond to the traditional meds used for anaphylaxis. Instead, use FFP to replace depleted factors. If a patient displays signs of respiratory compromise, intubation is indicated. Anesthesia should be consulted as this will be a very difficult airway. References: https://emcrit.org/pulmcrit/treatment-of-acei-induced-angioedema/

Author: Nick Hatch, M.D. Educational Pearls Unlike coin ingestions, button batteries can cause necrosis of the GI tract. If lodged in the esophagus, removal within 2 hours is important, because they can cause problems such as strictures or esophago-aortic fistula. If the battery is in the stomach or beyond, it may be ok to let it pass but give strict return precautions. Small hearing aid batteries are not as dangerous, but still require close follow-up to ensure the battery passes. Delayed effects (after passage of the battery) are possible. References: https://www.poison.org/battery/guideline

Author: Aaron Lessen, M.D. Educational Pearls A recent prospective observational study was performed to examine the safety of different sedation medications in the pediatric ED. This study included 6000 children, and looked at the rate of serious adverse events following administration of different sedatives. Overall, the safest drug to use was ketamine alone, with an adverse event rate of about 1%. Propofol, BZDs, and opiates had increased rates of adverse events. References: https://lifeinthefastlane.com/pediatric-procedural-sedation-with-ketamine/

Author: Sam Killian, M.D. Educational Pearls Difficulty with bag valve mask (BVM) ventilation can be addressed using the MOANS mnemonic. Mask seal, Obesity/obstruction, Age, No teeth, Sleep apnea. Often BVM difficulty can be addressed by an extra set of hands. References: https://www.aliem.com/2012/10/mnemonics-for-difficult-airway/

Author: David Rosenberg, M.D. Educational Pearls A study of 20,000 subjects found that reducing fever in sepsis did not improve outcomes such as morbidity, mortality, or length of stay. However, correcting fever may help for patient comfort. References: Zhang Z, Chen L, Ni H. Antipyretic Therapy in Critically Ill Patients with Sepsis: An Interaction with Body Temperature. Azevedo LCP, ed. PLoS ONE. 2015;10(3):e0121919. doi:10.1371/journal.pone.0121919.

Author: Chris Holmes, M.D. Educational Pearls The nexus chest CT scan rule is based on an 11,000 subject, multicenter study that looked for signs following a trauma that predicted significant findings on subsequent chest CT. Findings that were associated with abnormal chest CT included: abnormal CXR, distracting injury, chest wall, sternal, thoracic spine or scapular tenderness. Furthermore, a mechanism of injury that includes rapid deceleration was also associated. If a patient has none of the above findings, then there is only a small chance that there will be an abnormal chest CT. References: https://www.mdcalc.com/nexus-chest-ct-decision-instrument-ct-imaging

Author: Don Stader, M.D. Educational Pearls Wound botulism should be considered in patients with cutaneous lesions and neuromuscular weakness. The toxin produced by clostridium botulinum is the causative agent. It forms spores, so it is very resistant to killing by heat. It presents with weakness, most often in the extraocular muscles. Treatment includes wound care and respiratory support. Anti-toxin is rarely used as it is stored at the CDC and must be flown in. References: Kalka-Moll WM, Aurbach U, Schaumann R, Schwarz R, Seifert H. Wound Botulism in Injection Drug Users. Emerging Infectious Diseases. 2007;13(6):942-943. doi:10.3201/eid1306.061336.