Emergency Medical Minute

Author: Sam Killian, M.D. Educational Pearls: Defined as fracture of neck (distal segment) of 5th metacarpal. Intrinsic muscles of hand pull segment to palmar aspect of hand. 30 degrees of angulation is allowed. Any more increases risk of chronic pain, grip strength and grasping deficits, and rotational deformities. Reduce fracture if more than 30 degrees of angulation or if rotation is present. Splint fracture in "ulnar gutter" with goal being flexion at MCP and extension at DIP and PIP. References: http://www.emedicinehealth.com/boxers_fracture/article_em.htm

Author: Jared Scott, M.D. Educational Pearls: DDx for blood at urethral meatus includes: pelvic fracture, ruptured bladder, kidney laceration, penile trauma. Retrograde Urethrogram (RUG) must be performed before placing foley and is critical for diagnosis. References: https://www.ncbi.nlm.nih.gov/pubmed/16488282

Author: Michael Hunt, M.D. Educational Pearls: Research has shown that the higher temperatures post-cardiac arrests may lead to poorer outcomes. Initially, 33 deg C was the target temp. However, more research is being done to find therapeutic temperature levels. New studies have shown that the cooling protocol differs for inpatient cardiac arrests vs. outpatient cardiac arrests. The results show that it may not be necessary to cool inpatient cardiac arrests. References: http://www.hopkinsmedicine.org/healthlibrary/test_procedures/cardiovascular/therapeutic_hypothermia_after_cardiac_arrest_135,393/

Authors: Rebecca van Vliet MS, APN; Michelle Whaley MSN, CNS, CCNS, ANVP-VC The Stroke Team at Swedish Medical Center gives us a taste of how they are breaking records with door-to-needle time in management of acute cerebrovascular accidents.

Author: Aaron Lessen M.D. Educational Pearls: Thoracotomy is a potentially life-saving procedure. However, outcomes are often poor and the procedure itself poses many risks to provider and patient. Chance of surviving a thoracotomy when there is no cardiac activity on ultrasound is 0%. Performing a thoracotomy is unlikely to benefit patients with no cardiac activity on ultrasound or patients that lost vital signs greater than 10 minutes before starting the procedure. A thoracotomy is maximally beneficial in patients with a penetrating chest injury that occurred less than 10 minutes before the procedure. References: K. Inaba et al, "FAST Ultrasound Examination as a Predictor of Outcomes After Resuscitative Thoracotomy: A Prospective Evaluation" Ann. of Surgery, 2015. https://www.ncbi.nlm.nih.gov/pubmed/26258320

Author: Dave Rosenberg M.D. Educational Pearls: Louis Pasteur developed the technique that is now known as pasteurization. It was first used in the wine-producing regions of France, and eventually in dairy products like milk. Pasteur also investigated infectious disease. During one experiment, Pasteur's lab assistant accidentally infected chickens with a weakened form of cholera. When none of the chickens died, Pasteur re-infected them with a stronger strain. This time, none of the chickens became sick because they had been inoculated against the disease. This experiment paved the way for modern vaccination. References: Smith KA. Louis Pasteur, the Father of Immunology? Frontiers in Immunology. 2012;3:68. doi:10.3389/fimmu.2012.00068.

Author: Susan Brion M.D. Educational Pearls: Laundry and dishwasher detergent pods resemble candy and can be ingested by children. These tide pods are very highly concentrated and can cause chemical burns of the lips, airway, eyes, mouth and esophagus. The strong bases in detergent pods (pH>12) can cause liquefactive necrosis, which can cause immediate perforation of the esophagus. Common symptoms associated with ingestion of detergent pods include pain, dysphagia, drooling, mediastinal pain, upper airway inflammation. The presence or absence of symptoms does not indicate severity - suspected ingestions should be admitted and undergo bronchoscopy. Mental status should be assessed rapidly because detergent ingestion can lead to CNS depression and aspiration. References: Bonney AG, Mazor S, Goldman RD. Laundry detergent capsules and pediatric poisoning. Canadian Family Physician. 2013;59(12):1295-1296.

Author: Mark Kozlowski M.D. Educational Pearls: Humans cannot "multitask" effectively - a more accurate term is "task interruption." When doing more than one task at once, we are more likely to forget key details and perform both tasks more slowly overall. Do not interrupt people who are focusing on critical tasks - programming a pump or drawing up doses. Think about ways to reduce task interruption in your hospital for a better clinical practice. References: Westbrook JI, Woods A, Rob MI, Dunsmuir WTM, Day RO. Association of Interruptions With an Increased Risk and Severity of Medication Administration Errors. Arch Intern Med. 2010;170(8):683-690. doi:10.1001/archinternmed.2010.65

Author: Don Stader M.D. Educational Pearls: Non-traumatic back pain is a very common complaint in the Emergency Department. Conditions that can manifest with back pain include: ruptured abdominal aortic aneurysm, retroperitoneal bleeding, cauda equina syndrome, epidural abscess or cancer. Patients with cauda equina syndrome or epidural abscess prefer to sit forward, while people with disc issues tend to sit upright. References: https://emergencymedicinecases.com/episode-26-low-back-pain-emergencies/

Author: Arthur Lessen M.D. Educational Pearls: Zofran (ondansetron) is generally safe to use for the treatment of nausea and vomiting. However, it can prolong the QT interval and increase the chance for torsades. Low doses of Zofran are not likely to be an issue. However, when multiple doses are given, especially in the setting of a preexisting LQTS, clinical concern should be raised. When giving Zofran to a patient with an increased risk for torsades, consider continuous cardiac monitoring or an alternate anti-emetic. References: https://www.fda.gov/Drugs/DrugSafety/ucm310190.htm