Emergency Medical Minute

Author: Aaron Lessen M.D. Educational Pearls: Imodium (loperamide) is a mu-opioid receptor agonist. Traditionally, it is used as an anti-diarrheal. It is also abused recreationally for an opioid high and to self-treat opioid withdrawal. 40 or more pills are often ingested. People often co-ingest with cimetidine to potentiate the desired effects. Patients will present with opioid overdose symptoms (narrow pupils, respiratory depression). Narcan is effective in reversing an overdose of Imodium. Imodium prolongs QT and predisposes to Torsades, so monitor rhythm and then treat like any other opioid OD. References: http://www.tandfonline.com/doi/abs/10.3109/15563650.2016.1159310

Author: Dylan Luyten M.D. Educational Pearls: Ashman's Phenomenon occurs in the setting atrial fibrillation and mimics ventricular tachycardia, but is harmless. On ECG, the pattern of Ashman Phenomenon is a long cycle, followed a short cycle, followed by a complex wide complex beat. The wide complex beats have right BBB morphology. The long R-R followed by a short R-R leads to conduction down the left bundle branch while the right bundle branch is still in a refractory period. References: https://lifeinthefastlane.com/ecg-library/atrial-fibrillation/

Author: Samuel Killian M.D. Educational Pearls: Lower extremity DVTs are extremely common. There are more left lower extremity DVT due to anatomical variation. May-Thurner Syndrome is a form of anatomical variation in which the left iliac artery compresses the left iliac vein. Anticoagulation may not be sufficient to treat those with May-Thurner syndrome - endovascular stenting may be needed Patients with with recurrent LLE DVT, especially those in whom anticoagulation fails, should be referred to a specialist. References: Peters M, Syed RK, Katz M, et al. May-Thurner syndrome: a not so uncommon cause of a common condition. Proceedings (Baylor University Medical Center). 2012;25(3):231-233. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3377287/

Author: Don Stader, M.D Educational Pearls: It is important for providers to know how to use IV drugs properly so that they can instruct their patients on how to avoid injury. Heroin use is increasing. Hepatitis, HIV and infection are possible complications of improper IV drug use The first step of heroin use is to dissolve the solid heroin in water using heat - a spoon and lighter are often used for this step. Next, the heroin is drawn into the syringe through a filter (cotton is often used). Heroin concentration often varies widely - counsel patients to test their heroin first. Sterility of the needle, water, cooker, cotton and syringe is paramount. Refer patients to a needle exchange program where they can get clean supplies. Hepatitis C can live outside the body for 4 days - NEVER share ANY supplies. Sterile procedure is important - needles should not be licked. References: http://drugsense.org/flyers/10_tips_for_safer_use.pdf

Author: Peter Bakes, M.D Educational Pearls Intracerebral hemorrhage is an intracranial bleed within the brain tissue or ventricles. Subarachnoid aneurysm causes about 50% of all ICH. Amyloid deposition can lead to ICH in elderly patients. Hypertension is another common cause of atraumatic ICH, commonly leading to pontine, cerebellar, or basal ganglial bleeding. Bleeding in other locations is suggestive of a different etiology. ICH will often present with depressed mental status, but specifically a patient with a systolic BP > 220 is suggestive of hypertensive ICH. CT is the first diagnostic step. CTA should be considered when the bleeding is in an atypical area. Significant edema on imaging can be suggestive of a tumor. Treatment should include hemostatic measures and BP control. Transfuse platelets if necessary and reverse any anticoagulation. BP target is References: Sahni R, Weinberger J. Management of intracerebral hemorrhage. Vascular Health and Risk Management. 2007;3(5):701-709. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2291314/

Author: JP Brewer M.D. Educational Pearls: The "Quick Wee" was a method to get urine out of infants who need to have a UA in the Emergency Department. A randomized-controlled experiment was done with 350 infants between the ages of 1 to 12 months. The "Quick Wee" method is taking a sterile saline gauze with cool saline and rubbing it over the suprapubic abdomen for five minutes. The results were significant, with 31% in the treatment group voided after five minutes, 12% in the control group voided after five minutes. References: http://www.bmj.com/content/357/bmj.j1341

Author: Jared Scott M.D. Educational Pearls: There are two anatomical triangles on the back, the inferior lumbar triangle and the superior lumbar triangle. Herniation occurs whenever something moves to a place where it is not supposed to be, often through a fascial weakness. A "back hernia" can happen when the contents of of the abdominal cavity herniate into the back, usually through the superior lumbar triangle. This is also known as a Grynfeltt-Lesshaft hernia. Back hernias can be traumatic or congenital. These hernias are typically treated surgically. References: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3959346/

Author: Chris Holmes M.D. Educational Pearls: Mechanism of injury involves hyperextension/hyperflexion Pathophysiology: inside of the arteries in the neck becomes disrupted, similar to a dissection. This is thrombogenic and leads to cerebral infarction Neurologic deficit is common. Other risk factors include facial fracture and cervical-spine fracture. Treat with anticoagulation - aspirin or other antiplatelet agents are appropriate. Increase clinical suspicion when patient presents with neurological deficit and has a negative CT. References: https://www.east.org/education/practice-management-guidelines/blunt-cerebrovascular-injury

Author: Michael Hunt M.D. Dr. Hunt shares his wealth of experience with biological terrorism over the course of his career.

Author: Rachel Duncan, PharmD BCPS Educational Pearls: Toradol (Ketorolac) is an NSAID used for its anti-inflammatory properties In practice, the common dosages are 30mg IV or 60mg IM. Clinical concerns arise in patients with renal insufficiency or bleeding, but the risks are small ( Studies have found that doses over 7.5mg have the same efficacy in pain control as higher doses. Consider lower-dose Toradol (15mg) and decrease dose in the elderly and those with a CrCl References: Motov S, Yasavolian M, Likourezos A, et al. "Comparison of Intravenous Ketorolac at Three Single-Dose Regimens for Treating Acute Pain in the Emergency Department: A Randomized Controlled Trial". Ann Emerg Med 2016. http://www.annemergmed.com/article/S0196-0644(16)31244-6/fulltext