Emergency Medical Minute

Contributor: Megan Hurley, MD Educational Pearls: Assess first: confirm the hook isn't near vital structures. Removal Techniques Adjuncts: Hydrodissection with lidocaine along the tract can ease removal Post-Procedure References Summarized by Meg Joyce, MS2 | Edited by Meg Joyce & Jorge Chalit, OMS4

Contributor: Aaron Lessen MD Educational Pearls: References Summarized & Edited by Jorge Chalit, OMS4 Donate: https://emergencymedicalminute.org/donate/

Contributor: Meghan Hurley, MD Educational Pearls: 1. Initial Assessment Start with a physical examination: Determine if the bleed is anterior or posterior. Perform a primary survey: assess airway, breathing, and circulation (ABCs). Airway compromise = intubation immediately. If the patient is stable, have them blow out any clots, then re-examine the nares. 2. Topical Medications Anesthetics: provide local anesthesia and pain relief. Lidocaine Tetracaine Vasoconstrictors: reduce bleeding. LET (Lidocaine, Epinephrine, Tetracaine) is ideal because it provides anesthesia and vasoconstriction. Cocaine pledgets (less common). Tranexamic acid (TXA). Oxymetazoline (Afrin). Cautery (Chemical): If an anterior bleed is visualized, silver nitrate can be applied for cauterization 3. Technique Tips Use a nasal speculum. Spread up and down rather than side to side to avoid injury to the septum. Place LET-soaked gauze in the nares. Apply a nasal clamp for ~15 minutes to compress the vessels. Note that pledgets may cause upper lip numbness 4. Reassessment After 15 minutes, remove materials and inspect for a source of bleeding. If still bleeding and a source is identified, cauterize the site. Observe for 15 minutes to monitor for recurrence of bleeding. 5. Packing If the above measures fail to control bleeding: Anterior packing: Nasal tampon (Merocel) Convenient for outpatient removal. Balloon device Inflate the anterior balloon for compression. Posterior packing: More complex, should consult ENT for additional assistance. 6. Disposition & Follow-Up Although rare, toxic shock syndrome is a possible complication of nasal packing. Antibiotic prophylaxis is controversial, but may be considered in high-risk patients. Outpatient follow-up if stable: Tampon: The patient can remove it at home. Balloon: Return to ED for removal. 7. Risk Factors for Epistaxis & Prevention Advise on humidifier use, nasal saline, and medication review to minimize future episodes. References: Tunkel DE, Anne S, Payne SC, et al. Clinical Practice Guideline: Nosebleed (Epistaxis). Otolaryngology–Head and Neck Surgery. 2020;162(1_suppl):S1-S38. doi:10.1177/0194599819890327 Summarized by Ashley Lyons, OMS3 | Edited by Ashley Lyons and Jorge Chalit, OMS4 Donate: https://emergencymedicalminute.org/donate/

Contributor: Travis Barlock, MD Educational Pearls: What are some of the key considerations in electrical burns? What are the treatment considerations for patients who suffer electrical burns? Clinical Pearl on Voltage and Current: References Summarized by Dan Orbidan, OMS2 | Edited by Dan Orbidan and Jorge Chalit, OMS4 Donate: https://emergencymedicalminute.org/donate

Contributors: Preeya Prakash MD, Adam Greenhaw PharmD, Travis Barlock MD, and Jeffrey Olson MS4 In this episode, cardiologist Preeya Prakash and medical student Jeffrey Olson listen in as two cases are presented from EMM's recent event, Tox Talk 2025. Talk 1- Digoxin Overdose Dr. Adam Greenhaw presents a case of a Digoxin overdose along with many pearls. During the studio listen in, Dr. Prakash helps to answer the questions of: How does digoxin work? Why might a patient still be on digoxin in 2025? What are the EKG findings of digoxin toxicity? Is there any utility in atropine for bradycardia caused by digoxin? Should you use calcium to treat hyperkalemia in the setting of a digoxin overdose? If/when might a cardiologist get involved in a patient with a digoxin overdose? Talk 2- Propranolol Overdose Dr. Travis Barlock presents a case of a beta blocker overdose as well as many associated pearls. During our studio listen in, Dr. Prakash helps to answer the questions of: What are the different beta blockers and how do they work? If you are worried about a propranolol overdose, what medications do you want on hand? What POCUS cardiac view can give you the most information for different scenarios? Why or why not might transcutaneous or intravenous pacing be a good idea for a beta blocker overdose? If/when might you want a cardiologist to get involved in a patient with a beta blocker overdose? References Alahmed AA, Lauffenburger JC, Vaduganathan M, Aldemerdash A, Ting C, Fatani N, Fanikos J, Buckley LF. Contemporary Trends in the Use of and Expenditures on Digoxin in the United States. Am J Cardiovasc Drugs. 2022 Sep;22(5):567-575. doi: 10.1007/s40256-022-00540-x. Epub 2022 Jun 24. PMID: 35739347; PMCID: PMC10263277. Chan BS, Buckley NA. Digoxin-specific antibody fragments in the treatment of digoxin toxicity. Clin Toxicol (Phila). 2014 Sep-Oct;52(8):824-36. doi: 10.3109/15563650.2014.943907. Epub 2014 Aug 4. PMID: 25089630. Hack JB, Wingate S, Zolty R, Rich MW, Hauptman PJ. Expert Consensus on the Diagnosis and Management of Digoxin Toxicity. Am J Med. 2025 Jan;138(1):25-33.e14. doi: 10.1016/j.amjmed.2024.08.018. Epub 2024 Sep 11. PMID: 39265879. Krenz JR, Kaakeh Y. An Overview of Hyperinsulinemic-Euglycemic Therapy in Calcium Channel Blocker and β-blocker Overdose. Pharmacotherapy. 2018 Nov;38(11):1130-1142. doi: 10.1002/phar.2177. Epub 2018 Oct 4. PMID: 30141827. Patocka J, Nepovimova E, Wu W, Kuca K. Digoxin: Pharmacology and toxicology-A review. Environ Toxicol Pharmacol. 2020 Oct;79:103400. doi: 10.1016/j.etap.2020.103400. Epub 2020 May 7. PMID: 32464466. Rotella JA, Greene SL, Koutsogiannis Z, Graudins A, Hung Leang Y, Kuan K, Baxter H, Bourke E, Wong A. Treatment for beta-blocker poisoning: a systematic review. Clin Toxicol (Phila). 2020 Oct;58(10):943-983. doi: 10.1080/15563650.2020.1752918. Epub 2020 Apr 20. PMID: 32310006. Produced by Jeffrey Olson, MS4 Donate: https://emergencymedicalminute.org/donate/

Contributor: Aaron Lessen, MD Educational Pearls: Traumatic Brain Injuries are a frequent complaint in the Emergency Department and have increased in recent years. The American Association for Surgery of Trauma (AAST) has created Brain Injury Guidelines (BIG), in an attempt to categorize brain injuries and the level of treatment they require. They are… BIG 1 BIG 2 BIG 3 References Summarized by Jeffrey Olson, MS4 | Edited by Jeffrey Olson and Jorge Chalit, OMS4 Donate: https://emergencymedicalminute.org/donate/

Contributor: Taylor Lynch, MD Educational Pearls: References Summarized by Meg Joyce, MS2 | Edited by Meg Joyce & Jorge Chalit, OMS4 Donate: https://emergencymedicalminute.org/donate/

Contributor: Taylor Lynch, MD Educational Pearls: References Summarized and Edited by Jorge Chalit, OMS4 Donate: https://emergencymedicalminute.org/donate/

Contributor: Aaron Lessen, MD Educational Pearls: The cause of Alzheimer’s disease is multifactorial, but the most widely suspected mechanism is the amyloid cascade hypothesis: In recent years, advances have led to the development of targeted therapies with monoclonal antibodies. These drugs: For patients presenting to the emergency department with stroke-like symptoms, it is important to consider whether they have a history of Alzheimer’s disease and whether they are taking these medications. References Summarized by Ashley Lyons, OMS3 | Edited by Ashley Lyons and Jorge Chalit, OMS4 Donate: https://emergencymedicalminute.org/donate/

Contributor: Alec Coston, MD Case Report Summary: A 17-year-old female involved in a motor vehicle collision presented to a rural emergency facility via personally operated vehicle. During workup and initial CT scan, the patient began rapidly decompensating with CT revealing a 1.5cm epidural hematoma with 7mm of midline shift. The patient went from being able to walk and talk to being obtunded with a blown left pupil and unresponsive. Following intubation, the patient was being prepared for transport but potential delays required immediate emergency evacuation of the hematoma via a Burr Hole. A traditional Burr Drill was not immediately available at the facility, so an improvised Burr Drill using an Intraosseous (IO) drill was used. 35mL of blood was removed from the hematoma and the patient immediately improved from a GCS of 3 to GCS of 8. The patient was transferred to a higher level of care facility, extubated the following day, and made a full neurological recovery. Educational Pearls: What is an epidural hematoma? What are typical intracranial pressures and at what levels do they become pathologic? What is the takeaway in timing of epidural hematomas? References Summarized by Dan Orbidan, OMS2 | Edited by Dan Orbidan and Jorge Chalit, OMS4 Donate: https://emergencymedicalminute.org/donate/

Contributor: Aaron Lessen, MD Educational Pearls: What is a Nursemaid's Elbow? How are they identified? Treatment? Which is better? References Summarized by Jeffrey Olson, MS4 | Edited by Jeffrey Olson and Jorge Chalit, OMS4 Donate: https://emergencymedicalminute.org/donate/

Contributor: Ricky Dhaliwal, MD Educational Pearls: References Summarized by Meg Joyce, MS2 | Edited by Meg Joyce & Jorge Chalit, OMS4 Donate: https://emergencymedicalminute.org/donate/

Contributors: Travis Barlock MD, Jeffrey Olson MS4 Feel free to use the cases below for your own practice. All of the scenarios are completely made up and designed to hit several teaching points. Case 1 25 M, presents to the ED with chest pain. Stabbing, started a few hours ago, substernal. Thinks it is GERD. After 2-3 minutes, pain worsens and radiates to the back. VS: BP 125/50 (Right arm 190/110). HR 120. RR of 18. Sat 98% on RA. Additional VS: Temp of 37.2, height of 6’5”, BMI of 18. PMH: None, doesn’t see a doctor. Meds: None FH: Weird heart thing (Mitral Valve Prolapse), weird lung thing (spontaneous pneumothorax), tall family members with long fingers and toes Physical Exam: Cards: Diastolic decrescendo at the RUSB, diminished S2. UE pulses are asymmetric, LE pulses are asymmetric, carotid pulses are asymmetric, BP is asymmetric MSK: Knees, elbows, and wrists are hypermobile. Imaging: CXR #1 normal, #2 widened mediastinum (no read yet but shows widened mediastinum), POCUS shows small effusion CTA/MRA doesn’t come back until after the case. ECG: Sinus Tach Labs: NT-proBNP 500 pg/mL D-Dimer: 7000 ng/L CBC: Hemoglobin: 13.5 g/dL, WBC: 20,000/µL, Platelets: 250,000/µL Chem 7: Na 138, K, 5.7, Cl 102, Bicarb 17, BUN 45, Creatinine: 3.5 mg/dL, Glucose: 180 LFTs: Albumin 2.4, Total protein 5.5, ALP: 140, AST: 3500, ALT: 2800, TBili: 3.2, DirectBili: 2.4, Ca: 7.8 LDH: 2200 PT: 20.5, INR: 2.2, Fibrinogen: 170 5th gen High-Sensitivity Troponin: <3 Lactate: 7 mmol/L VBG: pH 7.22, paCO2 28, bicarb 15 Notes: Can have patient crash somewhere in middle and show 2nd xray Case 2: A 67-year-old female is brought to the ED by her daughter due to progressive weakness, confusion, and fatigue that have worsened over the past week. Unable to get out of bed and has become increasingly lethargic. Also having some nausea, constipation. The daughter denies any preceding illness, recent trauma, or travel. Does not know her meds but will head home to get them after talking with you. VS: BP 88/55 mmHg, HR 110, RR 20, O2 Sat 98% on room air. Additional VS: Temp 36.8°C. PMH: Hypertension, osteoarthritis, and depression. Physical exam: General: Thin, somnolent but arousable. HENT: Dry mucous membranes Neuro: Confused, A&Ox1 (self), hyporeflexia Labs (Includes many that would not return in the ED in case you want to take this case forward to the floor) CBC: WBC 9,500, Hb 16.5, Hct: 50%, Platelets 220,000 Chem7: Na 129, K 2.1, Cl 95, HCO3 34, Creatinine 1.6, BUN 40, Glucose 115 LFTs: normal Magnesium: 1.1 Calcium: 10.8 mg/dL (corrects to 12.8) iCal: 3.2 Phosphate: 2.3 mg/dL Albumin: 2 BUN:Cr ratio: 25 VBG: pH: 7.49, PaCO2 45, HCO3: 34 Lactate: 2.8 Serum Osmolality: 276 mOsm/kg (Osmolal gap of 2) Urine Osmolality: 550 mOsm/kg Urine Sodium (UNa): 10 mEq/L (low). Urine Potassium (UK): 25 mEq/L (elevated). Urine Chloride (UCl): 12 mEq/L (low). Urine Magnesium (UMg): 20 (Elevated). Urine Calcium (UCa): 50 in 24 hrs (Low) 100 cc of urine with foley FeNa <1% Plasma renin activity: 15 mg/mL/hr (elevated), Aldosterone: 25 ng/dL (Elevated), ADH: Elevated, Diuretic screen: Positive for thiazides PTH: 8 (low), HsTrop: 32, Cortisol and ACTH: Normal. EKG: Hypokalemia features CXR: Normal Renal US: shows stones Improves with fluids Note: Can have daughter return with med list at some point including HCTZ, ibuprofen, and sertraline Case 3: Patient Presentation EMS Report: A 27-year-old male involved in a high-speed motorcycle collision is brought to the emergency department by EMS. The patient was found unconscious at the scene with evidence of severe thoracic and extremity trauma. He was intubated en route for airway protection due to altered mental status (GCS 7). VS: HR 130, BP 90/60, RR: bagging at 12 bpm, satting 88% on 100% FiO2 Primary Survey Airway: Endotracheal tube in place. Breathing: Decreased breath sounds on the left side with visible chest asymmetry and paradoxical chest wall...

Contributor: Travis Barlock MD Educational Pearls: References Summarized & Edited by Jorge Chalit, OMS4 Get your tickets to Tox Talks Event, Sept 11, 2025: https://emergencymedicalminute.org/events-2/ Donate: https://emergencymedicalminute.org/donate/

Contributor: Alec Coston, MD Educational Pearls: References: Summarized by Ashley Lyons, OMS3 | Edited by Ashley Lyons & Jorge Chalit, OMS4 Get your tickets to Tox Talks Event, Sept 11, 2025: https://emergencymedicalminute.org/events-2/ Donate: https://emergencymedicalminute.org/donate/

Contributor: Taylor Lynch, MD Educational Pearls: What is atrial fibrillation with rapid ventricular response (AFib with RVR) and how does it differ from atrial fibrillation (AFib)? What is the treatment for AFib with RVR? Why pretreat patients receiving Diltiazem for AFib with RVR with calcium? Key takeaways? References Summarized by Dan Orbidan, OMS2 | Edited by Dan Orbidan and Jorge Chalit, OMS4 Get your tickets to Tox Talks Event, Sept 11, 2025: https://emergencymedicalminute.org/events-2/ Donate: https://emergencymedicalminute.org/donate/

Contributor: Aaron Lessen, MD Educational Pearls: Recorded March 2025 What is the best treatment for a fever? Tylenol? Ibuprofen? Combined? Alternating the two? What dose should I use? References Summarized by Jeffrey Olson, MS4 | Edited by Jeffrey Olson and Jorge Chalit, OMS4 Get your tickets to Tox Talks Event, Sept 11, 2025: https://emergencymedicalminute.org/events-2/ Donate: https://emergencymedicalminute.org/donate/

Contributor: Aaron Lessen, MD Educational Pearls: References Summarized by Meg Joyce, MS2 | Edited by Meg Joyce & Jorge Chalit, OMS4 Donate: https://emergencymedicalminute.org/donate/

Contributor: Megan Hurley MD Educational Pearls: Acute toxicity of heavy metals: Chronic toxicity of heavy metals: Four heavy metals that are tested for in a general panel and their sources: Management of heavy metal toxicity depends on the intoxicant References Summarized & Edited by Jorge Chalit, OMS4 Donate: https://emergencymedicalminute.org/donate/

Contributor: Taylor Lynch, MD Educational Pearls: Dilutional Hyponatremia: Commonly seen in DKA: Corrected sodium calculation: Use tools like MDCALC, or apply this formula: Clinical relevance: References: Summarized by Ashley Lyons, OMS3 | Edited by Ashley Lyons & Jorge Chalit, OMS4 Donate: https://emergencymedicalminute.org/donate/