In this podcast, we are back again with host, Jordan Ourada, and neurosurgeon, Dr. Eddie Tsvankin as they discuss an exciting and mind-blowing array of topics pertaining to neurosurgery. Listen as Dr. Tsvankin shares his views on not only the history of neurosurgery, but also the medical, surgical, and engineering advancements that are taking place today. You’ll also hear Dr. Tsvankin give intriguing details into how neurosurgeries are performed with cutting-edge technology including the exoscopes that are presently utilized at Swedish Medical Center. Finally, Jordan and Dr. Tsvankin delve into predictions for future advancements in neurosurgery and neurooncology, as well as why cancer seems more prevalent today than ever.  The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at https://emergencymedicalminute.org/cme-courses/ and create an account.  Donate to EMM today! Diversity and Inclusion Award

Emergency Medical Minute

On the Streets #12: Salient Pre-hospital Considerations for Neurosurgical Emergencies - a Smorgasbord Part II

Contributor: Donald Stader, MD Educational Pearls: Hip Dislocation Prolonged dislocations can impair blood supply to femoral head Hip dislocation for >6 hours puts patient at high risk for needing a hip replacement in the next two year Knee Dislocation High mechanism Often looks anatomically normal on knee x-ray Vascular injuries of the popliteal artery can cause significant morbidity with some studies suggesting an 80% amputation rate if not treated within 6 hours Ankle Dislocation Common dislocation and often co-occurs with ankle fractures (bimalleolar/trimalleolar) Pressure on the skin from the displaced joint can cause skin tenting, which can lead to skin necrosis Hematoma blocks work well for ankle reductions as an adjunct to or substitute for procedural sedation References Arnold C, Fayos Z, Bruner D, Arnold D. Managing dislocations of the hip, knee, and ankle in the emergency department. Emerg Med Pract. 2017;19(12):1-28. Dawson-Amoah K, Raszewski J, Duplantier N, Waddell BS. Dislocation of the Hip: A Review of Types, Causes, and Treatment. Ochsner J. 2018;18(3):242-252. doi:10.31486/toj.17.0079 Patterson BM, Agel J, Swiontkowski MF, Mackenzie EJ, Bosse MJ; LEAP Study Group. Knee dislocations with vascular injury: outcomes in the Lower Extremity Assessment Project (LEAP) Study. J Trauma. 2007;63(4):855-858. doi:10.1097/TA.0b013e31806915a7 Ross A, Catanzariti AR, Mendicino RW. The hematoma block: a simple, effective technique for closed reduction of ankle fracture dislocations. J Foot Ankle Surg. 2011;50(4):507-509. doi:10.1053/j.jfas.2011.04.037 Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD 

Podcast 722: Lower Extremity Dislocations

Contributor: Dylan Luyten, MD Educational Pearls: To place a Blakemore/Minnesota Tube: Insert into esophagus under visualization Inflate gastric port with 60 cc of air and obtain a chest xray to ensure the balloon below the diaphragm Once confirmed, place a total of 500cc of air into the gastric balloon via the gastric port Tie a liter saline bad to the tube using Kerlix and hang it off an IV pole or other object to provide about 2 lbs of traction Now the the tube is in place under traction, attach a manometer to the esophageal balloon port Provide low pressure to tamponade a variceal bleed, which is about 33 mmHg This is a temporizing measure and often patients need to get a Transjugular Intrahepatic Portosystemic Shunt (TIPS) from interventional radiology for more definitive treatment References Powell M, Journey JD. Sengstaken-Blakemore Tube. [Updated 2021 Jul 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK558924/ Amazing video of placement by EM:RAP ProductionsPlacement of a Minnesota Tube for Bleeding Varices Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD   The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at https://emergencymedicalminute.org/cme-courses/ and create an account.  Donate to EMM today! 

Podcast 721: Blakemore & Minnesota Tubes: Part II

On this episode of On The Streets, host, Jordan Ourada sits down with neurosurgeon/neurooncologist Dr. Eddie Tsvankin to discuss various topics concerning neurosurgery and how EMS workers in the field can better understand and manage neurological emergencies. In this episode specifically, you’ll hear Jordan and Dr. Tsvankin discuss topics including: Priorities in caring for patients experiencing seizures Short and long-term complications of tumor resection surgery Specifics on how brain tumors are operated on and the difficult decisions that must be made ahead of time Assessment of post-operative incisions and signs of infections How chemotherapy and radiation effect the healing process for neurosurgery patients Dr. Eddie’s thoughts on COVID and how it has impacted his career The ins and outs of ventriculoperitoneal shunts The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at https://emergencymedicalminute.org/cme-courses/ and create an account.  Donate to EMM today! Diversity and Inclusion Award

On the Streets #11: Salient Pre-hospital Considerations for Neurosurgical Emergencies - a Smorgasbord

Contributor: Dylan Luyten, MD Educational Pearls: Minnesota Tube has an extra port for suctioning otherwise is the same as a Blakemore Tube Indicated in MASSIVE upper GI bleeding often due to esophageal varices Esophageal varices are dilated, tortuous vessels in the esophagus due to increased portal venous pressure that can bleeding into the upper GI tract Patients with massive upper GI bleed should be intubated prior to placing a Blakemore/Minnesota tube References Meseeha M, Attia M. Esophageal Varices. [Updated 2021 Aug 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448078/ Biecker E. Portal hypertension and gastrointestinal bleeding: diagnosis, prevention and management. World J Gastroenterol. 2013;19(31):5035-5050. doi:10.3748/wjg.v19.i31.5035 Powell M, Journey JD. Sengstaken-Blakemore Tube. [Updated 2021 Jul 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK558924/ Photo from Wikimedia Commons Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD   The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at https://emergencymedicalminute.org/cme-courses/ and create an account.  Donate to EMM today! Check out our Diversity and Inclusion Award

Podcast 720: Blakemore & Minnesota Tubes: Part I

Contributor: Ricky Dhaliwal, MD Educational Pearls: Multiple RCTs and a Cochrane Review found there is no difference in wound infection rates when irrigating with tap water  Pressure of the water and how extensively the wound is irrigated were the most important factors affecting infection rates Quantity and type of water were independently not as important References Fernandez R, Griffiths R. Water for wound cleansing. Cochrane Database Syst Rev. 2012;(2):CD003861. Published 2012 Feb 15. doi:10.1002/14651858.CD003861.pub3 Lewis K, Pay JL. Wound Irrigation. [Updated 2021 Jun 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK538522/ Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD   The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at https://emergencymedicalminute.org/cme-courses/ and create an account.  Donate to EMM today! 

Podcast 719: Normal Saline vs. Tap Water for Wound Irrigation

Contributor: Aaron Lessen, MD Educational Pearls: Patients with acute renal failure often need medical management for hyperkalemia Those with severe electrolyte derangements or absent renal function may need emergent dialysis as well Dialysis catheters are 12 or 14 french catheters placed in the right internal jugular or left subclavian Placement is very similar to a central line or cordis catheter Trialysis catheter is one option that has an extra port that can be used for regular medication administration and drawing blood Do not default to use dialysis catheters for normal ED access due to risk of infection and clot development While dialysis catheters are typically reserved for dialysis only, they can be used in extreme circumstances, such as a cardiac arrest References Co I, Gunnerson K. Emergency Department Management of Acute Kidney Injury, Electrolyte Abnormalities, and Renal Replacement Therapy in the Critically Ill. Emerg Med Clin North Am. 2019;37(3):459-471. doi:10.1016/j.emc.2019.04.006 Simon LV, Hashmi MF, Farrell MW. Hyperkalemia. [Updated 2021 Aug 14]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470284/ Akaraborworn O. A review in emergency central venous catheterization. Chin J Traumatol. 2017;20(3):137-140. doi:10.1016/j.cjtee.2017.03.003 Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD   The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at https://emergencymedicalminute.org/cme-courses/ and create an account.  Donate to EMM today! 

Podcast 718: Renal Failure Follow Up

Contributor: Aaron Lessen, MD Educational Pearls: Hyperkalemia can cause EKG changes such as a widened QRS The fastest electrolyte results can be obtained off a VBG with electrolytes  or point-of-care labs Hyperkalemia may be reported as “hemolyzed” which indicated lysis of red blood cells and artificial elevation of the potassium level. However, always keep in mind the clinical context and look at other metabolic abnormalities like creatinine and BUN for other clues that it may actually not be hemolyzed References Co I, Gunnerson K. Emergency Department Management of Acute Kidney Injury, Electrolyte Abnormalities, and Renal Replacement Therapy in the Critically Ill. Emerg Med Clin North Am. 2019;37(3):459-471. doi:10.1016/j.emc.2019.04.006 Simon LV, Hashmi MF, Farrell MW. Hyperkalemia. [Updated 2021 Aug 14]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470284/ Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD   The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at https://emergencymedicalminute.org/cme-courses/ and create an account.  Donate to EMM today! 

Podcast 717: A cautionary tale of renal failure

Contributor: Nick Tsipis, MD Educational Pearls: Fluid choice may have an impact on outcomes in resuscitation, and a meta-analysis has relevant insight into their use in sepsis and trauma patients Large volume normal saline fluid resuscitation in sepsis is associated with acute kidney injury and metabolic acidosis compared to Lactated Ringers Choice of fluid did not have significant differences in trauma patients for initial resuscitation References Tseng CH, Chen TT, Wu MY, Chan MC, Shih MC, Tu YK. Resuscitation fluid types in sepsis, surgical, and trauma patients: a systematic review and sequential network meta-analyses. Crit Care. 2020;24(1):693. Published 2020 Dec 14. doi:10.1186/s13054-020-03419-y   The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at https://emergencymedicalminute.org/cme-courses/ and create an account.  Donate to EMM today!  

Podcast 716: Resuscitation Fluids

Contributor: Nick Hatch, MD Educational Pearls: High flow nasal cannula (HFNC) or “heated high flow” can deliver higher oxygen levels than nasal cannula It typically is used as an “intermediate” between oxygen via nasal cannula and other non-invasive positive pressure devices, such as BiPAP Can modify both the FiO2 and flow rate Maximum flow rate is typically  60 liters per minute (compare that to a typical breath that is 30-40 L/min) Humidification of HFNC is important due to risk of epistaxis from drying out the nasal mucosa Large energy expenditure to humidify airflow by a patient in respiratory distress, so humidified oxygen may help decrease this metabolic demand References Nishimura M. High-Flow Nasal Cannula Oxygen Therapy in Adults: Physiological Benefits, Indication, Clinical Benefits, and Adverse Effects. Respir Care. 2016;61(4):529-541. doi:10.4187/respcare.04577 Hacquin A, Perret M, Manckoundia P, et al. High-Flow Nasal Cannula Oxygenation in Older Patients with SARS-CoV-2-Related Acute Respiratory Failure. J Clin Med. 2021;10(16):3515. Published 2021 Aug 10. doi:10.3390/jcm10163515 Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD   The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at https://emergencymedicalminute.org/cme-courses/ and create an account.  Donate to EMM today! 

Podcast 715: Heated High Flow O2

Contributor: Aaron Lessen, MD Educational Pearls: Randomized controlled-trial evaluated intradermal injections of sterile water to manage low back pain versus an IV NSAID Four intradermal injections of 0.1 cc sterile water in a square around the area of musculoskeletal pain Reduction of pain was 7 points with the procedure and 2 points with the IV NSAID at 24 hours 12% in the injection group versus 50% in the IV NSAID group needed opioids 87% patient satisfaction in the injection group versus 16% patient satisfaction in the IV NSAID group References Tekin E, Gur A, Bayraktar M, Ozlu I, Celik BK. The effectiveness of intradermal sterile water injection for low back pain in the emergency department: A prospective, randomized controlled study. Am J Emerg Med. 2021;42:103-109. doi:10.1016/j.ajem.2021.01.038 Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD   The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at https://emergencymedicalminute.org/cme-courses/ and create an account.  Donate to EMM today! 

Podcast 714: Intradermal Sterile Water for Back Pain

Contributor: Don Stader, MD Educational Pearls: Those on chronic opioid therapy may have high tolerance to opioids and/or opioid hyperalgesia Ketamine is a good adjunct for pain control in patients on chronic opioid therapy To avoid the time constraints often required to push ketamine intravenously, it can be given orally: Ketamine IV 25-50 mg (~0.01-0.03 mg/kg) as a single dose by mouth References Blonk M, Koder B, et al. Use of oral ketamine in chronic pain management: A review. European Journal of Pain. 2009. Schwenk ES, et al. Consensus guidelines on the use of intravenous ketamine infusions for acute pain management from the America Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine and the American Society of Anesthesiologists. Reg Anesth Pain Med. 2018. Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD   The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at https://emergencymedicalminute.org/cme-courses/ and create an account.  Donate to EMM today! 

Podcast 713: Oral Ketamine

Contributor: Aaron Lessen, MD Educational Pearls: Retrospective cohort study in the Kaiser system looked at over 4 million patients receiving antibiotics to determine the effect of penicillin allergy prompts in the EHR on antibiotic prescribing Half of the sites removed prompts stating penicillin allergy and half kept the prompts Patients with penicillin allergies who received cephalosporins went up from 20% to 27% in areas where the prompt was remove No difference in mortality or no new allergies found between the two groups Reduced the use of fluoroquinolones and clindamycin in the group without the prompt References Macy E, McCormick TA, Adams JL, et al. Association Between Removal of a Warning Against Cephalosporin Use in Patients With Penicillin Allergy and Antibiotic Prescribing. JAMA Netw Open. 2021;4(4):e218367. Published 2021 Apr 1. doi:10.1001/jamanetworkopen.2021.8367 Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD   The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at https://emergencymedicalminute.org/cme-courses/ and create an account.  Donate to EMM today!

Podcast 712: Cephalosporin with a Penicillin Allergy

Dr. Glenda Quan, trauma surgeon from Swedish Medical Center joins our host Jordan Ourada to review a case of an incorrectly placed IO and how to avoid it. The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at https://emergencymedicalminute.org/cme-courses/ and create an account.

On the Streets #10: IO Administration Gone Awry

Contributor: Aaron Lessen, MD Educational Pearls: Insulin pumps provide a continuous infusion of fast-acting insulin using a basal rate and bolus prior to meals Some connect to a continuous glucometer but often blood glucose needs to be checked manually Hypoglycemia is rarely due to a malfunctioning pump - there is usually an another external factor Hyperglycemia can be caused by underdosing, illness, pump malfunction or expired insulin The pump can be used to give a bolus of insulin in the emergency department if necessary Stopping the  device can be done manually on the device or disconnecting it from the tubing attachment - do not remove the tubing from the skin site if possible References Nimri R, Nir J, Phillip M. Insulin Pump Therapy. Am J Ther. 2020;27(1):e30-e41. doi:10.1097/MJT.0000000000001097 Sora ND, Shashpal F, Bond EA, Jenkins AJ. Insulin Pumps: Review of Technological Advancement in Diabetes Management. Am J Med Sci. 2019;358(5):326-331. doi:10.1016/j.amjms.2019.08.008 Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD   The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at https://emergencymedicalminute.org/cme-courses/ and create an account.  Donate to EMM today! 

Podcast 711: Insulin Pumps

Our near daily podcasts move quickly to reflect current events, are inspired by real patient care, and speak to the true nature of what it’s like to work in the Emergency Room or Pre-Hospital Setting. Each medical minute is recorded in a real emergency department, by the emergency physician or clinical pharmacist on duty – the ER is our studio and everything is live.