Podcast #184: Frostbite

Run Time: 3 minutes

Author: Michael Hunt M.D.

Educational Pearls:

• Frostbite injuries are graded by the severity of tissue depth.
• A Grade 1 injury has no cyanosis of the tissue, and usually just redness is present.
• A Grade 2 injury has acral cyanosis.
• A Grade 3 injury has cyanosis past the mid phalanx of the digits, resulting in a high chance of amputation.
• A Grade 4 injury has cyanosis beyond metacarpal/metatarsal phalangeal joints, and almost certain amputation.
• Treatment for frostbite is gradual rewarming in water of 100-104 degrees fahrenheit. If a patient has injuries to all 4 extremities the entire patient can be placed into a warm bath.
• It is suggested that IV or intra arterial tPA can also be used to improve salvage of the digits because ice crystals form in the tissues when frostbite occurs, and when the patient is rewarmed they can be subjected to clotting.
• The tPA must be started within 24hrs of rewarming – the time that the patient suffered the frostbite injury is not as important.

Link to Podcast: http://medicalminute.madewithopinion.com/frostbite/

References: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3440898/

Podcast #176: Football Injuries

Run Time:  4 minutes

Author: Michael Hunt M.D.

Educational Pearls:

• Stinger – a stretch of cervical nerves from a lateral blow to the head and causes immediate pain and numbness in the arm. There is no specific treatment, and symptoms last seconds to minutes or as long as a few days. A small percentage of stingers result in significant neurologic damage.
• Hip pointer – a contusion of the pelvis most commonly at the iliac crest.
• Sports hernia – a soft tissue injury (muscle, ligament, tendon) that is torn or damaged in the groin or pelvic area. Some more serious tears may require surgery.
• Turf toe – hyperextension of the great toe that puts stress on MTP joint and causes a strain or sprain of the tendons. Categorized into grades 1, 2, & 3 based on severity from least serious to most serious.

Link to Podcast: http://medicalminute.madewithopinion.com/football-injuries/

References: http://www.stopsportsinjuries.org/STOP/Prevent_Injuries/Football_Skating_Injury_Prevention.aspx

Podcast #170: Spice

Run Time:  2 minutes

Author: John Winkler M.D.

Educational Pearls:

• There are multiple synthetic marijuana alternatives that causes more amphetamine reaction. Known as Spice, K2, and many other names, they are made by changing the side branches of THC.
• An overdose can cause a spectrum of reactions from general agitation to severe excited delirium to death.
• Patients present physiologically with tachycardia, elevated blood pressure, elevated temperature, psychosis, and severe agitation.
• It is important to make sure that the patient is kept calm and safe with multiple doses of sedating medication, end tidal CO2, and airway protection.
• In New York City on 7/13/16 33 people had a suspected overdose on synthetic marijuana.
• To make a synthetic marijuana illegal the exact chemical structure needs to be presented to the legislature, and can sometimes take up to 1 year. However, the frequency of changes in the chemical structure of synthetic marijuana hard to keep illegal.

Link to Podcast: http://medicalminute.madewithopinion.com/spice/

References: https://www.drugabuse.gov/publications/drugfacts/synthetic-cannabinoids

http://www.nytimes.com/2016/07/13/nyregion/k2-synthetic-marijuana-overdose-in-brooklyn.html?_r=0

Podcast #169: Lyme Disease

Run Time:  7 minutes

Author: Greg Burcham M.D.

Educational Pearls:

• Case presentation: A 48 year-old male cyclist travels to new england for a race. Afterwards he is sore, tired and fatigued, but 1 week later back in Colorado he is still sore, tired, and fatigued, and he also noticed a rash that started after a few days. The patient presents to the ED after a syncope with HR in the low 40s.
• This patient has Lyme Disease. Hallmarked by the rash that he has, known as erythema migrans – a migrating red rash.
• Symptoms usually present 1-2 weeks after a tick bite, and generally start as nonspecific – fever, myalgias, headache, arthralgias, malaise. 80% of patients present with the rash that starts as a small red lesion that enlarges with a bright red border.
• A smaller percentage of patient get early disseminated disease. The most concerning complications are cardiac – Atrioventricular Block, bradycardia, and syncope – or a meningitis presentation.
• Late disseminated findings include chronic joint and muscle arthralgias, seizures, paresthesias, memory and cognitive changes. Amy Tan – author of The Joy Luck Club – has chronic lyme and she loses memory if she is off her antibiotics for any period of time.
• Lyme Disease is increasing by more than 10% per year for several years due to the destruction of habitat of predators, leading to mice population explosion, and global warming.
• Each stage of the tick life cycle require a blood meal – larva to nymph to adult. Normally larva find it hard to get a blood meal in the fall after they hatch in the late summer. The larva go dormant until spring when they are able to find a blood meal and eventually become adults so the life cycle can start over on an annual basis.
• As the climate has warmed a higher percentage of larvae are feeding earlier in the year, with a greater frequency in the New England area.
• The bacteria that causes Lyme Disease needs time to replicate in the host, but due to asynchronous feeding between the mice and ticks there is a higher concentration of the bacteria in both the mice and the ticks.

Link to Podcast: http://medicalminute.madewithopinion.com/lyme-disease/

References: http://rstb.royalsocietypublishing.org/content/370/1665/20140051

https://www.cdc.gov/lyme/

Podcast #141: Heat Stroke

Run Time: 4 minutes

Author: Nicholas Hatch M.D.

Educational Pearls:

• It is possible to acclimatize to heat, however it takes approximately 2-3 weeks.
• Never give tylenol for a heat related illness and heat related hyperthermia, it is not helpful.
• Heat rash: most common in kids. Lotion should not be used because it blocks the ducts of the skin and can cause irritation and inflammation. The rash, which resembles a sunburn, is the body compensating for the increased heat by vasodilating blood vessels to get blood to the periphery and cool it off.
• Muscle cramps: Especially in major muscle groups, oral hydration often enough, but the patient will need more than just water. Patients require an electrolyte based solutions like gatorade.
• Heat syncope: characterized by passing out and returning to a normal level of consciousness and normal temperature. Patients potential can have a temperature up  to 104° Fahrenheit with mild brief altered mental status, but nothing significant.
• Heat stroke: characterized by major altered mental status, temperature above 104, deceased perspiration, nausea, vomiting, and other end organ dysfunction. This is a life threatening emergency. If a patient says that they have “heat stroke” they probably do not…these people are usually sick as stink.
• Hydration and rapid cooling are the treatment that should be initiated for heat stroke – undressing the patient and misting with a fan, ice packs applied to the groin and axilla, and chest tube and lavage or bladder irrigation w/ ice cold water are the hallmarks of therapy. .

Link to Podcast: http://medicalminute.madewithopinion.com/heat-stroke/

References: https://medlineplus.gov/ency/article/000056.htm

Podcast #129: SIPE

Run Time: 4 minutes

Author: Suzanne Chilton M.D.

Educational Pearls:

• SIPE or SWIPE stands for Swimming Induced Pulmonary Edema and usually occurs in young people without previous pulmonary problems or CHF.
• Happens more often in cold water, and could be a combination of increased cardiac output, increased permeability of capillary bed and increased pressure in capillary bed.
• Presents either during the swim or after the swim – most patients will be hypoxic and have to be pulled out of the water. Patients will have rales and can have hemoptysis.
• Treatment is symptomatic, most episodes resolve in 12-24 hours, but patients have an increased risk of recurrence in the future.
• Another swimming related issue is shallow water syncope – which happens in people who are extremely good swimmers.
• Generally happens when the patient is trying to hold their breath underwater for a long period of time.
• Hypercarbia is what causes the urge to breath, and good swimmers can resist this urge. Up to the point that they suddenly become hypoxic, lose consciousness, and may drown.

Link to Podcast: http://medicalminute.madewithopinion.com/sipe/

References:  http://www.endurancetriathletes.com/sipe.html

http://ndpa.org/loss-of-consciousness-in-breath-holding-swimmers/

Brew-Cast #1: Do Opioids Cause Chronic Pain?

PRESENTING THE EMERGENCY MEDICAL MINUTE BREW-CAST SERIES!Run Time: 20 minutes

Author: Don Stader M.D

Educational Pearls: 

• Don speaks with University of Colorado Dr. Peter Grace, a pain researcher. His paper: “Morphine paradoxically prolongs neuropathic pain in rats by amplifying spinal NLRP3 inflammasone activation” – suggests that morphine increases / causes chronic pain
• In this study rats were given nerve injuries – a group was given morphine to treat the pain. the other no morphine. The rats receiving morphine had significant negative effects – with longer duration of pain and hypersensitization! In papers words – “This study predicts that prolonged pain is an unrealized and clinically concerning consequence of the abundant use of opioids in chronic pain:”
• Interestingly – opioids seems to cause immunosupression in the peripheral nervous system and blood stream, but in the spinal cord cause inflammation. This changes spinal cord physiology and makes nerves hypersensitive to pain
• Interesting – and from some of Peters’ other studies – exercise both before an after nerve injury can reduce pain and how rats interpret pain can be transferred from rat to rat by transferring spleen cells.
• In other studies – IL-10 (an anti-inflammatory immuno-modulator) has been injected into rats and dog joints – and helps reduce pain from arthritis and other injuries.
• Peter & other pain researchers foresee a world where we treat the underlying inflammation and pathophysiologic changes that cause pain – rather than trying to mask it with potentially dangerous agents such as opioids.
• This is yet another reason to exercise caution with opioids – they are bad Ju-Ju!!

Link to Podcast: http://medicalminute.madewithopinion.com/do-opioids-cause-chronic-pain/#

References: A direct link to Peter’s article!

Podcast #124: Nets and Malaria

Run Time: 4 minutes

Author: Eric Miller M.D.

Educational Pearls:

• The WHO in 2000, set a goal of reversing incidence of mosquito deaths by 2015.
• One billion insecticide coated nets were given for free in areas of high malarial incidence in Africa. Each net costs 2-3 dollars.
• In 2000, there were 1 million deaths due to malaria per year. In 2015, there were about 400,000 deaths due to malaria per year showing a 60% decrease in deaths.
• From 2000 to 2015 the incidence of new malaria infections also decreased from 200 million new cases to 50-60 million new cases of malaria.
• While this was a great success in terms of decreasing death and incidence of mortality there are unintended consequences.  In communities by water, 87-90% of the nets distributed are being used for fishing. This causes issue as the insecticide on the nets are being directly introduced into the water sources.  As a result malaria rates in fish have also decreased precipitously but the fish all taste like “OFF!” (just kidding…pesticides and fish shouldn’t mix).  

Link to Podcast: http://medicalminute.madewithopinion.com/nets-and-malaria/

References: http://www.nytimes.com/2015/01/25/world/africa/mosquito-nets-for-malaria-spawn-new-epidemic-overfishing.html?_r=0

Podcast #123: Pediatric Oral Rehydration Therapy

Run Time: 3 minutes

Author: Christopher Holmes M.D.

Educational Pearls:

• For children with mild gastroenteritis, one option for treatment is oral rehydration therapy. This is ubiquitously used for children in third world countries as a staple therapy.
• A group in Canada, looked at 647 patients. Half were given half strength apple juice and half were given electrolyte solutions for treatment. The therapy was considered a failure if the patients had to – get an IV in 7 days, had greater than 3% dehydration, had an unscheduled visit, or were admitted to the hospital within 7 days.
• They found 16.5% of patient’s therapy failed with the half strength apple juice and 25% of patient’s therapy failed with the electrolyte solution.
• While the electrolyte solution is theoretically superior for rehydration, it tastes significantly worse than the half strength apple juice. This could possibly lead to less fluids consumed and less hydration for the patient.
• Half strength apple juice represents a great and potentially more efficacious alternative to electrolyte solutions in some pediatric populations.

Link to Podcast: http://medicalminute.madewithopinion.com/pediatric-oral-rehydration-therapy/

References:  http://www.ncbi.nlm.nih.gov/pubmed/27131100

Podcast #106: An Update on Zika

Run Time: 4 minutes

Author: Mark Kozlowski M.D.

Educational Pearls:

• Zika is a virus that has been around for about 50 years, but became a public concern last year.
• Most people who contract Zika are asymptomatic, but sometimes people will develop flu-like symptoms including fever, rash, and joint pain. Women who are pregnant and contract the Zika virus can have pregnancy complications including microcephaly and hydrocephalus. In rare cases, Zika has also been linked to Guillain-Barre Syndrome.
• Zika is transmitted through mosquitos, but it can also be transmitted through sexual intercourse. People who develop flu-like symptoms after travel to Zika endemic areas, women who are pregnant and have had travel to areas with Zika in the last 12 weeks, and anyone who has had unprotected sexual intercourse with someone who has been exposed to Zika or who has traveled recently to an area with Zika should be tested.
• For Zika, PCR testing is available from the state and is accompanied by a blood and urine test. You can also have testing done of amniotic fluid or CSF to determine if you have contracted Zika.

Link to Podcast:  http://medicalminute.madewithopinion.com/an-update-on-zika/

References: https://www.cdc.gov/zika/