Emergency Medical Minute

Contributor: Aaron Lessen, MD Educational Pearls: Febrile work-ups in the emergency department require obtaining a urine sample to assess for UTI. In non-toilet trained children, this often means using catheterization. Depending on the volume of urine in the bladder, there may not be enough present to get an adequate sample. Performing a bladder scan before catheterization may be helpful in determining if there is enough urine there in the first place to get a sample. A recent systematic review and meta-analysis of three randomized control trials found that performing a POCUS prior to catheterization in 337 children aged 36 months and younger led to higher success in obtaining a sample. The success of getting a sample on the first attempt increased from 72.5% to 89.7%. The rate of dry taps decreased from 23.9% to 3.6%. POCUS before catheterization is an easy tool providers can use to ensure an adequate first attempt and reduce unnecessary discomfort for the child. References: Vieira da Silva HF, Watanabe ET, Tavares MC, Ramos Bicalho AC, Ferraro LSD, Simões E Silva AC. Point-of-care ultrasound for pediatric urethral catheterization: a systematic review and meta-analysis of randomized controlled trials. Acad Emerg Med. 2026;33(6):e70342. doi:10.1111/acem.70342 Summarized by Ashley Lyons, OMS4 | Edited by Ashley Lyons & Ahmed Abdel-Hafiz, NREMT-P Donate: https://emergencymedicalminute.org/donate/ Join our mailing list: http://eepurl.com/c9ouHf

Contributor: Jeffrey Olson, MD Educational Pearls: What are they? A flexible balloon and suction tube that we insert into the esophagus and into the stomach to stop bleeding. When to use? Typically used for variceal bleeding. Use whenever the patient is too unstable to be transferred to more definitive therapy. What are the different types? Linton - Nachlas Tube Single gastric balloon with a suction port for the stomach and sometimes a suction port for the esophagus. Sengstaken - Blakemore Tube Gastric balloon and esophageal balloon with only a gastric suction port Minnesota Tube Both gastric and esophageal balloon and both gastric and esophageal suction ports How do you place one? Before placement Secure the airway first in a patient with massive ongoing hematemesis Insertion Fully lubricate the tube. Remove the white caps from the gastric and esophageal inflation ports. Test your balloons by placing them in the water and inflating them using your syringe. Place your three-way stopcocks on your esophageal and gastric inflation ports. Insert the tube similar to an OG tube until you have reached the 50 cm mark for the gastric balloon Use a slip syringe at the gastric aspiration site and auscultate to confirm that you are in the stomach. Then fill the gastric balloon with 50 cc of air. Verify the placement of the gastric balloon with a chest x-ray. (You can also pre-check with ultrasound) Fully inflate the gastric balloon Blakemore: 250ccs Minnesota: 450-500ccs Apply traction to the tube by tying a roller bandage to the end of it and then the other end to a 1L bag of IV fluids. Then hang the roller bandage over an IV pole. Place the nasogastric tube down to the pre-measured level above the gastric balloon and suction the esophageal space. If there is continued bleeding coming from the nasogastric tube then you will need to inflate the esophageal balloon. Note that Minnesota tubes already have their own esophageal suction port and will NOT need this NG tube placement to suction the esophagus. Use a "manometer" to inflate the esophageal balloon to 30mmHg. If bleeding persists, you can go to a maximum of 45mmHg What are some tricks? Using silk ties to add an accessory NG tube to add an extra suction port to a Blakemore tube Using a bougie to help advance Put the tube on ice to increase stiffness and make it easier to pass Use Macgills to help advance Use a laryngoscope Use endoscopic biopsy forceps threaded down the gastric port What does the data say? "The overall success rate of initial hemostasis with [Blakemore] tube was 75.8. Rebleeding rate after successful initial hemostasis with [Blakemore] tube was 22.0%, and esophageal rupture occurred in 6.1%. Mortality within 30 days was 42.4%" (Choi, 2017) References Choi JY, Jo YW, Lee SS, Kim WS, Oh HW, Kim CY, Yun EY, Kim JJ, Lee JM, Kim HJ, Kim HJ, Kim TH, Jung WT, Lee OJ, Kim RB. Outcomes of patients treated with Sengstaken-Blakemore tube for uncontrolled variceal hemorrhage. Korean J Intern Med. 2018 Jul;33(4):696-704. doi: 10.3904/kjim.2016.339. Epub 2017 Nov 10. PMID: 29117668; PMCID: PMC6030415. https://www.aliem.com/trick-inflating-esophageal-balloon-blakemore-minnesota-tube-without-manometer/ https://www.tamingthesru.com/blog/air-care-series/balloon-tamponade-of-variceal-hemorrhage https://radiopaedia.org/articles/esophageal-balloon-tamponade-device https://simkit.co/blakemore-minnesota-and-linton-tube-tips-and-tricks/ https://www.bjaed.org/article/S2058-5349%2817%2930055-0/fulltext Summarized by Jeffrey Olson MD | Edited by Jeffrey Olson MD Special thanks to Dr. Travis Barlock, Dr. Evan Fisch, and the Corewell Health East - William Beaumont Emergency Medicine Residency Program for their contributions in researching for this episode. Donate: https://emergencymedicalminute.org/donate/ Join our mailing list: http://eepurl.com/c9ouHf Golf Fundraiser: https://www.zeffy.com/en-US/ticketing/emergency-medical-minute-charity-golf--2026

Contributor: Taylor Lynch, MD Educational Pearls: Excessive caffeine intake can be dangerous. For normal adults, the toxicity level starts at 1000mg, which is equivalent to about 10 cups of coffee or 5 celsius drinks. For normal adults, lethal levels are about 5-10 grams, which is equivalent to about 50-100 cups of coffee. Most of these outcomes are not from drinking caffeine, but instead concentrated caffeine pills. For children, toxic levels are 15mg per kg of the child. Within the last 10 years 20-40 deaths due to caffeine intake have been reported. This may be lower than the actual number due to cardiac arrests that potentially could have been caused from caffeine intake. Clinical presentation of caffeine toxicity can present in many ways. Most common symptoms include agitation and jitteriness The far end of the spectrum includes seizures, tachydysrhythmias, and eventually cardiovascular collapse. Caffeine is a part of the methylxanthine class. Caffeine is a phosphodiesterase inhibitor, which causes the release of calcetamines that act on your beta-2 receptors. This activates the sodium potassium ATPase and causes potassium to shift intracellular. The clinical presentation of this mechanism is a patient with low potassium and agitation. Treatments for toxic caffeine levels include: Replacing potassium, but slowly since the total potassium levels in the body are normal and will eventually return to normal once the caffeine wears off. Benzodiazepines Activated charcoal Dialysis, since caffeine is dialyzable References National Center for Biotechnology Information. "PubChem Compound Summary for CID 2519, Caffeine" PubChem, https://pubchem.ncbi.nlm.nih.gov/compound/Caffeine. Accessed 9 July, 2026. Murray A, Traylor J. Caffeine Toxicity. [Updated 2025 Feb 6]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2026 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK532910/ Cyril Willson, The clinical toxicology of caffeine: A review and case study, Toxicology Reports, Volume 5, 2018, Pages 1140-1152, ISSN 2214-7500, https://doi.org/10.1016/j.toxrep.2018.11.002. Summarized by Aaryn David | Edited by Aaryn David & Ahmed Abdel-Hafiz, NREMT-P Donate: https://emergencymedicalminute.org/donate/ Join our mailing list: http://eepurl.com/c9ouHf Golf Fundraiser: https://www.zeffy.com/en-US/ticketing/emergency-medical-minute-charity-golf--2026

Contributor: Taylor Lynch, MD Educational Pearls: When a patient who missed dialysis presents to the emergency department, our clinical concern is who needs to be admitted to the hospital for emergent dialysis and who can wait for their next regularly scheduled session. Dialysis sessions typically occur on Monday, Wednesday, and Friday, or Tuesday, Thursday, and Saturday. Acronym for indications for emergent dialysis: AEIOU Acidosis Patients may have an underlying cause for acidosis such as sepsis or DKA. Treat the underlying cause, but if the acidosis is unable to be corrected, the patient needs dialysis. Electrolytes Most commonly elevated is potassium. In general, dialysis patients tend to have higher potassium levels, so don't just treat the number. Look for potassium greater than 6.5 or if EKG changes are present. Ingestion Intoxication with substances such as Lithium, Ethylene Glycol, Methanol, Salicylates. Overload Patients may present with evidence of fluid overload such as new oxygen requirement or pulmonary edema. If they are making urine, treat with diuretics, but if unresponsive to medical therapy, they will require dialysis. Uremia Build-up of nitrogenous waste products in the blood, which is indicated by an elevated BUN. Patients may develop complications such as altered mentation or pericardial effusions and subsequent cardiac tamponade. Keep in mind creatinine itself is not an indication for emergent dialysis. Serves as a surrogate marker of kidney function. Can be high or low depending on muscle mass or kidney filtration, and the patient may or may not need dialysis. References: Jentzer JC, Bihorac A, Brusca SB, et al. Contemporary Management of Severe Acute Kidney Injury and Refractory Cardiorenal Syndrome: JACC Council Perspectives. J Am Coll Cardiol. 2020;76(9):1084-1101. doi:10.1016/j.jacc.2020.06.070 Summarized by Ashley Lyons, OMS4 | Edited by Ashley Lyons & Ahmed Abdel-Hafiz, NREMT-P Donate: https://emergencymedicalminute.org/donate/ Join our mailing list: http://eepurl.com/c9ouHf

Contributor: Alec Coston, MD Educational Pearls: Benign Paroxysmal Positional Vertigo (BPPV) Common inner ear condition that can cause dizziness Diagnosis of BPPV can help to avoid admissions and extra imaging Three categories: positional, horizontal, and anterior Positional is the most common Dizziness is not a positive indicator, a torsional nystagmus must be induced Dix's hallpike maneuver is done to diagnose and an epley maneuver is then used for treatment Horizontal Usually determined to be the case if the vertigo seems positional and the dix hallpike does not work. A supine roll test would then be done to help diagnose. Instead of a rotational nystagmus, a unilateral horizontal nystagmus is expected. The two patterns are termed geotropic and apogeotropic. Geotropic means the fast phase beats toward the ground, and is treated by a barbeque roll maneuver. Apogeotropic means the fast phase beats toward the ceiling, and is treated by Gufoni maneuver. Anterior is more rare Most cases require neuro consults Determined by attempting to induce a down-beating nystagmus, which is a higher risk nystagmus. Treatment is tilting their head back up in a similar way Inducing the nystagmus is not sided and is more central References You, P., Instrum, R. and Parnes, L. (2019), Benign paroxysmal positional vertigo. Laryngoscope Investigative Otolaryngology, 4: 116-123. https://doi.org/10.1002/lio2.230 Ling X, Zhao D-H, Shen B, Si L-H, Li K-Z, Hong Y, Li Z-Y and Yang X (2020) Clinical Characteristics of Patients With Benign Paroxysmal Positional Vertigo Diagnosed Based on the Diagnostic Criteria of the Bárány Society. Front. Neurol. 11:602. doi: 10.3389/fneur.2020.00602 Rah YC. Advances in Benign Paroxysmal Positional Vertigo: Updated Insights on Diagnostic Pitfalls and Management. J Audiol Otol. 2026 Jan;30(1):1-12. doi: 10.7874/jao.2025.00717. Summarized by Aaryn David | Edited by Aaryn David & Ahmed Abdel-Hafiz, NREMT-P Donate: https://emergencymedicalminute.org/donate/ Join our mailing list: http://eepurl.com/c9ouHf

Contributor: Aaron Lessen, MD Educational Pearls: Big question in cardiac arrest: is the rhythm shockable? Shockable: ventricular fibrillation (VF) and pulseless ventricular tachycardia Non-shockable: asystole and pulseless electrical activity (PEA) Rhythm classification is typically based on ECG, but echocardiography can directly visualize myocardial fibrillation Occult VF: a rhythm that appears non-shockable on ECG but demonstrates VF on echocardiography A 2025 multicenter prospective study looked at 811 patients with out-of-hospital cardiac arrest 5.3% had occult VF detected by echocardiography Of the patients with occult VF: 81.4% had PEA on ECG 18.6% had asystole on ECG Patients with occult VF were less likely to receive defibrillation because their ECG suggested a nonshockable rhythm Clinical takeaway: echocardiography during cardiac arrest may reveal a potentially shockable rhythm hiding behind an apparently nonshockable ECG This identifies a subset of cardiac arrest patients who would otherwise be managed as PEA or asystole based on ECG References Gaspari R, Adhikari S, Gleeson T, Kapoor M, Lindsay R, Noble V, Nomura JT, Weekes A, Theodoro D. Occult Ventricular Fibrillation Visualized by Echocardiogram During Cardiac Arrest: A Retrospective Observational Study From the Real-Time Evaluation and Assessment for Sonography-Outcomes Network (REASON). J Am Coll Emerg Physicians Open. 2025 Jan 13;6(1):100028. doi: 10.1016/j.acepjo.2024.100028. PMID: 40012664; PMCID: PMC11853361. Summarized by Meg Joyce, MS3 | Edited by Meg Joyce & Ahmed Abdel-Hafiz, NREMT-P Donate: https://emergencymedicalminute.org/donate/

Contributor: Meghan Hurley, MD Educational Pearls: What is hypokalemia? Hypokalemia is when the measured blood level of potassium falls below 3.5 mEq/L (normal 3.5 - 5.2 mEq/L). Can generally be considered in mild (3.0 - 3.5 mEq/L); moderate (2.5 - 2.9 mEq/L); and severe ( Should be noted that blood levels of potassium can be low while total body potassium is normal due to intracellular shift by certain agents like β-2 agonists (e.g. Albuterol) or insulin. There is no appreciable loss of insulin despite hypokalemia being present in labs. What are the most common causes of hypokalemia? Medications are a predominant cause; mainly loop and thiazide diuretics. Gastrointestinal losses such as prolonged emesis or diarrhea (can occur in the setting of chronic illness and treatment such as chemotherapy patients with emesis). Other renal losses (e.g. hyperaldosteronism and renal tubular acidosis). A fun-fact renal loss: A compound found in some licorice (Glycyrrhizic acid) can inhibit 11-ß-hydroxysteroid dehydrogenase enzyme type 2 and cause mineralocorticoid excess. See a 2023 case study in references for Lethal Arrhythmia Induced by Licorice. What is a less common cause of hypokalemia? Hypokalemic Periodic Paralysis (HypoPP) is a genetic autosomal dominant channelopathy where patients leak potassium at rest causing a flaccid paralysis of muscle. Typically impacting legs more than arms, and proximal muscles more than distal muscles. Can be triggered carbohydrate rich meals, rest after exercise, febrile illness, and fasting. Male predominance, typically in early adulthood. Treatment is avoidance of triggers and supplementation with conservative oral potassium to avoid overcorrection during attacks. What are some symptoms and findings associated with hypokalemia? Patients may present with generalized weakness and fatigue. Highly crucial to monitor for EKG changes in the setting of hypokalemia. May notice flattening of T wave with the development of a U wave at certain potassium levels. The lower the potassium levels, the more likely a TU fusion can be seen. Prolongs QT interval which puts patients at risk for lethal arrhythmias. What are treatment considerations for hypokalemia? At milder levels of hypokalemia that are asymptomatic and a reversible cause is identified, oral repletion via potassium tablets should be considered. Patients may be a candidate to complete their course of treatment in the Emergency Room. At higher symptomatic levels with distinct EKG changes, more aggressive repletion (including IV Potassium) should be considered. Patients may be candidates for admission. Always monitor and replace magnesium levels as well, as they tend to follow potassium levels as well. Consider intracellular shifts as a source of hypokalemia to avoid risk of overcorrection into hyperkalemia. Hypokalemia can cause deadly heart rhythms such as ventricular fibrillation and ventricular tachycardia including Torsades Des Pointes that will be refractory to defibrillation. Treatment considerations at this point include: Consideration of esmolol Double Sequential Defibrillation Extracorporeal Membrane Oxygenation (ECMO). Key takeaways? Hypokalemia is most often associated with medication side effects or total volume loss from emesis or diarrhea. Depending on the degree of hypokalemia, different treatment considerations must be made. Monitor patient EKG closely for changes that can progress to lethal arrhythmias. References: Yannopoulos D, Bartos J, Raveendran G, et al. Advanced reperfusion strategies for patients with out-of-hospital cardiac arrest and refractory ventricular fibrillation (ARREST): a phase 2, single centre, open-label, randomised controlled trial. Lancet. 2020;396(10265):1807-1816. doi:10.1016/S0140-6736(20)32338-2 Cheskes S, Verbeek PR, Drennan IR, et al. Defibrillation Strategies for Refractory Ventricular Fibrillation. New England Journal of Medicine. 2022;387(21):1947-1956. doi:10.1056/NEJMoa2207304 Oswald S, Ravioli S, Schwarz C, Lindner G. Hypokalaemia in the emergency department: aetiology, diagnosis, and management. Swiss Medical Weekly. 2026;156(4):4767-4767. doi:10.57187/4767 Gao Z, Xing H, Zhang J, Chen S, Gao Z. Hypokalemic periodic paralysis: novel perspectives from genetic mutations to clinical management. Gene. 2026;999:150172. doi:10.1016/j.gene.2026.150172 Han EJ, Park JS. Lethal Arrhythmia Induced by Licorice. J Korean Med Sci. 2023;38(12):e107. doi:10.3346/jkms.2023.38.e107 Lee YH, Lee KJ, Min YH, et al. Refractory ventricular fibrillation treated with esmolol. Resuscitation. 2016;107:150-155. doi:10.1016/j.resuscitation.2016.07.243 Summarized by Dan Orbidan, OMS3 | Edited by Dan Orbidan & Ahmed Abdel-Hafiz, NREMT-P Donate: https://emergencymedicalminute.org/donate/ Join our mailing list: http://eepurl.com/c9ouHf

Contributor; Aaron Lessen, MD Educational Pearls: A 2026 survey asked Canadian emergency medicine (EM) physicians about their eating and drinking habits while on shift. Among 527 respondents, 35% reported that they never or hardly ever ate during shifts, and 37% said the same about drinking water. Lack of time was the most commonly cited barrier, reported by 91% of respondents. Lack of available food, personal health goals, perceived mental clarity, and emergency department culture were also commonly identified factors. Physicians who did not eat or drink on shift often reported that this negatively affected their work. Years in practice were associated with eating more often while on shift, suggesting that newer physicians may be less likely to eat during shifts. A 2023 study by Kontrick et al. found that 89% of US-based EM residency programs did not have a dedicated meal break, which may help explain why early-career physicians are less accustomed to eating during clinical shifts. Studies outside of emergency medicine have also suggested that inadequate food and fluid intake can affect fatigue, mood, attention, and cognitive performance, though direct evidence in emergency department physicians and patient care remains limited. Future studies could examine whether physician eating and drinking habits during shifts are associated with patient outcomes and broaden the scope of this study to other emergency department providers, nurses, and technicians. References: Farquhar, Madeleine et al. "A lot on their plates? Examining the on-shift eating and drinking habits of Canadian emergency medicine physicians." CJEM vol. 28,1 (2026): 64-73. doi:10.1007/s43678-025-01044-8 Kontrick, Amy V et al. "Do emergency medicine residents have access to healthy food options during work hours?." AEM education and training vol. 7,4 e10890. 17 Jul. 2023, doi:10.1002/aet2.10890 Lemaire, Jane B et al. "Physician nutrition and cognition during work hours: effect of a nutrition based intervention." BMC health services research vol. 10 241. 17 Aug. 2010, doi:10.1186/1472-6963-10-241 Wittbrodt, Matthew T, and Melinda Millard-Stafford. "Dehydration Impairs Cognitive Performance: A Meta-analysis." Medicine and science in sports and exercise vol. 50,11 (2018): 2360-2368. doi:10.1249/MSS.0000000000001682 Summarized by Sam Pahl | Edited by Sam Pahl & Ahmed Abdel-Hafiz, NREMT-P Donate: https://emergencymedicalminute.org/donate/ Join our mailing list: http://eepurl.com/c9ouHf