Emergency Medical Minute

Episode 943: Portal Vein Thrombosis

Contributor: Travis Barlock, MD

Educational Pearls:

1️⃣What is Portal Vein Thrombosis?

-The formation of a blood clot within the portal vein, which carries blood from the gastrointestinal tract, pancreas, and spleen to the liver

-Not only can this cause problems downstream in the liver, but the backup of venous blood can cause ischemia in the bowels

2️⃣How does it present?

-Similar to acute mesenteric ischemia: Sudden onset of abdominal pain, nausea, vomiting, and fever

3️⃣How is it diagnosed?

-Abdominal CT or MRI with contrast

4️⃣What causes it?

-Cirrhosis

-Coagulopathy (Factor V Leiden mutation, Prothrombin gene mutation, Antiphospholipid syndrome, Protein C, protein S, antithrombin III deficiency, etc.)

-Oral Contraceptive Pills (OCPs)

-Cancer such as hepatocellular carcinoma

5️⃣How is it treated?

-Aggressive fluid resuscitation

-Antibiotics. Be sure to cover enteric gram-negative bacteria and anaerobes

-Heparin, same dosing as a bolus for a DVT

-Endovascular treatment, such as a thrombectomy with IR

-Surgical evaluation if there has been tissue death in the mesentery

Summarized by Jeffrey Olson MS3 | Edited by Jorge Chalit, OMS3

Image from:
Gameiro AF, Robalo Nunes A, Guerra P, Mateus E, Fernandes F. Portal Vein Thrombosis Secondary to Occult Polycythemia Vera. Eur J Case Rep Intern Med. 2020 Nov 2;7(12):002003. doi: 10.12890/2020_002003. PMID: 33457359; PMCID: PMC7806286.

Episode 935: Pregnancy Extremis – TOLDD

Contributor: Aaron Lessen MD

Educational Pearls:

1️⃣Pregnant patients at high risk of cardiac arrest, in cardiac arrest, or in extremis require special care
2️⃣A useful mnemonic to recall the appropriate management of critically ill pregnant patients is TOLDD
➡️T: Tilt the patient to the left lateral decubitus position
-This position relieves pressure exerted from the uterus onto the inferior vena cava, which reduces cardiac preload
-If the patient is receiving CPR, an assistant should displace the uterus manually from the IVC towards the patient’s left side
➡️O: Administer high-flow adjunctive oxygen 
➡️L: Lines should be placed above the diaphragm
-Lines below the diaphragm are ineffective due to uterine compression of the IVC
-May consider humeral interosseous line vs. internal jugular or subclavian central line
➡️D: Dates should be estimated
-> 20 weeks, can consider a resuscitative hysterotomy (previously known as perimortem c-section) to improve chances of survival
-The uterus is palpable at the umbilicus at 20 weeks and 1 cm superior to the umbilicus for every week thereafter
➡️D: Call the labor and delivery unit for additional help

Summarized & Edited by Jorge Chalit, OMS3



Image from:
Pregnancy-related deaths are on the rise...and sepsis is a big reason | NIH MedlinePlus Magazine. MedlinePlus. Accessed December 16, 2024. https://magazine.medlineplus.gov/article/pregnancy-related-deaths-are-on-the-rise-and-sepsis-is-a-big-reason/.

Episode 931: Naloxone in Cardiac Arrest

Contributor: Aaron Lessen MD

Educational Pearls:

1️⃣Can opioids cause cardiac arrest?
-Opioids can cause respiratory suppression and the subsequent low oxygen levels can lead to arrhythmias and eventually cardiac arrest.
2️⃣In 2023, 17% of out-of-hospital cardiac arrests (OHCA) were attributable to opioids.
Given that this is a rising cause of cardiac arrest, should we just treat all cardiac arrest with naloxone (Narcan)?
3️⃣Naloxone is correlated with an increased chance of return of spontaneous circulation (ROSC)
4️⃣Additionally, a wide variety of individuals can be exposed to opioids and therefore opioid overdose should be considered in all cases of OHCA
But does naloxone improve neurologic outcomes?
5️⃣Yes, naloxone, especially when given early on in the resuscitation can improve neuro outcomes
6️⃣What is the dose?
-2-4 mg IN/IV depending on access.
7️⃣High suspicion for opioid overdose consider going with an even higher dose such as 4-8 mg IN/IV

Summarized by Jeffrey Olson, MS3 | Edited by Meg Joyce MS1 & Jorge Chalit, OMS3



Image from: NEXT Distro on Unsplash

Episode 929: Traumatic Aortic Injury

Contributor: Aaron Lessen MD

Educational Pearls:

1️⃣Aortic injury occurs in 1.5-2% of patients who sustain blunt thoracic trauma
-Majority are caused by automobile collisions or motorcycle accidents
-Due to sudden deceleration mechanism accidents
2️⃣Clinical manifestations
-Signs of hypovolemic shock including tachycardia and hypotension, though not always present
-Patients may have altered mental status
3️⃣Imaging
-Widened mediastinum on chest x-ray, though not highly sensitive
-CT is more sensitive and specific, and signs of thoracic injury include an intimal flap, aortic wall outpouching, and aortic contour abnormalities
-In hemodynamically unstable or otherwise unfit for CT patients, transesophageal echocardiogram may be used
4️⃣Four types of aortic injury (in order of ascending severity)
-I: Intimal tear or flap
-II: Intramural hematoma
-III: Pseudoaneurysm
-IV: Rupture
5️⃣Management
-Hemodynamically unstable: immediate OR for exploratory laparotomy and repair
-Hemodynamically stable: heart rate and blood pressure control with beta-blockers
-Minor injuries are treated with observation and hemodynamic control
-Severe injuries may receive surgical management
6️⃣Some patients benefit from delayed repair
7️⃣An endovascular aortic graft is a surgical option
8️⃣Mortality
-80-85% of patients die before hospital arrival
-50% of patients that make it to the hospital do not survive

Summarized by Jorge Chalit, OMS3 | Edited by Meg Joyce & Jorge Chalit

Image from: Mai JYL, Holmes A, Frahm-Jensen G. Grade four blunt traumatic aortic injury with massive haemothorax: Resuscitation considerations during the primary survey. Trauma Case Rep. 2020 Jun 29;29:100333. doi: 10.1016/j.tcr.2020.100333. Erratum in: Trauma Case Rep. 2023 Mar 01;45:100815. doi: 10.1016/j.tcr.2023.100815. PMID: 32760779; PMCID: PMC7393319.

Episode 928: Neutropenic Fever

Contributor: Taylor Lynch, MD

Educational Pearls:

1️⃣What is neutropenic fever?
-Specific type of fever that is seen in cancer patients and other patients with impaired immune systems
-These patients are highly susceptible to infection
-Typically occurs 7-10 days after the last chemotherapy dose, this is when the immune system is the weakest
-It is useful to know the specific type of malignancy. For example, heme malignancies (ALL, AML, etc.) have more intense chemo and are at higher risk of neutropenic fever
2️⃣To qualify as a neutropenic fever, a patient must have one recorded temperature greater than 38.3 degrees C or be over 38 degrees C for one hour.
-The severity of the neutropenic fever is established by the absolute neutrophil count. Abs neutrophil count under 1500 is mild, less than 1000 is moderate, less than 500 is severe.
-Also look at monocytes (cell that becomes a macrophage). Less than 200 is very concerning
What is the workup and treatment?
3️⃣Obtain a panculture (culture blood from both arms and all indwelling lines), obtain urine culture, and get a chest x-ray.
-Do not preform a re**al exam or obtain a re**al core temperature. This could cause bacteremia.
4️⃣Treat with Cefepime (broad range and includes pseudomonas but not MRSA). If there is concern for MRSA add vancomycin.
5️⃣Admit with Neutropenic precautions (gowns, gloves, mask, positive pressure room)

Summarized by Jeffrey Olson, MS3 | Edited by Meg Joyce & Jorge Chalit, OMS3



Image from Matteo Fusco on Unsplash

Episode 926: Supraventricular Tachycardia

Contributor: Taylor Lynch MD

1️⃣Supraventricular tachycardias (SVTs) arise above the bundle of His
-The term SVT includes AV nodal reentrant tachycardia (AVNRT), atrioventricular reentrant tachycardia (AVRT), atrial tachycardia, atrial fibrillation, atrial flutter, and multifocal atrial tachycardia
2️⃣AVNRT is the most common form of SVT
-Paroxysmal
-Spontaneous or provoked by exertion, coffee, alcohol, or thyroid disease
-More common in women (3:1 women:men ratio)
-HR 160-240
-Narrow complex with a normal QRS
3️⃣Unstable patients receive synchronized cardioversion at 0.5-1 J/kg
4️⃣Valsalva maneuver is attempted before pharmaceutical interventions
-Increases vagal tone at the AV node to slow conduction and prolongs its refractory period to normalize the conduction
-Traditionally, patients are asked to bear down, but this only works in 17% of patients
-REVERT trial assessed a modified valsalva that worked in 43% of patients
5️⃣Adenosine
-Slows conduction at the AV node by activating potassium channels and inhibiting calcium influx
-Extremely uncomfortable for most patients
-Not commonly used anymore
6️⃣Nondihydropyridine calcium-channel blockers are preferred
-A 2009 RCT investigated low-infusion CCBs compared with adenosine bolus
-The study found a conversion rate of 98% in the CCB group vs. adenosine group at 86.5%
-The main adverse effect of CCB is hypotension, which a slow infusion rate can mitigate
-Diltiazem dose is 0.25 mg/kg/2min and repeat at 0.35 mg/kg/15 minutes or slow infusion at 2.5 mg/min up to a conversion or 50 mg total

Photo from: Kassam N, Aziz O, Aghan E, Somji S, Mbithe H, Bapumia M, Mvungi R, Surani S. Smart Watch Detection of Supraventricular Tachycardia (SVT): First Case from Tanzania. Int Med Case Rep J. 2021 Aug 24;14:563-566. doi: 10.2147/IMCRJ.S328167. PMID: 34466038; PMCID: PMC8403020.

Summarized & Edited by Jorge Chalit, OMS3

Episode 925: Table Sugar for Tongue Entrapment

Contributor: Aaron Lessen, MD

Educational Pearls:

1️⃣Pediatric case study where the child’s tongue was stuck in the opening of a hard plastic drink lid

2️⃣Entrapment restricts circulation which causes fluid to build and the tongue becomes more edematous with time

-There is a risk of ischemia with prolonged entrapment

-Initially tried 2% viscous lidocaine for analgesia and lubricant

-The ER recognized that this mucosal, edematous tongue could benefit from the trick for ostomies and re**al prolapses → table sugar!

-Sugar granules absorb water which decreases tissue edema

3️⃣This option avoids sedation and aggressive treatment

Summarized by Meg Joyce, MS1 | Edited by Meg Joyce & Jorge Chalit, OMS3

Episode 923: Blunt Cerebrovascular Injury

1️⃣Assessment of head and neck vascular injury due to blunt trauma

-Symptomatic patients require screening head and neck CT angiography

2️⃣EAST guidelines include the following criteria for a screening CT angiography in blunt head trauma:

-Unexplained neurological deficits

-Arterial nosebleed

-GCS < 6

-Petrous bone fracture

-Cervical spine fracture

-Any size fracture through the transverse foramen

-LeFort fractures type II or type III

3️⃣EAST guidelines include a grading scale for vascular injury:

-Grade I: Luminal irregularity or dissection with 25% luminal narrowing, intraluminal thrombus, or raised intimal flap

-Grade III: Pseudoaneurysm

-Grade IV: Occlusion

-Grade V: Transection with free extravasation

Summarized & Edited by Jorge Chalit, OMS3



Image from:

Alalwi S, Alabbadi A, Alomair AM, Alfaraj D. Transient Bilateral Sixth Nerve Palsy: A Rare Sequela of Head Trauma. Cureus. 2021 Jan 20;13(1):e12805. doi: 10.7759/cureus.12805. PMID: 33628673; PMCID: PMC7894221.

Episode 922: Chest Tube Irrigation

Contributor: Aaron Lessen, MD

Educational Pearls:

1️⃣Hemothorax: blood in the pleural cavity, most commonly due to chest trauma

2️⃣Treatment: thoracostomy tube for blood drainage

-helps to avoid clotting, scarring, and infection

3️⃣A recent study looked at patients with hemothorax who either received or did not receive thoracic irrigation with saline

-Evaluated incidence of secondary intervention, such as video-assisted thoracoscopic surgery (VATS), for persistent hemothorax

-Patients who received irrigation had a slight decrease in secondary intervention frequency

-Multi-center study – all patients who had the irrigation procedure were at two centers

-Study limitation: variability in approaches at each location could be a confounder

4️⃣Technique that could potentially prevent future complications

Summarized by Meg Joyce, MS | Edited by Meg Joyce & Jorge Chalit, OMS3

Image from:

Al Hariri B, Alharafsheh AT, Hassan MA, Nashwan AJ, Mohamedali MG, Abusriwil HM. Spontaneous hemothorax caused by rivaroxaban treatment for pulmonary embolism: A case report. Clin Case Rep. 2023 Dec 11;11(12):e8333. doi: 10.1002/ccr3.8333. Erratum in: Clin Case Rep. 2024 Jul 11;12(7):e8668. doi: 10.1002/ccr3.8668. PMID: 38089488; PMCID: PMC10714055.

Episode 898: Takotsubo Cardiomyopathy

Contributor: Ricky Dhaliwal, MD

Educational Pearls:

1️⃣Takotsubo cardiomyopathy, also known as “broken heart syndrome,” is a temporary heart condition that can mimic the symptoms of a heart attack, including troponin elevations and mimic STEMI on ECG.
2️⃣The exact cause is not fully understood, but it is often triggered by severe emotional or physical stress. The stress can lead to a surge of catecholamines which affects the heart (multivessel spasm/paralysed myocardium).
3️⃣The name “Takotsubo” comes from the Japanese term for a type of octopus trap, as the left ventricle takes on a distinctive shape resembling this trap during systole. The LV is dilated and part of the wall becomes akenetic. These changes can be seen on ultrasound.
4️⃣The population most at risk for Takotsubo are post-menopausal women.
5️⃣Coronary angiography is one of the only ways to differentiate Takotsubo from other acute coronary syndromes.
6️⃣Most people with Takotsubo cardiomyopathy recover fully.

Summarized by Jeffrey Olson MS2 | Edited by Jorge Chalit, OMSII

Image showing ECG during first episode of Takotsubo stress cardiomyopathy with ST elevation V1–V6, Q waves in V1–V3.

From: A Case Report of Recurrent Takotsubo Cardiomyopathy in a Patient during Myasthenia Crisis. Case Rep Crit Care. 2017;2017:5702075. doi: 10.1155/2017/5702075. Epub 2017 Oct 19. PMID: 29201468; PMCID: PMC5671690.

Episode 897: Adrenal Crisis

Contributor: Ricky Dhaliwal MD

Educational Pearls:

1️⃣Primary adrenal insufficiency (most common risk factor for adrenal crises)
-An autoimmune condition commonly known as Addison’s Disease
-Defects in the cells of the adrenal glomerulosa and fasciculata result in deficient glucocorticoids and mineralocorticoids
-Mineralocorticoid deficiency leads to hyponatremia and hypovolemia
-Lack of aldosterone downregulates Endothelial Sodium Channels (ENaCs) at the renal tubules
-Water follows sodium and generates a hypovolemic state
-Glucocorticoid deficiency contributes further to hypotension and hyponatremia
-Decreased vascular responsiveness to angiotensin II
-Increased secretion of vasopressin (ADH) from the posterior pituitary
2️⃣An adrenal crisis is defined as a sudden worsening of adrenal insufficiency
-Presents with non-specific symptoms including nausea, vomiting, fatigue, confusion, and fevers
-Fevers may be the result of underlying infection
3️⃣Work-up in the ED includes labs looking for infection and adding cortisol + ACTH levels
4️⃣Emergent treatment is required
-100 mg hydrocortisone bolus followed by 50 mg every 6 hours
-Immediate IV fluid repletion with 1L normal saline
5️⃣The most common cause of an adrenal crisis is an acute infection in patients with baseline adrenal insufficiency
-Often due to a gastrointestinal infection

Summarized by Jorge Chalit, OMSII | Edited by Meg Joyce & Jorge Chalit

Episode 894: DKA and HHS

Contributor: Ricky Dhaliwal, MD

Educational Pearls:

What are DKA and HHS?
1️⃣DKA (Diabetic Ketoacidosis) and HHS (Hyperosmolar Hyperglycemic State) are both acute hyperglycemic states.
DKA
2️⃣More common in type 1 diabetes.
3️⃣Triggered by decreased circulating insulin.
-The body needs energy but cannot use glucose because it can’t get it into the cells.
-This leads to increased metabolism of free fatty acids and the increased production of ketones.
-The buildup of ketones causes acidosis.
-The kidneys attempt to compensate for the acidosis by increasing diuresis.
4️⃣These patients present as dry and altered, with sweet-smelling breath and Kussmaul (fast and deep) respirations.
HSS
5️⃣More common in type 2 diabetes.
6️⃣In this condition there is still enough circulating insulin to avoid the breakdown of fats for energy but not enough insulin to prevent hyperglycemia.
7️⃣Serum glucose levels are very high – around 600 to 1200 mg/dl.
8️⃣Also presents similarly to DKA with the patient being dry and altered.

Treatment
-Identify the cause, i.e. Has the patient stopped taking their insulin?
-Aggressive hydration with isotonic fluids.
-Normal Saline (NS) vs Lactated Ringers (LR)?
-LR might resolve the DKA/HHS faster with less risk of hypernatremia.
-Should you bolus with insulin? No, just start a drip.
-Make sure you have your potassium back before starting insulin as the insulin can shift the potassium into the cells and lead to dangerous hypokalemia.
-Should you treat hyponatremia? Make sure to correct for hyperglycemia before treating. This artificially depresses the sodium.
-Should you give bicarb? Replace if the pH < 6.9. Otherwise, it won’t do anything to help.
-Don’t intubate, if the patient is breathing fast it is because they are compensating for their acidosis.

Summarized by Jeffrey Olson MS2 | Edited by Meg Joyce & Jorge Chalit, OMSII