Emergency Medical Minute

• Episode 971: Calcium Pretreatment for Diltiazem in AFib with RVR

  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)? AFib is an abnormal heart rhythm in which the heart has disorganized atrial electrical activity. This causes the atria to quiver with only select signals being conducted through the Atrioventricular (AV) Node to reach the ventricles and result in ventricular contraction. Often described as “irregularly irregular”, a patient's EKG will present with no discernible P-waves, and irregular R-R intervals. AFib with RVR is distinguished from AFib when the patient’s ventricular rate is greater than 100-110 beats per minute in AFib with RVR. What is the treatment for AFib with RVR? Diltiazem is considered one of the first line therapeutic agents in the treatment of AFib with RVR. Diltiazem inhibits L-Type calcium channels in the AV Node, reducing the amount of signals conducted to the ventricles, thus reducing the ventricular rate. Why pretreat patients receiving Diltiazem for AFib with RVR with calcium? While diltiazem inhibits cardiac calcium channels, it may also cause peripheral vasodilation, resulting in diltiazem-induced hypotension. A recent study found that this hypotension can be blunted by pretreating with 1-2g IV Calcium Chloride (IV Calcium Gluconate can be used in the ED). Calcium is thought to peripherally stabilize the vascular smooth muscle, preventing vasodilation without impacting the desired calcium channel blocker action at the AV node. Key takeaways? In combination with slower pushes of diltiazem for patients in AFib with RVR (AFib with ventricular rate >100-110 bpm) with borderline low blood pressures, 1-2 g of IV Calcium Gluconate can combat diltiazem induced hypotension peripherally without negating the cardiac effect of diltiazem to reduce the heart rate.  References 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2024;149(1):e1-e156. doi:10.1161/CIR.0000000000001193 Az A, Sogut O, Dogan Y, et al. Reducing diltiazem-related hypotension in atrial fibrillation: Role of pretreatment intravenous calcium. Am J Emerg Med. 2025;88:23-28. doi:10.1016/j.ajem.2024.11.033 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/  

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• Episode 970: Fever Management

  Contributor: Aaron Lessen, MD Educational Pearls: Recorded March 2025 What is the best treatment for a fever? Tylenol? Ibuprofen? Combined? Alternating the two? The journal Pediatrics aimed to answer this question with a meta-analysis of 31 randomized controlled trials including 5,009 febrile children. Results showed that both combined and alternating acetaminophen/ibuprofen regimens were significantly more effective at reducing fever at 4 and 6 hours compared with acetaminophen alone, with numbers needed to treat (NNT) of 3 and 4, respectively. High-dose ibuprofen alone also offered modest benefit (NNT 8). What dose should I use? Oral acetaminophen 10 to 15 mg/kg Every 4–6 hours as needed Do not exceed 75 mg/kg/day (or 4,000 mg/day maximum for older/larger kids) Oral ibuprofen 5 to 10 mg/kg Every 6–8 hours as needed Do not exceed 40 mg/kg/day (or 2,400 mg/day maximum for older/larger kids) References De la Cruz-Mena JE, Veroniki AA, Acosta-Reyes J, Estupiñán-Bohorquez A, Ibarra JA, Pana MC, Sierra JM, Florez ID. Short-term Dual Therapy or Mono Therapy With Acetaminophen and Ibuprofen for Fever: A Network Meta-Analysis. Pediatrics. 2024 Oct 1;154(4):e2023065390. doi: 10.1542/peds.2023-065390. PMID: 39318339. 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/

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• Episode 969: Shoulder Reduction

  Contributor: Aaron Lessen, MD Educational Pearls: There are many techniques for reducing a shoulder dislocation A recent study discussed a new variation of closed reduction technique: wrist-clamping shoulder-lifting The patient is in a sitting position The provider holds the wrist of the injured arm with both hands and slowly rotates the arm to 90 degrees of abduction and 60 degrees of external rotation After this traction, the arm is slowly moved to 45 degrees of abduction and 60 degrees of external rotation The provider then secures the patient’s wrist between the provider’s knees and places their hand on the axilla to gently lift the shoulder upward for successful reduction There were 36 patients with shoulder dislocations in this study, and all 36 dislocations were successfully reduced with this technique There were no neurovascular complications or fractures No sedation or medication was required All procedures were performed by a single provider without assistance References Dai W, Liu L, Zong S, Zhou Y, Zheng J, Li X. An original closed reduction technique for acute shoulder dislocation: the wrist-clamping and shoulder-lifting. Int J Emerg Med. 2025 Mar 26;18(1):60. doi: 10.1186/s12245-025-00866-8. PMID: 40140973; PMCID: PMC11948627. Summarized by Meg Joyce, MS2 | Edited by Meg Joyce & Jorge Chalit, OMS4 Donate: https://emergencymedicalminute.org/donate/  

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• Episode 968: Heavy Metals

  Contributor: Megan Hurley MD Educational Pearls: Acute toxicity of heavy metals: Gastrointestinal upset is the most common presentation Chronic toxicity of heavy metals: Symptoms depend on the metal ingested Increased risk of cancer Altered mentation Developmental delays (in children) Kidney failure Four heavy metals that are tested for in a general panel and their sources: Lead Old paint (homes built before 1977) or some older toys Pipes of older homes or those with corrosive agents May obtain testing kits from home improvement stores to test water supply Mercury Previously in thermometers, although much less common now Compact fluorescent lightbulbs, LCD screens, and some batteries Large predatory fish like tuna, swordfish, dolphins, and shark Arsenic sources Most commonly found in pesticides Contaminated groundwater (especially private wells) Cadmiun sources Most commonly found in tobacco smoke Batteries Metal plating and welding Additional heavy metals that require specific testing Chromium, Nickel, & Thallium Thallium is found in rodenticides, pesticides, and fireworks Management of heavy metal toxicity depends on the intoxicant Generally, chelation therapy is used for acute and severe cases Arsenic: dimercaprol or DMSA Mercury: DMPS (chronic or mild) or DMSA (severe) Lead: succimer is first line, followed by dimercaprol or EDTA References Baker BA, Cassano VA, Murray C; ACOEM Task Force on Arsenic Exposure. Arsenic Exposure, Assessment, Toxicity, Diagnosis, and Management: Guidance for Occupational and Environmental Physicians. J Occup Environ Med. 2018;60(12):e634-e639. doi:10.1097/JOM.0000000000001485 Balali-Mood M, Naseri K, Tahergorabi Z, Khazdair MR, Sadeghi M. Toxic Mechanisms of Five Heavy Metals: Mercury, Lead, Chromium, Cadmium, and Arsenic. Front Pharmacol. 2021;12:643972. Published 2021 Apr 13. doi:10.3389/fphar.2021.643972 Kinally C, Fuller R, Larsen B, Hu H, Lanphear B. A review of lead exposure source attributional studies. Sci Total Environ. 2025;990:179838. doi:10.1016/j.scitotenv.2025.179838 Jannetto PJ, Cowl CT. Elementary Overview of Heavy Metals. Clin Chem. 2023;69(4):336-349. doi:10.1093/clinchem/hvad022 Järup L. Hazards of heavy metal contamination. Br Med Bull. 2003;68:167-182. doi:10.1093/bmb/ldg032 Zhang H, Reynolds M. Cadmium exposure in living organisms: A short review. Sci Total Environ. 2019;678:761-767. doi:10.1016/j.scitotenv.2019.04.395 Summarized & Edited by Jorge Chalit, OMS4 Donate: https://emergencymedicalminute.org/donate/

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• Episode 967: Dilutional Hyponatremia

  Contributor: Taylor Lynch, MD Educational Pearls: Dilutional Hyponatremia: Occurs when there is an excess of free water relative to sodium in the body. Causes a falsely low sodium concentration without a true change in total body sodium. Commonly seen in DKA: Hyperglycemia raises plasma osmolality. Water shifts from the intracellular to extracellular space. This dilutes serum sodium, creating apparent hyponatremia. Corrected sodium calculation: Use tools like MDCALC, or apply this formula: Add 1.6 mEq/L to the measured sodium for every 100 mg/dL increase in glucose above 100. Clinical relevance: Considering corrected sodium in DKA is crucial, as the lab value may not be reflective of actual sodium depletion. True severe hyponatremia can lead to complications like seizures May require treatment with hypertonic saline. References: Fulop M. Acid–base problems in diabetic ketoacidosis. Am J Med Sci. 2008;336(4):274-276. doi:10.1097/MAJ.0b013e318180f478 Palmer BF, Clegg DJ. Electrolyte and Acid–Base Disturbances in Patients with Diabetes Mellitus. N Engl J Med. 2015;373(6):548-559. doi:10.1056/NEJMra1503102 Spasovski G, Vanholder R, Allolio B, et al. Diagnosis and management of hyponatremia: a review. JAMA. 2014;312(24):2640–2650. doi:10.1001/jama.2014.13773 Summarized by Ashley Lyons, OMS3 | Edited by Ashley Lyons & Jorge Chalit, OMS4 Donate: https://emergencymedicalminute.org/donate/  

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