Contributor: Alec Coston, MD

Educational Pearls:

For patients presenting to the emergency room with hypertension, clinicians should determine if it is isolated and uncomplicated, or involves comorbidities with more complex underlying pathophysiology.

For uncomplicated and isolated hypertension, first-line treatment is thiazide diuretics.

How do thiazide diuretics work to treat hypertension?

• Thiazide diuretics work by blocking sodium and chloride resorption in the kidneys.
  “Where sodium goes, water follows,” thus promoting diuresis and lowering blood pressure.

Examples of thiazide diuretics and their benefits?

• Hydrochlorothiazide (HCTZ): First-line medication in uncomplicated and chronic hypertensive states. Cheaper and fewer significant adverse effects compared to chlorthalidone.
• HCTZ can be associated with decreased risk of stroke and myocardial infarction.
• However, for more complicated hypertension, especially in the setting of heart failure, Angiotensin Converting Enzyme (ACE) Inhibitors should be considered.

How do ACE Inhibitors manage blood pressure?

• The body’s kidneys drive the Renin-Angiotensin-Aldosterone-System (RAAS) to regulate blood pressure.
• It is easiest to understand RAAS as being pro-hypertensive as a response to decreased renal perfusion. As renal perfusion decreases, renin is released and activates angiotensin I, which is converted by ACE to Angiotensin II, which causes release of aldosterone.
• ACE Inhibitors prevent the conversion of Angiotensin I to Angiotensin II, thus decreasing the kidneys' production of Angiotensin II and Aldosterone levels.

Why, in the context of heart failure, are ACE Inhibitors preferred?

• In heart failure, especially left-sided or left-ventricular heart failure, a vicious cycle can develop wherein the left ventricle fails to perfuse the kidneys due to over-dilation.
• The kidneys are hypoperfused and activate RAAS to try to retain volume and increase peripheral vasoconstriction, promoting renal perfusion.
• The increase in blood pressure puts further strain on the heart, thereby further decreasing cardiac output. The cycle develops, and extremely elevated blood pressures can develop.
• ACE Inhibitors can directly block this cycle, hence their preference in heart failure.

Big takeaway?

• In uncomplicated hypertensive patients, consider thiazide diuretics. When comorbidities, especially heart failure, are introduced, then consider ACE Inhibitors.

References

1. Carey RM, Moran AE, Whelton PK. Treatment of Hypertension: A Review. JAMA. 2022;328(18):1849-1861. doi:10.1001/jama.2022.19590
2. Fan M, Zhang J, Lee CL, Zhang J, Feng L. Structure and thiazide inhibition mechanism of the human Na-Cl cotransporter. Nature. 2023;614(7949):788-793. doi:10.1038/s41586-023-05718-0
3. Hripcsak G, Suchard MA, Shea S, et al. Comparison of Cardiovascular and Safety Outcomes of Chlorthalidone vs Hydrochlorothiazide to Treat Hypertension. JAMA Internal Medicine. 2020;180(4):542-551. doi:10.1001/jamainternmed.2019.7454
4. Yu D, Li JX, Cheng Y, et al. Comparative efficacy of different antihypertensive drug classes for stroke prevention: A network meta-analysis of randomized controlled trials. PLoS One. 2025;20(2):e0313309. doi:10.1371/journal.pone.0313309

Summarized by Dan Orbidan, OMS2 | Edited by Dan Orbidan & Jorge Chalit, OMS4

Donate: https://emergencymedicalminute.org/donate/

Contributor: Taylor Lynch, MD
Educational Pearls:

How do we risk-stratify chest-pain patients?

• One option is the HEART score
  • This score predicts a patient’s 6-week risk of a major adverse cardiac event.
    • Ex. Cath procedure, CABG, PCI, death
• H stands for History
  • Ask 1) Was the patient diaphoretic? 2) Did they have nausea and/or vomiting? 3) Did the pain radiate down the right or left arm? 4) Was it exertional?
  • Yes to one = one point. Two or more = two points.
• E stands for EKG
  • One point for left ventricular hypertrophy, t-wave inversions, new bundle-branch blocks.
  • No points for first degree AV block, benign early repolarization, or QT-prolongation
  • Two points for ST-depression
• A stands for Age
  • >65 gets two points
  • 45-64 gets one point
• R stands for Risk factors
  • Hypertension, hyperlipidemia, diabetes, obesity, family history, smoking, previous MI, previous CABG, stroke, peripheral arterial disease
  • 1-2 risk factors get 1 point
  • More than two risk factors gets two points
• T stands for Troponin
  • 1-3x upper limit of normal gets one point
  • >3x upper limit of normal gets two points
• This gives you a score between zero and ten
  • 0-3 points, patients have a ~2% chance of an adverse event
    • These patients likely go home
  • 4-6 points, patients have a ~20% chance of an adverse event
    • These patients get admitted or expedited outpatient stress test/echo
  • 7-10 points, patients have a ~60% chance of an adverse event
    • Admit and call cardiology.
    • These patients likely get catheterized

References

1. Backus BE, Six AJ, Kelder JC, Bosschaert MA, Mast EG, Mosterd A, Veldkamp RF, Wardeh AJ, Tio R, Braam R, Monnink SH, van Tooren R, Mast TP, van den Akker F, Cramer MJ, Poldervaart JM, Hoes AW, Doevendans PA. A prospective validation of the HEART score for chest pain patients at the emergency department. Int J Cardiol. 2013 Oct 3;168(3):2153-8. doi: 10.1016/j.ijcard.2013.01.255. Epub 2013 Mar 7. PMID: 23465250.
2. Laureano-Phillips J, Robinson RD, Aryal S, Blair S, Wilson D, Boyd K, Schrader CD, Zenarosa NR, Wang H. HEART Score Risk Stratification of Low-Risk Chest Pain Patients in the Emergency Department: A Systematic Review and Meta-Analysis. Ann Emerg Med. 2019 Aug;74(2):187-203. doi: 10.1016/j.annemergmed.2018.12.010. Epub 2019 Feb 2. PMID: 30718010.
3. https://www.mdcalc.com/calc/1752/heart-score-major-cardiac-events

Summarized by Jeffrey Olson, MS4 | Edited by Jorge Chalit, OMS4

Donate: https://emergencymedicalminute.org/donate/

Contributor: Aaron Lessen, MD
Educational Pearls:

• A prospective study at the Mayo Clinic Rochester was conducted to examine whether patients actively using their phones on initial assessment in the ED was associated with higher discharge rates
• The study included 292 patients, and only about 15% of patients were on their phone
  • The patients on their phone tended to be a younger demographic
• Scribes were trained to record the data during their shifts
• The results did show that patients on their phone have a higher rate of discharge
  • 94% chance of discharge if the patient is on their phone
  • 64% chance of discharge if the patient is not on their phone
• This concept can potentially contribute to improving triage decisions

References

1. Garcia SI, Jacobson A, Moore GP, Frank J, Gifford W, Johnson S, Lazaro-Paulina D, Mullan A, Finch AS. Airway, breathing, cellphone: a new vital sign? Int J Emerg Med. 2024 Nov 22;17(1):177. doi: 10.1186/s12245-024-00769-0. PMID: 39578750; PMCID: PMC11583604.

Summarized by Meg Joyce, MS2 | Edited by Meg Joyce & Jorge Chalit, OMS4

Donate: https://emergencymedicalminute.org/donate/

Contributor: Travis Barlock MD
Educational Pearls

• Frank’s sign is a curious physical exam finding first described in the literature in 1973
  • Bilateral earlobe creases are recognized as a marker of coronary artery disease and cerebrovascular disease
• Some studies have found an increase in all-cause mortality in patients with bilateral diagonal earlobe creases
• The pathophysiology is still not fully understood
  • One 2020 study found histopathological changes associated with diagonal earlobe creases, potentially linking them via a model of hypoxia/reoxygenation

References

1. Elliott WJ, Karrison T. Increased all-cause and cardiac morbidity and mortality associated with the diagonal earlobe crease: a prospective cohort study. Am J Med. 1991;91(3):247-254. doi:10.1016/0002-9343(91)90123-f
2. Nazzal S, Hijazi B, Khalila L, Blum A. Diagonal Earlobe Crease (Frank's Sign): A Predictor of Cerebral Vascular Events. Am J Med. 2017;130(11):1324.e1-1324.e5. doi:10.1016/j.amjmed.2017.03.059
3. Stoyanov GS, Dzhenkov D, Petkova L, Sapundzhiev N, Georgiev S. The Histological Basis of Frank's Sign. Head Neck Pathol. 2021;15(2):402-407. doi:10.1007/s12105-020-01205-4

Summarized & Edited by Jorge Chalit, OMS4

Donate: https://emergencymedicalminute.org/donate/

Contributor: Taylor Lynch, MD
Educational Pearls:

The KLM Flight Disaster, also known as the Tenerife Airport Disaster, occurred on 27 March 1977. It involved the collision of two Boeing 747 passenger jets from KLM and Pan Am Airlines, resulting in 583 fatalities.

What fell through the cracks to cause this incident?

• The captain of the KLM flight believed he had received clearance from air traffic control to take off, when in fact he had not.
• This captain was one of the most senior pilots in the organization, and the culture often saw senior pilots as infallible and not to be questioned.
• The co-pilot, who noticed improper communication resulting from power dynamics, did not assertively speak up.

What lessons can be taken from the tragedy and applied to healthcare?

• Aviation and healthcare are both high-stakes industries that require extensive communication for the safety of passengers and patients.
• Within medicine, an inherent hierarchy exists, and it is crucial not to let this hierarchy and perceived power imbalance prevent people from speaking up.
• In healthcare, providers such as nurses, paramedics, and technicians may spend more time with patients and thus may notice warning signs earlier. It is imperative to foster a culture where they can speak up freely and without hesitation if something concerning is caught in a patient.

When might mistakes happen most often?

• Hanna et al. found that radiological interpretation errors were more likely to occur later in shifts, peaking around the 10-to-12-hour mark.
• Leviatan et al. found that medication prescription errors were more likely to occur by physicians working on 2nd and 3rd consecutive shifts.
• Hendey et al. found medication ordering errors were higher on overnight and post-call shifts.
• Gatz et al. found that surgical procedural complication rates are higher during the last 4 hours of a 12-hour shift.

In Short, Ends of shifts are when mistakes are most likely to occur.

Overall takeaway?

• In a healthcare team, it is critical to look after each other regardless of years of experience or post-nominal letters, and speak up for patient safety. Making a special note that we may need to do so more towards the end of shifts, where we might not be at our sharpest.
  

References

1. Gatz JD, Gingold DB, Lemkin DL, Wilkerson RG. Association of Resident Shift Length with Procedural Complications. Journal of Emergency Medicine. 2021 Aug 1;61(2):189–97.
2. Hanna TN, Lamoureux C, Krupinski EA, Weber S, Johnson JO. Effect of Shift, Schedule, and Volume on Interpretive Accuracy: A Retrospective Analysis of 2.9 Million Radiologic Examinations. Radiology. 2018 Apr;287(1):205–12.
3. Hendey GW, Barth BE, Soliz T. Overnight and postcall errors in medication orders. Acad Emerg Med. 2005 Jul;12(7):629–34.
4. Leviatan I, Oberman B, Zimlichman E, Stein GY. Associations of physicians’ prescribing experience, work hours, and workload with prescription errors. J Am Med Inform Assoc. 2021 Jun 12;28(6):1074–80.

Summarized by Dan Orbidan, OMS2 | Edited by Dan Orbidan & Jorge Chalit, OMS4

Donate: https://emergencymedicalminute.org/donate/

Contributor: Aaron Lessen, MD
Educational Pearls:

How do we take care of kids in severe pain?

• There are many non-pharmacologic options for pain (i.e. ice, elevation) as well as more conventional medication options (i.e. acetaminophen, NSAIDS) but in severe pain stronger medications might be indicated.
• These stronger medications include options such as IV morphine, a subdissociative dose of ketamine, as well as intranasal fentanyl.
• Intranasal fentanyl has many advantages:
  • Studies have shown it might be more effective early on in controlling pain, as in the first 15-20 minutes after administration, and then becomes equivalent to other pain control options
  • Total adverse effects were also lower with IN fentanyl, including low rates of nausea and vomiting
  • To administer, use the IV formulation with an atomizer and spray into the nose; therefore, you do not need an IV line
  • Dose is 1-2 micrograms per kilogram, can be redosed once at 10 minutes.
• Don’t forget about gabapentinoids for neuropathic pain, muscle relaxants for muscle spasms, and nerve blocks when appropriate. (Disclaimer: muscle relaxers have not been well studied in children)

References

1. Alsabri M, Hafez AH, Singer E, Elhady MM, Waqar M, Gill P. Efficacy and Safety of Intranasal Fentanyl in Pediatric Emergencies: A Systematic Review and Meta-analysis. Pediatr Emerg Care. 2024 Oct 1;40(10):748-752. doi: 10.1097/PEC.0000000000003187. Epub 2024 Apr 11. PMID: 38713846.
2. Bailey B, Trottier ED. Managing Pediatric Pain in the Emergency Department. Paediatr Drugs. 2016 Aug;18(4):287-301. doi: 10.1007/s40272-016-0181-5. PMID: 27260499.
3. Hadland SE, Agarwal R, Raman SR, Smith MJ, Bryl A, Michel J, Kelley-Quon LI, Raval MV, Renny MH, Larson-Steckler B, Wexelblatt S, Wilder RT, Flinn SK. Opioid Prescribing for Acute Pain Management in Children and Adolescents in Outpatient Settings: Clinical Practice Guideline. Pediatrics. 2024 Sep 30:e2024068752. doi: 10.1542/peds.2024-068752. Epub ahead of print. PMID: 39344439.

Summarized by Jeffrey Olson, MS4 | Edited by Jorge Chalit, OMS4

Donate: https://emergencymedicalminute.org/donate/

Contributor: Travis Barlock, MD
Educational Pearls:

• Wheezing is classically heard in asthma and COPD, but it can be the result of a wide range of processes that cause airflow limitation
  • Narrowed bronchioles lead to turbulent airflow → creates the wheezing
• Crackles (rales) suggest pulmonary edema which is often due to heart failure
• Approximately 35% of heart failure patients have bronchial edema, which can also produce wheezing
• COPD and heart failure can coexist in a patient, and both of these diseases can cause wheezing
  • It’s vital to differentiate whether the wheezing is due to the patient’s COPD or their heart failure because the treatment differs
• Diagnosing wheezing due to heart failure (cardiac asthma):
  • Symptoms: orthopnea, paroxysmal nocturnal dyspnea
  • Diagnostic tools: bedside ultrasound
  • Treatment: diuresis and BiPAP for respiratory support
• Not all wheezing is asthma
  • Consider heart failure in the differential and tailor treatment accordingly

References
1. Buckner K. Cardiac asthma. Immunol Allergy Clin North Am. 2013 Feb;33(1):35-44. doi: 10.1016/j.iac.2012.10.012. Epub 2012 Dec 23. PMID: 23337063.

2. Hollingsworth HM. Wheezing and stridor. Clin Chest Med. 1987 Jun;8(2):231-40. PMID: 3304813.

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

Donate: https://emergencymedicalminute.org/donate/

Contributor: Jorge Chalit-Hernandez, OMS3
Educational Pearls:

• Psychedelics are being studied for their therapeutic effects in mental illnesses, including major depressive disorder, post-traumatic stress disorder, anxiety, and many others
• Classic psychedelics include compounds like psilocybin, LSD, and ayahuasca
  • MDMA and ketamine are often included in psychedelic research, but have a different mechanism of action than the others
  • Their mechanism of action involves agonism of the 5HT2A receptor, among others
  • Given their resurgence, there is an increase in recreational use of these substances
• A recent study assessed the risks of recreational users developing subsequent psychotic disorders
  • Individuals who visited the ED for hallucinogen use had a greater risk of being diagnosed with a schizophrenia spectrum disorder in the following 3 years
  • Hazard ratio (HR) of 21.32
  • After adjustment for comorbid substance use and other mental illness, the hazard ratio was 3.53 - still a significant increase compared with the general population
  • They also found an elevated risk for psychedelics when compared to alcohol (HR 4.66) and cannabis (HR 1.47)
• The study did not assess whether patients received antipsychotics or other treatments in the ED

References

1. Lieberman JA. Back to the Future - The Therapeutic Potential of Psychedelic Drugs. N Engl J Med. 2021;384(15):1460-1461. doi:10.1056/NEJMe2102835
2. Livne O, Shmulewitz D, Walsh C, Hasin DS. Adolescent and adult time trends in US hallucinogen use, 2002-19: any use, and use of ecstasy, LSD and PCP. Addiction. 2022;117(12):3099-3109. doi:10.1111/add.15987
3. Myran DT, Pugliese M, Xiao J, et al. Emergency Department Visits Involving Hallucinogen Use and Risk of Schizophrenia Spectrum Disorder. JAMA Psychiatry. 2025;82(2):142-150. doi:10.1001/jamapsychiatry.2024.3532

Summarized & Edited by Jorge Chalit, OMS3
Donate: https://emergencymedicalminute.org/donate/