Emergency Medical Minute

Contributors: Travis Barlock MD, Ian Gillman PA, Jacob Altholz MD, Jeffrey Olson MS4
In this episode, EM attending Travis Barlock and medical student Jeffrey Olson listen in to the two remaining cases presented from EMM's recent event, Tox Talk 2025. 
Talk 1- Methemoglobinemia- Ian Gillman
Cyanosis + chocolate-colored blood + normal PaO₂ + pulse ox stuck at ~85% = Methemoglobinemia → Treat with methylene blue

The medications that can cause it can be remembered with…

Watch out with methylene blue as it can cause serotonin syndrome

While treating with methylene blue the pulse ox can drop dramatically but this is not a real drop in oxygenation but rather an effect of how the methylene blue affects the sensor

BADNAPS: causes of methemoglobinemia

Benzocaine

Aniline Dyes

Dapsone

Nitrites/Nitrates (Found in meds, preservatives, and well water)

Antimalarials

Pyridium

Sulfonamides


Talk 2- Intratecal TXA and Hierarchy of Controls for Error Avoidance - Jacob Altholz
Hierarchy of Controls in terms of error prevention includes all of the layers of protection which can be categorized as elimination, substitution, engineering controls, administration controls, and PPE

References
Centers for Disease Control and Prevention. (2022, April 28). Hierarchy of controls. National Institute for Occupational Safety and Health. https://www.cdc.gov/niosh/learning/safetyculturehc/module-3/2.html

Pushparajah Mak RS, Liebelt EL. Methylene Blue: An Antidote for Methemoglobinemia and Beyond. Pediatr Emerg Care. 2021 Sep 1;37(9):474-477. doi: 10.1097/PEC.0000000000002526. PMID: 34463662.

Produced by Jeffrey Olson, MS4
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Contributor: Alec Coston, MD
Educational Pearls:
BiPAP is often effective in severe asthma, but many patients struggle with mask tolerance due to intense air hunger–driven anxiety, often compounded by hypoxia.

Benzodiazepines are commonly used for anxiety, but they can depress respiratory drive, making clinical improvement difficult to interpret (a lower RR may reflect sedation rather than true physiologic improvement).

Low-dose fentanyl is a useful alternative when patients cannot tolerate BiPAP despite coaching.

Opioids blunt the perception of dyspnea and are well established for treating air hunger.

When carefully titrated, fentanyl provides anxiolysis without significant respiratory suppression.

It is rapidly titratable (e.g., 25 mcg IV every 5 minutes).

Evidence primarily comes from palliative and oncology literature, but growing clinical experience supports its use in severe asthma to improve BiPAP tolerance.

Failure of fentanyl should prompt escalation to ketamine, often signaling impending need for intubation.

References
Pang GS, Qu LM, Tan YY, Yee AC. Intravenous Fentanyl for Dyspnea at the End of Life: Lessons for Future Research in Dyspnea. Am J Hosp Palliat Care. 2016 Apr;33(3):222-7. doi: 10.1177/1049909114559769. Epub 2014 Nov 25. PMID: 25425740.

Summarized and edited by Meg Joyce, MS2
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Contributor: Aaron Lessen, MD
Educational Pearls
BRASH Syndrome:
Bradycardia

Renal Failure

AV Nodal Blockade

Shock

Hyperkalemia 

Clinical Features:
Profound bradycardia and shock in patients on AV nodal blockers:

Commonly, Beta Blockers or Calcium Channel Blockers

Etiology: 
Caused by an inciting kidney injury:

Common triggers include precipitating illness, dehydration, or medications 

Results in hyperkalemia

The enhanced effect of the combination of AV nodal blockade and hyperkalemia leads to a more profound presentation of shock.

Treatment: 
IV Fluids, unless volume overloaded

Epinephrine for bradycardia

Lasix for volume overload, only if the patient is still making urine

Low threshold to dialyze for hyperkalemia
Focus on treating early and more aggressively. 

References:
Farkas JD, Long B, Koyfman A, Menson K. BRASH Syndrome: Bradycardia, Renal Failure, AV Blockade, Shock, and Hyperkalemia. J Emerg Med. 2020 Aug;59(2):216-223. doi: 10.1016/j.jemermed.2020.05.001. Epub 2020 Jun 18. PMID: 32565167.
 
Summarized by Ashley Lyons OMS3
Editting by Ashley Lyons OMS3 and Jeffrey Olson MS4
 
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Contributor: Taylor Lynch, MD
Educational Pearls:
What is tramadol and how does it work?
Tramadol is a Schedule IV opioid analgesic used for moderate pain and is often perceived as safer than other opioids due to lower abuse potential.

It is a prodrug with weak direct μ-opioid receptor activity.

The parent compound also inhibits serotonin and norepinephrine reuptake, giving it SSRI/SNRI-like properties.

Tramadol is metabolized by CYP2D6 into O-desmethyltramadol (ODT), which has significantly stronger μ-opioid receptor agonism than the parent drug.

What are the concerns with tramadol?
Ultrarapid CYP2D6 metabolizers (more common in Middle Eastern and North African populations) rapidly convert tramadol to ODT, increasing the risk of opioid toxicity.

Poor CYP2D6 metabolizers generate little ODT and may experience primarily serotonergic effects, increasing the risk of serotonin syndrome, especially when combined with SSRIs or SNRIs.

CYP2D6 inhibitors (e.g., bupropion, paroxetine, terbinafine, celecoxib) can block tramadol's conversion to ODT, potentially precipitating opioid withdrawal or increasing serotonergic toxicity.

Tramadol is also associated with an increased risk of first-time seizures, even at therapeutic doses.

Key takeaways
Tramadol's effects are highly unpredictable, varying from minimal analgesia to exaggerated opioid effects depending on metabolism.

Drug–drug interactions can lead to serotonin syndrome or opioid withdrawal.

Despite its Schedule IV classification and reputation for safety, alternative analgesics may be preferable in many patients.

References
DailyMed - TRAMADOL HYDROCHLORIDE tablet, coated. Accessed January 10, 2026. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=61fb5ba7-6896-4ee4-83de-caee69b06a8e#ID57

Dean L, Kane M. Tramadol Therapy and CYP2D6 Genotype. In: Pratt VM, Scott SA, Pirmohamed M, Esquivel B, Kattman BL, Malheiro AJ, eds. Medical Genetics Summaries. National Center for Biotechnology Information (US); 2012. Accessed January 10, 2026. http://www.ncbi.nlm.nih.gov/books/NBK315950/

Aly SM, Tartar O, Sabaouni N, Hennart B, Gaulier JM, Allorge D. Tramadol-Related Deaths: Genetic Analysis in Relation to Metabolic Ratios. J Anal Toxicol. 2022;46(7):791-796. doi:10.1093/jat/bkab096

Summarized and edited by Dan Orbidan OMS2
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Contributor: Aaron Lessen, MD
Educational Pearls:
The Case
24F brought in for anxiety. Patient is tearful, not talking, and potentially hyperventilating. History from boyfriend is that she suddenly stopped talking and started crying and it was hard to understand what she was saying. On exam, patient appears anxious and has a gaze preference for the right side and is still having difficulty speaking.

Decision is made to stroke alert patient.

CT shows early MCA stroke and M2 occlusion.

Patient is treated by IR with mechanical thrombectomy.

What are the risk factors for strokes in young people ( Traditional risk factors still matter

Hypertension 

Most important modifiable risk factor, present in 30-50% of young stroke patients

Diabetes

Especially insulin dependent type 1

HLD

Smoking

Substance use

Cocaine

Meth

Alcohol, especially binge drinking

IV drug use

Structural heart disease

PFO

Valvular heart disease like rheumatic disease

Hypercoagulable states

Factor V Leiden

Protein C or S deficiency

Antithrombin III deficiency

Vertebral dissections

Recent trauma

References
Aigner A, Grittner U, Rolfs A, Norrving B, Siegerink B, Busch MA. Contribution of Established Stroke Risk Factors to the Burden of Stroke in Young Adults. Stroke. 2017 Jul;48(7):1744-1751. doi: 10.1161/STROKEAHA.117.016599. Epub 2017 Jun 15. PMID: 28619986.

Ekker MS, Boot EM, Singhal AB, Tan KS, Debette S, Tuladhar AM, de Leeuw FE. Epidemiology, aetiology, and management of ischaemic stroke in young adults. Lancet Neurol. 2018 Sep;17(9):790-801. doi: 10.1016/S1474-4422(18)30233-3. PMID: 30129475.

Khan M, Wasay M, O'Donnell MJ, Iqbal R, Langhorne P, Rosengren A, Damasceno A, Oguz A, Lanas F, Pogosova N, Alhussain F, Oveisgharan S, Czlonkowska A, Ryglewicz D, Yusuf S. Risk Factors for Stroke in the Young (18-45 Years): A Case-Control Analysis of INTERSTROKE Data from 32 Countries. Neuroepidemiology. 2023;57(5):275-283. doi: 10.1159/000530675. Epub 2023 May 17. PMID: 37231971.

Summarized and edited by Jeffrey Olson MS4
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