Emergency Medical Minute

Contributor; Taylor Lynch, MD
Educational Pearls:
Thoracotomy 

Thoracotomy is used in traumatic cardiac arrest to replace conventional CPR with direct access to the chest.

Goals include identifying and controlling reversible causes of bleeding, prioritizing blood flow to the heart and brain, and performing open cardiac massage.

Trauma categories

Penetrating trauma: Gunshot wounds and stab wounds.

Has a higher chance of survival because the injury may be localized and directly repairable.

Cardiac stab wounds may have the highest survivability because the defect can be visualized, repaired, and treated with blood administration.

Blunt trauma: Motor vehicle collisions and falls from height.

Has a much lower chance of survival.

Western guidelines

EMS must witness the patient lose pulses.

Penetrating trauma: CPR for less than 15 minutes.

Blunt trauma: CPR for less than 10 minutes.

Survival decreases to essentially zero beyond these time limits.

Eastern guidelines

Focus on the presence of signs of life in blunt or penetrating trauma.

Signs of life may include:

Pupillary response.

Measurable blood pressure.

Purposeful movement.

Patient selection

Thoracotomy should only be performed when the patient has a reasonable chance of survival.

It is a highly morbid procedure with significant occupational risks, including needlestick injury.

Appropriate patient selection and timing are essential.

Procedure

Begin on the left side of the chest.

Cross-clamp the aorta to restrict blood flow below the heart and prioritize circulation to the heart and brain.

Identify and repair visible sources of bleeding involving structures such as the heart or lungs.

Perform open cardiac massage as the equivalent of CPR.

ACLS medications may still be administered.

References:
Cothren CC, Moore EE. Emergency department thoracotomy for the critically injured patient: Objectives, indications, and outcomes. World J Emerg Surg. 2006;1:4. Published 2006 Mar 24. doi:10.1186/1749-7922-1-4

Rhee, Peter M. ; Acosta, Jose ; Bridgeman, Amy et al. / Survival after emergency department thoracotomy : Review of published data from the past 25 years. In: Journal of the American College of Surgeons. 2000 ; Vol. 190, No. 3. pp. 288-298.

Nunn, Andrew ; Prakash, Priya ; Inaba, Kenji et al. / Occupational exposure during emergency department thoracotomy : A prospective, multi-institution study. In: Journal of Trauma and Acute Care Surgery. 2018 ; Vol. 85, No. 1. pp. 78-84.

Burlew CC, Moore EE, Moore FA, et al. Western Trauma Association critical decisions in trauma: resuscitative thoracotomy. J Trauma Acute Care Surg. 2012;73(6):1359-1363. doi:10.1097/TA.0b013e318270d2df

Seamon MJ, Haut ER, Van Arendonk K, et al. An evidence-based approach to patient selection for emergency department thoracotomy: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2015;79(1):159-173. doi:10.1097/TA.0000000000000648




Summarized by Steven Fujaros NREMT | Edited by Steven Fujaros & Ahmed Abdel-Hafiz, NREMT-P
 
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Contributor: Aaron Lessen, MD
Educational Pearls: 
 
Agitated patients who are intoxicated with methamphetamine pose a unique challenge when selecting a sedative to counter their symptoms. Is there a superior medication?

A recent study compared the efficacy of commonly used medications for methamphetamine-induced agitation in the emergency department.

The study compared IM Droperidol 5mg, IM Olanzapine 10mg, IM Midazolam 5mg, and IM Lorazepam 2mg.

The study concluded that Droperidol, Olanzapine, and Midazolam performed similarly, with a median time to adequate sedation of 15 minutes.

Lorazepam took the longest, with a median time of 30 minutes to achieve adequate sedation.

Patients who received Lorazepam also required rescue medication more frequently after the initial dose.

Key takeaway: Droperidol, Olanzapine, and Midazolam may be more effective than Lorazepam for treating methamphetamine-induced agitation.

 
References:
Martel M, Klein LR, Cole JB, et al. Intramuscular droperidol, olanzapine, midazolam, or lorazepam to treat methamphetamine intoxication in the emergency department. Am J Emerg Med. 2021;49:142-148. doi:10.1016/j.ajem.2021.05.045

 
Summarized by Ashley Lyons, OMS4 | Edited by Ashley Lyons & Ahmed Abdel-Hafiz, NREMT-P
 
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Contributor: Meghan Hurley, MD
Educational Pearls:
What animal is the most lethal to humans? 
Depending on how we define lethal, and animal, this answer is actually not straight forward. 

Globally and in the U.S. the most lethal animal is humans, accounting for ~436,000 to ~20,000 deaths (homicides) per year on average respectively. 

In the United States the most lethal animal is of the Hymenoptera order (bees, wasps, and hornets). It accounts for approximately ~60 deaths per year from anaphylaxis. Globally the number is harder to track, but is estimated between 250–3,800 deaths globally annually. 

Globally the most lethal animal is venomous snakes, accounting for between 60,000-150,000 per year (whereas in the United States this number is closer to ~5). 

Mosquitos, as a vector however for the pathogens they transmit, out rank all as the most lethal globally (excluding humans).  

What are the key take-aways for each insect discussed in this episode?
Mosquitos:

In the United States, of lesser concern. Can potentially transmit West Nile Virus in the United States. Otherwise, treatment for general mosquito bites is topical antihistamines and over the counter steroid creams. 

Hymenoptera order (bees, wasps, and hornets):

Distributed throughout the US, and can also live in the ground. 

Bees lose their stinger during a sting. Whereas wasps do not and can sting multiple times. 

Typically stings are just localized for symptoms (pain and swelling) but can become anaphylactic. 

Treat with IM Epinephrine as the first line. Consider bronchodilators from bronchospasms. 

Multiple stings (around ~100), can cause end organ damage and rhabdomyolysis outside of just anaphylaxis alone. Require more aggressive management. 

Fire Ants:

Behave similar to bees (in swarm mentality), but have differing venoms. Can also cause global symptoms.

Black Widow: 

No deaths from Latrodectus hesperus (Western Black Widow) recorded in the United States. There are 3 deaths globally from widow species. Two from Madagascar, and one from a Mediterranean species of widow.

Debate in the toxicology community about use of the antivenom, which may account for more deaths than the bite itself. 

Black Widow bites are typically painful. Which is different from bites from recluse species.  

Brown Recluse: 

Rare in Colorado

Typically painless bite, that creates a center necrotic eschar. 

Tend to also not be lethal. 

Bed Bugs

Typically harmless and more of a nuisance to have. Can cause localized infections. 

Bite presents in a "Breakfast, Lunch, and Dinner" formation (i.e. linear 2-3 or more bites as the bug tracks and feeds on skin). 

Will feed primarily on exposed skin.

The biggest concern is ensuring no cross contamination from patient to provider or facility.

 Bed bug bite delivers a small amount of local anesthetic, which can make them hard to detect.

References
Haskell MG, Langley RL. Animal-Encounter Fatalities, United States, 1999-2016: Cause of Death and Misreporting. Public Health Rep. 2020;135(6):831-841. doi:10.1177/0033354920953211

Herness J, Snyder MJ, Newman RS. Arthropod Bites and Stings. AFP. 2022;106(2):137-147.

GBD 2019 Snakebite Envenomation Collaborators. Global mortality of snakebite envenoming between 1990 and 2019. Nat Commun. 2022;13(1):6160. doi:10.1038/s41467-022-33627-9

Wei YL, Wu Z, Li RL, Tang F. Review of selected mosquito-borne diseases: arboviruses (dengue, chikungunya, Zika, West Nile, Japanese encephalitis, yellow fever) and parasitic diseases (malaria, lymphatic Filariasis). Front Public Health. 2025;13:1712094. doi:10.3389/fpubh.2025.1712094

Forsberg K, Sheats KJ, Blair JM, et al. Surveillance for Violent Deaths - National Violent Death Reporting System, 50 States, the District of Columbia, and Puerto Rico, 2022. MMWR Surveill Summ. 2025;74(5):1-42. doi:10.15585/mmwr.ss7405a1

Summarized by Dan Orbidan, OMS2 | Edited by Dan Orbidan & Ahmed Abdel-Hafiz, NREMT-P
 
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Contributor: Travis Barlock, MD
Educational Pearls:
 
First-pass success is critical to limit complications from apnea, hypoxia, and airway trauma. 
Complication rate for patients intubated on the first pass is 14%

Complication rates increase to 47% after two attempts, 64% after three, and 71% after the fourth attempt

 
How to improve likelihood of first-pass success:
Use Video laryngoscopy (VL). VL increases chance of first-pass success to 85% from 71%

Use a bougie, especially in patients with anatomically difficult or otherwise obstructed airways. The BEAM study cites a success rate in these patients of 96% with a bougie, compared to 82% without

Use a Checklist mnemonic (SOAPME)

Suction – On, ready, and within reach

Oxygen – Patient is preoxygenated

Adjuncts – Oral/nasal adjuncts and BVM ready

Positioning - Patient positioned properly; consider obesity, using semi-Fowler/head-up positioning

Medications – Rapid sequence intubation (RSI), sedation, vasopressor, and other medications prepared as necessary

Equipment – Laryngoscope (blade), tube, bougie/stylet, syringe, scalpel/cric kit, others ready as necessary




References
Sakles, J.C., Chiu, S., Mosier, J., Walker, C. and Stolz, U. (2013), The Importance of First Pass Success When Performing Orotracheal Intubation in the Emergency Department. Acad Emerg Med, 20: 71-78. https://doi.org/10.1111/acem.12055

Prekker ME, Driver BE, Trent SA, et al. Video versus Direct Laryngoscopy for Tracheal Intubation of Critically Ill Adults. New England Journal of Medicine. 2023;389(5). doi:https://doi.org/10.1056/nejmoa2301601

Driver BE, Prekker ME, Klein LR, et al. Effect of Use of a Bougie vs Endotracheal Tube and Stylet on First-Attempt Intubation Success Among Patients With Difficult Airways Undergoing Emergency Intubation: A Randomized Clinical Trial. JAMA. 2018;319(21):2179–2189. doi:10.1001/jama.2018.6496

‌Turner JS, Bucca AW, Propst SL, et al. Association of Checklist Use in Endotracheal Intubation With Clinically Important Outcomes: A Systematic Review and Meta-analysis. JAMA Netw Open. 2020;3(7):e209278. doi:10.1001/jamanetworkopen.2020.9278

Turner, Joseph S et al. "Feasibility of  upright patient positioning and intubation success rates At two academic EDs." The American journal of emergency medicine vol. 35,7 (2017): 986-992. doi:10.1016/j.ajem.2017.02.011

 
Summarized by Sam Pahl | Edited by Sam Pahl & Ahmed Abdel-Hafiz, NREMT-P
 
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Dan Orbidan, OMS-II and Dr. Travis Barlock, MD discuss a real out of hospital call. This episode covers the implications of a pharmacologically abnormal patient presentation and the pre and post hospital considerations for patient management and care.