Contributor: Meghan Hurley, MD

Educational Pearls:

What is hypokalemia?

• Hypokalemia is when the measured blood level of potassium falls below 3.5 mEq/L (normal 3.5 - 5.2 mEq/L).

• Can generally be considered in mild (3.0 - 3.5 mEq/L); moderate (2.5 - 2.9 mEq/L); and severe (

• Should be noted that blood levels of potassium can be low while total body potassium is normal due to intracellular shift by certain agents like β-2 agonists (e.g. Albuterol) or insulin. There is no appreciable loss of insulin despite hypokalemia being present in labs.

What are the most common causes of hypokalemia?

• Medications are a predominant cause; mainly loop and thiazide diuretics.

• Gastrointestinal losses such as prolonged emesis or diarrhea (can occur in the setting of chronic illness and treatment such as chemotherapy patients with emesis).

• Other renal losses (e.g. hyperaldosteronism and renal tubular acidosis).

• A fun-fact renal loss: A compound found in some licorice (Glycyrrhizic acid) can inhibit 11-ß-hydroxysteroid dehydrogenase enzyme type 2 and cause mineralocorticoid excess. See a 2023 case study in references for Lethal Arrhythmia Induced by Licorice.

What is a less common cause of hypokalemia?

• Hypokalemic Periodic Paralysis (HypoPP) is a genetic autosomal dominant channelopathy where patients leak potassium at rest causing a flaccid paralysis of muscle.

• Typically impacting legs more than arms, and proximal muscles more than distal muscles.

• Can be triggered carbohydrate rich meals, rest after exercise, febrile illness, and fasting.

• Male predominance, typically in early adulthood.

• Treatment is avoidance of triggers and supplementation with conservative oral potassium to avoid overcorrection during attacks.

What are some symptoms and findings associated with hypokalemia?

• Patients may present with generalized weakness and fatigue.

• Highly crucial to monitor for EKG changes in the setting of hypokalemia.

• May notice flattening of T wave with the development of a U wave at certain potassium levels. The lower the potassium levels, the more likely a TU fusion can be seen.

• Prolongs QT interval which puts patients at risk for lethal arrhythmias.

What are treatment considerations for hypokalemia?

• At milder levels of hypokalemia that are asymptomatic and a reversible cause is identified, oral repletion via potassium tablets should be considered. Patients may be a candidate to complete their course of treatment in the Emergency Room.

• At higher symptomatic levels with distinct EKG changes, more aggressive repletion (including IV Potassium) should be considered. Patients may be candidates for admission.

• Always monitor and replace magnesium levels as well, as they tend to follow potassium levels as well.

• Consider intracellular shifts as a source of hypokalemia to avoid risk of overcorrection into hyperkalemia.

• Hypokalemia can cause deadly heart rhythms such as ventricular fibrillation and ventricular tachycardia including Torsades Des Pointes that will be refractory to defibrillation. Treatment considerations at this point include:

• Consideration of esmolol

• Double Sequential Defibrillation

• Extracorporeal Membrane Oxygenation (ECMO).

Key takeaways?

• Hypokalemia is most often associated with medication side effects or total volume loss from emesis or diarrhea. Depending on the degree of hypokalemia, different treatment considerations must be made. Monitor patient EKG closely for changes that can progress to lethal arrhythmias.

References:

1. Yannopoulos D, Bartos J, Raveendran G, et al. Advanced reperfusion strategies for patients with out-of-hospital cardiac arrest and refractory ventricular fibrillation (ARREST): a phase 2, single centre, open-label, randomised controlled trial. Lancet. 2020;396(10265):1807-1816. doi:10.1016/S0140-6736(20)32338-2

2. Cheskes S, Verbeek PR, Drennan IR, et al. Defibrillation Strategies for Refractory Ventricular Fibrillation. New England Journal of Medicine. 2022;387(21):1947-1956. doi:10.1056/NEJMoa2207304

3. Oswald S, Ravioli S, Schwarz C, Lindner G. Hypokalaemia in the emergency department: aetiology, diagnosis, and management. Swiss Medical Weekly. 2026;156(4):4767-4767. doi:10.57187/4767

4. Gao Z, Xing H, Zhang J, Chen S, Gao Z. Hypokalemic periodic paralysis: novel perspectives from genetic mutations to clinical management. Gene. 2026;999:150172. doi:10.1016/j.gene.2026.150172

5. Han EJ, Park JS. Lethal Arrhythmia Induced by Licorice. J Korean Med Sci. 2023;38(12):e107. doi:10.3346/jkms.2023.38.e107

6. Lee YH, Lee KJ, Min YH, et al. Refractory ventricular fibrillation treated with esmolol. Resuscitation. 2016;107:150-155. doi:10.1016/j.resuscitation.2016.07.243

Summarized by Dan Orbidan, OMS3 | Edited by Dan Orbidan & Ahmed Abdel-Hafiz, NREMT-P

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

Join our mailing list: http://eepurl.com/c9ouHf

Contributor: Meghan Hurley, MD

Educational Pearls:

What is hyperkalemia?

• Hyperkalemia is when the measured blood level of potassium reaches above 5.2 - 5.5 mEq/L (normal 3.5 - 5.2 mEq/L).

What are common causes of hyperkalemia?

• Chronic or acute kidney disease.

• Medications that impact the Renin-Angiotensin-Aldosterone-System (RAAS).

• Hypoaldosteronism and primary adrenal insufficiency (Addison's Disease).

What are concerns of hyperkalemia?

• The biggest concern with hyperkalemia is the impact on the cardiac conduction system.

• At differing levels of hyperkalemia, the patient may initially have peaked T waves, that then progress into a widening of the QRS complex which may eventually lead to a sine wave pattern.

• This increases risk for cardiac arrest with ventricular fibrillation, PEA, and asystole.

What is the treatment algorithm for hyperkalemia?

• Works through a three-tier approach.

• First tier treatment is with a calcium agent (calcium gluconate or chloride).

• Thought for the longest time to "stabilize the cardiac membrane/action potential". Recent research shows the true mechanism of action is likely through acting on calcium dependent channels.

• Does not fix underlying hyperkalemia, but buys time for the heart.

• Second tier treatment is inducing intracellular potassium shift.

• Can be achieved through agents such as insulin (which may need to be bolused with glucose to prevent hypoglycemia), albuterol, or sodium bicarbonate.

• Third tier is potassium elimination

• If the patient is producing urine, loop or thiazide diuretics can be considered.

• Hemodialysis may also be considered based on patient condition.

• Long term (and slowest method of elimination) through fecal excretion. Unlikely to see benefits in emergency management.

Key Takeaways?

• Hyperkalemia is a condition that can be brought on by primarily renal conditions and medication side effects. Careful attention must be paid to the patient's cardiac status, and urgent cardiac stabilization (though now we may know that calcium doesn't truly "stabilize" the cardiac membrane) must be performed to prevent deadly arrhythmias. Definitive management involves addressing the offending agent, offloading potassium, and stabilizing the patient long term.

References:

1. Geldermann N, Dzimiera J, Fischer H, Christ M. Acute hyperkalaemia in emergency care: evidence-based approaches. Emerg Med J. 2026;43(5):305-311. doi:10.1136/emermed-2025-215469

2. Piktel JS, Wan X, Kouk S, Laurita KR, Wilson LD. Beneficial Effect of Calcium Treatment for Hyperkalemia is Not Due to "Membrane Stabilization." Crit Care Med. 2024;52(10):1499-1508. doi:10.1097/CCM.0000000000006376

3. Hunter RW, Bailey MA. Hyperkalemia: pathophysiology, risk factors and consequences. Nephrol Dial Transplant. 2019;34(Suppl 3):iii2-iii11. doi:10.1093/ndt/gfz206

Summarized by Dan Orbidan, OMS3 | Edited by Dan Orbidan & Ahmed Abdel-Hafiz, NREMT-P

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

Join our mailing list: http://eepurl.com/c9ouHf

Contributor; Aaron Lessen, MD

Educational Pearls:

• A 2026 survey asked Canadian emergency medicine (EM) physicians about their eating and drinking habits while on shift.

• Among 527 respondents, 35% reported that they never or hardly ever ate during shifts, and 37% said the same about drinking water.

• Lack of time was the most commonly cited barrier, reported by 91% of respondents.

• Lack of available food, personal health goals, perceived mental clarity, and emergency department culture were also commonly identified factors.

• Physicians who did not eat or drink on shift often reported that this negatively affected their work.

• Years in practice were associated with eating more often while on shift, suggesting that newer physicians may be less likely to eat during shifts.

• A 2023 study by Kontrick et al. found that 89% of US-based EM residency programs did not have a dedicated meal break, which may help explain why early-career physicians are less accustomed to eating during clinical shifts.

• Studies outside of emergency medicine have also suggested that inadequate food and fluid intake can affect fatigue, mood, attention, and cognitive performance, though direct evidence in emergency department physicians and patient care remains limited.

• Future studies could examine whether physician eating and drinking habits during shifts are associated with patient outcomes and broaden the scope of this study to other emergency department providers, nurses, and technicians.

References:

1. Farquhar, Madeleine et al. "A lot on their plates? Examining the on-shift eating and drinking habits of Canadian emergency medicine physicians." CJEM vol. 28,1 (2026): 64-73. doi:10.1007/s43678-025-01044-8

2. Kontrick, Amy V et al. "Do emergency medicine residents have access to healthy food options during work hours?." AEM education and training vol. 7,4 e10890. 17 Jul. 2023, doi:10.1002/aet2.10890

3. Lemaire, Jane B et al. "Physician nutrition and cognition during work hours: effect of a nutrition based intervention." BMC health services research vol. 10 241. 17 Aug. 2010, doi:10.1186/1472-6963-10-241

4. Wittbrodt, Matthew T, and Melinda Millard-Stafford. "Dehydration Impairs Cognitive Performance: A Meta-analysis." Medicine and science in sports and exercise vol. 50,11 (2018): 2360-2368. doi:10.1249/MSS.0000000000001682

Summarized by Sam Pahl | Edited by Sam Pahl & Ahmed Abdel-Hafiz, NREMT-P

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

Join our mailing list: http://eepurl.com/c9ouHf

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:

1. 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

2. 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.

3. 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.

4. 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

5. 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

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

Join our mailing list: http://eepurl.com/c9ouHf

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:

1. 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

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

Join our mailing list: http://eepurl.com/c9ouHf

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

1. 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

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

3. 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

4. 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

5. 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

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

Join our mailing list: http://eepurl.com/c9ouHf

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

1. 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

2. 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

3. 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

4. ‌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

5. 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

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

Join our mailing list: http://eepurl.com/c9ouHf

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.

Carepoint Journal Club is a quarterly series with discussions about a medical topic, brought to you by Carepoint's Emergency Physicians.

Contributor: Aaron Lessen, MD

Educational Pearls:

UTIs are commonly seen in older women

• We often see them taking long-term prophylactic antibiotics because of common recurrence.

• Around 20-30% of older women who develop a UTI have a recurrence due to either diagnostic failure, treatment failure or non-compliance with treatment.

UTI signs and symptoms

• Burning sensation when urinating

• Strong urge to urinate

• Urinating often and passing small amounts of urine.

• Pelvic pain

There are currently more guidelines and studies on treatments to prevent these recurrent UTIs in women that we can start in the Emergency Department.

• Vaginal estrogen has been shown to significantly reduce this issue of recurrence.

• Very simple prescriptions can be prescribed in the ED

• It has little systemic absorption and is generally very safe and effective.

References

1. Wells BA, De EJB, Visingardi J, Feustel PJ. IP15-36 IMPACT OF VAGINAL ESTROGEN ON SERIOUS ADVERSE OUTCOMES IN POSTMENOPAUSAL WOMEN WITH RECURRENT URINARY TRACT INFECTIONS: A RETROSPECTIVE STUDY. Journal of Urology [Internet]. 2025 May 1;213(5S):e778. Available from: https://doi.org/10.1097/01.JU.0001109984.67114.74.36

2. Ackerman AL, Bradley M, D'Anci KE, Hickling D, Kim SK, Kirkby E. Updates to Recurrent Uncomplicated Urinary Tract Infections in Women: AUA/CUA/SUFU Guideline (2025). J Urol. 0(0). doi: 10.1097/JU.0000000000004723

3. Kaufman MR, Ackerman LA, Amin KA, et al. The AUA/SUFU/AUGS Guideline on Genitourinary Syndrome of Menopause. J Urol. 0(0). doi:10.1097/JU.0000000000004589

4. Meister MR, Wang C, Lowder JL, Mysorekar IU. Vaginal Estrogen Therapy Is Associated With Decreased Inflammatory Response in Postmenopausal Women With Recurrent Urinary Tract Infections. Female Pelvic Med Reconstr Surg. 2021 Jan 1;27(1):e39-e44. doi: 10.1097/SPV.0000000000000790. PMID: 31725016; PMCID: PMC7737516.

5. Nazarko L. Recurrent lower urinary tract infection in older women [Internet]. Urology & Continence Care Today. Available from: https://www.ucc-today.com/journals/issue/launch-edition/article/recurrent-lower-urinary-tract-infection-in-older-women-ucct

Summarized by Aaryn David & Ahmed Abdel-Hafiz | Edited by Aaryn David & Ahmed Abdel-Hafiz, NREMT-P

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

Join our mailing list: http://eepurl.com/c9ouHf