Hippo EM Podcast – Episode 08 – Syncope

“Why is syncope bad in patients with Bundle Branch Blocks (BBB)?” This question comes from a Hippo EM listener. Mel and Paul get to the heart of the matter in this episode of the superfantastically popular Hippo EM podcast. There are ECG cases, awesome illustrations and good times galore. The boys even provide an actual answer. What more could one ask for? Nothing. So stop asking and click to watch!

HEM_Podcast_Episode 08_Syncope

Coming Soon

The Prospective Applicants Page for Sinaiem.org is coming soon!


In the meantime please look at our “People” section to get to know the residency.


Click Here to view the official Residency Website.

Tramadol Intox

Tox Tuesday

Patient is 42 yo  M with PMH of chronic back pain (follows in pain clinic), depression BIBEMS found after wife found him with an apparent overdose attempt with an empty bottle of Tramadol next to him, last seen in USOH 4 hr prior. When EMS arrived on scene, noted some seizure-like activity lasting few minutes that stopped with Ativan. VS on arrival are BP 110/70 P 110 RR 8 T 97.8F O2 95% RA. You note the patient with some respiratory depression.


Is naloxone effective in Tramadol overdose?


Naloxone use in Tramadol has shown some partial efficacy when compared to typical opioids response, primarily believed to be based on the mixed receptor actions unique to Tramadol. Tramadol-induced­ apnea is rare, in case series of tramadol intoxication occurring at around ~4% prevelance [1]. There is caution with proconvulsive properties noted in animal models and proconvulsive properties in humans (28.3% vs. 11.2% control) in naloxone use with tramadol intoxication, accompanies as [2]. Another study looked at giving naloxone after seizures in tramadol intoxication, however, showing some clinical improvement[3].

Tramadol is a Class 4 scheduled drug, not typically considered a drug of abuse but have growing reports as use becomes more widespread, acts as a μ-opioid receptor agonist, serotonin releasing agent, NE reuptake inhibitor (lesser activity on NMDA antagonist, 5-HT2C antagonist, nicotinic antagonist).

Tramadol has inhibitory actions on the 5-HT2C receptor, may also account for its lowering of the seizure threshold, as 5-HT2C knockout mice display significantly increased vulnerability to epileptic seizures, sometimes resulting in spontaneous death. However, the reduction of seizure threshold could be attributed to tramadol’s putative inhibition of GABA-A receptors at high doses. In addition, tramadol’s major active metabolite, O-desmethyltramadol, is a high-affinity ligand of the δ- and κ-opioid receptors, and activity at the former receptor could be involved in tramadol’s ability to provoke seizures in some individuals, as δ-opioid receptor agonists are well known to induce seizures. Most Tramadol overdoses are non-fatal, fatal cases usually involving poly-substance abuse. Seizures are typically only seen in doses at least 6x the typical dose. Tramadol induced seizures also respond well to benzodiazepines [4].


Thanks to Eric Lee for the pearl idea.



1. Hassanian-Moghaddam H, Farajidana H, Sarjami S, Owliaey H. Tramadol-induced apnea. Am J Emerg Med. 2013 Jan;31(1):26-31. doi: 10.1016/j.ajem.2012.05.013. Epub 2012 Jul 16

2. Frahani A. Doctoral Thesis; Comparing the prevalence seizure in patients affected with tamadolpoisoning between two group treated and untreated with naloxone in Ardabil’s EmamKhomeinihospital: http://eprints.arums.ac.ir/2751/. Retrieved December 4, 2011.

3. Saidi, H., Ghadiri, M., Abbasi, S., and Ahmadi, S.F. Efficacy and safety of naloxone in the management of postseizure complaints of tramadol intoxicated patients: a self-controlled study. Emerg Med J. 2010; 27: 928–930

4. Nelson LS, Olsen D. Nelson L.S., Olsen D Chapter 38. Opioids. In: Nelson LS, Lewin NA, Howland M, Hoffman RS, Goldfrank LR, Flomenbaum NE. Nelson L.S., Lewin N.A., Howland M, Hoffman R.S., Goldfrank L.R., Flomenbaum N.E. eds. Goldfrank’s Toxicologic Emergencies, 9e . New York, NY: McGraw-Hill; 2011

Stroke after crotalidae antivenom

When it first came out, crotalidae polyvalent immune Fab (CroFab), was seen as a godsend by many. It didn’t cause anaphylaxis or serum sickness to nearly the same degree as the old product. There was plenty of safety data, so it started to be used in less severe cases that before, antivenom would be withheld because the risks outweigh the benefits. And now there are case reports like this.

Sean Bush, who just happens to have been on the tv show “Venom ER”, collected these two cases of acute ischemic stroke after treatment of snake bites with CroFab. Both were probably Southern Pacific rattlesnakes (one definitively identified, one presumptive).

Crotalus viridis Southern Pacific Rattlesnake Juvenile.jpg
Crotalus viridis Southern Pacific Rattlesnake Juvenile” by Matthew Robinson from Santa Monica, USA – baby rattle. Licensed under CC BY 2.0 via Wikimedia Commons.

The first case was a 50 yr old, bitten on the leg, with pain, swelling, shortness of breath, and parasthesias. He got the initial dose of 6 vials, then had his compartment pressures checked. That got him another 12 vials. Later that evening, he showed classic signs of CVA with slurred speech, right-sided weakness, and right facial droop. Labs remained normal, CT was negative, and tPA was withheld due to risk of hemorrhage. However, he got 6 more vials of antivenom because of neurologic symptoms. MRI showed devastating bilateral lesions, and the patient expired. Autopsy showed emboli in the lungs, heart, and multifocal infarcts of the CNS.

Case 2 was a little different. He was 17, bitten on the finger, and had pain, swelling, and parasthesias of that extremity. He got 6 vials initially, then got 20 more over the next 3 days. On that third day, he showed classic cva symptoms with left-sided facial droop, and total left-sided body weakness. His CT was negative, but again no tPA was given (for good reason). MRI showed multiple infarcts as well, but not as globally as the first.

Both patients were tested for hypercoagulability and were negative. So what gives? Why did two patients in the middle of a classic crotalidae envenomation develop ischemic CVAs after treatment? Fibrinogen and platelet levels were normal in both patients, indicating that they weren’t coagulopathic when given the CroFab. INR isn’t mentioned in the paper, presumably it was normal. The key aspect in this case series is the species of snake itself. One southern pacific rattler (Crotalus oreganus helleri) was discovered to have procoagulant activity in its venom, and among crotalidae, they have some of the most varied venom studied to this point. And it has been demonstrated that CroFab doesn’t have activity against rare, or small proteins that aren’t immunogenic.

Because it is unlikely that CroFab includes fabs specific for this procoagulant protein, in a patient envenomated by a southern pacific that was producing that protein, the net effect would be likely be procoagulation, thus causing the thrombotic phenomena shown. However, we can’t be so sure it is just this snake species, as the references in the paper have numerous other cases of ischemic strokes after multiple other types of snakes.

Yes, these are rare events, but neither of those patients appeared to be so sick that they would have died without antivenom. Perhaps judicious application of antivenom should be considered until the etiology of these events is fully understood.

Catastrophic Acute Ischemic Stroke After Crotalidae Polyvalent Immune Fab(Ovine)-Treated Rattlesnake Envenomation

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The Teaching Course is Coming!

Looking to infuse passion into your career as an educator? Not satisfied with the existing courses on medical education and teaching? Well, I give you….

The Teaching Course

What is the Teaching Course?

The Teaching Course is the premier experience in medical education and teaching. It’s a finely tuned blend of education, social media, and faculty development. If you can only choose one course in medical education to ignite (or re-ignite) passion in your career, this is it. This course aims to truly make a difference. And remember the course tagline: “Better Educators, Better Patient Care.”

The course is a week long experience of TED-like talks and workshops integrated with social media and FOAM (Free Open Access Medical Education). This is not your ordinary course filled with boring 60 minute Power Point lectures.

Please remember that this course is not just for emergency physicians. It’s for anyone who wants to make their mark on the world of medical education and social media. We have had pharmacists, nurses, and physician assistants take the course. If you want to be happier in your job as an educator and you would like to think that what you do on a daily basis makes a difference, then this is the course for you!

The Teaching Institute proudly presents The Teaching Course from Rob Rogers on Vimeo.

Why is this course special?

photo (11)

The Teaching Course Faculty

The course is special because we have captured the essence of why people attend conferences in the first place..to return home feeling refreshed, enthusiastic, and ready to change the world. It’s the same feeling I had after attending the SMACC Gold conference earlier this year. It is going to be an awesome course that will change how you view medical education and how you teach.

Who believes in us?

Several international societies and blogs/podcasts have already endorsed the Teaching Course because they believe in the phenomenal educational product we deliver.


What faculty are teaching in the course?

The faculty makes this course. Besides the usual University of Maryland suspects (Rob Rogers, Amal Mattu, Haney Mallemat, Mike Bond, et. al.), we have quite an impressive line up of guest speakers for the course. Just imagine a medical education & social media course with the likes of Victoria Brazil, Joe Lex, and Anand Swaminathan…UNBELIEVABLE!!  And this year we have a new Social Media Liaison, Anand Swaminathan (Swami). Folks, it is going to be amazing.


Victoria Brazil


Joe Lex

Swaminathan Headshot 2013

The Infamous “Swami”

How is this course different from others?

The Teaching Course is different from the “usual customers” in medical education/teaching conferences in many respects. We have broken the traditional mold and have developed a truly unique blend of short, TED-like talks and workshops. And don’t forget the social media and FOAM. Mix all of these together and you have a recipe for a course that can change the world of medical education.

Here is a short list of some of the things we do to set ourselves apart:

  • Livestreamed content (video-FOAM)
  • Livestreamed panel discussions (with live questions moderated from Twitter)
  • Heavy integration of social media and FOAM
  • Well known, motivational, dynamic speakers
  • “Flip the Classroom” packet delivered to all paid registrants prior to the course
  • Organized social events throughout the week
  • Emphasis on medical education, social media, and FOAM that will actually make a difference in your work setting.
  • The Legacy Program-if you pay for and attend a course you can come back to any future course (for FREE) and teach in it!
  • Unique workshops like the “Twitter Lounge” and the “Podcast Lounge.”
  • Group dinners including a very nice graduation dinner on the 4th night of the course
  • Tons of networking opportunities
  • Hands-on social media, FOAM, and medical education labs
  • Live Tweetwall
  • The PKTeach Talk Contest (deadline Aug 31st)

And that is just a short list. I don’t have room to include everything.

What’s new for 2014?

Lost coming this year. Lots of cool stuff. We will continue to Livestream some of our course content for free, and then we will release select presentations throughout the year. We just started our Legacy Program, so remember if you attend you become part of the Teaching Course family. You can come back to any future course for free. We will also find a way for you to teach some in the course.

We also have a new contest for this year (short notice): The PKTeach Contest. Just develop a PK talk on what your plans are to change the world of medical education and send to us. A winner will be chosen, and that lucky person will win FREE tuition to the course!

PKTeach Contest

What guest speakers do we have lined up for 2015?

We can’t release that one yet. Let’s just say it’s going to be huge. HUGE!

For more information about the course check out our website: The Teaching Course

Remember the dates for this year: Oct 20-24. We still have some spots open, so get on it and make your booking!

Hope to see you in Baltimore, Maryland in October!


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