Emergency Medical Minute

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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:

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

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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:

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
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
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

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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:

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
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
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
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

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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.

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

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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

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
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
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
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.
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

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Contributor: Aaron Lessen, MD

Educational Pearls:

Back pain is a common presenting complaint in the emergency department.
Challenges arise when tailoring care to elderly populations using standard medical therapy:
Muscle relaxants carry the risk of CNS depression or anticholinergic effects such as urinary retention and confusion.
Pain medications such as opiates have side effects including constipation, respiratory depression, and hypotension.
NSAIDs carry a risk of GI bleeding and worsening kidney function with chronic use.
A randomized clinical trial assessing the effects of acupuncture on low back pain took 800 adults aged 65 and older with chronic low back pain and placed them into one of three treatment arms:
Usual medical care
Standard acupuncture consisting of 8–15 treatment sessions over 12 weeks, plus usual medical care
Standard acupuncture consisting of 8–15 treatment sessions over 12 weeks, plus 4-6 maintenance sessions during the next 12 weeks, plus usual medical care
Using the Roland-Morris Disability Questionnaire (RMDQ) score, they assessed disability at 6 months and 12 months.
The study found that those who had undergone treatment with acupuncture had significantly greater improvements in disability related to low back pain compared to the group that was only treated with usual medical care.
Acupuncture is not used in the ER, but could represent a relatively safe adjunctive therapy for patients who are not responding to standard medical therapy alone.

References:

American College of Surgeons Committee on Trauma. Best practices guidelines: geriatric trauma management. American College of Surgeons; 2023. Accessed May 27, 2026. https://www.facs.org/media/ubyj2ubl/best-practices-guidelines-geriatric-trauma.pdf
DeBar LL, Wellman RD, Justice M, et al. Acupuncture for chronic low back pain in older adults: a randomized clinical trial. JAMA Netw Open. 2025;8(9):e2531348. doi:10.1001/jamanetworkopen.2025.31348

Summarized by Ashley Lyons, OMS3 | Edited by Ashley Lyons & Ahmed Abdel-Hafiz, NREMT-P

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Contributor: Travis Barlock, MD

Educational Pearls:

Caffeine Geography and Types:

Caffeine is found throughout the world and has evolved independently in various plants that are not evolutionarily related through direct lineage, but rather demonstrate convergent evolution (i.e. different species evolve the same traits).
These plants use caffeine as an insecticide.
Examples of caffeine sources include coffee, tea, yerba-mate, guaraná, cacao, and yaupon holly.
Roughly 85% of Americans are estimated to consume caffeine daily.

Caffeine Pharmacology in Humans:

In humans, caffeine is a nonselective competitive antagonist (blocker) of adenosine receptors (A1 and A2A).
During waking hours, neuronal metabolic activity consumes ATP, and a byproduct of ATP hydrolysis is created: adenosine.
Adenosine proceeds to build a "sleep pressure".
Acting on A1 and A2A adenosine receptors to induce sleep (on A1, it suppresses neuronal "wakefulness" and on A2A it is believed to be an inducer of sleep).
Caffeine, by blocking those receptors, blunts sleep induction and feelings of being tired.
Caffeine has a half-life of around 6 hours, and a quarter life of approximately 12 hours, which is when the caffeine will off-load and adenosine can once again occupy those receptors, potentially causing a "crash".
Thus, for shift-workers, it is important to time caffeine intake roughly 10 hours before target bed time.
Caffeine exerts other effects on the body.
It is methylxanthine similar to theophylline, which works as a bronchodilator (via phosphodiesterase and adenosine pathways). Caffeine has clinical use to promote bronchodilation in pre-term infants.
Caffeine exerts diuretic effects as well (blocking proximal renal tubule reabsorption).
Recent ingestion of caffeine may blunt therapeutic use of adenosine in patients with SVT.

Key Takeaway?

Caffeine exerts a wide variety of effects beyond making us feel more awake. It has cardiovascular, pulmonary, and renal implications in its pharmacodynamics.

References

Benarroch EE. Adenosine and its receptors: multiple modulatory functions and potential therapeutic targets for neurologic disease. Neurology. 2008;70(3):231-236. doi:10.1212/01.wnl.0000297939.18236.ec
Mitchell DC, Knight CA, Hockenberry J, Teplansky R, Hartman TJ. Beverage caffeine intakes in the U.S. Food Chem Toxicol. 2014;63:136-142. doi:10.1016/j.fct.2013.10.042
Bruschettini M, Brattström P, Russo C, Onland W, Davis PG, Soll R. Caffeine dosing regimens in preterm infants with or at risk for apnea of prematurity - Bruschettini, M - 2023 | Cochrane Library. Accessed May 23, 2026. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD013873.pub2/full?cookiesEnabled
Huang R, O'Donnell AJ, Barboline JJ, Barkman TJ. Convergent evolution of caffeine in plants by co-option of exapted ancestral enzymes. Proc Natl Acad Sci U S A. 2016;113(38):10613-10618. doi:10.1073/pnas.1602575113
Cabalag MS, Taylor DM, Knott JC, Buntine P, Smit D, Meyer A. Recent caffeine ingestion reduces adenosine efficacy in the treatment of paroxysmal supraventricular tachycardia. Acad Emerg Med. 2010;17(1):44-49. doi:10.1111/j.1553-2712.2009.00616.x

Summarized by Dan Orbidan, OMS2 | Edited by Dan Orbidan & Ahmed Abdel-Hafiz, NREMT-P

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Contributor: Travis Barlock, MD

Educational Pearls:

Endocannabinoid System: THC binds CB1 and CB2 receptors in neurons and immune cells

Δ9-Tetrahydrocannabinol (THC) is the main psychoactive compound in cannabis
CB1 and CB2 receptors typically bind endogenously-produced 2-arachidonoylglycerol (2-AG) and anandamide (AEA) to regulate pain, stress, and inflammation
THC similarly binds CB1 and CB2, leading to the cannabinoid high: euphoria, paranoia, anxiety, analgesia, anti-inflammation, and appetite, among a variety of others
Ingestion via edibles, vice inhalation via smoking, leads to chemical modification of Δ9-THC to 11-hydroxy-Δ9-THC, which more easily crosses the blood-brain barrier and binds CB1 with higher affinity, leading to increased psychoactivity

Cannabinoid Hyperemesis Syndrome (CHS): Chronic THC use leading to the classic presentation of persistent nausea and intense, frequent vomiting

Chronic activation of CB1 receptors in brain builds a tolerance and dependence on THC, in addition to chronic activation of the capsaicin and vanilloid receptor TRPV1, which binds capsaicin or is activated by heat
Treatment by warm showers works due to TRPV1 activation by heat
Treated with benzodiazepines, fluids, and gastro-intestinal or central nervous system agents according to patient presentation

Over 200 synthetic cannabinoids have been created (K2, spice, black mamba, mojo, etc), which are more dangerous and can lead to a variety of etiologies

Acetaminophen binds CB1 receptors to reduce inflammatory pain

References

Loganathan P, Gajendran M, Goyal H. A Comprehensive Review and Update on Cannabis Hyperemesis Syndrome. Pharmaceuticals (Basel). 2024;17(11):1549. Published 2024 Nov 18. doi:10.3390/ph17111549
Wall ME, Sadler BM, Brine D, Taylor H, Perez-Reyes M. Metabolism, disposition, and kinetics of delta-9-tetrahydrocannabinol in men and women. Clin Pharmacol Ther. 1983 Sep;34(3):352-63. doi: 10.1038/clpt.1983.179. PMID: 6309462.
Mills B, Yepes A, Nugent K. Synthetic Cannabinoids. Am J Med Sci. 2015 Jul;350(1):59-62. doi: 10.1097/MAJ.0000000000000466. PMID: 26132518.
Klinger-Gratz PP, Ralvenius WT, Neumann E, et al. Acetaminophen Relieves Inflammatory Pain through CB1 Cannabinoid Receptors in the Rostral Ventromedial Medulla. J Neurosci. 2018;38(2):322-334. doi:10.1523/JNEUROSCI.1945-17.2017

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

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Contributor: Aaron Lessen, MD

Educational Pearls:

There has long been many questions about which IV fluid is best for ED resuscitation
Multiple adult studies have shown no clear benefit of balanced fluid vs normal saline
A large pediatric randomized clinical trial published in April compared balanced fluid vs normal saline in children with septic shock
The study included about 9,000 patients from 47 emergency departments in five countries
Patients with septic shock were randomized to receive either balanced fluid or normal saline
The primary outcome was adverse kidney event (death, dialysis, or persistent kidney dysfunction) at 30 days or hospital discharge
Results showed no difference in any safety outcomes and no adverse events occurred
The key takeaway is that early fluid resuscitation matters more than which crystalloid you choose

References

Balamuth F, Weiss SL, Long E, et al. Balanced Fluid or 0.9% Saline in Children Treated for Septic Shock. New England Journal of Medicine. Published online April 23, 2026. doi:https://doi.org/10.1056/nejmoa2601969

Summarized by Meg Joyce, MS3 | Edited by Meg Joyce & Ahmed Abdel-Hafiz, NREMT-P

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

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Contributor: Taylor Lynch, MD

Educational Pearls:

Conduction abnormalities are a common and clinically significant complication in patients who undergo transcatheter aortic valve replacement (TAVR)

Clinical Features

The most common abnormalities include high grade AV block and new onset LBBB
Due to the close proximity of the aortic annulus to the AV node and His-Purkinje system
More common in males, the elderly, and those with pre-existing conduction disease (RBBB or LBBB)
Sinus pauses and sinus arrest are a rare post-TAVR rhythm disturbances
Temporary failure of sinus node firing with absent P waves, followed by return of sinus rhythm
Sinus Pauses: Typically last
Sinus Arrest: Typically last > 3 seconds
Not due to direct mechanical injury from the valve, but may occur in patients as a result of pre-existing disease or other external factors:
Medications
Beta blockers, calcium channel blockers, digoxin
Pre-existing damage to the SA node
Fibrosis from a previous MI

Treatment

If the patient is asymptomatic, provide ongoing surveillance
If the patient is symptomatic, treatment should be aimed at the underlying cause:
For medication-induced abnormalities, stop the offending medication
For acute, unstable bradycardia:
Medications: Atropine, Dopamine Infusion, Epinephrine Infusion
If cardiology is not immediately available, initiate transcutaneous pacing or insert a temporary transvenous pacemaker
Definitive treatment: Pacemaker
~10–15% of patients may develop a bradyarrhythmia post TAVR, with ~8-15% later requiring a pacemaker

Due to the risk of conduction abnormalities post TAVR, many patients are discharged with ambulatory rhythm monitoring such as a ZioPatch or Holter monitor, and may present to the emergency department for evaluation of rhythm disturbances.

References:

Kusumoto FM, Schoenfeld MH, Barrett C, et al. 2018 ACC/AHA/HRS guideline on the evaluation and management of patients with bradycardia and cardiac conduction delay. Heart Rhythm. 2019;16(9):e128-e226.
Lilly, S, Deshmukh, A, Epstein, A. et al. 2020 ACC Expert Consensus Decision Pathway on Management of Conduction Disturbances in Patients Undergoing Transcatheter Aortic Valve Replacement: A Report of the American College of Cardiology Solution Set Oversight Committee. JACC. 2020 Nov, 76 (20) 2391–2411.

https://doi.org/10.1016/j.jacc.2020.08.050

Sammour, Y, Krishnaswamy, A, Kumar, A. et al. Incidence, Predictors, and Implications of Permanent Pacemaker Requirement After Transcatheter Aortic Valve Replacement. J Am Coll Cardiol Intv. 2021 Jan, 14 (2) 115–134.

https://doi.org/10.1016/j.jcin.2020.09.063

Tarakji KG, Patel D, Krishnaswamy A, et al. Bradyarrhythmias detected by extended rhythm recording in patients undergoing transcatheter aortic valve replacement (Brady-TAVR Study). Heart Rhythm. 2022;19(3):381-388.

Summarized by Ashley Lyons, OMS3 | Edited by Ashley Lyons & Ahmed Abdel-Hafiz, NREMT-P

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Contributor: Alec Coston, MD

Educational Pearls:

What are nasal intubations and when do we use them?

Nasal intubations function similarly to oral intubations with the end goal of passing an endotracheal tube (ETT) through vocal cords and into the trachea to allow for a patent and secure airway, but differ in the main access point for the ETT (nare v.s. mouth).
Nasal Intubations are seldom preferred to oral intubations as they carry risk for inducing bleeding from trauma to the nasal passages.
Indications for nasal intubations include:
Anatomical abnormalities that may make access through the mouth difficult (i.e. tumors, macroglossia, or rare dental hardware that clenches the jaw shut).
Physiological states such as severe angioedema.
Nasal intubations are often done with the patient awake and could be advantageous if the patient is presenting in a severely hypoxic state such that prolonged hypoxia in a traditional RSI protocol may be detrimental.
A 2023 retrospective analysis in Germany found that nasal intubations were associated with requiring less sedation than oral intubations and had more spontaneous breathing during hospitalization than oral intubations.

How is a nasal intubation performed?

Consider the use of an anxiolytic medication such as versed to calm the patient down but not fully sedate them.
If there is adequate time without immediate patient compromise, consider glycopyrrolate to reduce airway secretions and dry up the mucous membranes.
Consider the use of Afrin or other local vasoconstrictor in target nare to minimize epistaxis.
Use 5% lidocaine ointment and lubricate an NPA and place it into the target nare. This will allow for local anesthesia as well as help to open up the nare slightly more.
Take 5% lidocaine ointment and place it on a tongue depressor and move it around the back of the tongue, allowing it to further anesthetize the oropharynx.
Remove the NPA and atomize/nebulize 4% lidocaine liquid into the nare and into the oropharynx for further anesthesia.
Insert the ETT without the bronchoscope through the nare and allow it to pass about 10 cm until visible in the oropharynx. This allows for a "clean" plastic tunnel to pass the bronchoscope through.
Advance both the ETT and bronchoscope, spraying lidocaine through the bronchoscope while advancing to allow for continued numbing.
Pass the ETT through the cords and inflate.
At this point, stronger sedation medications such as ketamine and propofol may be considered but the use of a paralytic like succinylcholine and rocuronium may not be needed to allow the patient to maintain their own negative pressure ventilation.

Which nare is the best to go through?

Most patients will have their right nare be the best (away from the septal deviation) according to a meta-analysis by Tan et al.
The right nare was generally associated with less epistaxis and lower intubation times.
However, do not always default to the right nare, and test which nare is more patent by occluding one nare at a time and assessing which one is less resonant (less resonant = more patent).

Key Takeaway?

Nasal intubations are rarer than oral intubations and can be more technically difficult, but may offer advantages in patients with difficult oral airways, but should never be first line.

References:

Grensemann J, Gilmour S, Tariparast PA, Petzoldt M, Kluge S. Comparison of nasotracheal versus orotracheal intubation for sedation, assisted spontaneous breathing, mobilization, and outcome in critically ill patients: an exploratory retrospective analysis. Sci Rep. 2023;13:12616. doi:10.1038/s41598-023-39768-1
Tan YL, Wu ZH, Zhao BJ, Ni YH, Dong YC. For nasotracheal intubation, which nostril results in less epistaxis: right or left?: A systematic review and meta-analysis. Eur J Anaesthesiol. 2021;38(11):1180-1186. doi:10.1097/EJA.0000000000001462
Holzapfel L. Nasal vs oral intubation. Minerva Anestesiol. 2003;69(5):348-352.

Summarized by Dan Orbidan, OMS2 | Edited by Dan Orbidan & Ahmed Abdel-Hafiz, NREMT-P

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Contributor: Aaron Lessen, MD

Educational Pearls:

What are the common causes of agitation in the elderly?

Baseline dementia causing a behavioral disturbance
Delirium precipitated by an acute medical problem such as a UTI, pneumonia, overdose/side effect of home medications, urinary retention, constipation, pain, hypoxia, electrolyte abnormality, etc.
Exacerbation of a primary psychotic condition such as schizophrenia or bipolar disorder.

What environmental changes can help reduce agitation?

Maintain a quiet, calm, uncluttered environment
Dim the lights
Ensure the patient has their glasses, hearing aids, and dentures
Avoid excessive lines such as foleys
Minimize restraints and other forms of immobilization
Reassure the patient frequently and have the family check in with the patient

What are the best options if medications are required?

If the patient is unsafe or non-pharmacologic measures fail, consider a second-generation ("atypical") antipsychotic using the lowest effective dose:
- Olanzapine
- Risperidone
- Quetiapine
One special consideration is Dementia with Lewy Bodies, which can be very sensitive to antipsychotics.
- In this case, Quetiapine is the preferred agent.

Avoid when possible:

Diphenhydramine and other anticholinergics, which can worsen delirium (including urinary retention and sedation)
Benzodiazepines, which may worsen confusion, falls, and respiratory depression
Haloperidol, which has a higher risk of extrapyramidal symptoms and QT prolongation than many atypicals

References

Badwal K, Kiliaki SA, Dugani SB, Pagali SR. Psychosis Management in Lewy Body Dementia: A Comprehensive Clinical Approach. J Geriatr Psychiatry Neurol. 2022 May;35(3):255-261. doi: 10.1177/0891988720988916. Epub 2021 Jan 19. PMID: 33461372.
Kurlan R, Cummings J, Raman R, Thal L; Alzheimer's Disease Cooperative Study Group. Quetiapine for agitation or psychosis in patients with dementia and parkinsonism. Neurology. 2007 Apr 24;68(17):1356-63. doi: 10.1212/01.wnl.0000260060.60870.89. PMID: 17452579.
Shenvi C, Kennedy M, Austin CA, Wilson MP, Gerardi M, Schneider S. Managing Delirium and Agitation in the Older Emergency Department Patient: The ADEPT Tool. Ann Emerg Med. 2020 Feb;75(2):136-145. doi: 10.1016/j.annemergmed.2019.07.023. Epub 2019 Sep 26. PMID: 31563402; PMCID: PMC7945005.

Summarized and edited by Jeffrey Olson, MS4

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Contributor: Aaron Lessen, MD

Educational Pearls:

Patients with pulmonary embolism (PE) are divided into three risk categories
- Low risk (non-massive PE): patients are stable
  - Treatment: prescribe anticoagulants and discharge home
- Intermediate risk (submassive PE): patients are stable but display evidence of clot burden such as elevated troponin, elevated BNP, and/or right heart strain
  - Treatment is controversial
- High risk (massive PE): patients are unstable with hypotension, hypoxia, and/or respiratory distress
  - Treatment: IV thrombolysis to prevent decompensation
A recent randomized controlled trial evaluated treatment of intermediate risk PE patients
- Patients were randomized to receive either thrombectomy with anticoagulation or anticoagulation alone
- The primary outcome evaluated changes in right ventricular enlargement at 48 hours
  - A controversial primary outcome because it does not speak to mortality or incidence of other necessary aggressive interventions
  - Low clinical significance
- The study found that thrombectomy significantly reduced right ventricular enlargement faster than anticoagulation alone. However, there was no statistical difference in mortality or need for other treatments
Treatment for intermediate risk PE patient remains controversial
The same study will have second follow-up at 90 days to see if there are other benefits

References

Lookstein RA, Konstantinides SV, Weinberg I, Dohad SY, Rosol Z, Kopeć G, Moriarty JM, Parikh SA, Holden A, Channick RN, McDonald B, Nagarsheth KH, Yamada K, Rosovsky RP; STORM-PE Trial Investigators. Randomized Controlled Trial of Mechanical Thrombectomy With Anticoagulation Versus Anticoagulation Alone for Acute Intermediate-High Risk Pulmonary Embolism: Primary Outcomes From the STORM-PE Trial. Circulation. 2026 Jan 6;153(1):21-34. doi: 10.1161/CIRCULATIONAHA.125.077232. Epub 2025 Nov 3. PMID: 41183181.

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

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Hosts: Don Stader, Nate Novotny, Travis Barlock, and Jeffrey Olson

In this episode, we reminice about the first 1000 medical minutes presented by EMM and what the next 1000 might hold. Below are all of the episodes referenced in this episode. Please go back and give them all a listen.

Segment 1- Recap and Facts

1st medical minute

o April 29, 2016. Almost exactly 10 years ago.

o Diverticulitis and Antibiotics by Dr. Chris Holmes

1000th Medical Minute

o March 30, 2026

o Treatment of burns by Aaron Lessen

o Edited by Ashley Lyons and published by Jorge Chalit

Favorite sub-topics have included:

o Cardiovascular topics- 150 episodes

o Pharmacology- 97 episodes

o Toxicology- 85 episodes

o Neurology- 75 episodes

The "Hunting for…" cinematic universe. -Michael Hunt

o 399: Hunting for Pancreatitis

o 424: Hunting for Measles

o 432: Hunting for UTIs

o 445: Hunting for the Endotracheal Tube

o 455: Hunting for PeeCP

o 460: Hunting for PE in Syncope

o 487: Hunting for Epiglottitis

Obsession with 1966- Chris Holmes

o 120: The State of Sepsis in 1966

o 125: Old School CPR - 1966

o 138: Bromide Toxicity - 1966

o 147: GI Bleed - 1966

o 675: CHF like it's 1966

Favorite drug: naloxone/narcan (9)

o 7: Heroin Overdose and OTC Narcan

o 464: Narcan't?

o 516: Narcan and Pulmonary Edema

o 931: Naloxone in Cardiac Arrest

Favorite disease state: Sepsis (13)

o 22: Sepsis Sofa

o 219: History of Sepsis

o 244: Fever in Sepsis

o 263: Early Antibiotics in Sepsis

o 272: More on Temperature in Sepsis

o 287: Sepsis Bundles

o 544: C is for Sepsis

Unhinged title combinations

o 84: Hypothermia and Lightning Strike: Code Blue

o 203: Wine, Milk and… Vaccines!?

o 216: Roller Coasters and Kidney Stones

o 299: Black Death, Lice, Math, and Pottery

o 427: Cookie Dough is Delicious

o 670: Operation Tat-Type

o 695: Einstein and Cellophane

o 777: Grass, weed and ancient Rome

o 781: Foxglove, dropsy, and Salvador Dali

o 959: The KLM Flight Disaster and Lessons in Healthcare Communication

Most frequent contributors

Aaron Lessen- 192
Don Stader- 84
Jarod Scott- 83
Peter Bakes- 53
Samuel Killian- 45
Dylan Luyten- 41
Erik Verzemnieks- Dozens
Michael Hunt- 34
Travis Barlock- 30
Ricky Dhaliwal- 25

Top female voices

o Rachael Duncan, PharmD

o Rachel Beham, PharmD

o Meghan Hurley

o Gretchen Hinson

o Suzanne Chilton

o Katie Sprinkle

Most listened to

1. Podcast 835: Syncope Review
1. Podcast 766: Truth about Tramadol
1. Podcast 839: Causes of Pancreatitis
1. Podcast 760: Why Fentanyl is the Worst
1. Podcast 844: Dental Infections
1. Podcast 846: Early Repolarization vs. Anterior STEMI
1. Podcast 845: Hyperkalemic Cardiac Arrest
1. Podcast 847: ECMO CPR

Mini-game: who has actually seen our most rare diagnoses?

o 18: Lemierre's Syndrome – Septic thrombophlebitis of the internal jugular vein after oropharyngeal infection leading to septic emboli.

o 139: Locked-in Syndrome – Ventral pontine lesion causing quadriplegia and inability to speak with preserved consciousness and eye movements.

o 144: Moyamoya Disease – Progressive stenosis of intracranial carotids with development of fragile collateral vessels causing strokes.

o 221: Cotard Delusion (Walking Corpse Syndrome) – Psychiatric disorder where patients believe they are dead or do not exist.

o 240: Pott's Puffy Tumor – Frontal bone osteomyelitis with subperiosteal abscess from sinusitis causing forehead swelling.

o 277: Mucormycosis (Rhizopus) – Angioinvasive fungal infection in immunocompromised patients causing rapid tissue necrosis.

o 293: Transient Global Amnesia – Sudden, transient loss of ability to form new memories that resolves within 24 hours.

o 329: Hypokalemic Periodic Paralysis – Episodic muscle weakness due to intracellular potassium shifts.

o 374: Iliac Artery Endofibrosis – Exercise-induced fibrosis of the iliac artery causing claudication in athletes.

o 466: Subacute Sclerosing Panencephalitis (SSPE) – Progressive, fatal neurodegenerative disease from persistent measles infection.

o 477: Postpolypectomy Electrocoagulation Syndrome – Transmural burn of the colon after polypectomy causing localized peritonitis without perforation.

o 578: Brown-Séquard Syndrome – Hemisection of the spinal cord causing ipsilateral motor/proprioception loss and contralateral pain/temperature loss.

o 697: Kounis Syndrome – Acute coronary syndrome triggered by allergic reaction causing coronary vasospasm or plaque rupture.

o 973: Meningitis Retention Syndrome – Acute urinary retention due to sacral nerve dysfunction during meningitis.

Segment 2- Individual Interviews

Segment 3- Looking forward

Segment 4- Trivia

Podcast 38, what is significant about diphtheria and March 18th?

o On March 18th, the Iditarod is run in Alaska to commemorate a sled dog team, led by Balto, that ran from Nome to Anchorage and back to provide children in Nome with the diphtheria anti-toxin serum.

Podcast 52: Syphilis the Great Imitator. The study of Syphilis or "Syphilology" evolved into the field of what?

o Dermatology

Podcast 121: The Poor Man's Methadone. What is the poor man's methadone?

o Imodium

Podcast 136: James Lind, conducted the first clinical trial in 1747 and proved that what cure what? Hint: think vitamins.

o Citrus fruits cure scurvy.

Podcast #213: --- and Potatoes. What food has been shown to lower LDL?

o Oats

Podcast #216: Roller Coasters and Kidney Stones. A study used a model of a kidney and ureter with different sized stones and put it on ------ roller coaster in Disney World.

o Thunder Mountain

Podcast #261. ---- was introduced to treat ACE-inhibitor induced angioendema. but later, better-powered studies showed that it had no benefit compared to standard treatment.

o Icatibant

Podcast #304: ---. ---- was a formal medical diagnosis, and one that dates back to 17th century when soldiers had longing for home and melancholy with a constellation of symptoms including lethargy, sadness, disturbed sleep, heart palpitations, GI complaints, and/or skin findings for which the only cure was to return home.

o Nostalgia

Podcast # 351: Steakhouse Syndrome. What is steakhouse syndrome?

o Impacted food bolus 2/2 esophageal stricture

Podcast # 362: Giant Hogweed. What can Giant Hogweed cause.

o Photosensitivity, severe blisters, and burns

Podcast #398: Who is gonna fail your antibiotic plan? What vital sign abnormality at triage had the highest odds ratio for treatment failure for the treatment of cellulitis with antibiotics.

o Tachypnea

Podcast # 458: A Tylenol a Day Keeps the ---- Away? A recent study investigated the effect of scheduled IV acetaminophen on the incidence of ---- in post-CABG patients in the ICU

o Delerium

Podcast 554: Sleeping Away Alzheimer's. What is the difference between white noise and pink noise?

o White noise is all the surrounding sound frequencies mixed together that your brain tunes down so you don't get distracted while you're sleeping

o Pink noise, or deep soothing noises, is the accentuated bass sounds like falling rain or waves crashing your brain keys into while sleeping.

o Pink noise during sleep has been shown to increase stage 4, creating more CSF washout of beta amyloid.

Podcast 580: Origin of PPE. Why were rubber gloves invented?

o The invention of surgical gloves are credited to surgeon William Halsted. He developed gloves because one of his assistants (and later wife), Carol Hampton, was having severe irritation due to a caustic pre-op disinfecting process. They developed the rubber glove for Hampton which garnered popularity, and by the early 20th century, half of surgeons were using rubber gloves.

Podcast 587: Puppies Preventing Burnout? Puppies lower stress, what activity in that study increased stress?

o Coloring, because they were denied a chance to play with a puppy

Podcast 596: Weather Can be a Headache. What are the three weather events that can increase the frequency of headaches?

o High temp

o Low humidity

o High air pollution

Podcast 612: Origin of Vaccines. Guess both diseases. The potential of vaccinations was first observed in the late 1600s when Jenner observed people who had cowpox never contracted ----. Years later, Louis Pasteur inoculated chickens with ---- after his assistant accidently created the first live attenuated vaccine by creating a weakened bacteria when he left the bacteria out while he went on vacation

o Smallpox, cholera

Podcast 670: Operation Tat-Type. In 1951, Operation Tat-Type began tattooing adults with their ---- in an effort to prepare for ---- in the time of the Cold War and the Korean War

o Blood type, rapid transfusions

Podcast 695: Einstein and Cellophane. Albert Einstein had ----- as a middle-aged man. Dr. Rudolph Nissen, founder of the Nissen fundoplication, performed exploratory surgery for this pain and found a ----

The only treatment for an AAA at that time was to----, causing a fibrotic response to prevent rupture
Einstein died 7 years after this surgery, likely from his leaking abdominal aortic aneurysm

o chronic abdominal pain

o AAA

o wrap the vessel in cellophane

Podcast 748: -----. Whale blubber, honey, home fermented foods, homemade wine (especially the wine made in prison), and improperly stored canned food can all contain the toxin

o Botulism

Podcast 777: Grass, Weed, and Ancient Rome. Wine and wormwood and white hellborn were used in ancient rome to treat ----.

o Nausea, sea sickness

Podcast 821: EKGs in Syncope. Travis suggests a mnemonic for remembering additional EKG findings to look for in syncope

o WOBBLER

§ Wolff-Parkinson-White (WPW)

§ Obstructed AV node

§ Brugada syndrome

§ Bifascicular block

§ Left Ventricular Hypertrophy (LVH)

§ Epsilon waves

§ Repolarization abnormalities

Podcast 890: Outdoor Cold Air for Croup A 2023 study, published in the Journal of Pediatrics, investigated whether a 30-minute exposure to outdoor cold air could improve mild to moderate croup symptoms before the onset of steroid effects. In what country was this study conducted.

o Switzerland

Podcast 925: Pediatric Tongue Entrapment. Case study of a peds patient with his/her tongue stuck in a drinking cap. What was the substance that finally set it free?

o Table sugar

Podcast 960: Frank's Sign - A Marker for Coronary Artery Disease. What is Frank's Sign?

o Bilateral earlobe crease

Thank you to all that make the EMM awesome!

Hosted and editted by Jeffrey Olson MS4 | Additional editting by Jorge Chalit, OMS4

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Contributor: Aaron Lessen, MD

Educational Pearls:

Burns range in complexity from minor first-degree burns to more severe full-thickness burns.
Initial basic burn management:
- Run the burn under cool running water for 20 minutes.
- Do not scrub the skin.
- Do not use ice water.
- Ideally initiated as soon as possible, but no later than 3 hours after injury.
- Applicable to all burns ranging from superficial to full thickness.
Then apply a non-adherent dressing or sterile gauze.
Can be done at home or upon presentation to the emergency department.
These steps decrease pain and minimize tissue damage.
A study published in Annals of Emergency Medicine found that, out of 371 EMS and emergency medicine providers,
- 90% had not heard of the recommendation to run burns under cool water for 20 minutes.
- The majority of providers interviewed expressed motivation to implement this burn cooling practice but cited barriers such as:
  - Difficulty immersing certain body parts (e.g., chest).
  - Critically ill patients requiring other urgent interventions.

References:

Holbert MD, Singer Y, Palmieri T, et al. Cool Running Water as a First Aid Treatment for Burn Injuries. Annals of Emergency Medicine. 2025;S0196-0644(25)01138-2. doi:10.1016/j.annemergmed.2025.08.003.
Olawoye OA, Isamah CP, Ademola SA, et al. Effect of Prehospital Topical Application of Water and Other Agents on Outcome in Burn Injured Patients: A Prospective Study. Burns. 2025;51(2):107357. doi:10.1016/j.burns.2024.107357.

Summarized by Ashley Lyons, OMS3 | Edited by Ashley Lyons & Jorge Chalit, OMS4

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Contributor: Travis Barlock, MD

Educational Pearls:

What is an internal jugular catheter (IJ) and when do we use it?

IJs are catheters that can be placed in either the left or the right internal jugular vein to provide central venous catheter (CVC) access. CVCs can be placed in other locations other than the internal jugular vein (i.e. subclavian vein or femoral veins).
IJs are used when the patient may require long-term venous access or have to receive hyperosmolar solutions (such as solutions with high glucose content for parenteral nutrition); solutions with extreme pHs (9); or vesicant drugs (drugs that can cause tissue necrosis with extravasation).
They are not to be confused with EJs (external jugular vein catheters) which can be placed in difficult to peripherally catheterize patients. EJs function similarly to a peripheral IV.
The advantage of IJs is their location in larger veins brings them closer to direct access to the heart (i.e. the right internal jugular vein will provide immediate/quicker access to the right atrium to the heart.)

What are concerns of using a right internal jugular catheter versus one in the left?

The right internal jugular vein provides quick access to the heart via the right atrium, making it ideal in critically ill patients who may require vasopressor support.
However it is also the site commonly used for additional cannulation procedures such as hemodialysis, pulmonary artery pressure measurements, extracorporeal membrane oxygenation (ECMO) and transvenous pacemaker placement.
These procedures are not uncommon in critically ill patients who also required a CVC for initial hemodynamic support via vasopressors.
Gharaibeh et al. found that patients who received a right IJ and hemodialysis had a higher need for re-insertion of the hemodialysis catheter (40% compared to 2.6% in the left IJ group).
Furthermore, it was found that with a right IJ, hemodialysis catheters had to be exchanged by a guidewire in 23% of those with a right IJ as opposed to 0.9% in the left IJ group (a guidewire exchange is often considered a salvage technique to try and maintain access).

Big Takeaway?

If you are able to obtain an IJ on the right, you can likely obtain one on the left, and if considering longitudinal care for your patient, consider obtaining an IJ on the left to allow for future critical access in the right IJ.

References

Gharaibeh KA, Abdelhafez MO, Guedze KEB, Siddiqi H, Hamadah AM, Verceles AC. Impact of initial jugular vein insertion site selection for central venous catheter placement on hemodialysis catheter complications. Journal of Critical Care. 2025;87:155011. doi:10.1016/j.jcrc.2024.155011
Gallieni M, Pittiruti M, Biffi R. Vascular access in oncology patients. CA: A Cancer Journal for Clinicians. 2008;58(6):323-346. doi:10.3322/CA.2008.0015

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

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Contributor: Aaron Lessen, MD

Educational Pearls:

How long do we need to watch patients with a presumed overdose who were treated with naloxone in the field?

A 2025 study in the Annals of Emergency Medicine took a look at this question
Methods
- Prospective, multi-institutional cohort study
- Included ED patients with suspected acute opioid overdose with biologic testing to confirm substances.
- This paper performed a secondary analysis evaluating the risk of "delayed intubation," defined as intubation occurring >4 hours after ED arrival.
Results
- 1,591 patients with presumed opioid overdose were included.
- Delayed intubation occurred in only 9 patients (0.6%).
- 8 of the 9 cases had non-respiratory causes contributing to intubation.
- Only 1 patient had respiratory-related deterioration, presenting with respiratory acidosis after receiving 6.4 mg naloxone prior to intubation.
Key Takeaway
- Delayed respiratory deterioration requiring intubation after 4 hours of ED monitoring is extremely rare, suggesting prolonged monitoring may not be necessary for most stabilized overdose patients.

How else can we mitigate risk?

Give patients take-home naloxone at discharge and educate them on how to use it (See Episode 673: Leaving the ED with Naloxone).

When are naloxone drips necessary?

If a patient requires repeated naloxone boluses, consider a drip
To get the dose, take the total naloxone dose that restored adequate breathing and give two-thirds of that dose per hour
Typically these patients are admitted to the ICU

References

McCabe DJ, Gibbs H, Pratt AA, Culbreth R, Sutphin AM, Abston S, Li S, Wax P, Brent J, Campleman S, Aldy K, Falise A, Manini AF; ToxIC Fentalog Study Group. Risk of Delayed Intubation After Presumed Opioid Overdose in the Emergency Department. Ann Emerg Med. 2025 Jun;85(6):498-504. doi: 10.1016/j.annemergmed.2025.01.022. Epub 2025 Mar 4. PMID: 40047773; PMCID: PMC12955731.

Summarized and edited by Jeffrey Olson MS4

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Contributor: Travis Barlock, MD

Educational Pearls:

D-dimer: fibrin degradation product used to evaluate for clot formation and breakdown
- Threshold:
- Elevated D-dimer indicates recent or ongoing intravascular coagulation and fibrinolysis
YEARS score: algorithm to assess PE risk using three clinical criteria
- Criteria: signs of DVT, hemoptysis, and PE as the most likely diagnosis
- YEARS score of 0 with D-dimer
- YEARS score of ≥1 with D-dimer
- A study found that YEARS score accurately predicted the presence or absence of PE in 80% of enrolled patients with 90% sensitivity and 65% specificity
D-dimer may also help exclude aortic dissection: Aortic Dissection Detection Risk Score (ADD-RS)
- When ADD-RS = 0 or 1 and D-dimer
- When ADD-RS >1, patients are considered high probability for aortic dissection and CT should be performed

References

Fayiad, H., Moussa, H., Nosair, Y. et al. Predictive accuracy of years score in diagnosis of pulmonary embolism. Egypt J Bronchol 18, 18 (2024). https://doi.org/10.1186/s43168-024-00269-y
Weitz JI, Fredenburgh JC, Eikelboom JW. A Test in Context: D-Dimer. J Am Coll Cardiol. 2017 Nov 7;70(19):2411-2420. doi: 10.1016/j.jacc.2017.09.024. PMID: 29096812.
Yichao Ma,Zhenjiang Ding,Yunong Zhao,Paijiao Zhang,Bo Du,Ye Shen,Junmei Hu,Luqi Zhu,Honghong Zhao,Chunrong Jin,Yuhong Wang,Lizhen Gao,Research progress on multi-marker detection technology for cardiovascular diseases (review), Journal of Electroanalytical Chemistry, 1008, (119969), (2026).

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

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Contributor: Taylor Lynch MD Educational Pearls:

Melatonin is an endogenous hormone released primarily by the pineal gland
- Also released by extrapineal regions in the retina, the GI tract, and some immune cells
Peak secretion occurs at night and is suppressed during the day
- Secretion and production decrease with age
- Older patients experience the greatest improvement in sleep latency and sleep quality
Mechanism of action in the suprachiasmatic nucleus of the hypothalamus
- MT1 receptor
  - Reduces normal firing
- MT2 receptor
  - Shifts the circadian rhythm
FDA approved for insomnia
- Decreases sleep latency by 7 minutes
- Increases total sleep time by 8 minutes
FDA approved for circadian sleep-wake disorders
- Jet lag
  - Most effective in west-to-east travel
  - Best if crossing at least 5 time zones
- Shift work
  - A study examined ED physicians and nurses with rotating shifts
  - Modest increase in deep sleep percentage
  - No difference in cognition or reaction time the day after taking melatonin
  - Nurses on rotating night shifts experienced increased total sleep time by 20 minutes
Dosing
- 0.5 - 3 mg is the most evidence-based dosing
- Higher doses increase the risk of rebound grogginess but do not improve outcomes

References

Ahmad SB, Ali A, Bilal M, et al. Melatonin and Health: Insights of Melatonin Action, Biological Functions, and Associated Disorders. Cell Mol Neurobiol. 2023;43(6):2437-2458. doi:10.1007/s10571-023-01324-w
Herxheimer A, Petrie KJ. Melatonin for the prevention and treatment of jet lag. Cochrane Database Syst Rev. 2002;(2):CD001520. doi:10.1002/14651858.CD001520
Morgenthaler TI, Lee-Chiong T, Alessi C, Friedman L, Aurora RN, Boehlecke B, Brown T, Chesson AL Jr, Kapur V, Maganti R, Owens J, Pancer J, Swick TJ, Zak R; Standards of Practice Committee of the American Academy of Sleep Medicine. Practice parameters for the clinical evaluation and treatment of circadian rhythm sleep disorders. An American Academy of Sleep Medicine report. Sleep. 2007 Nov;30(11):1445-59. doi: 10.1093/sleep/30.11.1445. Erratum in: Sleep. 2008 Jul 1;31(7):table of contents. PMID: 18041479; PMCID: PMC2082098.
Thottakam BMVJ, Webster NR, Allen L, Columb MO, Galley HF. Melatonin Is a Feasible, Safe, and Acceptable Intervention in Doctors and Nurses Working Nightshifts: The MIDNIGHT Trial. Front Psychiatry. 2020;11:872. Published 2020 Aug 27. doi:10.3389/fpsyt.2020.00872

Summarized and edited by Jorge Chalit, OMS4

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Contributor: Travis Barlock, MD

Educational Pearls:

Foul-smelling urine and cloudy urine are commonly misinterpreted as indicators of a UTI. However, these findings alone are not diagnostic.
Criteria for UTI:
- Presence of localized urinary symptoms:
- Suprapubic pain
- Dysuria
- Hesitancy
- Urgency
- Urinalysis with WBC > 10
- Urine culture with > 100,000 CFU/mL
Colonization differs from infection - many patients harbor asymptomatic bacteria but do not have a true infection.
Consequences of overtreatment
- One review showed 45% of patients treated with antibiotics for a presumed UTI actually had asymptomatic bacteriuria and were incorrectly treated.
- Unnecessary antibiotic treatment can have deleterious effects on the gut microbiome, increasing the risk of multidrug-resistant infections.
- Another problem with overdiagnosing UTI is missing the real diagnosis by explaining symptoms away as "just a UTI."
Be mindful of the risk of overtesting versus not testing at all.
- Clinicians must navigate a balance between moving patients efficiently through the ER and testing appropriately when a UTI is truly suspected.

References:

Baghdadi JD, Korenstein D, Pineles L, et al. Exploration of primary care clinician attitudes and cognitive characteristics associated with prescribing antibiotics for asymptomatic bacteriuria. JAMA Netw Open. 2022;5(5):e2214268. doi:10.1001/jamanetworkopen.2022.14268
Colgan R, Williams M. Acute uncomplicated urinary tract infections in adults. Am Fam Physician. 2024;109(2):167-174. Accessed February 21, 2026. https://www.aafp.org/pubs/afp/issues/2024/0200/acute-uncomplicated-utis-adults.html#afp20240200p167-ta1

Summarized by Ashley Lyons OMS3 | Edited by Ashley Lyons & Jorge Chalit OMS4

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Contributor: Aaron Lessen, MD Educational Pearls:

What is anaphylaxis and what are its treatments?

Anaphylaxis is a broad term for potentially life threatening allergic reactions that can progress to cardiovascular collapse (anaphylactic shock).
It is triggered by IgE and antigen cross-linking on mast cells to induce degranulation and the release of histamines, which can cause diffuse vasodilation and respiratory involvement with end-organ hypoperfusion.
First line treatment is the immediate administration of epinephrine at 0.01 mg/kg (max dose for pediatrics is 0.3 mg and for adults is 0.5 mg) as well as removal of the offending agent causing the reaction.
Additional pharmacologic treatments such as anti-histamines and steroids should be considered but not used instead of epinephrine when anaphylactic shock is evident as the sole therapy.

What is biphasic anaphylaxis and what is its occurrence?

Biphasic anaphylaxis is the return of anaphylactic symptoms after the initial anaphylactic event. Previous studies have reported an incidence ranging from 1-20% of patients having an initial anaphylactic reaction having biphasic anaphylaxis, at a range of time from 1-72 hours.
The mechanism of biphasic anaphylaxis is not completely known, but can be contributed to by initial interventions wearing off (and why patients will be monitored for 2-4 hours after initial symptoms and treatment), or delayed immune mediators beginning to take effect.
Recent studies show that the rate of biphasic anaphylaxis may be closer to 16% occurrence with a median time of occurrence being around 10 hours.

What is the key take away and patient education on biphasic anaphylaxis?

After patients have been observed for the initial 2-4 hours in the emergency room, they are generally safe to go home.
Patients should be informed of the need to carry an Epi-Pen for similar anaphylactic reactions, and informed that there is a chance within the next day (10-20 hours) that they may have the symptoms occur once again.
The biphasic reaction may be more mild, and patients should be educated on how to treat it and to seek immediate emergency care if the symptoms do not improve.

References

Golden DBK, Wang J, Waserman S, et al. Anaphylaxis: A 2023 practice parameter update. Annals of Allergy, Asthma & Immunology. 2024;132(2):124-176. doi:10.1016/j.anai.2023.09.015
Rubin S, Drowos J, Hennekens CH. Anaphylaxis: Guidelines From the Joint Task Force on Allergy-Immunology Practice Parameters. afp. 2024;110(5):544-546.
Weller KN, Hsieh FH. Anaphylaxis: Highlights from the practice parameter update. CCJM. 2022;89(2):106-111. doi:10.3949/ccjm.89a.21076
Gupta RS, Sehgal S, Brown DA, et al. Characterizing Biphasic Food-Related Allergic Reactions Through a US Food Allergy Patient Registry. The Journal of Allergy and Clinical Immunology: In Practice. 2021;9(10):3717-3727. doi:10.1016/j.jaip.2021.05.009

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

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Contributor: Alec Coston, MD

Educational Pearls:

Disclaimer: this has nothing to do with the ER but is too cool to not talk about.

Condition: Carbamoyl phosphate synthetase 1 (CPS1) deficiency
Rare inborn error of metabolism
Inability to properly break down ammonia
Leads to severe hyperammonemia and hepatic encephalopathy
Natural history:
Without treatment, typically fatal within the first few weeks of life
Even with current standard treatments, life expectancy is often limited to ~5–6 years
Breakthrough treatment:
A team of researchers at the Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania developed the CRISPR-based targeted gene therapy for this patient.
First-of-its-kind precision approach tailored to the patient's specific mutation
Key components of the therapy:
Whole-genome sequencing to identify the exact CPS1 mutation
Creation of a custom base-editing enzyme designed to correct that specific mutation
Design of a guide RNA to direct the base editor to the precise genomic location
Delivery method:
Lipid nanoparticles used to deliver the gene-editing machinery
Nanoparticles can be targeted to specific tissues
Why the liver works well:
CPS1 is primarily expressed in hepatocytes
The liver is relatively easy to target with lipid nanoparticles
Hepatocytes divide frequently, allowing edited genes to be passed on as cells replicate
Long-term impact:
Once edited, cells continue producing functional CPS1 enzyme
Potential for durable, possibly lifelong correction from a single treatment

References

https://www.nih.gov/news-events/news-releases/infant-rare-incurable-disease-first-successfully-receive-personalized-gene-therapy-treatment
Choi Y, Oh A, Lee Y, Kim GH, Choi JH, Yoo HW, Lee BH. Unfavorable clinical outcomes in patients with carbamoyl phosphate synthetase 1 deficiency. Clin Chim Acta. 2022 Feb 1;526:55-61. doi: 10.1016/j.cca.2021.11.029. Epub 2021 Dec 29. PMID: 34973183.
Bharti N, Modi U, Bhatia D, Solanki R. Engineering delivery platforms for CRISPR-Cas and their applications in healthcare, agriculture and beyond. Nanoscale Adv. 2026 Jan 5. doi: 10.1039/d5na00535c. Epub ahead of print. PMID: 41640466; PMCID: PMC12865601.

Summarized and edited by Jeffrey Olson MS4

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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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Contributor: Aaron Lessen, MD

Educational Pearls:

A 2025 multistate outbreak of infant botulism has been linked to ByHeart infant formula

As of December 10-17th, there have been at least 51 infants with suspected or confirmed botulism who were exposed to this formula across 19 states
All reported cases resulted in hospitalization but no deaths reported to date

Infant botulism

Occurs when C. botulinum spores germinate in the infant's intestine, producing toxin
Spores are classically found in honey but can also be in dirt or contaminated in infant formula
Infants are particularly susceptible because their body can't neutralize the spores
Symptoms may include initial constipation, poor feeding, weak cry, floppy movements, loss of head control, difficulty swallowing, generalized weakness, and respiratory compromise if progressive
Can be treated with antitoxin
Maintain a high index of suspicion for infant botulism in infants fed the recalled formula presenting with neuromuscular symptoms.

References

Human Foods Program. Outbreak Investigation of Infant Botulism: Infant Formula. U.S. Food and Drug Administration. Published 2025. https://www.fda.gov/food/outbreaks-foodborne-illness/outbreak-investigation-infant-botulism-infant-formula-november-2025

Summarized by Meg Joyce, MS2 | Edited by Meg Joyce & Jeffrey Olson, MS4

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

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Contributor: Meghan Hurley, MD

Educational Pearls:

OTC Medications

Dextromethorphan (DM)
- Most common OTC cough suppressant
- Minimal efficacy: Little evidence that it shortens the duration or severity of cough.
- Potential side effects:
  - At recommended doses: Mild dizziness, drowsiness, GI symptoms
  - Higher doses: Decreased consciousness, dissociative effects
Guaifenesin
- Found in Mucinex and other severe cough/cold products
- Thins secretions and loosens mucus in airways
- No more effective than increasing oral fluid intake

Prescription Medications

Codeine-containing products
- Suppresses cough center in the medulla
- Metabolized via CYP2D6 with significant differences in metabolism between individuals:
  - Low metabolizers experience little effect, high metabolizers have risk of increased toxicity
Benzonatate (Tessalon Perles)
- Topical anesthetic; inhibits pulmonary stretch receptors and reduces cough reflex.
- Efficacy is mixed; no clear benefit over placebo.
- Precautions: do not bite or chew; dangerous in children
Inhaled/Nebulized Lidocaine
- Used for chronic or refractory cough (patients with lung cancer, COPD)
- Side effects: bitter taste, perioral numbness
- Precautions: Keep patient NPO with continuous monitoring due to aspiration risk
- Improvement usually within a few hours; duration of effect unclear

Children Over 1 Year

Many children's OTC cough products are naturopathic and not FDA-approved.
Other remedies:
- Honey (only age >1 year; risk of botulism in infants), Vicks VapoRub on chest, thyme/honey/lemon tea mixture

Prolonged Cough

Cough >2 weeks or post-tussive emesis → consider pertussis.
Tdap immunity wanes over time; risk increases if Tdap is not received routinely.
If pertussis is suspected, consider trial of a macrolide antibiotic.

References

Chong CF, Chen CC, Ma HP, Wu YC, Chen YC, Wang TL. Comparison of lidocaine and bronchodilator inhalation treatments for cough suppression in patients with chronic obstructive pulmonary disease. Emerg Med J. 2005 Jun;22(6):429-32. doi: 10.1136/emj.2004.015719. PMID: 15911951; PMCID: PMC1726806.
Havers FP, Moro PL, Hunter P, Hariri S, Bernstein H. Use of Tetanus Toxoid, Reduced Diphtheria Toxoid, and Acellular Pertussis Vaccines: Updated Recommendations of the
Lam SHF, Homme J, Avarello J, Heins A, Pauze D, Mace S, Dietrich A, Stoner M, Chumpitazi CE, Saidinejad M. Use of antitussive medications in acute cough in young children. J Am Coll Emerg Physicians Open. 2021 Jun 18;2(3):e12467. doi: 10.1002/emp2.12467. PMID: 34179887; PMCID: PMC8212563.
Malesker MA, Callahan-Lyon P, Ireland B, Irwin RS; CHEST Expert Cough Panel. Pharmacologic and Nonpharmacologic Treatment for Acute Cough Associated With the Common Cold: CHEST Expert Panel Report. Chest. 2017 Nov;152(5):1021-1037. doi: 10.1016/j.chest.2017.08.009. Epub 2017 Aug 22. PMID: 28837801; PMCID: PMC6026258.
Singu B, Verbeeck RK. Should Codeine Still be Considered a WHO Essential Medicine? J Pharm Pharm Sci. 2021;24:329-335. doi: 10.18433/jpps31639. PMID: 34192509. U.S. National Library of Medicine. Benzonatate capsule. DailyMed. Updated July 31, 2023. Accessed December 13, 2025. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=c21afd18-3b04-4f15-874b-25e0c768f801

Summarized by Ashley Lyons, OMS3 | Edited by Ashley Lyons and Jorge Chalit, OMS4

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Contributor: Taylor Lynch, MD

Educational Pearls:

What is orbital compartment syndrome, and how is it assessed in the emergency room?

Orbital compartment syndrome (OCS) is an emergent ophthalmic condition in which intraorbital pressure in the orbital compartment rises dramatically, compromising perfusion of the optic nerve and retina, leading to risk of irreversible vision loss.
OCS occurs in the context of traumatic lesions with retrobulbar hemorrhage.
Intraocular pressures (IOP) are measured via tonometry as a surrogate for intraorbital pressures, with emergent pathology being present when IOP exceeds 30-40 mmHg (normal being around 20 mmHg).

What might be some physical exam findings beyond increased IOP for orbital compartment syndrome?

Proptosis (physical outward protrusion of eye) with resistance to being pushed posterior.
Afferent pupillary defect (when the non-impacted eye has light shown into it, the impacted eye will have pupillary constriction, and when light is removed it will begin to dilate, but when light is shown into the impacted eye, it will not constrict and continue to dilate).
Generalized complaints of vision loss or an inability to move the eye.

What is the treatment for orbital compartment syndrome?

Lateral canthotomy must be performed immediately upon clinical suspicion as permanent vision loss can occur within minutes to hours.
Lateral canthotomy Step-by Step:
- Ideally have the patient sedated or highly cooperative.
- Numb and vasoconstrict the surrounding eye/orbital skin tissue with lidocaine and epinephrine.
- Take hemostats and clamp the interior and exterior eyelid at the lateral canthus at a 90º angle towards the orbital rim for 30-60 seconds to further devascularize the region.
- Take iris scissors and cut laterally to the orbital bone/rim to reveal the lateral lanthal tendon.
- Cut the inferior crus of the lateral lanthal tendon as this will provide the most significant reduction in IOP.
- Reassess IOP during each step of the procedure to measure procedure efficacy. If no pressure reduction is noted with inferior cantholysis, cutting the superior crus of the lateral canthal tendon may be required to further allow the eye to bulge out and reduce intraorbital pressure.

Big takeaways?

Ocular compartment syndrome is a rare but emergent vision threatening condition that requires immediate lateral canthotomy to reduce intraocular and intraorbital pressures.
Lateral canthotomy done within 30-60 minutes of symptom development can save the patient from permanent vision loss.

References:

Mohammadi F, Rashan A, Psaltis A, et al. Intraocular Pressure Changes in Emergent Surgical Decompression of Orbital Compartment Syndrome. JAMA Otolaryngol Head Neck Surg. 2015;141(6):562-565. doi:10.1001/jamaoto.2015.0524
Haubner F, Jägle H, Nunes DP, et al. Orbital compartment: effects of emergent canthotomy and cantholysis. Eur Arch Otorhinolaryngol. 2015;272(2):479-483. doi:10.1007/s00405-014-3238-5
Bailey LA, van Brummen AJ, Ghergherehchi LM, Chuang AZ, Richani K, Phillips ME. Visual Outcomes of Patients With Retrobulbar Hemorrhage Undergoing Lateral Canthotomy and Cantholysis. Ophthalmic Plast Reconstr Surg. 2019;35(6):586-589. doi:10.1097/IOP.0000000000001401

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

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Contributor: Aaron Lessen, MD

Educational Pearls:

How do amiodarone and lidocaine work on the heart?

Amiodarone
- Blocks potassium channels (Class III effect).
- Also blocks sodium and calcium channels.
- Additional noncompetitive beta-blocker effects.
- Stabilizes cardiac tissue, slows heart rate, and suppresses both atrial and ventricular arrhythmias.
Lidocaine
- Blocks fast sodium channels in ventricular tissue (Class Ib).
- Shortens the action potential in ventricular myocardium, especially in ischemic tissue.
- Suppresses abnormal automaticity in damaged/irritable myocardium.

Which one should you pick for a patient in vtach/vfib cardiac arrest?

The current guidelines recommend amiodarone for shock-refractory cases but this is based on randomized trials showing better arrhythmia termination and short-term outcomes, but not long-term survival benefits.
Two recent studies suggest that lidocaine might actually be preferable.
A 2023 paper published in Chest
- Performed a large retrospective cohort study for treating in-hospital VT/VF cardiac arrest.
- Among more than 14,000 patients, lidocaine was associated with higher rates of ROSC, 24-hour survival, survival to discharge, and favorable neurologic outcomes.
- These results held after adjusting for covariates and using propensity score methods. Overall, lidocaine outperformed amiodarone across all major clinical outcomes in this population.
A 2025 paper published in Resuscitation
- Performed a target trial emulation in adults with out-of-hospital shockable cardiac arrest.
- After propensity score matching in more than 23,000 eligible cases, lidocaine was associated with higher odds of prehospital ROSC, fewer post-drug defibrillations, and greater survival to hospital discharge.
- These advantages were consistent across matched patient pairs.
Dose for lidocaine is an initial 1-1.5 mg/kg IV bolus, followed by additional boluses of 0.5-0.75 mg/kg every 5-10 minutes up to a total of 3 mg/kg if needed.
Dose for amiodarone is a 300 mg bolus followed by an additional 150 mg bolus if needed.

References

Al-Khatib SM, Stevenson WG, Ackerman MJ, Bryant WJ, Callans DJ, Curtis AB, Deal BJ, Dickfeld T, Field ME, Fonarow GC, Gillis AM, Granger CB, Hammill SC, Hlatky MA, Joglar JA, Kay GN, Matlock DD, Myerburg RJ, Page RL. 2017 AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: Executive summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Heart Rhythm. 2018 Oct;15(10):e190-e252. doi: 10.1016/j.hrthm.2017.10.035. Epub 2017 Oct 30. Erratum in: Heart Rhythm. 2018 Nov;15(11):e278-e281. doi: 10.1016/j.hrthm.2018.09.026. PMID: 29097320.
Smida T, Crowe R, Price BS, Scheidler J, Martin PS, Shukis M, Bardes J. A retrospective 'target trial emulation' comparing amiodarone and lidocaine for adult out-of-hospital cardiac arrest resuscitation. Resuscitation. 2025 Mar;208:110515. doi: 10.1016/j.resuscitation.2025.110515. Epub 2025 Jan 23. PMID: 39863130; PMCID: PMC11908894.
Wagner D, Kronick SL, Nawer H, Cranford JA, Bradley SM, Neumar RW. Comparative Effectiveness of Amiodarone and Lidocaine for the Treatment of In-Hospital Cardiac Arrest. Chest. 2023 May;163(5):1109-1119. doi: 10.1016/j.chest.2022.10.024. Epub 2022 Nov 2. PMID: 36332663.

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

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Contributor: Megan Hurley, MD

Educational Pearls:

Assess first: confirm the hook isn't near vital structures.

Automatic subspecialty consult for eye involvement or proximity to carotid artery, radial artery, peritoneum, testicle, or urethra
Barbed hook: cannot be pulled back through the entry without disengaging the barb

Removal Techniques

String-Pull: best for superficial, single-barbed hooks
- Depress shank and eye of hook to disengage barb and then pull string taut and jerk suddenly along the long axis
- Can only be used when the hook is in a body part that can be firmly secured so it won't move during the procedure
- Little or no anesthesia needed
Push-Through & Snip: best choice when barb is near the skin surface
- Anesthetize first and advance the hook forward until the barb emerges. Cut off the barb and then back hook out
- Small exit wound, no sutures needed
Needle Cover: for larger hooks that are superficial
- Anesthetize first and then slide an 18 or 20-gauge needle along the hook until the bevel covers the barb. Then back out the needle and hook together
Cut-it-out: last resort
- Make an incision along the body of hook to barb and then remove hook

Adjuncts: Hydrodissection with lidocaine along the tract can ease removal Post-Procedure

Irrigate thoroughly and apply antibiotic ointment
Routine prophylaxis not needed because complications are rare
- Consider prophylactic antibiotics if hook is deeply embedded in high-risk area or contaminated by fresh water or salt water

References

Aiello LP, Iwamoto M, Guyer DR. Penetrating ocular fish-hook injuries. Surgical management and long-term visual outcome. Ophthalmology. 1992 Jun;99(6):862-6. doi: 10.1016/s0161-6420(92)31881-0. PMID: 1630774.
Malitz DI. Fish-hook injuries. Ophthalmology. 1993 Jan;100(1):3-4. doi: 10.1016/s0161-6420(93)31700-8. PMID: 8433823.

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

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Contributor: Aaron Lessen MD

Educational Pearls:

Recent prospective randomized clinical trial assessed optimal head-of-bed positioning in patients with LVO
- 0º vs. 30º elevation
- Objective was to determine superiority of the two angles in stability prior to thrombectomy for LVO patients
45 patients randomized to the group with 0° head positioning and 47 patients randomized to the group with 30° head positioning
- Patients in the 30º group experienced worsening of NIHSS by 2 points or more
- Patients with head position at 0° showed score stability
- Hazard ratio 34.40; 95% CI, 4.65-254.37; P
- All-cause death occurred in 2 patients in the 0° group, compared with 10 patients in the 30° group.
Results suggest that 0º positioning of the head of the bed may be protective to maintain clinical stability in patients with LVO prior to thrombectomy

References

Alexandrov AW, Shearin AJ, Mandava P, et al. Optimal Head-of-Bed Positioning Before Thrombectomy in Large Vessel Occlusion Stroke: A Randomized Clinical Trial. JAMA Neurol. 2025;82(9):905-914. doi:10.1001/jamaneurol.2025.2253

Summarized & Edited by Jorge Chalit, OMS4

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Contributor: Meghan Hurley, MD

Educational Pearls:

Initial Assessment
Start with a physical examination:
Determine if the bleed is anterior or posterior.
Perform a primary survey: assess airway, breathing, and circulation (ABCs).
Airway compromise = intubation immediately.
If the patient is stable, have them blow out any clots, then re-examine the nares.
Topical Medications
Anesthetics: provide local anesthesia and pain relief.
Lidocaine
Tetracaine
Vasoconstrictors: reduce bleeding.
LET (Lidocaine, Epinephrine, Tetracaine) is ideal because it provides anesthesia and vasoconstriction.
Cocaine pledgets (less common).
Tranexamic acid (TXA).
Oxymetazoline (Afrin).
Cautery (Chemical): If an anterior bleed is visualized, silver nitrate can be applied for cauterization
Technique Tips
Use a nasal speculum.
Spread up and down rather than side to side to avoid injury to the septum.
Place LET-soaked gauze in the nares.
Apply a nasal clamp for ~15 minutes to compress the vessels.
Note that pledgets may cause upper lip numbness
Reassessment
After 15 minutes, remove materials and inspect for a source of bleeding.
If still bleeding and a source is identified, cauterize the site.
Observe for 15 minutes to monitor for recurrence of bleeding.
Packing
If the above measures fail to control bleeding:
Anterior packing:
Nasal tampon (Merocel)
Convenient for outpatient removal.
Balloon device
Inflate the anterior balloon for compression.
Posterior packing:
More complex, should consult ENT for additional assistance.
Disposition & Follow-Up
Although rare, toxic shock syndrome is a possible complication of nasal packing.
- Antibiotic prophylaxis is controversial, but may be considered in high-risk patients.
- Outpatient follow-up if stable:
- Tampon: The patient can remove it at home.
- Balloon: Return to ED for removal.
Risk Factors for Epistaxis & Prevention
Deviated septum, dry environments, and anticoagulant use
- Advise on humidifier use, nasal saline, and medication review to minimize future episodes.

References:

Tunkel DE, Anne S, Payne SC, et al. Clinical Practice Guideline: Nosebleed (Epistaxis). Otolaryngology–Head and Neck Surgery. 2020;162(1_suppl):S1-S38. doi:10.1177/0194599819890327

Summarized by Ashley Lyons, OMS3 | Edited by Ashley Lyons and Jorge Chalit, OMS4

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Contributor: Travis Barlock, MD

Educational Pearls:

Quick Statistics on Electrical Burns: Electrical burns compose roughly 2 to 9% of all burns that come into emergency departments.
The majority of patients who receive electrical burns are male, typically aged 20's to 30's, accounting for 80 to 90% of all electrical burn victims.
The majority of burns are linked to occupational exposure.
The upper extremities are more commonly impacted by electrical burns, accounting for 70 to 90% of entry points into the body during an exposure.

What are some of the key considerations in electrical burns?

Unlike chemical or fire/heat related burns, electrical burns have the potential to cause significant internal damage that may not be physically appreciated externally.
This damage can include, but is not limited to:
- Cardiac dysthymias (PVCs, SVT, AV block, to more serious ventricular dysrhythmias such as ventricular fibrillation or ventricular tachycardia).
- Deep tissue injury resulting in rhabdomyolysis from the initial surge of electricity
- Rare cases of compartment syndrome

What are the treatment considerations for patients who suffer electrical burns?

Remembering that cutaneous findings associated with burns may underestimate the severity of the injury, with deeper structures being more likely to be involved as the voltage of the burn injury is directly correlated to severity.
Manage the patient's airway, breathing, and circulation as always, and conduct further workup into potential cardiac involvement with EKGs, as well as analysis of the extremities where entry occurred for muscle breakdown and compartment syndrome.

Clinical Pearl on Voltage and Current:

Voltage can be thought of being equivalent to pressure in a fluid/liquid system. Higher voltages are equivalent to higher pressures, but the ultimate damage delivered to the system is from the rate of delivery/speed of the electrical energy surging (current) through the body.
Current is dependent on the tissue it is travelling through, with different tissues having differing electrical resistances. Tissues like the stratum corneum of the skin and the human bone confer the most resistance (thus lower current) whereas skeletal muscle confers lower electrical resistance (thus higher current) due to water and electrolyte content, which is why injuries like rhabdomyolysis are possible and increase with increasing voltage.

References

Khor D, AlQasas T, Galet C, et al. Electrical injuries and outcomes: A retrospective review. Burns. 2023;49(7):1739-1744. doi:10.1016/j.burns.2023.03.015
Durdu T, Ozensoy HS, Erturk N, Yılmaz YB. Impact of Voltage Level on Hospitalization and Mortality in Electrical Injury Cases: A Retrospective Analysis from a Turkish Emergency Department. Med Sci Monit. 2025;31:e947675. doi:10.12659/MSM.947675
Karray R, Chakroun-Walha O, Mechri F, et al. Outcomes of electrical injuries in the emergency department: epidemiology, severity predictors, and chronic sequelae. Eur J Trauma Emerg Surg. 2025;51(1):85. doi:10.1007/s00068-025-02766-1
Faes TJ, van der Meij HA, de Munck JC, Heethaar RM. The electric resistivity of human tissues (100 Hz-10 MHz): a meta-analysis of review studies. Physiol Meas. 1999;20(4):R1-10. doi:10.1088/0967-3334/20/4/201

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

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Contributors: Preeya Prakash MD, Adam Greenhaw PharmD, Travis Barlock MD, and Jeffrey Olson MS4

In this episode, cardiologist Preeya Prakash and medical student Jeffrey Olson listen in as two cases are presented from EMM's recent event, Tox Talk 2025.

Talk 1- Digoxin Overdose

Dr. Adam Greenhaw presents a case of a Digoxin overdose along with many pearls. During the studio listen in, Dr. Prakash helps to answer the questions of:

How does digoxin work?
Why might a patient still be on digoxin in 2025?
What are the EKG findings of digoxin toxicity?
Is there any utility in atropine for bradycardia caused by digoxin?
Should you use calcium to treat hyperkalemia in the setting of a digoxin overdose?
If/when might a cardiologist get involved in a patient with a digoxin overdose?

Talk 2- Propranolol Overdose

Dr. Travis Barlock presents a case of a beta blocker overdose as well as many associated pearls. During our studio listen in, Dr. Prakash helps to answer the questions of:

What are the different beta blockers and how do they work?
If you are worried about a propranolol overdose, what medications do you want on hand?
What POCUS cardiac view can give you the most information for different scenarios?
Why or why not might transcutaneous or intravenous pacing be a good idea for a beta blocker overdose?
If/when might you want a cardiologist to get involved in a patient with a beta blocker overdose?

References

Alahmed AA, Lauffenburger JC, Vaduganathan M, Aldemerdash A, Ting C, Fatani N, Fanikos J, Buckley LF. Contemporary Trends in the Use of and Expenditures on Digoxin in the United States. Am J Cardiovasc Drugs. 2022 Sep;22(5):567-575. doi: 10.1007/s40256-022-00540-x. Epub 2022 Jun 24. PMID: 35739347; PMCID: PMC10263277.
Chan BS, Buckley NA. Digoxin-specific antibody fragments in the treatment of digoxin toxicity. Clin Toxicol (Phila). 2014 Sep-Oct;52(8):824-36. doi: 10.3109/15563650.2014.943907. Epub 2014 Aug 4. PMID: 25089630.
Hack JB, Wingate S, Zolty R, Rich MW, Hauptman PJ. Expert Consensus on the Diagnosis and Management of Digoxin Toxicity. Am J Med. 2025 Jan;138(1):25-33.e14. doi: 10.1016/j.amjmed.2024.08.018. Epub 2024 Sep 11. PMID: 39265879.
Krenz JR, Kaakeh Y. An Overview of Hyperinsulinemic-Euglycemic Therapy in Calcium Channel Blocker and β-blocker Overdose. Pharmacotherapy. 2018 Nov;38(11):1130-1142. doi: 10.1002/phar.2177. Epub 2018 Oct 4. PMID: 30141827.
Patocka J, Nepovimova E, Wu W, Kuca K. Digoxin: Pharmacology and toxicology-A review. Environ Toxicol Pharmacol. 2020 Oct;79:103400. doi: 10.1016/j.etap.2020.103400. Epub 2020 May 7. PMID: 32464466.
Rotella JA, Greene SL, Koutsogiannis Z, Graudins A, Hung Leang Y, Kuan K, Baxter H, Bourke E, Wong A. Treatment for beta-blocker poisoning: a systematic review. Clin Toxicol (Phila). 2020 Oct;58(10):943-983. doi: 10.1080/15563650.2020.1752918. Epub 2020 Apr 20. PMID: 32310006.

Produced by Jeffrey Olson, MS4

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Contributor: Aaron Lessen, MD

Educational Pearls:

Traumatic Brain Injuries are a frequent complaint in the Emergency Department and have increased in recent years. The American Association for Surgery of Trauma (AAST) has created Brain Injury Guidelines (BIG), in an attempt to categorize brain injuries and the level of treatment they require. They are…

BIG 1

Normal neuro exam
Not intoxicated
Not on anticoagulation or antiplatelet medications
Minimal findings on head CT
- No fracture
- Maximum of "trace" subarachnoid hemorrhage
- No intraventricular hemorrhage
Monitor for 6 hours
No need to repeat the head CT
No need to consult neurosurgery

BIG 2

Normal neuro exam
Not on anticoagulation or antiplatelet medications
Any of the following
- Intoxicated
- Slightly more findings on head CT
  - Non-displaced skull fracture
  - 4-8 mm bleed (subdural, epidural, intraparenchymal (max two locations))
  - Maximum of "localized" subarachnoid hemorrhage
  - No intraventricular hemorrhage
Hospitalize
No need to transfer
No need to repeat the head CT
No need to consult neurosurgery

BIG 3

Abnormal neuro exam
On anticoagulation or antiplatelet medications
Intoxicated
Significant findings on head CT
- Displaced skull fracture
- 8 mm bleed (subdural, epidural, intraparenchymal (or more than 2 locations))
- "Scattered" subarachnoid hemorrhage
- Intraventricular hemorrhage
Full treatment, admission to trauma center, neurosurgery evaluation

References

Joseph B, Friese RS, Sadoun M, Aziz H, Kulvatunyou N, Pandit V, Wynne J, Tang A, O'Keeffe T, Rhee P. The BIG (brain injury guidelines) project: defining the management of traumatic brain injury by acute care surgeons. J Trauma Acute Care Surg. 2014 Apr;76(4):965-9. doi: 10.1097/TA.0000000000000161. PMID: 24662858.
Joseph B, Obaid O, Dultz L, Black G, Campbell M, Berndtson AE, Costantini T, Kerwin A, Skarupa D, Burruss S, Delgado L, Gomez M, Mederos DR, Winfield R, Cullinane D; AAST BIG Multi-institutional Study Group. Validating the Brain Injury Guidelines: Results of an American Association for the Surgery of Trauma prospective multi-institutional trial. J Trauma Acute Care Surg. 2022 Aug 1;93(2):157-165. doi: 10.1097/TA.0000000000003554. Epub 2022 Mar 28. PMID: 35343931.

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

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Contributor: Taylor Lynch, MD

Educational Pearls:

A recent study published in a pediatric journal in April 2025 compared temporal and oral thermometers
Paired temperature measurements (temporal and oral temperature within 30 minutes) were obtained from 1,412 pediatric patients
- 26% of patients had statistically different temporal and oral temperatures
  - The temporal reading was always lower than the oral reading
  - Children less than 12 years old were 2-3x more likely to actually have that statistical difference in temperatures
The study also evaluated 1,000 adult patients
- 36% had a temporal temperature that was 0.5 degrees Celsius lower than the oral temperature
Reasons for the statistical difference between the two types of thermometers:
- Environment: temporal thermometers are affected by ambient room temperature, diaphoresis, and inaccuracy in measuring temperature at the site of the temporal artery
- Physiologic: a patient with inadequate perfusion will not have an accurate temporal reading
Impact:
- Obtaining an accurate temperature is crucial in patient care
- For example, in the setting of sepsis, temperature is a necessary component to identifying when a patient meets SIRS criteria

References

Salhi RA, Meeker MA, Williams C, Iwashyna TJ, Samuels-Kalow ME. Inaccuracy of Temporal Thermometer Measurement by Age and Race. Acad Pediatr. 2025 Apr;25(3):102620. doi: 10.1016/j.acap.2024.102620. Epub 2024 Dec 15. PMID: 39681266.

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

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Contributor: Taylor Lynch, MD

Educational Pearls:

Delusional parasitosis is a subtype of the psychiatric condition delusional disorder
- Defined as a fixed, false belief of infestation by parasites or other organisms
- A somatic type of delusional disorder
Primary delusional parasitosis
- Occurs in the absence of other psychiatric or medical conditions
Secondary delusional parasitosis
- Causes include methamphetamine use disorder, schizophrenia, neurologic diseases, or medical conditions such as thyroid disease
Pathophysiology
- Poorly understood
- Upregulation of striatal dopamine system is implicated
Management
- Form a strong therapeutic alliance and do not discredit the patient immediately
- Perform a full physical exam
  - This helps reassure the patient and strengthen the therapeutic alliance
  - Some day there may be a patient in whom this is not a delusion
Treatment & Management
- Discontinuation of substances if substance-induced
- Antipsychotic medications like risperidone or olanzapine

References

Lepping P, Russell I, Freudenmann RW. Antipsychotic treatment of primary delusional parasitosis: systematic review. Br J Psychiatry. 2007;191:198-205. doi:10.1192/bjp.bp.106.029660
Moriarty N, Alam M, Kalus A, O'Connor K. Current Understanding and Approach to Delusional Infestation. Am J Med. 2019;132(12):1401-1409. doi:10.1016/j.amjmed.2019.06.017
Skelton M, Khokhar WA, Thacker SP. Treatments for delusional disorder. Cochrane Database Syst Rev. 2015;2015(5):CD009785. Published 2015 May 22. doi:10.1002/14651858.CD009785.pub2

Summarized and Edited by Jorge Chalit, OMS4

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Contributor: Aaron Lessen, MD Educational Pearls:

The cause of Alzheimer’s disease is multifactorial, but the most widely suspected mechanism is the amyloid cascade hypothesis:

Beta-amyloid proteins accumulate in the central nervous system, forming plaques that impair neuronal function.

In recent years, advances have led to the development of targeted therapies with monoclonal antibodies. These drugs:

Work by degrading amyloid plaques
Slow the rate of cognitive decline and disease progression
Have major side effects, most notably the development of amyloid-related imaging abnormalities (ARIA)
- ARIA may present as edema, effusion, or microhemorrhages, which are only detectable on MRI
- Symptoms can include headache, vertigo, or focal neurologic deficits that mimic stroke

For patients presenting to the emergency department with stroke-like symptoms, it is important to consider whether they have a history of Alzheimer’s disease and whether they are taking these medications.

This guides decisions about imaging and treatment:
- The work-up may require MRI, which can delay thrombolytic or endovascular therapy in patients with true strokeConversely, treating a patient with ARIA using thrombolytics increases the risk of bleeding and other complications

References

Ebell MH, Barry HC, Baduni K, Grasso G. Clinically Important Benefits and Harms of Monoclonal Antibodies Targeting Amyloid for the Treatment of Alzheimer Disease: A Systematic Review and Meta-Analysis. Ann Fam Med. 2024 Jan-Feb;22(1):50-62. doi: 10.1370/afm.3050. PMID: 38253509; PMCID: PMC11233076.
Ma C, Hong F, Yang S. Amyloidosis in Alzheimer's Disease: Pathogeny, Etiology, and Related Therapeutic Directions. Molecules. 2022 Feb 11;27(4):1210. doi: 10.3390/molecules27041210. PMID: 35209007; PMCID: PMC8876037.
Perneczky R, Dom G, Chan A, Falkai P, Bassetti C. Anti-amyloid antibody treatments for Alzheimer's disease. Eur J Neurol. 2024 Feb;31(2):e16049. doi: 10.1111/ene.16049. Epub 2023 Sep 11. PMID: 37697714; PMCID: PMC11235913.

Summarized by Ashley Lyons, OMS3 | Edited by Ashley Lyons and Jorge Chalit, OMS4

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Contributor: Alec Coston, MD

Case Report Summary:

A 17-year-old female involved in a motor vehicle collision presented to a rural emergency facility via personally operated vehicle. During workup and initial CT scan, the patient began rapidly decompensating with CT revealing a 1.5cm epidural hematoma with 7mm of midline shift. The patient went from being able to walk and talk to being obtunded with a blown left pupil and unresponsive. Following intubation, the patient was being prepared for transport but potential delays required immediate emergency evacuation of the hematoma via a Burr Hole. A traditional Burr Drill was not immediately available at the facility, so an improvised Burr Drill using an Intraosseous (IO) drill was used. 35mL of blood was removed from the hematoma and the patient immediately improved from a GCS of 3 to GCS of 8. The patient was transferred to a higher level of care facility, extubated the following day, and made a full neurological recovery.

Educational Pearls:

What is an epidural hematoma?

An epidural hematoma is a collection of blood between the dura mater (outermost layer of the meninges) and the skull, whereas a subdural hematoma is a collection of blood between the dura mater and arachnoid mater. Both can be life threatening depending on location and size.
Epidural hematomas tend to be arterial, and are typically secondary to trauma and can rapidly expand, but with timely recognition and evacuation of the bleed, favorable outcomes are often possible.

What are typical intracranial pressures and at what levels do they become pathologic?

Typical intracranial pressure (ICP) varies by age, but past infancy and early childhood, adolescents and adults have a value typically between 8-15mmHg. Values exceeding 20mmHg become pathologic and rise exponentially with increased volume.
Initial symptoms may include headache, nausea, and vomiting, but with increased pressures may progress to more life threatening symptoms such as loss of consciousness, cranial nerve palsies, pupillary constriction or dilation (sign of herniation), and respiratory irregularities.

What is the takeaway in timing of epidural hematomas?

Older studies show that evacuation of a hematoma with lateralizing features before the two hour mark of coma symptom onset is correlated with decreased mortality (ranging from 15-17%), but beyond 2 hours the mortality increases to well over 50%.
Though mortality statistics have grown more variable, early targeted evacuation of epidural hematomas still remains critical for improved patient outcomes. In austere conditions with limited resources, improvisation with interosseous drills and needles can improve patient outcomes and achieve the target therapy for epidural hematomas.

References

Haselsberger K, Pucher R, Auer LM. Prognosis after acute subdural or epidural haemorrhage. Acta Neurochir (Wien). 1988;90(3-4):111-116. doi:10.1007/BF01560563
Hawryluk GWJ, Nielson JL, Huie JR, et al. Analysis of Normal High-Frequency Intracranial Pressure Values and Treatment Threshold in Neurocritical Care Patients: Insights into Normal Values and a Potential Treatment Threshold. JAMA Neurol. 2020;77(9):1150-1158. doi:10.1001/jamaneurol.2020.1310
Pisică D, Volovici V, Yue JK, et al. Clinical and Imaging Characteristics, Care Pathways, and Outcomes of Traumatic Epidural Hematomas: A Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury Study. Neurosurgery. 2024;95(5):986-999. doi:10.1227/neu.0000000000002982

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

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Contributor: Aaron Lessen, MD

Educational Pearls:

What is a Nursemaid's Elbow?

A condition in which an elbow gets partially pulled out of place (a radial head subluxation)
Usually happens in kids under 5 because the ligaments around their elbow are still loose.
A common situation is when an adult pulls a child up by the hand or swings them by the arms. The sudden tug causes the radius to slip out of its normal spot at the elbow joint.

How are they identified?

These don’t normally need an xray
The child will often hold their arm close to their side and refuse to use it
There’s usually no swelling or obvious deformity.

Treatment?

Reduce the radial head subluxation. There are two possible techniques:
- Flexion and supination.
  - Start with the arm extended and pronated. Then supinate the forearm. Then bend the elbow up all the way.
- Hyper-pronation.
  - One hand stabilizes just above the child’s elbow, the other holds the wrist. Start with the arm extended. Hyperpronate the forearm. Listen/feel for a click
The child is normally back to normal quickly, if not get the xray

Which is better?

Hyperpronation (Aksel, 2025)
- 10% first attempt failure rate
- Flexion-pronation has a 25% first attempt failure rate

References

Aksel G, Küka B, İslam MM, Demirkapı F, Öztürk İ, İşlek OM, Ademoğlu E, Eroğlu SE, Satıcı MO, Özdemir S. Comparison of supination/flexion maneuver to hyperpronation maneuver in the reduction of radial head subluxations: A randomized clinical trial. Am J Emerg Med. 2025 Feb;88:29-33. doi: 10.1016/j.ajem.2024.11.026. Epub 2024 Nov 18. PMID: 39579408.
Ulici A, Herdea A, Carp M, Nahoi CA, Tevanov I. Nursemaid's Elbow - Supination-flexion Technique Versus Hyperpronation/forced Pronation: Randomized Clinical Study. Indian J Orthop. 2019 Jan-Feb;53(1):117-121. doi: 10.4103/ortho.IJOrtho_442_17. PMID: 30905991; PMCID: PMC6394198.

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

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Contributor: Ricky Dhaliwal, MD

Educational Pearls:

Angioedema in anaphylaxis
- Histamine and mast cell-mediated pathway
- Treatment:
  - First line: epinephrine for vasoconstriction and bronchodilation
  - Second line: H1 and H2 antihistamines such as Benadryl and famotidine
ACE inhibitor-induced angioedema
- Different pathway from anaphylaxis
  - ACE inhibitor-induced angioedema is mediated by bradykinins
  - Therefore, anaphylaxis medications are not beneficial in patients with ACE inhibitor-induced angioedema
- Leading cause of drug-induced angioedema in the US
- Patients most commonly present with swelling of the lips, tongue, or face
- Treatment:
  - Airway management: varies depending on the severity and progression of the presentation
    - If awake nasointubation is required, LMX is a 5% lidocaine water-soluble solution that provides anesthesia to the oropharynx
  - Medications:
    - Icatibant is a synthetic bradykinin B2-receptor antagonist that can be used in acute treatment
    - Tranexamic acid (TXA) inhibits the plasmin-dependent formation of bradykinin, but the data on this treatment are mixed and limited
    - Fresh frozen plasma (FFP) is thought to degrade high levels of bradykinin with subsequent resolution of angioedema
  - Discontinue ACE inhibitor

References

Bork K, Wulff K, Hardt J, Witzke G, Staubach P. Hereditary angioedema caused by missense mutations in the factor XII gene: clinical features, trigger factors, and therapy. J Allergy Clin Immunol. 2009 Jul;124(1):129-34. doi: 10.1016/j.jaci.2009.03.038. Epub 2009 May 27. PMID: 19477491.
Bova M, Guilarte M, Sala-Cunill A, Borrelli P, Rizzelli GM, Zanichelli A. Treatment of ACEI-related angioedema with icatibant: a case series. Intern Emerg Med. 2015 Apr;10(3):345-50. doi: 10.1007/s11739-015-1205-9. Epub 2015 Feb 10. PMID: 25666515.
Karim MY, Masood A. Fresh-frozen plasma as a treatment for life-threatening ACE-inhibitor angioedema. J Allergy Clin Immunol. 2002 Feb;109(2):370-1. doi: 10.1067/mai.2002.121313. PMID: 11842313.
Pathak GN, Truong TM, Chakraborty A, Rao B, Monteleone C. Tranexamic acid for angiotensin-converting enzyme inhibitor-induced angioedema. Clin Exp Emerg Med. 2024 Mar;11(1):94-99. doi: 10.15441/ceem.23.051. Epub 2023 Aug 1. PMID: 37525579; PMCID: PMC11009700.
Simons FE. First-aid treatment of anaphylaxis to food: focus on epinephrine. J Allergy Clin Immunol. 2004 May;113(5):837-44. doi: 10.1016/j.jaci.2004.01.769. Erratum in: J Allergy Clin Immunol. 2004 Jun;113(6):1039. Dosage error in article text. PMID: 15131564.

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

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Contributors: Travis Barlock MD, Jeffrey Olson MS4

Feel free to use the cases below for your own practice. All of the scenarios are completely made up and designed to hit several teaching points.

Case 1

25 M, presents to the ED with chest pain.

Stabbing, started a few hours ago, substernal. Thinks it is GERD.

After 2-3 minutes, pain worsens and radiates to the back.

VS: BP 125/50 (Right arm 190/110). HR 120. RR of 18. Sat 98% on RA.

Additional VS: Temp of 37.2, height of 6’5”, BMI of 18.

PMH: None, doesn’t see a doctor. Meds: None

FH: Weird heart thing (Mitral Valve Prolapse), weird lung thing (spontaneous pneumothorax), tall family members with long fingers and toes

Physical Exam:

Cards: Diastolic decrescendo at the RUSB, diminished S2. UE pulses are asymmetric, LE pulses are asymmetric, carotid pulses are asymmetric, BP is asymmetric

MSK: Knees, elbows, and wrists are hypermobile.

Imaging: CXR #1 normal, #2 widened mediastinum (no read yet but shows widened mediastinum), POCUS shows small effusion

CTA/MRA doesn’t come back until after the case.

ECG: Sinus Tach

Labs:

NT-proBNP 500 pg/mL

D-Dimer: 7000 ng/L

CBC: Hemoglobin: 13.5 g/dL, WBC: 20,000/µL, Platelets: 250,000/µL

Chem 7: Na 138, K, 5.7, Cl 102, Bicarb 17, BUN 45, Creatinine: 3.5 mg/dL, Glucose: 180

LFTs: Albumin 2.4, Total protein 5.5, ALP: 140, AST: 3500, ALT: 2800, TBili: 3.2, DirectBili: 2.4,

Ca: 7.8

LDH: 2200

PT: 20.5, INR: 2.2, Fibrinogen: 170

5th gen High-Sensitivity Troponin: <3

Lactate: 7 mmol/L

VBG: pH 7.22, paCO2 28, bicarb 15

Notes: Can have patient crash somewhere in middle and show 2nd xray

Case 2:

A 67-year-old female is brought to the ED by her daughter due to progressive weakness, confusion, and fatigue that have worsened over the past week.

Unable to get out of bed and has become increasingly lethargic. Also having some nausea, constipation. The daughter denies any preceding illness, recent trauma, or travel. Does not know her meds but will head home to get them after talking with you.

VS: BP 88/55 mmHg, HR 110, RR 20, O2 Sat 98% on room air.

Additional VS: Temp 36.8°C.

PMH: Hypertension, osteoarthritis, and depression.

Physical exam:

General: Thin, somnolent but arousable.

HENT: Dry mucous membranes

Neuro: Confused, A&Ox1 (self), hyporeflexia

Labs (Includes many that would not return in the ED in case you want to take this case forward to the floor)

CBC: WBC 9,500, Hb 16.5, Hct: 50%, Platelets 220,000

Chem7: Na 129, K 2.1, Cl 95, HCO3 34, Creatinine 1.6, BUN 40, Glucose 115

LFTs: normal

Magnesium: 1.1

Calcium: 10.8 mg/dL (corrects to 12.8)

iCal: 3.2

Phosphate: 2.3 mg/dL

Albumin: 2

BUN:Cr ratio: 25

VBG: pH: 7.49, PaCO2 45, HCO3: 34

Lactate: 2.8

Serum Osmolality: 276 mOsm/kg (Osmolal gap of 2)

Urine Osmolality: 550 mOsm/kg

Urine Sodium (UNa): 10 mEq/L (low). Urine Potassium (UK): 25 mEq/L (elevated). Urine Chloride (UCl): 12 mEq/L (low). Urine Magnesium (UMg): 20 (Elevated). Urine Calcium (UCa): 50 in 24 hrs (Low)

100 cc of urine with foley

FeNa

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Contributor: Travis Barlock MD

Educational Pearls:

Meningitis retention syndrome is a relatively novel and rare clinical condition
- Aseptic meningitis + acute urinary retention
- One study reports an incidence of about 8% in patients with acute aseptic meningitis
Clinical presentation
- Typical meningeal symptoms including fever, stiff neck, and headache
- Urinary retention occurs about one week after initial symptoms
Potential pathophysiology
- Immune-mediated dysfunction of the central nervous system
- Detrusor muscle underactivity from inflammation of the spinal cord
Management
- Supportive care
- Bladder decompression

References

Hiraga A, Kuwabara S. Meningitis-retention syndrome: Clinical features, frequency and prognosis. J Neurol Sci. 2018;390:261-264. doi:10.1016/j.jns.2018.05.008
Pellegrino F, Funiciello E, Pruccoli G, et al. Meningitis-retention syndrome: a review and update of an unrecognized clinical condition. Neurol Sci. 2023;44(6):1949-1957. doi:10.1007/s10072-023-06704-0

Summarized & Edited by Jorge Chalit, OMS4

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Contributor: Alec Coston, MD

Educational Pearls:

Hepatic encephalopathy (HE) is defined as a disruption in brain function that results from impaired liver function or portosystemic shunting.
- Manifests as various neurologic and psychiatric symptoms such as confusion, inattention, and cognitive dysfunction
Although ammonia levels have historically been recognized as important criteria for HE, the diagnosis is ultimately made clinically.
- An elevated ammonia level lacks sensitivity and specificity for HE
- Trends in ammonia levels do not correlate with disease improvement or resolution
- A 2020 study published in the American Journal of Gastroenterology evaluated 551 patients diagnosed with hepatic encephalopathy and treated with standard therapy
  - Only 60% of patients had an elevated ammonia level, demonstrating the limitations of ammonia levels
- However, a normal ammonia level in a patient with concern for HE should raise suspicion for other pathology.
In patients with cirrhosis presenting with neuropsychiatric symptoms, consider HE as the diagnosis after excluding other potential causes of altered mental status (i.e., Seizure, infection, intracranial hemorrhage)
The primary treatment is lactulose
- Works by acidifying the gastrointestinal tract.
- Ammonia (NH₃) is converted into ammonium (NH₄⁺), which is poorly absorbed and subsequently eliminated from the body
- Also exerts a laxative effect, further enhancing elimination

References:

Haj M, Rockey DC. Ammonia Levels Do Not Guide Clinical Management of Patients With Hepatic Encephalopathy Caused by Cirrhosis. Am J Gastroenterol. 2020 May;115(5):723-728. doi: 10.14309/ajg.0000000000000343. PMID: 31658104.\
Lee F, Frederick RT. Hepatic Encephalopathy-A Guide to Laboratory Testing. Clin Liver Dis. 2024 May;28(2):225-236. doi: 10.1016/j.cld.2024.01.003. Epub 2024 Jan 30. PMID: 38548435.
Vilstrup, Hendrik1; Amodio, Piero2; Bajaj, Jasmohan3,4; Cordoba, Juan1,5; Ferenci, Peter6; Mullen, Kevin D.7; Weissenborn, Karin8; Wong, Philip9. Hepatic encephalopathy in chronic liver disease: 2014 Practice Guideline by the American Association for the Study Of Liver Diseases and the European Association for the Study of the Liver. Hepatology 60(2):p 715-735, August 2014. | DOI: 10.1002/hep.27210
Weissenborn K. Hepatic Encephalopathy: Definition, Clinical Grading and Diagnostic Principles. Drugs. 2019 Feb;79(Suppl 1):5-9. doi: 10.1007/s40265-018-1018-z. PMID: 30706420; PMCID: PMC6416238.

Summarized by Ashley Lyons, OMS3 | Edited by Ashley Lyons & Jorge Chalit, OMS4

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Contributor: Taylor Lynch, MD

Educational Pearls:

What is atrial fibrillation with rapid ventricular response (AFib with RVR) and how does it differ from atrial fibrillation (AFib)?

AFib is an abnormal heart rhythm in which the heart has disorganized atrial electrical activity. This causes the atria to quiver with only select signals being conducted through the Atrioventricular (AV) Node to reach the ventricles and result in ventricular contraction.
Often described as “irregularly irregular”, a patient's EKG will present with no discernible P-waves, and irregular R-R intervals.
AFib with RVR is distinguished from AFib when the patient’s ventricular rate is greater than 100-110 beats per minute in AFib with RVR.

What is the treatment for AFib with RVR?

Diltiazem is considered one of the first line therapeutic agents in the treatment of AFib with RVR.
Diltiazem inhibits L-Type calcium channels in the AV Node, reducing the amount of signals conducted to the ventricles, thus reducing the ventricular rate.

Why pretreat patients receiving Diltiazem for AFib with RVR with calcium?

While diltiazem inhibits cardiac calcium channels, it may also cause peripheral vasodilation, resulting in diltiazem-induced hypotension.
A recent study found that this hypotension can be blunted by pretreating with 1-2g IV Calcium Chloride (IV Calcium Gluconate can be used in the ED).
Calcium is thought to peripherally stabilize the vascular smooth muscle, preventing vasodilation without impacting the desired calcium channel blocker action at the AV node.

Key takeaways?

In combination with slower pushes of diltiazem for patients in AFib with RVR (AFib with ventricular rate >100-110 bpm) with borderline low blood pressures, 1-2 g of IV Calcium Gluconate can combat diltiazem induced hypotension peripherally without negating the cardiac effect of diltiazem to reduce the heart rate.

References

2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2024;149(1):e1-e156. doi:10.1161/CIR.0000000000001193
Az A, Sogut O, Dogan Y, et al. Reducing diltiazem-related hypotension in atrial fibrillation: Role of pretreatment intravenous calcium. Am J Emerg Med. 2025;88:23-28. doi:10.1016/j.ajem.2024.11.033

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

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Contributor: Aaron Lessen, MD

Educational Pearls:

Recorded March 2025

What is the best treatment for a fever? Tylenol? Ibuprofen? Combined? Alternating the two?

The journal Pediatrics aimed to answer this question with a meta-analysis of 31 randomized controlled trials including 5,009 febrile children.
Results showed that both combined and alternating acetaminophen/ibuprofen regimens were significantly more effective at reducing fever at 4 and 6 hours compared with acetaminophen alone, with numbers needed to treat (NNT) of 3 and 4, respectively.
High-dose ibuprofen alone also offered modest benefit (NNT 8).

What dose should I use?

Oral acetaminophen
- 10 to 15 mg/kg
- Every 4–6 hours as needed
- Do not exceed 75 mg/kg/day (or 4,000 mg/day maximum for older/larger kids)
Oral ibuprofen
- 5 to 10 mg/kg
- Every 6–8 hours as needed
- Do not exceed 40 mg/kg/day (or 2,400 mg/day maximum for older/larger kids)

References

De la Cruz-Mena JE, Veroniki AA, Acosta-Reyes J, Estupiñán-Bohorquez A, Ibarra JA, Pana MC, Sierra JM, Florez ID. Short-term Dual Therapy or Mono Therapy With Acetaminophen and Ibuprofen for Fever: A Network Meta-Analysis. Pediatrics. 2024 Oct 1;154(4):e2023065390. doi: 10.1542/peds.2023-065390. PMID: 39318339.

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

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Contributor: Aaron Lessen, MD

Educational Pearls:

There are many techniques for reducing a shoulder dislocation
A recent study discussed a new variation of closed reduction technique: wrist-clamping shoulder-lifting
- The patient is in a sitting position
- The provider holds the wrist of the injured arm with both hands and slowly rotates the arm to 90 degrees of abduction and 60 degrees of external rotation
- After this traction, the arm is slowly moved to 45 degrees of abduction and 60 degrees of external rotation
- The provider then secures the patient’s wrist between the provider’s knees and places their hand on the axilla to gently lift the shoulder upward for successful reduction
There were 36 patients with shoulder dislocations in this study, and all 36 dislocations were successfully reduced with this technique
- There were no neurovascular complications or fractures
- No sedation or medication was required
- All procedures were performed by a single provider without assistance

References

Dai W, Liu L, Zong S, Zhou Y, Zheng J, Li X. An original closed reduction technique for acute shoulder dislocation: the wrist-clamping and shoulder-lifting. Int J Emerg Med. 2025 Mar 26;18(1):60. doi: 10.1186/s12245-025-00866-8. PMID: 40140973; PMCID: PMC11948627.

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

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Contributor: Megan Hurley MD Educational Pearls:

Acute toxicity of heavy metals:

Gastrointestinal upset is the most common presentation

Chronic toxicity of heavy metals:

Symptoms depend on the metal ingested
Increased risk of cancer
Altered mentation
Developmental delays (in children)
Kidney failure

Four heavy metals that are tested for in a general panel and their sources:

Lead
- Old paint (homes built before 1977) or some older toys
- Pipes of older homes or those with corrosive agents
- May obtain testing kits from home improvement stores to test water supply
Mercury
- Previously in thermometers, although much less common now
- Compact fluorescent lightbulbs, LCD screens, and some batteries
- Large predatory fish like tuna, swordfish, dolphins, and shark
Arsenic sources
- Most commonly found in pesticides
- Contaminated groundwater (especially private wells)
Cadmiun sources
- Most commonly found in tobacco smoke
- Batteries
- Metal plating and welding
Additional heavy metals that require specific testing
- Chromium, Nickel, & Thallium
- Thallium is found in rodenticides, pesticides, and fireworks

Management of heavy metal toxicity depends on the intoxicant

Generally, chelation therapy is used for acute and severe cases
Arsenic: dimercaprol or DMSA
Mercury: DMPS (chronic or mild) or DMSA (severe)
Lead: succimer is first line, followed by dimercaprol or EDTA

References

Baker BA, Cassano VA, Murray C; ACOEM Task Force on Arsenic Exposure. Arsenic Exposure, Assessment, Toxicity, Diagnosis, and Management: Guidance for Occupational and Environmental Physicians. J Occup Environ Med. 2018;60(12):e634-e639. doi:10.1097/JOM.0000000000001485
Balali-Mood M, Naseri K, Tahergorabi Z, Khazdair MR, Sadeghi M. Toxic Mechanisms of Five Heavy Metals: Mercury, Lead, Chromium, Cadmium, and Arsenic. Front Pharmacol. 2021;12:643972. Published 2021 Apr 13. doi:10.3389/fphar.2021.643972
Kinally C, Fuller R, Larsen B, Hu H, Lanphear B. A review of lead exposure source attributional studies. Sci Total Environ. 2025;990:179838. doi:10.1016/j.scitotenv.2025.179838
Jannetto PJ, Cowl CT. Elementary Overview of Heavy Metals. Clin Chem. 2023;69(4):336-349. doi:10.1093/clinchem/hvad022
Järup L. Hazards of heavy metal contamination. Br Med Bull. 2003;68:167-182. doi:10.1093/bmb/ldg032
Zhang H, Reynolds M. Cadmium exposure in living organisms: A short review. Sci Total Environ. 2019;678:761-767. doi:10.1016/j.scitotenv.2019.04.395

Summarized & Edited by Jorge Chalit, OMS4

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Contributor: Taylor Lynch, MD

Educational Pearls:

Dilutional Hyponatremia:

Occurs when there is an excess of free water relative to sodium in the body.
Causes a falsely low sodium concentration without a true change in total body sodium.

Commonly seen in DKA:

Hyperglycemia raises plasma osmolality.
Water shifts from the intracellular to extracellular space.
This dilutes serum sodium, creating apparent hyponatremia.

Corrected sodium calculation:

Use tools like MDCALC, or apply this formula:

Add 1.6 mEq/L to the measured sodium for every 100 mg/dL increase in glucose above 100.

Clinical relevance:

Considering corrected sodium in DKA is crucial, as the lab value may not be reflective of actual sodium depletion.
True severe hyponatremia can lead to complications like seizures
- May require treatment with hypertonic saline.

References:

Fulop M. Acid–base problems in diabetic ketoacidosis. Am J Med Sci. 2008;336(4):274-276. doi:10.1097/MAJ.0b013e318180f478
Palmer BF, Clegg DJ. Electrolyte and Acid–Base Disturbances in Patients with Diabetes Mellitus. N Engl J Med. 2015;373(6):548-559. doi:10.1056/NEJMra1503102
Spasovski G, Vanholder R, Allolio B, et al. Diagnosis and management of hyponatremia: a review. JAMA. 2014;312(24):2640–2650. doi:10.1001/jama.2014.13773

Summarized by Ashley Lyons, OMS3 | Edited by Ashley Lyons & Jorge Chalit, OMS4

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Contributors:

Col. (Dr.) Stacy Shackelford Dr. Sean Keenan Paramedic Alan Moreland Dr. Chris Tems Kara Napolitano

From military-inspired trauma protocols to behavioral health alternatives and cardiac resuscitation, EMS is evolving fast. Our Medical Minutes from EMSAC highlight the growing need for prehospital providers to think critically, act quickly, and adapt to new approaches in trauma, crisis response, and patient advocacy.

Educational Pearls:

What was covered & recorded at EMSAC 2024 by EMM?

Col. (Dr.) Stacy Shackelford, U.S. Air Force trauma surgeon and Director of the Joint Trauma System, emphasized the critical importance of early hemorrhage control and timely transfusions in prehospital trauma care. She highlighted military studies showing that interventions within 30 minutes can dramatically increase survival, underscoring the value of rapid response and frontline readiness.

Dr. Sean Keenan, retired Army emergency physician and EMS doctor, introduced the concept of prolonged field care—managing critically injured patients in environments where evacuation is delayed. He discussed how this model, developed in the military, is now being taught to civilian EMS providers in rural areas.

Paramedic Alan Moreland from Denver’s STAR Program (Support Team Assisted Response) explained how alternative response teams, pairing paramedics with clinical social workers, are reshaping how we respond to behavioral health emergencies, reducing reliance on police or ambulance transport and focusing on trauma-informed care.

Dr. Chris Tems, an emergency physician working with ECMO (extracorporeal membrane oxygenation), shared data on using ECMO for refractory cardiac arrest. With a survival rate of 87.5% in select emergency department cases, he highlighted ECMO’s growing role in cardiac resuscitation for patients not responding to CPR.

Kara Napolitano, of the Laboratory to Combat Human Trafficking, outlined the role EMS plays in recognizing human trafficking. She offered key indicators to look for and encouraged providers to stay alert to the signs of exploitation, emphasizing EMS’s role in early intervention.

Recorded by: Steven Fujaros, Brian Parga, & Ahmed Abdel-Hafiz Summarized by: Steven Fujaros

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Contributor: Jorge Chalit-Hernandez, OMS4

Educational Pearls:

What is the toxic dose of acetaminophen?
- 7.5 grams, in an adult. The safe daily limit is 4 grams in an adult with a normally functioning liver.
- This is equivalent to fifteen 500mg pills.
What are the symptoms of acetaminophen toxicity?
- First 24 hours, symptoms are non-specific e.g. nausea, vomiting, lack of appetite. Can also be asymptomatic.
- 24-72 hours, hepatotoxicity occurs (causing yellow skin, pruritus, abdominal pain, bleeding, and confusion)
- Fulminant liver failure at 72-96 hours
- Liver function tests (LFTs) peak at 72-96 hours.
When would you give activated charcoal?
- Within 4 hours of ingestion.
- The risk of activated charcoal is that it can be very dangerous if aspirated so use with caution with a poorly mentating patient
When would you give N-acetylcysteine (NAC)?
- The peak absorption of acetaminophen occurs at about 4 hours with acute ingestions
- Use the Rumack–Matthew nomogram to plot the serum level of acetaminophen versus the time since ingestion to see if you are above the treatment line.
- If the ingestion time is unknown then just give it.
How do you dose NAC?
- 3 bag system: First, a 150 mg/kg bolus is administered IV over 15-60 minutes (Bag 1), then a 50 mg/kg drip is administered over 4 hours (Bag 2), then a 100 mg/kg drip is administered over the following 16 hours (Bag 3).
  - This is the Prescott Protocol that requires three bag of IV fluids
- 2 bag system: There is a simplified protocol that only requires 2 bags, 200mg/kg IV over 4 hours (Bag 1) followed by 100mg/kg over 16 hours (Bag 2)
  - Less risk of anaphylactoid reactions with a 2-bag system due to the high rate of IV NAC given in the 3 bag system.
What are the endpoints for stopping NAC?
- If the INR is

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Contributor: Aaron Lessen, MD

Educational Pearls:

Many trauma patients are placed on oxygen via non-rebreather
A large, multicenter, controlled trial evaluated the outcomes of oxygen administration in trauma patients
Patients were randomized to two groups
- 1. 8-hour restrictive oxygen strategy: only receiving oxygen when the patient’s saturation dropped below 94% 2. 8-hour liberal oxygen strategy: 12-15 liters of oxygen per minute or fraction of inspired oxygen of 0.6-1.0
The study evaluated rates of death or major respiratory complications at 30 days
There was no statistical difference between the two groups
- Therefore, there is no clear benefit to administering liberal amounts of oxygen to trauma patients, but there is also no clear harm
Ultimately, trauma patients do not need to be on oxygen via non-rebreather unless they are hypoxic or short of breath

References

Arleth T, Baekgaard J, Siersma V, et al. Early Restrictive vs Liberal Oxygen for Trauma Patients: The TRAUMOX2 Randomized Clinical Trial. JAMA. 2025;333(6):479-489. doi:10.1001/jama.2024.25786

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

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Contributor: Aaron Lessen, MD

Educational Pearls:

Prehospital seizures are typically managed with intramuscular midazolam (Versed)
Seizures theoretically involve the NMDA pathway, and ketamine is a potent NMDA antagonist
A recent retrospective cohort study analyzed a Florida EMS protocol that uses ketamine in seizures refractory to midazolam
- One group received two doses of midazolam for seizure control
- The other group received a dose of midazolam followed by a dose of ketamine
After matching, 82% of the midazolam-only group patients had resolution of convulsions prior to ED arrival
- 94.4% of patients in the midazolam + ketamine group experienced resolution
- Absolute difference between groups was 12.4% (95% CI 3.1% to 21.7%)
Limitations to the study include its prehospital setting and limited long-term follow-up

References

Zitek T, Scheppke KA, Antevy P, et al. Midazolam and Ketamine for Convulsive Status Epilepticus in the Out-of-Hospital Setting. Ann Emerg Med. 2025;85(4):305-312. doi:10.1016/j.annemergmed.2024.11.002

Summarized & Edited by Jorge Chalit, OMS4

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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

Carey RM, Moran AE, Whelton PK. Treatment of Hypertension: A Review. JAMA. 2022;328(18):1849-1861. doi:10.1001/jama.2022.19590
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
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
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

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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

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.
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.
https://www.mdcalc.com/calc/1752/heart-score-major-cardiac-events

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

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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

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

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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

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
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
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

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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

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.
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.
Hendey GW, Barth BE, Soliz T. Overnight and postcall errors in medication orders. Acad Emerg Med. 2005 Jul;12(7):629–34.
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

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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

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.
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.
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

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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.

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

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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

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
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
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

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Contributor: Ricky Dhaliwal, MD Educational Pearls:

What factors are considered in a COVID-19 infection?

The viral load: Understood as the impact of SARS-CoV-2 viral particles infecting host cell tissue itself (utilizing ACE-2 receptors).
Pro-Inflammatory Response: Post-infection, the body's downstream systemic cytokine release (can be both normal or hyperactive, aka “cytokine storm”).

What cardiac impacts have been observed with COVID-19?

Arrhythmias: The mechanism of COVID-19 infection and arrhythmias is believed to be multifactorial. However, evidence suggests T-cell-mediated toxicity and cytokine storm may contribute to cardiac myocyte damage, precipitating proarrhythmias instead of direct viral entry.
- Bradycardia: Increased prevalence in patients with severe COVID-19 infection, but not associated with increased adverse outcomes.
- Atrial Fibrillation: Most common cardiac complication and risk factor for worsened outcomes in patients with COVID-19. Biggest associated risk is strokes, and may require heightened monitoring and anticoagulation therapy to mitigate stroke risk.
Fibrosis of Cardiac Tissue: Similar to arrhythmias, believed to be inflammation-mediated in COVID-19. Fibrosis of cardiac tissue increases the risk that any arrhythmias that develop during infection may persist after the infection has resolved.
Ventricular damage: Also inflammation mediated by an active infection and contributes to myocarditis.
- No evidence suggests that COVID-19 vaccination contributes to myocarditis.
Sinus node dysfunction induced by inflammation that may lead to or be similar to Postural Orthostatic Tachycardia Syndrome (POTS).

Big takeaway?

Patients who have had or currently have COVID-19 are at an increased risk of developing arrhythmias and sustaining them post-infection. However, a majority of patients will recover.
Due to atrial fibrillation being the most prevalent arrhythmia associated with COVID-19 infection, increased monitoring and potential anticoagulation therapy are required.

References

Gopinathannair R, Olshansky B, Chung MK, Gordon S, Joglar JA, Marcus GM, et al. Cardiac Arrhythmias and Autonomic Dysfunction Associated With COVID-19: A Scientific Statement From the American Heart Association. Circulation. 2024 Nov 19;150(21):e449–65.
Khan Z, Pabani UK, Gul A, Muhammad SA, Yousif Y, Abumedian M, et al. COVID-19 Vaccine-Induced Myocarditis: A Systemic Review and Literature Search. Cureus. 14(7):e27408.

Summarized by Dan Orbidan, OMS1 | Edited by Dan Orbidan & Jorge Chalit, OMS3

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Contributor: Aaron Lessen, MD

Educational Pearls:

What is a Rescue Inhaler?

A rescue inhaler is a medication for people with asthma to quickly reverse the symptoms of an asthma attack.
Historically albuterol (Short Acting Beta Agonist (SABA)) monotherapy has been the mainstay rescue inhaler. This is because albuterol works fast and is relatively cheap. \n\n

What are Combination Rescue Inhalers?

Combination rescue inhalers contain a fast-acting bronchodilator as well as an inhaled corticosteroid (ICS)
The steroid helps to reduce some of the chronic airway inflammation that is worsening the asthma attack and can help to prevent future attacks
Examples include budesonide-formoterol and albuterol-budesonide
Global Initiative for Asthma (GINA), states that combination therapy is now the preferred reliever for adults and adolescents with mild asthma

What are the drawbacks of Combination Rescue Inhalers?

These inhalers are generally more expensive than just using a SABA inhaler which can be a barrier for some people \n\n
Improper use can also lead to conditions like thrush due to the addition of the steroid

References

Krings JG, Beasley R. The Role of ICS-Containing Rescue Therapy Versus SABA Alone in Asthma Management Today. J Allergy Clin Immunol Pract. 2024 Apr;12(4):870-879. doi: 10.1016/j.jaip.2024.01.011. Epub 2024 Jan 17. PMID: 38237858; PMCID: PMC10999356.
Papi A, Chipps BE, Beasley R, Panettieri RA Jr, Israel E, Cooper M, Dunsire L, Jeynes-Ellis A, Johnsson E, Rees R, Cappelletti C, Albers FC. Albuterol-Budesonide Fixed-Dose Combination Rescue Inhaler for Asthma. N Engl J Med. 2022 Jun 2;386(22):2071-2083. doi: 10.1056/NEJMoa2203163. Epub 2022 May 15. PMID: 35569035.

Summarized by Jeffrey Olson, MS3 | Edited by Jorge Chalit, OMS3 \n\n

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Contributor: Geoff Hogan MD

Educational Pearls:

Penicillin allergies are relatively uncommon despite their frequent reports
10% of the population reports a penicillin allergy but only 5% of these cases are clinically significant
90-95% of patients may tolerate a rechallenge after appropriate allergy evaluation
Penicillin Allergy Decision Rule (PEN-FAST) on MD Calc
Useful tool to assess patients for penicillin allergies
Five years or less since reaction = 2 points (even if unknown)
Anaphylaxis or angioedema OR Severe cutaneous reaction = 2 points
Treatment required for reaction (e.g. epinephrine) = 1 point (even if unknown)
A score of 0 on PEN-FAST indicates a less than 1% risk of a positive penicillin allergy test
A score of 1 or 2 indicates a 5% risk of a positive penicillin allergy test
A low score on PEN-FAST should prompt clinicians to proceed with the best empiric antibiotic for the patient’s infection

References

Broyles AD, Banerji A, Barmettler S, et al. Practical Guidance for the Evaluation and Management of Drug Hypersensitivity: Specific Drugs [published correction appears in J Allergy Clin Immunol Pract. 2021 Jan;9(1):603. doi: 10.1016/j.jaip.2020.10.025.] [published correction appears in J Allergy Clin Immunol Pract. 2021 Jan;9(1):605. doi: 10.1016/j.jaip.2020.11.036.]. J Allergy Clin Immunol Pract. 2020;8(9S):S16-S116. doi:10.1016/j.jaip.2020.08.006
Piotin A, Godet J, Trubiano JA, et al. Predictive factors of amoxicillin immediate hypersensitivity and validation of PEN-FAST clinical decision rule [published correction appears in Ann Allergy Asthma Immunol. 2022 Jun;128(6):740. doi: 10.1016/j.anai.2022.04.005.]. Ann Allergy Asthma Immunol. 2022;128(1):27-32. doi:10.1016/j.anai.2021.07.005
Shenoy ES, Macy E, Rowe T, Blumenthal KG. Evaluation and Management of Penicillin Allergy: A Review. JAMA. 2019;321(2):188-199. doi:10.1001/jama.2018.19283
Trubiano JA, Vogrin S, Chua KYL, et al. Development and Validation of a Penicillin Allergy Clinical Decision Rule. JAMA Intern Med. 2020;180(5):745-752. doi:10.1001/jamainternmed.2020.0403

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Contributor: Travis Barlock, MD

Educational Pearls:

Key clinical considerations when managing heart transplant patients due to their unique pathophysiology
1. Arrhythmias
A transplanted heart is denervated, meaning it lacks autonomic nervous system innervation
The lack of vagal tone results in an increased resting heart rate
Adenosine can be used since it primarily slows conduction through the AV node
Atropine is ineffective in treating transplant bradyarrhythmia because its mechanism is to inhibit the vagus nerve - but the heart lacks vagal tone
Allograft rejection can also cause tachycardia
Consult transplant surgery - treatment is usually 500 mg methylprednisolone
1. Rejection
Transplant patients are administered immunosuppressants
Clinical presentation of acute rejection looks similar to heart failure with increased BNP, increased troponin, and pulmonary edema
Cardiac allograft vasculopathy is a form of chronic rejection
Patients will not report chest pain due to denervated heart
Symptoms are usually weakness and fatigue
1. High risk of infection due to immunosuppression
Increased risk of infections which includes CMV, legionella, tuberculosis, etc
Immunosuppressants have side effects such as acute kidney injury or pancytopenia
1. Radiographic Cardiomegaly
A study found that radiographic cardiomegaly does not connote heart failure
They hypothesized it is instead the result of a mismatch between the size of the transplanted heart and the space in the thoracic cavity

References

Murphy JD, Mergo PJ, Taylor HM, Fields R, Mills RM Jr. Significance of radiographic cardiomegaly in orthotopic heart transplant recipients. AJR Am J Roentgenol. 1998 Aug;171(2):371-4. doi: 10.2214/ajr.171.2.9694454. PMID: 9694454.
Park MH, Starling RC, Ratliff NB, McCarthy PM, Smedira NS, Pelegrin D, Young JB. Oral steroid pulse without taper for the treatment of asymptomatic moderate cardiac allograft rejection. J Heart Lung Transplant. 1999 Dec;18(12):1224-7. doi: 10.1016/s1053-2498(99)00098-4. PMID: 10612382.
Pethig K, Heublein B, Wahlers T, Dannenberg O, Oppelt P, Haverich A. Mycophenolate mofetil for secondary prevention of cardiac allograft vasculopathy: influence on inflammation and progression of intimal hyperplasia. J Heart Lung Transplant. 2004 Jan;23(1):61-6. doi: 10.1016/s1053-2498(03)00097-4. PMID: 14734128.

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

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Contributor: Taylor Lynch, MD

Educational Pearls:

Pediatric febrile seizures are defined as seizures that occur between the ages of six months to five years in the presence of a fever greater than or equal to 38.0 ºC (100.4 ºF). It is the most common pediatric convulsive disorder, with an incidence between 2-5%
What are the types of seizures?
Simple: Tonic-clonic seizure, duration 15 minutes, requires medication to stop the seizing, multiple occurrences in a 24-hour period, PRESENCE of focal features, PRESENCE of Todd’s paralysis
What are the causes?
Caused by infectious agents leading to fever. Seen with common childhood infections.
It is debated whether the absolute temperature of the fever or the rate of change of temperature incites the seizure, but current evidence points to the rate of change of the temperature being the primary catalyst
What are the treatment considerations?
For simple febrile seizures, work-up is similar to any pediatric patient presenting with a fever between the ages of six months and five years
Thorough physical exam to rule out any potential of meningeal or intracranial infections
Prophylactic antipyretics are not believed to prevent the occurrence of febrile seizures
Disposition?
If the patient has returned to normal baseline behavior following a simple febrile seizure, and the physical exam is reassuring, the patient can be discharged home.
Additional labs, electroencephalogram, or lumbar punctures are not indicated in simple febrile seizures as long as the physical exam is completely normal
Any evidence of a complex seizure requires further workup
Fast Facts:
Patients with a familial history of febrile seizures and developmental delays have a higher risk of developing febrile seizures
If a child has one febrile seizure, there is a 30-40% chance of another febrile seizure by age 5
Only 2-7% of children with febrile seizures go on to develop epilepsy

References:

Berg AT, Shinnar S, Hauser WA, Alemany M, Shapiro ED, Salomon ME, et al. A prospective study of recurrent febrile seizures. N Engl J Med. 1992 Oct 15;327(16):1122–7.
Schuchmann S, Vanhatalo S, Kaila K. Neurobiological and physiological mechanisms of fever-related epileptiform syndromes. Brain Dev. 2009 May;31(5):378–82.
Nilsson G, Westerlund J, Fernell E, Billstedt E, Miniscalco C, Arvidsson T, et al. Neurodevelopmental problems should be considered in children with febrile seizures. Acta Paediatr. 2019 Aug;108(8):1507–14.
Subcommittee on Febrile Seizures, American Academy of Pediatrics. Neurodiagnostic evaluation of the child with a simple febrile seizure. Pediatrics. 2011 Feb;127(2):389–94.
Pavlidou E, Panteliadis C. Prognostic factors for subsequent epilepsy in children with febrile seizures. Epilepsia. 2013 Dec;54(12):2101–7.
Huang CC, Wang ST, Chang YC, Huang MC, Chi YC, Tsai JJ. Risk factors for a first febrile convulsion in children: a population study in southern Taiwan. Epilepsia. 1999 Jun;40(6):719–25.
Hashimoto R, Suto M, Tsuji M, Sasaki H, Takehara K, Ishiguro A, et al. Use of antipyretics for preventing febrile seizure recurrence in children: a systematic review and meta-analysis. Eur J Pediatr. 2021 Apr;180(4):987–97.

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Contributor: Aaron Lessen, MD

Educational Pearls:

Point-of-care ultrasound (POCUS) is used to assess cardiac activity during cardiac arrest and can identify potential reversible causes such as pericardial tamponade
Ultrasound could be beneficial in another way during cardiac arrest as well: pulse checks
Manual palpation for detecting pulses is imperfect, with false positives and negatives
Doppler ultrasound can be used as an adjunct or replacement to manual palpation for improved accuracy
Options for Doppler ultrasound of carotid or femoral pulses during cardiac arrest:
Visualize arterial pulsation
Use color doppler
Numerically quantify the flow and correlate this to a BP reading - slightly more complex
Doppler ultrasound is much faster than manual palpation for pulse check
Can provide information almost instantaneously without waiting the full 10 seconds for a manual pulse check
The main priority during cardiac arrest resuscitation is to maintain quality compressions
If pulses are unable to be obtained through Doppler within the 10-second window, resume compressions and try again during the next pulse check

References

Cohen AL, Li T, Becker LB, Owens C, Singh N, Gold A, Nelson MJ, Jafari D, Haddad G, Nello AV, Rolston DM; Northwell Health Biostatistics Unit. Femoral artery Doppler ultrasound is more accurate than manual palpation for pulse detection in cardiac arrest. Resuscitation. 2022 Apr;173:156-165. doi: 10.1016/j.resuscitation.2022.01.030. Epub 2022 Feb 4. PMID: 35131404.

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

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Contributor: Travis Barlock, MD

Educational Pearls:

What is Hoover’s sign used to identify?

This physical exam maneuver differentiates between organic vs. functional (previously known as psychogenic) leg weakness.
Organic causes include disease processes such as stroke, MS, spinal cord compression, guillain-barre, ALS, and sciatica, among others
In Functional Neurologic Disorder, the dysfunction is in brain signaling, and treatment relies on more of a psychiatric approach

How is Hoover's Sign performed?

Place your hand under the heel of the unaffected leg and ask the patient to attempt to lift the paralyzed leg.
If the paralysis is due to an organic cause, then you should feel the unaffected leg push down.
This is due to the crossed-extensor reflex mechanism, an unconscious motor control function mediated by the corticospinal tract.
If you don’t feel the opposite heel push down, that is a positive Hoover’s Sign.

How sensitive/specific is it?

An unblinded cohort study in patients with suspected stroke found a sensitivity of 63% and a specificity of 100%

Fun Fact

There’s also a pulmonary Hoover’s sign, named after the same doctor, Charles Franklin Hoover, which refers to paradoxical inward movement of the lower ribs during inspiration due to diaphragmatic flattening in COPD.

References

McWhirter L, Stone J, Sandercock P, Whiteley W. Hoover's sign for the diagnosis of functional weakness: a prospective unblinded cohort study in patients with suspected stroke. J Psychosom Res. 2011 Dec;71(6):384-6. doi: 10.1016/j.jpsychores.2011.09.003. Epub 2011 Oct 6. PMID: 22118379.
Stone J, Aybek S. Functional limb weakness and paralysis. Handb Clin Neurol. 2016;139:213-228. doi: 10.1016/B978-0-12-801772-2.00018-7. PMID: 27719840.

Summarized by Jeffrey Olson, MS3 | Edited by Jorge Chalit, OMS3

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Contributor: Jorge Chalit-Hernandez, OMS3

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CYP enzymes are responsible for the metabolism of many medications, drugs, and other substances
CYP3A4 is responsible for the majority
Other common ones include CYP2D6 (antidepressants), CYP2E1 (alcohol), and CYP1A2 (cigarettes)
CYP inducers lead to reduced concentrations of a particular medication
CYP inhibitors effectively increase concentrations of certain medications in the body
Examples of CYP inducers
Phenobarbital
Rifampin
Cigarettes
St. John’s Wort
Examples of CYP inhibitors
-azole antifungals like itraconazole and ketoconazole
Bactrim (trimethoprim-sulfamethoxazole)
Ritonavir (found in Paxlovid)
Grapefruit juice
Clinical relevance
Drug-drug interactions happen frequently and often go unrecognized or underrecognized in patients with significant polypharmacy
A study conducted on patients receiving Bactrim and other antibiotics found increased rates of anticoagulation in patients receiving Bactrim
Currently, Paxlovid is prescribed to patients with COVID-19, many of whom have multiple comorbidities and are on multiple medications
Paxlovid contains ritonavir, a powerful CYP inhibitor that can increase concentrations of many other medications
A complete list of clinically relevant CYP inhibitors can be found on the FDA website:
https://www.fda.gov/drugs/drug-interactions-labeling/drug-development-and-drug-interactions-table-substrates-inhibitors-and-inducers

References

Glasheen JJ, Fugit RV, Prochazka AV. The risk of overanticoagulation with antibiotic use in outpatients on stable warfarin regimens. J Gen Intern Med. 2005;20(7):653-656. doi:10.1111/j.1525-1497.2005.0136.x
Lynch T, Price A. The effect of cytochrome P450 metabolism on drug response, interactions, and adverse effects. Am Fam Physician. 2007;76(3):391-396.
PAXLOVID™. Drug interactions. PAXLOVIDHCP. Accessed March 16, 2025. https://www.paxlovidhcp.com/drug-interactions

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Physiologic stimulation of ventilation occurs through changes in levels of:
Arterial carbon dioxide (PaCO2)
Arterial oxygen (PaO2)
Hypercapnia is an elevated level of CO2 in the blood - this primarily drives ventilation
Hypoxia is a decreased level of O2 in the body’s tissues - the backup drive for ventilation
Patients at risk of hypercapnia should maintain an O2 saturation between 88-92%
Normal O2 saturation is 95-100%
In patients who chronically retain CO2, their main drive for ventilation becomes hypoxia
An audit was performed of SpO2 observations of all patients with a target range of 88–92% at a single hospital over a four-year period
This found that excessive oxygen administration was more common than insufficient oxygen and is associated with an increased risk of harm
Individuals at risk of hypercapnia include but are not limited to patients with COPD, hypoventilation syndrome, or altered mental status

References

Homayoun Kazemi, Douglas C. Johnson, Respiration, Editor(s): V.S. Ramachandran, Encyclopedia of the Human Brain, Academic Press, 2002, Pages 209-216, ISBN 9780122272103, https://doi.org/10.1016/B0-12-227210-2/00302-2.
O'Driscoll BR, Bakerly ND. Are we giving too much oxygen to patients at risk of hypercapnia? Real world data from a large teaching hospital. Respir Med. 2025 Mar;238:107965. doi: 10.1016/j.rmed.2025.107965. Epub 2025 Jan 30. PMID: 39892771.

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Quick background info

Cardiac arrest is when the heart stops pumping blood for any reason. This is different from a heart attack in which the heart is still working but the muscle itself is starting to die.
One cause of cardiac arrest is when the electrical signals are very disrupted in the heart and start following chaotic patterns such as Ventricular tachycardia (VTach) and Ventricular fibrillation (VFib)
One of the only ways to save a person whose heart is in VFib or VTach is to jolt the heart with electricity and terminate the dangerous arrhythmia.

A recent study in the Netherlands looked at how important the time delay is from when cardiac arrest is first identified to when a defibrillation shock from an Automated External Defibrillator (AED) is actually given.

Their main take-away: each minute defibrillation is delayed drops the survival rate by 6%!
These findings reinforce the importance of rapid AED deployment and early defibrillation strategies in prehospital cardiac arrest response.

References

Stieglis, R., Verkaik, B. J., Tan, H. L., Koster, R. W., van Schuppen, H., & van der Werf, C. (2025). Association Between Delay to First Shock and Successful First-Shock Ventricular Fibrillation Termination in Patients With Witnessed Out-of-Hospital Cardiac Arrest. Circulation, 151(3), 235–244. https://doi.org/10.1161/CIRCULATIONAHA.124.069834

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Contributor: Ricky Dhaliwal, MD

Educational Pearls:

Ketorolac and ibuprofen are NSAIDs with equivalent efficacy for pain in the emergency department
Oral ibuprofen provides the same relief as intramuscular ketorolac
IM ketorolac is associated with the adverse effect of a painful injection
IM ketorolac is slightly faster in onset but not significant
Studies have assessed the two medications in head-to-head randomized-controlled trials and found no significant difference in pain scores
IM ketorolac takes longer to administer and has a higher cost
Ketorolac dosing
Commonly given in 10 mg, 15 mg, and 30 mg doses
However, higher doses are associated with more adverse effects
Gastrointestinal upset, nausea, and bleeding risk
Studies have demonstrated equal efficacy in pain reduction with lower doses

References

Motov S, Yasavolian M, Likourezos A, et al. Comparison of Intravenous Ketorolac at Three Single-Dose Regimens for Treating Acute Pain in the Emergency Department: A Randomized Controlled Trial. Ann Emerg Med. 2017;70(2):177-184. doi:10.1016/j.annemergmed.2016.10.014
Neighbor ML, Puntillo KA. Intramuscular ketorolac vs oral ibuprofen in emergency department patients with acute pain. Acad Emerg Med. 1998;5(2):118-122. doi:10.1111/j.1553-2712.1998.tb02595.x

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Educational Pearls:

Colchicine is most commonly used for the prevention and treatment of gout
There is research investigating the anti-inflammatory and cardioprotective effects of colchicine
This drug has a narrow therapeutic index: a small margin between effective dose and toxic dose
Colchicine overdoses can be unintentional or intentional and are associated with poor outcomes
Phase 1: 10 - 24 hours after ingestion
Patient looks well but may have mild symptoms mimicking gastroenteritis
Phase 2: 24 hours - 7 days after ingestion
Multiple organ dysfunction syndrome (MODS)
Phase 3: recovery is usually within a few weeks of ingestion
Treatment for colchicine overdose
Treat early and aggressively
Gastrointestinal decontamination with activated charcoal and orogastric lavage
Dialysis and ECMO for MODS treatment

References

Finkelstein Y, Aks SE, Hutson JR, Juurlink DN, Nguyen P, Dubnov-Raz G, Pollak U, Koren G, Bentur Y. Colchicine poisoning: the dark side of an ancient drug. Clin Toxicol (Phila). 2010 Jun;48(5):407-14. doi: 10.3109/15563650.2010.495348. PMID: 20586571.
Gasparyan AY, Ayvazyan L, Yessirkepov M, Kitas GD. Colchicine as an anti-inflammatory and cardioprotective agent. Expert Opin Drug Metab Toxicol. 2015;11(11):1781-94. doi: 10.1517/17425255.2015.1076391. Epub 2015 Aug 4. PMID: 26239119.

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What is Portal Vein Thrombosis?

The formation of a blood clot within the portal vein, which carries blood from the gastrointestinal tract, pancreas, and spleen to the liver
Not only can this cause problems downstream in the liver, but the backup of venous blood can cause ischemia in the bowels

How does it present?

Similar to acute mesenteric ischemia: Sudden onset of abdominal pain, nausea, vomiting, and fever

How is it diagnosed?

Abdominal CT or MRI with contrast

What causes it?

Cirrhosis
Coagulopathy (Factor V Leiden mutation, Prothrombin gene mutation, Antiphospholipid syndrome, Protein C, protein S, antithrombin III deficiency, etc.)
Oral Contraceptive Pills (OCPs)
Cancer such as hepatocellular carcinoma

How is it treated?

Aggressive fluid resuscitation
Antibiotics. Be sure to cover enteric gram-negative bacteria and anaerobes
Heparin, same dosing as a bolus for a DVT
Endovascular treatment, such as a thrombectomy with IR
Surgical evaluation if there has been tissue death in the mesentery

References

Hilscher, M. B., Wysokinski, W. E., Andrews, J. C., Simonetto, D. A., Law, R. J., & Kamath, P. S. (2024). Portal Vein Thrombosis in the Setting of Cirrhosis: Evaluation and Management Strategies. Gastroenterology, 167(4), 664–672. https://doi.org/10.1053/j.gastro.2024.05.017
Intagliata, N. M., Caldwell, S. H., & Tripodi, A. (2019). Diagnosis, Development, and Treatment of Portal Vein Thrombosis in Patients With and Without Cirrhosis. Gastroenterology, 156(6), 1582–1599.e1. https://doi.org/10.1053/j.gastro.2019.01.265
Ju, C., Li, X., Gadani, S., Kapoor, B., & Partovi, S. (2022). Portal Vein Thrombosis: Diagnosis and Endovascular Management. Pfortaderthrombose: Diagnose und endovaskuläres Management. RoFo : Fortschritte auf dem Gebiete der Rontgenstrahlen und der Nuklearmedizin, 194(2), 169–180. https://doi.org/10.1055/a-1642-0990

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Educational Pearls:

Acute mountain sickness (AMS) is the term given to what is otherwise colloquially known as altitude sickness
High altitude cerebral edema (HACE) is a severe form of AMS marked by encephalopathic changes
Symptoms begin at elevations as low as 6500 feet above sea level for people who ascend rapidly
May develop more severe symptoms at higher altitudes
The pathophysiology involves cerebral vasodilation
Occurs in everyone ascending to high altitudes but is more pronounces in those that develop symptoms
The reduced partial pressure of oxygen induces hypoxic vasodilation in the brain, which results in edema and, ultimately, HACE in some patients
Symptomatic presentation
Headache, nausea, and sleeping difficulties occur within 2-24 hours of arrival at altitude
HACE may occur between 12-72 hours after AMS and presents with ataxia, confusion, irritability, and ultimately results in coma if left untreated
Clinical presentation may be mistaken for simple exhaustion, so clinicians should maintain a high index of suspicion
Notably, if symptoms occur more than 2 days after arrival at altitude, clinicians should seek an alternative diagnosis but maintain AMS/HACE on the differential
Treatment and management
AMS
Adjunctive oxygen and descent to lower altitude
Acetazolamide is used as a preventive measure but is not helpful in acute treatment
+/- dexamethasone
HACE
Patients with HACE should receive dexamethasone to help reduce cerebral edema
Immediate descent to a lower altitude

References

Burtscher M, Wille M, Menz V, Faulhaber M, Gatterer H. Symptom progression in acute mountain sickness during a 12-hour exposure to normobaric hypoxia equivalent to 4500 m. High Alt Med Biol. 2014;15(4):446-451. doi:10.1089/ham.2014.1039
Levine BD, Yoshimura K, Kobayashi T, Fukushima M, Shibamoto T, Ueda G. Dexamethasone in the treatment of acute mountain sickness. N Engl J Med. 1989;321(25):1707-1713. doi:10.1056/NEJM198912213212504
Luks AM, Beidleman BA, Freer L, et al. Wilderness Medical Society Clinical Practice Guidelines for the Prevention, Diagnosis, and Treatment of Acute Altitude Illness: 2024 Update. Wilderness Environ Med. 2024;35(1_suppl):2S-19S. doi:10.1016/j.wem.2023.05.013

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Gastroenteritis clinical diagnoses:
Diarrhea with or without vomiting and fever
Vomiting in the absence of diarrhea has a large list of differential diagnoses, so the combination of diarrhea and vomiting in a patient is helpful to indicate the gastroenteritis diagnosis
Symptom timeline is usually 1-3 days, but can last up to 14 days – diarrhea persists the longest
Treatment for mild to moderate dehydration: oral or IV rehydration
Begin orally to avoid unnecessary IV in a pediatric patient
Administer ODT Ondansetron (Zofran) to prevent vomiting
1. Meta-analysis showed that 2-8 mg orally, based on body weight, decreased vomiting quickly
2. Wait 15-20 minutes for the medication to take effect
3. Use streamlined method for oral rehydration: Fluids such as over-the-counter Pedialyte, Infalyte, Rehydrate, Resol, and Naturalyte may be used
4. If patient weighs less than 10kg: administer 5mL of fluid per minute for 20 minutes
5. If patient weighs 10kg or more: administer 10mL of fluid for 20 minutes
6. If the patient can keep the fluid down, double the fluid volume and repeat
7. If the patient once again keeps the fluid down, double the fluid volume and repeat
If successful with each attempt, the patient may be discharged home
Can prescribe ODT Zofran for 1-2 days at home
If the patient vomits more than once during this oral rehydration process, intravenous rehydration must be initiated

References

Churgay CA, Aftab Z. Gastroenteritis in children: Part II. Prevention and management. Am Fam Physician. 2012 Jun 1;85(11):1066-70. PMID: 22962878.

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Educational Pearls:

If a patient sustains a cut, the provider has several options on how to close the wound. If they choose to suture the wound closed, it involves needles both in the form of injecting numbing medication (lidocaine) as well as with the suture itself. Other techniques are “needleless,” like closing the wound with adhesive strips (Steri-Strips) or skin adhesive (Dermabond). But which method is best?
A recent study looked to compare guardian-perceived cosmetic outcomes of pediatric lacerations repaired with absorbable sutures, Dermabond, and Steri-Strips. It also assessed pain and satisfaction with the procedure from both guardian and provider perspectives.
Participants: 55 patients were enrolled; 30 completed the 3-month follow-up.
Cosmetic Ratings (Median and IQR):
Sutures: 70.5 (59.8–76.8)
Dermabond: 85 (73–90)
Steri-Strips: 67 (55–78)
(P = 0.254, no statistically significant difference)
Satisfaction and Pain:
No significant differences in guardian or provider satisfaction
Pain levels were comparable across all methods
Even though there was no statistically significant difference in guardian-perceived cosmetic outcomes, the Dermabond did have the highest ratings at the end of the study.

References

Barton, M. S., Chaumet, M. S. G., Hayes, J., Hennessy, C., Lindsell, C., Wormer, B. A., Kassis, S. A., Ciener, D., & Hanson, H. (2024). A Randomized Controlled Comparison of Guardian-Perceived Cosmetic Outcome of Simple Lacerations Repaired With Either Dermabond, Steri-Strips, or Absorbable Sutures. Pediatric emergency care, 40(10), 700–704. https://doi.org/10.1097/PEC.0000000000003244

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Contributor: Jorge Chalit-Hernandez, OMS3

Educational Pearls:

Serotonin syndrome occurs most commonly due to the combination of monoamine oxidase inhibition with concomitant serotonergic medications like SSRIs
Examples of unexpected monoamine oxidase inhibitors
- Linezolid - a last-line antibiotic reserved for patients with true anaphylaxis to penicillins and cephalosporins
- Methylene blue - not mentioned in the podcast due to its uncommon usage for methemoglobinemia
- Other medications that can interact with SSRIs to cause serotonin syndrome
- Dextromethorphan - primarily an anti-tussive at sigma opioid receptors that also has serotonin reuptake inhibition
- Clinical presentation of serotonin syndrome
- Altered mental status
- Autonomic dysregulation leading to hypertension (most common), hypotension, and tachycardia
- Hyperthermia
- Neuromuscular hyperactivity - tremors, myoclonus, and hyperreflexia
- Hunter Criteria (high sensitivity and specificity for serotonin syndrome):
- Spontaneous clonus
- Inducible clonus + agitation or diaphoresis
- Ocular clonus + agitation or diaphoresis
- Tremor + hyperreflexia
- Hypertonia, temperature > 38º C, and ocular or inducible clonus
- Management of serotonin syndrome
- Primarily supportive - benzodiazepines can help treat hypertension, agitation, and hyperthermia. Patients often require repeated and higher dosing of benzodiazepines
- Avoid antipyretics to treat hyperthermia since the elevated temperature is due to sustained muscle contraction and not central temperature dysregulation
- In refractory patients, cyproheptadine (a 5HT2 antagonist) may be used as a second-line treatment
- Patients with temperatures > 41.1º C or 106º F require medically induced paralysis and intubation to control their temperature

References

Boyer EW, Shannon M. The serotonin syndrome [published correction appears in N Engl J Med. 2007 Jun 7;356(23):2437] [published correction appears in N Engl J Med. 2009 Oct 22;361(17):1714]. N Engl J Med. 2005;352(11):1112-1120. doi:10.1056/NEJMra041867
Dunkley EJ, Isbister GK, Sibbritt D, Dawson AH, Whyte IM. The Hunter Serotonin Toxicity Criteria: simple and accurate diagnostic decision rules for serotonin toxicity. QJM. 2003;96(9):635-642. doi:10.1093/qjmed/hcg109
Ramsay RR, Dunford C, Gillman PK. Methylene blue and serotonin toxicity: inhibition of monoamine oxidase A (MAO A) confirms a theoretical prediction. Br J Pharmacol. 2007;152(6):946-951. doi:10.1038/sj.bjp.0707430
Schwartz AR, Pizon AF, Brooks DE. Dextromethorphan-induced serotonin syndrome. Clin Toxicol (Phila). 2008;46(8):771-773. doi:10.1080/15563650701668625
Thomas CR, Rosenberg M, Blythe V, Meyer WJ 3rd. Serotonin syndrome and linezolid. J Am Acad Child Adolesc Psychiatry. 2004;43(7):790. doi:10.1097/01.chi.0000128830.13997.aa

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Contributor: Aaron Lessen, MD

Educational Pearls:

Many patients present to the ED with elevated BP
Many are referred from outpatient surgery centers or present after an elevated measurement at home
Persistent questions on the best way to treat these patients
The AHA published a scientific statement on the management of elevated BP in the acute care setting
Hypertensive emergencies: SBP/DBP >180/110–120 mm Hg with evidence of new or worsening target-organ damage
Includes aortic dissection or subarachnoid hemorrhage
Require aggressive treatment
Asymptomatic markedly elevated inpatient BP: SBP/DBP >180/110–120 mm Hg without evidence of new or worsening target-organ damage AND asymptomatic elevated inpatient BP: SBP/DBP ≥130/80 mm Hg without evidence of new or worsening target-organ damage
No benefits to urgent treatment in the ED, but there are harms to treating patients in this manner
These patients do not require IV medications
Provide reassurance and instructions on following up with their PCP to manage their BP in the outpatient setting
Removed the term “hypertensive urgency”

References

Bress AP, Anderson TS, Flack JM, et al. The Management of Elevated Blood Pressure in the Acute Care Setting: A Scientific Statement From the American Heart Association. Hypertension. 2024;81(8). doi:https://doi.org/10.1161/hyp.0000000000000238

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Contributor: Megan Hurley MD

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What is the mediastinum?

The thoracic cavity is separated into different compartments by membranes
The lungs exist in their own pleural cavities, and the mediastinum is everything in between
The mediastinum extends from the sternum to the thoracic vertebrae and includes the heart, the aorta, the trachea, the esophagus, the thymus, as well as many lymph nodes and nerves.

What is a pneumomediastinum?

Air in the mediastinum

How can pneumomediastinum be categorized?

Traumatic
Ex. Stab wound to the trachea
Ex. Boerhaave’s Syndrome of the esophagus, possibly from an endoscopic procedure. This mechanism in particular is a higher risk of infection because not only air but food can accumulate in the mediastinum
Ex. Intubation with a bougie
These will likely need surgical repair
Nontraumatic
Ex. Forceful inhalation causing microperforations in the trachea. Possibly while inhaling something like drugs
Ex. Bad asthma for similar reasons
Ex. Gas forming bacteria

What happens if you use positive pressure ventilation on a patient with a hole in their trachea?

The positive pressure will force extra air into the mediastinum
The air will move between the layers of subcutaneous tissue and can track up into the neck and face regions recognized as crepitus on exam
This can also cause a tension pneumomediastinum in which the air pressure in the compartment constricts the heart, impeding its ability to fill during diastole
These patients can undergo bronchoscopy because that procedure does not require positive pressure and will not worsen the condition. Endoscopies do require positive pressure so endoscopies are not an option

How is a tension pneumomediastinum treated?

By inserting a needle into the space from below the xiphoid process to allow the air to escape, similar to a pericardiocentesis
As a temporizing measure, if the hole is high enough in the trachea, the intubation can be continued by deliberately pushing the endotracheal tube into the right main bronchus, creating a seal, and only ventilating the right lung while the patient heads to surgery. This is called right-mainstemming.

References

Clancy DJ, Lane AS, Flynn PW, Seppelt IM. Tension pneumomediastinum: A literal form of chest tightness. J Intensive Care Soc. 2017 Feb;18(1):52-56. doi: 10.1177/1751143716662665. Epub 2016 Aug 3. PMID: 28979537; PMCID: PMC5606356.
Grewal, J., & Gillaspie, E. A. (2024). Pneumomediastinum. Thoracic surgery clinics, 34(4), 309–319. https://doi.org/10.1016/j.thorsurg.2024.06.001
Underner, M., Perriot, J., & Peiffer, G. (2017). Pneumomédiastin et consommation de cocaïne [Pneumomediastinum and cocaine use]. Presse medicale (Paris, France : 1983), 46(3), 249–262. https://doi.org/10.1016/j.lpm.2017.01.002

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Etomidate was previously the drug of choice for rapid sequence intubation (RSI)
However, it carries a risk of adrenal insufficiency as an adverse effect through inhibition of mitochondrial 11-β-hydroxylase activity
A recent meta-analysis analyzing etomidate as an induction agent showed the following:
11 randomized-controlled trials with 2704 patients
Number needed to harm is 31; i.e. for every 31 patients that receive etomidate for induction, there is one death
The probability of any mortality increase was 98.1%
Ketamine is preferable due to a better adverse effect profile
Laryngeal spasms and bronchorrhea are the most common adverse effects after IV push
Beneficial effects on hemodynamics via catecholamine surge, albeit not as pronounced in shock patients
2023 meta-analysis compared ketamine and etomidate for RSI
Ketamine’s probability of reducing mortality is cited as 83.2%
Overall, induction with ketamine demonstrates a reduced risk of mortality compared with etomidate
The dosage of each medication for induction
Etomidate: 20 mg based on 0.3 mg/kg for a 70 kg adult
Ketamine: 1-2 mg/kg (or 0.5-1 mg/kg in patients with shock)
Patients with asthma and/or COPD also benefit from ketamine induction due to putative bronchodilatory properties

References

Goyal S, Agrawal A. Ketamine in status asthmaticus: A review. Indian J Crit Care Med. 2013;17(3):154-161. doi:10.4103/0972-5229.117048
Koroki T, Kotani Y, Yaguchi T, et al. Ketamine versus etomidate as an induction agent for tracheal intubation in critically ill adults: a Bayesian meta-analysis. Crit Care. 2024;28(1):1-9. doi:10.1186/s13054-024-04831-4
Kotani Y, Piersanti G, Maiucci G, et al. Etomidate as an induction agent for endotracheal intubation in critically ill patients: A meta-analysis of randomized trials. J Crit Care. 2023;77(April 2023):154317. doi:10.1016/j.jcrc.2023.154317

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Contributor: Aaron Lessen MD

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Pregnant patients at high risk of cardiac arrest, in cardiac arrest, or in extremis require special care
A useful mnemonic to recall the appropriate management of critically ill pregnant patients is TOLDD
T: Tilt the patient to the left lateral decubitus position
This position relieves pressure exerted from the uterus onto the inferior vena cava, which reduces cardiac preload
If the patient is receiving CPR, an assistant should displace the uterus manually from the IVC towards the patient’s left side
O: Administer high-flow adjunctive oxygen
L: Lines should be placed above the diaphragm
Lines below the diaphragm are ineffective due to uterine compression of the IVC
May consider humeral interosseous line vs. internal jugular or subclavian central line
D: Dates should be estimated
20 weeks, can consider a resuscitative hysterotomy (previously known as perimortem c-section) to improve chances of survival
The uterus is palpable at the umbilicus at 20 weeks and 1 cm superior to the umbilicus for every week thereafter
D: Call the labor and delivery unit for additional help

References

ACOG Practice Bulletin No. 211 Summary: Critical Care in Pregnancy. Obstetrics & Gynecology. 2019;133(5)
Fujita N, Higuchi H, Sakuma S, Takagi S, Latif MAHM, Ozaki M. Effect of Right-Lateral Versus Left-Lateral Tilt Position on Compression of the Inferior Vena Cava in Pregnant Women Determined by Magnetic Resonance Imaging. Anesth Analg. 2019;128(6):1217-1222. doi:10.1213/ANE.0000000000004166
Jeejeebhoy FM, Zelop CM, Lipman S, et al. Cardiac Arrest in Pregnancy. Circulation. 2015;132(18):1747-1773. doi:doi:10.1161/CIR.0000000000000300
Singh, Ajay; Dhir, Ankita; Jain, Kajal; Trikha, Anjan1. Role of High Flow Nasal Cannula (HFNC) for Pre-Oxygenation Among Pregnant Patients: Current Evidence and Review of Literature. Journal of Obstetric Anaesthesia and Critical Care 12(2):p 99-104, Jul–Dec 2022. | DOI: 10.4103/JOACC.JOACC_18_22

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Contributor: Travis Barlock MD

Educational Pearls:

What is the ST segment?

The ST segment on an ECG represents the interval between the end of ventricular depolarization (QRS) and the beginning of ventricular repolarization (T-wave).
It should appear isoelectric (flat) in a normal ECG.

What if the ST segment is elevated?

This is evidence that there is an injury that goes all the way through the muscular wall of the heart (transmural)
This is very concerning for a heart attack (STEMI) but can be occasionally caused by other pathology, such as pericarditis

What if the ST segment is depressed?

This is evidence that only the innermost part of the muscular wall of the heart is becoming ischemic
This has a much broader differential and includes a partial occlusion of a coronary artery but also any other stress on the body that could cause a supply-and-demand mismatch between the oxygen the coronaries can deliver and the oxygen the heart needs
This is called subendocardial ischemia

What else should you look for in the ECG to identify subendocardial ischemia?

The ST-depressions should be at least 1 mm
The ST depressions should be present in leads I, II, V4-6 and a variable number of additional leads.
There is often reciprocal ST elevation in aVR > 1 mm

The most important thing to remember when you see subendocardial ischemia is…history

Still, keep all cardiac causes on your differential, such as unstable angina, stable angina, Prinzmetal angina, etc.
Also consider a wide array of non-cardiac causes such as severe anemia, severe hypertension, pulmonary embolism, COPD, severe pneumonia, sepsis, shock, thyrotoxicosis, stimulant use, DKA, or any other state that lead to reduced oxygen supply to the subendocardium and/or increased myocardial oxygen demand.

References

Birnbaum, Y., Wilson, J. M., Fiol, M., de Luna, A. B., Eskola, M., & Nikus, K. (2014). ECG diagnosis and classification of acute coronary syndromes. Annals of noninvasive electrocardiology : the official journal of the International Society for Holter and Noninvasive Electrocardiology, Inc, 19(1), 4–14. https://doi.org/10.1111/anec.12130
Buttà, C., Zappia, L., Laterra, G., & Roberto, M. (2020). Diagnostic and prognostic role of electrocardiogram in acute myocarditis: A comprehensive review. Annals of noninvasive electrocardiology : the official journal of the International Society for Holter and Noninvasive Electrocardiology, Inc, 25(3), e12726. https://doi.org/10.1111/anec.12726
Cadogan, E. B. a. M. (2024, October 8). Myocardial Ischaemia. Life in the Fast Lane • LITFL. Retrieved December 7, 2024, from https://litfl.com/myocardial-ischaemia-ecg-library/#:~:text=ST%20depression%20due%20to%20subendocardial,left%20main%20coronary%20artery%20occlusion.

Summarized by Jeffrey Olson, MS3 | Edited by Meg Joyce & Jorge Chalit, OMS3

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Contributor: Alec Coston MD

Educational Pearls:

Causes of seizures in a fairly well-appearing child with diarrhea:
Electrolyte abnormalities: hypocalcemia, hyponatremia
Also hyperkalemia which causes arrhythmias and syncope - can appear like seizures
Hypoglycemia
If the child has diarrhea and appears very sick, differential diagnosis may include:
Hemolytic uremic syndrome (HUS):
simultaneous occurrence of microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury
Typically caused by Shiga-like toxin producing Escherichia coli (also known as EHEC, or enterohemorragic E. coli)
One of the main causes of acute kidney injury in children
Toxic ingestions such as salicylates, lead, or iron
In this case, the child had a seizure but appeared well and was afebrile:
Consult with neurology led to a diagnosis of benign convulsions with mild gastroenteritis (CwG)
First identified in 1982 in Japan
Viral gastroenteritis with diarrhea and convulsions but does not include fever, severe dehydration, or electrolyte abnormalities
Uncommon illness caused by rotavirus and norovirus pathogens
Criteria for discharge is similar to a febrile seizure - the patient had one seizure that lasted less than 15 minutes and he quickly returned to his baseline, so he was able to be safely discharged home
This diagnosis does not predispose him to epilepsy later in life

References

Lee YS, Lee GH, Kwon YS. Update on benign convulsions with mild gastroenteritis. Clin Exp Pediatr. 2022 Oct;65(10):469-475. doi: 10.3345/cep.2021.00997. Epub 2021 Dec 27. PMID: 34961297; PMCID: PMC9561189.
Mauritz M, Hirsch LJ, Camfield P, et al. Acute symptomatic seizures: an educational, evidence-based review. Epileptic Disorders. 2200;1(1). doi:https://doi.org/10.1684/epd.2021.1376
‌Noris, Marina; Remuzzi, Giuseppe, †. Hemolytic Uremic Syndrome. Journal of the American Society of Nephrology 16(4):p 1035-1050, April 2005. | DOI: 10.1681/ASN.2004100861

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

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Contributor: Aaron Lessen MD

Educational Pearls:

Induction agent selection during rapid sequence intubation involves accounting for hemodynamic stability in the post-intubation setting
Many emergency departments use ketamine or etomidate
A recent study sought to explore the rates of post-induction hypotension of ketamine compared with propofol
- Single center retrospective cohort study of patients between 2018-2021
- Ketamine and propofol were both significantly associated with post-induction hypotension
- Ketamine adjusted odds ratio = 4.50
- Propofol adjusted odds ratio = 4.88
- 50% of patients became hypotensive after induction with either propofol or ketamine
- These findings suggest post-induction hypotension is mainly due to sympatholysis rather than the choice of agent itself

References

Tamsett Z, Douglas N, King C, et al. Does the choice of induction agent in rapid sequence intubation in the emergency department influence the incidence of post-induction hypotension?. Emerg Med Australas. 2024;36(3):340-347. doi:10.1111/1742-6723.14355

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Contributor: Aaron Lessen MD

Educational Pearls:

Can opioids cause cardiac arrest?

Opioids can cause respiratory suppression and the subsequent low oxygen levels can lead to arrhythmias and eventually cardiac arrest.
In 2023, 17% of out-of-hospital cardiac arrests (OHCA) were attributable to opioids.

Given that this is a rising cause of cardiac arrest, should we just treat all cardiac arrest with naloxone (Narcan)?

Naloxone is correlated with an increased chance of return of spontaneous circulation (ROSC)
Additionally, a wide variety of individuals can be exposed to opioids and therefore opioid overdose should be considered in all cases of OHCA

But does naloxone improve neurologic outcomes?

Yes, naloxone, especially when given early on in the resuscitation can improve neuro outcomes

What is the dose?

2-4 mg IN/IV depending on access.
High suspicion for opioid overdose consider going with an even higher dose such as 4-8 mg IN/IV

References

Orkin, A. M., & Dezfulian, C. (2024). Recognizing the fastest growing cause of out-of-hospital cardiac arrest. Resuscitation, 198, 110206. https://doi.org/10.1016/j.resuscitation.2024.110206
Quinn, E., & Du Pont, D. (2024). Naloxone administration in out-of-hospital cardiac arrest: What's next?. Resuscitation, 201, 110307. https://doi.org/10.1016/j.resuscitation.2024.110307
Saybolt, M. D., Alter, S. M., Dos Santos, F., Calello, D. P., Rynn, K. O., Nelson, D. A., & Merlin, M. A. (2010). Naloxone in cardiac arrest with suspected opioid overdoses. Resuscitation, 81(1), 42–46. https://doi.org/10.1016/j.resuscitation.2009.09.016
Wampler D. A. (2024). Naloxone in Out-of-Hospital Cardiac Arrest-More Than Just Opioid Reversal. JAMA network open, 7(8), e2429131. https://doi.org/10.1001/jamanetworkopen.2024.29131

Summarized by Jeffrey Olson, MS3 | Edited by Meg Joyce MS1 & Jorge Chalit, OMS3

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Contributor: Aaron Lessen MD

Educational Pearls:

A study evaluated the patient-care impact and financial costs of holding patients in the ED, a nationwide issue
Prospective, observational study of acute stroke management
Conducted at a large urban, comprehensive stroke center
The study evaluated patients in multiple categories:
admitted to med/surg
admitted to med/surg but held in the ED
admitted to the ICU
Admitted to ICU but held in the ED
Examined the amount of time nurses and providers spent with each patient
This was analyzed in conjunction with the knowledge of each providers’ salaries and the overhead costs of the med/surg unit, ICU, and ED
Conclusions:
Patients who required med/surg inpatient care but who were held in the ED resulted in a doubled daily cost
$1856 for med/surg inpatient boarding vs $993 for med/surg inpatient care
Patients who required ICU care but who were held in the ED also resulted in an increased daily cost, but this difference was not as large
$2267 for ICU inpatient boarding vs $2165 for ICU care
Holding in the ED negatively impacts patients since they receive less time from providers
Holding also results in increased financial costs

References

Canellas MM, Jewell M, Edwards JL, Olivier D, Jun-O’Connell AH, Reznek MA. Measurement of Cost of Boarding in the Emergency Department Using Time-Driven Activity-Based Costing. Annals of emergency medicine. Published online May 1, 2024. doi:https://doi.org/10.1016/j.annemergmed.2024.04.012

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

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Contributor: Aaron Lessen MD

Educational Pearls:

Aortic injury occurs in 1.5-2% of patients who sustain blunt thoracic trauma
Majority are caused by automobile collisions or motorcycle accidents
Due to sudden deceleration mechanism accidents
Clinical manifestations
Signs of hypovolemic shock including tachycardia and hypotension, though not always present
Patients may have altered mental status
Imaging
Widened mediastinum on chest x-ray, though not highly sensitive
CT is more sensitive and specific, and signs of thoracic injury include an intimal flap, aortic wall outpouching, and aortic contour abnormalities
In hemodynamically unstable or otherwise unfit for CT patients, transesophageal echocardiogram may be used
Four types of aortic injury (in order of ascending severity)
I: Intimal tear or flap
II: Intramural hematoma
III: Pseudoaneurysm
IV: Rupture
Management
Hemodynamically unstable: immediate OR for exploratory laparotomy and repair
Hemodynamically stable: heart rate and blood pressure control with beta-blockers
Minor injuries are treated with observation and hemodynamic control
Severe injuries may receive surgical management
Some patients benefit from delayed repair
An endovascular aortic graft is a surgical option
Mortality
80-85% of patients die before hospital arrival
50% of patients that make it to the hospital do not survive

References

Fox N, Schwartz D, Salazar JH, et al. Evaluation and management of blunt traumatic aortic injury: a practice management guideline from the Eastern Association for the Surgery of Trauma [published correction appears in J Trauma Acute Care Surg. 2015 Feb;78(2):447]. J Trauma Acute Care Surg. 2015;78(1):136-146. doi:10.1097/TA.0000000000000470
Lee WA, Matsumura JS, Mitchell RS, et al. Endovascular repair of traumatic thoracic aortic injury: clinical practice guidelines of the Society for Vascular Surgery. J Vasc Surg. 2011;53(1):187-192. doi:10.1016/j.jvs.2010.08.027
Osgood MJ, Heck JM, Rellinger EJ, et al. Natural history of grade I-II blunt traumatic aortic injury. J Vasc Surg. 2014;59(2):334-341. doi:10.1016/j.jvs.2013.09.007
Osman A, Fong CP, Wahab SFA, Panebianco N, Teran F. Transesophageal Echocardiography at the Golden Hour: Identification of Blunt Traumatic Aortic Injuries in the Emergency Department. J Emerg Med. 2020;59(3):418-423. doi:10.1016/j.jemermed.2020.05.003
Steenburg SD, Ravenel JG, Ikonomidis JS, Schönholz C, Reeves S. Acute traumatic aortic injury: imaging evaluation and management. Radiology. 2008;248(3):748-762. doi:10.1148/radiol.2483071416

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

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Laboring Under Pressure Episode 4: Obstetric Emergency in South Africa with Dr. Meghan Hurley

Contributors: Meghan Hurley MD, Travis Barlock MD, Jeffrey Olson MS3

Show Pearls

Map of South Africa Referenced

South Africa Geography Lesson

There is a big disparity between Cape Town and its neighbor Khayelitsha.
Cape Town is the legislative capital and economic hub of South Africa, known for its infrastructure, tourist attractions, and developed urban areas.
Khayelitsha Township is a large informal settlement on the outskirts of Cape Town, with limited infrastructure and services compared to the city center. Many residents live in informal housing.
This disparity is the lasting effect of how land was divided up and populations were moved around during Apartheid.
Apartheid was a policy of segregation that lasted from 1948 to 1994.

How does medical education work in South Africa?

Medical education in South Africa typically follows a 6-year undergraduate program directly after high school
Registrars our the equivalent of Resident in America. They are graduated doctors who work in hospitals under the supervision of senior doctors as they progress toward becoming specialists.

Pearls from the case and the discussion afterward

Whole blood from a draw can be used instead of urine on a POC pregnancy test. Wait a little bit longer before making a determination because blood is more viscous. Although the casettes are not approved for whole blood several studies have shown this to be efficacious.
Free fluid in the abdomen and a pregnancy of unknown location is a rupture ectopic until proven otherwise.
Appendicitis can present on the left side. Most commonly from an extra appendix, but can also result from situs inversus or mid-gut malrotation. This presentation can also be the result of an atypically large appendix.
Fever is common in appendicitis (~40%) and becomes less common with older patients.
Don’t be falsely reassured by a normal hemoglobin in acute bleeding because patients bleed whole blood and the hemoglobin concentration is not affected. These patients should be resuscitated with whole blood.
Give rhesus factor negative blood to female patients of childbearing age to prevent them from developing antibodies to the rhesus factor which can lead to Rh disease in future pregnancies.
Rhogam can be given in cases of ruptured ectopic pregnancies to lower the risk of alloimmunization.
Blood transfusions carry the risk of lung and heart injury from the extra volume. The treatment for this condition is to diurese the patient.

Other topics discussed include the complications of working in a South African township hospital at night, the epidemiology of burns, and the importance of global health.

References

Akbulut S, Ulku A, Senol A, Tas M, Yagmur Y. Left-sided appendicitis: review of 95 published cases and a case report. World J Gastroenterol. 2010 Nov 28;16(44):5598-602. doi: 10.3748/wjg.v16.i44.5598. PMID: 21105193; PMCID: PMC2992678.
Barash, J. H., Buchanan, E. M., & Hillson, C. (2014). Diagnosis and management of ectopic pregnancy. American family physician, 90(1), 34–40.
Fromm C, Likourezos A, Haines L, Khan AN, Williams J, Berezow J. Substituting whole blood for urine in a bedside pregnancy test. J Emerg Med. 2012 Sep;43(3):478-82. doi: 10.1016/j.jemermed.2011.05.028. Epub 2011 Aug 27. PMID: 21875776.
Moris, D., Paulson, E. K., & Pappas, T. N. (2021). Diagnosis and Management of Acute Appendicitis in Adults: A Review. JAMA, 326(22), 2299–2311. https://doi.org/10.1001/jama.2021.20502
Sowder AM, Yarbrough ML, Nerenz RD, Mitsios JV, Mortensen R, Gronowski AM, Grenache DG. Analytical performance evaluation of the i-STAT Total β-human chorionic gonadotropin immunoassay. Clin Chim Acta. 2015 Jun 15;446:165-70. doi: 10.1016/j.cca.2015.04.025. Epub 2015 Apr 25. PMID: 25916696.

Produced by Jeffrey Olson, MS3 | Edited by Jeffrey Olson and Jorge Chalit, OMSIII

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Contributor: Taylor Lynch, MD

Educational Pearls:

What is neutropenic fever?

Specific type of fever that is seen in cancer patients and other patients with impaired immune systems
These patients are highly susceptible to infection
Typically occurs 7-10 days after the last chemotherapy dose, this is when the immune system is the weakest
It is useful to know the specific type of malignancy. For example, heme malignancies (ALL, AML, etc.) have more intense chemo and are at higher risk of neutropenic fever
To qualify as a neutropenic fever, a patient must have one recorded temperature greater than 38.3 degrees C or be over 38 degrees C for one hour.
The severity of the neutropenic fever is established by the absolute neutrophil count. Abs neutrophil count under 1500 is mild, less than 1000 is moderate, less than 500 is severe.
Also look at monocytes (cell that becomes a macrophage). Less than 200 is very concerning

What is the workup and treatment?

Obtain a panculture (culture blood from both arms and all indwelling lines), obtain urine culture, and get a chest x-ray.
Do not preform a rectal exam or obtain a rectal core temperature. This could cause bacteremia.
Treat with Cefepime (broad range and includes pseudomonas but not MRSA). If there is concern for MRSA add vancomycin.
Admit with Neutropenic precautions (gowns, gloves, mask, positive pressure room)

References

Peseski, A. M., McClean, M., Green, S. D., Beeler, C., & Konig, H. (2021). Management of fever and neutropenia in the adult patient with acute myeloid leukemia. Expert review of anti-infective therapy, 19(3), 359–378. https://doi.org/10.1080/14787210.2020.1820863
Zimmer, A. J., & Freifeld, A. G. (2019). Optimal Management of Neutropenic Fever in Patients With Cancer. Journal of oncology practice, 15(1), 19–24. https://doi.org/10.1200/JOP.18.00269

Summarized by Jeffrey Olson, MS3 | Edited by Meg Joyce & Jorge Chalit, OMS3

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Contributor: Jorge Chalit-Hernandez, OMS3

Typically presents with biliary colic
Right upper quadrant abdominal pain lasting more than 30 minutes and subsiding over several hours
Often associated with fatty meals but not always
Must rule out other causes of pain
Peptic ulcer disease - typically presents with epigastric pain
Pancreatitis - pain that radiates to the back or family history of pancreatitis
Laboratory workup
LFTs including ALT, AST, and alkaline phosphatase are within the reference range
Lipase and amylase within the reference range
Imaging workup
RUQ ultrasound is unremarkable
Upper endoscopy with ultrasound can help rule out peptic ulcer disease and small stones
HIDA scan may show a reduced gallbladder ejection fraction below 30-35% or it may be normal
Opiates may give false-positive results
Opiates can sometimes make biliary colic worse due to their contractile effect on the sphincter of Oddi
Some patients may benefit from surgical intervention i.e. cholecystectomy
Classic biliary-type pain (best predictor of response to cholecystectomy)
Pain for > 3 months duration
Positive HIDA scan

References

Alhayo S, Eslick GD, Cox MR. Cholescintigraphy may have a role in selecting patients with biliary dyskinesia for cholecystectomy: a systematic review. ANZ J Surg. 2020;90(9):1647-1652. doi:10.1111/ans.16003
Arshi J, Layfield LJ, Esebua M. Mast cell infiltration and activation in the gallbladder wall: Implications for the pathogenesis of functional gallbladder disorder in adult patients. Ann Diagn Pathol. 2021;54:151798. doi:10.1016/j.anndiagpath.2021.151798
Carr JA, Walls J, Bryan LJ, Snider DL. The treatment of gallbladder dyskinesia based upon symptoms: results of a 2-year, prospective, nonrandomized, concurrent cohort study. Surg Laparosc Endosc Percutan Tech. 2009;19(3):222-226. doi:10.1097/SLE.0b013e3181a74690
Joehl RJ, Koch KL, Nahrwold DL. Opioid drugs cause bile duct obstruction during hepatobiliary scans. Am J Surg. 1984;147(1):134-138. doi:10.1016/0002-9610(84)90047-3
Mahid SS, Jafri NS, Brangers BC, Minor KS, Hornung CA, Galandiuk S. Meta-analysis of cholecystectomy in symptomatic patients with positive hepatobiliary iminodiacetic acid scan results without gallstones. Arch Surg. 2009;144(2):180-187. doi:10.1001/archsurg.2008.543

Summarized & Edited by Jorge Chalit, OMS3

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Contributor: Taylor Lynch MD

Supraventricular tachycardias (SVTs) arise above the bundle of His
The term SVT includes AV nodal reentrant tachycardia (AVNRT), atrioventricular reentrant tachycardia (AVRT), atrial tachycardia, atrial fibrillation, atrial flutter, and multifocal atrial tachycardia
AVNRT is the most common form of SVT
Paroxysmal
Spontaneous or provoked by exertion, coffee, alcohol, or thyroid disease
More common in women (3:1 women:men ratio)
HR 160-240
Narrow complex with a normal QRS
Unstable patients receive synchronized cardioversion at 0.5-1 J/kg
Valsalva maneuver is attempted before pharmaceutical interventions
Increases vagal tone at the AV node to slow conduction and prolongs its refractory period to normalize the conduction
Traditionally, patients are asked to bear down, but this only works in 17% of patients
REVERT trial assessed a modified valsalva that worked in 43% of patients
Adenosine
Slows conduction at the AV node by activating potassium channels and inhibiting calcium influx
Extremely uncomfortable for most patients
Not commonly used anymore
Nondihydropyridine calcium-channel blockers are preferred
A 2009 RCT investigated low-infusion CCBs compared with adenosine bolus
The study found a conversion rate of 98% in the CCB group vs. adenosine group at 86.5%
The main adverse effect of CCB is hypotension, which a slow infusion rate can mitigate
Diltiazem dose is 0.25 mg/kg/2min and repeat at 0.35 mg/kg/15 minutes or slow infusion at 2.5 mg/min up to a conversion or 50 mg total

References

1. Appelboam A, Reuben A, Mann C, et al. Postural modification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): A randomised controlled trial. Lancet. 2015;386(10005):1747-1753. doi:10.1016/S0140-6736(15)61485-4
Belz MK, Stambler BS, Wood MA, Pherson C, Ellenbogen KA. Effects of enhanced parasympathetic tone on atrioventricular nodal conduction during atrioventricular nodal reentrant tachycardia. Am J Cardiol. 1997;80(7):878-882. doi:10.1016/s0002-9149(97)00539-0
Lim SH, Anantharaman V, Teo WS, Chan YH. Slow infusion of calcium channel blockers compared with intravenous adenosine in the emergency treatment of supraventricular tachycardia. Resuscitation. 2009;80(5):523-528. doi:10.1016/j.resuscitation.2009.01.017
Page RL, Joglar JA, Caldwell MA, et al. 2015 ACC/AHA/HRS Guideline for the Management of Adult Patients With Supraventricular Tachycardia: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society [published correction appears in Circulation. 2016 Sep 13;134(11):e234-5. doi: 10.1161/CIR.0000000000000448]. Circulation. 2016;133(14):e506-e574. doi:10.1161/CIR.0000000000000311

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Contributor: Aaron Lessen, MD

Educational Pearls:

Pediatric case study where the child’s tongue was stuck in the opening of a hard plastic drink lid
Entrapment restricts circulation which causes fluid to build and the tongue becomes more edematous with time
There is a risk of ischemia with prolonged entrapment
Initially tried 2% viscous lidocaine for analgesia and lubricant
The ER recognized that this mucosal, edematous tongue could benefit from the trick for ostomies and rectal prolapses → table sugar!
Sugar granules absorb water which decreases tissue edema
This option avoids sedation and aggressive treatment

References

A Young Girl with Tongue Swelling Jarjour, Jane et al. Annals of Emergency Medicine, Volume 84, Issue 3, 317 - 318

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

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Contributor: Megan Hurley, MD

Educational Pearls:

Fevers

Tylenol
Up until 20 weeks NSAIDs are ok but after 20 weeks they are contraindicated
Can limit the amount of amniotic fluid produced
Can lead to growth restriction
Can cause premature closure of the ductus arteriosus

Cough

Cough drops
Humidifier
Guafenesine and dextromethorphan (Mucinex) is not well studied but is probably ok with caution in certain circumstances such as post-tussive emesis causing poor PO intake and weight loss

Congestion

Flonase (Fluticasone nasal spray)
Nasal rinses
Humidifier
1st generation anti-histamines (Diphenhydramine, Doxylamine, etc.)
However, these tend to have more side effects such as fatigue, drowsiness, and dizziness
Concider switching to a 2nd generation (Cetirizine, Loratidine, etc.) during the day

Disease specific treatments

Flu (A and B) gets tamiflu (Oseltamivir)
Covid gets paxlovid (Nirmatrelvir/ritonavir)
Antibiotics for suspected pneumonia

Additional recommendations

Elevating the head of bed
Nasal strips
Stay well hydrated
Tea
Ice chips
Echinacea
Zinc
Rest

Avoid

NSAIDs
Pseudophedrine
Afrin (Oxymetazoline)
Combined meds in general

References

Antonucci, R., Zaffanello, M., Puxeddu, E., Porcella, A., Cuzzolin, L., Pilloni, M. D., & Fanos, V. (2012). Use of non-steroidal anti-inflammatory drugs in pregnancy: impact on the fetus and newborn. Current drug metabolism, 13(4), 474–490. https://doi.org/10.2174/138920012800166607
Black, E., Khor, K. E., Kennedy, D., Chutatape, A., Sharma, S., Vancaillie, T., & Demirkol, A. (2019). Medication Use and Pain Management in Pregnancy: A Critical Review. Pain practice : the official journal of World Institute of Pain, 19(8), 875–899. https://doi.org/10.1111/papr.12814
D'Ambrosio, V., Vena, F., Scopelliti, A., D'Aniello, D., Savastano, G., Brunelli, R., & Giancotti, A. (2023). Use of non-steroidal anti-inflammatory drugs in pregnancy and oligohydramnios: a review. The journal of maternal-fetal & neonatal medicine : the official journal of the European Association of Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International Society of Perinatal Obstetricians, 36(2), 2253956. https://doi.org/10.1080/14767058.2023.2253956

Summarized by Jeffrey Olson MS3 | Edited by Meg Joyce, MS1 & Jorge Chalit, OMS3

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Contributor: Travis Barlock MD

Educational Pearls:

Assessment of head and neck vascular injury due to blunt trauma
Symptomatic patients require screening head and neck CT angiography
EAST guidelines include the following criteria for a screening CT angiography in blunt head trauma:
Unexplained neurological deficits
Arterial nosebleed
GCS < 6
Petrous bone fracture
Cervical spine fracture
Any size fracture through the transverse foramen
LeFort fractures type II or type III
EAST guidelines include a grading scale for vascular injury:
Grade I: Luminal irregularity or dissection with 25% luminal narrowing, intraluminal thrombus, or raised intimal flap
Grade III: Pseudoaneurysm
Grade IV: Occlusion
Grade V: Transection with free extravasation

References

Bensch FV, Varjonen EA, Pyhältö TT, Koskinen SK. Augmenting Denver criteria yields increased BCVI detection, with screening showing markedly increased risk for subsequent ischemic stroke. Emerg Radiol. 2019;26(4):365-372. doi:10.1007/s10140-019-01677-0
Biffl WL, Moore EE, Offner PJ, et al. Optimizing screening for blunt cerebrovascular injuries. Am J Surg. 1999;178(6):517-522. doi:10.1016/s0002-9610(99)00245-7
Kim DY, Biffl W, Bokhari F, et al. Evaluation and management of blunt cerebrovascular injury: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2020;88(6):875-887. doi:10.1097/TA.0000000000002668

Summarized & Edited by Jorge Chalit, OMS3

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Contributor: Aaron Lessen, MD

Educational Pearls:

Hemothorax: blood in the pleural cavity, most commonly due to chest trauma
Treatment: thoracostomy tube for blood drainage
helps to avoid clotting, scarring, and infection
A recent study looked at patients with hemothorax who either received or did not receive thoracic irrigation with saline
Evaluated incidence of secondary intervention, such as video-assisted thoracoscopic surgery (VATS), for persistent hemothorax
Patients who received irrigation had a slight decrease in secondary intervention frequency
Multi-center study - all patients who had the irrigation procedure were at two centers
Study limitation: variability in approaches at each location could be a confounder
Technique that could potentially prevent future complications

References

Carver TW, Berndtson AE, McNickle AG, et al. Thoracic irrigation for prevention of secondary intervention after thoracostomy tube drainage for hemothorax: A Western Trauma Association multi-center study. J Trauma Acute Care Surg. Published online May 20, 2024. doi:10.1097/TA.0000000000004364
Yi JH, Liu HB, Zhang M, et al. Management of traumatic hemothorax by closed thoracic drainage using a central venous catheter. J Zhejiang Univ Sci B. 2012;13(1):43-48. doi:10.1631/jzus.B1100161

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

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Contributor: Taylor Lynch, MD

Educational Pearls:

When it comes to hypoglycemia, the age dictates possible causes

Neonate:
Hormonal deficiency
Congenital Adrenal Hyperplasia (21-hydroxylase deficiency, 11β-hydroxylase deficiency)
Primary or Secondary Adrenal Insufficiency leading to cortisol deficiency
Hypopituitarism
Inborn errors of metabolism
Systemic infection (Under 30 days old should trigger a full infectious workup)
Toddler
Accidental ingestions
Sulfonylureas such as glipizide or glyburide
Older children
Addison’s Disease (Hypocortisolism)
Accidential or intentional ingestions
Exogenous insulin

How is it diagnosed?

Child or infant
Glucose

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Contributor: Kiersten Williams MD, Travis Barlock MD, Jeffrey Olson MS3

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Hypertensive disorders of pregnancy are one of the leading causes of maternal mortality worldwide.
Hypertension (HTN) complicates 2-8% of pregnancies
The definition of HTN in pregnancy is a systolic >140 or diastolic >90, measured 4 hours apart
There is a range of HTN disorders
Chronic HTN which could have superimposed preeclampsia (preE) on top
Gestational HTN in which there are no lab abnormalities
PreE w/o severe features
Protein in urine
Urine protein >300 mg in 24 hours
Urine Protein to Creatinine ratio of .3
+2 Protein on urine dipstick
PreE w/ severe features
Systolics above 160 mmHg
Diastolics above 110 mmHg
Headache, especially not going away with meds, or different than previous headaches
Visual changes, anything that lasts more than a few minutes
RUQ pain, which could present as heartburn
Pulmonary edema
Low platelets, if

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Contributor: Sean Fox, MD

Educational Pearls:

Newborns may lose up to 10% of their birth weight in the first week of life
Weight loss is greatest in exclusively breastfed infants
Should regain birth weight by age 2 weeks
Newborns should gain an average of 30g (1 oz) per day in the first 3 months of life
Some will gain more and some will gain less
Infants double their birth weight by 6 months of life and triple their weight by 12 months
A 1-year-old should weigh on average 10 kg (22 lbs)
A 3-year-old should weigh on average 15 kg (33 lbs)
2-year-olds are between 10-15 kg on average
Weight assessment can help determine causes of forceful vomiting
Not all “projectile” vomiting is due to pyloric stenosis
Some infants may experience vigorous vomiting from overfeeding
Weight estimates can also provide information for quick decisions on medical management for children coming via EMS
Helps to prepare medications and dosages based on predicted average weight

References

Crossland DS, Richmond S, Hudson M, Smith K, Abu-Harb M. Weight change in the term baby in the first 2 weeks of life. Acta Paediatr. 2008;97(4):425-429. doi:10.1111/j.1651-2227.2008.00685.x
Grummer-Strawn LM, Reinold C, Krebs NF; Centers for Disease Control and Prevention (CDC). Use of World Health Organization and CDC growth charts for children aged 0-59 months in the United States [published correction appears in MMWR Recomm Rep. 2010 Sep 17;59(36):1184]. MMWR Recomm Rep. 2010;59(RR-9):1-15.
Macdonald PD, Ross SR, Grant L, Young D. Neonatal weight loss in breast and formula fed infants. Arch Dis Child Fetal Neonatal Ed. 2003;88(6):F472-F476. doi:10.1136/fn.88.6.f472
Paul IM, Schaefer EW, Miller JR, et al. Weight Change Nomograms for the First Month After Birth. Pediatrics. 2016;138(6):e20162625. doi:10.1542/peds.2016-2625

Summarized & Edited by Jorge Chalit, OMS3

Special thanks to the Carolinas Medical Center for their contribution to this episode

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Contributor: Travis Barlock, MD

Educational Pearls:

SVT: supraventricular tachycardia
Pharmacotherapy for SVT includes drugs that block the AV node, such as adenosine
EKG criteria before adenosine administration in SVT
Regular rhythm
Monomorphic: all QRS complexes are identical
If the EKG is polymorphic, with QRS complexes displaying changing morphologies, it is unsafe to administer adenosine
Adenosine can worsen polymorphic VTach and lead to VFib

References

Ganz, Leonard I., and Peter L. Friedman. “Supraventricular Tachycardia.” New England Journal of Medicine, vol. 332, no. 3, 19 Jan. 1995, pp. 162–173, https://doi.org/10.1056/nejm199501193320307.
Smith JR, Goldberger JJ, Kadish AH. Adenosine induced polymorphic ventricular tachycardia in adults without structural heart disease. Pacing Clin Electrophysiol. 1997;20(3 Pt 1):743-745. doi:10.1111/j.1540-8159.1997.tb03897.x
Viskin, Sami, et al. “Polymorphic Ventricular Tachycardia: Terminology, Mechanism, Diagnosis, and Emergency Therapy.” Circulation, vol. 144, no. 10, 7 Sept. 2021, pp. 823–839, https://doi.org/10.1161/circulationaha.121.055783.

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

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Contributor: Aaron Lessen, MD

Educational Pearls:

How does an automated blood pressure cuff work?

Automated blood pressure cuffs work differently than taking a manual blood pressure.
While taking a manual blood pressure, one typically listens for Korotkoff sounds (turbulent flow) while slowly deflating the cuff.
An automatic blood pressure cuff only senses the pressure in the cuff itself and specifically pays attention to oscillations in the pressure caused by when the pressure of the cuff is between the systolic (heart squeezing) and diastolic (heart relaxed) pressures.
These oscillations are at a maximum when the pressure in the cuff matches the mean arterial pressure (MAP) and therefore the machines are most accurate at reporting the MAP.
The machines then use the MAP and other information about the oscillations to estimate the systolic and diastolic pressures, which are less accurate.

What should you do if you need more accurate systolic and diastolic blood pressures?

Take a manual blood pressure.
Get an arterial-line (a-line), which provides continuous data for the blood pressure at the end of a catheter.

What happens if the cuff is too big or too small for the patient?

If the cuff is too small it will overestimate the pressure.
If the cuff is too large it will underestimate the pressure.

What should you do if the cuff cycles a bunch of times before reporting a blood pressure?

It probably isn’t very accurate so consider another method.

Bonus fact!

The MAP is not directly in the middle of the systolic and diastolic pressures but is weighted towards the diastolic pressure. The MAP can be calculated by adding two-thirds of the diastolic pressure to one third of the systolic pressure. For example if the BP is 120/90 the MAP is 100 mmHg.

References

Benmira, A., Perez-Martin, A., Schuster, I., Aichoun, I., Coudray, S., Bereksi-Reguig, F., & Dauzat, M. (2016). From Korotkoff and Marey to automatic non-invasive oscillometric blood pressure measurement: does easiness come with reliability?. Expert review of medical devices, 13(2), 179–189. https://doi.org/10.1586/17434440.2016.1128821
Liu, J., Li, Y., Li, J., Zheng, D., & Liu, C. (2022). Sources of automatic office blood pressure measurement error: a systematic review. Physiological measurement, 43(9), 10.1088/1361-6579/ac890e. https://doi.org/10.1088/1361-6579/ac890e
Vilaplana J. M. (2006). Blood pressure measurement. Journal of renal care, 32(4), 210–213. https://doi.org/10.1111/j.1755-6686.2006.tb00025.x

Summarized by Jeffrey Olson, MS3 | Edited by Meg Joyce, MS1 & Jorge Chalit, OMS3

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Contributor: Megan Hurley, MD

Educational Pearls:

Heat cramps
Occur due to electrolyte disturbances
Most common electrolyte abnormalities are hyponatremia and hypokalemia
Heat edema
Caused by vasodilation with pooling of interstitial fluid in the extremities
Heat rash (miliaria)
Common in newborns and elderly
Due to accumulation of sweat beneath eccrine ducts
Heat syncope
Lightheadedness, hypotension, and/or syncope in patients with peripheral vasodilation due to heat exposure
Treatment is removal from the heat source and rehydration (IV fluids or Gatorade)
Heat exhaustion
Patients have elevated body temperature (greater than 38º C but less than 40º C)
Symptoms include nausea, tachycardia, headache, sweating, and others
Normal mental status or mild confusion that improves with cooling
Treatment is removal from the heat source and hydration
Classic heat stroke
From prolonged exposure to heat
Defined as a core body temperature > 40.5º C, though not required for diagnosis or treatment
Presentation is similar to heat exhaustion with the addition of neurological deficits including ataxia
Patients present “dry”
Exertional heat stroke
Prolonged exposure to heat during exercise
Similar to classic heat stroke but the patients present “wet” due to antecedent treatment in ice baths or other field treatments
Management of heat-related illnesses includes:
Cooling
Rehydration
Evaluation of electrolytes
Antipyretics are not helpful because heat-induced illnesses are not due to hypothalamic dysregulation

References

Casa DJ, McDermott BP, Lee EC, et al. Cold water immersion: the gold standard for exertional heatstroke treatment. Exerc Sport Sci Rev 2007; 35:141.
Ebi KL, Capon A, Berry P, et al. Hot weather and heat extremes: health risks. Lancet 2021; 398:698.
Epstein Y, Yanovich R. Heatstroke. N Engl J Med 2019; 380:2449.
Gardner JW, JA K. Clinical diagnosis, management, and surveillance of exertional heat illness. In: Textbook of Military Medicine, Zajitchuk R (Ed), Army Medical Center Borden Institute, Washington, DC 2001.
Khosla R, Guntupalli KK. Heat-related illnesses. Crit Care Clin 1999; 15:251.
Lipman GS, Gaudio FG, Eifling KP, et al. Wilderness Medical Society Clinical Practice Guidelines for the Prevention and Treatment of Heat Illness: 2019 Update. Wilderness Environ Med 2019; 30:S33.

Summarized by Jorge Chalit, OMSIII | Edited by Meg Joyce, MS1

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Contributor: Taylor Lynch, MD

Educational Pearls:

What is Central Cord Syndrome (CCS)?

Incomplete spinal cord injury caused by trauma that compresses the center of the cord
More common in hyperextension injuries like falling and hitting the chin
Usually happens only in individuals with preexisting neck and spinal cord conditions like cervical spondylosis (age-related wear and tear of the cervical spine)

Anatomy of spinal cord

Motor tracts
The signals the brain sends for the muscles to move travel in the corticospinal tracts of the spinal cord
The tracts that control the upper limbs are more central than the ones that control the lower limbs
The tracts that control the hands are more central than the ones that control the upper arm/shoulder
Fine touch, vibration, and proprioception (body position) tracts
These sensations travel in separate tracts in the spinal cord than the sensation of pain and temperature
Their pathway is called the dorsal column-medial lemniscus (DCML) pathway
This information travels in the most posterior aspect of the spinal cord
Pain, crude touch, pressure, and temperature tracts
These sensations travel in the spinothalamic tract, which is more centrally located
These signals also cross one side of the body to the other within the spinal cord near the level that they enter

How does this anatomy affect the presentation of CCS?

Patients typically experience more pronounced weakness or paralysis in their upper extremities as compared to their lower extremities with their hands being weaker than more proximal muscle groups
Sensation of pain, crude touch, pressure, and temperature are much morelikely to be diminished while the sensation of fine touch, vibration, and proprioception are spared

What happens with reflexes?

Deep tendon reflexes become exaggerated in CCS
This is because the disruption in the corticospinal tract removes inhibitory control over reflex arcs

What happens to bladder control?

The neural signals that coordinate bladder emptying are disrupted, therefore patients can present with urinary retention and/or urge incontinence

What is a Babinski’s Sign?

When the sole of the foot is stimulated a normal response in adults is for the toes to flex downward (plantar flexion)
If there is an upper motor neuron injury like in CCS, the toes will flex upwards (dorsiflexion)

How is CCS diagnosed?

CCS is mostly a clinical diagnosis
These patient also need an MRI to see the extent of the damage which will show increased signal intensity within the central part of the spinal cord on T2-weighted images

How is CCS treated?

Strict c-spine precautions
Neurogenic shock precautions. Maintain a mean arterial pressure (MAP) of 85-90 to ensure profusion of the spinal cord
Levophed (norepinephrine bitartrate) and/or phenylephrine can be used to support their blood pressure to support spinal perfusion
Consider intubation for injuries above C5 (C3, 4, and 5 keep the diaphragm alive)
Consult neurosurgery for possible decompression surgery
Physical Therapy

References

Avila, M. J., & Hurlbert, R. J. (2021). Central Cord Syndrome Redefined. Neurosurgery clinics of North America, 32(3), 353–363. https://doi.org/10.1016/j.nec.2021.03.007
Brooks N. P. (2017). Central Cord Syndrome. Neurosurgery clinics of North America, 28(1), 41–47. https://doi.org/10.1016/j.nec.2016.08.002
Engel-Haber, E., Snider, B., & Kirshblum, S. (2023). Central cord syndrome definitions, variations and limitations. Spinal cord, 61(11), 579–586. https://doi.org/10.1038/s41393-023-00894-2

Summarized by Jeffrey Olson, MS3 | Edited by Jorge Chalit, OMSIII

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Contributor: Megan Hurley, MD

Educational Pearls:

Initial assessment of patients with severe burn injuries begins with ABCs
Airway: consider inhalation injury
Breathing: circumferential burns of the trunk region can reduce respiratory muscle movement
Circulation: circumferential burns compromise circulation
Exposure: Important to assess the affected surface area
Escharotomy: emergency procedure to release the tourniquet-ing effects of the eschar
Differs from a fasciotomy in that it does not breach the deep fascial layer
PEEP = positive end-expiratory pressure
The positive pressure remaining in the airway after exhalation
Keeps airway pressure higher than atmospheric pressure
Common formulas for initial fluid rate in burn shock resuscitation
Parkland formula: 4 mL/kg body weight/% TBSA burns (lactated Ringer's solution)
Modified Brooke formula: 2 mL/kg/% (also lactated Ringer's solution)
Less fluid = lower risk of intra-abdominal compartment syndrome
Lactated Ringer’s solution is preferred over normal saline in burn injuries
Normal saline is avoided in large quantities due to the possibility of it leading to hyperchloremic acidosis

References

Acosta P, Santisbon E, Varon J. “The Use of Positive End-Expiratory Pressure in Mechanical Ventilation.” Critical Care Clinics. 2007;23(2):251-261. doi:10.1016/j.ccc.2006.12.012
Orgill DP, Piccolo N. Escharotomy and decompressive therapies in burns. J Burn Care Res. 2009;30(5):759-768. doi:10.1097/BCR.0b013e3181b47cd3
Snell JA, Loh NH, Mahambrey T, Shokrollahi K. Clinical review: the critical care management of the burn patient. Crit Care. 2013;17(5):241. Published 2013 Oct 7. doi:10.1186/cc12706

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

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Contributor: Taylor Lynch, MD

Educational Pearls:

What is NMS?

Neuroleptic Malignant Syndrome
Caused by anti-dopamine medication or rapid withdrawal of pro-dopamenergic medications
Mechanism is poorly understood
Life threatening

What medications can cause it?

Typical antipsychotics
Haloperidol, chlorpromazine, prochlorperazine, fluphenazine, trifluoperazine
Atypical antipsychotics
Less risk
Risperidone, clozapine, quetiapine, olanzapine, aripiprazole, ziprasidone
Anti-emetic agents with anti dopamine activity
Metoclopramide, promethazine, haloperidol
Not ondansetron
Abrupt withdrawal of levodopa

How does it present?

Slowly over 1-3 days (unlike serotonin syndrome which has a more acute onset)
Altered mental status, 82% of patients, typically agitated delirium with confusion
Peripheral muscle rigidity and decreased reflexes. AKA lead pipe rigidity. (As opposed to clonus and hyperreflexia in serotonin syndrome)
Hyperthermia (>38C seen in 87% of patients)
Can also have tachycardia, labile blood pressures, tachypnea, and tremor

How is it diagnosed?

Clinical diagnosis, focus on the timing of symptoms
No confirmatory lab test but can see possible elevated CK levels and WBC of 10-40k with a left shift

What else might be on the differential?

Sepsis
CNS infections
Heat stroke
Agitated delirium
Status eptilepticus
Drug induced extrapyramidal symptoms
Serotonin syndrome
Malignant hyperthermia

What is the treatment?

Start with ABC’s
Stop all anti-dopaminergic meds and restart pro-dopamine meds if recently stopped
Maintain urine output with IV fluids if needed to avoid rhabdomyolysis
Active or passive cooling if needed
Benzodiazapines, such as lorazepam 1-2 mg IV q 4hrs

What are active medical therapies?

Controversial treatments
Bromocriptine, dopamine agonist
Dantrolene, classically used for malignant hyperthermia
Amantadine, increases dopamine release
Use as a last resort

Dispo?

Mortality is around 10% if not recognized and treated
Most patients recover in 2-14 days
Must wait 2 weeks before restarting any medications

References

Oruch, R., Pryme, I. F., Engelsen, B. A., & Lund, A. (2017). Neuroleptic malignant syndrome: an easily overlooked neurologic emergency. Neuropsychiatric disease and treatment, 13, 161–175. https://doi.org/10.2147/NDT.S118438
Tormoehlen, L. M., & Rusyniak, D. E. (2018). Neuroleptic malignant syndrome and serotonin syndrome. Handbook of clinical neurology, 157, 663–675. https://doi.org/10.1016/B978-0-444-64074-1.00039-2
Velamoor, V. R., Norman, R. M., Caroff, S. N., Mann, S. C., Sullivan, K. A., & Antelo, R. E. (1994). Progression of symptoms in neuroleptic malignant syndrome. The Journal of nervous and mental disease, 182(3), 168–173. https://doi.org/10.1097/00005053-199403000-00007
Ware, M. R., Feller, D. B., & Hall, K. L. (2018). Neuroleptic Malignant Syndrome: Diagnosis and Management. The primary care companion for CNS disorders, 20(1), 17r02185. https://doi.org/10.4088/PCC.17r02185

Summarized by Jeffrey Olson MS2 | Edited by Meg Joyce & Jorge Chalit, OMSIII

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Contributor: Travis Barlock MD

Educational Pearls:

Recent study assessed outcomes after ROSC with epinephrine vs. norepinephrine
Observational multicenter study from 2011-2018
285 patients received epineprhine and 481 received norepinephrine
Epinephrine was associated with an increase in all-cause mortality (primary outcome)
Odds ratio 2.6; 95%CI 1.4-4.7; P = 0.002
Higher cardiovascular mortality (secondary outcome)
Higher proportion of unfavorable neurological outcome (secondary outcome)
Norepinephrine is the vasopressor of choice in post-cardiac arrest care

References

Bougouin W, Slimani K, Renaudier M, et al. Epinephrine versus norepinephrine in cardiac arrest patients with post-resuscitation shock. Intensive Care Med. 2022;48(3):300-310. doi:10.1007/s00134-021-06608-7

Summarized by Jorge Chalit, OMSIII | Edited by Meg Joyce & Jorge Chalit

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Contributor: Taylor Lynch, MD

Educational Pearls:

Opioid Epidemic- quick facts

Drug overdoses, primarily driven by opioids, have become the leading cause of accidental death in the U.S. for individuals aged 18-45.
In 2021, opioids were involved in nearly 75% of all drug overdose deaths
The rise of synthetic opioids like fentanyl, which is much more potent than heroin or prescription opioids, has played a major role in the increase in overdose deaths

What is Narcan AKA Naloxone?

Competitive opioid antagonist. It sits on the receptor but doesn’t activate it.

When do we give Narcan?

Respiratory rate less than 8-10 breaths per minute

Should you check the pupils?

An opioid overdose classically presents with pinpoint pupils BUT…
Hypercapnia from bradypnea can normalize the pupils
Taking other drugs at the same time like cocaine or meth can counteract the pupillary effects
Basilar stroke could also cause small pupils, so don’t anchor on an opioid overdose

How does Narcan affect the body?

Relatively safe even if the patient is not experiencing an opioid overdose. So when in doubt, give the Narcan.
What if the patient is opioid naive and overdosing?
Use a large dose given that this patient is unlikely to withdraw
0.4-2 mg every 3-5 minutes
What if the patient is a chronic opioid user
Use a smaller dose such as 0.04-0.4 mg to avoid precipitated withdrawal

How fast does Narcan work?

Given intravenously (IV), onset is 1-2 min
Given intranasal (IN), onset is 3-4 min
Given intramuscularly (IM), onset is ~6 min
Duration of action is 60 mins, with a range of 20-90 minutes

How does that compare to the duration of action of common opioids?

Heroine lasts 60 min
Fentanyl lasts 30-60 min, depending on route
Carfentanyl lasts ~5 hrs
Methadone lasts 12-24 hrs
So we really need to be conscious about redosing

How do you monitor someone treated with Narcan?

Pay close attention to the end-tidal CO2 to ensure that are ventilating appropriately
Be cautious with giving O2 as it might mask hypoventilation
Watch the respiratory rate
Give Narcan as needed
Observe for at least 2-4 hours after the last Narcan dose
Larger the dose, longer the observation period

Who gets a drip?

If they have gotten ~3 doses, time to start the drip
Start at 2/3rds last effective wake-up dose

Complications

Flash pulm edema
0.2-3.6% complication rate
Might be from the catecholamine surge from abrupt wake-up
Might also be from large inspiratory effort against a partially closed glottis which creates too much negative pressure
Treat with BIPAP if awake and intubation if not awake

Should you give Narcan in cardiac arrest?

Short answer no. During ACLS you take over breathing for the patient and that is pretty much the only way that Narcan can help
Just focus on high quality CPR

References

https://nida.nih.gov/research-topics/trends-statistics/overdose-death-rates#:~:text=Drug%20overdose%20deaths%20involving%20prescription,of%20deaths%20declined%20to%2014%2C716.
Elkattawy, S., Alyacoub, R., Ejikeme, C., Noori, M. A. M., & Remolina, C. (2021). Naloxone induced pulmonary edema. Journal of community hospital internal medicine perspectives, 11(1), 139–142. https://doi.org/10.1080/20009666.2020.1854417
van Lemmen, M., Florian, J., Li, Z., van Velzen, M., van Dorp, E., Niesters, M., Sarton, E., Olofsen, E., van der Schrier, R., Strauss, D. G., & Dahan, A. (2023). Opioid Overdose: Limitations in Naloxone Reversal of Respiratory Depression and Prevention of Cardiac Arrest. Anesthesiology, 139(3), 342–353. https://doi.org/10.1097/ALN.0000000000004622
Yousefifard, M., Vazirizadeh-Mahabadi, M. H., Neishaboori, A. M., Alavi, S. N. R., Amiri, M., Baratloo, A., & Saberian, P. (2019). Intranasal versus Intramuscular/Intravenous Naloxone for Pre-hospital Opioid Overdose: A Systematic Review and Meta-analysis. Advanced journal of emergency medicine, 4(2), e27. https://doi.org/10.22114/ajem.v0i0.279

Summarized by Jeffrey Olson MS2 | Edited by Meg Joyce & Jorge Chalit, OMSII

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Contributor: Taylor Lynch MD

Educational Pearls:

Anticholinergics are found in many medications, including over-the-counter remedies
Medications include:
Diphenhydramine
Tricyclic antidepressants like amitriptyline
Atropine
Antipsychotics like olanzapine
Antispasmodics - dicyclomine
Jimsonweed
Muscaria mushrooms
Mechanism of action involves competitive antagonism of the muscarinic receptor
Symptomatic presentation is easily remembered via the mnemonic:
Dry as a bone - anhidrosis due to cholinergic antagonism at sweat glands
Red as a beet - cutaneous vasodilation leads to skin flushing
Hot as a hare - anhidrotic hyperthermia
Blind as a bat - pupillary dilation and ineffective accommodation
Mad as a hatter - anxiety, agitation, dysarthria, hallucinations, and others
Clinical management
ABCs
Benzodiazepines for supportive care, agitation, and seizures
Sodium bicarbonate for TCA toxicity due to widened QRS
Activated charcoal if patient present < 1 hour after ingestion
Temperature monitoring
Contact poison control with questions
Physostigmine controversy
Acetylcholinesterase inhibitor
Black box warning for asystole and seizure
Contraindicated in TCA overdoses
Crosses blood-brain barrier, so useful for TCA overdoses
Indicated only in certain anticholinergic overdose with delirium
Disposition
Admission criteria include: symptoms >6 hours, CNS findings, QRS prolongation, hyperthermia, and rhabdomyolysis
ICU admission criteria include: delirium, dysrhythmias, seizures, coma, or requirement for physostigmine drip

References

Arens AM, Shah K, Al-Abri S, Olson KR, Kearney T. Safety and effectiveness of physostigmine: a 10-year retrospective review. Clin Toxicol (Phila). 2018;56(2):101-107. doi:10.1080/15563650.2017.1342828
Nguyen TT, Armengol C, Wilhoite G, Cumpston KL, Wills BK. Adverse events from physostigmine: An observational study. Am J Emerg Med. 2018;36(1):141-142. doi:10.1016/j.ajem.2017.07.006
Scharman E, Erdman A, Wax P, et al. Diphenhydramine and dimenhydrinate poisoning: An evidence-based consensus guideline for out-of-hospital management. Clin Toxicol. 2006;44(3):205-223. doi:10.1080/15563650600585920
Shervette RE 3rd, Schydlower M, Lampe RM, Fearnow RG. Jimson "loco" weed abuse in adolescents. Pediatrics. 1979;63(4):520-523.
Woolf AD, Erdman AR, Nelson LS, et al. Tricyclic antidepressant poisoning: An evidence-based consensus guideline for out-of-hospital management. Clin Toxicol. 2007;45(3):203-233. doi:10.1080/15563650701226192

Summarized by Jorge Chalit, OMSIII | Edited by Jorge Chalit

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Contributor: Aaron Lessen, MD

Educational Pearls:

How fast does cellulitis recover?

A recent prospective cohort study took a look at this question.
The study included 300 adults with cellulitis (excluding those with peri-orbital cellulitis or abscesses) in two emergency departments in Queensland, Australia.
They collected data from initial and follow-up surveys at 3, 7, and 14 days, and compared clinician and patient assessments at day 14.
Improvement was fastest between day 0 and day 3, with gradual progress thereafter.
At day 14, many still had skin redness and swelling, though warmth had often resolved. Clinicians reported higher cure rates than patients (85.8% vs. 52.8%).
Conclusion:
Cellulitis symptoms improve quickly at first but continue to linger for many patients.
Patients and doctors often have different views on when cellulitis is fully cured.

How should we counsel patients?

Even on antibiotics, the margins of the cellulitis may continue to spread a small amount.
Skin warmth should be the first symptom to go away.
It takes time to get better. Only about 50% of patients believed their cellulitis was cured at 2 weeks.

References

Nightingale, R. S., Etheridge, N., Sweeny, A. L., Smyth, G., Dace, W., Pellatt, R. A. F., Snelling, P. J., Yadav, K., & Keijzers, G. (2024). Cellulitis in the Emergency Department: A prospective cohort study with patient-centred follow-up. Emergency medicine Australasia : EMA, 10.1111/1742-6723.14401. Advance online publication. https://doi.org/10.1111/1742-6723.14401

Summarized by Jeffrey Olson MS2 | Edited by Meg Joyce & Jorge Chalit, OMSIII

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Contributor: Aaron Lessen MD

Educational Pearls:

A recent study assessed EMS treatment of high blood pressure in the field
2404 patients randomized to prehospital treatment (1205) vs. usual care (1199)
Included patients with prehospital BP greater than 150 mm Hg
The treatment arm’s BP goal was 130-140 mm Hg
The primary efficacy outcome was functional status 90 days out
Stroke was confirmed by imaging upon hospital arrival
On arrival, the mean SBP of the treatment arm was 159 mm Hg compared with 170 mm Hg in the usual care group
No significant difference in functional outcomes between the treatment group and the usual care group (Common Odds Ratio of 1.00, 95% CI = 0.87-1.15)
Post-imaging analysis revealed 46.5% of the undifferentiated patients had a hemorrhagic stroke
Prehospital reduction in BP did reduce the odds of poor functional outcome in hemorrhagic stroke patients alone (Common Odds Ratio 0.75, 95% CI 0.60-0.92)
Those with ischemic stroke had increased odds of poor functional outcome (Common Odds Ratio 1.30, 95% CI 1.06-1.60)
Bottom line: it is challenging to identify the stroke type in the prehospital setting and therefore not necessarily helpful to treat the blood pressure

References

Ren X, Zhang C, Xu P, et al. Intensive Ambulance-Delivered Blood- Pressure Reduction in Hyperacute Stroke. New England Journal of Medicine. 2024;390(20):1862-1872. doi:10.1056/NEJMoa2314741

Summarized by Jorge Chalit, OMSIII | Edited by Meg Joyce & Jorge Chalit

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Contributor: Taylor Lynch MD

Educational Pearls:

Overview:
- Sympathomimetic drugs mimic the fight or flight response, affecting monoamines such as dopamine, norepinephrine, and epinephrine
- Limited therapeutic use, often abused.
Types:
- Amphetamines: Methamphetamine, Adderall, Ritalin, Vyvanse
- MDMA (Ecstasy)
- Cocaine (Both hydrochloride salt & free based crack cocaine)
- Theophylline (Asthma treatment)
- Ephedrine (For low blood pressure)
- BZP, Oxymetazoline (Afrin), Pseudoephedrine (Sudafed)
- MAO Inhibitors (treatment-resistant depression)
Mechanisms:
- Act on adrenergic and dopaminergic receptors.
- Cocaine blocks dopamine and serotonin reuptake.
- Methamphetamines increase stimulatory neurotransmitter release
- MAO Inhibitors prevent neurotransmitter breakdown.
Symptoms:
- Agitation, tachycardia, hypertension, hyperactive bowel sounds, diuresis, hyperthermia.
- Severe cases: Angina, seizures, cardiovascular collapse.
Diagnosis:
- Clinical examination and history.
- Differentiate from anticholinergic toxidrome by diaphoresis and hyperactive bowel sounds.
- Tests: EKG, cardiac biomarkers, chest X-ray, blood gas, BMP, CK, coagulation studies, U-tox screen.
Treatment:
- Stabilize ABCs, IV hydration, temperature monitoring, benzodiazepines.
- Avoid beta-blockers due to unopposed alpha agonism.
- Whole bowel irrigation for body packers; surgical removal if packets rupture.
- IV hydration for high CK levels.
- Observation period often necessary.
Recap:
- Mimic sympathetic nervous system.
- Key symptoms: Diaphoresis, hyperactive bowel sounds.
- Treatment: Supportive care, benzodiazepines.
- Use poison control as a resource.

References:

Costa VM, Grazziotin Rossato Grando L, Milandri E, Nardi J, Teixeira P, Mladěnka P, Remião F. Natural Sympathomimetic Drugs: From Pharmacology to Toxicology. Biomolecules. 2022;12(12):1793. doi:10.3390/biom12121793
Kolecki P. Sympathomimetic Toxicity From Emergency Medicine. Medscape. Updated March 11, 2024. https://emedicine.medscape.com/article/818583-overview
Williams RH, Erickson T, Broussard LA. Evaluating Sympathomimetic Intoxication in an Emergency Setting. Lab Med. 2000;31(9):497-508. https://doi.org/10.1309/WVX1-6FPV-E2LC-B6YG

Summarized by Steven Fujaros | Edited by Jorge Chalit, OMSIII

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Contributor: Travis Barlock MD

Educational Pearls:

Wide-complex tachycardia is defined as a heart rate > 100 BPM with a QRS width > 120 milliseconds
Wide-complex tachycardia of supraventricular origin is known as SVT with aberrancy
Aberrancy is due to bundle branch blocks
Mostly benign
Treated with adenosine or diltiazem
Wide-complex tachycardia of ventricular origin is also known as VTach
Originates from ventricular myocytes, which are poor inherent pacemakers
Dangerous rhythm that can lead to death
Treated with amiodarone or lidocaine
80% of wide-complex tachycardias are VTach
90% likelihood for patients with a history of coronary artery disease
In assessing a wide-complex tachycardia, it is best to treat it as a presumed ventricular tachycardia
Treating SVT with amiodarone or lidocaine does no harm
However, treating VTach with adenosine or diltiazem may worsen the condition

References

Littmann L, Olson EG, Gibbs MA. Initial evaluation and management of wide-complex tachycardia: A simplified and practical approach. Am J Emerg Med. 2019;37(7):1340-1345. doi:https://doi.org/10.1016/j.ajem.2019.04.027
Viskin S, Chorin E, Viskin D, Hochstadt A, Schwartz AL, Rosso R. Polymorphic Ventricular Tachycardia: Terminology, Mechanism, Diagnosis, and Emergency Therapy. Circulation. 2021;144(10):823-839. doi:10.1161/CIRCULATIONAHA.121.055783
Williams SE, O’Neill M, Kotadia ID. Supraventricular tachycardia: An overview of diagnosis and management. Clin Med J R Coll Physicians London. 2020;20(1):43-47. doi:10.7861/clinmed.cme.20.1.3

Summarized by Jorge Chalit, OMSIII | Edited by Meg Joyce & Jorge Chalit

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Contributor: Aaron Lessen MD

Educational Pearls:

The case:

A gentleman came in from a nursing home with symptoms concerning for sepsis. He was hypotensive, hypoxic, febrile, and mentally altered.
His past medical history included previous strokes which had left him with deficits for which he required a feeding tube.
Initial workup included some point of care labs which revealed a sodium of 165 mEq/L (normal range 135-145)

Hypernatremia

What causes it?
Dehydration, from insufficient fluid intake. This might happen in individuals who cannot drink water independently, such as infants, elderly, or disabled people, as was the case for this patient.
Other causes of dehydration/hypernatremia include excessive sweating; diabetes insipidus; diuretic use; kidney dysfunction; and severe burns which can lead to fluid loss through the damaged skin.
How do you correct it?
Need to correct slowly, not more than 10 to 12 meq/L in 24 hours
Can do normal saline (0.9%) or half saline (0.45%) and D5, at 150-200 mL per hour.
Check the sodium frequently (every 2-3 hours)
Will likely need ICU-level monitoring
What happens if you correct it too quickly?
Cerebral edema
Seizures

Bonus fact: Correction of hyponatremia too quickly causes osmotic demyelination syndrome (ODS).

References

Chauhan, K., Pattharanitima, P., Patel, N., Duffy, A., Saha, A., Chaudhary, K., Debnath, N., Van Vleck, T., Chan, L., Nadkarni, G. N., & Coca, S. G. (2019). Rate of Correction of Hypernatremia and Health Outcomes in Critically Ill Patients. Clinical journal of the American Society of Nephrology : CJASN, 14(5), 656–663. https://doi.org/10.2215/CJN.10640918
Lindner, G., & Funk, G. C. (2013). Hypernatremia in critically ill patients. Journal of critical care, 28(2), 216.e11–216.e2.16E20. https://doi.org/10.1016/j.jcrc.2012.05.001
Muhsin, S. A., & Mount, D. B. (2016). Diagnosis and treatment of hypernatremia. Best practice & research. Clinical endocrinology & metabolism, 30(2), 189–203. https://doi.org/10.1016/j.beem.2016.02.014

Summarized by Jeffrey Olson MS2 | Edited by Meg Joyce & Jorge Chalit, OMSIII

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Contributor: Aaron Lessem MD

Educational Pearls:

Oseltamivir (Tamiflu) is an antiviral medication used commonly to treat influenza
Trials show that the medication reduces the duration of illness by less than 1 day (~16 hours in one systematic review)
Benefit only occurs if taken within 48 hours of symptom onset
Must be taken for 5 days
A 2024 meta-analysis reviewed 15 randomized-controlled trials for the risk of hospitalization
No reduction in hospitalizations with oseltamivir in patients over the age of 12
No difference in high-risk patients over the age of 65 or those with comorbidities
The authors note that the confidence interval in these populations is wide, indicating a need for subsequent studies in high-risk populations
Oseltamivir is associated with adverse effects including nausea, vomiting, and neurologic symptoms
The risk of adverse effects may outweigh the benefits of a small reduction in the duration of illness

References

Hanula R, Bortolussi-Courval É, Mendel A, Ward BJ, Lee TC, McDonald EG. Evaluation of Oseltamivir Used to Prevent Hospitalization in Outpatients with Influenza: A Systematic Review and Meta-Analysis. JAMA Intern Med. 2024;184(1):18-27. doi:10.1001/jamainternmed.2023.0699
Jefferson T, Jones M, Doshi P, Spencer EA, Onakpoya I, Heneghan CJ. Oseltamivir for influenza in adults and children: Systematic review of clinical study reports and summary of regulatory comments. BMJ. 2014;348(April):1-18. doi:10.1136/bmj.g2545

Summarized by Jorge Chalit, OMSII | Edited by Meg Joyce & Jorge Chalit

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Contributor: Aaron Lessen MD

Educational Pearls:

Epinephrine is essential in the treatment of anaphylaxis, but is epinephrine dangerous from a cardiovascular perspective?

A 2024 study in the Journal of the American College of Emergency Physicians Open sought to answer this question.

Methods:

Retrospective observational study at a Tennessee quaternary care academic ED that analyzed ED visits from 2017 to 2021 involving anaphylaxis treated with IM epinephrine.
The primary outcome was cardiotoxicity

Results:

Out of 338 patients, 16 (4.7%) experienced cardiotoxicity. Events included ischemic EKG changes (2.4%), elevated troponin (1.8%), atrial arrhythmias (1.5%), ventricular arrhythmia (0.3%), and depressed ejection fraction (0.3%).
Affected patients were older, had more comorbidities, and often received multiple epinephrine doses.

Bottom line:

All adults presenting with anaphylaxis should be rapidly treated with epinephrine but monitored closely for cardiotoxicity, especially in patients with a history of hypertension and those who receive multiple doses.

These results are supported by a 2017 study that found that 9% (4/44) of older patients who received epinephrine for anaphylaxis had cardiovascular complications.

References

Kawano, T., Scheuermeyer, F. X., Stenstrom, R., Rowe, B. H., Grafstein, E., & Grunau, B. (2017). Epinephrine use in older patients with anaphylaxis: Clinical outcomes and cardiovascular complications. Resuscitation, 112, 53–58. https://doi.org/10.1016/j.resuscitation.2016.12.020
Pauw, E. K., Stubblefield, W. B., Wrenn, J. O., Brown, S. K., Cosse, M. S., Curry, Z. S., Darcy, T. P., James, T. E., Koetter, P. E., Nicholson, C. E., Parisi, F. N., Shepherd, L. G., Soppet, S. L., Stocker, M. D., Walston, B. M., Self, W. H., Han, J. H., & Ward, M. J. (2024). Frequency of cardiotoxicity following intramuscular administration of epinephrine in emergency department patients with anaphylaxis. Journal of the American College of Emergency Physicians open, 5(1), e13095. https://doi.org/10.1002/emp2.13095

Summarized by Jeffrey Olson MS2 | Edited by Meg Joyce & Jorge Chalit OMS II

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Contributor: Aaron Lessen MD

Educational Pearls:

Opioid overdoses that are reversed with naloxone (Narcan), a mu-opioid antagonist, can precipitate acute withdrawal in some patients
Treatment of opioid use disorder with buprenorphine can also precipitate withdrawal
Opioid withdrawal symptoms include nausea, vomiting, diarrhea, and agitation
Buprenorphine works as a partial agonist at mu-opioid receptors, which may alleviate withdrawal symptoms
The preferred dose of buprenorphine is 16 mg
Treatment of buprenorphine-induced opioid withdrawal is additional buprenorphine
Adjunctive treatments may be used for other opioid withdrawal symptoms
Nausea with ondansetron
Diarrhea with loperamide
Agitation with hydroxyzine

References

Quattlebaum THN, Kiyokawa M, Murata KA. A case of buprenorphine-precipitated withdrawal managed with high-dose buprenorphine. Fam Pract. 2022;39(2):292-294. doi:10.1093/fampra/cmab073
Spadaro A, Long B, Koyfman A, Perrone J. Buprenorphine precipitated opioid withdrawal: Prevention and management in the ED setting. Am J Emerg Med. 2022;58:22-26. doi:10.1016/j.ajem.2022.05.013

Summarized by Jorge Chalit, OMSII | Edited by Meg Joyce & Jorge Chalit

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Contributor: Travis Barlock MD

Educational Pearls:

How do you differentiate between compensated and decompensated cirrhosis?

Use the acronym VIBE to look for signs of being decompensated.

V-Volume
Cirrhosis can cause volume overload through a variety of mechanisms such as by increasing pressure in the portal vein system and the decreased production of albumin.
Look for pulmonary edema (dyspnea, orthopnea, wheezing/crackles, coughing up frothy pink sputum, etc.) or a tense abdomen.
I-Infection
The ascitic fluid can become infected with bacteria, a complication called Spontaneous Bacterial Peritonitis (SBP).
Look for abdominal pain, fever, hypotension, and tachycardia. Diagnosis is made with ascitic fluid cell analyses (polymorphonuclear neutrophils >250/mm3)
B-Bleeding
Another consequence of increased portal pressure is that blood backs up into smaller blood vessels, including those in the esophagus.
Over time, this increased pressure can result in the development of dilated, fragile veins called esophageal varices, which are prone to bleeding.
Look for hematemesis, melena, lightheadedness, and pale skin.
E-Encephalopathy
A failing liver also does not clear toxins which can affect the brain.
Look for asterixis (flapping motion of the hands when you tell the patient to hold their hands up like they are going to stop a bus)

Other complications to look out for.

Hepatorenal syndrome
Hepatopulmonary syndrome

References

Engelmann, C., Clària, J., Szabo, G., Bosch, J., & Bernardi, M. (2021). Pathophysiology of decompensated cirrhosis: Portal hypertension, circulatory dysfunction, inflammation, metabolism and mitochondrial dysfunction. Journal of hepatology, 75 Suppl 1(Suppl 1), S49–S66. https://doi.org/10.1016/j.jhep.2021.01.002
Enomoto, H., Inoue, S., Matsuhisa, A., & Nishiguchi, S. (2014). Diagnosis of spontaneous bacterial peritonitis and an in situ hybridization approach to detect an "unidentified" pathogen. International journal of hepatology, 2014, 634617. https://doi.org/10.1155/2014/634617
Mansour, D., & McPherson, S. (2018). Management of decompensated cirrhosis. Clinical medicine (London, England), 18(Suppl 2), s60–s65. https://doi.org/10.7861/clinmedicine.18-2-s60

Summarized by Jeffrey Olson MS2 | Edited by Meg Joyce & Jorge Chalit, OMS II

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Contributor: Aaron Lessen MD

Educational Pearls:

Lorazepam (Ativan) is dosed at 0.1 mg/kg up to a maximum of 4 mg in status epilepticus
Some ED protocols only give 2 mg initially
The maximum recommended dose of levetiracetam (Keppra) is 60 mg/kg or 4.5 g
In one retrospective study, only 50% of patients received the correct dose of lorazepam
For levetiracetam, it was only 35% of patients
Underdosing leads to complications
Higher rates of intubations
More likely to progress to refractory status epilepticus

References

Cetnarowski A, Cunningham B, Mullen C, Fowler M. Evaluation of intravenous lorazepam dosing strategies and the incidence of refractory status epilepticus. Epilepsy Res. 2023;190(November 2022):107067. doi:10.1016/j.eplepsyres.2022.107067
Sathe AG, Tillman H, Coles LD, et al. Underdosing of Benzodiazepines in Patients With Status Epilepticus Enrolled in Established Status Epilepticus Treatment Trial. Acad Emerg Med. 2019;26(8):940-943. doi:10.1111/acem.13811

Summarized by Jorge Chalit, OMSII | Edited by Meg Joyce & Jorge Chalit

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Contributor: Travis Barlock MD

Educational Pearls:

Ketamine is an NMDA receptor antagonist with a wide variety of uses in the emergency department. To dose ketamine remember the numbers 0.3, 1, and 3.

Pain dose

For acute pain relief administer 0.3 mg/kg of ketamine IV over 10-20 minutes (max of 30 mg).
Note: There is evidence that a lower dose of 0.1-0.15 mg/kg can be just as effective.

Dissociative dose

To use ketamine as an induction agent for intubation or for procedural sedation administer 1 mg/kg IV over 1-2 minutes.

IM for acute agitation

If a patient is out of control and a danger to themselves or others, administer 3 mg/kg intramuscularly (max 500 mg).
If you are giving IM ketamine it has to be in the concentrated 100 mg/ml vial.

Additional pearls

Pushing ketamine too quickly can cause laryngospasm.
Between .3 and 1 mg/kg is known as the recreational dose. You want to avoid this range because this is where ketamine starts to pick up its dissociative effects and can cause unpleasant and intense hallucinations. This is colloquially known as being in the “k-hole”.

References

Gao, M., Rejaei, D., & Liu, H. (2016). Ketamine use in current clinical practice. Acta pharmacologica Sinica, 37(7), 865–872. https://doi.org/10.1038/aps.2016.5
Lin, J., Figuerado, Y., Montgomery, A., Lee, J., Cannis, M., Norton, V. C., Calvo, R., & Sikand, H. (2021). Efficacy of ketamine for initial control of acute agitation in the emergency department: A randomized study. The American journal of emergency medicine, 44, 306–311. https://doi.org/10.1016/j.ajem.2020.04.013
Stirling, J., & McCoy, L. (2010). Quantifying the psychological effects of ketamine: from euphoria to the k-Hole. Substance use & misuse, 45(14), 2428–2443. https://doi.org/10.3109/10826081003793912

Summarized by Jeffrey Olson MS2 | Edited by Jorge Chalit, OMS II

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Contributor: Travis Barlock MD

Educational Pearls:

Thrombolytic therapy (tPA or TNK) is often used in the ED for strokes
Use of anticoagulants with INR > 1.7 or PT >15
Warfarin will reliably increase the INR
Current use of Direct thrombin inhibitor or Factor Xa inhibitor
aPTT/PT/INR are insufficient to assess the degree of anticoagulant effect of Factor Xa inhibitors like apixaban (Eliquis) and rivaroxaban (Xarelto)
Intracranial or intraspinal surgery in the last 3 months
Intracranial neoplasms or arteriovenous malformations also increase the risk of bleeding
Current intracranial or subarachnoid hemorrhage
History of intracranial hemorrhage from thrombolytic therapy also contraindicates tPA/TNK
Recent (within 21 days) or active gastrointestinal bleed
Hypertension
BP >185 systolic or >110 diastolic
Administer labetalol before thrombolytics to lower blood pressure
Timing of symptoms
Onset > 4.5 hours contraindicates tPA
Platelet count < 100,000
BGL < 50
Potential alternative explanation for stroke-like symptoms obviating need for thrombolytics

References

Fugate JE, Rabinstein AA. Absolute and Relative Contraindications to IV rt-PA for Acute Ischemic Stroke. The Neurohospitalist. 2015;5(3):110-121. doi:10.1177/1941874415578532
Powers WJ, Rabinstein AA, Ackerson T, et al. Guidelines for the Early Management of Patients with Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke a Guideline for Healthcare Professionals from the American Heart Association/American Stroke Association. Vol 50.; 2019. doi:10.1161/STR.0000000000000211

Summarized by Jorge Chalit, OMSII | Edited by Jorge Chalit

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Contributor: Ricky Dhaliwal, MD

Educational Pearls:

Takotsubo cardiomyopathy, also known as "broken heart syndrome,” is a temporary heart condition that can mimic the symptoms of a heart attack, including troponin elevations and mimic STEMI on ECG.
The exact cause is not fully understood, but it is often triggered by severe emotional or physical stress. The stress can lead to a surge of catecholamines which affects the heart (multivessel spasm/paralysed myocardium).
The name "Takotsubo" comes from the Japanese term for a type of octopus trap, as the left ventricle takes on a distinctive shape resembling this trap during systole. The LV is dilated and part of the wall becomes akenetic. These changes can be seen on ultrasound.
The population most at risk for Takotsubo are post-menopausal women.
Coronary angiography is one of the only ways to differentiate Takotsubo from other acute coronary syndromes.
Most people with Takotsubo cardiomyopathy recover fully.

References

Amin, H. Z., Amin, L. Z., & Pradipta, A. (2020). Takotsubo Cardiomyopathy: A Brief Review. Journal of medicine and life, 13(1), 3–7. https://doi.org/10.25122/jml-2018-0067
Bossone, E., Savarese, G., Ferrara, F., Citro, R., Mosca, S., Musella, F., Limongelli, G., Manfredini, R., Cittadini, A., & Perrone Filardi, P. (2013). Takotsubo cardiomyopathy: overview. Heart failure clinics, 9(2), 249–x. https://doi.org/10.1016/j.hfc.2012.12.015
Dawson D. K. (2018). Acute stress-induced (takotsubo) cardiomyopathy. Heart (British Cardiac Society), 104(2), 96–102. https://doi.org/10.1136/heartjnl-2017-311579
Kida, K., Akashi, Y. J., Fazio, G., & Novo, S. (2010). Takotsubo cardiomyopathy. Current pharmaceutical design, 16(26), 2910–2917. https://doi.org/10.2174/138161210793176509

Summarized by Jeffrey Olson MS2 | Edited by Jorge Chalit, OMSII

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Contributor: Ricky Dhaliwal MD

Educational Pearls:

Primary adrenal insufficiency (most common risk factor for adrenal crises)
An autoimmune condition commonly known as Addison's Disease
Defects in the cells of the adrenal glomerulosa and fasciculata result in deficient glucocorticoids and mineralocorticoids
Mineralocorticoid deficiency leads to hyponatremia and hypovolemia
Lack of aldosterone downregulates Endothelial Sodium Channels (ENaCs) at the renal tubules
Water follows sodium and generates a hypovolemic state
Glucocorticoid deficiency contributes further to hypotension and hyponatremia
Decreased vascular responsiveness to angiotensin II
Increased secretion of vasopressin (ADH) from the posterior pituitary
An adrenal crisis is defined as a sudden worsening of adrenal insufficiency
Presents with non-specific symptoms including nausea, vomiting, fatigue, confusion, and fevers
Fevers may be the result of underlying infection
Work-up in the ED includes labs looking for infection and adding cortisol + ACTH levels
Emergent treatment is required
100 mg hydrocortisone bolus followed by 50 mg every 6 hours
Immediate IV fluid repletion with 1L normal saline
The most common cause of an adrenal crisis is an acute infection in patients with baseline adrenal insufficiency
Often due to a gastrointestinal infection

References

Bancos I, Hahner S, Tomlinson J, Arlt W. Diagnosis and management of adrenal insufficiency. Lancet Diabetes Endocrinol. 2015;3(3):216-226. doi:10.1016/S2213-8587(14)70142-1
Bornstein SR, Allolio B, Arlt W, et al. Diagnosis and Treatment of Primary Adrenal Insufficiency: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2016;101(2):364-389. doi:10.1210/jc.2015-1710
Cronin CC, Callaghan N, Kearney PJ, Murnaghan DJ, Shanahan F. Addison disease in patients treated with glucocorticoid therapy. Arch Intern Med. 1997;157(4):456-458.
Feldman RD, Gros R. Vascular effects of aldosterone: sorting out the receptors and the ligands. Clin Exp Pharmacol Physiol. 2013;40(12):916-921. doi:10.1111/1440-1681.12157
Hahner S, Loeffler M, Bleicken B, et al. Epidemiology of adrenal crisis in chronic adrenal insufficiency: the need for new prevention strategies. Eur J Endocrinol. 2010;162(3):597-602. doi:10.1530/EJE-09-0884

Summarized by Jorge Chalit, OMSII | Edited by Meg Joyce & Jorge Chalit

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Contributor: Travis Barlock, MD

Educational Pearls:

Cancer-related emergencies can be sorted into a few buckets:

Infection
Cancer itself and the treatments (chemotherapy/radiation) can be immunosuppressive. Look out for conditions such as sepsis and neutropenic fever.
Obstruction
Cancer causes a hypercoagulable state. Look out for blood clots which can cause emergencies such as a pulmonary embolism, stroke, superior vena cava (SVC) syndrome, and cardiac tamponade.
Metabolic
Cancer can affect the metabolic system in a variety of ways. For example, certain cancers like bone cancers can stimulate the bones to release large amounts of calcium leading to hypercalcemia. Tumor lysis syndrome is another consideration in which either spontaneously or due to treatment, tumor cells will release large amounts of electrolytes into the bloodstream causing hyperuricemia, hyperkalemia, hyperphosphatemia, and hypocalcemia.
Medication side effect
Immunomodulators can have strange side effects. A common one to know is Keytruda (pembrolizumab), which can cause inflammation in any organ. So if you have a cancer patient on immunomodulators with any inflammatory changes (cystitis, colitis, pneumonitis, etc), talk to oncology about whether steroids are indicated.
Chemotherapy can cause tumor lysis syndrome (see above), and multiple chemotherapeutics are known to cause heart failure (doxorubicin, trastuzumab), kidney failure (cisplatin), and pulmonary toxicity (bleomycin).

References

Campello, E., Ilich, A., Simioni, P., & Key, N. S. (2019). The relationship between pancreatic cancer and hypercoagulability: a comprehensive review on epidemiological and biological issues. British journal of cancer, 121(5), 359–371. https://doi.org/10.1038/s41416-019-0510-x
Gyamfi, J., Kim, J., & Choi, J. (2022). Cancer as a Metabolic Disorder. International journal of molecular sciences, 23(3), 1155. https://doi.org/10.3390/ijms23031155
Kwok, G., Yau, T. C., Chiu, J. W., Tse, E., & Kwong, Y. L. (2016). Pembrolizumab (Keytruda). Human vaccines & immunotherapeutics, 12(11), 2777–2789. https://doi.org/10.1080/21645515.2016.1199310
Wang, S. J., Dougan, S. K., & Dougan, M. (2023). Immune mechanisms of toxicity from checkpoint inhibitors. Trends in cancer, 9(7), 543–553. https://doi.org/10.1016/j.trecan.2023.04.002
Zimmer, A. J., & Freifeld, A. G. (2019). Optimal Management of Neutropenic Fever in Patients With Cancer. Journal of oncology practice, 15(1), 19–24. https://doi.org/10.1200/JOP.18.00269

Summarized by Jeffrey Olson MS2 | Edited by Meg Joyce & Jorge Chalit, OMSII

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Contributor: Travis Barlock MD

Educational Pearls:

There are three indications for IV albumin in the ED
Spontaneous bacterial peritonitis (SBP)
Patients with SBP develop renal failure from volume depletion
Albumin repletes volume stores and reduces renal impairment
Albumin binds inflammatory cytokines and expands plasma volume
Reduced all-cause mortality if IV albumin is given with antibiotics
Hepatorenal syndrome
Cirrhosis of the liver causes the release of endogenous vasodilators
The renin-angiotensin-aldosterone system (RAAS) fails systemically but maintains vasoconstriction at the kidneys, leading to decreased renal perfusion
IV albumin expands plasma volume and prevents failure of the RAAS
Large volume paracentesis
Large-volume removal may lead to circulatory dysfunction
IV albumin is associated with a reduced risk of paracentesis-associated circulatory dysfunction
There are many other FDA-approved conditions for which to use exogenous albumin but the data are conflicted about the benefits on mortality

References

Arroyo V, Fernandez J. Pathophysiological basis of albumin use in cirrhosis. Ann Hepatol. 2011;10(SUPPL. 1):S6-S14. doi:10.1016/s1665-2681(19)31600-x
Bai Z, Wang L, Wang R, et al. Use of human albumin infusion in cirrhotic patients: a systematic review and meta-analysis of randomized controlled trials. Hepatol Int. 2022;16(6):1468-1483. doi:10.1007/s12072-022-10374-z
Batool S, Waheed MD, Vuthaluru K, et al. Efficacy of Intravenous Albumin for Spontaneous Bacterial Peritonitis Infection Among Patients With Cirrhosis: A Meta-Analysis of Randomized Control Trials. Cureus. 2022;14(12). doi:10.7759/cureus.33124
Kwok CS, Krupa L, Mahtani A, et al. Albumin reduces paracentesis-induced circulatory dysfunction and reduces death and renal impairment among patients with cirrhosis and infection: A systematic review and meta-analysis. Biomed Res Int. 2013;2013. doi:10.1155/2013/295153
Sort P, Navasa M, Arroyo V, et al. Effect of Intravenous Albumin on Renal Impairment and Mortality in Patients with Cirrhosis and Spontaneous Bacterial Peritonitis. N Engl J Med. 1999;341(6):403-409.

Summarized by Jorge Chalit, OMSII | Edited by Meg Joyce & Jorge Chalit

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Contributor: Ricky Dhaliwal, MD

Educational Pearls:

What are DKA and HHS?

DKA (Diabetic Ketoacidosis) and HHS (Hyperosmolar Hyperglycemic State) are both acute hyperglycemic states.

DKA

More common in type 1 diabetes.
Triggered by decreased circulating insulin.
The body needs energy but cannot use glucose because it can’t get it into the cells.
This leads to increased metabolism of free fatty acids and the increased production of ketones.
The buildup of ketones causes acidosis.
The kidneys attempt to compensate for the acidosis by increasing diuresis.
These patients present as dry and altered, with sweet-smelling breath and Kussmaul (fast and deep) respirations.

HSS

More common in type 2 diabetes.
In this condition there is still enough circulating insulin to avoid the breakdown of fats for energy but not enough insulin to prevent hyperglycemia.
Serum glucose levels are very high – around 600 to 1200 mg/dl.
Also presents similarly to DKA with the patient being dry and altered.

Important labs to monitor

Serum glucose
Potassium
Phosphorus
Magnesium
Anion gap (Na - Cl - HCO3)
Renal function (Creatinine and BUN)
ABG/VBG for pH
Urinalysis and urine ketones by dipstick

Treatment

Identify the cause, i.e. Has the patient stopped taking their insulin?
Aggressive hydration with isotonic fluids.
Normal Saline (NS) vs Lactated Ringers (LR)?
LR might resolve the DKA/HHS faster with less risk of hypernatremia.
Should you bolus with insulin?
No, just start a drip.
0.1-0.14 units per kg of insulin.
Make sure you have your potassium back before starting insulin as the insulin can shift the potassium into the cells and lead to dangerous hypokalemia.
Should you treat hyponatremia?
Make sure to correct for hyperglycemia before treating. This artificially depresses the sodium.
Should you give bicarb?
Replace if the pH < 6.9. Otherwise, it won’t do anything to help.
Don’t intubate, if the patient is breathing fast it is because they are compensating for their acidosis.

References

Andrade-Castellanos, C. A., Colunga-Lozano, L. E., Delgado-Figueroa, N., & Gonzalez-Padilla, D. A. (2016). Subcutaneous rapid-acting insulin analogues for diabetic ketoacidosis. The Cochrane database of systematic reviews, 2016(1), CD011281. https://doi.org/10.1002/14651858.CD011281.pub2
Chaithongdi, N., Subauste, J. S., Koch, C. A., & Geraci, S. A. (2011). Diagnosis and management of hyperglycemic emergencies. Hormones (Athens, Greece), 10(4), 250–260. https://doi.org/10.14310/horm.2002.1316
Dhatariya, K. K., Glaser, N. S., Codner, E., & Umpierrez, G. E. (2020). Diabetic ketoacidosis. Nature reviews. Disease primers, 6(1), 40. https://doi.org/10.1038/s41572-020-0165-1
Duhon, B., Attridge, R. L., Franco-Martinez, A. C., Maxwell, P. R., & Hughes, D. W. (2013). Intravenous sodium bicarbonate therapy in severely acidotic diabetic ketoacidosis. The Annals of pharmacotherapy, 47(7-8), 970–975. https://doi.org/10.1345/aph.1S014
Modi, A., Agrawal, A., & Morgan, F. (2017). Euglycemic Diabetic Ketoacidosis: A Review. Current diabetes reviews, 13(3), 315–321. https://doi.org/10.2174/1573399812666160421121307
Self, W. H., Evans, C. S., Jenkins, C. A., Brown, R. M., Casey, J. D., Collins, S. P., Coston, T. D., Felbinger, M., Flemmons, L. N., Hellervik, S. M., Lindsell, C. J., Liu, D., McCoin, N. S., Niswender, K. D., Slovis, C. M., Stollings, J. L., Wang, L., Rice, T. W., Semler, M. W., & Pragmatic Critical Care Research Group (2020). Clinical Effects of Balanced Crystalloids vs Saline in Adults With Diabetic Ketoacidosis: A Subgroup Analysis of Cluster Randomized Clinical Trials. JAMA network open, 3(11), e2024596. https://doi.org/10.1001/jamanetworkopen.2020.24596

Summarized by Jeffrey Olson MS2 | Edited by Meg Joyce & Jorge Chalit, OMSII

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Contributor: Aaron Lessen MD

Educational Pearls:

Button batteries cause alkaline corrosion and erosion of the esophagus when swallowed
Children swallow button batteries, which create a medical emergency as they can perforate the esophagus
A recent study compared various home remedies as first-aid therapy for button battery ingestion
Honey, jam, normal saline, Coca-Cola, orange juice, milk, and yogurt
The study used a porcine esophageal model to assess resistance to alkalinization with the different home remedies
Honey and jam demonstrated a significantly lower esophageal tissue pH compared with normal saline
Histologic changes in the tissue samples appeared 60 minutes later with honey and jam compared with normal saline
These treatments do not preclude medical intervention and battery removal

References

Chiew AL, Lin CS, Nguyen DT, Sinclair FAW, Chan BS, Solinas A. Home Therapies to Neutralize Button Battery Injury in a Porcine Esophageal Model. Ann Emerg Med. 2023:1-9. doi:10.1016/j.annemergmed.2023.08.018

Summarized by Jorge Chalit, OMSII | Edited by Meg Joyce & Jorge Chalit

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Contributor: Ricky Dhaliwal, MD

Educational Pearls:

What can you do to control bleeding in a penetrating wound?

Apply direct pinpoint pressure on the wound as well as proximal to the wound.
Build a compression dressing.

How do you build a compression dressing?

Think about building an upside-down pyramid with the gauze.
Consider coagulation agents such as an absorbent gelatin sponge material, microporous polysaccharide hemispheres, oxidized cellulose, fibrin sealants, topical thrombin, or tranexamic acid.

What are the indications to use a tourniquet?

The Stop The Bleed campaign recommends looking for the following features of “life-threatening” bleeding.
Pulsatile bleeding.
Blood is pooling on the ground.
The overlying clothes are soaked.
Bandages are ineffective.
Partial or full amputation.
And if the patient is in shock.

How do you put on a tourniquet?

If using a Combat Application Tourniquet (C-A-T) tourniquet, apply it proximal to the wound, then rotate the plastic rod until the bleeding stops. Then secure the plastic rod with a clip and make sure the Velcro is in place.
Mark the time - generally, there is a spot on the tourniquet to write.
Have a plan for the next steps. Does the patient need emergent surgery? Do they need to be transfered?

How long can you leave a tourniquet on?

Less than 90 minutes.

What are the risks?

Nerve injury.
Ischemia.

References

Latina R, Iacorossi L, Fauci AJ, Biffi A, Castellini G, Coclite D, D'Angelo D, Gianola S, Mari V, Napoletano A, Porcu G, Ruggeri M, Iannone P, Chiara O, On Behalf Of Inih-Major Trauma. Effectiveness of Pre-Hospital Tourniquet in Emergency Patients with Major Trauma and Uncontrolled Haemorrhage: A Systematic Review and Meta-Analysis. Int J Environ Res Public Health. 2021 Dec 6;18(23):12861. doi: 10.3390/ijerph182312861. PMID: 34886586; PMCID: PMC8657739.
Martinson J, Park H, Butler FK Jr, Hammesfahr R, DuBose JJ, Scalea TM. Tourniquets USA: A Review of the Current Literature for Commercially Available Alternative Tourniquets for Use in the Prehospital Civilian Environment. J Spec Oper Med. 2020 Summer;20(2):116-122. doi: 10.55460/CT9D-TMZE. PMID: 32573747.
Resources poster booklet. (n.d.). Stop the Bleed. https://www.stopthebleed.org/resources-poster-booklet/

Summarized by Jeffrey Olson MS2 | Edited by Meg Joyce & Jorge Chalit, OMSII

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Contributors: Kali Olson PharmD, Travis Barlock MD, Jeffrey Olson MS2

Summary:

In this episode of Pharmacy Phriday, Dr. Kali Olson joins Dr. Travis Barlock and Jeffrey Olson in studio to discuss a variety of interesting topics in the form of a segment show. Dr. Kali Olson earned her Doctorate of Pharmacy from the University of Colorado, Skaggs School of Pharmacy and completed a PGY1 residency at Detroit Receiving Hospital and a PGY2 residency in Emergency Medicine at Denver Health. She now works as an Emergency Medicine Pharmacist at Denver Health.

In segment one of the show, Kali and Travis answer the Get-To-Know-You questionnaire. In segment two, they work together to answer a series of pharmacy-based riddles. In segment three they play a “Balderdash” like game in which they guess the definitions of medical jargon. In segment four they play the Number Needed to Treat game, invented by the AFP podcast. And in segment five they work together to answer a question about a far-out scenario involving medications and time travel!

References

· American Family Physician Podcast, https://www.aafp.org/pubs/afp/multimedia/podcast.html

· Gragnolati, A. (2022, May 5). The Yuzpe method of emergency contraception. GoodRx. https://www.goodrx.com/conditions/emergency-contraceptive/yuzpe-method

· Manikandan S, Vani NI. Holiday reading: Learning medicine through riddles. CMAJ. 2010 Dec 14;182(18):E863-4. doi: 10.1503/cmaj.100466. PMID: 21149530; PMCID: PMC3001539.

· Riddle Me This: Mixing Medicine, https://peimpact.com/riddle-me-this-mixing-medicine/

· https://thennt.com/nnt/corticosteroids-treatment-kawasaki-disease-children/

· https://thennt.com/nnt/aspirin-acute-ischemic-stroke/

· https://thennt.com/nnt/tranexamic-acid-treatment-epistaxis/

· https://thennt.com/nnt/antibiotics-culture%e2%80%90positive-asymptomatic-bacteriuria-pregnant-women/

Produced, Hosted, Edited, and Summarized by Jeffrey Olson MS2 | Additional editing by Jorge Chalit, OMSII

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Contributor: Taylor Lynch MD

Educational Pearls

Hypothermia is defined as a core body temperature less than 35 degrees Celsius or less than 95 degrees Fahrenheit
Mild Hypothermia: 32-35 degrees Celsius
Presentation: alert, shivering, tachycardic, and cold diuresis
Management: Passive rewarming i.e. remove wet clothing and cover the patient with blankets or other insulation
Moderate Hypothermia: 28-32 degrees Celsius
Presentation: Drowsiness, lack of shivering, bradycardia, hypotension
Management: Active external rewarming
Severe Hypothermia: 24-28 degrees Celsius
Presentation: Heart block, cardiogenic shock, no shivering
Management: Active external and internal rewarming
Less than 24 degrees Celsius
Presentation: Pulseless, ventricular arrhythmia
Active External Rewarming
Warm fluids are insufficient for warming due to a minimal temperature difference (warmed fluids are maintained at 40 degrees vs. a patient at 30 degrees is not a large enough thermodynamic difference)
External: Bear hugger, warm blankets
Active Internal Rewarming
Thoracic lavage (preferably on the patient’s right side)
Place 2 chest tubes (anteriorly and posteriorly); infuse warm IVF anteriorly and hook up the posterior tube to a Pleur-evac
Warms the patient 3-6 Celsius per hour
Bladder lavage
Continuous bladder irrigation with 3-way foley or 300 cc warm fluid
Less effective than thoracic lavage due to less surface area
Pulseless patients
ACLS does not work until patients are rewarmed to 30 degrees
High-quality CPR until 30 degrees (longest CPR in a hypothermic patient was 6 hours and 30 minutes)
Give epinephrine once you reach 35 degrees, spaced out every 6 minutes
ECMO is the best way to warm these patients up (10 degrees per hour)
Pronouncing death must occur at 32 degrees or must have potassium > 12

References

2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care - Part 1: Introduction. Circulation. 2005;112(24 SUPPL.). doi:10.1161/CIRCULATIONAHA.105.166550
Brown DJA, Burgger H, Boyd J, Paal P. Accidental Hypothermia. N Engl J Med. 2012;367:1930-1938. doi:10.1136/bmj.2.5543.51-c
Dow J, Giesbrecht GG, Danzl DF, et al. Wilderness Medical Society Clinical Practice Guidelines for the Out-of-Hospital Evaluation and Treatment of Accidental Hypothermia: 2019 Update. Wilderness Environ Med. 2019;30(4S):S47-S69. doi:10.1016/j.wem.2019.10.002
Kjærgaard B, Bach P. Warming of patients with accidental hypothermia using warm water pleural lavage. Resuscitation. 2006;68(2):203-207. doi:10.1016/j.resuscitation.2005.06.019
Lott C, Truhlář A, Alfonzo A, et al. European Resuscitation Council Guidelines 2021: Cardiac arrest in special circumstances. Resuscitation. 2021;161:152-219. doi:10.1016/j.resuscitation.2021.02.011
Plaisier BR. Thoracic lavage in accidental hypothermia with cardiac arrest - Report of a case and review of the literature. Resuscitation. 2005;66(1):99-104. doi:10.1016/j.resuscitation.2004.12.024

Summarized by Jorge Chalit, OMSII | Edited by Meg Joyce & Jorge Chalit, OMSII

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Contributor: Jared Scott MD

Educational Pearls:

Croup is a respiratory condition typically caused by a viral infection (e.g., parainfluenza). The disease is characterized by inflammation of the larynx and trachea, which often leads to a distinctive barking cough.
A common treatment for croup is the powerful steroid dexamethasone, but it can take up to 30 minutes to start working.
A folk remedy for croup is to take the afflicted child outside in the cold to help them breathe better, but does it really work?
A 2023 study in Switzerland, published in the Journal of Pediatrics, investigated whether a 30-minute exposure to outdoor cold air could improve mild to moderate croup symptoms before the onset of steroid effects.
The randomized controlled trial included children aged 3 months to 10 years with croup.
After receiving a single-dose oral dexamethasone, participants were exposed to either outdoor cold air or indoor room air. The primary outcome was a decrease in the Westley Croup Score (WCS) by at least 2 points at 30 minutes.
The results indicated that exposure to outdoor cold air, in addition to dexamethasone, significantly reduced symptoms in children with croup, especially in those with moderate cases.

References

Siebert JN, Salomon C, Taddeo I, Gervaix A, Combescure C, Lacroix L. Outdoor Cold Air Versus Room Temperature Exposure for Croup Symptoms: A Randomized Controlled Trial. Pediatrics. 2023 Sep 1;152(3):e2023061365. doi: 10.1542/peds.2023-061365. PMID: 37525974.

Summarized by Jeffrey Olson, MS2 | Edited by Meg Joyce & Jorge Chalit, OMSII

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Contributor: Aaron Lessen MD

Educational Pearls:

Does the size of a blood pressure (BP) cuff matter?

A recent randomized crossover trial revealed that, indeed, cuff size can affect blood pressure readings

Design

195 adults with varying mid-upper arm circumferences were randomized to the order of BP cuff application:
Appropriate
Too small
Too large
Individuals had their mid-upper arm circumference measured to determine the appropriate cuff size
Participants underwent 4 sets of triplicate blood pressure measurements, the last of which was always with the appropriately sized cuff

Results

In individuals requiring a small cuff, the use of a regular cuff resulted in blood pressure readings 3.6 mm Hg lower than with the small cuff
In individuals requiring large cuffs, the use of a regular cuff resulted in pressures 4.8 mm Hg higher than with the large cuffs
In individuals requiring extra-large cuffs, the use of a regular cuff resulted in pressures 19.5 mm Hg higher than with extra-large cuffs

Conclusion

Miscuffing results in significantly inaccurate blood pressure measurements
It is important to emphasize individualized BP cuff selection

References

Ishigami J, Charleston J, Miller ER, Matsushita K, Appel LJ, Brady TM. Effects of Cuff Size on the Accuracy of Blood Pressure Readings: The Cuff(SZ) Randomized Crossover Trial. JAMA Intern Med. 2023;183(10):1061-1068. doi:10.1001/jamainternmed.2023.3264

Summarized by Jorge Chalit, OMSII | Edited by Jorge Chalit

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Contributor: Aaron Lessen MD

Educational Pearls:

Is the adage, “GCS of 8, you’ve got to intubate” accurate? A recent study published in the November 2023 issue of JAMA attempted to answer this question.

Design

Multicenter, randomized trial, in France from 2021 to 2023.
225 patients experiencing comatose in the setting of acute poisoning were randomly assigned to either a conservative airway strategy of withholding intubation or “routine practice” of much more frequent intubation.
The primary outcome was a composite endpoint including in-hospital death, length of intensive care unit stay, and length of hospital stay.
Secondary outcomes included adverse events from intubation and pneumonia within 48 hours.

Results

Results showed that in the intervention group (with intubation withholding), only 16% of patients were intubated, compared to 58% in the control group.
No in-hospital deaths occurred in either group.
The intervention group demonstrated a significant clinical benefit for the primary endpoint, with a win ratio of 1.85 (95% CI, 1.33 to 2.58).
The conservative airway management strategy also saw a statistically significant decrease in adverse events from intubation and pneumonia.

Conclusion

Among comatose patients with suspected acute poisoning, a conservative strategy of withholding intubation was associated with a greater clinical benefit.
This suggests that a judicious approach to intubation is appropriate in many other settings and clinicians should rely on more than the GCS to make this decision.

References

Freund Y, Viglino D, Cachanado M, Cassard C, Montassier E, Douay B, Guenezan J, Le Borgne P, Yordanov Y, Severin A, Roussel M, Daniel M, Marteau A, Peschanski N, Teissandier D, Macrez R, Morere J, Chouihed T, Roux D, Adnet F, Bloom B, Chauvin A, Simon T. Effect of Noninvasive Airway Management of Comatose Patients With Acute Poisoning: A Randomized Clinical Trial. JAMA. 2023 Dec 19;330(23):2267-2274. doi: 10.1001/jama.2023.24391. PMID: 38019968; PMCID: PMC10687712.

Summarized by Jeffrey Olson MS2 | Edited by Meg Joyce & Jorge Chalit, OMSII

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Contributor: Aaron Lessen MD

Educational Pearls:

A 2013 study randomized families of those in cardiac arrest into two groups:
Actively offered patients’ families the opportunity to observe CPR
Follow standard practice regarding family presence (control group)
Of the 266 relatives that received offers to observe CPR, 211 (79%) accepted vs. 43% in the control group observed CPR
The study assessed a primary end-point of PTSD-related symptoms 90 days after the event
Secondary end-points included depression, anxiety, medicolegal claims, medical efforts at resuscitation, and the well-being of the healthcare team
The frequency of PTSD-related symptoms was significantly higher in the control group
Lower rates of anxiety and depression for the families who witnessed CPR
There were no effects on resuscitation efforts, patient survival, medicolegal claims, or stress on the healthcare team
If families choose to witness CPR, it’s beneficial to have someone with the family to explain the process

References

Jabre P, Belpomme V, Azoulay E, et al. Family Presence during Cardiopulmonary Resuscitation. N Engl J Med. 2013;368(11):1008-1018. doi:10.1056/NEJMoa1203366

Summarized by Jorge Chalit, OMSII | Edited by Jorge Chalit

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Contributor: Ricky Dhaliwal, MD

Educational Pearls:

Croup

Caused by:
Parainfluenza, Adenovirus, RSV, Enterovirus (big right now)
Age range:
6 months to 3 years
Symptoms:
Barky cough
Inspiratory stridor (Severe = stidor at rest)
Use the Westley Croup Score to gauge the severity
Treatment:
High flow, humidified, cool oxygen
Dexamethasone 0.6 mg/kg oral, max 16mg
Severe: Racemic Epinephrine 0.5 mL/kg
Consider heliox, a mixture of helium and oxygen
Very severe: be ready to intubate

Bronchiolitis

Caused by:
RSV, Rhinovirus
Symptoms are driven by secretions
Symptoms:
Cough
Wheezing
Dehydration (often the symptom that makes them look the worst)
Age range:
2 to 6 months
Treatment:
Suctioning
Oxygen
IV fluids
Nebulized hypertonic saline
DuoNebs? No.

Asthma

Caused by:
Environmental factors
Viral illness with a predisposition
Treatment:
Beta agonists
Steroids
Ipratropium
Magnesium (relaxes smooth muscle)

References

Dalziel SR, Haskell L, O'Brien S, Borland ML, Plint AC, Babl FE, Oakley E. Bronchiolitis. Lancet. 2022 Jul 30;400(10349):392-406. doi: 10.1016/S0140-6736(22)01016-9. Epub 2022 Jul 1. PMID: 35785792.
Hoch HE, Houin PR, Stillwell PC. Asthma in Children: A Brief Review for Primary Care Providers. Pediatr Ann. 2019 Mar 1;48(3):e103-e109. doi: 10.3928/19382359-20190219-01. PMID: 30874817.
Midulla F, Petrarca L, Frassanito A, Di Mattia G, Zicari AM, Nenna R. Bronchiolitis clinics and medical treatment. Minerva Pediatr. 2018 Dec;70(6):600-611. doi: 10.23736/S0026-4946.18.05334-3. Epub 2018 Oct 18. PMID: 30334624.
Smith DK, McDermott AJ, Sullivan JF. Croup: Diagnosis and Management. Am Fam Physician. 2018 May 1;97(9):575-580. PMID: 29763253.
Westley CR, Cotton EK, Brooks JG. Nebulized racemic epinephrine by IPPB for the treatment of croup: a double-blind study. Am J Dis Child. 1978 May;132(5):484-7. doi: 10.1001/archpedi.1978.02120300044008. PMID: 347921.
https://www.mdcalc.com/calc/677/westley-croup-score

Summarized by Jeffrey Olson | Edited by Meg Joyce & Jorge Chalit, OMSII

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Contributor: Ricky Dhaliwal MD

Educational Pearls:

Three zones of the neck with different structures and risks for injuries:
Zone 1 is the most caudal region from the clavicle to the cricoid cartilage
Zone 2 is from the cricoid cartilage to the angle of the mandible
Zone 3 is superior to the angle of the mandible
Zone 1 contains the thoracic outlet vasculature (subclavian arteries and veins, internal jugular veins), carotid arteries, vertebral artery, apices of the lungs, trachea, esophagus, spinal cord, thoracic duct, thyroid gland, jugular veins, and the vagus nerve.
Zone 2 contains the common carotid arteries, internal and external branches of carotid arteries, vertebral arteries, jugular veins, trachea, esophagus, larynx, pharynx, spinal cord, and vagus and recurrent laryngeal nerves
Lower risk than Zone 1 or Zone 3
Zone 3 contains the distal carotid arteries, vertebral arteries, jugular veins, pharynx, spinal cord, cranial nerves IX, X, XI, XII, the sympathetic chain, and the salivary and parotid glands
Hard signs that indicate direct transfer to OR:
Airway compromise
Active, brisk bleeding
Pulsatile hematomas
Hematemesis
Massive subcutaneous emphysema
Soft signs that may obtain imaging to determine further interventions:
Hemoptysis
Oropharyngeal bleeding
Dysphagia
Dysphonia
Expanding hematomas
Soft sign management includes ABCs, type & screen, and airway interventions followed by imaging of the head & neck area
Patients with dysphonia or dysphagia with subsequent negative CTAs may get further work-up via swallow studies

References

Asensio JA, Chahwan S, Forno W, et al. Penetrating esophageal injuries: multicenter study of the American Association for the Surgery of Trauma. J Trauma. 2001;50(2):289-296. doi:10.1097/00005373-200102000-00015
Azuaje RE, Jacobson LE, Glover J, et al. Reliability of physical examination as a predictor of vascular injury after penetrating neck trauma. Am Surg. 2003;69(9):804-807.
Ibraheem K, Wong S, Smith A, et al. Computed tomography angiography in the "no-zone" approach era for penetrating neck trauma: A systematic review. J Trauma Acute Care Surg. 2020;89(6):1233-1238. doi:10.1097/TA.0000000000002919
Nowicki JL, Stew B, Ooi E. Penetrating neck injuries: A guide to evaluation and managementx. Ann R Coll Surg Engl. 2018;100(1):6-11. doi:10.1308/rcsann.2017.0191

Summarized by Jorge Chalit, OMSII | Edited by Meg Joyce & Jorge Chalit, OMSII

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Contributor: Kiersten Williams MD, Travis Barlock MD, Jeffrey Olson MS2

Summary:

In this episode, Dr. Travis Barlock and Jeffrey Olson meet in the studio to discuss a clip from Dr. Williams’ talk at the “Laboring Under Pressure, Managing Obstetric Emergencies in a Global Setting” event from May 2023. This event was hosted at the University of Denver and was organized with the help of Joe Parker as a fundraiser for the organization Health Outreach Latin America (HOLA).

Dr. Kiersten Williams completed her OBGYN residency at Bay State Medical Center and practices as an Obstetric Hospitalist at Presbyterian/St. Luke’s Medical Center in Denver, Colorado.

During her talk, Dr. Williams walks the audience through the common causes and treatments for post-partum hemorrhage (PPH).

Some important take-away points from this talk are:

The most common causes of PPH can be remembered by the 4 T’s. Tone (atony), Trauma, Tissue (retained placenta), and Thrombin (coagulopathies).
AV malformations of the uterus are probably underdiagnosed.
Quantitative blood loss is much more accurate than estimated blood loss (EBL).
The ideal fibrinogen for an obstetric patient about to deliver is above 400 mg/dl - under 200 is certain to cause bleeding.
Do not deliver oxytocin via IV push dose, it can cause significant hypotension.
Tranexamic Acid is available in both IV and PO and can be administered in the field. The dose is 1 gram and can be run over 10 minutes if administered via IV. It is best if used within 3 hours of delivery.
When performing a uterine massage, place one hand inside the vagina and one hand on the lower abdomen. Then rub the lower abdomen like mad.
A new option for treating PPH is called the JADA System which is slimmer than a Bakri Balloon and uses vacuum suction to help the uterus clamp down.*
Another option for a small uterus is to insert a 60 cc Foley catheter.
In an operating room, a B-Lynch suture can be put in place, uterine artery ligation can be performed, and as a last resort, a hysterectomy can be done.

*EMM is not sponsored by JADA system or the Bakri balloon.

References

Andrikopoulou M, D'Alton ME. Postpartum hemorrhage: early identification challenges. Semin Perinatol. 2019 Feb;43(1):11-17. doi: 10.1053/j.semperi.2018.11.003. Epub 2018 Nov 14. PMID: 30503400.
Committee on Practice Bulletins-Obstetrics. Practice Bulletin No. 183: Postpartum Hemorrhage. Obstet Gynecol. 2017 Oct;130(4):e168-e186. doi: 10.1097/AOG.0000000000002351. PMID: 28937571.
Federspiel JJ, Eke AC, Eppes CS. Postpartum hemorrhage protocols and benchmarks: improving care through standardization. Am J Obstet Gynecol MFM. 2023 Feb;5(2S):100740. doi: 10.1016/j.ajogmf.2022.100740. Epub 2022 Sep 2. PMID: 36058518; PMCID: PMC9941009.
Health Outreach for Latin America Foundation - HOLA Foundation. (n.d.). http://www.hola-foundation.org/
Kumaraswami S, Butwick A. Latest advances in postpartum hemorrhage management. Best Pract Res Clin Anaesthesiol. 2022 May;36(1):123-134. doi: 10.1016/j.bpa.2022.02.004. Epub 2022 Feb 24. PMID: 35659949.
Pacheco LD, Saade GR, Hankins GDV. Medical management of postpartum hemorrhage: An update. Semin Perinatol. 2019 Feb;43(1):22-26. doi: 10.1053/j.semperi.2018.11.005. Epub 2018 Nov 14. PMID: 30503399.

Produced by Jeffrey Olson, MS2 | Edited by Jeffrey Olson and Jorge Chalit, OMSII

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Contributor: Meghan Hurley MD

Educational Pearls:

What is a nerve block?

A nerve block is the medical procedure of injecting anesthetic into the area around a nerve to block pain signals.
They are typically done with ultrasound guidance.

Are nerve blocks effective?

Most of the information we have about nerve blocks is extrapolated from fascia iliaca blocks. This nerve block targets the fascia iliaca compartment, which contains the femoral, lateral femoral cutaneous, and obturator nerves. These blocks are commonly done for hip fractures to help stabilize the patient while awaiting surgical repair.
The data for these types of injections is strong. They decrease pain, they decrease total morphine equivalents needed while a patient is in the hospital, they help mobilize patients earlier and start physical therapy earlier, and they help patients leave the hospital about a day earlier.

What is an example of an agent that can be used?

Bupivacaine. A long acting amide-type local anesthetic. It works best when paired with epinephrine which causes local vasoconstriction and allows the bupivaciaine to bathe the nerve for longer. It gives 5-15 hours of anesthesia (complete sensation loss), and up to 30 hours of analgesia (pain loss).

What’s an example of another block that can be done?

An Erector Spinae Plane (ESP) block is performed in the paraspinal fascial plane in the back. This can be used for pain around the ribs and before a variety of medical procedures including a Nuss procedure, thoracotomies, percutaneous nephrolithotomies, ventral hernia repairs, and even lumbar fusions.

What is one potential complication of a nerve block?

Local Anesthetic Systemic Toxicity (LAST).
There are three ways this can happen:
1) Using too much total anesthetic (Maximum dose of bupivacaine is 2.5 mg/kg).
2) Too much anesthetic is injected into a confined space which then gets absorbed into the venous system.
3) Injecting directly into the vasculature by mistake.

What are the signs that this complication has occurred?

Perioral tingling
Stupor
Coma
Seizures

What can that cause?

Cardiovascular collapse

How is that treated?

Intralipid AKA Soybean Oil, or “lipid emulsion” should be given as a bolus followed by a drip. These patients need to be admitted.
Bolus 1.5 ml/kg (lean body mass) intravenously over 1 min (max ~100 ml).
Continuous infusion at 0.25 mL/kg/min. Max dosing in the first 30 minutes is around 100 ml/kg.
Fun fact: Patients being treated for LAST with intralipid cannot undergo general anesthesia because the intralipid will impact the anesthesia drugs.

References

Long B, Chavez S, Gottlieb M, Montrief T, Brady WJ. Local anesthetic systemic toxicity: A narrative review for emergency clinicians. Am J Emerg Med. 2022 Sep;59:42-48. doi: 10.1016/j.ajem.2022.06.017. Epub 2022 Jun 13. PMID: 35777259.
Carvalho Júnior LH, Temponi EF, Paganini VO, Costa LP, Soares LF, Gonçalves MB. Reducing the length of hospital stay after total knee arthroplasty: influence of femoral and sciatic nerve block. Rev Assoc Med Bras (1992). 2015 Jan-Feb;61(1):40-3. doi: 10.1590/1806-9282.61.01.040. Epub 2015 Jan 1. PMID: 25909207.
Jain N, Kotulski C, Al-Hilli A, Yeung-Lai-Wah P, Pluta J, Heegeman D. Fascia Iliaca Block in Hip and Femur Fractures to Reduce Opioid Use. J Emerg Med. 2022 Jul;63(1):1-9. doi: 10.1016/j.jemermed.2022.04.018. Epub 2022 Aug 4. PMID: 35933265.
Kot P, Rodriguez P, Granell M, Cano B, Rovira L, Morales J, Broseta A, Andrés J. The erector spinae plane block: a narrative review. Korean J Anesthesiol. 2019 Jun;72(3):209-220. doi: 10.4097/kja.d.19.00012. Epub 2019 Mar 19. PMID: 30886130; PMCID: PMC6547235.
Lee SH, Sohn JT. Mechanisms underlying lipid emulsion resuscitation for drug toxicity: a narrative review. Korean J Anesthesiol. 2023 Jun;76(3):171-182. doi: 10.4097/kja.23031. Epub 2023 Jan 26. PMID: 36704816; PMCID: PMC10244607.
Weinberg, Guy. LipidRescue™ Resuscitation. http://www.lipidrescue.org/

Summarized by Jeffrey Olson MS2 | Edited by Jorge Chalit, OMSII

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Contributor: Jorge Chalit, OMS II

Educational Pearls:

Migraine pathophysiology
Primarily mediated through the trigeminovascular system
Serotonin, dopamine, and calcitonin gene-related peptide (CGRP)
Trigeminovascular system is linked to the trigeminal nucleus caudalis, which relays pain to the hypothalamus and cerebral cortex
One effective treatment for acute migraines is -triptan medications
5-HT1D/1B agonists such as sumatriptan
Often combined with NSAIDs and dopamine antagonists (as antiemetics) in migraine cocktails
Diphenhydramine (Benadryl) was shown to be ineffective in a randomized controlled trial comparing it with placebo and a dopamine antagonist antiemetic.
The -triptan medications carry significant risk for peripheral vasoconstriction and are therefore avoided in cardiovascular disease
One serotonin agonist specifically approved for use in vascular disease
Lasmiditan - 5-HT1F agonist
Slightly different mechanism of action avoids peripheral vasoconstriction
CGRP antagonists are also used in patients who are unresponsive to -triptans

References

Friedman WB, Cabral L, Adewunmi V, et al. Diphenhydramine as adjuvant therapy for acute migraine. An ED-based randomized clinical trial. Ann Emerg Med. 2016;67(1):32-39.e3. doi:doi:10.1016/j.annemergmed.2015.07.495
Lasmiditan (Reyvow) and ubrogepant (Ubrelvy) for acute treatment of migraine. (2020). The Medical letter on drugs and therapeutics, 62(1593), 35–39.
Robbins MS. Diagnosis and Management of Headache: A Review. JAMA - J Am Med Assoc. 2021;325(18):1874-1885. doi:10.1001/jama.2021.1640
Vanderpluym JH, Halker Singh RB, Urtecho M, et al. Acute Treatments for Episodic Migraine in Adults: A Systematic Review and Meta-analysis. JAMA - J Am Med Assoc. 2021;325(23):2357-2369. doi:10.1001/jama.2021.7939

Summarized by Jorge Chalit, OMSII | Edited by Meg Joyce & Jorge Chalit, OMSII

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Contributor: Aaron Lessen MD

Educational Pearls:

How is the severity of a stroke assessed?

Strokes are assessed by the NIH Stroke Scale (NIHSS), this scale has different tasks, such as asking the person to repeat words, move their arms, or follow simple instructions. The maximum score is 42 but any score over 21 is considered severe.

What would qualify as a minor storke?

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Contributor: Nick Tsipis MD

Educational Pearls:

The review article assessed 16.3 million patients across six states to identify those at high-risk for critical revisit
Criteria for critical revisit was ICU admission or death within three days of discharge from the ED
Critical revisits are extremely rare
0.1% of patients have a critical revisit after discharge
0.00001% die after revisit
Of the patients that do experience critical revisits, the two major risk factors are
Asthma - relative risk 2.24
Chronic medical conditions - incidence rate ratio 11.03
Of the top ten diagnoses that lead to critical revisits, 5 are respiratory
Others include cellulitis, seizures, gastrointestinal disease, appendectomy, and sickle cell crisis.

References

Cavallaro SC, Michelson KA, D’Ambrosi G, Monuteaux MC, Li J. Critical Revisits Among Children After Emergency Department Discharge. Ann Emerg Med. 2023;82(5):575-582. doi:10.1016/j.annemergmed.2023.06.006

Summarized by Jorge Chalit, OMSII | Edited by Meg Joyce & Jorge Chalit, OMSII

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Contributor: Meghan Hurley MD

Educational Pearls:

Pearls about labor:

Labor is split into 3 stages.
Stage 1 starts when the first persistent contractions are felt and goes up until the cervix is fully dilated and the mother starts pushing. Stage 1 is split into two phases: the latent phase (cervix is dilated from 0-4 cm), and the active phase (cervix dilates from 4-10 cm). The latent phase can take between 6 and 12 hours with contractions happening every 5 to 15 minutes. The active phase usually lasts 4-8 hours with contractions occurring as close as every 3 minutes.
Stage 2 is the birth itself, lasting between 20 minutes and 2 hours.
Stage 3 is the delivery of the placenta and typically takes 30 minutes.
37 weeks gestational age is the cutoff for preterm.
Placenta previa: Condition when the placenta overlies the cervix. Classically presents as painless vaginal bleeding in the 3rd trimester. If suspected placenta previa, avoid a speculum exam. Placenta previa can be confirmed on ultrasound.
If the baby is crowning in the ER then the baby should be delivered in the ER. The ideal presentation on crowning is head first (Vertex), specifically ‘left occiput anterior’. In this position, the baby is head first and the head is facing towards the gurney at a slight angle. If the baby is coming out in a breech position then the provider should “elevate the presenting part” by maintaining pressure on the baby as the mother is wheeled to the OR for an emergency C-section.
If a vertex-presenting baby is being delivered vaginally, after the head has been delivered an event called ‘restitution’ must occur to align the baby’s shoulders properly. During this event, the baby goes from facing down towards the gurney to facing sideways.
After restitution, the anterior shoulder should be delivered, followed by the posterior.
After complete delivery, the cord should be clamped (after a 1-3 minute delay), with something sterile.
Gentle downward traction on the cord helps to deliver the placenta. You can place pressure above the pubic bone to prevent the uterus from involuting during this process. This is not the same as a fundal massage which happens after the delivery of the placenta to help the uterus clamp down and prevent postpartum hemorrhage.

References

Hutchison J, Mahdy H, Hutchison J. Stages of Labor. 2023 Jan 30. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan–. PMID: 31335010.
Lavery JP. Placenta previa. Clin Obstet Gynecol. 1990 Sep;33(3):414-21. doi: 10.1097/00003081-199009000-00005. PMID: 2225572.
Qian Y, Ying X, Wang P, Lu Z, Hua Y. Early versus delayed umbilical cord clamping on maternal and neonatal outcomes. Arch Gynecol Obstet. 2019 Sep;300(3):531-543. doi: 10.1007/s00404-019-05215-8. Epub 2019 Jun 15. PMID: 31203386; PMCID: PMC6694086.

Summarized by Jeffrey Olson MS2 | Edited by Meg Joyce & Jorge Chalit, OMSII

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Contributor: Dr. Taylor Lynch

Educational Pearls:

Time of arrival until intubation was 26 minutes but nobody tried anterior neck access like a cricothyrotomy until his dad arrived
Traditional ACLS protocol is not enough for anaphylactic respiratory arrest
Circulating O2 from compressions alone is not enough to sustain the brain
Patients need a definitive airway and endotracheal tube is the best method
BVM ventilation is not enough to get patients the oxygen they need
Time to anoxic brain injury during a respiratory arrest is 4 minutes
Definition of anaphylactic shock:
Acute laryngeal involvement with bronchospasms after known exposure to an allergen
Do not need to have skin symptoms like the classic wheal and flare
Must also have either hypotension (from vasodilation or end-organ hypoperfusion) or severe GI symptoms (crampy abdominal pain or repetitive vomiting)
Treatment of anaphylactic shock:
Push-dose IV epinephrine is better than IM epinephrine because IM epinephrine takes 4 minutes to circulate and get to the lungs
Ketamine has broncho-dilating properties so it can be used as an induction agent for intubation
Albuterol and ipratropium as continuous bronchodilators
Magnesium and IV steroids
AMAX4 acronym
Adrenaline, Muscle relaxant, Airway, Xtra (bronchodilators, ventilation, vasopressors, and consideration of pneumothorax), 4 minutes to anoxic brain injury

References

Commins SP. Outpatient Emergencies: Anaphylaxis. Med Clin North Am. 2017;101(3):521-536. doi:10.1016/j.mcna.2016.12.003
Ring J, Beyer K, Biedermann T, Bircher A, Duda D FJ et al. Guideline for acute therapy and management of anaphylaxis. S2 guideline of DGAKI, AeDA, GPA, DAAU, BVKJ, ÖGAI, SGAI, DGAI, DGP, DGPM, AGATE and DAAB. Allergo J Int. 2014;23(23):96-112.
McKenzie B. AMAX4: Every Second Counts. Accessed Sunday, November 26, 2023. https://www.amax4.org/

Summarized by Jorge Chalit, OMSII | Edited by Meg Joyce & Jorge Chalit, OMSII

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Contributor: Jared Scott MD

Educational Pearls:

Should we use opioids to treat low back and neck pain? The OPAL Trial, published in The Lancet, in June 2023, attempted to answer this very question.

Objective: Investigate the efficacy and safety of a short course of opioid analgesic (oxycodone-naloxone) for acute low back pain and neck pain.
Trial Design: Triple-blinded, placebo-controlled randomized trial, conducted in Emergency and Primary Care in Sydney, Australia, involving adults with 12 weeks or less of low back or neck pain.
Participants: 347 recruited adults (174 in the opioid group, 173 in the placebo group) with at least moderate pain severity.
Intervention: Participants were assigned to receive either an opioid or a placebo for up to 6 weeks.
Primary Outcome: Pain severity at 6 weeks measured with the pain severity subscale of the Brief Pain Inventory (10-point scale).
Results: No significant difference in pain severity at 6 weeks between the opioid group (mean score 2.78) and placebo group (mean score 2.25).
Adverse events were reported by 35% in the opioid group and 30% in the placebo group, with more opioid-related adverse events in the opioid group (e.g., constipation).
Conclusion: Opioids should not be recommended for acute non-specific low back pain or neck pain, as there was no significant difference in pain severity compared with the placebo. The study calls for a change in the frequent use of opioids for these conditions.

Pharmacy Pearl: Why was naloxone mixed with oxycodone?

Naloxone is an opioid receptor antagonist, meaning it can block the effects of opioids. When combined with oxycodone, naloxone's presence discourages certain forms of opioid misuse.
Additionally, naloxone can bind to opioid receptors in the gut and improve symptoms of Opioid Induced Constipation (OIC).
This is the same idea behind Suboxone (buprenorphine/naloxone).

References

Jones CMP, Day RO, Koes BW, Latimer J, Maher CG, McLachlan AJ, Billot L, Shan S, Lin CC; OPAL Investigators Coordinators. Opioid analgesia for acute low back pain and neck pain (the OPAL trial): a randomised placebo-controlled trial. Lancet. 2023 Jul 22;402(10398):304-312. doi: 10.1016/S0140-6736(23)00404-X. Epub 2023 Jun 28. Erratum in: Lancet. 2023 Aug 19;402(10402):612. PMID: 37392748.
Camilleri M, Lembo A, Katzka DA. Opioids in Gastroenterology: Treating Adverse Effects and Creating Therapeutic Benefits. Clin Gastroenterol Hepatol. 2017 Sep;15(9):1338-1349. doi: 10.1016/j.cgh.2017.05.014. Epub 2017 May 19. PMID: 28529168; PMCID: PMC5565678.

Summarized by Jeffrey Olson MS2 | Edited by Jorge Chalit, OMSII

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Contributor: Jared Scott MD

Educational Pearls

A recently published study assessed the burden of respiratory viruses in a longitudinal cohort of children from 0 to 2 years of age
The children in the study received nasal swab PCR testing weekly to determine infectivity
They were also monitored for symptoms via weekly text surveys
The study differentiated between infection and illness by defining an acute respiratory illness (ARI) as fever ≥38°C or cough.
The median infectivity rate was 9.4 viral infections per child per year
The median illness rate was 3.3 ARIs per child per year
The most common etiological viruses isolated from the nasal samples were rhinovirus and enterovirus
Most infections were asymptomatic or mild

References

Teoh, Z., Conrey, S., McNeal, M., Burrell, A., Burke, R. M., Mattison, C., McMorrow, M., Payne, D. C., Morrow, A. L., & Staat, M. A. (2023). Burden of Respiratory Viruses in Children Less Than 2 Years Old in a Community-based Longitudinal US Birth Cohort. Clinical infectious diseases: an official publication of the Infectious Diseases Society of America, 77(6), 901–909. https://doi.org/10.1093/cid/ciad289

Summarized by Jorge Chalit, OMSII | Edited by Meg Joyce & Jorge Chalit, OMSII

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Contributor: Travis Barlock MD

Educational Pearls:

Common sedatives used in the Emergency Department and a few pearls for each.

Propofol
Type: Non-barbiturate sedative hypnotic agonizing GABA receptors.
Benefit: Quick on and quick off (duration of action is approximately 2-7 minutes), helpful for suspected neurologic injury so the patient can wake up and be re-evaluated. Also has the benefit of reducing intracranial pressure (ICP).
Downsides: Hypotension, bradycardia, respiratory depression.
What should you do if a patient is getting hypotensive on propofol?
Do not stop the propofol. Start pressors. May have to reduce the propofol dose if delay in pressors.
Dexmedetomidine (Precedex)
Type: Alpha 2 agonist - causes central sedation
Uses: Patients are more alert and responsive and therefore can be on BiPAP instead of being intubated. Does not cause respiratory depression.
Downsides: Hypotension and Bradycardia.
Caution in using this for head injuries, its side effects can mask the Cushing reflex and make it more difficult to spot acute elevations in ICP and uncal herniation.
Ketamine
Type: NMDA antagonist and dissociative anesthetic, among other mechanisms.
Benefits: Quick Onset (but slower than propofol). Does not cause hypotension, but can even increase HR and BP (Thought to potentially cause hypotension if patient is catecholamine-depleted (ie. sepsis, delayed trauma)).
Dosing ketamine can be challenging. Typically low doses (0.1-0.3mg/kg (max ~30mg)) can give good pain relief. Higher doses (for intubation/procedural sedation) are generally thought to have a higher risk of dissociation.
Downsides: Emergence reactions which include hallucinations, vivid dreams, and agitation. Increased secretions.
Benzos
Type: GABA agonists.
Benefits: Seizure, alcohol withdrawal, agitation due to toxic overdoses.
Push doses are useful because doses can stack. Longer half-life than propofol.
Downsides: Respiratory depression. Longer half-life can make neuro assessments difficult to complete.
Etomidate
MOA: Displaces endogenous GABA inhibitors.
Useful as a one-time dose for quick procedures (cardioversion, intubation). Often drug of choice for intubation since it is thought to have no hemodynamic effects.
Downsides; If used without paralytic - myoclonus. Though to have some adrenal suppression.
Fentanyl
Type: Opioid analgesic. Not traditional sedative.
Benefits: There are many instances in emergency medicine in which sedation can be avoided by prioritizing proper analgesia. Fentanyl can even be used to maintain intubated patients without needing to keep them constantly sedated.
Downsides: Respiratory depression. Patients may have tolerance.

References

Chawla N, Boateng A, Deshpande R. Procedural sedation in the ICU and emergency department. Curr Opin Anaesthesiol. 2017 Aug;30(4):507-512. doi: 10.1097/ACO.0000000000000487. PMID: 28562388.
Keating GM. Dexmedetomidine: A Review of Its Use for Sedation in the Intensive Care Setting. Drugs. 2015 Jul;75(10):1119-30. doi: 10.1007/s40265-015-0419-5. PMID: 26063213.
Lundström S, Twycross R, Mihalyo M, Wilcock A. Propofol. J Pain Symptom Manage. 2010 Sep;40(3):466-70. doi: 10.1016/j.jpainsymman.2010.07.001. PMID: 20816571.
Matchett G, Gasanova I, Riccio CA, Nasir D, Sunna MC, Bravenec BJ, Azizad O, Farrell B, Minhajuddin A, Stewart JW, Liang LW, Moon TS, Fox PE, Ebeling CG, Smith MN, Trousdale D, Ogunnaike BO; EvK Clinical Trial Collaborators. Etomidate versus ketamine for emergency endotracheal intubation: a randomized clinical trial. Intensive Care Med. 2022 Jan;48(1):78-91. doi: 10.1007/s00134-021-06577-x. Epub 2021 Dec 14. PMID: 34904190.
Mihaljević S, Pavlović M, Reiner K, Ćaćić M. Therapeutic Mechanisms of Ketamine. Psychiatr Danub. 2020 Autumn-Winter;32(3-4):325-333. doi: 10.24869/psyd.2020.325. PMID: 33370729.
Nakauchi C, Miyata M, Kamino S, Funato Y, Manabe M, Kojima A, Kawai Y, Uchida H, Fujino M, Boda H. Dexmedetomidine versus fentanyl for sedation in extremely preterm infants. Pediatr Int. 2023 Jan-Dec;65(1):e15581. doi: 10.1111/ped.15581. PMID: 37428855.

Summarized by Jeffrey Olson MS2 | Edited by Jorge Chalit, OMSII

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Contributor: Meghan Hurley MD

Educational Pearls:

Pericarditis is inflammation of the pericardial sac, which can arise from infectious or non-infectious etiologies
Myocarditis is inflammation of the myocardium, which may accompany pericarditis
Pericarditis clinical findings include:
Diffuse concave ST elevation, classic for acute pericarditis with myocardial involvement. More common in younger male patients
Elevated high-sensitivity troponin - higher levels may occur in young healthy patients
Ultrasound may show pericardial effusions
POCUS may be helpful in assessing left ventricular ejection fraction (LVEF) via E-point septal separation (EPSS)
Elevation in EPSS correlates with decreased LVEF
Treatments:
Anti-inflammatories including NSAIDs and colchicine
Monitor inflammation
Repeat ultrasounds
Risk factors in this patient’s case:
mRNA COVID vaccine - the risk of myocarditis from vaccination is significantly lower than that from COVID-19 infection
Preceding infection

References

Gao J, Feng L, Li Y, et al. A Systematic Review and Meta-analysis of the Association Between SARS-CoV-2 Vaccination and Myocarditis or Pericarditis. Am J Prev Med. 2023;64(2):275-284.
Imazio M, Gaita F, LeWinter M. Evaluation and treatment of pericarditis: A systematic review. JAMA - J Am Med Assoc. 2015;314(14):1498-1506. doi:10.1001/jama.2015.12763
Mckaigney CJ, Krantz MJ, La Rocque CL, Hurst ND, Buchanan MS, Kendall JL. E-point septal separation: A bedside tool for emergency physician assessment of left ventricular ejection fraction. Am J Emerg Med. 2014;32(6):493-497. doi:10.1016/j.ajem.2014.01.045

Summarized by Jorge Chalit, OMSII | Edited by Meg Joyce & Jorge Chalit, OMSII

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Contributor: Dylan Luyten MD

Educational Pearls:

What is a Bradyarrhythmia?

Also known as a bradyarrhythmia, it is an irregular heart rate that is also slow (below 60 beats per minute).

What can cause it?

Complete heart block AKA third-degree AV block; identified on ECG by a wide QRS, and complete dissociation between the atrial and ventricular rhythms with the ventricular being much slower. Treat with a pacemaker.
Medication overdose, especially beta blockers. Many other drugs can slow the heart as well including: opioids, clonidine, digitalis, amiodarone, diltiazem, and verapamil to name a few.
Electrolyte abnormalities, specifically hyperkalemia. Hypokalemia, hypocalcemia, and hypomagnesemia can also cause bradyarrhythmias.
Myocardial infarction. Either by damaging the AV node or the conduction system itself or by triggering a process called Reperfusion Bradycardia.
Hypothermia. Bradycardia is generally a sign of severe or advanced hypothermia.

References

Jurkovicová O, Cagán S. Reperfúzne arytmie [Reperfusion arrhythmias]. Bratisl Lek Listy. 1998 Mar-Apr;99(3-4):162-71. Slovak. PMID: 9919746.
Simmons T, Blazar E. Synergistic Bradycardia from Beta Blockers, Hyperkalemia, and Renal Failure. J Emerg Med. 2019 Aug;57(2):e41-e44. doi: 10.1016/j.jemermed.2019.03.039. Epub 2019 May 30. PMID: 31155316.
Wung SF. Bradyarrhythmias: Clinical Presentation, Diagnosis, and Management. Crit Care Nurs Clin North Am. 2016 Sep;28(3):297-308. doi: 10.1016/j.cnc.2016.04.003. Epub 2016 Jun 22. PMID: 27484658.

Summarized by Jeffrey Olson MS2 | Edited by Meg Joyce & Jorge Chalit, OMSII

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Contributor: Aaron Lessen MD

Educational Pearls:

Tranexamic acid (TXA) is a common medication to achieve hemostasis in a variety of conditions
Patients visiting the ED for gross hematuria (between March 2022 and September 2022) were treated with intravesical TXA
1 g tranexamic acid in 100 mL NS via Foley catheter
Clamped Foley for 15 minutes
Subsequent continuous bladder irrigation, as is standard in most EDs
Compared with a cohort of patients visiting the ED for a similar concern between March 2021 and September 2021, the TXA patients had:
A shorter median length of stay in the ED (274 min vs. 411 mins, P < 0.001).
A shorter median duration of Foley catheter placement (145 min vs. 308 mins, P < 0.001)
Fewer revisits after ED discharge (2.3% vs. 12.3%, P = 0.031)

References

Choi H, Kim DW, Jung E, et al. Impact of intravesical administration of tranexamic acid on gross hematuria in the emergency department: A before-and-after study. Am J Emerg Med. 2023;68:68-72. doi:10.1016/j.ajem.2023.03.020

Summarized by Jorge Chalit, OMSII | Edited by Meg Joyce & Jorge Chalit, OMSII

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Contributor: Meghan Hurley MD

Educational Pearls:

What is Cellulitis?

A common and potentially serious bacterial skin infection.
Caused by various types of bacteria, with Streptococcus and Staphylococcus species being the most common.

What is Preseptal Cellulitis and why is it more serious than facial cellulitis?

Preseptal Cellulitis, also known as Periorbital Cellulitis, is a bacterial infection of the soft tissues in the eyelid and the surrounding area.
This requires prompt and aggressive treatment to avoid progression into Orbital Cellulitis.

How is Preseptal Cellulitis treated?

Oral antibiotics for five to seven days.
In the setting of trauma (scratching bug bites) Clindamycin or TMP-SMX (for MRSA coverage) and Amoxicillin-clavulanic acid or Cefpodoxime or Cefdinir.
If there is no trauma, monotherapy with amoxicillin-clavulanic acid is appropriate.
Check immunization status against H.influenzae and adjust appropriately.

What is Orbital Cellulitis, how is it diagnosed, and why is it more serious than Preseptal Cellulitis?

Orbital cellulitis involves the tissues behind the eyeball and within the eye socket itself.
Key features include:
Eye pain.
Proptosis (Bulging of the eye out of its normal position).
Impaired eye movement.
Blurred or double vision.
This can lead to three very serious complications:
Orbital Compartment Syndrome. This can push eye forward, stretch optic nerve, and threaten vision.
Meningitis given that the meninges of the brain are continuous with optic nerve.
Endophthalmitis, which is inflammation of the inner coats of the eye. This can also threaten vision.
If suspected, get a CT of the orbits and/or an MRI to look for an abscess behind the eyes.

How is Orbital Cellulitis treated?

IV antibiotics. Cover for meningitis with Ceftriaxone and Vancomycin.
Add Metronidazole until intracranial involvement has been ruled out.
Drain the abscess surgically. Usually this is performed by an ophthalmologist or an otolaryngologist.
Admit to the hospital.

References

Bae C, Bourget D. Periorbital Cellulitis. 2023 Jul 17. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan–. PMID: 29261970.
Chaudhry IA, Shamsi FA, Elzaridi E, Al-Rashed W, Al-Amri A, Al-Anezi F, Arat YO, Holck DE. Outcome of treated orbital cellulitis in a tertiary eye care center in the middle East. Ophthalmology. 2007 Feb;114(2):345-54. doi: 10.1016/j.ophtha.2006.07.059. PMID: 17270683.
Seltz LB, Smith J, Durairaj VD, Enzenauer R, Todd J. Microbiology and antibiotic management of orbital cellulitis. Pediatrics. 2011 Mar;127(3):e566-72. doi: 10.1542/peds.2010-2117. Epub 2011 Feb 14. PMID: 21321025.
Wong SJ, Levi J. Management of pediatric orbital cellulitis: A systematic review. Int J Pediatr Otorhinolaryngol. 2018 Jul;110:123-129. doi: 10.1016/j.ijporl.2018.05.006. Epub 2018 May 8. PMID: 29859573.

Summarized by Jeffrey Olson MS2 | Edited by Meg Joyce & Jorge Chalit, OMSII

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Contributors:

Andrew White MD - Outpatient Psychiatrist; Fellowship Trained in Addiction Psychiatry; Denver Health

Travis Barlock MD - Emergency Medicine Physician; Swedish Medical Center

Summary

In this episode of Mental Health Monthly, Dr. Travis Barlock hosts Dr. Andrew White to discuss the elements of mania that may be encountered in the emergency department. The discussion includes a helpful mnemonic to assess mania, work-up and treatment in the ED, underlying causes of mania, mental health holds, inpatient treatment, and the role of sleep in mania.

Educational Pearls

Initial assessment of suspected mania can be done via DIGFAST:
Distractibility - Individual that is unable to carry a linear, goal-directed conversation
Impulsivity - Executive functioning is impaired and patients are unable to control their behaviors
Grandiosity - Elevated mood and sense of self to delusions of grandeur
Flight of ideas - Usually described as racing thoughts
Agitation - Increase in psychomotor activity; start several projects of which they have little previous knowledge
Sleep decrease - Typically, manic episodes start with insomnia and can devolve into multiday sleeplessness
Talkativeness - More talkative than usual with pressured speech and a tangential thought process
Interviewing patients requires an understanding of mood-based mania vs. psychosis-based mania
An individual with mood-based mania will more likely be restless, whereas a patient with psychosis-based mania will be more relaxed from a psychomotor standpoint
Treatment of manic patients in the ED includes the use of antipsychotics to manage acute symptomatology
Management can be informed and directed by the patient’s history i.e. known medications that have worked for the patient
ED management of manic patients involves a work-up for a broad differential including agitated delirium, substance-induced mania, metabolic disorders, and autoimmune diseases.
Some individuals experience manic episodes from marijuana and other illicit substances
Antidepressants used in bipolar patients for suspected depression may induce mania
Important to avoid using antidepressants as first-line therapy
Mental health holds can be beneficial in patients with grave disabilities from mania
Oftentimes, undertreatment of manic episodes leads to re-hospitalization
Inpatient treatment:
Environment is important - ensure that patients get solo rooms if possible to minimize stimulation
Antipsychotics, including risperidone and olanzapine, with or without a benzodiazepine, are useful for short-term agitation
Long-term treatment involves coupled pharmacological treatments with non-pharmacological treatments
Sleep
Fractured sleep is one of the earliest warning signs that someone has an imminent manic episode
Poor sleep can be an inciting factor for mania, which then turns into a cycle that further propagates a patient’s manic episode

Summarized and edited by Jorge Chalit, OMSII | Studio production by Jeffrey Olson, MS2

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Contributor: Travis Barlock MD

Education Pearls:

The Cushing Reflex is a physiologic response to elevated intracranial pressure (ICP)
Cushing’s Triad: widened pulse pressure (systolic hypertension), bradycardia, and irregular respirations
Increased ICP results from systolic hypertension, which causes a parasympathetic reflex to drop heart rate, leading to Cushing’s Triad.
The Cushing Reflex is a sign of herniation
Treatment includes:
Hypertonic saline is comparable to mannitol and preferable in patients with hypovolemia or hyponatremia
Give 250-500mL of 3%NaCl
20% Mannitol - given at a dose of 0.5-1 g/kg
Each additional dose of 0.1 g/kg reduces ICP by 1 mm Hg
23.4% hypertonic saline is more often given in the neuro ICU
8.4% Sodium bicarbonate lowers ICP for 6 hours without causing metabolic acidosis
Non-pharmacological interventions:
Raise the head of the bed to 30-45 degrees
Remove the c-collar to improve blood flow to the head
Hyperventilation induces hypocapnia, which will vasoconsrict the cerebral arterioles
You hyperventilate on the way to the OR. Otherwise, maintain normocapnia.

References

Alnemari AM, Krafcik BM, Mansour TR, Gaudin D. A Comparison of Pharmacologic Therapeutic Agents Used for the Reduction of Intracranial Pressure After Traumatic Brain Injury. World Neurosurg. 2017;106:509-528. doi:10.1016/j.wneu.2017.07.009
Bourdeaux C, Brown J. Sodium bicarbonate lowers intracranial pressure after traumatic brain injury. Neurocrit Care. 2010;13(1):24-28. doi:10.1007/s12028-010-9368-8
Dinallo S, Waseem M. Cushing Reflex. [Updated 2023 Mar 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK549801/
Godoy DA, Seifi A, Garza D, Lubillo-Montenegro S, Murillo-Cabezas F. Hyperventilation therapy for control of posttraumatic intracranial hypertension. Front Neurol. 2017;8(JUL):1-13. doi:10.3389/fneur.2017.00250

Summarized by Jorge Chalit, OMSII | Edited by Meg Joyce & Jorge Chalit, OMSII

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Contributors:

Kalen Abbott, MD - EM Physician and Medical Director for AirLife Denver
Brendan Reiss - Flight Nurse AirLife Denver
Matt Spoon - Flight Paramedic AirLife Denver
Jordan Ourada - EMS Coordinator at Swedish Medical Center and Paramedic

Summary:

In this episode, hosted by Jordan Ourada, Brendan Reiss and Matt Spoon present a first-hand experience case of hydrofluoric acid exposure in a pediatric patient. Commentary and educational pearls are provided by EM Physician, Kalen Abbott.

The case:

The patient was a male infant who had spilled a large amount of heavy-duty acid aluminum wheel cleaner on himself while playing in his parent's garage. Unclear if he had ingested any fluid. The cleaning fluid contained a large percentage of hydrofluoric acid.
He was brought by EMS to his local hospital, who quickly decided to transport the infant by helicopter to a large Denver hospital.
Initial labs were unremarkable and the EKG was normal. Heart rate was in the 140s. Blood pressure was 110/73. Respirations were around 30 and non-labored. Chest and abdominal x-rays were unremarkable.
The patient had received a water-based decontamination and 1 gram of calcium gluconate IV.

Complications:

Immediately before leaving a nurse informed Brendan and Matt that the serum calcium was 6.8 mg/dl (normal range: 8.5 to 10.2).
During the flight, the patient went into cardiac arrest.
The patient achieved ROSC after CPR was administered in the helicopter.
Once on the ground, an I/O line was started and calcium chloride, sodium bicarb, and normal saline were administered.
Within the first 2 hours that patient received the equivalent of 310 mg/kg of calcium (the pediatric dose is 20 mg/kg)

Care resolution:

The patient ended up having a several-week stay in the pediatric ICU. There were some complications such as pulmonary hemorrhage. Calcium gluconate was continued via nebulization for several days. Ultimately, the child was weaned off the ventilator and spontaneous respirations resumed. They were able to wean the child off vasopressors and sedation over the course of several days. A gastric lavage with calcium gluconate was completed as well during the inpatient stay. The child was able to leave the hospital, neurologically intact after about 14 days.

Pearls:

Lower concentrations of acids can be more dangerous because they don’t immediately burn but rather can be absorbed systemically through the skin.
Calcium is the antidote to hydrofluoric acid exposure.
Calcium chloride has 3 times the elemental calcium as calcium gluconate.
The maximum infusion rate of calcium chloride through a peripheral line is 1 gram every 10 minutes, calcium gluconate can be infused at 1 gram every 5 minutes.
When intubating a patient with acid exposure, avoid succinylcholine because of the risk of hyperkalemia.

References

Caravati EM. Acute hydrofluoric acid exposure. Am J Emerg Med. 1988 Mar;6(2):143-50. doi: 10.1016/0735-6757(88)90053-8. PMID: 3281684.
Pepe J, Colangelo L, Biamonte F, Sonato C, Danese VC, Cecchetti V, Occhiuto M, Piazzolla V, De Martino V, Ferrone F, Minisola S, Cipriani C. Diagnosis and management of hypocalcemia. Endocrine. 2020 Sep;69(3):485-495. doi: 10.1007/s12020-020-02324-2. Epub 2020 May 4. PMID: 32367335.
Strayer RJ. Succinylcholine, rocuronium, and hyperkalemia. Am J Emerg Med. 2016 Aug;34(8):1705-6. doi: 10.1016/j.ajem.2016.05.039. Epub 2016 May 19. PMID: 27241569.
Vallentin MF, Granfeldt A, Meilandt C, Povlsen AL, Sindberg B, Holmberg MJ, Iversen BN, Mærkedahl R, Mortensen LR, Nyboe R, Vandborg MP, Tarpgaard M, Runge C, Christiansen CF, Dissing TH, Terkelsen CJ, Christensen S, Kirkegaard H, Andersen LW. Effect of Intravenous or Intraosseous Calcium vs Saline on Return of Spontaneous Circulation in Adults With Out-of-Hospital Cardiac Arrest: A Randomized Clinical Trial. JAMA. 2021 Dec 14;326(22):2268-2276. doi: 10.1001/jama.2021.20929. PMID: 34847226; PMCID: PMC8634154.

Summarized by Jeffrey Olson MS2 | Edited by Jeffrey Olson, Meg Joyce, & Jorge Chalit, OMSII

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Contributor: Meghan Hurley MD

Educational Pearls:

What is ATLS?

Advanced Trauma Life Support (ATLS) is a systematic and comprehensive approach to the evaluation and management of trauma patients
It was developed by the American College of Surgeons (ACS)
The key components include the Primary Survey ("ABCDE"), the Secondary Survey, Definitive Care, and Special Considerations

What are the issues with ATLS?

ATLS relies on many algorithms and rules-of-thumb, which might be helpful for individuals with basic skills and training but might actually present obstacles for those with higher levels of training. Dr. Hurley cites several examples.

Example 1: ABC approach to trauma patients

ABC stands for Airway, Breathing, and Circulation but focusing on the airway first is not always the best decision.
Immediate attention may need to be applied to massive hemorrhage.
Intubating a patient that is hemodynamically unstable may cause cardiac arrest.
A more helpful phrase might be “Resuscitate before you intubate.”

Example 2: C-spine precautions

Cervical collars may impede the likelihood of first-pass success when intubating. The risk of complications from a failed airway may often outweigh the risk of causing a spinal cord injury.

Example 3:Cutting clothes off.

The E of ABCDE stands for exposure which means fully undressing the patient to look for missing injuries. This often involves cutting their clothes off.
This practice might be too broadly applied and leave low-risk trauma patients without any clothes to wear when discharged home.

Example 4: Digital rectal exam

A rectal exam can be a useful tool in the evaluation of patients with abdominal or pelvic injuries. It can help screen for rectal bleeding, pelvic fractures, and neurological function
However, the rectal exam is not a sensitive test. A retrospective study from the Indian Journal of Surgery found that a rectal exam missed 100% of urethra injuries, 92% of spinal cord injuries, 93% of small bowel injuries, 100% of colon injuries, and 67% of rectal injuries in trauma patients.

Example 6: Pushing on pelvis for pelvic injuries

Pushing on the pelvis to check for instability can cause further damage to an unstable pelvis. Imaging the pelvis is far more important than pressing on it if a pelvic fracture is suspected.

Example 7: FAST exam

A FAST exam, which stands for "Focused Assessment with Sonography for Trauma," is a rapid ultrasound examination used to assess trauma patients for signs of internal bleeding or organ damage in the abdomen and chest.
These can be very useful as an initial test to tell a trauma surgeon where to start looking for internal bleeding in an unstable blunt traumatic injury
If a patient is stable and likely going to get a CT scan whether the FAST is positive or negative then the test is unnecessary

References

ATLS Subcommittee; American College of Surgeons’ Committee on Trauma; International ATLS working group. Advanced trauma life support (ATLS®): the ninth edition. J Trauma Acute Care Surg. 2013 May;74(5):1363-6. doi: 10.1097/TA.0b013e31828b82f5. PMID: 23609291.
Bloom BA, Gibbons RC. Focused Assessment With Sonography for Trauma. 2023 Jul 24. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan–. PMID: 29261902.
Brown R. Oxygenate and Resuscitate Before You Intubate. Common pitfalls to avoid when managing the crashing airway. EMS World. 2016 Jan;45(1):48-50, 52, 54-5. PMID: 26852546.
Chrimes N, Marshall SD. Attempt XYZ: airway management at the opposite end of the alphabet. Anaesthesia. 2018 Dec;73(12):1464-1468. doi: 10.1111/anae.14361. Epub 2018 Jul 11. PMID: 29998563.
Docimo S Jr, Diggs L, Crankshaw L, Lee Y, Vinces F. No Evidence Supporting the Routine Use of Digital Rectal Examinations in Trauma Patients. Indian J Surg. 2015 Aug;77(4):265-9. doi: 10.1007/s12262-015-1283-y. Epub 2015 May 19. PMID: 26702232; PMCID: PMC4688269.
Groeneveld A, McKenzie ML, Williams D. Logrolling: establishing consistent practice. Orthop Nurs. 2001 Mar-Apr;20(2):45-9. doi: 10.1097/00006416-200103000-00011. PMID: 12024634.
Morgenstern, J. The FAST exam: overused and overrated?, First10EM, August 30, 2021.
Rodrigues IFDC. To log-roll or not to log-roll - That is the question! A review of the use of the log-roll for patients with pelvic fractures. Int J Orthop Trauma Nurs. 2017 Nov;27:36-40. doi: 10.1016/j.ijotn.2017.05.001. Epub 2017 May 10. PMID: 28797555.
Sapsford W. Should the 'C' in 'ABCDE' be altered to reflect the trend towards hypotensive resuscitation? Scand J Surg. 2008;97(1):4-11; discussion 12-3. doi: 10.1177/145749690809700102. PMID: 18450202.
Sundstrøm T, Asbjørnsen H, Habiba S, Sunde GA, Wester K. Prehospital use of cervical collars in trauma patients: a critical review. J Neurotrauma. 2014 Mar 15;31(6):531-40. doi: 10.1089/neu.2013.3094. Epub 2013 Nov 6. PMID: 23962031; PMCID: PMC3949434.

Summarized by Jeffrey Olson MS2 | Edited by Meg Joyce & Jorge Chalit, OMSII

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Contributor: Meghan Hurley MD

Educational Pearls:

Shift work is defined as anything that takes place outside of a 9-5 schedule, not exempting day-shift medical workers
Various ill effects of shift work on overall health:
Increased all-cause mortality
Increased number of accidents
Glucose metabolism dysregulation
Increased BMI
Fertility impacts for men and women
Increased breast cancer risk
Decreased cognitive functioning
Mitigation strategies
Work at the same time every day
Anchor Sleep - always try to be asleep at the same time of day
Progressive shifts: day- into swing- into night shift instead of the other way around
Three days off after a stretch of nights can help reset sleep schedule
Shorter night shifts
Morning shifts should start no earlier than 8 AM
Sleep hygiene
Ensure an ideal sleep environment; cool, dark, and damp
Avoid bright lights when going to sleep
Exposure to bright lights when waking up
Hydration throughout your shift
Stop caffeine at midnight if you are working a night shift
Eat healthy meals and avoid junk food
Avoid eating 2-3 hours before going to sleep

References

Boivin, D. B., Boudreau, P., & Kosmadopoulos, A. (2022). Disturbance of the Circadian System in Shift Work and Its Health Impact. Journal of biological rhythms, 37(1), 3–28. https://doi.org/10.1177/07487304211064218
Jang TW. Work-Fitness Evaluation for Shift Work Disorder. Int J Environ Res Public Health. 2021;18(3):1294. Published 2021 Feb 1. doi:10.3390/ijerph18031294
Minors DS, Waterhouse JM. Anchor sleep as a synchronizer of rhythms on abnormal routines. Int J Chronobiol. 1981;7(3):165-188.
Reinganum MI, Thomas J. Shift Work Hazards. [Updated 2023 Jan 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK589670/

Summarized by Jorge Chalit, OMSII | Edited by Meg Joyce & Jorge Chalit, OMSII

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Contributor: Aaron Lessen MD

Educational Pearls:

Why is airway management more difficult in obesity?

Larger body habitus causes the chest to be above the head when the patient is lying supine, creating difficult angles for intubation.
Reduced Functional Residual Capacity (FRC) causes these patients to deoxygenate much more quickly, reducing the amount of time during which the intubation can take place.

What special considerations need to be made?

Positioning. The auditory canal and sternal notch should be aligned in a horizontal plane. Do this by stacking blankets to lift the neck and head. Also, try to make the head itself parallel to the ceiling.
Pre-oxygenation. Use Bi-level Positive Airway Pressure (BiPAP) with Positive End Expiratory Pressure (PEEP) or a Bag-Valve-Mask (BVM) with a PEEP valve. PEEP helps prevent alveoli from collapsing after every breath and improves oxygenation.
Dosing of paralytics. Succinylcholine is dosed on total body weight so the dose will be much larger for the obese patient. Rocuronium is dosed on ideal body weight, but adjusted body weight may also be used in obese cases.

References

De Jong A, Wrigge H, Hedenstierna G, Gattinoni L, Chiumello D, Frat JP, Ball L, Schetz M, Pickkers P, Jaber S. How to ventilate obese patients in the ICU. Intensive Care Med. 2020 Dec;46(12):2423-2435. doi: 10.1007/s00134-020-06286-x. Epub 2020 Oct 23. PMID: 33095284; PMCID: PMC7582031.
Langeron O, Birenbaum A, Le Saché F, Raux M. Airway management in obese patient. Minerva Anestesiol. 2014 Mar;80(3):382-92. Epub 2013 Oct 14. PMID: 24122033.
Sharma S, Arora L. Anesthesia for the Morbidly Obese Patient. Anesthesiol Clin. 2020 Mar;38(1):197-212. doi: 10.1016/j.anclin.2019.10.008. Epub 2020 Jan 2. PMID: 32008653.
Singer BD, Corbridge TC. Basic invasive mechanical ventilation. South Med J. 2009 Dec;102(12):1238-45. doi: 10.1097/SMJ.0b013e3181bfac4f. PMID: 20016432.

Summarized by Jeffrey Olson, MS2 | Edited by Jorge Chalit, OMSII

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Contributor: Nick Tsipis MD

Educational Pearls:

The scaphoid bone is the most proximal carpal bone just distal to the radius
Fractures of the scaphoid bone are sometimes missed by plain X-rays
A 2020 review found a 21.8% incidence of missed scaphoid fractures later diagnosed by advanced imaging modalities
Only MRI has a sensitivity above 90% for diagnosing scaphoid fractures
Sensitivity of plain-film radiography is low unless it is a displaced fracture
Physical examination techniques fail to definitively rule out scaphoid fractures
A 2023 systematic review assessed the sensitivity and specificity of several common physical exam maneuvers:
Tenderness of the anatomical snuffbox has a sensitivity of 92.1% and specificity of 48.4%; i.e. absence reduces the likelihood of an occult scaphoid fracture but does not rule it out
Another common physical exam maneuver is pain with ulnar deviation, which carries a sensitivity of 55.2% and specificity of 76.4%.
Elicitation of pain with supination against resistance demonstrated a sensitivity of 100% and specificity of 97.9% in the study, so the authors recommend externally validating this method
Patients should be counseled on the importance of follow-up given that a fracture may not show up on imaging unless an MRI or repeat XR is done

References

Bäcker HC, Wu CH, Strauch RJ. Systematic Review of Diagnosis of Clinically Suspected Scaphoid Fractures. J Wrist Surg. 2020;09(01):081-089. doi:10.1055/s-0039-1693147
Coventry L, Oldrini I, Dean B, Novak A, Duckworth A, Metcalfe D. Which clinical features best predict occult scaphoid fractures? A systematic review of diagnostic test accuracy studies. Emerg Med J. 2023;40(8):576 LP - 582. doi:10.1136/emermed-2023-213119

Summarized by Jorge Chalit, OMSII | Edited by Meg Joyce & Jorge Chalit, OMSII

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Contributor: Aaron Lessen MD

Educational Pearls:

What is Carbamazepine (Tegretol)?

Carbamazepine is an anti-epileptic drug with mood-stabilizing properties that is used to treat bipolar disorder, epilepsy, and neuropathic pain.
It functions primarily by blocking sodium channels which can prevent repetitive action potential firing.

What are the symptoms of an overdose?

Common initial signs include diminished conscious state, nystagmus, ataxia, hyperreflexia, CNS depression, dystonia, and tachycardia
Severe toxicity can cause seizures, respiratory depression, decreased myocardial contractility, pulmonary edema, hypotension, and dysrhythmias.

How is an overdose treated?

An overdose is treated with large doses of activated charcoal and correction of electrolyte disturbances.
Be ready to intubate given the potential for respiratory depression.
Carbamazepine is moderately dialyzable and dialysis is recommended in severe overdoses.

Additional educational pearl: Individuals in correctional facilities can occasionally self-administer medications which means that medication overdose should still be on the differential for any of these individuals.

References

Epilepsies in children, Young People and adults: NICE guideline [NG217]. National Institute for Health and Care Excellence. (2022, April 27). https://www.nice.org.uk/guidance/ng217
Ghannoum M, Yates C, Galvao TF, Sowinski KM, Vo TH, Coogan A, Gosselin S, Lavergne V, Nolin TD, Hoffman RS; EXTRIP workgroup. Extracorporeal treatment for carbamazepine poisoning: systematic review and recommendations from the EXTRIP workgroup. Clin Toxicol (Phila). 2014 Dec;52(10):993-1004. doi: 10.3109/15563650.2014.973572. Epub 2014 Oct 30. PMID: 25355482; PMCID: PMC4782683.
Seymour JF. Carbamazepine overdose. Features of 33 cases. Drug Saf. 1993 Jan;8(1):81-8. doi: 10.2165/00002018-199308010-00010. PMID: 8471190.
Spiller HA. Management of carbamazepine overdose. Pediatr Emerg Care. 2001 Dec;17(6):452-6. doi: 10.1097/00006565-200112000-00015. PMID: 11753195.
Tran NT, Pralong D, Secrétan AD, Renaud A, Mary G, Nicholas A, Mouton E, Rubio C, Dubost C, Meach F, Bréchet-Bachmann AC, Wolff H. Access to treatment in prison: an inventory of medication preparation and distribution approaches. F1000Res. 2020 May 13;9:357. doi: 10.12688/f1000research.23640.3. PMID: 33123347; PMCID: PMC7570324.

Summarized by Jeffrey Olson, MS2 | Edited by Meg Joyce & Jorge Chalit, OMSII

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Contributor: Jason Papazian MD, Travis Barlock MD, Jeffrey Olson

Summary:

In this episode, Dr. Travis Barlock and Jeffrey Olson meet in the studio to discuss several clips from Dr. Jason Papazian’s talk at the event “Laboring Under Pressure, Managing Obstetric Emergencies in a Global Setting” from May 2023. This event was hosted at the University of Denver and was organized with the help of Joe Parker as a fundraiser for the organization Health Outreach Latin America (HOLA).

Dr. Jason Papazian practices Obstetric Anesthesiology for the Maternal Fetal Care Unit at Children's Hospital Colorado. He is the Assistant Program Director of Didactics for the Anesthesiology Residency at the University of Colorado, as well as the Faculty Advisor to Residents and Obstetric Anesthesiology Fellows.

During his talk, Dr. Papazian walks the audience through the steps of a maternal cardiac arrest from initial rapid response, to intubation, CPR, ACLS, and eventually emergency cesarean section.

Some important take-away points from this talk are:

The basics save lives. Focus on oxygenating the patient and providing high quality CPR
In order to maximize blood return during CPR on an obstetric patient, manually retract the gravid uterus to the left
If an arresting mother does not obtain return of spontaneous circulation (ROSC) by 4 minutes, the most qualified person should perform a rapid 1-minute bedside cesarean section. This has mortality benefits for both the mother and the infant.

Other medical topics discussed include changes in the obstetric patient’s physiology, roles during a rapid response, steps of intubation, causes of cardiac arrest, management of cardiac arrest, and how pregnancy does (and doesn’t) change ACLS.

References

Bennett TA, Katz VL, Zelop CM. Cardiac Arrest and Resuscitation Unique to Pregnancy. Obstet Gynecol Clin North Am. 2016 Dec;43(4):809-819. doi: 10.1016/j.ogc.2016.07.011. PMID: 27816162.
Campbell TA, Sanson TG. Cardiac arrest and pregnancy. J Emerg Trauma Shock. 2009 Jan;2(1):34-42. doi: 10.4103/0974-2700.43586. PMID: 19561954; PMCID: PMC2700584.
Health Outreach for Latin America Foundation - HOLA Foundation. (n.d.). http://www.hola-foundation.org/
Kikuchi J, Deering S. Cardiac arrest in pregnancy. Semin Perinatol. 2018 Feb;42(1):33-38. doi: 10.1053/j.semperi.2017.11.007. Epub 2017 Dec 13. PMID: 29246735.

Produced by Jeffrey Olson, MS2 | Edited by Jeffrey Olson and Jorge Chalit, OMSII

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Contributor: Aaron Lessen MD

Educational Pearls:

A recent randomized controlled trial compared ondansetron 8 mg IV with droperidol 2.5 mg IV for the treatment of nausea & vomiting in the emergency department.
Overall, droperidol and ondansetron had similar primary outcomes in acute nausea control
Symptom improvement in 93% of patients receiving droperidol vs. 87% receiving ondansetron (P = 0.362)
Secondary measures were, however, statistically significantly different between groups
Patients needed fewer rescue/additional antiemetics in the droperidol group (16%) compared with the ondansetron group (37%); p = 0.016
Similarly, more patients in the droperidol group reported they achieved the desired effect of the medication (85% vs. 63%; p = 0.006)
Patients receiving droperidol did experience increased drowsiness
40% in the droperidol group vs. 11% in the ondansetron group
The trial did not assess the length of stay in the ED after administering medications, which is a potential avenue for future research.

References

Philpott L, Clemensen E, Lau GT. Droperidol versus ondansetron for nausea treatment within the emergency department. EMA - Emerg Med Australas. 2023;(December 2022):605-611. doi:10.1111/1742-6723.14174

Summarized & Edited by Jorge Chalit, OMSII

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Contributor: Aaron Lessen MD

Educational Pearls:

What is measured in an ABG/VBG?

Blood values for oxygen tension (pO2), carbon dioxide tension (pCO2), acidity (pH), oxyhemoglobin saturation, and bicarbonate (HCO3) in either arterial or venous blood
Other tests can measure methemoglobin, carboxyhemoglobin, hemoglobin levels, base excess, and lactate

What are they used for?

Identification of ventilation/acid-base disturbances. For example: if a patient is in septic shock, oxyhemoglobin saturation can be used to guide resuscitation efforts (early goal- directed therapy)

What's the difference between an ABG and VBG?

One of the main differences is how the blood samples are collected. Venous blood gas is normally collected from existing venous access such as a central venous catheter. Arterial blood gases must be drawn from an artery, such as the radial artery.
Arterial blood draws can be difficult, painful, and contraindicated in many situations.
ABGs have traditionally provided more accurate measurements for assessing oxygenation, ventilation, and acid-base status.
However, several studies have found that VBGs can still be used to accurately assess pH, pCO2, HCO3, lactate, sodium, potassium, chloride, ionized calcium, blood urea nitrogen, base excess, and arterial/alveolar oxygen ratio. This is supported by a recent study in 2023 in the International Journal of Emergency Medicine which specifically studied patients with hypotension and use of VBGs for resuscitation guidance.

Are there other non-invasive methods that can be used to fill in the gaps to avoid ordering an ABG?

Oxygenation can be measured by pulse oximetry
Arterial carbon dioxide tension can be estimated by end-tidal carbon dioxide (PetCO2)
Mixed venous blood gases are another alternative for patients who already have a pulmonary artery catheter

References

Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B, Peterson E, Tomlanovich M; Early Goal-Directed Therapy Collaborative Group. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001 Nov 8;345(19):1368-77. doi: 10.1056/NEJMoa010307. PMID: 11794169.
Prasad H, Vempalli N, Agrawal N, Ajun UN, Salam A, Subhra Datta S, Singhal A, Ranjan N, Shabeeba Sherin PP, Sundareshan G. Correlation and agreement between arterial and venous blood gas analysis in patients with hypotension-an emergency department-based cross-sectional study. Int J Emerg Med. 2023 Mar 10;16(1):18. doi: 10.1186/s12245-023-00486-0. PMID: 36899297; PMCID: PMC9999648.

Summarized by Jeffrey Olson, MS2 | Edited by Jorge Chalit, OMSII

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Contributor: Aaron Lessen MD

Educational Pearls:

Patients with alcohol use disorder are frequently discharged from the ED without further resources
Pharmacological treatments to reduce cravings in AUD exist
Naltrexone
Effective at reducing alcohol cravings and heavy drinking
Gabapentin
Reduces the percentage of heavy drinking days in AUD
Patients being discharged from the ED should be asked if they feel their alcohol use is a problem, which can further direct appropriate pharmacological interventions

References

Kranzler M.D. HR, Feinn Ph.D. R, Morris B.A. P, Hartwell Ph.D. EE. A Meta-analysis of the Efficacy of Gabapentin for Treating Alcohol Use Disorder Henry. Addiction. 2019;114(9):1547-1555. doi:10.1111/add.14655
Maisel NC, Blodgett JC, Wilbourne PL, Humphreys K, Finney JW. Meta-analysis of naltrexone and acamprosate for treating alcohol use disorders: When are these medications most helpful? Addiction. 2013;108(2):275-293. doi:10.1111/j.1360-0443.2012.04054.x
Mariani JJ, Pavlicova M, Basaraba C, et al. Pilot randomized placebo-controlled clinical trial of high-dose gabapentin for alcohol use disorder. Alcohol Clin Exp Res. 2021;45(8):1639-1652. doi:10.1111/acer.14648

Summarized & Edited by Jorge Chalit, OMSII

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Contributor: Travis Barlock MD

Educational Pearls:

When might you need to apply a painful stimulus in a medical setting?

The main reason is to assess the patient's level of consciousness, such as when they are waking up from anesthesia or have potentially suffered a brain injury.
It can be part of the Glasgow Coma Scale (GCS) if patients are not responding to auditory stimuli.
Possible levels of consciousness include Alert, Lethargic, Obtunded, and Comatose (ALOC)

What are the approved ways to apply a painful stimulus to assess central nervous system function?

Trapezius squeeze. Grab the trapezius muscle and twist (contraindicated in clavicle fractures).
Supraorbital rim pressure. Find the notch in the supraorbital rim of the patient and push hard with your thumb (contraindicated in facial fractures).
Mandibular pressure (not mentioned). Press hard at the angle of the jaw on the mandibular nerve (contraindicated in mandible fractures).
Sternal rub. Push down with your knuckles into the patient’s sternum and rub vigorously (contraindicated in chest injury/surgery).
Each technique should be done for between 15 and 30 seconds.
If skin damage is observed in one location, move to a different location. This is especially true of the sternal rub.

Important note: Peripheral techniques such as nail tip pressure should only be used to evaluate spinal nerve reflexes and not as a method of assessing the level of consciousness.

References

Lower J. Using pain to assess neurologic response. Nursing. 2003 Jun;33(6):56-7. doi: 10.1097/00152193-200306000-00047. PMID: 12799591.
Middleton PM. Practical use of the Glasgow Coma Scale; a comprehensive narrative review of GCS methodology. Australas Emerg Nurs J. 2012 Aug;15(3):170-83. doi: 10.1016/j.aenj.2012.06.002. Epub 2012 Aug 3. PMID: 22947690.
Mistovich JJ, Krost W, Limmer DD. Beyond the basics: patient assessment. Emerg Med Serv. 2006 Jul;35(7):72-7; quiz 78-9. PMID: 16878751.
Naalla R, Chitirala P, Chittaluru P, Atreyapurapu V. Sternal rub causing presternal abrasion in a patient with capsuloganglionic haemorrhage. BMJ Case Rep. 2014 Apr 7;2014:bcr2014204028. doi: 10.1136/bcr-2014-204028. PMID: 24711478; PMCID: PMC3987201.

Summarized by Jeffrey Olson, MS2 | Edited by Jorge Chalit, OMSII

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Contributor: Travis Barlock MD

Educational Pearls:

Alcohol binds the GABA receptor, which produces an inhibitory response, hence the “depressive” effects of ethanol beverages.
Over time, alcohol downregulates the GABA receptors, leading to unopposed glutamate activity. Given that glutamate is excitatory, this can lead to seizures.
Alcohol also suppresses REM sleep; in patients with chronically suppressed REM sleep, the brain starves for dream sleep and it spills over into the wakeful state, inducing a dream-like state when someone is awake.
The awake dream-like state of delirium tremens (DT) differs from alcohol hallucinosis
Alcohol hallucinosis presents with visual hallucinations in a wakeful state
DT presents with a generalized clouding of the sensorium and a dream-like state
Treatment for DT is better achieved with phenobarbital due to predictable pharmacology
Phenobarbital acts on GABA and NMDA receptors

References

Davies M. The role of GABAA receptors in mediating the effects of alcohol in the central nervous system. J Psychiatry Neurosci. 2003;28(4):263-274.
Fujimoto J, Lou JJ, Pessegueiro AM. Use of Phenobarbital in Delirium Tremens. J Investig Med High Impact Case Reports. 2017;5(4):4-6. doi:10.1177/2324709617742166
Walker, M. Chapter 13: iPads, Factory Whistles, and Nightcaps In: Walker, M, Why We Sleep. Scribner; 2017, pg. 272.
Zarcone V. Alcoholism and sleep. Adv Biosci. 1978;21:29-38.

Summarized & Edited by Jorge Chalit, OMSII

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Contributors: David Young MD, John Hesling MD, Travis Barlock MD, Jeffrey Olson

Summary:

In this episode, Dr. Travis Barlock and Jeffrey Olson meet in the studio to discuss several clips from the event “Ukraine Brewtalk” from October 2022. This event was hosted by the University of Colorado’s Center for COMBAT Research and Emergency Medical Minute assisted in the audio recording of the speakers.

The first clip is of a brief talk by Dr. John Hesling who was presenting some of his research about Pediatric Supermassive Transfusions.

The second and third clips are from the keynote speaker, Dr. Dave Young, an Emergency Medicine Physician at the University of Colorado Hospital, talking about his experience of serving with USA’s Team Rubicon providing medical aid in war-torn Ukraine.

Medical topics discussed include Pediatric trauma, blood transfusions, tourniquet use, refugee care, and blast injuries.

References

Hesling JD, Paulson MW, McKay JT, Bebarta VS, Flarity K, Keenan S, Fisher AD, Borgman MA, April MD, Schauer SG. Characterizing pediatric supermassive transfusion and the contributing injury patterns in the combat environment. Am J Emerg Med. 2022 Jan;51:139-143. doi: 10.1016/j.ajem.2021.10.032. Epub 2021 Oct 24. Erratum in: Am J Emerg Med. 2022 Feb;52:275. PMID: 34739866.
UNHCR. (2023, July 11). Ukraine Refugee Situation. Operational Data Portal. https://data2.unhcr.org/en/situations/ukraine
Ainsley, J. (2023, February 24). U.S. has admitted 271,000 Ukrainian refugees since Russian invasion, far above Biden’s goal of 100,000. NBCNews.com. https://www.nbcnews.com/politics/immigration/us-admits-271000-ukrainian-refugees-russia-invasion-biden-rcna72177
Built to serve. Team Rubicon. https://teamrubiconusa.org/

Summarized by Jeffrey Olson, MS1 | Edited by Jeffrey Olson MS1 and Jorge Chalit, OMSII

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Contributor: Travis Barlock MD

Educational Pearls:

Clinical picture: A patient comes in with altered mental status, tachycardia, fever, elevated T4, and low TSH. What’s the diagnosis?... Thyrotoxicosis secondary to Graves’ Disease.

How do you treat thyrotoxicosis?

First, give a beta-blocker such as propranolol. This suppresses the elevated adrenergic activity.
Second, give a thionamide such as propylthiouracil (PTU) or methimazole. This decreases the synthesis of new thyroid hormone. PTU is preferred because it also blocks the conversion of T4 to T3.
Third, give an iodine solution such as potassium iodide. This blocks the release of thyroid hormone through a mechanism called the Wolff-Chaikoff effect. Note, this should be given about an hour after the PTU/methimazole to ensure iodine cannot be taken up and used to synthesize more thyroid hormone in individuals with toxic adenoma or toxic multinodular goiter.
Fourth, give a glucocorticoid such as hydrocortisone. This will reduce thyroid hormone conversion from T4 to T3 and treat any concurrent adrenal insufficiency.

References

Abuid J, Larsen PR. Triiodothyronine and thyroxine in hyperthyroidism. Comparison of the acute changes during therapy with antithyroid agents. J Clin Invest. 1974 Jul;54(1):201-8. doi: 10.1172/JCI107744. PMID: 4134836; PMCID: PMC301541.
Cooper DS, Saxe VC, Meskell M, Maloof F, Ridgway EC. Acute effects of propylthiouracil (PTU) on thyroidal iodide organification and peripheral iodothyronine deiodination: correlation with serum PTU levels measured by radioimmunoassay. J Clin Endocrinol Metab. 1982 Jan;54(1):101-7. doi: 10.1210/jcem-54-1-101. PMID: 6274892.
Das G, Krieger M. Treatment of thyrotoxic storm with intravenous administration of propranolol. Ann Intern Med. 1969 May;70(5):985-8. doi: 10.7326/0003-4819-70-5-985. PMID: 5769631.
Nayak B, Burman K. Thyrotoxicosis and thyroid storm. Endocrinol Metab Clin North Am. 2006 Dec;35(4):663-86, vii. doi: 10.1016/j.ecl.2006.09.008. PMID: 17127140.
Tsatsoulis A, Johnson EO, Kalogera CH, Seferiadis K, Tsolas O. The effect of thyrotoxicosis on adrenocortical reserve. Eur J Endocrinol. 2000 Mar;142(3):231-5. doi: 10.1530/eje.0.1420231. PMID: 10700716.

Summarized by Jeffrey Olson, MS2 | Edited by Jorge Chalit, OMSII

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Contributor: Aaron Lessen MD

Educational Pearls:

33 Medical residents and 91 nurses at Massachusetts General Hospital were randomized into two groups:
Intervention group: 15 PGY-1 residents assigned to the same medical service floor for a 16-week period (12 weeks after adjustment for COVID-19 restrictions) alongside 43 nurses.
Control group: 18 PGY-1 residents assigned to the usual 4-week block rotations across 6 medical floors.
At 6 months, there were no differences in teamwork performance metrics including advanced medical simulations and nurse presence at rounds.
The 12-month assessment demonstrated improvement in performance metrics.
Increased time together allows individuals to get to know each other better and therefore improve performance metrics that rely on communication.

References

Iyasere CA, Wing J, Martel JN, Healy MG, Park YS, Finn KM. Effect of Increased Interprofessional Familiarity on Team Performance, Communication, and Psychological Safety on Inpatient Medical Teams: A Randomized Clinical Trial. JAMA Intern Med. 2022;182(11):1190-1198. doi:10.1001/jamainternmed.2022.4373

Summarized by Jorge Chalit, OMSII | Edited by Meg Joyce & Jorge Chalit, OMSII

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Contributor: Meghan Hurley MD

Educational Pearls:

What do you do if you need a stat pregnancy test on an incapacitated patient?

You can send a serum quantitative human chorionic gonadotropin (beta-HCG), but that might take a while for the lab to process.
Another option is to place a drop of whole blood on a urine pregnancy immunoassay.
These tests are already verified for urine and serum.
2012 study showed that whole blood was 95.8% sensitive for pregnancy compared to 95.3% for urine.
Takes a little bit longer (10 minutes was used in the study) due to the viscosity of blood.
Word of caution: This study only looked at a single urine pregnancy kit type. It is possible that other kits would have a different efficacy.
There are new finger stick tests coming out for capillary blood.
Anecdotally, Dr. Hurley was able to use this technique to support a diagnosis of ruptured ectopic pregnancy in a patient that needed emergent surgery.

References

Fromm C, Likourezos A, Haines L, Khan AN, Williams J, Berezow J. Substituting whole blood for urine in a bedside pregnancy test. J Emerg Med. 2012 Sep;43(3):478-82. doi: 10.1016/j.jemermed.2011.05.028. Epub 2011 Aug 27. PMID: 21875776.
Sowder AM, Yarbrough ML, Nerenz RD, Mitsios JV, Mortensen R, Gronowski AM, Grenache DG. Analytical performance evaluation of the i-STAT Total β-human chorionic gonadotropin immunoassay. Clin Chim Acta. 2015 Jun 15;446:165-70. doi: 10.1016/j.cca.2015.04.025. Epub 2015 Apr 25. PMID: 25916696.

Summarized by Jeffrey Olson, MS1 | Edited by Meg Joyce & Jorge Chalit, OMSII

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Contributor: Chris Holmes MD

Educational Pearls:

“It’s a poor sort of memory that only works backwards” - Transient Global Amnesia
A syndrome with sudden retrograde memory loss in which patients cannot retain new information
Characterized by perseveration in frequent intervals
Typically improves within hours
MRI is normal initially
Alice In Wonderland Syndrome
A disorder in which patients experience distortions in their visual perceptions
Most often characterized by micropsia and/or macropsia
Other symptoms may include illusory movement or wavy lines
Alice in Wonderland as a metaphor for birth
Traveling down the rabbit hole is conception
Alice getting bigger in a confined space is pregnancy
Drinking potions is amniotic fluid
Escaping to explore a scary world is childbirth

References

Blom JD. Alice in wonderland syndrome. Alice Wonderl Syndr. 2019;(June):1-221. doi:10.1007/978-3-030-18609-8
Ropper M.D. AH. Transient Global Amnesia. N Engl J Med. 2023;(388):635-640. doi:10.1056/NEJMra2213867

Summarized by Jorge Chalit, OMSII | Edited by Meg Joyce & Jorge Chalit, OMSII

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Contributor: Nicholas Tsipis, MD

Educational Pearls:

What study was Dr. Tsipis talking about?

In December of 2022, the Agency for Healthcare Research and Quality (AHRQ) put out a study titled “Diagnostic Errors in the Emergency Department: A Systematic Review.”
This study triggered many news stories from prominent outlets with headlines such as, “More than 7 million incorrect diagnoses made in US emergency rooms every year, government report finds,” from CNN, and “E.R. Doctors Misdiagnose Patients With Unusual Symptoms,” from the New York Times.

What was the response?

Matt Bivens, MD from Emergency Medicine News responded to the original study in an article titled, “AHRQ Errors Report was ‘Outright Unconscionable.’”
Dr. Bivens points out that AHRQ’s biggest claims – including that 5.7% of patients are misdiagnosed in the ED and 2.0% suffer an adverse event as a result – were based only on three small studies out of Canada, Spain, and Switzerland (combined n=1,758).
Spain and Switzerland did not have emergency medicine residency-trained physicians at the time of the studies.
The Swiss study looked at when the diagnosis changed significantly between admittance and discharge to which Bivens responded, “Are we describing errors in this study or just an ongoing collaborative process?”
The Canadian study looked at 503 high-acuity patients of which one died of a missed aortic dissection. Bivens notes that this is too small of sample size to be generalized to the American ER population which includes a mix of low and high acuity.

Moral of the story?

Mistakes do happen in the ED and they do negatively impact patients but be careful in how you interpret studies and news articles that report on them.

References

Newman-Toker DE, Peterson SM, Badihian S, Hassoon A, Nassery N, Parizadeh D, Wilson LM, Jia Y, Omron R, Tharmarajah S, Guerin L, Bastani PB, Fracica EA, Kotwal S, Robinson KA. Diagnostic Errors in the Emergency Department: A Systematic Review. Comparative Effectiveness Review No. 258. (Prepared by the Johns Hopkins University Evidence-based Practice Center under Contract No. 75Q80120D00003.) AHRQ Publication No. 22(23)-EHC043. Rockville, MD: Agency for Healthcare Research and Quality; December 2022. DOI: 10.23970/AHRQEPCCER258.
Kounang, N. (2022, December 16). More than 7 million incorrect diagnoses made in US emergency rooms every year, government report finds. CNN. https://www.cnn.com/2022/12/15/health/hospital-misdiagnoses-study/index.html
Abelson, R. (2022, December 15). E.R. Doctors Misdiagnose Patients With Unusual Symptoms. The New York Times. https://www.nytimes.com/2022/12/15/health/medical-errors-emergency-rooms.html?searchResultPosition=3
Bivens, Matt MD. Evidence-Based Medicine: AHRQ Errors Report was ‘Outright Unconscionable’. Emergency Medicine News 45(3):p 1,21, March 2023. | DOI: 10.1097/01.EEM.0000922716.51556.31

Summarized by Jeffrey Olson, MS1 | Edited by Meg Joyce & Jorge Chalit, OMSII

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Contributor: Travis Barlock MD

Educational Pearls

The QT interval represents phases 2 and 3 of ventricular plateau and repolarization, respectively.
As the QT interval lengthens, more sodium and calcium channels are available and susceptible to action potentials.
Prolonged QT interval is more concerning in the setting of bradycardia.
This scenario increases the likelihood of R on T phenomenon.
R on T phenomenon occurs due to an early afterdepolarization event in which a premature ventricular contraction (PVC) occurs during the repolarization period (superimposed on the T wave), leading to an aberrant re-entry circuit.
The re-entry circuit leads to Torsades de Pointes (polymorphic ventricular tachycardia with prolonged QT) and subsequent ventricular fibrillation.
Treatment for Torsades de Pointes is 2g MgSO4.
The preferred antiarrhythmic for VTach is IV lidocaine 1.5 mg/kg over 2 minutes.
Avoid amiodarone due to risk of further QT prolongation.
A heart rate under 80 does not need QT correction
Corrected QT interval is used in the setting of tachycardia due to an abnormally small T wave
Correction for the QT interval in tachycardia:
472 ms for males vs. 482 ms for females

References

Banai S, Schuger C, Benhorin J, Tzivoni D. Treatment of torsade de pointes with intravenous magnesium. Am J Cardiol. 1989;63(20):1539-1540. doi:10.1016/0002-9149(89)90033-7
Gorgels APM, Van Den Dool A, Hofs A, et al. Comparison of procainamide and lidocaine in terminating sustained monomorphic ventricular tachycardia. Am J Cardiol. 1996;78(1):43-46. doi:10.1016/S0002-9149(96)00224-X
Liu MB, Vandersickel N, Panfilov A V., Qu Z. R-From-T as a Common Mechanism of Arrhythmia Initiation in Long QT Syndromes. Circ Arrhythmia Electrophysiol. 2019;12(12):1-15. doi:10.1161/CIRCEP.119.007571
Sagie A, Larson MG, Goldberg RJ, Bengtson JR, Levy D. An improved method for adjusting the QT interval for heart rate (the Framingham Heart Study). Am J Cardiol. 1992;70(7):797-801. doi:10.1016/0002-9149(92)90562-D
Vandenberk B, Vandael E, Robyns T, et al. Which QT correction formulae to use for QT monitoring? J Am Heart Assoc. 2016;5(6). doi:10.1161/JAHA.116.003264
Zipes DP, Camm AJ, Borggrefe M, et al. ACC/AHA/ESC 2006 Guidelines for Management of Patients with Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death - Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines. Vol 114.; 2006. doi:10.1161/CIRCULATIONAHA.106.178104

Summarized by Jorge Chalit, OMSII | Edited by Meg Joyce & Jorge Chalit, OMSII

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Contributors: Andrew White MD & Travis Barlock MD

In this follow-up episode Dr. Andrew White, a practicing psychiatrist with an addiction medicine fellowship, and Dr. Travis Barlock, an emergency physician at Swedish Medical Center, discuss mental health holds, psychiatric placement, pharmacologic vs. non-pharmacologic treatments, and outpatient care of psychotic patients. If you missed it, be sure to listen to part I for details on the management of psychotic patients in the ED.

Educational Pearls:

Mental health holds should be approached on a case-by-case basis; this includes assessing safety risks immediately, over a 24-hour period, and chronically over the last few months. Lastly, collateral information is useful in assessing a mental health hold.
What happens after patients get placed in inpatient psychiatry? Typically an antipsychotic is started; in the absence of metabolic risks, patients will often be started on Zyprexa, especially in oral dissolvable form. Doses of Zyprexa ODT start at 2.5 - 5 mg per day.
If psychotic patients do not pose direct harm to the environment, they do not necessarily need to be medicated. However, patients will often need medication at some point; for example, some people may be calm during their psychosis but unable to feed themselves or perform other ADLs.
The goal of pharmacologic treatment for psychosis is to save the brain; each episode of psychosis damages the brain. Oftentimes, patients will be started on long-acting injectables like aripiprazole or risperidone to give patients 30 days of treatment with one shot.
Non-pharmacologic approaches to psychosis are challenging given the nature of the disease. There have been attempts at therapy for psychosis but not have not been hugely successful. Options for support include PT/OT, family support via organizations like NAMI, and other resources for families of patients with psychosis.
Outpatient care of patients with psychosis includes contextualizing the events. For example, many people who experience brief psychotic episodes do not go on to develop schizophrenia so it is important to identify a prognosis. On the other hand, someone who has worsening symptoms over several months may require more aggressive treatment.
The primary goal of outpatient management of older patients is to reduce the adverse effects of long-term treatments. The CATIE trial in the early 2000s showed that only 25% of people were on antipsychotics by the end of the trial; it is more important to engage patients than focus too much on medications' adverse effects.

Summarized and edited by Jorge Chalit, OMSII | Studio production by Jeffrey Olson, MS1

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Contributor: Aaron Lessen, MD

Educational Pearls:

What is Tranq?

Tranq is the street name for xylazine, a sedative drug typically used in veterinary medicine.
Xylazine has recently emerged as a recreational drug, often mixed with heroin or fentanyl.
The mechanism of action of xylazine is similar to dexmedetomidine (Precedex), an alpha-2 adrenergic receptor agonist.
At toxic levels, either by itself or when combined with opioids, can cause apnea, bradycardia, coma, and hypotension.

How is it different from other adulterants, such as fentanyl?

Because It is not an opioid, naloxone (Narcan) does not reverse its effects.
It may cause local peripheral vasoconstriction leading to necrotic ulcerations at sites of repeated injection.

How do you treat a suspected overdose of Tranq +/- an opioid?

Consult with a clinical toxicologist.
Naloxone should still be used despite its limited effect. At the very least it will not make the situation worse.
Be ready to intubate.
Provide supportive care.
Non-selective alpha antagonists are NOT recommended.

References

Ruiz-Colón K, Chavez-Arias C, Díaz-Alcalá JE, Martínez MA. Xylazine intoxication in humans and its importance as an emerging adulterant in abused drugs: A comprehensive review of the literature. Forensic Sci Int. 2014 Jul;240:1-8. doi: 10.1016/j.forsciint.2014.03.015. Epub 2014 Mar 26. PMID: 24769343.
Ayub S, Parnia S, Poddar K, Bachu AK, Sullivan A, Khan AM, Ahmed S, Jain L. Xylazine in the Opioid Epidemic: A Systematic Review of Case Reports and Clinical Implications. Cureus. 2023 Mar 29;15(3):e36864. doi: 10.7759/cureus.36864. PMID: 37009344; PMCID: PMC10063250.
Malayala SV, Papudesi BN, Bobb R, Wimbush A. Xylazine-Induced Skin Ulcers in a Person Who Injects Drugs in Philadelphia, Pennsylvania, USA. Cureus. 2022 Aug 19;14(8):e28160. doi: 10.7759/cureus.28160. PMID: 36148197; PMCID: PMC9482722.
United States Drug Enforcement Administration. DEA Reports Widespread Threat of Fentanyl Mixed with Xylazine | DEA.gov. (n.d.). https://www.dea.gov/alert/dea-reports-widespread-threat-fentanyl-mixed-xylazine

Summarized by Jeffrey Olson, MS1 | Edited by Meg Joyce & Jorge Chalit, OMSII

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Contributor: Travis Barlock MD

Educational Pearls:

Three categories of pressors: inopressors, pure vasoconstrictors, and inodilators
Inopressors:
Epinephrine - nonselective beta- and alpha-adrenergic agonism, leading to increased cardiac contractility, chronotropy (increased heart rate), and peripheral vasoconstriction. Dose 0.1mcg/kg/min.
Levophed (norepinephrine) - more vasoconstriction peripherally than inotropy; useful in most cases of shock. Dose 0.1mcg/kg/min.
Peripheral vasoconstrictors:
Phenylephrine - pure alpha agonist; useful in atrial fibrillation because it avoids cardiac beta receptor activation and also in post-intubation hypotension to counteract the RSI medications. Start at 1mcg/kg/min and increase as needed.
Vasopressin - No effect on cardiac contractility. Fixed dose of 0.4 units/min.
Inodilators are useful in cardiogenic shock but often not started in the ED since patients mostly have undifferentiated shock
Dobutamine - start at 2.5mcg/kg/min.
Milrinone - 0.125mcg/kg/min.

References

Ellender TJ, Skinner JC. The Use of Vasopressors and Inotropes in the Emergency Medical Treatment of Shock. Emerg Med Clin North Am. 2008;26(3):759-786. doi:https://doi.org/10.1016/j.emc.2008.04.001
Hollenberg SM. Vasoactive drugs in circulatory shock. Am J Respir Crit Care Med. 2011;183(7):847-855. doi:10.1164/rccm.201006-0972CI
Lampard JG, Lang E. Vasopressors for hypotensive shock. Ann Emerg Med. 2013;61(3):351-352. doi:10.1016/j.annemergmed.2012.08.028

Summarized by Jorge Chalit, OMSII | Edited by Meg Joyce & Jorge Chalit, OMSII

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Contributor: Aaron Lessen, MD

Educational Pearls:

What is thrombolysis?

Thrombolysis is performed by administration of a medication that promotes the body’s natural ability to break up clots. These medications include Alteplase (tPA) and Tenecteplase (TNK).
The main side effect of using such an agent is bleeding which typically occurs at puncture sites but can also occur internally. However, an unusual side effect of thrombolytic agents, which occurs in about 1-5% of cases, is angioedema.

What is angioedema?

Angioedema is a medical condition that causes swelling beneath the surface of the skin, typically in the face, lips, and throat (orolingual angioedema). Fluid leaks from blood vessels and accumulates in the deeper layers of the skin.

How are these two connected?

The mechanism by which angioedema occurs after thrombolysis is not well understood, but it is likely connected to how tPA can increase levels of bradykinin and histamine.
Swelling can appear suddenly but can also occur up to 24 hours after thrombolysis, and may last for a few hours or several days.
In some cases, angioedema can affect the airways, leading to difficulty breathing.

What can be done?

If this side effect occurs the provider can stop the medication or infusion and treat the patient with anti-histamines, steroids, epinephrine, and airway monitoring.
Medications such as Berinert or Icatibant, typically used in hereditary angioedema or ACE-i-induced angioedema, can also be used but have limited evidence for their efficacy.

Fun fact

tPA-related angioedema is about 4 times more likely in patients on ACE inhibitors. This is likely related to how ACE inhibitors also increase bradykinin and histamine in a patient’s body.

References

Zhu A, Rajendram P, Tseng E, Coutts SB, Yu AYX. Alteplase or tenecteplase for thrombolysis in ischemic stroke: An illustrated review. Res Pract Thromb Haemost. 2022 Sep 20;6(6):e12795. doi: 10.1002/rth2.12795. PMID: 36186106; PMCID: PMC9487449.
Pahs L, Droege C, Kneale H, Pancioli A. A Novel Approach to the Treatment of Orolingual Angioedema After Tissue Plasminogen Activator Administration. Ann Emerg Med. 2016 Sep;68(3):345-8. doi: 10.1016/j.annemergmed.2016.02.019. Epub 2016 May 10. PMID: 27174372.
Burd M, McPheeters C, Scherrer LA. Orolingual Angioedema After Tissue Plasminogen Activator Administration in Patients Taking Angiotensin-Converting Enzyme Inhibitors. Adv Emerg Nurs J. 2019 Jul/Sep;41(3):204-214. doi: 10.1097/TME.0000000000000250. PMID: 31356244.
Sczepanski M, Bozyk P. Institutional Incidence of Severe tPA-Induced Angioedema in Ischemic Cerebral Vascular Accidents. Crit Care Res Pract. 2018 Sep 27;2018:9360918. doi: 10.1155/2018/9360918. PMID: 30363665; PMCID: PMC6180929.

Summarized by Jeffrey Olson, MS1 | Edited by Meg Joyce & Jorge Chalit, OMS1

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Contributor: Aaron Lessen MD

Educational Pearls:

SCAPE (Sympathetic Crashing Acute Pulmonary Edema), formerly known as flash pulmonary edema, is a life-threatening condition due to a sudden sympathetic surge that leads to hypertensive heart failure, pulmonary edema, hypoxia, and respiratory distress.
The initial treatment for SCAPE stabilization is BiPAP to assist with ventilation.
Pharmacological treatment for SCAPE is best achieved with high-dose nitroglycerin (HDN), which induces venodilation and redistributes pulmonary edema.
Dosing should be high; boluses of HDN are given at doses of 1-2 mg every 3-5 minutes vs. infusions at 200-400 mcg/min then titrating down.
HDN leads to reduced intubations, less need for ICU admission, and shortened length of hospital stay in patients with SCAPE.

References

Agrawal N, Kumar A, Aggarwal P, Jamshed N. Sympathetic crashing acute pulmonary edema. Indian J Crit Care Med. 2016;20(12):719-723. doi:10.4103/0972-5229.195710
Paone S, Clarkson L, Sin B, Punnapuzha S. Recognition of Sympathetic Crashing Acute Pulmonary Edema (SCAPE) and use of high-dose nitroglycerin infusion. Am J Emerg Med. 2018;36(8):1526.e5-1526.e7. doi:https://doi.org/10.1016/j.ajem.2018.05.013
Stemple K, DeWitt KM, Porter BA, Sheeser M, Blohm E, Bisanzo M. High-dose nitroglycerin infusion for the management of sympathetic crashing acute pulmonary edema (SCAPE): A case series. Am J Emerg Med. 2021;44:262-266. doi:https://doi.org/10.1016/j.ajem.2020.03.062
Wilson SS, Kwiatkowski GM, Millis SR, Purakal JD, Mahajan AP, Levy PD. Use of nitroglycerin by bolus prevents intensive care unit admission in patients with acute hypertensive heart failure. Am J Emerg Med. 2017;35(1):126-131. doi:https://doi.org/10.1016/j.ajem.2016.10.038

Summarized by Jorge Chalit, OMS1 | Edited by Meg Joyce & Jorge Chalit, OMS1

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Contributor: Travis Barlock, MD

Educational Pearls:

Sudden Cardiac Arrest (SCA) is defined as when the heart suddenly stops beating. Immediate treatment for SCA includes Cardiopulmonary Resuscitation (CPR) and defibrillation. This event is commonly depicted in medical dramas as an intense moment but often with the patient surviving and making a full recovery (67-75%). This depiction has likely led the general population astray when it comes to the true survivability of SCA. When surveyed, the general population tends to believe that in excess of 50% of patients requiring CPR survive and return to daily life with no long-term consequences.

What percent of patients actually survive cardiac arrest?

SCA due to Ventricular Fibrillation (VF): 25-40%

SCA due to Pulseless Electrical Activity (PEA): 11%

SCA due to noncardiac causes (trauma ect.): 11%

SCA when the initially observed rhythm is Asystole: Less than 5%, by some measures as low as 2%.

References

Diem SJ, Lantos JD, Tulsky JA. Cardiopulmonary resuscitation on television. Miracles and misinformation. N Engl J Med. 1996 Jun 13;334(24):1578-82. doi: 10.1056/NEJM199606133342406. PMID: 8628340.
Bitter CC, Patel N, Hinyard L. Depiction of Resuscitation on Medical Dramas: Proposed Effect on Patient Expectations. Cureus. 2021 Apr 11;13(4):e14419. doi: 10.7759/cureus.14419. PMID: 33987068; PMCID: PMC8112599.
Engdahl J, Bång A, Lindqvist J, Herlitz J. Can we define patients with no and those with some chance of survival when found in asystole out of hospital? Am J Cardiol. 2000 Sep 15;86(6):610-4. doi: 10.1016/s0002-9149(00)01037-7. PMID: 10980209.
Cobb LA, Fahrenbruch CE, Walsh TR, Copass MK, Olsufka M, Breskin M, Hallstrom AP. Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillation. JAMA. 1999 Apr 7;281(13):1182-8. doi: 10.1001/jama.281.13.1182. PMID: 10199427.
Rea TD, Eisenberg MS, Becker LJ, Murray JA, Hearne T. Temporal trends in sudden cardiac arrest: a 25-year emergency medical services perspective. Circulation. 2003 Jun 10;107(22):2780-5. doi: 10.1161/01.CIR.0000070950.17208.2A. Epub 2003 May 19. PMID: 12756155.
Panchal AR, Bartos JA, Cabañas JG, Donnino MW, Drennan IR, Hirsch KG, Kudenchuk PJ, Kurz MC, Lavonas EJ, Morley PT, O'Neil BJ, Peberdy MA, Rittenberger JC, Rodriguez AJ, Sawyer KN, Berg KM; Adult Basic and Advanced Life Support Writing Group. Part 3: Adult Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2020 Oct 20;142(16_suppl_2):S366-S468. doi: 10.1161/CIR.0000000000000916. Epub 2020 Oct 21. PMID: 33081529.

Summarized by Jeffrey Olson, MS1 | Edited by Meg Joyce & Jorge Chalit, OMS1

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Contributors: Andrew White MD & Travis Barlock MD

In this episode of Mental Health Monthly, Dr. Andrew White, a practicing psychiatrist with an addiction medicine fellowship, and Dr. Travis Barlock, an emergency physician at Swedish Medical Center, discuss the various presentations and etiologies of acute psychosis. They explore the medical presentations compared with primary psychiatric manifestations and how to narrow the differential. Furthermore, Dr. Barlock discusses the management of psychotic patients from the ED perspective while Dr. White provides invaluable insight into their respective psychiatric care.

Educational Pearls:

Auditory hallucinations are more consistent with primary psychiatric psychosis, whereas visual hallucinations are indicative of drug-induced or withdrawal psychosis.
Negative symptoms in schizophrenia can be remembered by the four A’s: Alogia, Affect, Ambivalence, and Associations.
Typical primary psychosis presents before age 40, except for in perimenopausal and post-partum women, who are at higher risk of psychiatric psychosis.
Medical etiology clues: acute and rapid onset, focal neurologic deficits, abnormal vital signs (especially fever), drugs, endocrine sources, autoimmune diseases, infectious disease, and brain lesions.
To LP or not to LP? Dr. Barlock discusses indications for LP including fever, rapid onset, and change in level of consciousness.

Summarized by Jorge Chait, OMSI | Edited by Jorge Chalit, OMSI | Studio production by Jeffrey Olson

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Contributor: Travis Barlock MD

Educational Pearls:

Large Vessel Occlusion (LVO) is a condition where a clot blocks one of the major blood vessels in the brain, leading to a stroke.

What are the vessels that can experience an LVO?

Middle Cerebral artery (MCA)

Internal Carotid Artery (ICA)

Anterior Cerebral Artery (ACA)

Posterior Cerebral Arteries (PCA)

Basilar Artery (BA)

Vertebral Arteries (VA)

What are the locations at which a mechanical thrombectomy can be performed as a treatment for an LVO?

Distal ICA, M1 or M2 segments of the MCA, A1 or A2 segments of the ACA, and some evidence for the BA.

What are the symptoms of LVO?

Use the mnemonic FANG-D to remember a few key symptoms:

Field Cut (A person loses vision in a portion of their visual field)

Aphasia (Difficulty speaking)

Neglect (A person may have difficulty paying attention to or acknowledging stimuli on the affected side of their body or in their environment. For example, a person with neglect may deny that their left hand belongs to them)

Gaze Deviation (One or both eyes are turned away from the direction of gaze)

Dense Hemiparesis (Paralysis affecting one side of the body)

What are the treatment windows for treating an LVO?

24 hours for mechanical thrombectomy

0-4.5 hours for tPA/TNK

References

Brain embolism, Caplan LR, Manning W (Eds), Informa Healthcare, New York 2006.
Berkhemer OA, et al. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med. 2015 Jan 1;372(1):11-20. doi: 10.1056/NEJMoa1411587. Epub 2014 Dec 17. Erratum in: N Engl J Med. 2015 Jan 22;372(4):394. PMID: 25517348.
Herpich, Franziska MD1,2; Rincon, Fred MD, MSc, MB.Ethics, FACP, FCCP, FCCM1,2. Management of Acute Ischemic Stroke. Critical Care Medicine 48(11):p 1654-1663, November 2020.
Warner JJ, Harrington RA, Sacco RL, Elkind MSV. Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke. Stroke. 2019 Dec;50(12):3331-3332. doi: 10.1161/STROKEAHA.119.027708. Epub 2019 Oct 30. PMID: 31662117.
Hoglund J, Strong D, Rhoten J, Chang B, Karamchandani R, Dunn C, Yang H, Asimos AW. Test characteristics of a 5-element cortical screen for identifying anterior circulation large vessel occlusion ischemic strokes. J Am Coll Emerg Physicians Open. 2020 Jul 24;1(5):908-917. doi: 10.1002/emp2.12188. PMID: 33145539; PMCID: PMC7593424.

Summarized by Jeffrey Olson | Edited by Meg Joyce & Jorge Chalit, OMS1

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Contributor: Meghan Hurley, MD

Educational Pearls:

Two main reasons to choose non-traditional RSI
Anatomically challenging airway
Physiologically difficult patients: hypoxia, metabolic acidosis, hemodynamic instability
Ketamine may help patients remain hemodynamically stable
In critical patients, it is important to consider non-traditional RSI medications to improve outcomes

References

Lyon RM, Perkins ZB, Chatterjee D, Lockey DJ, Russell MQ. Significant modification of traditional rapid sequence induction improves safety and effectiveness of pre-hospital trauma anaesthesia. Crit Care. 2015;19(1). doi:10.1186/s13054-015-0872-2
Merelman AH, Perlmutter MC, Strayer RJ. Alternatives to rapid sequence intubation: Contemporary airway management with ketamine. West J Emerg Med. 2019;20(3):466-471. doi:10.5811/westjem.2019.4.42753

Summarized by Jorge Chalit, OMS1 | Edited by Meg Joyce

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Contributor: Aaron Lessen, MD

Educational Pearls:

Extracorporeal Membrane Oxygenation (ECMO) has been attempted as an adjunct to CPR during cardiac arrest but few studies on outcomes exist
One prior small study stopped early when it showed ECMO with CPR (ECPR) was significantly superior to CPR
Recent large, multicenter randomized control study in Netherlands evaluated neurologic outcomes in CPR versus ECPR
At 30 days and 6 months no significant difference between the groups was found
More studies are required determine if certain patients may benefit from ECPR

References

Belohlavek J, Smalcova J, Rob D, et al. Effect of Intra-arrest Transport, Extracorporeal Cardiopulmonary Resuscitation, and Immediate Invasive Assessment and Treatment on Functional Neurologic Outcome in Refractory Out-of-Hospital Cardiac Arrest: A Randomized Clinical Trial. JAMA. 2022;327(8):737-747. doi:10.1001/jama.2022.1025

Suverein MM, Delnoij TSR, Lorusso R, et al. Early Extracorporeal CPR for Refractory Out-of-Hospital Cardiac Arrest. N Engl J Med. 2023;388(4):299-309. doi:10.1056/NEJMoa2204511

Summarized by Kirsten Hughes, MS4 | Edited by John Spartz, MD, & Erik Verzemnieks, MD

The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at https://emergencymedicalminute.org/cme-courses/ and create an account.

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Contributor: Travis Barlock, MD

Educational Pearls:

Early repolarization a benign EKG pattern that can mimic an anterior STEMI
Can be seen in the anterior leads typically in young male patients
Can differentiate Early Repolarization vs Anterior STEMI by looking at four variables:
Corrected QT interval
QRS amplitude in V2
R wave amplitude in V4
ST elevation 60 ms after J point in V3
These four variables can be plugged into a formula (available on MDCalc)
Note that a longer QT is more corelated with STEMI

References

Macfarlane PW, Antzelevitch C, Haissaguerre M, et al. The Early Repolarization Pattern: A Consensus Paper. J Am Coll Cardiol. Jul 28 2015;66(4):470-7. doi:10.1016/j.jacc.2015.05.033

Smith SW, Khalil A, Henry TD, et al. Electrocardiographic differentiation of early repolarization from subtle anterior ST-segment elevation myocardial infarction. Ann Emerg Med. Jul 2012;60(1):45-56.e2. doi:10.1016/j.annemergmed.2012.02.015

Summarized by Mark O’Brien, MS4 | Edited by John Spartz, MD, & Erik Verzemnieks, MD

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Contributor: Aaron Lessen, MD

Educational Pearls:

Hyperkalemia may cause cardiac arrest
Treatment of suspected hyperkalemic cardiac arrest begins with typical management of cardiac arrest including high-quality CPR, defibrillation if appropriate, and resuscitation medications
Administer calcium products to stabilize cardiac membrane and potassium shifting medications
If ROSC is achieved, initiate dialysis
There are several case reports of patients being dialyzed while CPR is ongoing, with some success
Dialysis during resuscitation may be an appropriate treatment for some patients

References

Jackson MA, Lodwick R, Hutchinson SG. Hyperkalaemic cardiac arrest successfully treated with peritoneal dialysis. BMJ. 1996;312(7041):1289-1290. doi:10.1136/bmj.312.7041.1289

Kao KC, Huang CC, Tsai YH, Lin MC, Tsao TC. Hyperkalemic cardiac arrest successfully reversed by hemodialysis during cardiopulmonary resuscitation: case report. Chang Gung Med J. 2000;23(9):555-559.

Torrecilla C, de la Serna JL. Hyperkalemic cardiac arrest, prolonged heart massage and simultaneous hemodialysis. Intensive Care Med. 1989;15(5):325-326. doi:10.1007/BF00263870

Summarized by Kirsten Hughes, MS4 | Edited by John Spartz, MD, & Erik Verzemnieks, MD

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Contributor: Meghan Hurley, MD

Educational Pearls:

Dental infections can be categorized into two main groups
Infections of the gums
Pericoronitis
Tooth eruption leading to inflammation/irritation
Can progress to an infection
Requires pain control, no antibiotics
Gingivitis
Inflammation of the gums
Can lead to an infection requiring antibiotics
Abscess (gums)
If an infection develops in the gums it can progress to an abscess
May require drainage
Acute necrotizing ulcerative gingivitis (ANUG) aka Trench Mouth
Filmy, grayish discoloration of the gums with “punched out” lesions
Extremely painful
Can cause teeth to loosen and fall out
Treat with IV antibiotics + admission
Infections of the teeth
Dental caries
Causes sensitivity tooth enamel is worn through
Can lead to infection
Periapical abscess
Abscess that extends through the root of the tooth
Can develop up elsewhere in tooth/gums/mouth
Causes tooth sensitivity when tapped
Ludwig angina
Infection of the soft tissue under the tongue
Can compromise airway as it expands
Treat with extensive antibiotics and debridement
Antibiotic stewardship
Commonly used antibiotics for dental infections
Clindamycin
Augmentin
Amoxicillin
Chlorhexidine (Peridex)
Antiseptic and disinfectant that is helpful for gingival irritation

References

Bridwell R, Gottlieb M, Koyfman A, Long B. Diagnosis and management of Ludwig's angina: An evidence-based review. Am J Emerg Med. Mar 2021;41:1-5. doi:10.1016/j.ajem.2020.12.030

Dufty J, Gkranias N, Donos N. Necrotising Ulcerative Gingivitis: A Literature Review. Oral Health Prev Dent. 2017;15(4):321-327. doi:10.3290/j.ohpd.a38766

Herrera D, Roldán S, Sanz M. The periodontal abscess: a review. J Clin Periodontol. Jun 2000;27(6):377-86. doi:10.1034/j.1600-051x.2000.027006377.x

Kumar S. Evidence-Based Update on Diagnosis and Management of Gingivitis and Periodontitis. Dent Clin North Am. Jan 2019;63(1):69-81. doi:10.1016/j.cden.2018.08.005

Kwon G, Serra M. Pericoronitis. StatPearls. StatPearls Publishing

Summarized by Mark O’Brien, MS4 | Edited by John Spartz, MD, & Erik Verzemnieks, MD

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Contributor: Jared Scott, MD

Educational Pearls:

Commotio cordis is sudden ventricular fibrillation precipitated by direct impact to the chest
A national registry, US Commotio Cordis Registry, reports an average of 10-20 cases annually
95% of reported cases occur in males, indicating possible genetic component
Average age of patient in registry is 15
Most cases occur during sporting events (baseball in particular), in addition to physical altercations and industrial accidents
Treatment is high quality CPR and early defibrillation
Survival rate is improving but remains around 35%
In recent events, American football player Damar Hamlin survived a Commotio cordis event after being tackled on field and receiving CPR

References

Link MS. Commotio cordis: ventricular fibrillation triggered by chest impact-induced abnormalities in repolarization. Circ Arrhythm Electrophysiol. 2012;5(2):425-432. doi:10.1161/CIRCEP.111.962712

Maron BJ, Poliac LC, Kaplan JA, Mueller FO. Blunt impact to the chest leading to sudden death from cardiac arrest during sports activities. N Engl J Med. 1995;333(6):337-342. doi:10.1056/NEJM199508103330602

Summarized by Kirsten Hughes, MS4 | Edited by John Spartz, MD, & Erik Verzemnieks, MD

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Contributor: Chris Holmes, MD

Educational Pearls:

Through world history, there have been various interesting approaches to wound care
Ancient Egyptians applied honey, lint, and grease which provided antimicrobial, absorptive and moisturizing properties, respectively
Ancient Greeks irrigated wounds with clean water and applied wine and vinegar which may have been antimicrobial
One of the first synthetic topical antimicrobials was a dye researched by scientist Gerhard Domagk and later produced by Bayer under the name Prontosil
Some current wound care methods include wet-to-dry dressings, Dankin’s Solution (sodium hypochlorite) and the use of maggots

References

Fleck CA. Why "wet to dry"?. J Am Col Certif Wound Spec. 2009;1(4):109-113. Published 2009 Oct 6. doi:10.1016/j.jcws.2009.09.003

Shah JB. The history of wound care. J Am Col Certif Wound Spec. 2011;3(3):65-66. doi:10.1016/j.jcws.2012.04.002

Ueno CM, Mullens CL, Luh JH, Wooden WA. Historical review of Dakin's solution applications. J Plast Reconstr Aesthet Surg. 2018;71(9):e49-e55. doi:10.1016/j.bjps.2018.05.023

Summarized by Kirsten Hughes, MS4 | Edited by John Spartz, MD, & Erik Verzemnieks, MD

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Contributor: Aaron Lessen, MD

Educational Pearls:

Through world history, there have been various interesting approaches to wound care
Ancient Egyptians applied honey, lint, and grease which provided properties of being antimicrobial, absorption and moisturization, respectively
Ancient Greeks irrigated wounds with clean water and applied wine and vinegar
One of the first synthetic topical antimicrobials was a dye researched by scientist Gerhard Domagk and later produced by Bayer under the name Prontosil
Some current wound care methods include wet-to-dry dressings, Dankin’s Solution (sodium hypochlorite) and the use of maggots

References

Fleck CA. Why "wet to dry"?. J Am Col Certif Wound Spec. 2009;1(4):109-113. Published 2009 Oct 6. doi:10.1016/j.jcws.2009.09.003

Shah JB. The history of wound care. J Am Col Certif Wound Spec. 2011;3(3):65-66. doi:10.1016/j.jcws.2012.04.002

Ueno CM, Mullens CL, Luh JH, Wooden WA. Historical review of Dakin's solution applications. J Plast Reconstr Aesthet Surg. 2018;71(9):e49-e55. doi:10.1016/j.bjps.2018.05.023

Summarized by Kirsten Hughes, MS4 | Edited by John Spartz, MD, & Erik Verzemnieks, MD

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Contributor: Aaron Lessen, MD

Educational Pearls:

Pediatric patients frequently have vital signs considered abnormal for age at discharge
Large multicenter study recently evaluated if pediatric patients discharged with abnormal vital signs have worse outcomes
97,824 pediatric discharges were included in the study
18.1% were discharged with vitals considered abnormal for age
No significant difference in readmission rates at 48 hours (2.28% in abnormal cohort vs. 2.45% in normal cohort)
No significant adverse outcomes in those discharged with abnormal vital signs (4 total PICU admissions with no deaths, CPR, or intubations)
When considering discharging pediatric patients, it is important to evaluate how the patient looks rather than just relying on vital signs
Consider leaving the child attached to a monitor, leaving the room, and then reevaluating them if they could be agitated by the presence of healthcare providers

References

Kazmierczak M, Thompson AD, DePiero AD, Selbst SM. Outcomes of patients discharged from the pediatric emergency department with abnormal vital signs. Am J Emerg Med. Jul 2022;57:76-80. doi:10.1016/j.ajem.202

Image from:

Vital Signs. MedlinePlus. https://medlineplus.gov/vitalsigns.html. Accessed December 29, 2022.

Summarized by Mark O’Brien, MS4 | Edited by John Spartz, MD, & Erik Verzemnieks, MD

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Contributor: Travis Barlock, MD

Educational Pearls:

The causes of pancreatitis can be remembered with the mnemonic: “GET SMASHED”
G: Gallstones (Most common cause of pancreatitis overall)
E: Ethanol (Alcohol consumption is the most common cause of chronic pancreatitis)
T: Trauma
S: Steroids
M: Malignancy
A: Autoimmune
S: Scorpion Sting
H: Hypertryglyceridemia
E: ERCP
D: Drugs (e.g. Valproate, Antiretrovirals)

References

Beyer G, Habtezion A, Werner J, Lerch MM, Mayerle J. Chronic pancreatitis. Lancet. 2020;396(10249):499-512. doi:10.1016/S0140-6736(20)31318-0

Lankisch PG, Apte M, Banks PA. Acute pancreatitis [published correction appears in Lancet. 2015 Nov 21;386(10008):2058]. Lancet. 2015;386(9988):85-96. doi:10.1016/S0140-6736(14)60649-8

Summarized by Kirsten Hughes, MS4 | Edited by John Spartz, MD, & Erik Verzemnieks, MD

In an effort to promote diversity, equity, and inclusion in Emergency Medicine, The Emergency Medical Minute is proud to present our 2nd annual Diversity and Inclusion Award. We support increasing the representation of underrepresented groups in medicine and extend this award to individuals applying to emergency medicine residencies during the 2022-2023 cycle. For information on award eligibility and the application process, visit https://emergencymedicalminute.com/edi-award/

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Contributor: Aaron Lessen, MD

Educational Pearls:

Septic arthritis of the sternoclavicular joint is uncommon accounting for

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Contributor: Meghan Hurley, MD

Educational Pearls:

Venomous snakes in the United States include species from the family Elapidae and subfamily Crotalinae
In prehospital setting, elevate the bitten extremity and transport to hospital immediately
Do not attempt interventions with the bite site
Monitor for progression of swelling past any joint line, systemic symptoms or lab abnormalities for 8-12 hours
Symptoms may present up to hours after bite
Crotalinae venom has heme toxicity and may present with lab pattern of DIC
Treatment for all symptoms is antivenom
If symptoms persist or progress, continue to treat with antivenom
Compartment syndrome is rare with snake bites

References

Ruha AM, Kleinschmidt KC, Greene S, et al. The Epidemiology, Clinical Course, and Management of Snakebites in the North American Snakebite Registry. J Med Toxicol. 2017;13(4):309-320. doi:10.1007/s13181-017-0633-5

Aziz H, Rhee P, Pandit V, Tang A, Gries L, Joseph B. The current concepts in management of animal (dog, cat, snake, scorpion) and human bite wounds. J Trauma Acute Care Surg. 2015;78(3):641-648. doi:10.1097/TA.0000000000000531

Summarized by Kirsten Hughes, MS4 | Edited by John Spartz, MD, & Erik Verzemnieks, MD

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Contributor: Jared Scott, MD

Educational Pearls:

Two conventional ways to aid in external jugular vein (EJ) catheter placement are Trendelenburg’s position and Valsalva’s maneuver by patient
One study compared ultrasound visualization of cross sections of EJ and common femoral vein at baseline and with patients in Trendelenburg's position, Valsalva's maneuver, and while humming
The study found all three conditions distended the veins from baseline, but there was no significant difference in diameter between the conditions
Humming may be a viable technique in distended EJ for catheter placement, and may be easier for patients to comprehend than Valsalva

References

Lewin MR, Stein J, Wang R, et al. Humming is as effective as Valsalva's maneuver and Trendelenburg's position for ultrasonographic visualization of the jugular venous system and common femoral veins. Ann Emerg Med. 2007;50(1):73-77. doi:10.1016/j.annemergmed.2007.01.024

Summarized by Kirsten Hughes, MS4 | Edited by John Spartz, MD, & Erik Verzemnieks, MD

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Contributor: Meghan Hurley, MD

Educational Pearls:

Syncope is defined as a loss of consciousness with an immediate return to baseline
Differential is broad
Cardiogenic
Structural (aortic stenosis, HOCUM, etc.)
Electrical (long QT syndrome, Brugada, etc.)
Neurogenic/neurovascular (brain bleed, etc.)
Seizure
Everything else
Hypoglycemia, anemia, and bleeding into the abdominal cavity are some potential causes to rule out
Vasovagal
Diagnosis of exclusion
Work Up
EKG
Good H&P
Labs especially Hb and glucose

References

Morris J. Emergency department management of syncope. Emerg Med Pract. Jun 2021;23(6):1-24.

Reed MJ. Approach to syncope in the emergency department. Emerg Med J. Feb 2019;36(2):108-116. doi:10.1136/emermed-2018-207767

Summarized by Mark O’Brien, MS4 | Edited by John Spartz, MD, & Erik Verzemnieks, MD

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Contributor: Aaron Lessen, MD

Educational Pearls:

Torus (Buckle) fractures are a commonly encountered pediatric fracture pattern
Typically presents as wrist pain secondary to a child falling on outstretched hand
One edge of the bone “buckles” or bends because children’s bones are softer and more pliable
Management
Older studies have shown that short term immobilization with a velcro splint and primary care follow up is sufficient
Recent randomized trial compared immobilization with Velcro splint with as needed wrist support using a gauze wrap
No significant differences noted in outcomes between the two cohorts
Physicians can consider using an ace or gauze wrap as needed for buckle fracture management along with OTC analgesics for pain management

References

Asokan A, Kheir N. Pediatric Torus Buckle Fracture. StatPearls. StatPearls Publishing

Kennedy SA, Slobogean GP, Mulpuri K. Does degree of immobilization influence refracture rate in the forearm buckle fracture? J Pediatr Orthop B. Jan 2010;19(1):77-81. doi:10.1097/BPB.0b013e32832f067a

Perry DC, Achten J, Knight R, et al. Immobilisation of torus fractures of the wrist in children (FORCE): a randomised controlled equivalence trial in the UK. Lancet. Jul 2 2022;400(10345):39-47. doi:10.1016/s0140-6736(22)01015-7

Summarized by Mark O’Brien, MS4 | Edited by John Spartz, MD, & Erik Verzemnieks, MD

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Contributor: Travis Barlock, MD

Educational Pearls:

Normal Saline (NS) contains 154 mEq of both Sodium (Na) and Chloride (Cl), and has a pH of 5.5
Normal Na and Cl in adult humans are about 140 mEq/L and 103 mEq/L. respectively
Excess negative charge resulting from hyperchloremia is managed via bicarbonate excretion leading to loss of base
Overall, administration of NS drives metabolic acidosis
Lactated Ringers (LR) contains 130 mEq of Na and 109 mEq Cl, and has a pH of 6.5
LR components are closer to physiologic levels thus may generally be a more efficacious fluid choice
NS is still frequently given in scenarios where there is concern for increased intracranial pressure or existing hypochloremic alkalosis from emesis.

References
Li H, Sun SR, Yap JQ, Chen JH, Qian Q. 0.9% saline is neither normal nor physiological. J Zhejiang Univ Sci B. 2016;17(3):181-187. doi:10.1631/jzus.B1500201

Lehr AR, Rached-d'Astous S, Barrowman N, et al. Balanced Versus Unbalanced Fluid in Critically Ill Children: Systematic Review and Meta-Analysis. Pediatr Crit Care Med. 2022;23(3):181-191. doi:10.1097/PCC.0000000000002890

Self WH, Semler MW, Wanderer JP, et al. Saline versus balanced crystalloids for intravenous fluid therapy in the emergency department: study protocol for a cluster-randomized, multiple-crossover trial. Trials. 2017;18(1):178. Published 2017 Apr 13. doi:10.1186/s13063-017-1923-6

Semler MW, Self WH, Wanderer JP, et al. Balanced Crystalloids versus Saline in Critically Ill Adults. N Engl J Med. 2018;378(9):829-839. doi:10.1056/NEJMoa1711584

Summarized by Kirsten Hughes, MS4 | Edited by John Spartz, MD, & Erik Verzemnieks, MD

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Happy Thanksgiving EMM listeners, Mason here wanting to extend a special thank you to all of you for tuning in to our show. Today we are featuring a special episode on health disparities in the opioid epidemic and their intersection with the ER that we produced for the Iowa Healthcare Collaborative’s Compass Opioid Stewardship Program, a national initiative to provide comprehensive education on opioid stewardship and best practices.

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Educational Pearls:

Most common sexually transmitted disease (STD) in North America: Human Papillomavirus (HPV)
- From the emergency department patients should be connected to follow-up care and educated on vaccine series
Most common non-viral STD in North America: Trichomonas Vaginalis
- While men may be asymptomatic, they can transmit the disease to women who may experience irritation leading to increased likelihood of PID and contraction of other STDs and HIV
- Trichomonas is diagnosed via wet preparation with visualization of motile parasites
- - Similarly, men’s urine can be tested for visualized motile parasites
  - Expedite lab as parasites are motile for about one hour
- PCR test is becoming more available
Most common bacterial STD in North America: Chlamydia trachomatis
- Neisseria gonorrhoeae is a less common bacterial STD but does have high rates of drug resistance
Empiric STD treatment includes IM Ceftriaxone and PO Doxycycline
- Providers should consider adding Flagyl for Trichomonas Vaginalis coverage

References
Sexually transmitted disease surveillance, 2020. Centers for Disease Control and Prevention. https://www.cdc.gov/std/statistics/2020/default.htm. Published August 22, 2022. Accessed November 21, 2022.

Workowski KA, Bachmann LH, Chan PA, et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep. 2021;70(4):1-187. Published 2021 Jul 23. doi:10.15585/mmwr.rr7004a1

Summarized by Kirsten Hughes, MS4 | Edited by John Spartz, MD, & Erik Verzemnieks, MD

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Contributor: Aaron Lessen,MD

Educational Pearls:

Recent study looked at mechanically ventilated patients in ED and ICU to determine if O2 saturation level impacted patient outcomes
- 2541 patients randomized to one of three target O2 saturation levels
- - Low: 90% (Range: 88-92%)
  - Intermediate: 94% (Range: 92-96%)
  - High: 98% (Range: 96-100%)
- Outcome indicators
- - Primary: Number of days alive and ventilator free by day 28 of hospital admission
  - Secondary: Mortality at 28 days
- No significant difference was seen for either primary or secondary outcomes between all three groups at 28 days
This study shows that the target oxygenation level is not likely to significantly impact outcomes in mechanically ventilated patients in the ED

References

Semler MW, Casey JD, Lloyd BD, et al. Oxygen-Saturation Targets for Critically Ill Adults Receiving Mechanical Ventilation. N Engl J Med. Nov 10 2022;387(19):1759-1769. doi:10.1056/NEJMoa2208415

Summarized by Mark O’Brien, MS4 | Edited by John Spartz, MD, & Erik Verzemnieks, MD

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Contributor: Travis Barlock, MD

Educational Pearls:

Gauge and length of catheter are determinants of flow rate
Smaller gauges produce higher flow rate
Longer catheters reduce flow rate
Common IV gauges produce predictable rates of flow:
20 gauge = 60 cc/min
18 gauge = 105 cc/min
16 gauge = 220 cc/min
Central lines typically have two 18 gauge and one 16 gauge lumen, both with long catheters, producing the following slower flow rates:
18 gauge = 26 cc /min
16 gauge = 55 cc/min
Sheath Introducers, such as Cordis brand catheters, are wider and shorter than classic central lines.
Flow rates are 150 cc/min, or 130 cc/min with pressure bag
Maximal flow allows for one unit of blood to be delivered over one minute
It is important to consider length and gauge of catheter when patients require fluids

References

Greene N, Bhananker S, Ramaiah R. Vascular access, fluid resuscitation, and blood transfusion in pediatric trauma. International Journal of Critical Illness and Injury Science. 2012;2(3):135. doi:10.4103/2229-5151.100890

Khoyratty SI, Gajendragadkar PR, Polisetty K, Ward S, Skinner T, Gajendragadkar PR. Flow rates through intravenous access devices: an in vitro study. J Clin Anesth. 2016;31:101-105. doi:10.1016/j.jclinane.2016.01.048

Summarized by Kirsten Hughes, MS4 | Edited by John Spartz, MD, & Erik Verzemnieks, MD

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Contributor: Aaron Lessen, MD

Educational Pearls:

Monkeypox transmission is still occurring in the United States
Transmitted by contact to exposed lesion
MSM are a high-risk group for monkeypox infection
Symptoms include rash and flu like symptoms
Monkeypox lesions are often described as blister-like, firm, clear, and rubbery
Most commonly develop on the face and/or anogenital regions
Patients with potential monkeypox infection should be moved to isolation to reduce risk of transmission
Providers should use full PPE including N95, facial covering, gown, and gloves when interacting with a potential case of monkeypox
Diagnosis involves swabbing the lesion and sending it for analysis
People at risk for severe disease (i.e. immunocompromised) or who have severe symptoms (i.e. eye involvement) should begin treatment with Tecovirimat (TPOXX) in the ED
Infectious Disease (ID) should be consulted, and the patient will need to follow up with ID regardless of symptom severity

References

Rizk JG, Lippi G, Henry BM, Forthal DN, Rizk Y. Prevention and Treatment of Monkeypox. Drugs. Jun 2022;82(9):957-963. doi:10.1007/s40265-022-01742-y

Thornhill JP, Barkati S, Walmsley S, et al. Monkeypox Virus Infection in Humans across 16 Countries - April-June 2022. N Engl J Med. Aug 25 2022;387(8):679-691. doi:10.1056/NEJMoa2207323

Summarized by Mark O’Brien, MS4 | Edited by John Spartz, MD, & Erik Verzemnieks, MD

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Contributor: Nick Hatch, MD

Educational Pearls:

In the setting of traumatic injury, tranexamic acid (TXA) is given to stabilize clots which minimizes bleeding and decreases risk of hemorrhagic shock
Current TXA dose for trauma is 1 g bolus followed by a 1 g infusion; both doses should be given within 3 hours from time of injury
Due to the split dose and narrow window, patients with complicated care, particularly if they require transfer may miss the infusion dose
Various smaller studies have shown that dosing 2 g initially or 2 g followed by a 1 g infusion produces the same patient outcomes and no additional harm
Receiving hospitals should strive to acquire accurate information regarding previous doses of TXA given and confirm timeline of injury

References

Roberts I, Shakur H, Coats T, et al. The CRASH-2 trial: a randomised controlled trial and economic evaluation of the effects of tranexamic acid on death, vascular occlusive events and transfusion requirement in bleeding trauma patients. Health Technol Assess. 2013;17(10):1-79. doi:10.3310/hta17100

Ramirez RJ, Spinella PC, Bochicchio GV. Tranexamic Acid Update in Trauma. Crit Care Clin. 2017;33(1):85-99. doi:10.1016/j.ccc.2016.08.004

Spinella PC, Thomas KA, Turnbull IR, et al. The Immunologic Effect of Early Intravenous Two and Four Gram Bolus Dosing of Tranexamic Acid Compared to Placebo in Patients With Severe Traumatic Bleeding (TAMPITI): A Randomized, Double-Blind, Placebo-Controlled, Single-Center Trial. Front Immunol. 2020;11:2085. Published 2020 Sep 8. doi:10.3389/fimmu.2020.02085

Summarized by Kirsten Hughes, MS4 | Edited by John Spartz, MD, & Erik Verzemnieks, MD

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Contributor: Aaron Lessen, MD

Educational Pearls:

Recent study evaluated if early exposure to an allergen impacted the rate of allergy development later in childhood
Children were exposed to peanut, milk, wheat, and egg allergens at 3 months of age and then followed for 3 years
2.5-3% of children who were not exposed developed allergies to these allergens
1% of children exposed to the allergens developed allergies to these allerrgens
Exposing 63 children to allergens at 3 months would prevent the development of food allergy in one child with no significant adverse events
Future recommendations will likely be to gradually introduce allergens to children starting around 3 months

References

Skjerven HO, Lie A, Vettukattil R, et al. Early food intervention and skin emollients to prevent food allergy in young children (PreventADALL): a factorial, multicentre, cluster-randomised trial. Lancet. Jun 25 2022;399(10344):2398-2411. doi:10.1016/s0140-6736(22)00687-0

Summarized by Mark O’Brien, MS4 | Edited by John Spartz, MD, & Erik Verzemnieks, MD

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The presence of a STEMI has traditionally been used to determine if a patient with acute chest pain requires urgent cath lab management
STEMI indicates an occluded coronary artery, and urgent intervention is needed to restore perfusion to ischemic tissue
Patients with occluded coronary arteries can present with EKG findings other than STEMI
2022 ACC Expert Consensus Decision Pathway on the Evaluation and Disposition of Acute Chest Pain in the Emergency Department was recently published in the Journal of the American College of Cardiology
Recognizes STEMI equivalents that necessitate cath lab management
ST depression in precordial leads
Indicates a posterior infarct/possible RCA occlusion
LBBB c ST elevation meeting modified Sgarbossa criteria
Hyperacute and/or De Winter T wave
First indication of coronary artery occlusion
Most beneficial time to initiate cath lab because more tissue is salvageable
These recommendations will likely alter clinical practice for ED management of acute chest pain

References

Kontos MC, de Lemos JA, Deitelzweig SB, et al. 2022 ACC Expert Consensus Decision Pathway on the Evaluation and Disposition of Acute Chest Pain in the Emergency Department: A Report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol. Oct 6 2022;doi:10.1016/j.jacc.2022.08.750

Meyers HP, Bracey A, Lee D, et al. Comparison of the ST-Elevation Myocardial Infarction (STEMI) vs. NSTEMI and Occlusion MI (OMI) vs. NOMI Paradigms of Acute MI. J Emerg Med. Mar 2021;60(3):273-284. doi:10.1016/j.jemermed.2020.10.026

Tziakas D, Chalikias G, Al-Lamee R, Kaski JC. Total coronary occlusion in non ST elevation myocardial infarction: Time to change our practice? Int J Cardiol. Apr 15 2021;329:1-8. doi:10.1016/j.ijcard.2020.12.082

Summarized by Mark O’Brien, MS4 | Edited by John Spartz, MD, & Erik Verzemnieks, MD

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Contributor: Aaron Lessen, MD

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In urban settings, it is becoming more common for police to transport critical patients from scene to hospital
A 2022 multicenter observational study compared mortality rates in patients with penetrating injury to torso and/or proximal extremity when transported by EMS versus police
Approximately 18% of patients were transported by police
Overall mortality was approximately 15% in both groups
In patients with more severe injury, mortality was still similar at approximately 36% and 38% respectively

References

Taghavi S, Maher Z, Goldberg AJ, et al. An analysis of police transport in an Eastern Association for the Surgery of Trauma multicenter trial examining prehospital procedures in penetrating trauma patients. J Trauma Acute Care Surg. 2022;93(2):265-272. doi:10.1097/TA.0000000000003563

Jacoby SF, Branas CC, Holena DN, Kaufman EJ. Beyond survival: the broader consequences of prehospital transport by police for penetrating trauma. Trauma Surg Acute Care Open. 2020;5(1):e000541. Published 2020 Nov 26. doi:10.1136/tsaco-2020-000541

Summarized by Kirsten Hughes, MS4 | Edited by John Spartz, MS4 & Erik Verzemnieks, MD

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Catheter related blood infections were thought to be caused by skin flora seeding the catheter. Thus, significant effort is applied to sterility and skin preparation.
However, studies have shown that bacteria growing on the tip of the catheter is not consistent with growth on cultures of skin.
Staphylococcus epidermidis is commonly found on cultures of catheter sites. It has also been found in the gut flora of >50% of ICU patients. Rates of catheter related blood infections have been decreased through oral decontamination and early feeding.
These findings suggest enteral bacterial translation as a major source of blood stream infection.

References

O'Grady NP, Alexander M, Burns LA, et al. Guidelines for the prevention of intravascular catheter-related infections. Clin Infect Dis. 2011;52(9):e162-e193. doi:10.1093/cid/cir257

von Eiff C, Becker K, Machka K, Stammer H, Peters G. Nasal carriage as a source of Staphylococcus aureus bacteremia. Study Group. N Engl J Med. 2001;344(1):11-16. doi:10.1056/NEJM200101043440102

ALTEMEIER WA, HUMMEL RP, HILL EO. Staphylococcal enterocolitis following antibiotic therapy. Ann Surg. 1963;157(6):847-858. doi:10.1097/00000658-196306000-00003

Marshall JC, Christou NV, Horn R, Meakins JL. The microbiology of multiple organ failure. The proximal gastrointestinal tract as an occult reservoir of pathogens. Arch Surg. 1988;123(3):309-315. doi:10.1001/archsurg.1988.01400270043006

Mrozek N, Lautrette A, Aumeran C, et al. Bloodstream infection after positive catheter cultures: what are the risks in the intensive care unit when catheters are routinely cultured on removal?. Crit Care Med. 2011;39(6):1301-1305. doi:10.1097/CCM.0b013e3182120190

Atela I, Coll P, Rello J, et al. Serial surveillance cultures of skin and catheter hub specimens from critically ill patients with central venous catheters: molecular epidemiology of infection and implications for clinical management and research. J Clin Microbiol. 1997;35(7):1784-1790. doi:10.1128/jcm.35.7.1784-1790.1997

Tani T, Hanasawa K, Endo Y, et al. Bacterial translocation as a cause of septic shock in humans: a report of two cases. Surg Today. 1997;27(5):447-449. doi:10.1007/BF02385710

Summarized by Kirsten Hughes, MS4 | Edited by John Spartz, MS4 & Erik Verzemnieks, MD

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Contributor: Jared Scott, MD

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Immediate resuscitative thoracotomy can be performed in the ED to gain rapid access to the thoracic cavity in cases of traumatic cardiac arrest
Western Trauma Association Society Criteria for ED thoracotomy
- Blunt trauma + <10 min of prehospital CPR
- Penetrating trauma to torso + <15 min prehospital CPR
- Penetrating trauma to the neck/extremity + <5 min prehospital CPR
- Signs of life with refractory shock can consider resuscitative thoracotomy
Outcomes in immediate resuscitative thoracotomy are poor but are improving
A recent study evaluated over 2,000 patients meeting inclusion criteria for immediate resuscitative thoracotomy
- Overall survival rate of 20%
- - 26% survival rate in penetrating trauma
  - 7% survival rate in blunt trauma
- Predictors for poor outcomes
- - Patient age > 60 years
  - Blunt trauma mechanism of injury
  - A prehospital or ED HR <60 bpm
  - Absent signs of life at time of ED arrival
When criteria are met, immediate resuscitative thoracotomy should rapidly be performed in the ED

References

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.

Panossian VS, Nederpelt CJ, El Hechi MW, et al. Emergency Resuscitative Thoracotomy: A Nationwide Analysis of Outcomes and Predictors of Futility. J Surg Res. 2020;255:486-494.

Summarized by Mark O’Brien, MS4 | Edited by John Spartz, MS4 & Erik Verzemnieks, MD

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Contributor: Aaron Lessen, MD

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Lateral Cutaneous Femoral Nerve Entrapment Syndrome, also known as Meralgia Paresthetica, results from entrapment of the lateral cutaneous femoral nerve, often as it exits the pelvis under the inguinal ligament.
Meralgia Paresthetica is associated with obesity, pregnancy, compression from clothing or belts and diabetes.
Symptoms include numbness, paresthesia and pain of the proximal lateral thigh. Signs or symptoms of radiculopathy such as weakness, loss of reflexes or severe back pain should not be present.
Diagnosis is clinical and does not require further imaging if there are no additional or concerning findings.
Meralgia Paresthetica typically resolves over time without intervention; however patients should be counseled on weight loss, diabetes control and avoidance of compressive clothing as relieving factors.

References

Solomons JNT, Sagir A, Yazdi C. Meralgia Paresthetica. Curr Pain Headache Rep. 2022;26(7):525-531. doi:10.1007/s11916-022-01053-7

Grossman MG, Ducey SA, Nadler SS, Levy AS. Meralgia paresthetica: diagnosis and treatment. J Am Acad Orthop Surg. 2001;9(5):336-344. doi:10.5435/00124635-200109000-00007

Image from my.clevelandclinic.org

Summarized by Kirsten Hughes, MS4 | Edited by John Spartz, MD & Erik Verzemnieks, MD

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Contributor: Travis Barlock, MD

Educational Pearls:

An EKG should be obtained quickly after a syncopal event to identify possible life-threatening causes such as ischemia and arrhythmia
WOBBLER is a good mnemonic for remembering additional EKG findings to look for in syncope
Wolff-Parkinson-White (WPW)
Check for delta wave on QRS
Obstructed AV node
Any potential heart blocks
Brugada syndrome
Na channel blockade that can cause ST elevations in anterior leads
Bifascicular block
Conduction blockade in two of the three fascicles increases risk of complete heart block
Left Ventricular Hypertrophy (LVH)
Can be a sign of HOCM (younger patients) or aortic stenosis (older patients)
Epsilon waves
Positive deflections after the QRS that is seen in arrhythmogenic right ventricular dysplasia
Repolarization abnormalities
Prolonged/shortened QT segments

References

Martow E, Sandhu R. When Is Syncope Arrhythmic? Med Clin North Am. 2019;103(5):793-807.

Solbiati M, Dipaola F, Villa P, et al. Predictive Accuracy of Electrocardiographic Monitoring of Patients With Syncope in the Emergency Department: The SyMoNE Multicenter Study. Acad Emerg Med. 2020;27(1):15-23.

Summarized by Mark O’Brien, MS4 | Edited by John Spartz, MD & Erik Verzemnieks, MD

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Contributor: Don Stader, MD

Educational Pearls:

Home naloxone is traditionally given to those at high risk for opioid overdose such as those in the ED due to an opioid overdose, opioid intoxication, or admit to illicit opioid use
There are a number of other patient populations that benefit from home naloxone including those on chronic opioid or benzodiazepine therapy, and those who report any type of illicit drug use
Any illicit drug could be laced with opioids, and those who use drugs are more likely to be present as bystanders when an opioid overdose occurs
Some important tips to remember when prescribing home naloxone
There is often a scannable QR code that instructs bystanders on how to recognize and intervene in an overdose
Inform the patient that naloxone is temporary and those who overdose are at high risk of overdosing again
Provide support and inform the patient that if they decide they would like to enter treatment/rehabilitation programs, they can return to the ED to start that process

References

Strang J, McDonald R, Campbell G, et al. Take-Home Naloxone for the Emergency Interim Management of Opioid Overdose: The Public Health Application of an Emergency Medicine. Drugs. 2019;79(13):1395-1418.

Moustaqim-Barrette A, Dhillon D, Ng J, et al. Take-home naloxone programs for suspected opioid overdose in community settings: a scoping umbrella review. BMC Public Health. 2021;21(1):597.

Summarized by Mark O’Brien, MS4 | Edited by John Spartz, MD & Erik Verzemnieks, MD

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Educational Pearls:

Elevated lactate levels can be a useful indicator of critical illness in patients who meet SIRS criteria
Lactate can also be elevated due to other causes including seizures and medications such as albuterol and metformin
A recent study from Switzerland* performed routine point-of-care lactate testing in all elderly patients presenting at triage in the emergency department in order to determine the prevalence of elevated lactate in the population and its utility in predicting poor patient outcomes
Patients with seizure as their chief complaint were excluded from the study due to expected transient elevated lactate levels
Poor outcomes were defined as requiring extensive IVF and/orvasoactive medications, undergoing intubation, admission to the ICU, or death
27.1% of patients had an increased lactate but only 7.3% actually met poor outcome criteria
ED physicians should note that an increased lactate in an elderly patient does not mean that they are critically ill
Routine point-of-care lactate monitoring at triage is of limited usefulness and should instead be targeted towards those who meet critical illness criteria

*Errata: This study was performed in Switzerland, not Sweden as was stated in the podcast

References

Gosselin M, Mabire C, Pasquier M, et al. Prevalence and clinical significance of point of care elevated lactate at emergency admission in older patients: a prospective study. Intern Emerg Med. 2022;17(6):1803-1812.

Summarized by Mark O’Brien, MS4 | Edited by John Spartz, MD & Erik Verzemnieks, MD

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Contributor: Don Stader, MD

Educational Pearls:

There are two major groups of local anesthetics: Amide and Esther
To recall what group an anesthetic belongs to, use this memory trick:

Amide has an ‘i’ in the name and Amide anesthetics have 2 ‘i’s e.g., Lidocaine.
Ester has no ‘i’ and most common Ester anesthetics have only one ‘i’ e.g., Tetracaine.

In a true allergy and/or contraindication to both local anesthetic groups, diphenhydramine is an acceptable alternative.
Epinephrine is administered with local anesthetics to decrease bleeding, increase duration of action, and minimize systemic spread of the anesthetic, thus reducing toxicity.
Symptoms of Local Anesthetic Systemic Toxicity (LAST) may begin with dizziness, confusion and/or slurred speech, and can progress to cardiovascular collapse and death.
Treat LAST with lipid emulsion therapy i.e. ‘Intralipids’ to create a lipid sink that absorbs anesthetic agent
Administer initial 1.5 ml/kg bolus (approximately 100 ml in 70 mg adult) followed by infusion rate of 0.25 mg/kg/hour. Do not surpass 10 mg/kg total.

References

Dickerson DM, Apfelbaum JL. Local anesthetic systemic toxicity. Aesthet Surg J. 2014;34(7):1111-1119. doi:10.1177/1090820X14543102

Bina B, Hersh EV, Hilario M, Alvarez K, McLaughlin B. True Allergy to Amide Local Anesthetics: A Review and Case Presentation. Anesth Prog. 2018;65(2):119-123. doi:10.2344/anpr-65-03-06

Macfarlane AJR, Gitman M, Bornstein KJ, El-Boghdadly K, Weinberg G. Updates in our understanding of local anaesthetic systemic toxicity: a narrative review. Anaesthesia. 2021;76 Suppl 1:27-39. doi:10.1111/anae.15282

Summarized by Kirsten Hughes, MS4 | Edited by John Spartz MD & Erik Verzemnieks, MD

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Contributor: Aaron Lessen, MD

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2020 retrospective study with dat from two California hospitals compared rates of cardiovascular admissions in a five day period two weeks before and the five days after the presidential election
Hospitalization rate for acute cardiovascular disease increased by 17% and rate of acute myocardial infarction increased by 42%
Highest rates occurred in demographic of white males older than 75 years old
No significant difference between groups in rates of stroke and heart failure

References

Mefford MT, Rana JS, Reynolds K, et al. Association of the 2020 US Presidential Election With Hospitalizations for Acute Cardiovascular Conditions. JAMA Netw Open. 2022;5(4):e228031. Published 2022 Apr 1. doi:10.1001/jamanetworkopen.2022.8031

Summarized by Kirsten Hughes, MS4 | Edited by John Spartz MD & Erik Verzemnieks, MD

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Contributor: Aaron Lessen, MD

Educational Pearls:

The management of severe asthma or COPD exacerbation is complex, especially when the patient requires intubation/ventilation
Asthma is an obstructive airway disease that can cause air trapping and hyperinflation of the lungs
To avoid worsening hyperinflation patients typically require slower respiratory rates, lower tidal volumes, and increased expiratory time when on a ventilator
- Patients on a ventilator require very close monitoring to prevent worsening hyperinflation and associated complications including barotrauma and hypotension/cardiac arrest secondary to decreased venous return
If patient condition starts to worsen, decrease respiratory rate and tidal volume
- In these cases, a decreased oxygen saturation is acceptable until their condition improves
If patient status continues to worsen, consider disconnecting the ventilator and pushing on the chest for approximately 30 seconds to help force out trapped air
If patient continues to decompensate, consider the possibility of a pneumothorax and determine if a chest tube is necessary
Remember to continue asthma/COPD management including albuterol/duonebs, steroids, magnesium, and alternatives including as heliox

References

Demoule A, Brochard L, Dres M, et al. How to ventilate obstructive and asthmatic patients. Intensive Care Med. 2020;46(12):2436-2449

Garner O, Ramey JS, Hanania NA. Management of Life-Threatening Asthma: Severe Asthma Series. Chest. 2022

Laher AE, Buchanan SK. Mechanically Ventilating the Severe Asthmatic. J Intensive Care Med. 2018;33(9):491-501

Summarized by Mark O’Brien, MS4 | Edited by John Spartz MD & Erik Verzemnieks, MD

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Contributor: Aaron Lessen, MD

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Historically, pancreatitis has been treated with aggressive IV fluid rehydration. Recently published data shows this may not be appropriate.
A randomized, controlled, multi-hospital trial evaluated outcomes for patients with acute pancreatitis receiving lactated Ringer’s solution
Aggressive fluid resuscitation group received 20ml/kg bolus + 3ml/hour
Moderate fluid resuscitation groups received either 10 ml/kg bolus if hypovolemic or no bolus if normovolemic. Both moderate resuscitation groups received 1.5ml/hr.
The primary outcome was development of moderately severe or severe pancreatitis. 22.1% of aggressive fluid resuscitation and 17.3% of moderate fluid resuscitation patients developed primary outcome.
The safety outcome was fluid overload. Fluid overload developed in 20.5% of aggressive resuscitation group and only 6.3% of moderate resuscitation group.
This trial was ended early due to differences in safety outcomes without obvious difference in primary outcome
Overall, aggressive fluid resuscitation had no benefit in treatment of acute pancreatitis and providers should be aware of fluid overload risk.

References

de-Madaria E, Buxbaum JL, Maisonneuve P, et al. Aggressive or Moderate Fluid Resuscitation in Acute Pancreatitis. N Engl J Med. 2022;387(11):989-1000. doi:10.1056/NEJMoa2202884

Summarized by Kirsten Hughes, MS4 | Edited by John Spartz, MD & Erik Verzemnieks, MD

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Recent study looked at the impact of screen time on duration of post-concussive symptoms
125 patients aged 12-25 diagnosed with a concussion were randomized to either abstain from or have unrestricted screen time for 48 hours after injury
Patients with unrestricted screen time averaged approximately 5 hours/day of screen time
Patients in the no screen time group averaged approximately 1 hour/day of screen time
Statistically significant difference in duration of post-concussive symptoms
- Unrestricted screen time cohort averaged 8 days of post-concussive symptoms
- No screen time cohort averaged 3.5 days of post-concussive symptoms
ED physicians should encourage patients to limit screen time as much as possible in the first 48 hours after a concussion to promote faster recovery from post-concussive symptoms

References

Macnow T, Curran T, Tolliday C, et al. Effect of Screen Time on Recovery From Concussion: A Randomized Clinical Trial. JAMA Pediatr. 2021;175(11):1124-1131.

Summarized by Mark O’Brien, MS4 | Edited by John Spartz, MD & Erik Verzemnieks, MD

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Contributor: Travis Barlock, MD

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Most oxygen in the body is bound to hemoglobin, forming oxyhemoglobin. Less than 1% of the oxygen in the body is dissolved in plasma.
Pulse Oximeters (Pulse Ox) function by emitting wavelengths of light from one side, and capturing the amount absorbed on the opposite side. A calculation determined the amount of saturation.
Pulse Ox relies on pulsations in arterial flow to create a photoplethysmogram (pleth) for measurements
- Patients with poor peripheral perfusion may have unreliable pulse ox.
- Patient with an LVAD have constant flow and also unreliable pulse ox.
Pulse Ox is a useful tool when pacing to determine mechanical capture. If there is disparity between the electrical wave pulse and the rate on pulse ox, there is likely no mechanical capture leading to poor distal flow.

References

Eecen CMW, Kooter AJJ. Pulsoximeters: werking, valkuilen en praktische tips [Pulse oximetry: principles, limitations and practical applications]. Ned Tijdschr Geneeskd. 2021;165:D5891. Published 2021 May 11.

Elgendi M. On the analysis of fingertip photoplethysmogram signals. Curr Cardiol Rev. 2012;8(1):14-25. doi:10.2174/157340312801215782

Summarized by Kirsten Hughes, MS4 | Edited by John Spartz MD & Erik Verzemnieks, MD

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Contributor: Nick Tsipis, MD

Educational Pearls:

PO medications are less frequently used in the ED due to their longer onset of action
The position the patient is in when given PO medications may affect how quickly the medication is absorbed
The quicker the medication passes through the stomach into the small intestine, the quicker it can be absorbed and metabolized
Recent study used in silico gastric biomechanics model to compare the length of time it took PO medications to pass through the stomach based on the patient’s positioning
Compared the medication transit time in a stomach model placed in right lateral, left lateral, upright, and supine positions
Right lateral positioning resulted in the fastest time for medication to pass through the stomach and enter the duodenum
Likely due to the direction of gravity aligning with the antrum and pylorus of the stomach
Left lateral positioning had the slowest time for the pill to enter the small intestine
Likely due to gravity not aligning with stomach anatomy
The time to absorption in the right and left lateral position were significantly faster and slower respectively than that seen in the upright and supine positions
These results indicate that placing a patient in the right lateral position when giving PO medications may result in faster rate of medication onset than if the patient is in another position

References

Lee JH, Kuhar S, Seo JH, Pasricha PJ, Mittal R. Computational modeling of drug dissolution in the human stomach: Effects of posture and gastroparesis on drug bioavailability. Phys Fluids (1994). 2022;34(8):081904.

Summarized by Mark O’Brien, MS4 | Edited by John Spartz MD & Erik Verzemnieks, MD

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Contributor: Lessen, Aaron MD

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Ketamine can be given at 0.2-0.3 mg/kg as subdissociative doses for pain control in the ED
- Ketamine coadministered with Haldol may reduce agitation
A recent study in Iran compared subdissociative Ketamine given with 2.5 mg Haldol to 1 mg/kg Fentanyl for pain control in the ED
- Ketamine with Haldol had better pain control than Fentanyl at 5, 10, 15 and 30 minutes
- Ketamine with Haldol less frequently required rescue medication
- Ketamine with Haldol did have increased agitation at only the 10 minute mark
- Of note, there was not a Ketamine only group to compare
Ketamine with Haldol is a viable alternative combination for pain control

References

Moradi MM, Moradi MM, Safaie A, Baratloo A, Payandemehr P. Sub dissociative dose of ketamine with haloperidol versus fentanyl on pain reduction in patients with acute pain in the emergency department; a randomized clinical trial. Am J Emerg Med. 2022;54:165-171. doi:10.1016/j.ajem.2022.02.012

Sin B, Ternas T, Motov SM. The use of subdissociative-dose ketamine for acute pain in the emergency department. Acad Emerg Med. 2015;22(3):251-257. doi:10.1111/acem.12604

Summarized by Kirsten Hughes, MS4 | Edited by John Spartz, MD & Erik Verzemnieks, MD

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Contributor: Jarod Scott, MD

Educational Pearls:

There is a 1-hour window for tooth replantation in ED
Cold milk is often best transport media unless there is access to specialized solutions (Hank’s Balanced Solution)
Goal is to preserve periodontal ligament
Soaking in tap water should be avoided as it will lyse cells of periodontal ligament
If oral surgeon is rapidly available, have them perform replantation
Do not delay replantation to wait for an oral surgeon to become available
Steps in tooth reimplantation
Disturb the socket as little as possible
Handle tooth only by crown, don’t touch root
Rinse tooth gently with tap water or saline, do not scrub it
Tooth should click back in place and remain stable
Don’t manipulate after reimplantation
It may take weeks to determine if the tooth will survive
Studies have shown that replantation performed within one hour has a significantly better prognosis than those taking place after a greater amount of time has passed

References

Andreasen JO, Andreasen FM, Skeie A, Hjørting-Hansen E, Schwartz O. Effect of treatment delay upon pulp and periodontal healing of traumatic dental injuries – a review article. Dent Traumatol. 2002;18(3):116-128.

De Brier N, O D, Borra V, Singletary EM, Zideman DA, De Buck E. Storage of an avulsed tooth prior to replantation: A systematic review and meta-analysis. Dent Traumatol. 2020;36(5):453-476.

Summarized by Mark O’Brien, MS4 | Edited by John Spartz, MD & Erik Verzemnieks, MD

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Contributor: Aaron Lessen, MD

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Achilles tendon rupture usually presents in younger, healthy patients after a sports injury
Patients typically present complaining of an abrupt onset ankle pain after feeling a “pop”
- Pain can be localized to posterior ankle and patient’s lack the ability to plantarflex
- Achilles rupture is a clinical diagnosis and does not usually require imaging in the ED
- Thompson test
- - Having patient lay on their stomach and squeezing the calf on the injured side should result in plantarflexion
  - If the Achilles is ruptured, no plantarflexion will occur
Treatment in the ED is to place the patient in a short leg posterior splint with some mild plantarflexion to aid in healing
After discharge patients should follow up with orthopedics
Recent study compared those who underwent the traditional open surgery, a minimally invasive surgery, and no surgery
- No difference in functionality was noted between the groups 3 months to 1 year post injury
- Those in the nonoperative group had slightly higher rates of repeat rupture (6%) than those in the surgical groups (<0.6% in each)
- Patients undergoing minimally invasive surgery had the highest risk of nerve injury (5.2%), followed by traditional surgery (2.8%), and then nonoperative (0.6%)

References

Cuttica DJ, Hyer CF, Berlet GC. Intraoperative value of the thompson test. J Foot Ankle Surg. 2015;54(1):99-101.

Kauwe M. Acute Achilles Tendon Rupture: Clinical Evaluation, Conservative Management, and Early Active Rehabilitation. Clin Podiatr Med Surg. 2017;34(2):229-243.

Myhrvold SB, Brouwer EF, Andresen TKM, et al. Nonoperative or Surgical Treatment of Acute Achilles' Tendon Rupture. N Engl J Med. 2022;386(15):1409-1420.

Summarized by Mark O’Brien, MS4 | Edited by John Spartz MD & Erik Verzemnieks, MD

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Contributor: Aaron Lessen, MD

Educational Pearls:

Achilles tendon rupture usually presents in younger, healthy patients after a sports injury
Patients typically present complaining of an abrupt onset ankle pain after feeling a “pop”
- Pain can be localized to posterior ankle and patient’s lack the ability to plantarflex
- Achilles rupture is a clinical diagnosis and does not usually require imaging in the ED
- Thompson test
- - Having patient lay on their stomach and squeezing the calf on the injured side should result in plantarflexion
  - If the Achilles is ruptured, no plantarflexion will occur
Treatment in the ED is to place the patient in a short leg posterior splint with some mild plantarflexion to aid in healing
After discharge patients should follow up with orthopedics
Recent study compared those who underwent the traditional open surgery, a minimally invasive surgery, and no surgery
- No difference in functionality was noted between the groups 3 months to 1 year post injury
- Those in the nonoperative group had slightly higher rates of repeat rupture (6%) than those in the surgical groups (<0.6% in each)
- Patients undergoing minimally invasive surgery had the highest risk of nerve injury (5.2%), followed by traditional surgery (2.8%), and then nonoperative (0.6%)

References

Cuttica DJ, Hyer CF, Berlet GC. Intraoperative value of the thompson test. J Foot Ankle Surg. 2015;54(1):99-101.

Kauwe M. Acute Achilles Tendon Rupture: Clinical Evaluation, Conservative Management, and Early Active Rehabilitation. Clin Podiatr Med Surg. 2017;34(2):229-243.

Myhrvold SB, Brouwer EF, Andresen TKM, et al. Nonoperative or Surgical Treatment of Acute Achilles' Tendon Rupture. N Engl J Med. 2022;386(15):1409-1420.

Summarized by Mark O’Brien, MS4 | Edited by John Spartz MD & Erik Verzemnieks, MD

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Contributor: Dylan Luyten, MD

Educational Pearls:

Positive End Expiratory Pressure (PEEP) is positive pressure within the lungs and maintained throughout the entire respiratory cycle. It is the pressure preventing alveoli from collapsing at the end of exhalation.
When using a bag valve mask (BVM) to ventilate patients, always attach the PEEP valve to prevent intrathoracic pressure from returning to atmospheric pressure which would allow alveoli collapse.
A BVM with a good seal to patients face and with an attached PEEP valve provides the same support as BiPAP or CPAP.
A generally acceptable PEEP setting is 5 cmH2O.

References

Mora Carpio AL, Mora JI. Positive End-Expiratory Pressure. In: StatPearls. Treasure Island (FL): StatPearls Publishing; August 27, 2021.

Harrison MJ. PEEP and CPAP. Br Med J (Clin Res Ed). 1986;292(6521):643-644. doi:10.1136/bmj.292.6521.643

Summarized by Kirsten Hughes, MS4 | Edited by John Spartz, MD & Erik Verzemnieks, MD

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Contributor: Dylan Luyten, MD

Educational Pearls:

Positive End Expiratory Pressure (PEEP) is positive pressure within the lungs and maintained throughout the entire respiratory cycle. It is the pressure preventing alveoli from collapsing at the end of exhalation.
When using a bag valve mask (BVM) to ventilate patients, always attach the PEEP valve to prevent intrathoracic pressure from returning to atmospheric pressure which would allow alveoli collapse.
A BVM with a good seal to patients face and with an attached PEEP valve provides the same support as BiPAP or CPAP.
A generally acceptable PEEP setting is 5 cmH2O.

References

Mora Carpio AL, Mora JI. Positive End-Expiratory Pressure. In: StatPearls. Treasure Island (FL): StatPearls Publishing; August 27, 2021.

Harrison MJ. PEEP and CPAP. Br Med J (Clin Res Ed). 1986;292(6521):643-644. doi:10.1136/bmj.292.6521.643

Summarized by Kirsten Hughes, MS4 | Edited by John Spartz, MD & Erik Verzemnieks, MD

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Contributor: Jared Scott, MD

Educational Pearls:

If a patient is in significant pain, a digital block can be helpful. Pain management alone may allow for manual ring removal.
Ring cutters and trauma shears with specialized ring cutters can be attempted but will destroy the ring and some materials may be resistant to cutting.
2 alternative options are presented which aim to reduce edema above the ring to assist removal:
Move the ring as proximally as possible. Wrap large size suture from the ring distally beyond PIP joint. Slide the ring over the suture and off the finger.
Wrap a tourniquet from distal to proximal including over the ring. Have the patient hold the tourniquet in place while they elevate their hand above the head for 15 minutes. Take down the tourniquet then remove the ring.

References

Asher CM, Fleet M, Bystrzonowski N. Ring removal: an illustrated summary of the literature. Eur J Emerg Med. 2020;27(4):268-273. doi:10.1097/MEJ.0000000000000658

Walter J, DeBoer M, Koops J, Hamel LL, Rupp PE, Westgard BC. Quick cuts: A comparative study of two tools for ring tourniquet removal. Am J Emerg Med. 2021;46:238-240. doi:10.1016/j.ajem.2020.07.039

Summarized by Kirsten Hughes, MS4 | Edited by John Spartz, MD & Erik Verzemnieks, MD

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Contributor: Jarod Scott, MD

Educational Pearls:

Physicians are typically advised not to trust computer interpretation of ECGs
Retrospective study was done of computer interpreted normal ECGs to evaluate the accuracy of such an interpretation
989 ECGs were interpreted as “Normal sinus rhythm, Normal ECG” by proprietary cardiology software on MUSE Cardiology Information System
These EKGs received follow up interpretation by cardiologists which was considered the “gold standard” for interpretation
18.6% of “normal ECG” had at least one abnormality identified by the cardiologist
6.1% of these discrepant interpretations were deemed potentially clinically significant
Only 1% were classified as possible ischemia
On retrospective chart review:
Six patients underwent non-emergent cardiac catheterization
Two had cardiac interventions
One had three PCI stents to a prior CABG graft
One had a scheduled outpatient cardiac catheterization but was admitted and ended up receiving a CABG graft
Study showed that discrepancies between computer interpretation of “Normal ECG” and cardiologist re-interpretation were not clinically significant
Emergency physicians should still screen ECGs per AHA guidelines

References

Winters LJ, Dhillon RK, Pannu GK, Terrassa P, Holmes JF, Bing ML. Emergent cardiac outcomes in patients with normal electrocardiograms in the emergency department. Am J Emerg Med. 2022;51:384-387.

Summarized by Mark O’Brien, MS4 | Edited by John Spartz MD & Erik Verzemnieks, MD

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Contributor: Aaron Lessen, MD

Educational Pearls:

Patients with recurrent ascites may need frequent outpatient or emergency department paracentesis which can be time consuming and uncomfortable for patients.
Tunneled peritoneal catheters are a permanent alternative therapy which allows fluid drainage at home by patient or caregiver.
There has been theoretical concern that long term placement of tunneled peritoneal catheters may increase risk of infection, thus they are more commonly placed as a palliative measure for patients with end stage cancer and malignant ascites with shorter anticipated life spans.
However, a recent small study found that in both patients with malignant ascites and recurrent ascites from cirrhosis, tunneled peritoneal catheter placement reduced symptoms from ascites and did not increase risk of infection or leakage at catheter site, or spontaneous bacterial peritonitis after four weeks. More research is emerging and tunneled peritoneal catheters may become more common.

References

Kimer N, Riedel AN, Hobolth L, et al. Tunneled Peritoneal Catheter for Refractory Ascites in Cirrhosis: A Randomized Case-Series. Medicina (Kaunas). 2020;56(11):565. Published 2020 Oct 27. doi:10.3390/medicina56110565

Petzold G, Bremer SCB, Heuschert FC, et al. Tunnelled Peritoneal Catheter for Malignant Ascites-An Open-Label, Prospective, Observational Trial. Cancers (Basel). 2021;13(12):2926. Published 2021 Jun 11. doi:10.3390/cancers13122926

Corrigan M, Thomas R, McDonagh J, et al. Tunnelled peritoneal drainage catheter placement for the palliative management of refractory ascites in patients with liver cirrhosis. Frontline Gastroenterol. 2020;12(2):108-112. Published 2020 Feb 28. doi:10.1136/flgastro-2019-101332

Summarized by Kirsten Hughes, MS4 | Edited by John Spartz, MD & Erik Verzemnieks, MD

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Contributor: Aaron Lessen, MD

Educational Pearls:

Patients with recurrent ascites may need frequent outpatient or emergency department paracentesis which can be time consuming and uncomfortable for patients.
Tunneled peritoneal catheters are a permanent alternative therapy which allows fluid drainage at home by patient or caregiver.
There has been theoretical concern that long term placement of tunneled peritoneal catheters may increase risk of infection, thus they are more commonly placed as a palliative measure for patients with end stage cancer and malignant ascites with shorter anticipated life spans.
However, a recent small study found that in both patients with malignant ascites and recurrent ascites from cirrhosis, tunneled peritoneal catheter placement reduced symptoms from ascites and did not increase risk of infection or leakage at catheter site, or spontaneous bacterial peritonitis after four weeks. More research is emerging and tunneled peritoneal catheters may become more common.

References

Summarized by Kirsten Hughes, MS4 | Edited by John Spartz, MD & Erik Verzemnieks, MD

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Contributor: Peter Bakes, MD

Educational Pearls:

Tachycardia describes a heart rate of >120 beats per minute
Wide Complex describes a QRS duration of >120 ms or 3 small boxes on a standard EKG
The major differential for a wide complex tachycardia is Ventricular Tachycardia (VT), aka “V Tach”, or Supraventricular Tachycardia (SVT) with Aberrancy
SVT alone is a narrow complex tachycardia, but as rate increases a right or left bundle branch block pattern may emerge, creating SVT with Aberrancy seen as a wide complex on EKG
It is important to distinguish the rhythms as treatment for stable VT differs from treatment(s) for stable SVT
Brugada Criteria is an algorithm for determining if wide complex tachycardia is VT with a high degree of sensitivity and specificity.
Following is a simple ED approach based on brugada criteria to determine VT on EKG. If either condition is true, suspect and treat VT:
Concordance: All precordial leads have QRS complexes that are either all positive or all negative.
R-S interval: >100 ms in any one precordial lead.
Also note that VT is more common in patients who are elderly and/or have cardiac comorbidities of ischemic or structural heart disease

References

Reithmann C. Tachykardien mit breiten QRS-Komplexen [Differential diagnosis of wide QRS complex tachycardia]. MMW Fortschr Med. 2019;161(13):48-56. doi:10.1007/s15006-019-0022-x

Ding WY, Mahida S. Wide complex tachycardia: differentiating ventricular tachycardia from supraventricular tachycardia. Heart. 2021;107(24):1995-2003. doi:10.1136/heartjnl-2020-316874

Brugada P, Brugada J, Mont L, Smeets J, Andries EW. A new approach to the differential diagnosis of a regular tachycardia with a wide QRS complex. Circulation. 1991;83(5):1649-1659. doi:10.1161/01.cir.83.5.1649

Summarized by Kirsten Hughes, MS4 | Edited by John Spartz, MD & Erik Verzemnieks, MD

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Contributor: Aaron Lessen, MD

Educational Pearls:

Awareness with recall of paralysis can occur in intubated and ventilated patients receiving paralytic medications
Patients who suffer from this effect are at high risk of developing severe PTSD, depression, and suicidal ideations
Occurs in approximately 0.1-0.2% of patients undergoing general anesthesia in an OR setting
2021 study showed patients intubated in the ED have a much higher rate of experiencing awareness during intubation
2.6% chance of awareness in patients undergoing intubation and mechanical ventilation in the ED
Higher rates with rocuronium likely due to its longer duration of action
New follow up study from 2022 showed 3.4% of patients aware when paralyzed for mechanical ventilation in ED
5.5% of patients receiving rocuronium had awareness occur
Patients who received other paralytics had a <1% rate of awareness during intubation
Important to be proactive with sedation and pain medications to decrease risk of awareness with recall of paralysis, especially in patients receiving rocuronium

References

Fuller BM, Pappal RD, Mohr NM, et al. Awareness With Paralysis Among Critically Ill Emergency Department Patients: A Prospective Cohort Study. Crit Care Med. 2022.

Leslie K, Davidson AJ. Awareness during anesthesia: a problem without solutions? Minerva Anestesiol. 2010;76(8):624-628.

Pappal RD, Roberts BW, Mohr NM, et al. The ED-AWARENESS Study: A Prospective, Observational Cohort Study of Awareness With Paralysis in Mechanically Ventilated Patients Admitted From the Emergency Department. Ann Emerg Med. 2021;77(5):532-544.

Summarized by Mark O’Brien, MS4 | Edited by John Spartz, MD & Erik Verzemnieks, MD

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Selected audio from our event, Palliative, hosted on June 27, 2022 in conjunction with Children's Hospital Colorado's Department of Palliative Medicine and The Denver Hospice's Footprints Program.

Keynote address by Dr. Nadia Tremonti, pediatric palliative care physician at Children's Hospital of Michigan

Expert Panel composed of Dr. Kimberly Bennett, medical director for TDH's Footprints Program, Dora Mueller, clinical nurse coordinator for palliative care at Children's and Cassie Matz, LCSW bereavement coordinator at Children's.

The evening commenced following a screening of the 2019 award-winning documentary, Palliative, featuring Dr. Nadia Tremonti's work at Children's Hospital of Michigan. You can watch the documentary for free at Kanopy.com using your library card using the following link: https://www.kanopy.com/product/palliative

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Contributor: Aaron Lessen, MD

Educational Pearls:

Intranasal medication administration is a convenient, quick, and relatively painless option for pediatric patients
Often used as an initial medication to help control pain in children prior to establishing an IV
Using an atomizer is preferred when administering intranasal medications
The syringe should be angled towards the ipsilateral eye or occiput rather than straight upwards
Do not administer more than 1 mL of fluid per nostril as volumes greater than 1 mL are not sufficiently absorbed
Intranasal medication doses differ from the traditional IV dosages and have a slower onset of action

References

Del Pizzo J, Callahan JM. Intranasal medications in pediatric emergency medicine. Pediatr Emerg Care. 2014;30(7):496-501; quiz 502-494.

Fantacci C, Fabrizio GC, Ferrara P, Franceschi F, Chiaretti A. Intranasal drug administration for procedural sedation in children admitted to pediatric Emergency Room. Eur Rev Med Pharmacol Sci. 2018;22(1):217-222.

Rech MA, Barbas B, Chaney W, Greenhalgh E, Turck C. When to Pick the Nose: Out-of-Hospital and Emergency Department Intranasal Administration of Medications. Ann Emerg Med. 2017;70(2):203-211.

Schoolman-Anderson K, Lane RD, Schunk JE, Mecham N, Thomas R, Adelgais K. Pediatric emergency department triage-based pain guideline utilizing intranasal fentanyl: Effect of implementation. Am J Emerg Med. 2018;36(9):1603-1607.

Summarized by Mark O’Brien, MS4 | Edited by John Spartz, MD & Erik Verzemnieks, MD

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In this second episode of a two-part mini-series, we feature Dr. Nadia Haddad, a Colorado psychiatrist, and Dr. Ricky Dhaliwal, an emergency medicine physician, as they discuss the various treatment modalities for substance-induced psychosis. They explore pharmacologic treatments, inpatient and outpatient treatments, and ways that emergency providers can improve their care for psychiatric patients with comorbid medical conditions. Lastly, they consider the different causes for repeat visits from mentally ill patients.

Key Points:

Pharmacologic treatments for substance-induced psychosis are similar to those for other types of psychosis; these include medications like Zyprexa, Haldol, and, as a third-line treatment, IM Thorazine.
Droperidol is used more commonly in the emergency setting, compared with the psychiatric setting.
Given the risk for respiratory depression from Zyprexa combined with benzodiazepines, psychiatrists may choose to use Thorazine or Haldol/Ativan/Benadryl instead.
It is important to reassess patients after substances wear off to determine whether they meet criteria for admission to inpatient psychiatry, though psychiatric assessments are limited by geographic constraints.
The admitting psychiatry team will reassess the patient to differentiate substance-induced psychosis vs other psychoses; often this includes obtaining collateral.
Helpful notes from the ED include: medications administered or restraints placed (can help extrapolate a patient’s level of agitation), vital signs, prior records.
Some people will be more open about suicidality while intoxicated and less open about it while sober so it is important to obtain additional information for corroboration.
On average, patients stay in the detox unit for 3-4 days, though some may stay longer for protracted substance-induced psychosis if they have a long-standing history of daily substance use.
It is important to discharge patients with quick follow-up and potential placement into the various mental health programs including partial hospitalization, residential, or outpatient programs.
Emergency rooms can improve by taking psychiatric patients seriously, especially when they are transferred to the hospital from a psychiatric facility for medical management.
Repeat visits stem partially from the ambivalence that accompanies substance use disorders, including patients’ difficulty in giving up the substance due the purpose it may serve in their lives.
Many substance use disorder programs are siloed from the medical system, which pose a challenge to interdisciplinary communication.

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Key Points:

Pharmacologic treatments for substance-induced psychosis are similar to those for other types of psychosis; these include medications like Zyprexa, Haldol, and, as a third-line treatment, IM Thorazine.
Droperidol is used more commonly in the emergency setting, compared with the psychiatric setting.
Given the risk for respiratory depression from Zyprexa combined with benzodiazepines, psychiatrists may choose to use Thorazine or Haldol/Ativan/Benadryl instead.
It is important to reassess patients after substances wear off to determine whether they meet criteria for admission to inpatient psychiatry, though psychiatric assessments are limited by geographic constraints.
The admitting psychiatry team will reassess the patient to differentiate substance-induced psychosis vs other psychoses; often this includes obtaining collateral.
Helpful notes from the ED include: medications administered or restraints placed (can help extrapolate a patient’s level of agitation), vital signs, prior records.
Some people will be more open about suicidality while intoxicated and less open about it while sober so it is important to obtain additional information for corroboration.
On average, patients stay in the detox unit for 3-4 days, though some may stay longer for protracted substance-induced psychosis if they have a long-standing history of daily substance use.
It is important to discharge patients with quick follow-up and potential placement into the various mental health programs including partial hospitalization, residential, or outpatient programs.
Emergency rooms can improve by taking psychiatric patients seriously, especially when they are transferred to the hospital from a psychiatric facility for medical management.
Repeat visits stem partially from the ambivalence that accompanies substance use disorders, including patients’ difficulty in giving up the substance due the purpose it may serve in their lives.
Many substance use disorder programs are siloed from the medical system, which pose a challenge to interdisciplinary communication.

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Contributor: Aaron Lessen, MD

Educational Pearls:

There are two common options for push-dose vasopressor: phenylephrine and epinephrine. Both have been studied in the setting of the OR, but are lacking data in emergency room utilization.
A recent retrospective study at one hospital compared the two options for effectiveness and safety. The data showed phenylephrine raised systolic pressure an average 26 points while epinephrine raised the systolic pressure higher, an average of 33 points.
Additionally, the same study showed dosing errors were more common in epinephrine. The error rates were 13% and 2% when using premixed syringes of epinephrine and phenylephrine respectively. However, overall no increase in adverse outcomes were reported between the two drugs in this study.

References

Nam E, Fitter S, Moussavi K. Comparison of push-dose phenylephrine and epinephrine in the emergency department. Am J Emerg Med. 2022;52:43-49. doi:10.1016/j.ajem.2021.11.033

Weingart S. Push-dose pressors for immediate blood pressure control. Clin Exp Emerg Med. 2015;2(2):131-132. Published 2015 Jun 30. doi:10.15441/ceem.15.010

Summarized by Kirsten Hughes, MS4 | Edited by John Spartz, MD & Erik Verzemnieks, MD

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Contributor: Aaron Lessen, MD

Educational Pearls:

A recent study evaluated the association between the degree of fever and mortality rate in patients presenting to a set of Emergency Departments in Israel
Febrile patients with a temperature > 38.0 C were recorded and these patients were compared against local death records to determine the all-cause 30-day mortality rate
8.1% of patients evaluated in the ED were determined to be febrile
30-day mortality for all febrile patients was around 12%
Patients with fever >40 C have a mortality rate approaching 24%
Patients febrile to >40 C had increased mortality, ICU admissions, and AKIs compared to those with lesser degrees of fever
Those with a body temperature of between 39.2-39.5 C had the lowest mortality rates which may indicate the protective role of fever and warrants further research

References

Marcusohn E, Gibory I, Miller A, Lipsky AM, Neuberger A, Epstein D. The association between the degree of fever as measured in the emergency department and clinical outcomes of hospitalized adult patients. Am J Emerg Med. 2022;52:92-98.

Summarized by Mark O’Brien, MS4 | Edited by John Spartz, MD & Erik Verzemnieks, MD

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Contributor: Peter Bakes, MD

Educational Pearls:

Patients in renal failure may have elevated serum potassium levels which can result in EKG changes.
EKG changes in the setting of hyperkalemia generally depend on the serum level. Mild elevation may cause peaked T waves. At higher serum levels there will be loss of P waves plus wide complex tachycardia. There can be progression to fatal arrhythmias.
Treatment of acute hyperkalemia involves multiple mechanisms. Calcium gluconate stabilizes the cardiac membrane (of note, its duration of action is 1 hour). Insulin with Glucose and Bicarbonate both act to shift extracellular potassium into cells. Enhanced elimination of potassium is accomplished via Kayexalate or Lokelma. Definitive treatment for hyperkalemia is hemodialysis.
The differential for wide complex non-tachycardic rhythm on EKG includes: left ventricular hypertrophy, left bundle branch block, pacemaker, electrolyte abnormalities including hyperkalemia.

References

Palmer BF, Clegg DJ. Diagnosis and treatment of hyperkalemia. Cleve Clin J Med. 2017;84(12):934-942. doi:10.3949/ccjm.84a.17056

Watanabe R. Hyperkalemia in chronic kidney disease. Rev Assoc Med Bras (1992). 2020;66Suppl 1(Suppl 1):s31-s36. Published 2020 Jan 13. doi:10.1590/1806-9282.66.S1.31

Summarized by Kirsten Hughes, MS4 | Edited by John Spartz, MD & Erik Verzemnieks, MD

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Contributor: Aaron Lessen, MD

Educational Pearls:

Multiple factors affect if a digit can be reattached including: location of digit injury, mechanism of injury, duration since injury, preservation mechanism.
Recommended preservation is via indirect cooling. This is accomplished by wrapping the amputated digit piece in saline soaked gauze, placing the wrapped piece in a waterproof bag and putting the bag in ice water for transport. Avoid direct contact of the digit with ice.
A single center study showed that only 34% of the total digits received were properly preserved. Lower rates of indirect cooling were seen in patients arriving from home or via EMS (25% and 35% respectively). Of those transported from referring hospitals, still only 45% of digits were properly preserved. Therefore, consider providing preservation instructions for indirect cooling to those transporting amputated digits.

References

Zhang L, Azmat CE, Buckley CJ. Digit Amputation. In: StatPearls. Treasure Island (FL): StatPearls Publishing; April 30, 2022.

Massand S, Sinatro H, Liu AT, Shen C, Ingraham JM. Improper Preservation of Amputated Parts: A Pervasive Problem. Plast Reconstr Surg Glob Open. 2020;8(9 Suppl):100-101. Published 2020 Oct 9. doi:10.1097/01.GOX.0000720828.15941.c5

Summarized by Kirsten Hughes, MS4 | Edited by John Spartz, MD & Erik Verzemnieks, MD

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Contributor: Aaron Lessen, MD

Educational Pearls:

Prior, smaller studies showed intravenous Vitamin C given to patients with sepsis significantly improved patient mortality and additional outcomes.
A recently published, randomized control trial with >800 ICU patients who received up to 4 days of IV Vit C or placebo concluded that the end points of death or persistent organ dysfunction at 28 days were unaffected by Vitamin C administration. There were no adverse safety outcomes associated with Vitamin C administration.
Based on this trial, it is unlikely that Vitamin C will become a mainstay of treatment for sepsis patients.

References

Marik PE, Khangoora V, Rivera R, Hooper MH, Catravas J. Hydrocortisone, Vitamin C, and Thiamine for the Treatment of Severe Sepsis and Septic Shock: A Retrospective Before-After Study. Chest. 2017;151(6):1229-1238. doi:10.1016/j.chest.2016.11.036

Lamontagne F, Masse MH, Menard J, et al. Intravenous Vitamin C in Adults with Sepsis in the Intensive Care Unit. N Engl J Med. 2022;386(25):2387-2398. doi:10.1056/NEJMoa2200644

Summarized by Kirsten Hughes, MS4 | Edited by John Spartz, MD & Erik Verzemnieks, MD

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Contributor: Aaron Lessen, MD

Educational Pearls:

Septic shock management has traditionally endorsed rapid fluid resuscitation and the administration of vasopressors
Current guidelines are for patients to initially receive a 30 ml/kg fluid bolus then additional fluid as needed for continued hypotension
The ideal volume of fluid needed to maximize patient outcomes has been debated
A recent ICU-based study examined mortality differences between patient receiving restricted vs standard fluid therapy for septic shock
There was no significant difference in the rate of mortality or adverse outcomes between the two groups indicating that the amount of fluid used after the initial bolus does not affect patient outcomes
More research needed to evaluate the ideal fluid volumes used in the initial resuscitation of septic shock

Errata: *** “The primary outcome was death within 90 days after randomization”

References

Evans L, Rhodes A, Alhazzani W, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive Care Med. 2021;47(11):1181-1247.

Meyhoff TS, Møller MH, Hjortrup PB, Cronhjort M, Perner A, Wetterslev J. Lower vs higher fluid volumes during initial management of sepsis: a systematic review with meta-analysis and trial sequential analysis. Chest. 2020;157(6):1478-1496.

Meyhoff TS, Hjortrup PB, Wetterslev J, et al. Restriction of Intravenous Fluid in ICU Patients with Septic Shock. N Engl J Med. 2022;386(26):2459-2470.

Summarized by Mark O’Brien, MS4 | Edited by John Spartz, MD & Erik Verzemnieks, MD

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Contributor: Peter Bakes, MD

Educational Pearls:

Lithium remains a commonly used medication for treating bipolar disorder
Lithium toxicity can be acute, acute-on-chronic, or chronic
Measuring blood lithium level
Therapeutic range of lithium is around 1.6-1.8 mEq/L
2 mEq/L is likely to cause significant toxicity
4 mEq/L necessitates lifesaving treatment
The lethal dose of lithium is 700 mg/kg
Lithium can have delayed absorption resulting in levels increasing during hospitalization
Symptoms associated with acute lithium toxicity
Gastrointestinal
Nausea, vomiting, abdominal pain
Neurological
Tremor, nystagmus, CNS depression (late finding)
Cardiovascular
Bradycardia, QT prolongation, EKG changes
Treatment for lithium toxicity
ABCs
Get a good history
GI Decontamination:
Whole bowel irrigation if patient ingested extended-release tablets
Dialysis
Most effective treatment for lithium toxicity

References

Baird-Gunning J, Lea-Henry T, Hoegberg LCG, Gosselin S, Roberts DM. Lithium Poisoning. J Intensive Care Med. 2017;32(4):249-263.

McKnight RF, Adida M, Budge K, Stockton S, Goodwin GM, Geddes JR. Lithium toxicity profile: a systematic review and meta-analysis. Lancet. 2012;379(9817):721-728.

Summarized by Mark O’Brien, MS4 | Edited by John Spartz, MD & Erik Verzemnieks, MD

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Contributor: Don Stader, MD

Educational Pearls:

Pain sensation is generated and modified by the brain
Multiple case reports provide evidence that the degree of pain a patient experiences correlates with how severe they perceive their injury/illness to be
Patients who feel safe and reassured about the care they are receiving have less pain
The patient’s narrative about their pain is the strongest factor in determining long-term outcomes of their pain
Helping to shape the narrative around the patient’s pain is essential in reducing the incidence of chronic pain and increases the likelihood of pain completely resolving

References

Bushnell MC, Ceko M, Low LA. Cognitive and emotional control of pain and its disruption in chronic pain. Nat Rev Neurosci. 2013;14(7):502-511.

Dimsdale JE, Dantzer R. A biological substrate for somatoform disorders: importance of pathophysiology. Psychosom Med. 2007;69(9):850-854.

Fenton BW, Shih E, Zolton J. The neurobiology of pain perception in normal and persistent pain. Pain Manag. 2015;5(4):297-317.

Marshall PWM, Schabrun S, Knox MF. Physical activity and the mediating effect of fear, depression, anxiety, and catastrophizing on pain related disability in people with chronic low back pain. PLoS One. 2017;12(7):e0180788.

Summarized by Mark O’Brien, MS4 | Edited by John Spartz, MD & Erik Verzemnieks, MD

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Contributor: Peter Bakes, MD

Educational Pearls:

When intubating a patient, it is important to consider what medications will be used for post-intubation sedation and analgesia
The common non-benzodiazepine sedating medications are propofol, precedex, and ketamine
Propofol is frequently used in the emergency department, and it lowers ICP and MAP making it the preferred sedative for patients with intracranial bleeds
Precedex is a milder sedative used in the ICU because it decreases time to extubation and reduces the risk of complications associated with long term intubation
Ketamine should be used in hypotensive patients because it does not lower blood pressure, and its bronchodilatory effect is beneficial for asthmatic patients
Versed and ativan are the most commonly encountered benzodiazepine sedatives, but they are infrequently used because they increase the risk of delirium and delay extubation
Benzodiazepines are useful for sedation in patients with delirium tremens
For post intubation analgesia, fentanyl is the drug of choice since it has a lower risk of hypotension than is seen in other narcotics
In the emergency department, intubated and sedated patients should initially be sedated to a RASS of -2 while obtaining imaging, but aim for a RASS of -1 after to decrease side effects and promote earlier extubation

References

Ely EW, Truman B, Shintani A, et al. Monitoring sedation status over time in ICU patients: reliability and validity of the Richmond Agitation-Sedation Scale (RASS). JAMA. 2003;289(22):2983-2991.

Garner O, Ramey JS, Hanania NA. Management of Life-Threatening Asthma: Severe Asthma Series. Chest. 2022.

Keating GM. Dexmedetomidine: A Review of Its Use for Sedation in the Intensive Care Setting. Drugs. 2015;75(10):1119-1130.

McKeage K, Perry CM. Propofol: a review of its use in intensive care sedation of adults. CNS Drugs. 2003;17(4):235-272.

Summarized by Mark O’Brien, MS4 | Edited by John Spartz, MD & Erik Verzemnieks, MD

Emergency Medical Minute's Palliative screening event is tonight! There is still time to buy tickets to this intimate evening diving into the nuance of pediatric palliative care, purchase tickets on eventbrite!

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Contributor: Aaron Lessen, MD

Educational Pearls:

There are several online products that have been marketed towards individuals with SI
Sodium nitrite
Food preservative that can cause methemoglobinemia when ingested in large amounts
Patients present with blue skin discoloration and severe respiratory distress
Treat with methylene blue to reduce methemoglobin back to hemoglobin
Formic acid and sulfuric acid
These two acids can be combined in a confined space to create a potentially lethal exposure to carbon monoxide
Patients present with symptoms of CO poisoning as well as possible chemical burns and inhalation injuries
Patients require decontamination and treatment for CO poisoning in the emergency department
Hydrogen sulfide
Toxic gas that is produced from combining strong acid (toilet bowl cleaner) and a sulfur containing product (selenium sulfide shampoo and sulfa drugs)
“Knock down gas” that causes cyanide toxicity that rapidly affects anyone exposed to it including family members and rescuers

References

Kreutz K, Danielsen T, Quinton RA. Suicidal Carbon Monoxide Poisoning by Formic and Sulfuric Acids. Acad Forensic Pathol. 2019;9(3-4):217-224.

McCann SD, Kennedy JM, Tweet MS, Bryant SM. Sodium Nitrite Ingestion: an Emerging Trend in Suicide Attempts Shared via Online Communities. J Emerg Med. 2021;60(3):409-412.

Sams RN, Carver HW, 2nd, Catanese C, Gilson T. Suicide with hydrogen sulfide. Am J Forensic Med Pathol. 2013;34(2):81-82.

Summarized by Mark O’Brien, MS4 | Edited by John Spartz, MD & Erik Verzemnieks, MD

Our educational event Palliative is today! You can still buy tickets to join us at what is sure to be a powerful evening exploring the nuance of pediatric palliative care. Buy tickets here.

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Contributor: Jarod Scott, MD

Educational Pearls:

Rectal prolapse is an evagination of the rectal tissue through the anal opening
Factors that weaken the pelvic floor muscles increase the risk of rectal prolapse
These include age > 40, female, multiple pregnancies, constipation, diarrhea, cystic fibrosis, prior pelvic floor surgeries, or other pelvic floor abnormalities
Noninvasive treatment options include increasing fluid and fiber intake to soften stools as well as using padding/taping to reinforce the perineum
Surgery is an option to repair the prolapse so long as the patient is a good surgical candidate
Medical sugar can be used as a desiccant to dry out and shrink the prolapse thus allowing for easier manual replacement

References

Coburn WM, 3rd, Russell MA, Hofstetter WL. Sucrose as an aid to manual reduction of incarcerated rectal prolapse. Ann Emerg Med. 1997;30(3):347-349.

2Gachabayov M, Bendl R, Flusberg M, et al. Rectal prolapse and pelvic descent. Curr Probl Surg. 2021;58(9):100952.

Summarized by Mark O’Brien, MS4 | Edited by John Spartz MS4 & Erik Verzemnieks, MD

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Contributor: Aaron Lessen, MD

Educational Pearls:

Hyperglycemic Hyperosmolar State (HHS) is less common than Diabetic Ketoacidosis (DKA) but is associated with a mortality rate up to 10 times greater than that seen in DKA
Typically seen in elderly patients with severely elevated blood glucose levels (>1000 mg/dL) and an increased plasma osmolality
- Unlike in DKA, patients with HHS do not have elevated ketones
Treatment of HHS includes insulin administration along with correcting fluid and electrolyte abnormalities
When treating HHS, it is important to monitor and follow osmolality regularly because over-rapid correction can result in the development of cerebral edema

References

Fayfman M, Pasquel FJ, Umpierrez GE. Management of Hyperglycemic Crises: Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar State. Med Clin North Am. 2017;101(3):587-606.

Gosmanov AR, Gosmanova EO, Kitabchi AE. Hyperglycemic Crises: Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar State. In: Feingold KR, Anawalt B, Boyce A, et al., eds. Endotext. South Dartmouth (MA): MDText.com, Inc. Copyright © 2000-2022, MDText.com, Inc.; 2000.

Long B, Willis GC, Lentz S, Koyfman A, Gottlieb M. Diagnosis and Management of the Critically Ill Adult Patient with Hyperglycemic Hyperosmolar State. J Emerg Med. 2021;61(4):365-375.

Summarized by Mark O’Brien, MS4 | Edited by John Spartz MS4 & Erik Verzemnieks, MD

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The Emergency Medical Minute is excited to announce that we our upcoming event, Palliative. Check out our event page for more information and to buy tickets: Palliative Eventbrite Page

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Contributor: Aaron Lessen, MD

Educational Pearls:

NSAIDs are a potential alternative to opioids for pain management and are associated with decreased rates of adverse effects
A recent study evaluated the effectiveness of ibuprofen and oxycodone for pain management in pediatric patients with isolated, acute-limb fractures
Participants were discharged home with either ibuprofen or oxycodone and followed for six weeks
There was no difference in pain scores between those taking ibuprofen and those taking oxycodone indicating that they had comparable analgesic effects
Those in the ibuprofen group experienced significantly less adverse events compared to those taking oxycodone
The participants in the ibuprofen group showed quicker return to their normal activities and improved quality of life
In pediatric patients with fracture-related pain, ibuprofen is a safer alternative to oxycodone that is equally effective for pain control

References

Ali S, Manaloor R, Johnson DW, et al. An observational cohort study comparing ibuprofen and oxycodone in children with fractures. PLoS One. 2021;16(9):e0257021.

Cooney MF. Pain Management in Children: NSAID Use in the Perioperative and Emergency Department Settings. Paediatr Drugs. 2021;23(4):361-372.

Yin X, Wang X, He C. Comparative efficacy of therapeutics for traumatic musculoskeletal pain in the emergency setting: A network meta-analysis. Am J Emerg Med. 2021;46:424-429.

Summarized by Mark O’Brien, MS4 | Edited by John Spartz MS4 & Erik Verzemnieks, MD

The Emergency Medical Minute is excited to announce that we our upcoming event, Palliative. Check out our event page for more information and to buy tickets: Palliative Eventbrite Page

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Contributor: Aaron Lessen, MD

Educational Pearls:

Direct Oral Anticoagulants (DOACs) have surpassed Warfarin and Lovenox® for anticoagulation as they do not require injection and allow for easier discharge. In the ED, they are commonly prescribed after PE or DVT diagnosis.
Common DOACs are Apixaban (Eliquis®) and Rivaroxaban (Xarelto®). There has not been a direct head to head study comparing outcomes.
2 large observational studies evaluated the recurrence of clots and bleeding risk in patients with newly prescribed Eliquis® or Xarelto® for DVT or PE. Both studies found that Eliquis® had superior outcomes.
Further data is required to determine the preferred DOAC. A randomized trial comparing the two DOACs is upcoming with enrollment ending in 2023.

References

Dawwas GK, Leonard CE, Lewis JD, Cuker A. Risk for Recurrent Venous Thromboembolism and Bleeding With Apixaban Compared With Rivaroxaban: An Analysis of Real-World Data. Ann Intern Med. 2022;175(1):20-28. doi:10.7326/M21-0717

Aryal MR, Gosain R, Donato A, et al. Systematic review and meta-analysis of the efficacy and safety of apixaban compared to rivaroxaban in acute VTE in the real world. Blood Adv. 2019;3(15):2381-2387. doi:10.1182/bloodadvances.2019000572

Image from:

Bristol-Myers Squibb Company. Eliquis 10 Million Patients and Counting. Sec.gov. https://www.sec.gov/Archives/edgar/data/14272/000114036119003478/s002621x16_425.htm. Accessed June 12, 2022.

Summarized by Kirsten Hughes, MS4 | Edited by John Spartz MS4 & Erik Verzemnieks, MD

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Substance-Induced Psychosis (Part I) In this first episode of a two-part mini-series, we feature Dr. Nadia Haddad, a Colorado psychiatrist, and Dr. Ricky Dhaliwal, an emergency medicine physician, as they discuss the different substances that cause psychosis and their unique presentations in the ED and in the psychiatric world. First, Dr. Haddad establishes a medical definition of psychosis. Then, Dr. Haddad and Dr. Dhaliwal partake in a fruitful discussion, each providing their unique perspective on the drugs that affect our patient populations today.

Key Points:

Psychosis is a cognitive processing disorder, which leads to auditory hallucinations, visual hallucinations, and delusions.
Axis one psychosis like that from schizophrenia or mania typically produces auditory hallucinations, not visual hallucinations. Delusions are also common in underlying psychiatric psychosis.
One of the most common substances that cause psychosis today is methamphetamine. Meth-induced psychosis can mimic schizophrenia symptoms, though tactile hallucinations are very common with methamphetamine use.
Methamphetamine is active for up to about 8 hours but can vary depending on underlying mental health predispositions, which can be exacerbated for several days or a week before neurotransmitters right themselves after meth use.
Cannabis can lead to psychosis and paranoia for people - especially young people - with a predisposition to schizophrenia or bipolar.
Alcohol-related psychosis comes primarily from withdrawal, though acute alcohol intoxication may cause mild alcoholic hallucinosis.
The hallmark of delirium tremens is a fluctuating, waxing-and-waning consciousness, which can occur 72 hours after the last drink. DTs can occur after treatment of the physical withdrawal symptoms.
Alcohol withdrawal can occur even at high BALs relative to a patient’s baseline.
Cocaine psychosis is similar to methamphetamine-induced psychosis.

Recorded, Summarized, and Edited By: Jorge Chalit

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Contributor: Aaron Lessen, MD

Educational Pearls:

Tracheostomy bleeding is a rare but potentially life-threatening complication that usually occurs within the first month of tracheostomy tube placement
No matter how severe the bleeding, every patient should be evaluated to rule out a tracheo-innominate fistula between the tracheostomy and the innominate artery
If the patient is currently bleeding and has a cuffed tracheostomy tube, over-inflate the balloon to compress the bleeding vessel
Consider replacing an uncuffed tracheostomy tube with a cuffed tube or an ET tube
If the tracheostomy was performed in the last seven days, use a bougie or bronchoscope to replace the uncuffed tube due to increased risk of opening a false track into the subcutaneous tissue
If bleeding cannot be controlled, follow mass-transfusion protocols, and as a last resort, remove the tube and insert a finger into the stoma to manually compress the artery

References

Bontempo LJ, Manning SL. Tracheostomy Emergencies. Emerg Med Clin North Am. 2019;37(1):109-119.

Khanafer A, Hellstern V, Meißner H, et al. Tracheoinnominate fistula: acute bleeding and hypovolemic shock due to a trachea-innominate artery fistula after long-term tracheostomy, treated with a stent-graft. CVIR Endovasc. 2021;4(1):30.

Manning Sara, Bontempo Laura. Complications of Tracheostomies. In: Mattu A and Swadron S, ed. ComPendium. Burbank, CA: CorePendium, LLC. https://www.emrap.org/corependium/chapter/reckOdDn9Ljn7sBLy/Complications-of-Tracheostomies. Updated August 17, 2021. Accessed June 5, 2022.

Summarized by Mark O’Brien, MS4 | Edited by John Spartz, MD, MPH & Erik Verzemnieks, MD

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Contributor: Nick Hatch, MD

Educational Pearls:

Transcatheter aortic valve replacement (TAVR) is an increasingly common endovascular procedure to treat aortic stenosis
TAVR is an alternative to the open approach surgical aortic valve replacement (SAVR) for patients who are inoperable or are high risk surgical candidates
Following TAVR, there is increased risk of stroke, particularly in the first 30 days
TAVR-related strokes are due to embolic debris left on the valve root, which is generally cleaned out during SAVR
Further, following the procedure many patients are anticoagulated which increases the risk for conversion to hemorrhagic stroke
Isolated, unexplained nausea and vomiting in elderly patients should prompt concern for a neurologic workup with imaging - even more so if they have recently undergone TAVR

References

Davlouros PA, Mplani VC, Koniari I, Tsigkas G, Hahalis G. Transcatheter aortic valve replacement and stroke: a comprehensive review. J Geriatr Cardiol. 2018;15(1):95-104. doi:10.11909/j.issn.1671-5411.2018.01.008

Gleason TG, Reardon MJ, Popma JJ, et al. 5-Year Outcomes of Self-Expanding Transcatheter Versus Surgical Aortic Valve Replacement in High-Risk Patients. J Am Coll Cardiol. 2018;72(22):2687-2696. doi:10.1016/j.jacc.2018.08.2146

Siontis GCM, Overtchouk P, Cahill TJ, et al. Transcatheter aortic valve implantation vs. surgical aortic valve replacement for treatment of symptomatic severe aortic stenosis: an updated meta-analysis. Eur Heart J. 2019;40(38):3143-3153. doi:10.1093/eurheartj/ehz275

Summarized by Kirsten Hughes, MS4 | Edited by John Spartz MS4 & Erik Verzemnieks, MD

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Contributor: Nick Hatch, MD Educational Pearls:

“Smiling Death” describes the prehospital phenomenon of a person who is happy to be extricated from an extended period of crush injury, but dies suddenly soon after the rescue.
Smiling Death is caused by Crush Syndrome. Crush Syndrome begins when large areas of tissue are damaged by compression and subsequent impeded blood flow. Resultant cell death is followed by release of myoglobin and efflux of electrolytes including potassium. Upon removal of the crushing force, high levels of potassium enter circulation and cause cardiac arrhythmias leading to sudden death.
Prevention measures include aggressive hydration using normal saline before extrication. An acceptable starting rate is 1L per hour, but providers should take patient status into consideration and titrate appropriately.
Standard techniques for controlling hyperkalemia by intracellular shifting may be less effective. Early dialysis may be useful.

References

Gonzalez D. Crush syndrome. Crit Care Med. 2005;33(1 Suppl):S34-S41. doi:10.1097/01.ccm.0000151065.13564.6f

Better OS. Rescue and salvage of casualties suffering from the crush syndrome after mass disasters. Mil Med. 1999;164(5):366-369.

Summarized by Kirsten Hughes, MS4 | Edited by John Spartz MS4 & Erik Verzemnieks, MD

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Contributor: Jared Scott, MD

Educational Pearls:

Pepper spray is a chemical irritant derived from oleoresin capsicum (OC), an extract from pepper plants. It can be used by police for riot or crowd control, or by individuals for self defense.
In the event of an exposure, those affected should immediately disperse from the area, remove contact lenses with clean or gloved hands, and remove contaminated clothing.
Pepper spray can spread from patients to providers by contact. When caring for those exposed, providers should use PPE including gloves and should double bag personal belongings.
For patient management consider the following:
If the eyes are affected, first remove contacts then irrigate with clean water. Use proparacaine drops for relief.
Clean exposed skin thoroughly with soap and water.
Inhalation and ingestion may cause nausea, vomiting, shortness of breath and generalized anxiety from discomfort. Treatment can include antiemetics and anxiolytics. Symptoms may persist for many days.

References

Schep LJ, Slaughter RJ, McBride DI. Riot control agents: the tear gases CN, CS and OC-a medical review. J R Army Med Corps. 2015;161(2):94-99. doi:10.1136/jramc-2013-000165

Tidwell RD, Wills BK. Tear Gas and Pepper Spray Toxicity. [Updated 2022 Jan 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK544263/

Summarized by Kirsten Hughes, MS4 | Edited by John Spartz MS4 & Erik Verzemnieks, MD

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Contributor: Jared Scott, MD

Educational Pearls:

About 50% of those infected with SARS-CoV-2 will shed the virus in their feces
Wastewater surveillance can be used to track COVID burden, which may be easier than collating test data from multiple hospitals across a region
Viral shedding begins 5-7 days prior to symptom onset, so wastewater data can be used to anticipate outbreaks and inform policy and public health initiatives
Some existing limitations to wastewater surveillance include:
Reporting by counties were water sources may be mixed
Septic tanks and other closed water systems will not be counted
Not all those infected will shed the virus

References

Weidhaas J, Aanderud ZT, Roper DK, et al. Correlation of SARS-CoV-2 RNA in wastewater with COVID-19 disease burden in sewersheds. Sci Total Environ. 2021;775:145790. doi:10.1016/j.scitotenv.2021.145790

Kirby AE, Walters MS, Jennings WC, et al. Using Wastewater Surveillance Data to Support the COVID-19 Response — United States, 2020–2021. MMWR Morb Mortal Wkly Rep 2021;70:1242–1244. DOI: http://dx.doi.org/10.15585/mmwr.mm7036a2

Covid-19 monitoring in wastewater. Colorado COVID-19 Updates. https://covid19.colorado.gov/covid-19-monitoring-in-wastewater. Accessed May 21, 2022.

Summarized by Kirsten Hughes, MS4 | Edited by John Spartz, MD, MPH & Erik Verzemnieks, MD

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Contributor: Jared Scott, MD

Educational Pearls:

A study randomized 34 healthy patient to have their left anterior descending artery (LAD) occluded by balloon for 0, 15, 30, or 90 seconds
Subsequently, cardiac troponins (cTns) and Copeptin were measured every 15 minutes for 3 hours, then every 30 minutes for the next 3 hours
5 conclusions were drawn:
Copeptin is not a useful marker of cardiac ischemia
cTn may be detected after only 30 seconds of ischemia
cTn may be detected in a little as 15 minutes after ischemic event
After only 90 seconds of ischemia, cTn levels met threshold for MI
Troponin I is a better marker than troponin T as it rises faster and reaches a higher peak
Patients very recent or very brief ischemic events may have elevated troponin in the ED

References

Árnadóttir Á, Pedersen S, Bo Hasselbalch R, et al. Temporal Release of High-Sensitivity Cardiac Troponin T and I and Copeptin After Brief Induced Coronary Artery Balloon Occlusion in Humans [published correction appears in Circulation. 2021 Jun 22;143(25):e1116]. Circulation. 2021;143(11):1095-1104. doi:10.1161/CIRCULATIONAHA.120.046574

Summarized by Kirsten Hughes, MS4 | Edited by John Spartz, MD, MPH & Erik Verzemnieks, MD

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Contributor: Aaron Lessen, MD

Educational Pearls:

Tidal volume is the amount of breath a patient receives in a single ventilation
Traditional tidal volume (TV) setting was 10 ml/kg but studies showed lower TV had less incidence of respiratory distress, ARDS, and overall better outcomes
ED ventilation settings may get carried on for hours or days when a patient is admitted, making this an important part of patient care
Recent large systematic review shows that low TV setting in the ED leads to decreased incidence of ARDS, shorter ICU and hospital length of stay, shorter duration of mechanical ventilation, and decreased mortality
Consider an ED low tidal volume ventilation setting at around 6 ml/kg of predicted body weight

References

De Monnin K, Terian E, Yaegar LH, et al. Low Tidal Volume Ventilation for Emergency Department Patients: A Systematic Review and Meta-Analysis on Practice Patterns and Clinical Impact [published online ahead of print, 2022 Feb 7]. Crit Care Med. 2022;10.1097/CCM.0000000000005459. doi:10.1097/CCM.0000000000005459

Summarized by Kirsten Hughes, MS4 | Edited by John Spartz MS4 & Erik Verzemnieks, MD

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Contributor: Chris Holmes, MD

Educational Pearls:

Foxglove plant contains the cardiac glycoside digoxin
Foxglove leaf potions were once used to treat Dropsy; a historic term for symptoms of heart failure
Digoxin, previously used for treating heart failure, works by increases heart contraction strength and slows heart rate
Of note, the EKG of patient on digitalis may have a ‘Dali Mustache’ appearance
Digoxin toxicity can lead to a variety of dysrhythmias as well as neurological, GI, and metabolic effects
Treatment of digoxin toxicity is digoxin-immune fab, which is an antibody that binds digoxin

References

David MNV, Shetty M. Digoxin. [Updated 2021 Dec 23]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK556025/

Cummings ED, Swoboda HD. Digoxin Toxicity. [Updated 2021 Jul 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470568/?report=classic

Summarized by Kirsten Hughes, MS4 | Edited by John Spartz MS4 & Erik Verzemnieks, MD

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Contributor: Aaron Lessen, MD

Educational Pearls:

Recent study looking at a pediatric emergency department to determine what percentage of patients after intubation received sedation within 10 minutes after intubation
About 25% of the patients in the study received sedation within 10 minutes after intubation
Only 75% of the patients in the study received sedation in the ED at some point after intubation
Those who received rocuronium were less likely to received sedation post-intubation

References

Berg K, Gregg V, Cosgrove P, Wilkinson M. The Administration of Postintubation Sedation in the Pediatric Emergency Department. Pediatr Emerg Care. 2021;37(11):e732-e735. doi:10.1097/PEC.0000000000001744

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Aaron Lessen, MD Educational Pearls: * Pulse pressure is the difference between the systolic and diastolic blood pressure, normal is about 40 * A narrow pulse pressure is generally thought of as less than 30 mmHg which may signal peripheral vasoconstriction in response to lower blood volumes * 2020 study examined hypotension and narrow pulse pressure in trauma and outcomes * 37% of patients who were hypotensive on ED arrival had a severe injury, 22% of patients who had a narrow pulse pressure had a severe injury, and 11% of patients with normal blood pressure and normal pulse pressure had a severe injury * Need for thoracotomy, death, cardiac arrest, and need for other interventions was highest in the hypotensive group, the lowest in the normal blood pressure/normal pulse pressure group, and narrow pulse pressure group outcomes fell in the middle * Narrow pulse pressure in the setting of trauma may be a helpful vital sign to incorporate into trauma care in the ED

References

Schellenberg M, Owattanapanich N, Getrajdman J, Matsushima K, Inaba K. Prehospital Narrow Pulse Pressure Predicts Need for Resuscitative Thoracotomy and Emergent Intervention After Trauma [published correction appears in J Surg Res. 2021 Oct 6;270:1]. J Surg Res. 2021;268:284-290. doi:10.1016/j.jss.2021.06.051

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Peter Bakes, MD

Educational Pearls:

Mild frostbite injury usually only requires supportive care
In severe frostbite injury, patients should receive an immediate angiogram, be admitted, and receive tPA if there is evidence of vascular occlusion
Salvage rate is around 80% for appropriate patients who receive tPA in phalangeal frostbite injury

References

Paine RE, Turner EN, Kloda D, Falank C, Chung B, Carter DW. Protocoled thrombolytic therapy for frostbite improves phalangeal salvage rates. Burns Trauma. 2020;8:tkaa008. Published 2020 Apr 10. doi:10.1093/burnst/tkaa008

Basit H, Wallen TJ, Dudley C. Frostbite. In: StatPearls. Treasure Island (FL): StatPearls Publishing; November 5, 2021.

Wexler A, Zavala S. The Use of Thrombolytic Therapy in the Treatment of Frostbite Injury. J Burn Care Res. 2017;38(5):e877-e881. doi:10.1097/BCR.0000000000000512

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Chris Holmes, MD

Educational Pearls:

Antiemetics were used in ancient Rome to help with sea-sickness and included toxic substances such as wine and wormwood and white hellborn
The first antihistamine used for nausea, dramamine, was introduced in 1947 for motion sickness
After this chlorpromazine, prochlorperazine, and promethazine came about in the 1950s and 1960s
Cannabis, colloquially referred to as weed, isolates like THC used in the 1970s to help with chemotherapy-induced
After this in the 1980s, ondansetron and metoclopramide were introduced for more severe chemotherapy-induced nausea
Lastly, NK-1 inhibitors were introduced to treat nausea

References

Sanger GJ, Andrews PLR. A History of Drug Discovery for Treatment of Nausea and Vomiting and the Implications for Future Research. Front Pharmacol. 2018;9:913. Published 2018 Sep 4. doi:10.3389/fphar.2018.00913

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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In this special episode of MHM, we feature Dr. Nadia Haddad, a Colorado psychiatrist, and Dr. Ricky Dhaliwal, an emergency medicine physician, as they discuss the implications of OUD in Colorado. As a substance use disorder specialist, Dr. Haddad provides an invaluable perspective on various treatment modalities for OUD in the outpatient and inpatient settings. Finally, Dr. Haddad and Dr. Dhaliwal discuss the implications of the newly introduced Colorado legislation affecting patients with OUD and their providers.

Key Points:

The classic Suboxone therapy for heroin or prescription opioid detox can precipitate severe withdrawal in street fentanyl users.
The three FDA-approved MATs include methadone (full opioid agonist), buprenorphine (partial opioid agonist), and naltrexone (opioid antagonist).
Street fentanyl does not behave like pharmaceutical-grade fentanyl; a recent study found that the chemical composition of a street pill varied and included opioid analogs and benzodiazepines
Fentanyl attaches and detaches to/from the receptor more easily and quickly than buprenorphine. Dr. Haddad suspects that as fentanyl weans from the patient’s system, there is not enough to compete with Suboxone, therefore precipitating withdrawal.
Suboxone vs. naltrexone: Suboxone can be started sooner to treat post-acute withdrawal. Naltrexone helps to prevent relapse but may slow a patient’s emotional return to baseline.
Dr. Haddad recently developed a new home induction program to provide patients with supportive measures for the withdrawal period, which include pharmacologic interventions like clonidine, trazodone, dicyclomine, or loperamide.
Resources after discharge in Colorado include mental health centers, Front Range Clinic, Magnolia Mental Health
The criminalization of substance use disorders moves people from treatment-focused settings to punitive settings and leads to prison population expansion without adequate mental healthcare resources.

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Contributor: Aaron Lessen, MD

Educational Pearls:

Traditionally, blood cultures are drawn from two separate sites despite no data to suggest this is better than drawing blood from one site
Recent study evaluated multi-site versus single-site blood cultures to determine if there was a difference in accuracy or contamination
Positive yield was 20% in the single-site year and 17% in the multi-site year
No difference in contamination between the two groups

References

Ekwall-Larson A, Yu D, Dinnétz P, Nordqvist H, Özenci V. Single-Site Sampling versus Multisite Sampling for Blood Cultures: a Retrospective Clinical Study. J Clin Microbiol. 2022;60(2):e0193521. doi:10.1128/JCM.01935-21

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Aaron Lessen, MD

Educational Pearls:

Olecranon bursitis refers to inflammation in the bursa of the elbow and can be due to infection or trauma
Recent study examined treating suspected septic olecranon bursitis with antibiotics versus drainage
About 90% of the patients treated with antibiotic therapy for this issue did not require subsequent drainage or hospitalization for intravenous antibiotics
Consider treating suspected olecranon bursitis with antibiotic therapy and good return precautions rather than defaulting to drainage

References

Beyde A, Thomas AL, Colbenson KM, et al. Efficacy of empiric antibiotic management of septic olecranon bursitis without bursal aspiration in emergency department patients. Acad Emerg Med. 2022;29(1):6-14. doi:10.1111/acem.14406

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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On this episode of On the Streets, our host, Jordan Ourada, talks with cardiologist, Dr. Chirag Chauhan, about all things cardiac. Highlighted topics: * Wrist versus femoral access in the cath lab * The most important prehospital interventions for an MI * Nitroglycerin: Who gets it and what are the precautions * Lidocaine and amiodarone in a heart attack * CPR assist devices

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Contributor: Chris Holmes, MD

Educational Pearls:

Maggots were discovered as a therapy to help wound healing in WWI, but this fell out of favor after the discovery of penicillin
One study from Israel used maggots in treating diabetic foot wound with positive results but notable patient discomfort
Maggots debride tissue, kill MRSA, promote angiogenesis, and promote fibroblast migration to lay down new tissue
While maggots may be very useful in wound healing, the reality of the therapy may make patients very uncomfortable

References

Gilead L, Mumcuoglu KY, Ingber A. The use of maggot debridement therapy in the treatment of chronic wounds in hospitalised and ambulatory patients. J Wound Care. 2012 Feb;21(2):78, 80, 82-85. doi: 10.12968/jowc.2012.21.2.78. PMID: 22584527.

Mohd Zubir MZ, Holloway S, Mohd Noor N. Maggot Therapy in Wound Healing: A Systematic Review. Int J Environ Res Public Health. 2020;17(17):6103. Published 2020 Aug 21. doi:10.3390/ijerph17176103

McCaughan, Dorothy et al. “Patients' perceptions and experiences of venous leg ulceration and their attitudes to larval therapy: an in-depth qualitative study.” Health expectations : an international journal of public participation in health care and health policy vol. 18,4 (2015): 527-41. doi:10.1111/hex.12053

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Aaron Lessen, MD

Educational Pearls:

Atrial fibrillation is an irregular heart rhythm that sometimes requires rate control in setting of rapid ventricular response (RVR)
Calcium channel blocker and beta blockers are the most frequently used medications to block the AV node and slow down the heart rate in atrial fibrillation with RVR
If a patient is on one of these agents at home, the IV form should be used first
Recent systematic review and meta-analysis found 3 trials addressing which medication to use to control heart rate in atrial fibrillation with RVR with a total of 150 patients
Found diltiazem, a CCB, was 4x more likely to reduce heart rate than metoprolol
50% of patients had a normal heart rate at 21 minutes with diltiazem versus 22% in those who received metoprolol
Both agents had a similar decrease in blood pressure after administration

References

Jafri SH, Xu J, Warsi I, Cerecedo-Lopez CD. Diltiazem versus metoprolol for the management of atrial fibrillation: A systematic review and meta-analysis. Am J Emerg Med. 2021 Oct;48:323-327. doi: 10.1016/j.ajem.2021.06.053. Epub 2021 Jun 30. PMID: 34274577.

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Aaron Lessen, MD

Educational Pearls:

Firearms are a dangerous potential method of committing suicide
Death occurs in about 5-15% of suicide attempts overall, but death in suicide attempts using firearms occurs in 85-90% of cases
In some states, families can petition a judge to remove firearms from a house although healthcare providers cannot do this

References

Sarai SK, Abaid B, Lippmann S. Guns and Suicide: Are They Related? Prim Care Companion CNS Disord. 2017 Dec 21;19(6):17br02116. doi: 10.4088/PCC.17br02116. PMID: 29272571.

Anestis MD, Bandel SL, Butterworth SE, Bond AE, Daruwala SE, Bryan CJ. Suicide risk and firearm ownership and storage behavior in a large military sample. Psychiatry Res. 2020 Sep;291:113277. doi: 10.1016/j.psychres.2020.113277. Epub 2020 Jul 2. PMID: 32886959.

Mann JJ, Michel CA. Prevention of Firearm Suicide in the United States: What Works and What Is Possible. Am J Psychiatry. 2016 Oct 1;173(10):969-979. doi: 10.1176/appi.ajp.2016.16010069. Epub 2016 Jul 22. PMID: 27444796.

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Don Stader, MD

Educational Pearls:

In a secondary analysis of the PART trial, the mortality effect of timing of airway management for patients in cardiac arrest was examined
Study looked at whether timing played a part in both laryngeal tube placement or endotracheal intubation during cardiac arrest
Did not find any association of timing and survival to hospital discharge
High-quality CPR and defibrillation are the only two things that improve outcomes in cardiac arrest

References

Okubo M, Komukai S, Izawa J, Aufderheide TP, Benoit JL, Carlson JN, Daya MR, Hansen M, Idris AH, Le N, Lupton JR, Nichol G, Wang HE, Callaway CW. Association of Advanced Airway Insertion Timing and Outcomes After Out-of-Hospital Cardiac Arrest. Ann Emerg Med. 2022 Feb;79(2):118-131. doi: 10.1016/j.annemergmed.2021.07.114. Epub 2021 Sep 16. PMID: 34538500.

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Don Stader, MD Educational Pearls:

Xylazine, referred to as tranq dope colloquially, is an FDA approved animal tranquilizer that is circulating in the illicit drug markets of the northeastern United states
It is a powerful alpha-2 agonist, similar to clonidine, and patients with xylazine overdose may present similarly to opioid overdose
Naloxone will not reverse the effects of xylazine and management is supportive care
Withdrawal symptoms from xylazine use can be treated with clonidine

References

https://www.acep.org/tacticalem/newsroom/oct-2021/xylazine-an-emerging-adulterant/

Nunez J, DeJoseph ME, Gill JR. Xylazine, a Veterinary Tranquilizer, Detected in 42 Accidental Fentanyl Intoxication Deaths. Am J Forensic Med Pathol. 2021 Mar 1;42(1):9-11. doi: 10.1097/PAF.0000000000000622. PMID: 33031124.

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Aaron Lessen, MD Educational Pearls:

Hypotension after cardiac arrest often requires a vasopressor to improve blood pressure
Recent observational study from France examined outcomes of patients who received either epinephrine or norepinephrine for post-resuscitation shock
Norepinephrine had significantly better outcomes
Death from shock was 35% in the epinephrine group vs. 9% in the norepinephrine group
Recurrent cardiac arrest was 9% in epinephrine group vs. 3% in norepinephrine group
For epinephrine:
The all cause mortality was 2.5 times higher than norepinephrine
Cardiovascular mortality was 5 times higher than norepinephrine
Favorable neurological outcomes was 3 times worse than norepinephrine

References

Bougouin W, Slimani K, Renaudier M, Binois Y, Paul M, Dumas F, Lamhaut L, Loeb T, Ortuno S, Deye N, Voicu S, Beganton F, Jost D, Mekontso-Dessap A, Marijon E, Jouven X, Aissaoui N, Cariou A; Sudden Death Expertise Center Investigators. Epinephrine versus norepinephrine in cardiac arrest patients with post-resuscitation shock. Intensive Care Med. 2022 Mar;48(3):300-310. doi: 10.1007/s00134-021-06608-7. Epub 2022 Feb 7. PMID: 35129643.

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Dr. Kimberly Nordstrom

De-escalation usually takes less time than physical and chemical restraints, which leads to decreased injury to staff members, better patient trust and increased patient throughput as accepting facilities oftentimes delay transfer acceptance following physical restraints
Prepare to engage prior to entering their room in two ways: cognitively and emotionally
- Why do you want to de-escalate the patient? Remind yourself you don’t want to introduce more trauma
- Check your emotions, and ensure you don’t bring your emotional state into
If possible, engage the patient when they’re in mild agitation before their anger is out of control
Be authoritative not authoritarian or permissive, impart your expertise in medicine and explain your rationale to them without claiming to be an expert on them personally
Small acts of kindness like the provision of a warm blanket, snacks or voluntary medications appropriate to the situation can aid in establishing trust and rapport
Take a break to cool off if the interaction is too charged
Verbal de-escalation pearls:
- Respectful introduction, etiquette can be perceived as empathy to a patient in crisis
- Confirm story and allow patient to offer corrections to what you’ve been told
- Utilize active listening techniques, both verbally and nonverbally
- Avoid assigning blame, but use distant third parties if necessary without being detrimental to your colleagues
- Offer choices in medications within your clinical comfort zone for the patient

Verbal De-escalation videos:

Identification and Assessment of Agitation

Basic Elements of Verbal De-escalation

More Practice with Verbal De-escalation

Advanced Skills in De-escalation

Personal Safety and Escape Skills

References:

Berlin JS. Collaborative De-escalation. In: Zeller SL, Nordstrom KD, Wilson MP, eds. The Diagnosis and Management of Agitation. Cambridge: Cambridge University Press; 2017:144-155. doi:10.1017/9781316556702.012
Richmond JS, Berlin JS, Fishkind AB, et al. Verbal De-escalation of the Agitated Patient: Consensus Statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup. West J Emerg Med. 2012;13(1):17-25. doi:10.5811/westjem.2011.9.6864

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Contributor: Peter Bakes, MD

Educational Pearls:

3% of cases of acute coronary syndrome are due to Takotsubo
Takotsubo cardiomyopathy or “broken heart syndrome” can occur with severe physiologic or emotional stressors, as these events can result in a profound outpouring of sympathetic neurotransmitters (epinephrine/norepinephrine)
Receptors for these catecholamines are very dense around the apex of the heart, so the apical aspect of the heart can balloon outward as a result of this surge
Most often cases resolve in several weeks although in rare cases it can lead to congestive heart failure or a thrombus formation

References

Ahmad SA, Brito D, Khalid N, et al. Takotsubo Cardiomyopathy. [Updated 2022 Jan 14]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430798/

Bossone E, Savarese G, Ferrara F, et al. Takotsubo cardiomyopathy: overview. Heart Fail Clin. 2013;9(2):249-x. doi:10.1016/j.hfc.2012.12.015

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Sam Killian, MD

Educational Pearls:

Transaminitis refers to the elevation of transaminases, enzymes of the liver (AST and ALT)
Elevation of ALT is relatively specific to the liver, but AST is found in more organs than the liver including the muscle
If AST is significantly greater than ALT, consider a musculoskeletal origin such as rhabdomyolysis
Transaminitis is not always a liver specific issue

References

Lala V, Goyal A, Minter DA. Liver Function Tests. [Updated 2021 Aug 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482489/

Lim AK. Abnormal liver function tests associated with severe rhabdomyolysis. World J Gastroenterol. 2020;26(10):1020-1028. doi:10.3748/wjg.v26.i10.1020

Jo KM, Heo NY, Park SH, et al. Serum Aminotransferase Level in Rhabdomyolysis according to Concurrent Liver Disease. Korean J Gastroenterol. 2019;74(4):205-211. doi:10.4166/kjg.2019.74.4.205

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Aaron Lessen, MD

Educational Pearls:

Tramadol is often thought of as a mild-opiate to use for analgesia, but it is a more complicated drug
Tramadol needs to be metabolized into an effective drug making it not pharmacologically reliable
3-10% of people cannot metabolize tramadol and it does not work
Some others over-metabolize tramadol and it causes greater effect
Studies have shown it is not any better as a acetaminophen or ibuprofen for analgesia, it can lower a seizure threshold, and it acts to inhibit serotonin reuptake
Recent study evaluated all-cause mortality of tramadol compared to codeine and found tramadol had nearly double the all-cause mortality as those prescribed codeine
Overall tramadol has many risks and should be critically evaluated before prescribing

References

Dhesi M, Maldonado KA, Maani CV. Tramadol. [Updated 2021 May 25]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK537060/

Association of tramadol vs codeine prescription dispensation with mortality and other adverse clinical outcomes Xie J, Strauss VY, Martinez-Laguna D, et al. JAMA. 2021;326(15):1504-1515.

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Aaron Lessen, MD

Educational Pearls:

Retrospective cohort study looked at return rate of discharged patients after receiving either phenobarbital or benzodiazepines or both in the ED for treatment of alcohol withdrawal
Patients who received benzodiazepines had a 25% chance of returning in 3 days versus a 10% chance of returning in 3 days for those who received phenobarbital
13% of patients returned in 3 days after receiving both phenobarbital and benzodiazepines
Phenobarbital may make it less likely for patients to come back to the ED after receiving treatment for alcohol withdrawal

References

Lebin JA, Mudan A, Murphy CE 4th, Wang RC, Smollin CG. Return Encounters in Emergency Department Patients Treated with Phenobarbital Versus Benzodiazepines for Alcohol Withdrawal. J Med Toxicol. 2022;18(1):4-10. doi:10.1007/s13181-021-00863-2

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Chris Holmes, MD

Educational Pearls:

Many are taught that patients with cocaine chest pain should not receive beta-blockers due to unopposed alpha agonism, but is this true?
363 consecutive admissions for chest pain with positive cocaine on urine toxicology were reviewed in a retrospective cohort study
60 patients in this cohort received a beta-blocker and multivariate analysis demonstrated a reduction in myocardial infarction risk
Another retrospective cohort study demonstrated no association of negative outcomes with beta-blocker administration in those with a recent positive result on cocaine urine toxicology
Two more recent meta-analyses were performed finding no association between adverse clinical outcomes and beta-blocker administration for cocaine chest pain
No prospective randomized-controlled trials have been performed to evaluate the use of beta-blockers for treatment of cocaine chest pain in the ED setting

References

Dattilo PB, Hailpern SM, Fearon K, Sohal D, Nordin C. Beta-blockers are associated with reduced risk of myocardial infarction after cocaine use [published correction appears in Ann Emerg Med. 2008 Jul;52(1):90]. Ann Emerg Med. 2008;51(2):117-125. doi:10.1016/j.annemergmed.2007.04.015

Rangel C, Shu RG, Lazar LD, Vittinghoff E, Hsue PY, Marcus GM. Beta-blockers for chest pain associated with recent cocaine use. Arch Intern Med. 2010;170(10):874-879. doi:10.1001/archinternmed.2010.115

Pham D, Addison D, Kayani W, et al. Outcomes of beta blocker use in cocaine-associated chest pain: a meta-analysis. Emerg Med J. 2018;35(9):559-563. doi:10.1136/emermed-2017-207065

Lo KB, Virk HUH, Lakhter V, et al. Clinical Outcomes After Treatment of Cocaine-Induced Chest Pain with Beta-Blockers: A Systematic Review and Meta-Analysis. Am J Med. 2019;132(4):505-509. doi:10.1016/j.amjmed.2018.11.041

Richards JR, Hollander JE, Ramoska EA, et al. β-Blockers, Cocaine, and the Unopposed α-Stimulation Phenomenon. J Cardiovasc Pharmacol Ther. 2017;22(3):239-249. doi:10.1177/1074248416681644

Lange RA, Cigarroa RG, Flores ED, et al. Potentiation of cocaine-induced coronary vasoconstriction by beta-adrenergic blockade. Ann Intern Med. 1990;112(12):897-903. doi:10.7326/0003-4819-112-12-897

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Aaron Lessen, MD

Educational Pearls:

Septic arthritis can occur at any joint, including the sternoclavicular joint
Sternoclavicular joint infections comprise 1% of all bone and joint infections
Patients who use intravenous drugs have a higher occurrence of this type of infection compared to the general population, accounting for 17% of all sternoclavicular joint infections
Usual treatment includes intravenous antibiotics and, in some cases, surgery

References

Tapscott DC, Benham MD. Sternoclavicular Joint Infection. [Updated 2021 Dec 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK551721/

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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Tune in for a double feature with our Equity, Diversity and Inclusion Award winners from this fall as Nick asks them about their backgrounds, what brought them into medicine and Emergency Medicine specifically.

Patricia is a 4th year medical student at PennMed. As a first-generation immigrant, college, and medical student, she is committed to actively promoting and being an advocate for diversity, equity, and inclusion because she sees the value in having a diverse workforce to build a more equitable health care system. In diversity, there is beauty, there is growth and there is strength.

Leyanet is an MS4 at Caribbean Medical University. As a Cuban refugee, she strives to facilitate better rapport & cultural sensitivity to those who are underrepresented. She believes in the importance of having a workforce paradigm that comprehensively represents the community. Leyanet aspires to be a transformational leader & be a role model for others pursuing medicine to demonstrate that shattering glass ceilings and creating an inclusive workplace is important & possible.

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Contributor: Jared Scott, MD

Educational Pearls:

Variability of organisms in infecting the myocardial valves
Duke Criteria for Infective Endocarditis includes three categories that can be used to definitively diagnose endocarditis
Pathologic Criteria
pathological evidence of infection
Major Clinical Criteria
positive blood cultures
positive echocardiogram findings (TEE is more sensitive than a TTE)
Minor Clinical Criteria (must include all of the below criteria)
Fever
Underlying heart condition or IV drug use
Vascular phenomena (includes Janeway’s lesions)
Immunologic phenomena (includes Osler’s nodes, Roth spots)
Positive blood cultures or serologic evidence of infection with bacteria known to cause endocarditis
Some studies show up to a 33% one-year mortality of people diagnosed with endocarditis
This criteria was developed by David Durack, MD and he was affiliated with Duke University, shout out to Dr. Pete Bakes!

References

https://www.mdcalc.com/duke-criteria-infective-endocarditis

https://www.youtube.com/watch?v=3NLtNg-pqv0

Holland TL, Baddour LM, Bayer AS, Hoen B, Miro JM, Fowler VG Jr. Infective endocarditis. Nat Rev Dis Primers. 2016;2:16059. Published 2016 Sep 1. doi:10.1038/nrdp.2016.59

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Jared Scott, MD

Educational Pearls:

Often present with complaints of sore throat, pain with swallowing, difficulty swallowing, voice change, and possible fever
Retrospective study from 2018 evaluated outcomes of peritonsillar abscess with two management arms, surgical vs. non-surgical treatment
Non-surgical treatment only included IV fluids as well as IV ceftriaxone + clindamycin; Surgical treatment included either needle aspiration or incision and drainage of the abscess as well as the medical treatment from the non-surgical arm
Failure rate in both arms were statistically equivalent, but patients in the surgical arm had more days missed from work and more use of opioid medications for pain

References

Battaglia A, Burchette R, Hussman J, Silver MA, Martin P, Bernstein P. Comparison of Medical Therapy Alone to Medical Therapy with Surgical Treatment of Peritonsillar Abscess. Otolaryngol Head Neck Surg. 2018;158(2):280-286. doi:10.1177/0194599817739277

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Don Stader, MD Educational Pearls:

Fentanyl’s common administration route through pills has lowered the psychological barrier of using opioid compared to injecting and smoking heroin
Fentanyl is showing up in all illicit drugs with documented cases even in marijuana
Testing for fentanyl is difficult and requires a send out test because UA does not show up not common in ED but can better inform our care
Fentanyl doesn’t show up on UA drug screen and requires a send out test, thus we should ask patients if they’re using fentanyl specifically
Send any patient using an illicit drug home with Narcan to protect them from potential opioid overdoses
Start patients on buprenorphine for opioid withdrawal in the ED
Fentanyl is very lipophilic, thus patients require longer washout times (sometimes over 24 hours) before buprenorphine induction to avoid precipitated withdrawal

References:

Adams, K.K., Machnicz, M. & Sobieraj, D.M. Initiating buprenorphine to treat opioid use disorder without prerequisite withdrawal: a systematic review. Addict Sci Clin Pract 16, 36 (2021). https://doi.org/10.1186/s13722-021-00244-8

Moustaqim-Barrette, A., Dhillon, D., Ng, J. et al. Take-home naloxone programs for suspected opioid overdose in community settings: a scoping umbrella review. BMC Public Health 21, 597 (2021). https://doi.org/10.1186/s12889-021-10497-2

*Image from NIDA

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Contributor: Nick Tsipis, MD

Educational Pearls:

Acute hyperkalemia is characterized as serum K of 5.4 or higher in non-hemolyzed samples
Hyperkalemia is commonly associated with end stage renal disease, acute kidney injury or acute renal failure
Cardiac dysrhythmias are the primary concern with hyperkalemia, common EKG changes (and approximate serum levels) can include:
- Peaked T waves that start to show at serum K of 6
- Second sign is lengthening of PR and QRS intervals due to extended repolarization
- Severe hyperkalemia manifests as a sine wave around serum of 8-9
Three approaches to treat hyperkalemia:
- Stabilize cardiac membrane with calcium
- Shift potassium back into the cell, insulin and albuterol are common agents used.
- Potassium binding for excretion
Cochrane review showed no significant effects of Kayexalate on serum K in 4 hours
Bowel necrosis is a rare adverse event that can occur with Kayexalate
More myths and misconceptions about hyperkalemia addressed in reference below!

References:

Gupta AA, Self M, Mueller M, Wardi G, Tainter C. Dispelling myths and misconceptions about the treatment of acute hyperkalemia. Am J Emerg Med. 2022;52:85-91. doi:10.1016/j.ajem.2021.11.030

Mahoney BA, Smith WA, Lo DS, Tsoi K, Tonelli M, Clase CM. Emergency interventions for hyperkalaemia. Cochrane Database Syst Rev. 2005;2005(2):CD003235. Published 2005 Apr 18. doi:10.1002/14651858.CD003235.pub2

Li T, Vijayan A. Insulin for the treatment of hyperkalemia: a double-edged sword?. Clin Kidney J. 2014;7(3):239-241. doi:10.1093/ckj/sfu049

Summarized by Mason Tuttle| Edited by Nick Tsipis, MD

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Dr. Kim Nordstrom, a practicing emergency psychiatrist and associate professor with the University of Colorado, discusses various work-up models alongside valuable bedside tools for elderly patients with acute psychosis. In this podcast, she explores the methods to differentiate primary psychiatric psychosis from medically mediated psychosis in the elderly using an empirical bedside tool. Furthermore, Dr. Nordstrom educates our listeners on the treatment modalities available and currently recommended for new psychosis in the elderly.

Key Points:

Non-psychiatric causes of psychosis include lobar degeneration, sensory deficits, pharmacologic mediators, and others.
ADEPT tool, developed by CPE under an ACEP sponsorship, is a useful guideline for rapid and reliable assessment of psychosis in the elderly.
DTS (delirium triage screen) tool, embedded in the ADEPT, is 98% sensitive to rule-out delirium.
BCAM (brief concussion assessment method) is used if DTS is positive to rule-in delirium with high specificity.

ADEPT Tool: https://www.acep.org/patient-care/adept

DTS Tool: http://eddelirium.org/delirium-assessment/dts-calculator/

BCAM Tool: http://eddelirium.org/delirium-assessment/bcam-calculator/

Source: Shenvi C, Kennedy M, et al. Managing delirium and agitation in the older emergency department patient: The ADEPT Tool. Ann Emerg Med. 2020 Feb; 75(2): 136–145.

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Contributor: Nick Tsipis, MD

Educational Pearls:

Observational study in Israel evaluated cohort of vaccinated pregnant women receiving the initial Pfizer-BioNTech COVID-19 mRNA vaccine
Looked at 24,288 newborns with about 16,697 exposed to maternal vaccination in utero
Longitudinal follow up showed no significant difference in preterm births, neonatal hospitalizations, post-natal hospitalizations, congenital abnormalities, or mortality
While this is not a randomized-controlled trial, this observational trial has a very large population that was studied supporting the safety profile of birth outcomes relating to receiving COVID mRNA vaccines during pregnancy

References

Goldshtein I, Steinberg DM, Kuint J, et al. Association of BNT162b2 COVID-19 Vaccination During Pregnancy With Neonatal and Early Infant Outcomes [published online ahead of print, 2022 Feb 10]. JAMA Pediatr. 2022;e220001. doi:10.1001/jamapediatrics.2022.0001

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Chris Holmes, MD

Educational Pearls:

Dr. Carl Reinhold August Wunderlich, of the mid-1800s, was the first physician to suggest temperature was related to disease processes and his measurements set the 37˚C (98.6˚F) as the baseline temperature
Thermometers were adapted to be sold to the public with guidelines for temperature measurement interpretation
Taller and thinner individuals, anyone taking a temperature in the morning, and the elderly have decreased temperatures
Temperature averages have been decreased and the actual average temperature appears to be closer to 97.5˚ currently

References

Wright WF. Early evolution of the thermometer and application to clinical medicine. J Therm Biol. 2016;56:18-30. doi:10.1016/j.jtherbio.2015.12.003

Geneva II, Cuzzo B, Fazili T, Javaid W. Normal Body Temperature: A Systematic Review. Open Forum Infect Dis. 2019;6(4):ofz032. Published 2019 Apr 9. doi:10.1093/ofid/ofz032

Chen W. Thermometry and interpretation of body temperature [published correction appears in Biomed Eng Lett. 2019 Feb 25;9(1):19]. Biomed Eng Lett. 2019;9(1):3-17. Published 2019 Feb 9. doi:10.1007/s13534-019-00102-2

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Jared Scott, MD

Educational Pearls:

ACEP survey was done in 2018 looking at violence towards staff in the ED with only 10% of those solicited responding
Survey found 47% of respondents were assaulted and 71% had witnessed violence towards staff
Regarding what was done about the violence, 28% said patients were flagged by the hospital, 21% said patient was arrested by police/hospital security, 6% of the cases resulted in the hospital pressing charges, and in 3% of cases the staff were advised to press charges
Analyzing the type of violence that occurred, it was found that in 44% of the incidents staff were hit/slapped, 30% were spit on, 28% were punched, 27% were kicked, 17% were scratched, 6% were bitten, 2% were assaulted with a weapon, and 1% were sexually assaulted
ED violence is a very serious matter and you can learn more about the survey and initiatives at the links below

References

https://www.acep.org/administration/violence-in-the-emergency-department-resources-for-a-safer-workplace/

https://www.emergencyphysicians.org/press-releases/2018/10-2-2018-violence-in-emergency-departments-is--increasing-harming-patients-new-research-finds

https://stopedviolence.org/

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Peter Bakes, MD

Educational Pearls:

Tubo-ovarian abscess is a rare complication of pelvic inflammatory disease
Usually presents with chief complaint of abdominal pain and is often diagnosed by CT of the abdomen/pelvis
Hospitalization is indicated 60-80% of patients improve with an IV anaerobic cephalosporin (cefoxitin or cefotetan) with doxycycline or using clindamycin and gentamicin
Mortality can occur in up to 5% of patients, often as a result of progression to septic shock

References

Kairys N, Roepke C. Tubo-Ovarian Abscess. [Updated 2021 Jul 18]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448125/

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Aaron Lessen, MD

Educational Pearls:

Normal saline is thought to interfere with renal function and cause an acidosis and balanced fluids (like lactated ringers) are a better option
The SALT-ED trial and SMART trial showed a small benefit with renal injury and need for dialysis using balanced fluid in critically ill patients
Recent multicenter RCT in Brazil evaluated balanced fluids versus normal saline and looked at 90-day mortality
Found no difference in 90-day mortality or secondary outcomes like renal function
PLUS trial is currently being done in Australia and New Zealand to further evaluate fluid choice
Larger trials don’t show a major difference at this point, keep an eye out for future trials

References

Semler MW, Wanderer JP, Ehrenfeld JM, et al. Balanced Crystalloids versus Saline in the Intensive Care Unit. The SALT Randomized Trial. Am J Respir Crit Care Med. 2017;195(10):1362-1372. doi:10.1164/rccm.201607-1345OC

Semler MW, Self WH, Wanderer JP, et al. Balanced Crystalloids versus Saline in Critically Ill Adults. N Engl J Med. 2018;378(9):829-839. doi:10.1056/NEJMoa1711584

Zampieri FG, Machado FR, Biondi RS, et al. Effect of Intravenous Fluid Treatment With a Balanced Solution vs 0.9% Saline Solution on Mortality in Critically Ill Patients: The BaSICS Randomized Clinical Trial [published online ahead of print, 2021 Aug 10]. JAMA. 2021;326(9):1-12. doi:10.1001/jama.2021.11684

https://clinicaltrials.gov/ct2/show/NCT02721654

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Aaron Lessen, MD

Educational Pearls:

Techniques regarding ring removal in the ED were evaluated in a recent study which looked at using trauma shears versus the motorized ring cutters
A certain type of trauma shear has a ring-cutter attached to it, 7 seconds to remove vs. about 70 seconds for motorized ring cutters
Both the users of the devices and the patients preferred the ring-cutter shears

References

Walter J, DeBoer M, Koops J, Hamel LL, Rupp PE, Westgard BC. Quick cuts: A comparative study of two tools for ring tourniquet removal. Am J Emerg Med. 2021;46:238-240. doi:10.1016/j.ajem.2020.07.039

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Aaron Lessen, MD Educational Pearls:

Recent study evaluated budesonide for outpatient COVID-19 infection treatment to see if there was a decrease in length of illness or hospitalization rates
Found patients who received a budesonide inhaler had recovery times that were about 3 days shorter and there was a slight (non-significant) decrease in hospitalizations

References

Berezowski I, Patel J, Shaw M, Pourmand A. High-dose budesonide for early COVID-19. Lancet. 2021;398(10317):2146-2147. doi:10.1016/S0140-6736(21)02441-7

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Aaron Lessen, MD

Educational Pearls:

An endotracheal tube introducer or bougie are often used as a rescue device during difficult intubations as they are small and can be placed blindly
Large randomized-controlled trial looked at first-pass bougie use versus standard intubation to determine if there was improvement in first-pass success rate
No difference in first-pass success rate, about 80% for both techniques
This does not mean that bougies are not great rescue devices or options for managing an airway

References

Driver BE, Semler MW, Self WH, et al. Effect of Use of a Bougie vs Endotracheal Tube With Stylet on Successful Intubation on the First Attempt Among Critically Ill Patients Undergoing Tracheal Intubation: A Randomized Clinical Trial. JAMA. 2021;326(24):2488–2497.

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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Dr. Kim Nordstrom discusses a valuable bedside tool for evidence-based assessment in patients that visit the ED and are at risk for suicidality. Dr. Nordstrom is a practicing emergency psychiatrist and associate professor with the University of Colorado. As a developer and user of the tool, Dr. Nordstrom gives us invaluable insight into a new avenue for psychiatric care in emergency medicine.

Educational Pearls:

An app-based tool made in conjunction with ACEP
Identifying suicidal risk for each patient, including assessment of clues like bodily injuries
Communicating with patients to create a safe space and enhance rapport
Assessing for threats such as environmental or personal objects
Risk assessment; previous attempts, mental state, life stressors, etc.
Risk reduction once discharge is thought possible
Extension of care once patients leave the ED

Link to Access the ICAR2E Tool

References

Wilson MP, Moutier C, et al. Emergency department recommendations for suicide prevention in adults: The ICAR2E mnemonic and a systematic review of the literature. Am J Emerg Med. 2020; 38:571-581.

Summarized by Jorge Chalit

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Contributor: Aaron Lessen, MD

Educational Pearls:

Think about giving take home naloxone kits for anyone on long-term opioids as well as anyone with an opioid use disorder, those in opioid withdrawal, or those who recently overdosed on opioids
Also consider for individuals with non-opioid substance use disorders
For patients seen in the ED with an opioid overdose the 1-year mortality is about 5% and 1-month mortality is about 1%
Also 50% of accidental pediatric overdose deaths are due to opioids, so ensuring naloxone is present in the household can save lives
Prescriptions have a very low fill rate, so getting naloxone in the hands of people before they leave is important

References

Strang J, McDonald R, Campbell G, et al. Take-Home Naloxone for the Emergency Interim Management of Opioid Overdose: The Public Health Application of an Emergency Medicine. Drugs. 2019;79(13):1395-1418. doi:10.1007/s40265-019-01154-5

Katzman JG, Takeda MY, Greenberg N, et al. Association of Take-Home Naloxone and Opioid Overdose Reversals Performed by Patients in an Opioid Treatment Program. JAMA Netw Open. 2020;3(2):e200117. Published 2020 Feb 5. doi:10.1001/jamanetworkopen.2020.0117

Weiner SG, Baker O, Bernson D, Schuur JD. One-Year Mortality of Patients After Emergency Department Treatment for Nonfatal Opioid Overdose. Ann Emerg Med. 2020;75(1):13-17. doi:10.1016/j.annemergmed.2019.04.020

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Nick Tsipis, MD Educational Pearls:

Prothrombin complex concentrate (Kcentra) and Vitamin K are used to reverse life-threatening bleeds in patients on warfarin (Coumadin)
Factors II, VII, IX, and X are included in four-factor PCC
PCC/Kcentra dosing is 500-2000 units based on INR and patient weight
PROPER3 RCT was a non-inferiority trial done to evaluate standardized dosing of PCC/Kcentra versus variable dosing based on INR and weight
Looked at end-points to assess hemostasis, but ultimately this trial did not show non-inferiority of standardized dosing compared to variable dosing

References

Abdoellakhan RA, Khorsand N, Ter Avest E, et al. Fixed Versus Variable Dosing of Prothrombin Complex Concentrate for Bleeding Complications of Vitamin K Antagonists-The PROPER3 Randomized Clinical Trial. Ann Emerg Med. 2022;79(1):20-30. doi:10.1016/j.annemergmed.2021.06.016

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Nick Hatch, MD

Educational Pearls:

Botulism requires a prompt clinical diagnosis as lab results can take about 5 days to return
Whale blubber, honey, home fermented foods, homemade wine (especially the wine made in prison), and improperly stored canned food can all contain the toxin
The botulinum toxin is create by a Clostridium botulinum that is prevalent on our food and in the soil, but the toxin is readily degraded with heat and light
Blocks release of acetylcholine at the neuromuscular junction preventing release of neurotransmitter and therefore the propagation of an electrical nerve potential
Descending paralysis, often first including bulbar muscles, and anticholinergic symptoms can be present on exam
Infantile botulism, classically seen as floppy baby syndrome, occurs up to a week after ingestion, because the infant GI tract is not acidic enough to deactivate the toxin
Antitoxin is available to neutralize the botulism toxin present, but it cannot prevent the already established symptoms

References

Jeffery IA, Karim S. Botulism. [Updated 2021 Jul 19]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459273/

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Ricky Dhaliwal, MD

Educational Pearls:

Esophageal food impaction can be managed in the ED prior to calling GI for endoscopy
Coca-cola, glucagon, benzodiazepines, calcium channel blockers, and dissolved nitroglycerin are all options to try
For pediatric patients, weighted bougies can be used under sedation to attempt retrieval of the food bolus
Always evaluate airway status, especially if the patient cannot maintain secretions

References

Long B, Koyfman A, Gottlieb M. Esophageal Foreign Bodies and Obstruction in the Emergency Department Setting: An Evidence-Based Review. J Emerg Med. 2019;56(5):499-511. doi:10.1016/j.jemermed.2019.01.025

Khayyat YM. Pharmacological management of esophageal food bolus impaction. Emerg Med Int. 2013;2013:924015. doi:10.1155/2013/924015

Schimmel J, Slauson S. Swallowed Nitroglycerin to Treat Esophageal Food Impaction. Ann Emerg Med. 2019;74(3):462-463. doi:10.1016/j.annemergmed.2019.04.003

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Aaron Lessen, MD

Educational Pearls:

Biggest study to date examined new protocol for repeat head CT in anticoagulated elderly patients with head trauma and an initial negative head CT
- 0.5%-6% of patients in this category will get a delayed ICH and this can occur up to a week out from initial injury
18% of the study group had an ICH on initial head CT, but the rest who had negative head CT initially received a repeat head CT at 6 hours
0.9% had a bleed identified on repeat head CT 6 hours after initial imaging, but of this group no one had an intervention for this bleed
Suggests repeat head CT may not be needed and that good counseling for return precautions and discharge is a reasonable disposition in caring for these patients
Supratherapeutic INR was a risk factor for delayed bleed, so they should be treated as a higher risk group of patients

References

Borst J, Godat LN, Berndtson AE, Kobayashi L, Doucet JJ, Costantini TW. Repeat head computed tomography for anticoagulated patients with an initial negative scan is not cost-effective. Surgery. 2021;170(2):623-627. doi:10.1016/j.surg.2021.02.024

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Alicia Oberle, MD

Educational Pearls:

Nitrous oxide (N2O) can cause a vitamin B12 deficiency in patients after regular use
N2O is used in procedural sedation but also as a popular recreational drug
N2O binds and inactivate B12 in the body, therefore decreasing usable supply
Lack of B12, which is essential for myelinating nerves, can lead to subacute combined degeneration of the spinal cord
Presentation may include paresthesias, ataxia, gait changes, or bilateral lower extremity motor weakness
B12 can be normal on labs, as the B12 is present but inactivated
Treatment is daily B12 injections and oral supplementation

References

Stockton L, Simonsen C, Seago S. Nitrous oxide-induced vitamin B12 deficiency. Proc (Bayl Univ Med Cent). 2017;30(2):171-172. doi:10.1080/08998280.2017.11929571

Samia AM, Nenow J, Price D. Subacute Combined Degeneration Secondary to Nitrous Oxide Abuse: Quantification of Use With Patient Follow-up. Cureus. 2020;12(10):e11041. Published 2020 Oct 19. doi:10.7759/cureus.11041

Edigin E, Ajiboye O, Nathani A. Nitrous Oxide-induced B12 Deficiency Presenting With Myeloneuropathy. Cureus. 2019;11(8):e5331. Published 2019 Aug 6. doi:10.7759/cureus.5331

*Image obtained from Wikimedia author Hansmuller and licensed under Creative Commons Attribution-Share Alike 4.0 International license.

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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Educational Pearls:

Glucagon can be used to treat hypoglycemia and esophageal foreign body, but it can also be used in beta-blocker toxicity to bypass cardiac beta-blockade
The superior option for treating bradycardia due to beta-blocker toxicity is glucagon
Glucagon has decreased efficacy in patients with heart failure, so increased doses up to 10 mg might be required in the event of beta-blocker toxicity

References

Khalid MM, Galuska MA, Hamilton RJ. Beta-Blocker Toxicity. [Updated 2021 Jul 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448097/

Rotella JA, Greene SL, Koutsogiannis Z, et al. Treatment for beta-blocker poisoning: a systematic review. Clin Toxicol (Phila). 2020;58(10):943-983. doi:10.1080/15563650.2020.1752918

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Jared Scott, MD

Educational Pearls:

A rust ring can occur after a metallic foreign body is left in the eye for a prolonged period of time
Issues occur when the rust ring is left as it can epithelialize and become a permanent spot in the patient’s vision
An eye burr or Alger brush can help to gouge out the rust ring in the emergency setting
These tools have a failsafe mechanism to prevent the eye burr from going through layers past the cornea (though this does not work if the foreign body is already through the cornea)
Referral to ophthalmology, antibiotic drops, and dilating drops are recommended options upon discharge
Complications include poor wound healing, scarring, and infection

References

Camodeca AJ, Anderson EP. Corneal Foreign Body. [Updated 2021 Apr 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK536977/

https://www.reviewofoptometry.com/article/no-insult-to-injury-managing-foreign--body-removal

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Aaron Lessen, MD

Educational Pearls:

Pulse checks are necessary during CPR to check for return of spontaneous circulation (ROSC)
Previous studies have shown that assessing ROSC with palpating for pulse are not a very consistent
Study compared palpating pulses at carotid/femoral artery versus a newly contrived gold standard for pulse checks
The gold standard used was an increase in end tidal CO2 + cardiac activity on ultrasound + perfusing rhythm on ECG
Carotid artery palpation was the best location to confirm pulse during pulse check, although femoral artery palpation
- Carotid artery palpation was 92% accurate versus 82% accuracy with femoral pulse check
Regardless of chosen site, remember 10 seconds is the maximum amount of time for a pulse check before resuming CPR

References

Yılmaz G, Bol O. Comparison of femoral and carotid arteries in terms of pulse check in cardiopulmonary resuscitation: A prospective observational study. Resuscitation. 2021;162:56-62. doi:10.1016/j.resuscitation.2021.01.042

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Aaron Lessen, MD

Educational Pearls:

Study of nearly 400 patients evaluating giving calcium during cardiac arrest with the endpoint as return of spontaneous circulation (ROSC)
Compared giving 1 amp calcium chloride with each round of epinephrine for the first two rounds of epinephrine versus saline placebo
ROSC occurred in 19% of patients in the calcium groups versus 27% in saline placebo group
No magic drugs in cardiac arrest, good CPR and early defibrillation are still the most important factors for ROSC in cardiac arrest

References

Vallentin MF, Granfeldt A, Meilandt C, et al. Effect of Intravenous or Intraosseous Calcium vs Saline on Return of Spontaneous Circulation in Adults With Out-of-Hospital Cardiac Arrest: A Randomized Clinical Trial. JAMA. 2021;326(22):2268-2276. doi:10.1001/jama.2021.20929

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Peter Bakes, MD

Educational Pearls:

High concern causes of third trimester vaginal bleeding include placenta previa, placental abruption, or vasa previa
In placenta previa, the placenta implants over the cervix and this condition
- Often noted during routine prenatal care on transabdominal ultrasound
Patients present with painful vaginal bleeding, usually in the absence of trauma
Avoid pelvic exam, transvaginal ultrasound, or digital vaginal exam in placenta previa
Risk factors for placenta previa include multiple gestations, previous medical abortions, advanced maternal age, and previous placenta previa
Management usually includes admission to the hospital
- 37 weeks: admission for c-section
- 34-37 weeks: judgment call based on maternal/fetal stability
- <34 weeks: steroids for fetal lung maturation and delay delivery

References

Anderson-Bagga FM, Sze A. Placenta Previa. [Updated 2021 Jun 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK539818/

Young JS, White LM. Vaginal Bleeding in Late Pregnancy. Emerg Med Clin North Am. 2019;37(2):251-264. doi:10.1016/j.emc.2019.01.006

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

*Image from BruceBlaus via Wikimedia Commons licensed under Creative Commons license

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Contributor: Aaron Lessen, MD

Educational Pearls:

Study examined patient perceptions of providers wearing traditional white coats, fleece coats and soft-shell jackets
Found that white coats were seen as more professional than other types of dress
Also found that female physicians were viewed as less professional than their male counterparts regardless of dress
Older respondents thought more of white coats than younger respondents
Patient perspective should be considered and reiterating roles may help build relationships with patients

References

Xun H, Chen J, Sun AH, Jenny HE, Liang F, Steinberg JP. Public Perceptions of Physician Attire and Professionalism in the US. JAMA Netw Open. 2021;4(7):e2117779. Published 2021 Jul 1. doi:10.1001/jamanetworkopen.2021.17779

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Ian Gillman, PA-C

Educational Pearls:

Acute mesenteric ischemia is a condition where bowel loses blood supply from an acute occlusion of the mesenteric arteries
A frequent sign is abdominal pain that is out of proportion to the exam
Atrial fibrillation is one risk factor for mesenteric ischemia
Treatment includes anticoagulation and possible surgical intervention depending on the extent of the ischemia

References

Monita MM, Gonzalez L. Acute Mesenteric Ischemia. [Updated 2021 Jun 29]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-.

Kühn F, Schiergens TS, Klar E. Acute Mesenteric Ischemia. Visc Med. 2020;36(4):256-262. doi:10.1159/000508739

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Aaron Lessen, MD

Educational Pearls:

Study evaluating patient outcomes after traumatic brain injury (TBI) over 1 year
Trial followed patients with severe TBI (GCS 3-8) and moderate TBI (GCS 9-12)
At 1 year out ½ of the severe TBI group were able to be independent for at least 8 hours per day; ⅔ were independent to this level at one year in the moderate TBI group
¼ of the patient who were in a vegetative state 2 weeks after the traumatic brain injury had good outcomes at 1 year

References

McCrea MA, Giacino JT, Barber J, et al. Functional Outcomes Over the First Year After Moderate to Severe Traumatic Brain Injury in the Prospective, Longitudinal TRACK-TBI Study. JAMA Neurol. 2021;78(8):982-992. doi:10.1001/jamaneurol.2021.2043

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Adam Barkin, MD

Educational Pearls:

Seasonal Affective Disorder (SAD) a form of seasonal depression which can result in trouble sleeping, concentration difficulties, changes in appetite, and decreased mood
SAD is a common condition affecting millions of people in the US
Coupling this with the stresses of COVID, these affects may be compounded
To reduce the effects of SAD:
- Stick to a routine
- Exercise
- Light therapy
- Engage with your community
- Meditation
- Tangible bucket list to set goals for the winter
- Nostalgic activity

References

Melrose S. Seasonal Affective Disorder: An Overview of Assessment and Treatment Approaches. Depress Res Treat. 2015;2015:178564. doi:10.1155/2015/178564

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

The Emergency Medical Minute offers AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at https://emergencymedicalminute.org/cme-courses/ and create an account.

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Contributor: Aaron Lessen, MD

Educational Pearls:

End tidal CO2 is accurate to 1-4 mmHg in intubated patient but use with those on positive pressure ventilation like BiPAP is unclear
Study looked at patients on BiPAP for COPD or CHF and found end tidal CO2 measurements were significantly underestimated when compared to VBG levels
End tidal CO2 measurements for those on positive pressure ventilation appears to be inaccurate

References

Uzunay H, Selvi F, Bedel C, Karakoyun OF. Comparison of ETCO2 Value and Blood Gas PCO2 Value of Patients Receiving Non-invasive Mechanical Ventilation Treatment in Emergency Department [published online ahead of print, 2021 Apr 27]. SN Compr Clin Med. 2021;1-5. doi:10.1007/s42399-021-00935-y

Casati A, Gallioli G, Scandroglio M, Passaretta R, Borghi B, Torri G. Accuracy of end-tidal carbon dioxide monitoring using the NBP-75 microstream capnometer. A study in intubated ventilated and spontaneously breathing nonintubated patients. Eur J Anaesthesiol. 2000;17(10):622-626. doi:10.1046/j.1365-2346.2000.00731.x

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Aaron Lessen, MD

Educational Pearls:

Recent study at a hospital in Chicago with a shortage of normal saline decided to push IV ceftriaxone rather than the typical infusion of the antibiotic
Retrospective chart analysis of about 800 patients to determine safety of giving a push dose of ceftriaxone
Only 1 complication due to the ceftriaxone causing a patient to vomit

References

Agunbiade A, Routsolias JC, Rizvanolli L, Bleifuss W, Sundaresan S, Moskoff J. The effects of ceftriaxone by intravenous push on adverse drug reactions in the emergency department. Am J Emerg Med. 2021;43:245-248. doi:10.1016/j.ajem.2020.03.022

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Nick Hatch, MD

Educational Pearls:

Inhaled nitric oxide or Flolan may be considered in COVID
- Flolan is a prostaglandin can be inhaled or given IV
These medications are classically used for right-sided heart failure, but may be used in COVID
Causes pulmonary vasodilation to reduce the resistance against the right ventricle
Complications include hypotension and hemolysis, but nitric oxide can be turned off very quickly if needed
- Be careful and wean patients on nitric oxide for pulmonary hypertension

References

Lotz C, Muellenbach RM, Meybohm P, et al. Effects of inhaled nitric oxide in COVID-19-induced ARDS - Is it worthwhile?. Acta Anaesthesiol Scand. 2021;65(5):629-632. doi:10.1111/aas.13757

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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Educational Pearls:

Organophosphates affect the cholinergic system by inhibiting acetylcholinesterase affecting muscarinic and nicotinic receptors
Symptoms include lacrimation, salivation, bronchoconstriction, blurred vision, bradycardia, bronchorrhea, emesis, and diarrhea
Initially, the patient should be decontaminated to prevent further organophosphate exposure
Treatment consists of atropine every 5 minutes, 1-3 mg to start and doubling the dose each time it is given until reversal of symptoms is seen
Atropine only works on muscarinic receptors, so nicotinic receptor activation continues despite atropine administration resulting in muscle contractions and eventually respiratory arrest
Pralidoxime (2-PAM) should also be given to prevent the nicotinic effects and maturation of the organophosphate-acetylcholinesterase complex

References

Robb EL, Baker MB. Organophosphate Toxicity. [Updated 2021 Jul 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470430/

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Chris Holmes, MD

Educational Pearls:

Parkland Formula: 4 mL x [Total Body Surface Area Burned (%)] x [body weight (kg)] given in 24 hours
- 50% given over 8 hours and 50% given over the next 16 hours
Brooke Formula: 2 mL x [Total Body Surface Area Burned (%)] x [body weight (kg)] given in 24 hours
- 50% given over 8 hours and 50% given over the next 16 hours
2009 military study evaluated Parkland vs. Brooke formulas for severe burn patients and found the outcomes were the same
Guidelines are in flux on which formula to use, but reducing the overall volume using the Brooke formula can be done without significant change in morbidity or mortality
Using fluid responsiveness by measuring urine output and signs of fluid overload can help guide overall resuscitative approach in burn patients

References

Chung KK, Wolf SE, Cancio LC, et al. Resuscitation of severely burned military casualties: fluid begets more fluid. J Trauma. 2009;67(2):231-237. doi:10.1097/TA.0b013e3181ac68cf

Schaefer TJ, Nunez Lopez O. Burn Resuscitation And Management. [Updated 2021 Aug 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430795/

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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Educational Pearls:

Recent updates to treatment guidelines increased the 250 mg ceftriaxone IM dose to 500 mg ceftriaxone IM
IM dosing can be very painful, so other methods of administration can help decrease pain for patients
Using IV ceftriaxone instead of IM has no significant difference in pharmacokinetics or bioavailability, so it can be considered in patients with an IV already placed

References

St Cyr S, Barbee L, Workowski KA, et al. Update to CDC's Treatment Guidelines for Gonococcal Infection, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(50):1911-1916. Published 2020 Dec 18. doi:10.15585/mmwr.mm6950a6

Product Information: ROCEPHIN(R) IV, IM injection, ceftriaxone sodium IV, IM injection. Genentech USA, Inc. (per Manufacturer), South San Francisco, CA, 2010.

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Jared Scott, MD

Educational Pearls:

A press release from Merck introduced Molnupiravir for treatment of mild to moderate COVID-19
The yet to be published study is a randomized control trial at around 100 different sites
Reported outcomes were hospitalization and mortality from COVID and mortality from COVID
Molnupiravir was found to be twice as effective as placebo looking at these two endpoints (7% vs. 14%)
5 day course of the drug taken twice per day costs $700, but cost-saved from using this drug was $32,000 per patient

References

https://www.merck.com/news/merck-and-ridgebacks-investigational-oral-antiviral-molnupiravir-reduced-the-risk-of-hospitalization-or-death-by-approximately-50-percent-compared-to-placebo-for-patients-with-mild-or-moderat/

https://www.merck.com/news/merck-and-ridgebacks-molnupiravir-an-oral-covid-19-antiviral-medicine-receives-first-authorization-in-the-world/

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Nick Tsipis, MD

Educational Pearls:

Meaningful survival under 10% for out of hospital cardiac arrest
The most common cause of out-of-hospital cardiac arrest is due to cardiac ischemia
Study looked at whether taking patients without ST elevation who had an out-of-hospital cardiac arrest with return of spontaneous circulation (ROSC) should receive angiography upon arrival to the hospital
Took 530 patients and randomized to early vs. delayed angiography after resuscitation from out-of-hospital arrest
Found no benefit to early angiography using 30-day all-cause risk of death as the primary endpoint

References

Desch S, Freund A, Akin I, et al. Angiography after Out-of-Hospital Cardiac Arrest without ST-Segment Elevation [published online ahead of print, 2021 Aug 29]. N Engl J Med. 2021;10.1056/NEJMoa2101909. doi:10.1056/NEJMoa2101909

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Aaron Lessen, MD

Educational Pearls:

Classically, diverticulitis is diagnosed via CT scan and patients are discharged home on antibiotics if they are without complication
The DINAMO study is a multicenter open-label RCT that evaluated if it is safe to not give antibiotics to patients with mild acute diverticulitis
Found no difference in readmission, return visits to ED, pain control, or likelihood of surgical intervention between the group that was sent home with antibiotics and the group without
Medical societies have not reached a consensus on this issue, likely further studies need to be completed

References

Mora-López L, Ruiz-Edo N, Estrada-Ferrer O, et al. Efficacy and Safety of Nonantibiotic Outpatient Treatment in Mild Acute Diverticulitis (DINAMO-study): A Multicentre, Randomised, Open-label, Noninferiority Trial. Ann Surg. 2021;274(5):e435-e442. doi:10.1097/SLA.0000000000005031

*Image from Hellerhoff, CC BY-SA 3.0 https://creativecommons.org/licenses/by-sa/3.0, via Wikimedia Commons

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Peter Bakes, MD

Educational Pearls:

Ophthalmia Neonatorum encompasses any conjunctivitis that presents within the first 28 days of life
Neonates often receive prophylactic silver nitrate eye drops for gonorrhea prophylaxis, but the drops can cause chemical conjunctivitis
Etiology & Timing of Presentation:
- Silver nitrate conjunctivitis presents 0-2 days after birth
- Neisseria gonorrhae presents 2-5 days after birth
- Chlamydia trachomatis presents 5 days to 5 weeks
Neisseria gonorrhoeae conjunctivitis is vision-threatening, typically requiring admission and IV antibiotics with a 3rd generation cephalosporin

References

Castro Ochoa KJ, Mendez MD. Ophthalmia Neonatorum. [Updated 2021 Jul 22]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK551572/

US Preventive Services Task Force, Curry SJ, Krist AH, et al. Ocular Prophylaxis for Gonococcal Ophthalmia Neonatorum: US Preventive Services Task Force Reaffirmation Recommendation Statement. JAMA. 2019;321(4):394-398. doi:10.1001/jama.2018.21367

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Aaron Lessen, MD

Educational Pearls:

Preterm deliveries in the ED can be complex and preventing hypothermia is essential to the health of the baby
Recent meta-analysis examined methods for warming preterm deliveries to prevent hypothermia
The most effective way to warm the baby is by wrapping them in plastic

References

Abiramalatha T, Ramaswamy VV, Bandyopadhyay T, et al. Delivery Room Interventions for Hypothermia in Preterm Neonates: A Systematic Review and Network Meta-analysis. JAMA Pediatr. 2021;175(9):e210775. doi:10.1001/jamapediatrics.2021.0775

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Don Stader, MD

Educational Pearls:

Ivermectin is a Nobel-Prize winning antiparasitic used to treat filariasis and onchocerciasis
Ivermectin is receiving press due to a scientific study examining ivermectin on COVID-19 viral replication in vitro, but the dosages needed for this effect were much higher than is safe for human use
Ivermectin has since been studied in humans with no evidence suggesting it is a viable treatment for COVID-19
Ivermectin is a neurotoxin but at normal levels it does not cross the blood-brain barrier
Ivermectin toxicity can include altered mental status, seizures, coma, tachycardia, hypotension, nausea, vomiting and diarrhea
Treatment of suspected ivermectin overdose is predominately supportive

References

Caly L., Druce J.D., Catton M.G., Jans D.A., Wagstaff K.M. The FDA-approved drug ivermectin inhibits the replication of SARS-CoV-2 in vitro. Antivir Res. 2020;178:104787. doi: 10.1016/j.antiviral.2020.104787

López-Medina E, López P, Hurtado IC, et al. Effect of Ivermectin on Time to Resolution of Symptoms Among Adults With Mild COVID-19: A Randomized Clinical Trial. JAMA. 2021;325(14):1426–1435. doi:10.1001/jama.2021.3071

Roder JD, Stair EL. An overview of ivermectin toxicosis. Vet Hum Toxicol. 1998;40(6):369-370.

Roman YM, Burela PA, Pasupuleti V, Piscoya A, Vidal JE, Hernandez AV. Ivermectin for the treatment of COVID-19: A systematic review and meta-analysis of randomized controlled trials [published online ahead of print, 2021 Jun 28]. Clin Infect Dis. 2021;ciab591. doi:10.1093/cid/ciab591

Chandler RE. Serious Neurological Adverse Events after Ivermectin-Do They Occur beyond the Indication of Onchocerciasis?. Am J Trop Med Hyg. 2018;98(2):382-388. doi:10.4269/ajtmh.17-0042

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Alec Coston, MD

Educational Pearls:

Flash pulmonary edema or Sympathetic Crash Acute Pulmonary Edema (SCAPE) is a severe illness that requires aggressive treatment
Often in patients with heart failure and a sympathetic surge increasing heart rate, decreased diastolic filling, increased preload, and increased afterload causing pulmonary edema
Clinical diagnosis: acute onset diaphoresis and respiratory distress, hypoxia and tachypnea on exam
Bedside lung ultrasound will demonstrate B-lines, indicative of pulmonary edema
Treatment is nitroglycerin and BiPAP
Nitroglycerin drip can be started at 80 micrograms/minute, which is similar to the dose delivered by sublingual nitroglycerin

References

Stemple K, DeWitt KM, Porter BA, Sheeser M, Blohm E, Bisanzo M. High-dose nitroglycerin infusion for the management of sympathetic crashing acute pulmonary edema (SCAPE): A case series. Am J Emerg Med. 2021;44:262-266. doi:10.1016/j.ajem.2020.03.062

Agrawal N, Kumar A, Aggarwal P, Jamshed N. Sympathetic crashing acute pulmonary edema. Indian J Crit Care Med. 2016;20(12):719-723. doi:10.4103/0972-5229.195710

Wilson SS, Kwiatkowski GM, Millis SR, Purakal JD, Mahajan AP, Levy PD. Use of nitroglycerin by bolus prevents intensive care unit admission in patients with acute hypertensive heart failure. Am J Emerg Med. 2017;35(1):126-131. doi:10.1016/j.ajem.2016.10.038

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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In this podcast, we are back again with host, Jordan Ourada, and neurosurgeon, Dr. Eddie Tsvankin as they discuss an exciting and mind-blowing array of topics pertaining to neurosurgery. Listen as Dr. Tsvankin shares his views on not only the history of neurosurgery, but also the medical, surgical, and engineering advancements that are taking place today. You’ll also hear Dr. Tsvankin give intriguing details into how neurosurgeries are performed with cutting-edge technology including the exoscopes that are presently utilized at Swedish Medical Center. Finally, Jordan and Dr. Tsvankin delve into predictions for future advancements in neurosurgery and neurooncology, as well as why cancer seems more prevalent today than ever.

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Contributor: Donald Stader, MD

Educational Pearls:

Hip Dislocation
- Prolonged dislocations can impair blood supply to femoral head
- Hip dislocation for >6 hours puts patient at high risk for needing a hip replacement in the next two year
Knee Dislocation
- High mechanism
- Often looks anatomically normal on knee x-ray
- Vascular injuries of the popliteal artery can cause significant morbidity with some studies suggesting an 80% amputation rate if not treated within 6 hours
Ankle Dislocation
- Common dislocation and often co-occurs with ankle fractures (bimalleolar/trimalleolar)
- Pressure on the skin from the displaced joint can cause skin tenting, which can lead to skin necrosis
- Hematoma blocks work well for ankle reductions as an adjunct to or substitute for procedural sedation

References

Arnold C, Fayos Z, Bruner D, Arnold D. Managing dislocations of the hip, knee, and ankle in the emergency department. Emerg Med Pract. 2017;19(12):1-28.

Dawson-Amoah K, Raszewski J, Duplantier N, Waddell BS. Dislocation of the Hip: A Review of Types, Causes, and Treatment. Ochsner J. 2018;18(3):242-252. doi:10.31486/toj.17.0079

Patterson BM, Agel J, Swiontkowski MF, Mackenzie EJ, Bosse MJ; LEAP Study Group. Knee dislocations with vascular injury: outcomes in the Lower Extremity Assessment Project (LEAP) Study. J Trauma. 2007;63(4):855-858. doi:10.1097/TA.0b013e31806915a7

Ross A, Catanzariti AR, Mendicino RW. The hematoma block: a simple, effective technique for closed reduction of ankle fracture dislocations. J Foot Ankle Surg. 2011;50(4):507-509. doi:10.1053/j.jfas.2011.04.037

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Dylan Luyten, MD

Educational Pearls:

To place a Blakemore/Minnesota Tube:
- Insert into esophagus under visualization
- Inflate gastric port with 60 cc of air and obtain a chest xray to ensure the balloon below the diaphragm
- Once confirmed, place a total of 500cc of air into the gastric balloon via the gastric port
- Tie a liter saline bad to the tube using Kerlix and hang it off an IV pole or other object to provide about 2 lbs of traction
- Now the the tube is in place under traction, attach a manometer to the esophageal balloon port
- Provide low pressure to tamponade a variceal bleed, which is about 33 mmHg
This is a temporizing measure and often patients need to get a Transjugular Intrahepatic Portosystemic Shunt (TIPS) from interventional radiology for more definitive treatment

References

Powell M, Journey JD. Sengstaken-Blakemore Tube. [Updated 2021 Jul 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK558924/

Amazing video of placement by EM:RAP ProductionsPlacement of a Minnesota Tube for Bleeding Varices

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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On this episode of On The Streets, host, Jordan Ourada sits down with neurosurgeon/neurooncologist Dr. Eddie Tsvankin to discuss various topics concerning neurosurgery and how EMS workers in the field can better understand and manage neurological emergencies. In this episode specifically, you’ll hear Jordan and Dr. Tsvankin discuss topics including:

Priorities in caring for patients experiencing seizures
Short and long-term complications of tumor resection surgery
Specifics on how brain tumors are operated on and the difficult decisions that must be made ahead of time
Assessment of post-operative incisions and signs of infections
How chemotherapy and radiation effect the healing process for neurosurgery patients
Dr. Eddie’s thoughts on COVID and how it has impacted his career
The ins and outs of ventriculoperitoneal shunts

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Contributor: Dylan Luyten, MD

Educational Pearls:

Minnesota Tube has an extra port for suctioning otherwise is the same as a Blakemore Tube
Indicated in MASSIVE upper GI bleeding often due to esophageal varices
Esophageal varices are dilated, tortuous vessels in the esophagus due to increased portal venous pressure that can bleeding into the upper GI tract
Patients with massive upper GI bleed should be intubated prior to placing a Blakemore/Minnesota tube

References

Meseeha M, Attia M. Esophageal Varices. [Updated 2021 Aug 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448078/

Biecker E. Portal hypertension and gastrointestinal bleeding: diagnosis, prevention and management. World J Gastroenterol. 2013;19(31):5035-5050. doi:10.3748/wjg.v19.i31.5035

Photo from Wikimedia Commons

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Ricky Dhaliwal, MD

Educational Pearls:

Multiple RCTs and a Cochrane Review found there is no difference in wound infection rates when irrigating with tap water
Pressure of the water and how extensively the wound is irrigated were the most important factors affecting infection rates
Quantity and type of water were independently not as important

References

Fernandez R, Griffiths R. Water for wound cleansing. Cochrane Database Syst Rev. 2012;(2):CD003861. Published 2012 Feb 15. doi:10.1002/14651858.CD003861.pub3

Lewis K, Pay JL. Wound Irrigation. [Updated 2021 Jun 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK538522/

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Aaron Lessen, MD

Educational Pearls:

Patients with acute renal failure often need medical management for hyperkalemia
Those with severe electrolyte derangements or absent renal function may need emergent dialysis as well
Dialysis catheters are 12 or 14 french catheters placed in the right internal jugular or left subclavian
Placement is very similar to a central line or cordis catheter
Trialysis catheter is one option that has an extra port that can be used for regular medication administration and drawing blood
Do not default to use dialysis catheters for normal ED access due to risk of infection and clot development
While dialysis catheters are typically reserved for dialysis only, they can be used in extreme circumstances, such as a cardiac arrest

References

Co I, Gunnerson K. Emergency Department Management of Acute Kidney Injury, Electrolyte Abnormalities, and Renal Replacement Therapy in the Critically Ill. Emerg Med Clin North Am. 2019;37(3):459-471. doi:10.1016/j.emc.2019.04.006

Simon LV, Hashmi MF, Farrell MW. Hyperkalemia. [Updated 2021 Aug 14]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470284/

Akaraborworn O. A review in emergency central venous catheterization. Chin J Traumatol. 2017;20(3):137-140. doi:10.1016/j.cjtee.2017.03.003

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Aaron Lessen, MD

Educational Pearls:

Hyperkalemia can cause EKG changes such as a widened QRS
The fastest electrolyte results can be obtained off a VBG with electrolytes or point-of-care labs
Hyperkalemia may be reported as “hemolyzed” which indicated lysis of red blood cells and artificial elevation of the potassium level. However, always keep in mind the clinical context and look at other metabolic abnormalities like creatinine and BUN for other clues that it may actually not be hemolyzed

References

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Nick Tsipis, MD

Educational Pearls:

Fluid choice may have an impact on outcomes in resuscitation, and a meta-analysis has relevant insight into their use in sepsis and trauma patients
Large volume normal saline fluid resuscitation in sepsis is associated with acute kidney injury and metabolic acidosis compared to Lactated Ringers
Choice of fluid did not have significant differences in trauma patients for initial resuscitation

References

Tseng CH, Chen TT, Wu MY, Chan MC, Shih MC, Tu YK. Resuscitation fluid types in sepsis, surgical, and trauma patients: a systematic review and sequential network meta-analyses. Crit Care. 2020;24(1):693. Published 2020 Dec 14. doi:10.1186/s13054-020-03419-y

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Contributor: Nick Hatch, MD

Educational Pearls:

High flow nasal cannula (HFNC) or “heated high flow” can deliver higher oxygen levels than nasal cannula
It typically is used as an “intermediate” between oxygen via nasal cannula and other non-invasive positive pressure devices, such as BiPAP
Can modify both the FiO2 and flow rate
Maximum flow rate is typically 60 liters per minute (compare that to a typical breath that is 30-40 L/min)
Humidification of HFNC is important due to risk of epistaxis from drying out the nasal mucosa
Large energy expenditure to humidify airflow by a patient in respiratory distress, so humidified oxygen may help decrease this metabolic demand

References

Nishimura M. High-Flow Nasal Cannula Oxygen Therapy in Adults: Physiological Benefits, Indication, Clinical Benefits, and Adverse Effects. Respir Care. 2016;61(4):529-541. doi:10.4187/respcare.04577

Hacquin A, Perret M, Manckoundia P, et al. High-Flow Nasal Cannula Oxygenation in Older Patients with SARS-CoV-2-Related Acute Respiratory Failure. J Clin Med. 2021;10(16):3515. Published 2021 Aug 10. doi:10.3390/jcm10163515

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Aaron Lessen, MD

Educational Pearls:

Randomized controlled-trial evaluated intradermal injections of sterile water to manage low back pain versus an IV NSAID
Four intradermal injections of 0.1 cc sterile water in a square around the area of musculoskeletal pain
Reduction of pain was 7 points with the procedure and 2 points with the IV NSAID at 24 hours
12% in the injection group versus 50% in the IV NSAID group needed opioids
87% patient satisfaction in the injection group versus 16% patient satisfaction in the IV NSAID group

References

Tekin E, Gur A, Bayraktar M, Ozlu I, Celik BK. The effectiveness of intradermal sterile water injection for low back pain in the emergency department: A prospective, randomized controlled study. Am J Emerg Med. 2021;42:103-109. doi:10.1016/j.ajem.2021.01.038

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Don Stader, MD

Educational Pearls:

Those on chronic opioid therapy may have high tolerance to opioids and/or opioid hyperalgesia
Ketamine is a good adjunct for pain control in patients on chronic opioid therapy
To avoid the time constraints often required to push ketamine intravenously, it can be given orally:
- Ketamine IV 25-50 mg (~0.01-0.03 mg/kg) as a single dose by mouth

References

Blonk M, Koder B, et al. Use of oral ketamine in chronic pain management: A review. European Journal of Pain. 2009.

Schwenk ES, et al. Consensus guidelines on the use of intravenous ketamine infusions for acute pain management from the America Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine and the American Society of Anesthesiologists. Reg Anesth Pain Med. 2018.

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Aaron Lessen, MD

Educational Pearls:

Retrospective cohort study in the Kaiser system looked at over 4 million patients receiving antibiotics to determine the effect of penicillin allergy prompts in the EHR on antibiotic prescribing
Half of the sites removed prompts stating penicillin allergy and half kept the prompts
Patients with penicillin allergies who received cephalosporins went up from 20% to 27% in areas where the prompt was remove
No difference in mortality or no new allergies found between the two groups
Reduced the use of fluoroquinolones and clindamycin in the group without the prompt

References

Macy E, McCormick TA, Adams JL, et al. Association Between Removal of a Warning Against Cephalosporin Use in Patients With Penicillin Allergy and Antibiotic Prescribing. JAMA Netw Open. 2021;4(4):e218367. Published 2021 Apr 1. doi:10.1001/jamanetworkopen.2021.8367

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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Dr. Glenda Quan, trauma surgeon from Swedish Medical Center joins our host Jordan Ourada to review a case of an incorrectly placed IO and how to avoid it.

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Contributor: Aaron Lessen, MD

Educational Pearls:

Insulin pumps provide a continuous infusion of fast-acting insulin using a basal rate and bolus prior to meals
Some connect to a continuous glucometer but often blood glucose needs to be checked manually
Hypoglycemia is rarely due to a malfunctioning pump - there is usually an another external factor
Hyperglycemia can be caused by underdosing, illness, pump malfunction or expired insulin
The pump can be used to give a bolus of insulin in the emergency department if necessary
Stopping the device can be done manually on the device or disconnecting it from the tubing attachment - do not remove the tubing from the skin site if possible

References

Nimri R, Nir J, Phillip M. Insulin Pump Therapy. Am J Ther. 2020;27(1):e30-e41. doi:10.1097/MJT.0000000000001097

Sora ND, Shashpal F, Bond EA, Jenkins AJ. Insulin Pumps: Review of Technological Advancement in Diabetes Management. Am J Med Sci. 2019;358(5):326-331. doi:10.1016/j.amjms.2019.08.008

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Nick Tsipis, MD

Educational Pearls:

Prospective trial studied 5 mg IM droperidol to 10 mg IM olanzapine (Zyprexa) in the reducing levels of agitation
Time to adequate sedation was about 16 minutes for both agents
Droperidol was slightly less sedating than olanzapine and length of stay for olanzapine was longer
Olanzapine had a higher rate of requiring another agent for adequate sedation
Droperidol had a higher rate of adverse events (mainly extrapyramidal symptoms) than olanzapine
Remember to put the safety of the staff and patient at the forefront of sedation practices and be cognizant of the psychological effect of giving involuntary medications to patients

References

Cole JB, Stang JL, DeVries PA, Martel ML, Miner JR, Driver BE. A Prospective Study of Intramuscular Droperidol or Olanzapine for Acute Agitation in the Emergency Department: A Natural Experiment Owing to Drug Shortages. Ann Emerg Med. 2021;78(2):274-286. doi:10.1016/j.annemergmed.2021.01.005

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Jared Scott, MD

Educational Pearls:

Using LET, procedural sedation, and distraction techniques are often needed to successfully perform painful procedures in pediatrics patients
The technique of clown therapy has been studied as an adjunct to LET and other distraction techniques for procedures in pediatric patients
One randomized-controlled trial from 2016 found anxiety was greatly reduced using medical clown therapy to aid in painful procedures in pediatrics patients

References

Felluga M, Rabach I, Minute M, et al. A quasi randomized-controlled trial to evaluate the effectiveness of clowntherapy on children's anxiety and pain levels in emergency department. Eur J Pediatr. 2016;175(5):645-650. doi:10.1007/s00431-015-2688-0

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Peter Bakes, MD

Educational Pearls:

Paracentesis is a procedure where fluid is removed from the peritoneal cavity by needle
Indications for paracentesis include: large volume paracentesis (5-6L), diagnosis of transudative or exudative ascites, evaluation for spontaneous bacterial peritonitis (SBP)
Infection of ascitic fluid is more likely in transudative processes due to the increased frequency of paracentesis
E coli is the most common pathogen to cause SBP
Treatment with 3rd generation cephalosporin, like ceftriaxone

References

Aponte EM, Katta S, O'Rourke MC. Paracentesis. [Updated 2020 Sep 9]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK435998/

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Aaron Lessen, MD

Educational Pearls:

Sigmoid volvulus occurs when the sigmoid colon twists 180 to 360 degrees
10% of intestinal obstructions in the US; 50-70% of intestinal obstructions worldwide
More common in elderly patients with chronic constipation
Eventually may lead to bowel perforation, a surgical emergency
Treatment is sigmoidoscopy or sigmoid colectomy

References

Lieske B, Antunes C. Sigmoid Volvulus. [Updated 2021 Aug 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441925/

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Ramnik Dhaliwal, MD JD

Educational Pearls:

Pepper spray is a highly irritating compound with active ingredient of capsaicin
Techniques to help decontaminate and alleviate symptoms of an exposure include:
- Disrobing the patient to prevent further exposure
- Half milk of magnesia and half water mixture can be used to soothe the skin in the area of exposure
- Proparacaine followed by Morgan lens to irrigate the eye in adults
- Nasal cannula connected to a liter of normal saline can passively irrigate the eye in small children and other less than cooperating patients

References

Tidwell RD, Wills BK. Tear Gas and Pepper Spray Toxicity. [Updated 2020 Nov 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK544263/

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Neil Cella, MD

Educational Pearls:

Pylorus becomes hypertrophied and does not allow food or liquid to pass through to the duodenum
tOccurs between the ages of 3 weeks to 3 months
Classic presentation includes projectile nonbilious vomiting and palpable abdominal mass
Ultrasound can visualize/diagnose pyloric stenosis and the treatment is surgical correction
Be aware that electrolyte abnormalities and acid/base disturbances may occur

References

Garfield K, Sergent SR. Pyloric Stenosis. [Updated 2021 Feb 6]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK555931/

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Adam Barkin, MD

Educational Pearls:

Multi-center open-label non-inferiority trial looked at treatment of pneumothorax with a small-bore chest tube versus conservative management with exceptional follow up
316 patients ages 14-50 with moderate to large pneumothorax (>32% measured on CXR) were randomized into one of the two treatment arms
15% of the conservative group required further intervention as determined by prespecified protocols
94.4% of the intervention group had resolution at 8 weeks, whereas 98.5% of the conservative group had resolution at 8 weeks
- These data were affected by poor follow up
CXR resolution average of 16 days in the intervention group and 30 days in the conservative group
Symptom resolution was similar between the two groups (median 15 days vs. 14 days)
Recurrence at 12 months was 17% in interventional group vs 8% in conservative group
41 adverse events in intervention group and 13 adverse events in conservative group

References

Brown SGA, Ball EL, Perrin K, et al. Conservative versus Interventional Treatment for Spontaneous Pneumothorax. N Engl J Med. 2020;382(5):405-415. doi:10.1056/NEJMoa1910775

Franzen, D. (2019, November). Pneumothorax. Society of Academic Emergency Medicine. https://www.saem.org/about-saem/academies-interest-groups-affiliates2/cdem/for-students/online-education/m4-curriculum/group-m4-respiratory/pneumothorax.

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Randi Libbon, MD

The Core features of trauma-informed care include:

Patient empowerment, choice and collaboration. This means educating patients and allowing patients to make choices about their care when possible. Collaboration helps to level the power differential between patients and providers through shared decision making.
Safety and sensitivity: Developing health care settings and activities that ensure patients’ physical and emotional safety taking into account their diverse backgrounds of gender, sexuality, race, culture, and ethnicity
Trustworthiness and transparency: Creating clear expectations with patients about what proposed treatments entail, who will provide services, and how care will be provided.

Resources:

Reeves E. A synthesis of the literature on trauma-informed care. Issues Ment Health Nurs. 2015;36(9):698-709. doi: 10.3109/01612840.2015.1025319. PMID: 26440873.

Molloy L, Fields L, Trostian B, Kinghorn G. Trauma-informed care for people presenting to the emergency department with mental health issues. Emerg Nurse. 2020 Mar 10;28(2):30-35. doi: 10.7748/en.2020.e1990. Epub 2020 Feb 25. PMID: 32096370.

Key ingredients for Trauma-informed care from SAMHSA

https://www.samhsa.gov/sites/default/files/programs_campaigns/childrens_mental_health/atc-whitepaper-040616.pdf

The National Childhood Traumatic Stress Network:

https://www.nctsn.org/trauma-informed-care

The Science of Adverse Childhood Events and Toxic Stress:

https://www.acesaware.org/ace-fundamentals/the-science-of-aces-toxic-stress/

From the Institute for Health Care Improvement:

http://www.ihi.org/communities/blogs/how-trauma-informed-care-can-help-patients-and-clinicians-during-behavioral-health-emergencies

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Contributor: Neil Cella, MD

Educational Pearls:

<29 day old well-appearing febrile infant:
- 10% of patients <29 days old with a fever (>100.4) have an serious bacterial infection
- Most of these are UTIs, but also consider pneumonia and meningitis
- Requires CXR, LP, labs, and UA to work up cause of fever
29-60 day old well-appearing febrile infant:
- Can discharge without abx if CXR, lumbar puncture, labs and UA without signs of bacterial infection
If UA is positive for UTI a LP is still indicated for febrile infants <29 days old, but may not be required for febrile infants 29-60 days old

References

Hamilton JL, Evans SG, Bakshi M. Management of Fever in Infants and Young Children. Am Fam Physician. 2020;101(12):721-729.

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Aaron Lessen, MD

Educational Pearls:

Known risk factors for being awake and paralyzed in the OR include only receiving IV medications, long-acting paralytics, and no formal monitoring system for being awake
The ED-AWARENESS study, a prospective single-center study found 2.6% of patients with induced paralysis during mechanical ventilation were aware
Rocuronium was a risk factor for developing awareness while paralyzed in this study
Ensure adequate sedation during paralysis for mechanical ventilation in the ED setting, especially when using rocuronium

References

Pappal RD, Roberts BW, Winkler W, Yaegar LH, Stephens RJ, Fuller BM. Awareness With Paralysis in Mechanically Ventilated Patients in the Emergency Department and ICU: A Systematic Review and Meta-Analysis. Crit Care Med. 2021;49(3):e304-e314. doi:10.1097/CCM.0000000000004824

The Emergency Medical Minute offers AMA PRA Category 1 credits™ via online course modules. For more information and to access this content,, visit our website at www.emergencymedicalminute.org/cme-courses/ and create an account.

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Contributor: Aaron Lessen, MD

Educational Pearls:

Recent retrospective cohort study looked at elevated BP readings in the ED and correlation to underlying hypertension
Large cohort of over 30,000 patients found that nearly 50% had an elevated blood pressure reading in the ED
Less than 15% of patients with elevated BP readings in the ED were diagnosed with hypertension within 2 years
Only 25% of patients with BP readings >160/100 were diagnosed with hypertension within 2 years
Patients with an elevated blood pressure reading of >160/100 had only a slightly increased risk of stroke, transient ischemic attack, acute coronary syndrome, heart failure, or death in the next 2 years

References

McAlister FA, Youngson E, Rowe BH. Elevated Blood Pressures Are Common in the Emergency Department but Are They Important? A Retrospective Cohort Study of 30,278 Adults. Ann Emerg Med. 2021;77(4):425-432. doi:10.1016/j.annemergmed.2020.11.005

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Aaron Lessen, MD

Educational Pearls:

Recent RCT compared pain relief in patients receiving five medications for acute musculoskeletal pain
- Acetaminophen 1000mg/ibuprofen 400 mg
- Acetaminophen 1000mg/ibuprofen 800 mg
- Acetaminophen 300 mg/codeine 30 mg
- Acetaminophen 300mg/hydrocodone 5mg
- Acetaminophen 325mg/oxycodone 5mg
No significant difference in pain relief at 1 and 2 hours between all of 5 groups

References

Bijur PE, Friedman BW, Irizarry E, Chang AK, Gallagher EJ. A Randomized Trial Comparing the Efficacy of Five Oral Analgesics for Treatment of Acute Musculoskeletal Extremity Pain in the Emergency Department. Ann Emerg Med. 2021;77(3):345-356. doi:10.1016/j.annemergmed.2020.10.004

The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.org/cme-courses/ and create an account.

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Contributor: Aaron Lessen, MD

Educational Pearls:

Traditionally, fingernails were replaced after avulsion using sutures
Sometimes artificial material was placed when the fingernail was not available
Recent study evaluated treatment of fingernail avulsions pediatric patients by replacing the nail versus cleaning and putting a non-adhesive dressing
No difference in the aesthetics or patient satisfaction with the new fingernail between the two treatment groups

References

Seiler M, Gerstenberg A, Kalisch M, Kennedy U, Scheer HS, Weber DM. Non-operative treatment versus suture refixation of the nail plate in paediatric fingernail avulsion injuries. J Hand Surg Eur Vol. 2021;46(5):523-529. doi:10.1177/1753193420965390

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Aaron Lessen, MD

Educational Pearls:

Survey of EM physicians to self-report empathy and burnout levels and correlated with patient satisfaction scores
Patient satisfaction was not affected by what the physicians thought about their level of empathy or burnout
Patient satisfaction was affected by the patient’s perception of empathetic behavior by the physician

References

Byrd J, Knowles H, Moore S, et al. Synergistic effects of emergency physician empathy and burnout on patient satisfaction: a prospective observational study [published online ahead of print, 2020 Nov 25]. Emerg Med J. 2020;emermed-2019-209393. doi:10.1136/emermed-2019-209393

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.org/cme-courses/ and create an account.

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Contributor: Aaron Lessen, MD

Educational Pearls:

Kounis syndrome is an allergic acute coronary syndrome
Triggers include medications (antibiotics), insect bites, or other common allergens
Believed to be due to mast cell activation, inflammatory cytokines, and platelet activation causing coronary vasospasm or plaque rupture in setting of existing atherosclerosis
Consider Kounis syndrome in the setting of chest pain in anaphylaxis
Treatment involves treatment of allergic reaction, although epinephrine should be used cautiously
Avoid morphine as this can cause mast cell activation

References

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Contributor: Peter Bakes, MD

Educational Pearls:

ST elevation clinical guidelines for myocardial infarction include:
- 2.5 mm elevation for males <40 in V2 and V3
- 2 mm elevation in males >40 in V2 and V3
- 1.5 mm elevation for females in V2 and V3
- 1 mm elevation in 2 or more contiguous leads (not V2 or V3)
Differential diagnosis of ST elevation includes, but is not limited to:
- STEMI
- Electrolyte abnormalities
- Pericarditis/myocarditis
- Brugada syndrome
- LVH
- Bundle branch blocks
- Ventricular aneurysm

References

de Bliek EC. ST elevation: Differential diagnosis and caveats. A comprehensive review to help distinguish ST elevation myocardial infarction from nonischemic etiologies of ST elevation. Turk J Emerg Med. 2018;18(1):1-10. Published 2018 Feb 17. doi:10.1016/j.tjem.2018.01.008

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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Educational Pearls:

Albert Einstein had chronic abdominal pain as a middle-aged man
Dr. Rudolph Nissen, founder of the Nissen fundoplication, performed exploratory surgery for this pain and found an abdominal aortic aneurysm (AAA)
The only treatment for an AAA at that time was to wrap the vessel in cellophane, causing a fibrotic response to prevent rupture
Einstein died 7 years after this surgery, likely from his leaking abdominal aortic aneurysm

References

Cervantes Castro J. Albert Einstein y su aneurisma de la aorta [Albert Einstein and his abdominal aortic aneurysm]. Gac Med Mex. 2011;147(1):74-76.

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Nick Hatch, MD

Educational Pearls:

Complete heart block or 3rd degree atrioventricular (AV) block is diagnosed via EKG and occurs when electrical signals from the sinoatrial (SA) node are blocked from reaching the ventricles via the AV node and AV bundles
P waves and QRS complexes are independent
Often QRS rate is around 40
The rate is slow because the ventricular purkinje fibers have an intrinsic rate of 20-40 bpm, whereas the SA node has an intrinsic rate of 60-100 bpm
Treatment is usually with pacemaker, unless there is an identifiable etiology causing the heart block that can be reversed

References

Knabben V, Chhabra L, Slane M. Third-Degree Atrioventricular Block. [Updated 2020 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK545199/

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Contributor: Nick Tsipis, MD

Educational Pearls:

Humerus fractures can be characterized as proximal, midshaft, and distal fractures
Proximal humerus fracture is the second-most common fracture in elderly patients
- Primary complication is with the axillary nerve and axillary artery
- Vast majority are managed nonoperatively with a sling, reduction usually not indicated
- Women comprise 70% of proximal humerus fractures, often secondary to fall with osteoporosis
Midshaft humerus fractures are more often managed operatively, but can be managed nonoperatively
- Primary complication is with radial nerve, look for wrist drop!
- May require reduction and splinting
Distal humerus fractures can include supracondylar fractures and involve the radius or ulna
- One atypical is the Holstein-Lewis fracture, that can cause radial nerve damage
- Management is varied depending on the exact type of distal humerus fracture
Assess degree of angulation, neurovascular status, and likelihood of compartment syndrome both before and after splint application

References

Attum B, Thompson JH. Humerus Fractures Overview. [Updated 2020 Aug 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482281/

The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.org/cme-courses/ and create an account.

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Contributor: Peter Bakes, MD

Educational Pearls:

Pelvis is comprised of the iliac, ischium, and sacrum
Three mechanisms for pelvic fractures by Young-Burgess Classification
- Anterior-posterior compression causing open-book pelvic fractures that can be complicated by retroperitoneal bleeding or urethral injury
- Lateral compression causing rami fractures
- Vertical sheer causing offset of sacroiliac joint or sacrum
Mechanically stable pelvic ring fractures can be conservatively treated with weight bearing as tolerated
Unstable fractures and those with complications will require operative fixation

References

Davis DD, Foris LA, Kane SM, et al. Pelvic Fracture. [Updated 2021 Feb 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430734/

Weatherford B. Pelvic Ring Fractures. OrthoBullets. Updated 25 May 2021. https://www.orthobullets.com/trauma/1030/pelvic-ring-fractures

The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.org/cme-courses/ and create an account.

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Contributor: Ricky Dhaliwal, MD

Educational Pearls:

CRASH 3 Trial looked at over 12,000 patients with traumatic intracranial bleeds, randomizing patients to a therapy with TXA or standard of care without TXA
Dosing was 1 gram over 10 min for loading dose and then an infusion of 1 gram over 8 hours
Found Improvement in survival and neurologic outcomes when patient received TXA within 3 hours

References

CRASH-3 trial collaborators. Effects of tranexamic acid on death, disability, vascular occlusive events and other morbidities in patients with acute traumatic brain injury (CRASH-3): a randomised, placebo-controlled trial [published correction appears in Lancet. 2019 Nov 9;394(10210):1712]. Lancet. 2019;394(10210):1713-1723. doi:10.1016/S0140-6736(19)32233-0

The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.org/cme-courses/ and create an account.

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Contributor: Chris Holmes, MD

Educational Pearls:

In the 1700s, boxes lined the River Thames to pump smoke up the rectum to resuscitate people who had been found unconscious in the river
Sea cucumbers can extract oxygen through their rectum
Perflourocarbon, a liquid that can become oxygenated, provided rectally was able to oxygenate pigs and mice in a recent study

References

Okabe R, Chen-Yoshikawa T, Yoneyama Y, et al. Mammalian enteral ventilation ameliorates respiratory failure. Clinical and Translational Resource and Technology Insights. 2021;2(6):773-783. doi:https://doi.org/10.1016/j.medj.2021.04.004

The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.org/cme-courses/ and create an account.

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Contributor: Ricky Dhaliwal, MD

Educational Pearls:

Hypotension in patients requiring intubation should be resuscitated as much as possible
While intubating, the negative inspiratory pressure goes away decreasing cardiac preload and worsening hypotension
Phenylephrine can be given via push doses to increase blood pressure from alpha agonism
For sedation, avoid propofol with hypotension and opt for etomidate or ketamine

References

April MD, Arana A, Schauer SG, et al. Ketamine Versus Etomidate and Peri-intubation Hypotension: A National Emergency Airway Registry Study. Acad Emerg Med. 2020;27(11):1106-1115. doi:10.1111/acem.14063

Panchal AR, Satyanarayan A, Bahadir JD, Hays D, Mosier J. Efficacy of Bolus-dose Phenylephrine for Peri-intubation Hypotension. J Emerg Med. 2015;49(4):488-494. doi:10.1016/j.jemermed.2015.04.033

Jaber S, Amraoui J, Lefrant JY, et al. Clinical practice and risk factors for immediate complications of endotracheal intubation in the intensive care unit: a prospective, multi-center study. Crit Care Med. 2006;34:2355–61.

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Aaron Lessen, MD

Educational Pearls:

DEVT Trial, a recent non-inferiority study, looked at giving tPA prior to endovascular thrombectomy and was stopped early because there was no benefit shown to giving tPA before this intervention
Coupled with the SKIP and DIRECT MT trials corroborating these findings, it appears that giving tPA prior to thrombectomy is not indicated
Whether patients should receive tPA prior to transfer for thrombectomy (i.e. they are in a rural healthcare setting) is still unclear

References

Yang P, Treurniet KM, Zhang L, et al. Direct Intra-arterial thrombectomy in order to Revascularize AIS patients with large vessel occlusion Efficiently in Chinese Tertiary hospitals: A Multicenter randomized clinical Trial (DIRECT-MT)-Protocol. Int J Stroke. 2020;15(6):689-698. doi:10.1177/1747493019882837

Suzuki K, Matsumaru Y, Takeuchi M, et al. Effect of Mechanical Thrombectomy Without vs With Intravenous Thrombolysis on Functional Outcome Among Patients With Acute Ischemic Stroke: The SKIP Randomized Clinical Trial [published correction appears in JAMA. 2021 May 4;325(17):1795]. JAMA. 2021;325(3):244-253. doi:10.1001/jama.2020.23522

Zi W, Qiu Z, Li F, et al. Effect of Endovascular Treatment Alone vs Intravenous Alteplase Plus Endovascular Treatment on Functional Independence in Patients With Acute Ischemic Stroke: The DEVT Randomized Clinical Trial. JAMA. 2021;325(3):234-243. doi:10.1001/jama.2020.23523

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Jared Scott, MD

Educational Pearls:

PID (pelvic inflammatory disease) occurs when the infection ascends into the uterus
Tubo-ovarian abscess occurs when the infection ascends to the fallopian tubes
Fitz-Hugh-Curtis syndrome occurs when the infection enters the peritoneum and causes peritoneal inflammation with peri-hepatic inflammation
These conditions require GYN consultation and often more robust antibiotic therapy for treatment

References

Lareau SM, Beigi RH. Pelvic inflammatory disease and tubo-ovarian abscess. Infect Dis Clin North Am. 2008;22(4):693-708. doi:10.1016/j.idc.2008.05.008

Basit H, Pop A, Malik A, et al. Fitz-Hugh-Curtis Syndrome. [Updated 2021 May 7]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan.

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Jared Scott, MD

Educational Pearls:

Recent study evaluated vaginal self swab testing for STIs to determine if they are equally sensitive to provider-obtained swab
515 patients consented to both tests and 95% agreement was found between the two methods of obtaining samples
75% of participants who preferred this over the pelvic exam, although some patients were concerned they did not perform the self swab correctly
Consider vaginal self swab with proper coaching as an option for patients

References

Chinnock B, Yore M, Mason J, et al. Self-obtained vaginal swabs are not inferior to provider-performed endocervical sampling for emergency department diagnosis of Neisseria gonorrhoeae and Chlamydia trachomatis [published online ahead of print, 2021 Jan 18]. Acad Emerg Med. 2021;10.1111/acem.14213. doi:10.1111/acem.14213

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.org/cme-courses/ and create an account.

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Contributor: Dr. Nick Gorton, MD

Educational Pearls:

Use transgender people’s correct names and pronouns, the Russell study found a 56% reduction in suicide behavior with chosen name usage
⅕ to ½ of transgender people report they avoided seeking care in the ED because of fear of transphobic treatment
Understanding the definitions of gender identity, gender expression, assigned sex at birth, physical attraction, and emotional attraction are necessary for improving treatment of the LGBTIQ+ community
Explain reasons for asking questions that address physical characteristics and/or sexual attraction
Lastly, if you make a mistake simply correct the mistake, apologize, and immediately move on

References

Transgender Unicorn

TransLine

Treatment Guideline

Silicone pumping handout for patients and providers

https://www.ustranssurvey.org/reports

Pollitt, A. M., Ioverno, S., Russell, S. T., Li, G., & Grossman, A. H. (2019). Predictors and mental health benefits of chosen name use among transgender youth. Youth & society, 0044118X19855898.

Russell, S. T., Pollitt, A. M., Li, G., & Grossman, A. H. (2018). Chosen name use is linked to reduced depressive symptoms, suicidal ideation, and suicidal behavior among transgender youth. Journal of Adolescent Health, 63(4), 503-505.

Samuels, E. A., Tape, C., Garber, N., Bowman, S., & Choo, E. K. (2018). “Sometimes you feel like the freak show”: a qualitative assessment of emergency care experiences among transgender and gender-nonconforming patients. Annals of emergency medicine, 71(2), 170-182.

Thompson-Blum, D. N., Coleman, T. A., Phillips, N. E., Richardson, S., Travers, R., Coulombe, S., ... & Davis, C. (2021). Experiences of Transgender Participants in Emergency Departments: Findings from the OutLook Study. Transgender Health.

Bauer, G. R., Scheim, A. I., Deutsch, M. B., & Massarella, C. (2014). Reported emergency department avoidance, use, and experiences of transgender persons in Ontario, Canada: results from a respondent-driven sampling survey. Annals of emergency medicine, 63(6), 713-720.

*Ongoing LGBTQIA+ topics are identified through collaborations with local Denver organization the Queer Umbrella as part of a new longitudinal effort to raise awareness of health disparities affecting the LGBTQIA+ community.

Stay tuned as we continue to provide educational content to support this community and uplift LGBTQIA+ health providers and their practices all year long.

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Contributor: Nick Tsipis, MD

Educational Pearls:

pH <7.35 = acidemia; pH>7.45=alkalemia
If pH low and pCO2 high, indicates a respiratory acidosis
If pH low and pCO2 low, indicates metabolic acidosis
After determining type of acidosis, check bicarb to determine compensation for acidosis and check electrolytes to calculate anion gap
Metabolic acidosis can present with tachypnea (Kussmaul breathing) and hypotension due to loss of catecholamine function and suboptimal cardiac function at low pH
Treat with IV fluids and address the underlying cause, limited role for bicarb

References

Burger MK, Schaller DJ. Metabolic Acidosis. [Updated 2020 Nov 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan.

Cadogan M. Acid Base Disorders. Life in the Fast Lane • LITFL. https://litfl.com/acid-base-disorders/. Published November 3, 2020. Accessed June 23, 2021.

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Jared Scott, MD

Educational Pearls:

Around 30 patients with cannabinoid hyperemesis syndrome (CHS) randomized treatment in three arms with 8mg Zofran, Haldol 0.05 mg/kg, and Haldol 0.1 mg/kg
Haldol arms performed better on all measures compared to Zofran
Extrapyramidal symptoms were significantly higher in the Haldol group than Zofran, especially the high-dose Haldol group

References

Ruberto AJ, Sivilotti MLA, Forrester S, Hall AK, Crawford FM, Day AG. Intravenous Haloperidol Versus Ondansetron for Cannabis Hyperemesis Syndrome (HaVOC): A Randomized, Controlled Trial. Ann Emerg Med. 2021;77(6):613-619. doi:10.1016/j.annemergmed.2020.08.021

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Gretchen Hinson, MD

Educational Pearls:

Pit vipers include cottonmouths, rattlesnakes, and copperheads
- All have folding long fangs, triangular face, and elliptical pupils
About 5,000 snakebites per year reported to Poison Control
Initially develop a local reaction (swelling, bruising, pain, bullae)
Complications can include
25% of snake bites result in no envenomation (dry bites)
20% of bites have serious side-effects, which can include hematologic, cardiovascular, neurologic and, muscular abnormalities, or even anaphylaxis to the envenomation itself
Minor symptoms should be observed for 12-24 hours
Moderate to severe symptoms are typically treated with antivenom
CroFab and other antivenoms are expensive, with costs upwards of $3200 per vial wholesale, though newer agents are cheaper
Treat with 4-6 vials of CroFab initially with moderate symptoms and subsequent redosing with

References

Buchanan JT, Thurman J. Crotalidae Envenomation. [Updated 2021 Jan 29]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan.

Kanaan NC, Ray J, Stewart M, et al. Wilderness Medical Society Practice Guidelines for the Treatment of Pitviper Envenomations in the United States and Canada. Wilderness Environ Med. 2015;26(4):472-487. doi:10.1016/j.wem.2015.05.007

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.com/cme-courses/ and create an account.

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Contributor: Adam Barkin, MD

Educational Pearls:

Internal hernias, when bowel herniates through iatrogenic or congenital defect in mesentery, represent 1-6% of all small bowel obstructions
Mortality of strangulated internal hernias is over 50% due to bowel necrosis and sepsis
Intermittent symptoms presenting with nausea, vomiting, abdominal pain, abdominal distension
Increased risk in patients with gastric bypass, liver transplant, or laparascopic surgery
CT is very >90% sensitivity and specific in diagnosing SBO due to internal hernia
- Mesenteric swirl is a classic radiology finding
Treatment with immediate surgical consultation for possible OR bowel decompression
Start on broad spectrum antibiotics with any signs of sepsis

References

Lanzetta MM, Masserelli A, Addeo G, et al. Internal hernias: a difficult diagnostic challenge. Review of CT signs and clinical findings. Acta Biomed. 2019;90(5-S):20-37. Published 2019 Apr 24. doi:10.23750/abm.v90i5-S.8344

Martin LC, Merkle EM, Thompson WM. Review of internal hernias: radiographic and clinical findings. AJR Am J Roentgenol. 2006;186(3):703-717. doi:10.2214/AJR.05.0644

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.com/cme-courses/ and create an account.

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Contributor: Adam Barkin, MD

Educational Pearls:

Spontaneous coronary artery dissection (SCAD) is the most common cause of acute MI in women under 50 years old
Risk factors include fibromuscular dysplasia, extreme exercise, stress, pregnancy, and recent birth
Diagnosed in cath lab but medically managed and usually do not get a stent
Treated with dual antiplatelet therapy and beta-blockers

References

Yip A, Saw J. Spontaneous coronary artery dissection-A review. Cardiovasc Diagn Ther. 2015;5(1):37-48. doi:10.3978/j.issn.2223-3652.2015.01.08

Janssen EBNJ, de Leeuw PW, Maas AHEM. Spontaneous coronary artery dissections and associated predisposing factors: a narrative review. Neth Heart J. 2019;27(5):246-251. doi:10.1007/s12471-019-1235-4

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.com/cme-courses/ and create an account.

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Contributor: Peter Bakes, MD

Educational Pearls:

Community-acquired pneumonia (CAP) is normally stratified into outpatient-candidates vs. inpatient candidates for treatment
For outpatient treatment, antibiotic selection is driven by presence or absence comorbid health conditions (chronic lung/kidney/liver disease, DM, immunocompromised state, alcoholism, asplenia)
- No comorbidities: High dose amoxicillin, doxycycline, azithromycin
- Comorbidities: augmentin, cephalosporin, doxycycline, macrolide with fluoroquinolones as an alternatives
For inpatient treatment, standard treatment is a macrolide and 3rd-generation cephalosporin
- Prior MRSA isolate or pseudomonas isolate as well as severe pneumonia are indications for adding MDR organism coverage with vancomycin and anti-pseudomonal coverage

References

Metlay JP, Waterer GW, Long AC, et al. Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019;200(7):e45-e67. doi:10.1164/rccm.201908-1581ST

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.com/cme-courses/ and create an account.

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Contributor: Aaron Lessen, MD

Educational Pearls:

Refractory ventricular fibrillation, defined as 3 defibrillation shocks without resolution, was studied via RCT looking to compare ECMO with cardiac cath vs. typical resuscitation
After 30 patients (15 each arm), the trial was stopped because such a significant benefit seen in the ECMO arm
6 patients survived and 3 had good neurological outcomes at 6 months with ECMO
This is compared to 1 patient surviving initially and none surviving at 6 months in the typical resuscitation arm

References

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

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.com/cme-courses/ and create an account.

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Contributor: Jared Scott, MD

Educational Pearls:

Hand eczema is present in about 10% of the population and has a great prevalence in hairdressers, healthcare workers, and food service employees
Using 1% oatmeal cream instead of a base cream showed statistically significant improvement in outcomes of HE in healthcare workers in a double-blind study

References

Sobhan M, Hojati M, Vafaie SY, Ahmadimoghaddam D, Mohammadi Y, Mehrpooya M. The Efficacy of Colloidal Oatmeal Cream 1% as Add-on Therapy in the Management of Chronic Irritant Hand Eczema: A Double-Blind Study. Clin Cosmet Investig Dermatol. 2020;13:241-251. Published 2020 Mar 25. doi:10.2147/CCID.S246021

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.com/cme-courses/ and create an account.

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Contributor: Sam Killian, MD

Educational Pearls:

Patients with cirrhosis and ascites are frequently evaluated for spontaneous bacterial peritonitis, an infection of the ascites fluid that is not from a surgically treated source
Fever, abdominal pain, and altered mental status should all raise clinical suspicion in a patient with ascites
Fluid from paracentesis may show increased WBCS (polys and neutrophils), high LDH, high amylase, and decreased glucose
Outcomes are very poor in these patients with 30-40% of these patients continue to renal failure with 60-80% in-hospital mortality
Typically treat with a third generation cephalosporin or ampicillin+gentamicin

References

Long B, Koyfman A. The emergency medicine evaluation and management of the patient with cirrhosis. Am J Emerg Med. 2018;36(4):689-698. doi:10.1016/j.ajem.2017.12.047

MacIntosh T. Emergency Management of Spontaneous Bacterial Peritonitis - A Clinical Review. Cureus. 2018;10(3):e2253. Published 2018 Mar 1. doi:10.7759/cureus.2253

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.com/cme-courses/ and create an account.

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This week's Pharmacy Phriday features a short excerpt from a longer podcast released as promo for the Colorado's CURE initiative, Clinicians United to Resolve the Epidemic, that combats the opioid crisis through education. Frequent contributor to the podcast, Rachael Duncan, PharmD, is joined by host, Elizabeth Esty, MD, to discuss the opioid prescribing guidelines for pharmacists released by the Colorado Hospital Association in collaboration with the Colorado Pharmacists Society.

Colorado's CURE focuses on four pillars:

Limiting the use of opioids in clinical practice
Using multimodal alternatives to opioids (ALTO) to better treat pain without the risks that come with opioids
Harm Reduction
Improving care for those who have developed an opioid use disorder

Access Colorado's CURE Opioid Prescribing Guidelines for Pharmacists and other specialties here!

You can listen to the full Pharmacy episode of the Colorado's CURE Podcast for a more in-depth overview of the guidelines below:

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Contributor: Chris Holmes, MD

Educational Pearls:

Medicine is cyclical and practice is always evolving
A description of recommended treatment for CHF from 1966
- Give oxygen
- Give one dose morphine then switch to demerol
- Decrease venous return and start PPV
- Immediately apply tourniquet to 3 extremities rotating tourniquets every 20 minutes
- Phlebotomy of 350-500 cc blood into a donor bag and draw off plasma as RBCs settle down
- Give aminophylline (make sure it is warmed)
- Induce hypotension with nitroglycerin and trimethoprim camphorsulfonate (infused at 10 drips/minute)
- Start digitalis
- Don’t use any diuretics as they are ineffective
- If in shock, release tourniquets and hang the phlebotomized blood
- Isoproterenol might be beneficial

References

Messer JV. Management of emergencies. 13. Acute cardiac decompensation. N Engl J Med. 1966;274(26):1491-1493. doi:10.1056/NEJM196606302742608

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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Photo Credit: Photo presented without modification courtesy of Kipp Teague , CC license

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Contributor: Aaron Lessen, MD

Educational Pearls:

Facial nerve palsy (Bell’s palsy) can occur in pediatric patients with Lyme disease, viral infection, or even leukemia
One trial sought out to find if steroids and acyclovir would benefit pediatric patients with facial nerve palsy
However, during screening process, around 1% of enrollees had leukemia (5 of the 644 patients)
This is important as steroids can partially treat the leukemia thereby prolonging diagnosis and put the patient at risk for tumor lysis syndrome

References

Babl FE, Kochar A, Osborn M, et al. Risk of Leukemia in Children With Peripheral Facial Palsy. Ann Emerg Med. 2021;77(2):174-177. doi:10.1016/j.annemergmed.2020.06.029

Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Don Stader, MD

Educational Pearls:

Patients are more likely to survive an opioid overdose if they have naloxone
10% risk of death in the year following an opioid overdose of patients seen in the ED
Those who receive naloxone:
- Have better survival rates
- Are more likely to enter recovery
- Are more likely to use the naloxone on another person who has overdosed
Better to give the patient naloxone at discharge from the ED as rates of filling prescriptions are low
Any patient who uses illicit drugs, chronic opioid medications, or opioids with benzodiazepines are good candidates for naloxone at discharge
Remember to instruct the patient and those who live with them on how to use it

References

Gunn AH, Smothers ZPW, Schramm-Sapyta N, Freiermuth CE, MacEachern M, Muzyk AJ. The Emergency Department as an Opportunity for Naloxone Distribution. West J Emerg Med. 2018;19(6):1036-1042. doi:10.5811/westjem.2018.8.38829

Olfson M, Wall M, Wang S, Crystal S, Blanco C. Risks of fatal opioid overdose during the first year following nonfatal overdose. Drug Alcohol Depend. 2018;190:112-119. doi:10.1016/j.drugalcdep.2018.06.004

Olfson M, Crystal S, Wall M, Wang S, Liu SM, Blanco C. Causes of Death After Nonfatal Opioid Overdose [published correction appears in JAMA Psychiatry. 2018 Aug 1;75(8):867]. JAMA Psychiatry. 2018;75(8):820-827. doi:10.1001/jamapsychiatry.2018.1471

http://naloxoneproject.com/

Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD

The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.com/cme-courses/ and create an account.

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Contributor: Aaron Lessen , MD

Educational Pearls:

Patients on 10L or more of oxygen per minute in the ICU were randomized to oxygen goals of 90% or 96% to compare 90-day mortality rates
Mortality rates were about 42% for both of oxygen target groups, indicating no significant difference

References

Schjørring OL, Klitgaard TL, Perner A, et al. Lower or Higher Oxygenation Targets for Acute Hypoxemic Respiratory Failure. N Engl J Med. 2021;384(14):1301-1311. doi:10.1056/NEJMoa2032510

Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD

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Contributor: Adam Barkin, MD

Educational Pearls:

Represents less than 1% of all fractures that occur, although it has a significant mortality rate of 2-5%
Typically occurs in high-energy trauma and are commonly associated with high injury severity scores and other fractures
Concomitant Injuries:
- 50% have rib fracture
- 25% have clavicle fracture
- 30% have a spine fracture
- 5% have a brachial plexus injury
- 40% have a pulmonary contusion
- 30% have a pneumothorax
- 34% have a head injury
- 11% have a vascular injury

References

Cole PA, Freeman G, Dubin JR. Scapula fractures. Curr Rev Musculoskelet Med. 2013;6(1):79-87. doi:10.1007/s12178-012-9151-x

Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD

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Contributor: Dave Rosenberg, MD

Educational Pearls:

In 1951, Operation Tat-Type began tattooing adults with their blood type in an effort to prepare for rapid transfusions in the time of the Cold War and the Korean War
School children in northern Indiana and areas in Utah were tattooed with their blood type beginning in 1952 under the same operation
Based on tattoos given to SS officers during WWII
This wasn't to identify who needed what blood but rather to identify who could give what blood in the event of a massive attack

References

Wolf EK, Laumann AE. The use of blood-type tattoos during the Cold War. J Am Acad Dermatol. 2008;58(3):472-476. doi:10.1016/j.jaad.2007.11.019

Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD

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Contributor: Gretchen Hinson, MD

Educational Pearls:

Three episodes of ventricular tachycardia within 24 hours or two episodes back-to-back
Treat with IV amiodarone and IV beta-blockers initially as well as IV lidocaine
Correct underlying causes:
- IV magnesium for QT prolongation
- Replete potassium in hypokalemia
- Urgent revascularization in ischemia
For refractory vtach, urgent radiofrequency ablation or stellate ganglion block can be done
Last resort is placing on the patient on ECMO

References

Muser D, Santangeli P, Liang JJ. Management of ventricular tachycardia storm in patients with structural heart disease. World J Cardiol. 2017;9(6):521-530. doi:10.4330/wjc.v9.i6.521

Eifling M, Razavi M, Massumi A. The evaluation and management of electrical storm. Tex Heart Inst J. 2011;38(2):111-121.

Summarized by John Spartz, MS3

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Contributor: Donald Stader, MD

Educational Pearls:

Opioids target kappa and NMDA receptors that can lead to central nervous system sensitization and therefore increased pain
For patients with opioid-induced hyperalgesia (OIH), oral ketamine (25-50 mg) can be used to treat their pain as it targets the NMDA receptor
Other treatments is IV magnesium, NSAIDs, tylenol, and clonidine
Buprenorphine and methadone are options for chronic pain management in the setting of OIH

References

Lee M, Silverman SM, Hansen H, Patel VB, Manchikanti L. A comprehensive review of opioid-induced hyperalgesia. Pain Physician. 2011;14(2):145-161.

Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD

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Contributor: Aaron Lessen, MD

Educational Pearls:

Recent study looked at whether lactated ringers might be a better choice for fluid resuscitation in patients with DKA compared to normal saline
Normal saline can cause a hyperchloremic metabolic acidosis
Time to resolution of acidosis was 4 hours less with lactated ringers compared to normal saline
Time on an insulin drip decreased by about 4 hours with lactated ringers compared to normal saline
LR might be a better choice for fluid resuscitation in patients with DKA

References

Self WH, Evans CS, Jenkins CA, et al. Clinical Effects of Balanced Crystalloids vs Saline in Adults With Diabetic Ketoacidosis: A Subgroup Analysis of Cluster Randomized Clinical Trials. JAMA Netw Open. 2020;3(11):e2024596. doi:10.1001/jamanetworkopen.2020.24596

Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD

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Contributor: Jared Scott, MD

Educational Pearls:

About ½ of the patients in the ED present with some form of pain
One study looked at patients presenting in pain and followed up two days after discharge to determine if their pain was addressed, asking if the patient received anything for pain and if the patient refused pain medication
Non-analgesic pain management: About 30% discordance between patient reports and documentation
Conventional analgesic pain management: About 15% discordance between patient reports and documentation

References

Taylor DM, Valentine S, Majer J, Grant N. Discordance between patient-reported and actual emergency department pain management. Emerg Med Australas. 2020 Nov 22. doi: 10.1111/1742-6723.13690. Epub ahead of print. PMID: 33225600.

Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD

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Contributor: Peter Bakes, MD

Educational Pearls:

Incidence 2.5-10 per million people occurring primarily in those with environmental allergens
Typically occurs with mRNA vaccines in lipid nanoparticles (Moderna/Pfizer) rather than the adenovirus vaccine (J&J)
Recommendation is to forego 2nd dose of the mRNA vaccine and instead get the adenovirus vaccine after weighing the risks and benefits

References

Kounis NG, Koniari I, de Gregorio C, Velissaris D, Petalas K, Brinia A, Assimakopoulos SF, Gogos C, Kouni SN, Kounis GN, Calogiuri G, Hung MY. Allergic Reactions to Current Available COVID-19 Vaccinations: Pathophysiology, Causality, and Therapeutic Considerations. Vaccines (Basel). 2021 Mar 5;9(3):221. doi: 10.3390/vaccines9030221. PMID: 33807579; PMCID: PMC7999280.

Blumenthal KG, Robinson LB, Camargo CA, et al. Acute Allergic Reactions to mRNA COVID-19 Vaccines. JAMA. Published online March 08, 2021. doi:10.1001/jama.2021.3976

Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD

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Contributor: Jared Scott, MD

Educational Pearls:

1-3 cases of rabies per year in US with 55,000 people per year receiving rabies prophylaxis
90% of rabies cases come from wildlife, most commonly by racoons, bats, foxes, and skunks
Because of rabies prophylaxis, domesticated pets almost never have rabies in the United States
Rabies is typical transmitted via a bite, but direct contact with saliva or brain tissue on an open wound can transmit the virus
Some people exposed to rabies from bats will never report a bite

References

Kessels J, Tarantola A, Salahuddin N, Blumberg L, Knopf L. Rabies post-exposure prophylaxis: A systematic review on abridged vaccination schedules and the effect of changing administration routes during a single course. Vaccine. 2019 Oct 3;37 Suppl 1:A107-A117. doi: 10.1016/j.vaccine.2019.01.041. Epub 2019 Feb 5. PMID: 30737043.

Centers for Disease Control and Prevention. Rabies Postexposure Prophylaxis (PEP). Published June 11, 2019. https://www.cdc.gov/rabies/medical_care/index.html

Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD

The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.com/cme-courses/ and create an account.

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Contributor: Alicia Oberle, MD

Educational Pearls:

Down Syndrome with Trisomy 21 have three copies of chromosome 21
Current birth rates are around 1 in 700 births
Average life span 25 years in 1980, today the average life span is 60 years of age
Patients with Down syndrome require additional therapies in the first 3 years due to developmental delays
They also have increased risk for childhood leukemias, seizures, hypothyroidism, celiac disease, and early-onset Alzheimers
Half have a cardiac defect requiring surgery at birth

References

Tsou AY, Bulova P, Capone G, et al. Medical Care of Adults With Down Syndrome: A Clinical Guideline. JAMA. 2020;324(15):1543–1556. doi:10.1001/jama.2020.17024

Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD

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This week’s episode features a fascinating conversation with Dr. Nadia Tremonti, medical director for the pediatric palliative care program at Children’s Hospital of Michigan in Detroit. Dr. Tremonti was the featured physician in an independent short film Palliative and subsequent New York Times shorter excerpt Dying in your Mother’s Arms that explore her work with terminally ill pediatric patients. From conversations of religion’s role in processing disease to the physician’s role in alleviating suffering for patients and their families, Nick and Nadia explore the existential ground in this thought-provoking segment.

Time Stamps

00:47 Introductions

3:50 How patients led her to pursue palliative care

14:32 Dr. Tremonti’s approach to palliative care

21:42 Understanding patients’ and family’s language to guide counseling

31:38 Most frequent anxieties and fears of families of pediatric palliative care patients

37:21 How emergent interventions can shift burden of decision to continue life-sustaining measures to families

47:45 Navigating existential questions of life or death with patients and their families

55:38 Saddest part of palliative care

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Contributor: Aaron Lessen, MD

Educational Pearls:

Droperidol for sedation in agitated patients in the emergency department was studied compared to ziprasidone (Geodon) and lorazepam (Ativan)
Double-blinded RCT showed droperidol was 65% effective to get patients to a good level of sedation in 15 minutes compared to ativan and geodon which were 25-35% effective
Droperidol had less respiratory depression and prolongation of the QT compared to Ativan and Geodon

References

Martel ML, Driver BE, Miner JR, Biros MH, Cole JB. Randomized Double-blind Trial of Intramuscular Droperidol, Ziprasidone, and Lorazepam for Acute Undifferentiated Agitation in the Emergency Department. Acad Emerg Med. 2021 Apr;28(4):421-434. doi: 10.1111/acem.14124. Epub 2020 Oct 5. PMID: 32888340.

Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD

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Contributor: Ricky Dhaliwal, MD

Educational Pearls:

Primarily affects children <6 years old and adults with kidney disease
Caused by staph aureus releasing exotoxins that result in erythema and sloughing of the skin
Present with significant pain, dehydration and underlying staph infection
Treatment typically oxacillin/nafcillin with admission for wound care with petroleum gel and xeroform
Burn centers may be treatment centers of choice for this condition
Most patients recover in 2-3 days with treatment

References

Patel GK, Finlay AY. Staphylococcal scalded skin syndrome: diagnosis and management. Am J Clin Dermatol. 2003;4(3):165-75. doi: 10.2165/00128071-200304030-00003. PMID: 12627992.

Jordan KS. Staphylococcal Scalded Skin Syndrome: A Pediatric Dermatological Emergency. Adv Emerg Nurs J. 2019 Apr/Jun;41(2):129-134. doi: 10.1097/TME.0000000000000235. PMID: 31033660.

Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD

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Contributor: Ricky Dhaliwal, MD

Educational Pearls:

Rhabdomyolysis occurs when high levels of myoglobin are released from dying muscle tissue into the blood
Severe levels of myoglobin cause renal injury
Causes include elevated temperature, excessive exercise, toxins, infection, muscle ischemia, crush injury, and prolonged immobilization
Can also be caused by medications, like antipsychotics, statins, SSRIs, colchicine, lithium
Workup typically includes creatinine kinase, potassium, creatinine levels and serial EKGs
Firstline treatment is with IV fluids with a goal urine output of 300 ml/hr
Sodium bicarbonate and mannitol have had some use in treatment but weak evidence

References

Long B, Koyfman A, Gottlieb M. An evidence-based narrative review of the emergency department evaluation and management of rhabdomyolysis. Am J Emerg Med. 2019 Mar;37(3):518-523. doi: 10.1016/j.ajem.2018.12.061. Epub 2019 Jan 2. PMID: 30630682.

Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD

The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.com/cme-courses/ and create an account.

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Contributor: Aaron Lessen, MD

Educational Pearls:

Study in NEJM looked at occult hypoxemia, when oxygen saturation reads at >92% when the actual saturation is <88%
Rate of occult hypoxemia was 3 times higher in those who identified as black (12% vs 4%)
Keep this disparity in mind when providing care to patients of all backgrounds and incorporate into clinical decision-making

References

Sjoding MW, Dickson RP, Iwashyna TJ, Gay SE, Valley TS. Racial Bias in Pulse Oximetry Measurement. N Engl J Med. 2020;383(25):2477-2478. doi:10.1056/NEJMc2029240

Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD

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Contributor: Peter Bakes, MD

Educational Pearls:

Febrile Seizure clinical criteria
- 6 months - 5 years of age
- Rapid rise in temp
- No preexisting seizure disorder
- No other explanation for the seizure
- Nonfocal seizure lasting less than 15 minutes
If the seizure does not meet the above criteria, a full workup needs to be completed
Regardless of cause, treat the seizure with IV/IO benzodiazepines or IN versed if unable to obtain access
Risk of developing epilepsy after a simple febrile seizure roughly doubles

References

Leung AK, Hon KL, Leung TN. Febrile seizures: an overview. Drugs Context. 2018;7:212536. Published 2018 Jul 16. doi:10.7573/dic.212536

Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD

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Contributor: Aaron Lessen, MD

Educational Pearls:

Acid and alkali ingestions have differing prognosis and immediate concerns
Immediate issues can include superficial irritation, severe burns, esophageal perforation, and even airway compromise from edem
Long term morbidity can include strictures
Supportive care is typically all that can be provided in the emergency department
Diagnostics may include imaging and endoscopy
For more severe ingestions without immediate issues,, patients may be monitored for up to 24 hours

References

Hoffman RS, Burns MM, Gosselin S. Ingestion of Caustic Substances. N Engl J Med. 2020 Apr 30;382(18):1739-1748. doi: 10.1056/NEJMra1810769. PMID: 32348645.

Summarized by Erik Verzemnieks, MD

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Contributor: Peter Bakes, MD

Educational Pearls:

Lyme disease gives a single expanding target lesion with central clearing called erythema chronicum migrans
Erythema multiforme is another targetoid rash that presents with multiple target lesions
Characterized into erythema minor and major based on severity but typically resolves
More severe hypersensitivity reactions include Stevens-Johnson Syndrome (<10% skin involvement), or Toxic Epidermal Necrolysis (>30% skin involvement)
SJS and TEN is associated with NSAIDS including aspirin, antiemetics like phenergan, anticonvulsants like dilantin or phenobarbital, and antibiotics like penicillin or sulfa drugs
Other causes include viral illnesses like Herpes simplex virus or mycoplasma pneumoniae
Treat by removing offending agent and treat supportively with monitoring for rash progression to SJS or TEN

References

Trayes KP, Love G, Studdiford JS. Erythema Multiforme: Recognition and Management. Am Fam Physician. 2019 Jul 15;100(2):82-88. PMID: 31305041.

Read J, Keijzers GB. Pediatric Erythema Multiforme in the Emergency Department: More Than "Just a Rash". Pediatr Emerg Care. 2017 May;33(5):320-324. doi: 10.1097/PEC.0000000000000618. PMID: 26555305.

Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD

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Contributor: Adam Barkin, MD

Educational Pearls:

Fever is an adaptive response to infection, but elderly and immunocompromised patients may not be able to mount a hyperthermic response in sepsis
Patients with fever in sepsis end up receiving treatment earlier and have better outcomes
Hypothermic patients with severe sepsis admitted to the ICU had a 32% mortality versus 21% mortality in those who had a fever on presentation
3-hour sepsis bundle compliance was less frequent in hypothermic patients than in febrile patients (56% versus 71%)
Early broad spectrum antibiotics were administered less in patients who were hypothermic than those that were febrile (77% versus 87%)

References

Blair E, Buxton RW, Cowley RA, Mansberger AR. The Use of Hypothermia in Septic Shock. JAMA. 1961;178(9):916–919. doi:10.1001/jama.1961.73040480005008b

Kushimoto S, Abe T, Ogura H, et al. Impact of Body Temperature Abnormalities on the Implementation of Sepsis Bundles and Outcomes in Patients With Severe Sepsis: A Retrospective Sub-Analysis of the Focused Outcome Research on Emergency Care for Acute Respiratory Distress Syndrome, Sepsis and Trauma Study. Crit Care Med. 2019;47(5):691-699.

Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD

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Contributor: Aaron Lessen, MD

Educational Pearls:

Survey study compared depression symptom prevalence in the United States at the beginning of COVID compared to data acquired by a similar survey for 2017-2018 and found it was three-fold higher
- Mild symptoms: 25% during pandemic; 16% before
- Moderate: 15% during pandemic; 6% before
- Moderately Severe symptoms: 8% during pandemic; 2% before
- Severe symptoms: ~5% during pandemic; 1% before
Those with lower income, less savings, and exposure to more stressors were at greater risk for developing depression symptoms

References

Ettman CK, Abdalla SM, Cohen GH, Sampson L, Vivier PM, Galea S. Prevalence of Depression Symptoms in US Adults Before and During the COVID-19 Pandemic. JAMA Netw Open. 2020;3(9):e2019686. doi:10.1001/jamanetworkopen.2020.19686

Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD

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Contributor: Ricky Dhaliwal, MD, JD

Educational Pearls:

Glucagon administered intravenously has a high rate of adverse events (nausea/vomiting) with very weak evidence
NItroglycerin too has very limited evidence but a much better adverse event profile
- Mix 0.4 mg (1 sublingual tablet) nitro in 10 mL of water and administer orally
Nothing beats upper endoscopy for effectiveness but in settings where GI is not immediately available, nitroglycerin may be worth an attempt given its better safety profile to other medications

References

Arora S, Galich P. Myth: glucagon is an effective first-line therapy for esophageal foreign body impaction. CJEM 2015;11:169–71

Schimmel J, Slauson S. Swallowed Nitroglycerin to Treat Esophageal Food Impaction. Ann Emerg Med. 2019 Sep;74(3):462-463.

Summarized/Edited by Erik Verzemnieks, MD

The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.com/cme-courses/ and create an account.

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Contributor: Jared Scott, MD

Educational Pearls:

While it is rare to have a native hip dislocation, it is relatively common to dislocate a prosthetic hip
The mechanism for dislocation is usually adduction, flexion, and internal rotation the hip which can occur when walking
Arthroplasty in the setting of trauma or fracture, posterior approach during surgery, and using a small femoral head increase the likelihood of later dislocation
If a patient with a total hip arthroplasty says they were walking and then developed hip pain, do not discount a potential dislocation

References

Zahar A, Rastogi A, Kendoff D. Dislocation after total hip arthroplasty. Curr Rev Musculoskelet Med. 2013;6(4):350-356. doi:10.1007/s12178-013-9187-6

Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD

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A heartfelt excerpt from our most recent UnfilterED episode with Dr. Don Stader.

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Contributor: Katie Sprinkel, MD

Educational Pearls:

Hereditary angioedema (HA) is an autosomal dominant bradykinin-mediated disease affecting the airway, skin or gastrointestinal tract and typically presents with swelling in the absence of pruritus
HA episodes last 3-5 days, typically occur first in childhood or adolescence, and decrease in frequency with aging
Airway angioedema is the most dangerous but least common
Skin angioedema is usually uncomfortable and should be monitored if involving the face
GI angioedema involves nausea, vomiting, and severe abdominal pain
No definitive triggers, but episodes may be preceded by a variable prodrome but can include headache, GI symptoms, and even a rash
Treatment can include infusion of a C-1 inhibitor, such as Berinert but it is very expensive

References

Busse PJ, Christiansen SC. Hereditary Angioedema. N Engl J Med. 2020 Mar 19;382(12):1136-1148. doi: 10.1056/NEJMra1808012. PMID: 32187470.

Longhurst HJ, Bork K. Hereditary angioedema: an update on causes, manifestations and treatment. Br J Hosp Med (Lond). 2019 Jul 2;80(7):391-398. doi: 10.12968/hmed.2019.80.7.391. PMID: 31283393.

Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD

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Contributor: Katie Sprinkel, MD

Educational Pearls:

Psychogenic Non-Epileptic Seizures (PNES) are due to a psychogenic rather than an epileptic cause
Despite common assumption, PNES are not always volitional
20-40% of those with PNES can also have true epileptic seizures 20-40%
True diagnosis requires a video EEG
Characteristics of PNES include:
- Waxing and waning of the seizure intensity
- Eyes clenched shut
- Pelvic thrusting, rolling from side-to-side
- Ability to respond to verbal stimuli during the seizure
- Ability to recall information during the seizure
- Weeping or stuttering
- Guarding the face on passive hand drop
Characteristics of epileptic seizures:
- Tongue biting
- Prolonged postictal state
- Incontinence
Haldol or Zyprexa may be better for PNES and benzodiazepines tend to be better for epileptic seizures

References

Huff JS, Murr N. Psychogenic Nonepileptic Seizures. 2021 Jan 28. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan–. PMID: 28722901.

Asadi-Pooya AA. Psychogenic nonepileptic seizures: a concise review. Neurol Sci. 2017 Jun;38(6):935-940. doi: 10.1007/s10072-017-2887-8. Epub 2017 Mar 8. PMID: 28275874.

Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD

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High in the mountains of Colorado, a crew of unsuspecting docs stumble upon the EMS scene of a head-on collision after an arduous mountain bike ride. Trauma is a Journey is a four part rural trauma mini series that recounts this tale as this group springs into action to assist the EMS crews dealing with two critical patients. Elizabeth Esty hosts a panel discussion with the key players: Dr. Dylan Luyten, Dr. JP Brewer, Dr. Madison Macht, Dr. Glenda Quan and Jeremiah Grantham as this story unfolds.

This final episode explores how addressing psychological and emotional trauma is the final step in a patient's journey once their physical illnesses have been addressed. The group discusses how this can take time and how they support patients through these tough journeys. Dr. Luyten brings everything full circle as he recounts his own story of being a patient in a rural car crash and how that experience affected him and ultimately set him on a path to become an ER physician. This episode also emphasizes the need for healthcare professionals to support each other through debriefs to prevent burnout and remain resilient themselves when providing care.

Thank you all for listening!

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The third episode opens up with an ode to ATLS and how important those training protocols really are to real-world applications like the one in this story. The group segues into discussion of the various opinions on the essentials for emergency first aid supplies you should have on hand. Dr. JP Brewer circles back to the role of teamwork and establishing roles in order to accomplish a successful resuscitation and the others chime in based on their experiences.

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This second episode follows the patients as they arrive to St. Vincent, a small critical access hospital in Leadville, the next stop on their journey. Teamwork is the main theme throughout this episode as these doctors work to stabilize these patients and coordinate air transport to definitive care at Level 1 Trauma Center Swedish Medical Center. Dr. Quan goes into detail about the extent of the patients’ internal injuries, the role of damage control surgery in their management and how appropriate pre-hospital management is crucial for these critical trauma patients.

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High in the mountains of Colorado, a crew of unsuspecting docs stumble upon the EMS scene of a head-on collision after an arduous mountain bike ride. Trauma is a Journey is a four part rural trauma mini series that recounts this tale as this group springs into action to assist the EMS crews dealing with two critical patients. Elizabeth Esty hosts a panel discussion with the key players: Dr. Dylan Luyten, Dr. JP Brewer, Dr. Madison Macht, Dr. Glenda Quan and Jeremiah Grantham as this story unfolds.

In this first episode, the scene is set for the arc of this storyline and while the journey of these patients is the primary focus, the doctors involved come to realize that this experience also took them on a journey as they debrief the events following their ride. Tune in for discussion of the pre-hospital management and insightful commentary on the situation as a whole.

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Contributor: Samuel Killian, MD

Educational Pearls:

Anecdotally, when the computer reads a triage EKG as normal it is most often normal
One study tested this theory by examining 855 computer-read EKGS (222 of which were read as normal)
Two cardiologists reviewed these 222 normal EKGs and only found 13 EKGs that were slightly abnormal with nonspecific abnormalities
Two EM physicians then reviewed these EKGs and only one physician on one EKG said they would change the patient’s course of care by rooming them faster
The study may support eliminating physician review of normal triage EKGs as a safe practice that would decrease physician interruption

References

Hughes KE, Lewis SM, Katz L, Jones J. Safety of Computer Interpretation of Normal Triage Electrocardiograms. Acad Emerg Med. 2017 Jan;24(1):120-124. doi: 10.1111/acem.13067. PMID: 27519772.

Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD

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Contributor: Aaron Lessen, MD

Educational Pearls:

Ivermectin is an antiparasitic medication that has been used for a long time, but has sparked new interest in the past year as a potential treatment for COVID-19
In-vitro studies have shown it decreases how quickly COVID replicates and may make it less likely to adhere to cells
Observational studies have found lower rates of COVID-19 infections in areas that provide ivermectin prophylaxis
In several studies it was shown that it decreased severity and mortality, though there were significant methodological limitations
NIH gave a statement saying there is not enough evidence to support or refute based on current trials and larger more rigorous trials are needed

References

Caly L, Druce JD, Catton MG, Jans DA, Wagstaff KM. The FDA-approved drug ivermectin inhibits the replication of SARS-CoV-2 in vitro. Antiviral Res. 2020 Jun;178:104787. doi: 10.1016/j.antiviral.2020.104787. Epub 2020 Apr 3. PMID: 32251768; PMCID: PMC7129059.

Hellwig MD, Maia A. A COVID-19 prophylaxis? Lower incidence associated with prophylactic administration of ivermectin. Int J Antimicrob Agents. 2021 Jan;57(1):106248. doi: 10.1016/j.ijantimicag.2020.106248. Epub 2020 Nov 28. PMID: 33259913; PMCID: PMC7698683.

Rajter JC, Sherman MS, Fatteh N, Vogel F, Sacks J, Rajter JJ. Use of Ivermectin Is Associated With Lower Mortality in Hospitalized Patients With Coronavirus Disease 2019: The Ivermectin in COVID Nineteen Study. Chest. 2021 Jan;159(1):85-92. doi: 10.1016/j.chest.2020.10.009. Epub 2020 Oct 13. PMID: 33065103; PMCID: PMC7550891.

Chaccour C, Casellas A, Blanco-Di Matteo A, Pineda I, Fernandez-Montero A, Ruiz-Castillo P, Richardson MA, Rodríguez-Mateos M, Jordán-Iborra C, Brew J, Carmona-Torre F, Giráldez M, Laso E, Gabaldón-Figueira JC, Dobaño C, Moncunill G, Yuste JR, Del Pozo JL, Rabinovich NR, Schöning V, Hammann F, Reina G, Sadaba B, Fernández-Alonso M. The effect of early treatment with ivermectin on viral load, symptoms and humoral response in patients with non-severe COVID-19: A pilot, double-blind, placebo-controlled, randomized clinical trial. EClinicalMedicine. 2021 Feb;32:100720. doi: 10.1016/j.eclinm.2020.100720. Epub 2021 Jan 19. PMID: 33495752; PMCID: PMC7816625.

Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD

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If you listen to this podcast, then you're probably familiar with our founder and frequent contributor, Dr. Donald Stader, and his fascination with the intersection of Emergency Medicine, opioids and Addiction Medicine. He is board certified in both specialties and is an active clinician in the ED that is constantly working to improve systems of best practice surrounding opioid uses there and in other specialties. In this episode of UnfilterED, Nick touches on these topics briefly before diving much deeper into the evolution of Don's perspectives on life and death in the context of his mother's recent passing due to COVID-19.

Tune in to hear Don's unfiltered personal account that can only be described as real, raw and relevant.

Time Stamps

1:35 Don introduction

3:00 Opioid epidemic impacted by COVID

10:00 Upcoming Don projects and the role of stories

14:42 Sources of aspirational inspiration

34:07 Mother’s death and learning how to die

49:12 Ending on a happier note

The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.com/cme-courses/ and create an account.

Donate to EMM today!

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Contributor: Erik Verzemnieks, MD

Educational Pearls:

INR measures the clotting cascade including factors II, VII, IX, and X
Coumadin most commonly elevates the INR, and it is used to monitor the anticoagulant’s effectiveness
Liver failure can cause a similar elevation in the INR due to lack of synthesis of factors II, VII, IX, X
An elevated INR in liver failure does not mean that the patient is anticoagulated, at increased risk for bleeding, or is at less risk of forming a clot
There is more commonly an increased risk of clot formation due to lack of production of protein C and S, which are natural anticoagulants
Lack of production of proteins C and S have a larger effect and lead to typically a net clotting risk
Levels of these can be indirectly measured through albumin
Portal venous thrombosis is one of the most common examples of this phenomenon

References

Harrison MF. The Misunderstood Coagulopathy of Liver Disease: A Review for the Acute Setting. West J Emerg Med. 2018;19(5):863-871. doi:10.5811/westjem.2018.7.37893

Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD

The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.com/cme-courses/ and create an account.

Donate to EMM today!

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Contributor: Aaron Lessen, MD

Educational Pearls:

When evaluating a thunderclap headache, don’t forget RCVS!
- RCVS: reversible cerebral vasoconstriction syndrome
- Due to reversible spasms of cerebral blood vessels
Can sometimes be seen on CTA or MRA, but often the imaging is normal and formal angiograms only occasionally show it
It can be caused by medications, intense physical activity, orgasm, and postpartum conditions, but the exact etiology is unknown
Typically seen in females in their 40s
Can result in bleeding, strokes, and seizures
There is no good treatment, but stopping the suspected offending agent may help

References

Sattar A, Manousakis G, Jensen MB. Systematic review of reversible cerebral vasoconstriction syndrome. Expert Rev Cardiovasc Ther. 2010;8(10):1417-1421. doi:10.1586/erc.10.124

Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD

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Contributor: Peter Bakes, MD

Educational Pearls:

Necrotizing Enterocolitis (NEC)
- Presents in the first few days of life (often in the NICU) to 3 weeks old
- Risk factors include prematurity, excess feeding, neonatal sepsis
- Pneumatosis Intestinalisis on abdominal xray caused by bacterial translocation into the bowel wall
- Treated with NG tube, bowel rest and surgical resection
Other causes of pediatric abdominal pain
- Malrotation with volvulus
- - Malrotation is caused by failure of intestinal rotation in the 8th-12th week of development
  - Presents with bilious vomiting, which is a surgical emergency in a neonate
  - 90% of cases present in the first year of life, with most of these presenting in the first month
  - Diagnosed with an upper GI series
- Pyloric Stenosis
- - Typically in males <2 months of age who present with signs of dehydration in the setting of non-bilious vomiting
  - Diagnosed with abdominal ultrasound and treated surgically
- Intussusception
- - Typically presents between 2 months and 2 years with a palpable mass in the RUQ
  - Diagnosed with abdominal ultrasound
- Duodenal atresia
- - Congenital stricture in the duodenum
  - Presents with bilious vomiting and a double-bubble on abdominal xray

References

Alwan R, Drake M, Gurria Juarez J, Emery KH, Shaaban AF, Szabo S, Sobolewski B. A Newborn With Abdominal Pain. Pediatrics. 2017 Nov;140(5):e20164267. doi: 10.1542/peds.2016-4267. PMID: 29042421.

Hostetler MA, Schulman M. Necrotizing enterocolitis presenting in the Emergency Department: case report and review of differential considerations for vomiting in the neonate. J Emerg Med. 2001 Aug;21(2):165-70. doi: 10.1016/s0736-4679(01)00371-7. PMID: 11489407.

Summarized by John Spartz, MS3

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Contributor: Aaron Lessen, MD

Educational Pearls:

Meta-analysis of 57,420 COVID+ patients evaluated mortality after intubation
- 45% mortality rate for all patients in the study
- 84.4% mortality in patients over 80 years old
POSITIONED Trail assessed need for intubation in patients awake self-proning compared to not
- Risk of intubation and mortality was lower for those self-proning
- 0.3 hazard ratio for intubation in those self-proning

References

Lim ZJ, Subramaniam A, Ponnapa Reddy M, et al. Case Fatality Rates for Patients with COVID-19 Requiring Invasive Mechanical Ventilation. A Meta-analysis. Am J Respir Crit Care Med. 2021;203(1):54-66. doi:10.1164/rccm.202006-2405OC

Jagan N, Morrow LE, Walters RW, Klein LP, Wallen TJ, Chung J, Plambeck RW. The POSITIONED Study: Prone Positioning in Nonventilated Coronavirus Disease 2019 Patients-A Retrospective Analysis. Crit Care Explor. 2020 Oct 1;2(10):e0229. doi: 10.1097/CCE.0000000000000229. PMID: 33063033; PMCID: PMC7531752.

Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD

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Contributor: Jared Scott, MD

Educational Pearls:

Differential Diagnosis: non-accidental trauma, febrile seizure, meningitis, hyponatremia, epilepsy
Convulsions with gastroenteritis is a known entity to cause seizures in infancy
- Predominantly occurs in ages 6 months to 3 years
- Occur with diarrheal episodes
- No electrolyte abnormalities associated with the seizure nor severe dehydration
- Seizures tend to come in clusters
- Most have a normal EEG and do not develop epilepsy
- Reported incidence in gastroenteritis of 1-2% of gastroenteritis
- Treatment addresses the seizures but long term anti-epileptic drugs are typically not needed

References

Kang B, Kwon YS. Benign convulsion with mild gastroenteritis. Korean J Pediatr. 2014;57(7):304-309. doi:10.3345/kjp.2014.57.7.304

Ma X, Luan S, Zhao Y, Lv X, Zhang R. Clinical characteristics and follow-up of benign convulsions with mild gastroenteritis among children. Medicine (Baltimore). 2019;98(2):e14082. doi:10.1097/MD.0000000000014082

Image credit: Kurt Christensen

Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD

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Contributor: Nick Tsipis, MD

Educational Pearls:

Epinephrine: alpha-1, alpha-2, beta-1, and beta 2 agonist - used in cardiac arrest with positive effects on ROSC in prehospital and peri-hopsital setting
Norepinephrine: alpha-1 and beta-1 agonist - used in septic shock to increase cardiac output and peripheral vasoconstriction
Phenylephrine: alpha-1 adrenergic agonist - used in spinal/neurogenic shock as well as medication-induced peri-procedural hypotension (propofol for RSI) as it only helps with vasoconstriction
Dopamine: alpha-1, alpha-2, beta-1, beta 2, and dopamine agonist - used for sepsis in the past, but not recommended due to dysrhythmias
Vasopressin: V1 agonist (vasoconstricts) - used when maxed out of norepinephrine for septic shock
Milrenone: phosphodiesterase inhibitor - used in heart failure to drop preload and afterload
Dobutamine: beta-2 (with minimal beta-1) adrenergic agonist - used in heart failure and cardiogenic shock to reduce afterload

References

Shields SH, Holland RM. Pharmacology of Vasopressors and Inotropes. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7e. McGraw-Hill; Accessed February 14, 2021.

Episode 31 - Vasopressors. FOAMcast: An Emergency Medicine Podcast. 25 July 2015. https://foamcast.org/tag/vasopressors/

Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD

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Contributor: Jared Scott, MD

Educational Pearls:

Small capsule pacemaker (2.5 cm, 1 ml volume) resides in the heart without any associated wires or leads like a traditional pacemaker
The new version has a 6 year battery life, after which it can be deactivated and a traditional pacemaker put in place
Cost is around 2-4 times that of a traditional pacemaker
NEJM study from 2015 showed it met the primary efficacy endpoint in 90% of patients and the primary safety endpoint in 93.3% of patients
Follow up study showed 3% complication with the intracardiac pacemaker compared to 9% in traditional

References

Groner, Ashley PA-C; Grippe, Kristen PA-C The leadless pacemaker, Journal of the American Academy of Physician Assistants: June 2019 - Volume 32 - Issue 6 - p 48-50 doi: 10.1097/01.JAA.0000554750.85170.d4

Reddy VY, Exner DV, Cantillon DJ, Doshi R, Bunch TJ, Tomassoni GF, Friedman PA, Estes NA 3rd, Ip J, Niazi I, Plunkitt K, Banker R, Porterfield J, Ip JE, Dukkipati SR; LEADLESS II Study Investigators. Percutaneous Implantation of an Entirely Intracardiac Leadless Pacemaker. N Engl J Med. 2015 Sep 17;373(12):1125-35. doi: 10.1056/NEJMoa1507192. Epub 2015 Aug 30. PMID: 26321198.

Chan KH, McGrady M, Wilcox I. A Leadless Intracardiac Transcatheter Pacing System. N Engl J Med. 2016 Jun 30;374(26):2604. doi: 10.1056/NEJMc1604852. PMID: 27355553.

Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD

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Contributor: Peter Bakes , MD

Educational Pearls:

Pediatric Fever + Rash Differential: scarlet fever, measles, rubella, chicken pox, fifth’s disease, HHV-6, adenovirus, anaphylaxis, Kawasaki’s disease
Kawasaki’s is diagnosed clinically with prolonged fever (>7 days fever in <6 months > 5 days of fever >6 months with 4 of the following:
- Strawberry tongue/fissured lips
- Bilateral conjunctival injection
- Cervical lymphadenopathy
- Hand/foot edema
- Maculopapular rash
Can develop life threatening coronary artery aneurysms
Treated with aspirin/IVIG

References

Modesti AM, Plewa MC. Kawasaki Disease. [Updated 2020 Jul 2]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK537163/?report=classic

Ramphul K, Mejias SG. Kawasaki disease: a comprehensive review. Arch Med Sci Atheroscler Dis. 2018;3:e41-e45. Published 2018 Mar 21. doi:10.5114/amsad.2018.74522

Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD

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Contributor: Rachael Duncan, PharmD BCPS

Educational Pearls:

According to the Department of Public Health and Environment who puts out a weekly report on the influenza virus in Colorado, there appears to be less influenza in Colorado than previous years
A milder influenza outbreak is likely due to mask wearing and social distancing practices
There have only been 22 hospitalizations for influenza in Colorado since the start of the flu season back in September and 0 outbreaks in long-term care facilities
Xofluza (baloxavir marboxil) is an antiviral PA endonuclease inhibitor and was approved by the FDA in 2018 for uncomplicated influenza in patients 12 years and older that have been symptomatic for less than 48 hours
Patient’s getting Xofluza must be otherwise healthy or at risk of developing influenza-related complications
Due to limited data, Xofluza would not be a good option for those that are inpatient or critically ill and is best utilized for patients who are being seen in the emergency department and will be sent home
Currently Xofluza is not approved for complicated patients, pregnant patients or those that are breast-feeding which limits its use
When compared with Tamiflu in phase 3 studies, Xofluza was superior to placebo and similar to Tamiflu in shortening the duration of illness
Xofluza is a single dose that is weight based and appears to be very well tolerated with some adverse effects including headache, nausea and diarrhea
Xofluza showed a quicker recovery compared to Tamiflu by 8 hours which could be related to its one-time dosing
Cost is a limiting factor for the use of Xofluza. Tamiflu costs around $25 where as Xofluza (only available as brand name currently) is $156 at the cheapest
Pharmacists are still encouraging everyone to get their influenza vaccines despite less influenza cases this year

References:

Cdphe.colorado.gov. 2021. Influenza (flu) | Department of Public Health & Environment. [online] Available at: [Accessed 11 February 2021].

Ison, M., Portsmouth, S., Yoshida, Y., Shishido, T., Mitchener, M., Tsuchiya, K., Uehara, T. and Hayden, F., 2020. Early treatment with baloxavir marboxil in high-risk adolescent and adult outpatients with uncomplicated influenza (CAPSTONE-2): a randomised, placebo-controlled, phase 3 trial. The Lancet Infectious Diseases, 20(10), pp.1204-1214.

Hayden, F., Sugaya, N., Hirotsu, N., Lee, N., de Jong, M., Hurt, A., Ishida, T., Sekino, H., Yamada, K., Portsmouth, S., Kawaguchi, K., Shishido, T., Arai, M., Tsuchiya, K., Uehara, T. and Watanabe, A., 2018. Baloxavir Marboxil for Uncomplicated Influenza in Adults and Adolescents. New England Journal of Medicine, 379(10), pp.913-923.

Summarized by Emily Mack OMSIII

The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.com/cme-courses/ and create an account.

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This episode of Mental Health Monthly we will be discussing drugs screens in the Emergency Department with Dr. Justin Romano and Eddie Carillo. Dr. Justin Romano is a current psychiatry resident and Eddie Carillo is a licensed mental health therapist. Check out their podcast Millennial Mental Health Channel on all major podcast platforms. Shout out to Dr. Dave Marshall whose grand round presentation this was based on.

Key Points:

Try not to judge your patient based on the results of their drug screen
Drug screens are used a lot; they are not always accurate
Based on one study there was no significant change in outcome, treatment, disposition or psychiatric course when a drug screen was obtained
Specific good uses for drug screens include new onset of psychiatric symptoms

Educational Pearls:

1 in 8 ED visits are due to psychiatric complaints which is up 44% since mid 2000’s
63% of new psychiatric complaints had a medical cause
Physicians use drug screens commonly in the Emergency Department, but often do not understand their limitations and are often not using them in the most clinically effective manner
Urine is by far the most commonly used in the Emergency Department
UA drug screens are notorious for having false positives and false negatives
Length of clearance from the urine:
- Alcohol 12 hours
- Methamphetamines/Amphetamines 48 hours
- Benzodiazepines 3 days
- Opiates 2-3 days
- Cocaine 2-4 days
- Marijuana dependent on use: 3- 15 days
- Phencyclidine (PCP) 8 days
Urine drug screens have a false positive rate of 5-10 % and a false negative rate of 10-15%
False Positive; urine drug screen positive, but drug is not in their body
- False positives for amphetamines: bupropion, trazodone, metformin, promethazine, pseudoephedrine, phentermine and atomoxetine
- False positives for benzodiazepines: sertraline
- False positives for cannabis: ibuprofen, naproxen, proton pump inhibitors
- False positives for opiates: poppy seeds, antibiotics, Benadryl
- False positives for PCP: venlafaxine, ibuprofen and Ambien
- False positives for cocaine: amoxicillin
False Negative; urine drug screen negative, but drug is in the body
- Benzodiazepines: such as alprazolam, clonazepam, lorazepam or triazolam
- Cannabinoids: CBD, synthetic marijuana such as K2
- Opiates: oxycodone, fentanyl, methadone and tramadol
If you get a test that you don’t think is accurate you can always send off for a confirmatory test

References

Summarized by Emily Mack OMSIII | Edited by Mason Tuttle

The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.com/cme-courses/ and create an account.

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Contributor: Aaron Lessen, MD

Educational Pearls:

Retrospective review of 5,021 patients over 65 with 2 or more rib fractures recently published
3577 (78 %) were admitted to non-ICU setting
1.1% of these patients had unexpected intubation or ICU transfer
Findings raise questions regarding current guidelines for ICU admission in elderly patients with isolated rib fractures

References

Naar L, El Hechi MW, van Erp IA, Mashbari HNA, Fawley J, Parks JJ, Fagenholz PJ, King DR, Mendoza AE, Velmahos GC, Kaafarani HMA, Saillant NN. Isolated rib cage fractures in the elderly: Do all patients belong to the intensive care unit? A retrospective nationwide analysis. J Trauma Acute Care Surg. 2020 Dec;89(6):1039-1045. doi: 10.1097/TA.0000000000002891. PMID: 32697447.

Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD

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Contributor: Aaron Lessen, MD

Educational Pearls:

Pyogenic liver abscesses can be caused by
- Intra-abdominal infection progressing to peritonitis which then drains into liver
- Bacteremia leading to hematogenous spead and seeding
- Local biliary infection with contiguous spread
Patients typically present with signs of sepsis or septic shock and the abscess can be diagnosed using ultrasound or CT
Treat with IV fluids, broad spectrum antibiotics, and consultation for drainage

References

Kurland JE, Brann OS. Pyogenic and amebic liver abscesses. Curr Gastroenterol Rep. 2004 Aug;6(4):273-9. doi: 10.1007/s11894-004-0078-2. PMID: 15245694.

Rahimian J, Wilson T, Oram V, Holzman RS. Pyogenic liver abscess: recent trends in etiology and mortality. Clin Infect Dis. 2004 Dec 1;39(11):1654-9. doi: 10.1086/425616. Epub 2004 Nov 9. PMID: 15578367.

Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD

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Contributor: Katie Sprinkel, MD

Educational Pearls:

Commonly known as “acid,” LSD is seeing a resurgence in the population as a recreational hallucination
Onset is about 30 minutes with peak pharmacologic effects at 2-4 hours, the drug’s half life is 3 hours resulting in some prolonged effects
While there is not an significant addictive component of LSD, tolerance for LSD does occur and prolonged usage is associated with increased incidence of schizophreniform disorders
Hallucinations and pseudo-hallucinations (sensory misperceptions) are typical of LSD intoxication, other common signs of intoxication include nausea, diaphoresis, tachycardia, mydriasis, and hypertension
More serious effects can be coma, hyperthermia, seizures, cardiac arrest, serotonin syndrome (with concomitant SSRI use) and coagulopathy, although the dose to cause these effects is very high
Treatment is decreasing sensory stimulation, benzodiazepines in some cases, and symptomatic treatment - no specific antidote exists

References

Blaho K, Merigian K, Winbery S, Geraci SA, Smartt C. Clinical pharmacology of lysergic acid diethylamide: case reports and review of the treatment of intoxication. Am J Ther. 1997 May-Jun;4(5-6):211-21. doi: 10.1097/00045391-199705000-00008. PMID: 10423613.

Klock JC, Boerner U, Becker CE. Coma, hyperthermia and bleeding associated with massive LSD overdose. A report of eight cases. West J Med. 1974;120(3):183-188.

Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD

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Contributor: Sam Killian, MD

Educational Pearls:

iliac vein compression syndrome is also called May-Thurner Syndrome
The left leg more frequently develops deep venous thrombosis (DVT) in part because about 1/4 of the population has May-Thurner
May-Thurner syndrome anatomic variant results in a right iliac artery compresses the left iliac vein against the spine, which can promote DVT formation
This is thought to be the cause of 2-3% of DVTs in patients seen in the ED and suspicion for this disease should increased in those with recurrent DVT
Diagnosis is made with MRV/MRA and will typically not be seen on duplex ultrasound
Typical anticoagulation treatment fails to address the underlying structural cause

References

Demir MC, Kucur D, Çakır E, Aksu NM, Onur MR, Sabuncu T, Akkaş M. May-Thurner syndrome: A curious syndrome in the ED. Am J Emerg Med. 2016 Sep;34(9):1920.e1-3. doi: 10.1016/j.ajem.2016.02.045. Epub 2016 Feb 19. PMID: 26971822.

Sharafi S, Farsad K. Variant May-Thurner syndrome: Compression of the left common iliac vein by the ipsilateral internal iliac artery. Radiol Case Rep. 2018;13(2):419-423. Published 2018 Feb 20. doi:10.1016/j.radcr.2018.01.001

Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD

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Educational Pearls:

Atropine has been shown to reduce hypersalivation as well as nausea and vomiting induced by ketamine sedation.
Atropine can increase the occurrence of a transient rash, as well as tachycardia.
There are no guidelines that recommend for or against atropine use in pediatric patients undergoing ketamine induced sedation.
Ultimately, it is the providers decision to include atropine when performing ketamine sedation.
Pediatric dosing for atropine is 0.01mg/kg IM.

References 1. Heinz P, Geelhoed GC, Wee C, Pascoe EM. Is atropine needed with ketamine sedation? A prospective, randomised, double blind study. Emerg Med J. 2006 Mar;23(3):206-9. doi: 10.1136/emj.2005.028969. PMID: 16498158; PMCID: PMC2464444. 2. Chong JH, Chew SP, Ang AS. Is prophylactic atropine necessary during ketamine sedation in children? J Paediatr Child Health. 2013 Apr;49(4):309-12. doi: 10.1111/jpc.12149. Epub 2013 Mar 15. PMID: 23495827. 3. Shi J, Li A, Wei Z, Liu Y, Xing C, Shi H, Ding H, Pan D, Ning G, Feng S. Ketamine versus ketamine pluses atropine for pediatric sedation: A meta-analysis. Am J Emerg Med. 2018 Jul;36(7):1280-1286. doi: 10.1016/j.ajem.2018.04.010. Epub 2018 Apr 5. PMID: 29656945.

Presented and Summarized by Devan Naughton, 4th year pharmacy student | Edited by Ruben Marrero-Vasquez

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Contributor: Peter Bakes, MD

Educational Pearls:

Two main differentials for wide complex tachycardia (WCT) include ventricular tachycardia (most common) and supraventricular tachycardia with aberrancy
Brugada syndrome and Wolff-Parkinson White are potential causes
Arrhythmogenic right ventricular dysplasia is a rare congenital cause of WCT that should be considered in younger patients presenting with WCT

References

B Garner J, M Miller J. Wide Complex Tachycardia - Ventricular Tachycardia or Not Ventricular Tachycardia, That Remains the Question. Arrhythm Electrophysiol Rev. 2013;2(1):23-29. doi:10.15420/aer.2013.2.1.23

Katritsis DG, Brugada J. Differential Diagnosis of Wide QRS Tachycardias. Arrhythm Electrophysiol Rev. 2020;9(3):155-160. doi:10.15420/aer.2020.20

Li KHC, Bazoukis G, Liu T, et al. Arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D) in clinical practice. J Arrhythm. 2017;34(1):11-22. Published 2017 Dec 21. doi:10.1002/joa3.12021

Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD

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Contributor: Dylan Luyten, MD

Educational Pearls:

D10 may be a better alternative to D50 in correcting hypoglycemia
Risks of D50:
- Can cause extravasation injury
- Risk of rebound hypoglycemia
D10 does not have the same risks and has no significant difference in reversal time of hypoglycemia compared to D50

References

Kiefer MV, Gene Hern H, Alter HJ, Barger JB. Dextrose 10% in the treatment of out-of-hospital hypoglycemia. Prehosp Disaster Med. 2014 Apr;29(2):190-4. doi: 10.1017/S1049023X14000284. Epub 2014 Apr 15. PMID: 24735872.

Moore C, Woollard M. Dextrose 10% or 50% in the treatment of hypoglycaemia out of hospital? A randomised controlled trial. Emerg Med J. 2005 Jul;22(7):512-5. doi: 10.1136/emj.2004.020693. PMID: 15983093; PMCID: PMC1726850.

Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD

The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.com/cme-courses/ and create an account.

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Contributor: Jared Scott, MD

Educational Pearls:

Pathologic bone fractures occur due to weakened bones from chronic disease and with less force when compared to non-pathologic fractures
Can be due to bone tumors, bone cysts, infections (osteomyelitis), osteogenesis imperfecta, Paget's disease of bone, and multiple myeloma
Have moth bitten or lytic appearance and you can sometimes see the periosteum peeling away from the bone

References

Angelini A, Trovarelli G, Berizzi A, Pala E, Breda A, Maraldi M, Ruggieri P. Treatment of pathologic fractures of the proximal femur. Injury. 2018 Nov;49 Suppl 3:S77-S83. doi: 10.1016/j.injury.2018.09.044. PMID: 30415673.

Marshall RA, Mandell JC, Weaver MJ, Ferrone M, Sodickson A, Khurana B. Imaging Features and Management of Stress, Atypical, and Pathologic Fractures. Radiographics. 2018 Nov-Dec;38(7):2173-2192. doi: 10.1148/rg.2018180073. PMID: 30422769.

Unbreakable

Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.com/cme-courses/ and create an account.

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Contributor: Jared Scott, MD

Educational Pearls:

Bilirubin is natural breakdown product of red blood cells but can be neurotoxic if levels become too high
Fetal red blood cells are fragile and break down easier, leading to higher bilirubin levels in neonates
Immature livers and increased intestinal absorption from sterile bowels also contribute to elevated levels and jaundice in all neonates
Other risk factors for neonatal jaundice include: temperature instability, poor feeding, hypoxia at birth, and being of East Asian descent
Neonatal bilirubin levels are referenced to time since birth using a nomogram to determine the need for light therapy (or exchange transfusion)

References

Mitra S, Rennie J. Neonatal jaundice: aetiology, diagnosis and treatment. Br J Hosp Med (Lond). 2017 Dec 2;78(12):699-704. doi: 10.12968/hmed.2017.78.12.699. PMID: 29240507.

Woodgate P, Jardine LA. Neonatal jaundice: phototherapy. BMJ Clin Evid. 2015 May 22;2015:0319. PMID: 25998618; PMCID: PMC4440981.

Colletti JE, Kothari S, Jackson DM, Kilgore KP, Barringer K. An emergency medicine approach to neonatal hyperbilirubinemia. Emerg Med Clin North Am. 2007 Nov;25(4):1117-35, vii. doi: 10.1016/j.emc.2007.07.007. Erratum in: Emerg Med Clin North Am. 2008 Feb;26(1):xi. Kothori, Samip [corrected to Kothari, Samip]. PMID: 17950138.

Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.com/cme-courses/ and create an account.

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Contributor: Cheyenne Bean, PharmD

Educational Pearls:

Bactrim (TMP-SMX) is a sulfa antibiotic used for a number of infections but can have untoward effects.
Hypoglycemia can be induced by the sulfa component of Bactrim, which binds receptors in the pancreas causing insulin to be secreted, dropping blood sugar levels.
- Oral diabetic medications, specifically sulfonylureas, when taken with Bactrim most often lead to these hypoglycemic episodes.
Hyperkalemia can be induced by Trimethoprim by blocking potassium excretion in the kidney, so Bactrim in combination with ACE inhibitors/ARBs/spironolactone can induce high potassium.
When prescribing Bactrim, remember to check home medications and if a patient is taking an above medication, check a baseline BGL and potassium.

References

1) Khorvash F, Moeinzadeh F, Saffaei A, Hakamifard A. Trimethoprim-sulfamethoxazole Induced Hyponatremia and Hyperkalemia, The Necessity of Electrolyte Follow-up in Every Patient. Iran J Kidney Dis. 2019 Jul;13(4):277-280. PMID: 31422395.

2) Kennedy KE, Teng C, Patek TM, Frei CR. Hypoglycemia Associated with Antibiotics Alone and in Combination with Sulfonylureas and Meglitinides: An Epidemiologic Surveillance Study of the FDA Adverse Event Reporting System (FAERS). Drug Saf. 2020 Apr;43(4):363-369. doi: 10.1007/s40264-019-00901-7. PMID: 31863282; PMCID: PMC7117991.

Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.com/cme-courses/ and create an account.

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Contributor: Gretchen Hinson, MD

Educational Pearls:

Viruses mutate frequently and a new variant of COVID has been found in the United Kingdom.
Mutations typically occur due to transcription errors during virus replication leading to slight changes in the virus which can alter its virulence, and this UK mutation has shown more infectivity.
The UK variant was first identified on 9/20/20 and sequenced in October
The variant has a mutation of the spike protein with increased receptor binding capacity, making it more efficient at infecting cells
Children seem to be more susceptible to this variant as compared to the prior COVID strains.

References

1) Tang JW, Tambyah PA, Hui DS. Emergence of a new SARS-CoV-2 variant in the UK. J Infect. 2020 Dec 28:S0163-4453(20)30786-6. doi: 10.1016/j.jinf.2020.12.024. Epub ahead of print. PMID: 33383088.

Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.com/cme-courses/ and create an account.

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Contributor: Peter Bakes, MD

Educational Pearls:

Hyperacute T waves can occur immediately and typical last less than an hour
- Hyperacute T waves are typically broader than peaked T-waves, which are associated with hyperkalemia
ST elevation which usually starts within an hour of the inciting event and can last up to a few days, and often follows the hyperacute T-waves
Q waves can begin at the time ST elevation begins and can remain permanently
T waves can invert before normalizing again days later

References

Levis JT. ECG Diagnosis: Hyperacute T Waves. Perm J. 2015;19(3):79. doi:10.7812/TPP/14-243

Vogel B, Claessen BE, Arnold SV, Chan D, Cohen DJ, Giannitsis E, Gibson CM, Goto S, Katus HA, Kerneis M, Kimura T, Kunadian V, Pinto DS, Shiomi H, Spertus JA, Steg PG, Mehran R. ST-segment elevation myocardial infarction. Nat Rev Dis Primers. 2019 Jun 6;5(1):39. doi: 10.1038/s41572-019-0090-3. PMID: 31171787.

Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.com/cme-courses/ and create an account.

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Contributor: Jared Scott, MD

Educational Pearls:

EKGs look at different angles, or vectors, of the heart’s electrical conduction as it travels through the heart. Knowing how to read these vectors is essential in diagnosing locations of cardiac pathologies
Leads II, III, and aVF follow an inferior path, so ST elevation in those leads indicates inferior involvement
Major complications more common with inferior STEMIs can include:
- hypotension which can be made worse by nitroglycerin
- Severe bradycardia due to SA/AV node involvement
Inferior STEMI, barring no hypotension or bradycardia, have better mortality than other types

References

Warner MJ, Tivakaran VS. Inferior Myocardial Infarction. 2020 Aug 8. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan–. PMID: 29262146.

Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.com/cme-courses/ and create an account.

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Contributor: Peter Bakes, MD

Educational Pearls:

STEMI criteria is not just 1mm elevation in contiguous leads
- 1.5 mm in V2-V3 for women
- 2.0 mm in V2-V3 for men
- 2.5 mm in V2-V3 for men under 40
Inferior MI typically have ST elevation in leads II, III and aVF
- Usually inferior MI’s show reciprocal changes (ST depression) in the lateral leads.
Lateral MI typically elevation in V5, V6, I, and aVL
Anterior MI show elevation in leads V1-4
Right sided MIs have mixed pattern, showing elevation in V1-V2 and V4 along with the inferior leads.
Right sided MI’s are very sensitive to nitrates, especially if they become intubated because this combination can drop pre-load significantly leading to profound hypotension

References

Akbar H, Foth C, Kahloon RA, et al. Acute ST Elevation Myocardial Infarction. [Updated 2020 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK532281/

Namana V, Gupta SS, Abbasi AA, Raheja H, Shani J, Hollander G. Right ventricular infarction. Cardiovasc Revasc Med. 2018 Jan;19(1 Pt A):43-50. doi: 10.1016/j.carrev.2017.07.009. Epub 2017 Jul 14. PMID: 28822687.

Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.com/cme-courses/ and create an account.

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Contributor: Aaron Lessen, MD

Educational Pearls:

High flow nasal cannula (HFNC) has become more utilized with COVID pandemic
Multiple studies have shown this method improves both oxygenation and ventilation
Newer studies have shown the respiratory benefit of HFNC vs normal oxygen in patients suffering from CHF and those with do not intubate orders who are experiencing respiratory distress.
Heated high flow is another option to provide ventilator and oxygen support to patients who either do not need or do not want to be intubated

References

Kang MG, Kim K, Ju S, et al. Clinical efficacy of high-flow oxygen therapy through nasal cannula in patients with acute heart failure . J Thorac Dis. 2019;11(2):410-417. doi:10.21037/jtd.2019.01.51

Peters SG, Holets SR, Gay PC. High-flow nasal cannula therapy in do-not-intubate patients with hypoxemic respiratory distress. Respir Care. 2013 Apr;58(4):597-600. doi: 10.4187/respcare.01887. PMID: 22781059.

Sharma S, Danckers M, Sanghavi D, et al. High Flow Nasal Cannula. [Updated 2020 Jul 2]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK526071/

Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.com/cme-courses/ and create an account.

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Contributor: Ruben Marrero-Vasquez, PharmD

Educational Pearls:

ACEP and FDA have both issued warnings about the viral Tik Tok Benadryl (diphenhydramine) challenge where individuals voluntarily overdose on diphenhydramine which can cause fatal toxicity
Diphenhydramine is typically dosed at 0.5-1 mg/kg in pediatric patients Q4-6 PRN and carries a fatal dose of 20-40 mg/kg but anywhere from 3-5x recommended dose does can cause toxicity
Diphenhydramine toxicity causes both central and peripheral anticholinergic toxicity
- Central anticholinergic toxicity symptoms: delirium, agitation, combativeness, confusion, restlessness, hallucinations, ataxia, tremor and seizures
- Peripheral anticholinergic toxicity symptoms: tachycardia, dry flushed skin, dry mucus membranes, thick secretions, dilation of pupils, urinary retention, and decreased bowel sounds
Pneumatic to help you remember anticholinergic toxidrome:
- Red as a beet
- Dry as a bone
- Blind as a bat
- Mad as a hatter
- Hot as a hare
- Full as a flask
- Management typically only requires supportive care, agitation from central anticholinergic delirium can be hardest aspect to treat, IV benzodiapines are first line treatment to control and may require large doses to prevent rhabdomyolysis and hyperthermia
- Diphenhydramine toxicity has been associated with blockade of sodium and potentially potassium channels increasing risk of arrhythmia and seizures. Cardiac changes can include: QRS widening, myocardial depression, QT prolongation and torasades-type ventricular tachycardia.
- Wide QRS complexes indicate delayed ventricular depolarization caused by sodium channel blockade, bolus of sodium bicarbonate can be used dosed 1-2 mEq/kg followed by continuous infusion
- Prolonged QT: restoration of low serum potassium and magnesium to high normal range
- Benzodiazipines should be used as first line therapy for toxin induced seizures
- Don’t use fosphenytoin or phenytoin sodium channel blockers as they can worsen cardiac conduction

References

                       1. Olson KR, Anderson IB, Benowitz NL, Blanc PD, Clark RF, Kearney TE, Kim-Katz SY, Wu AH. Diphenhydramine. In: Poisoning & Drug Overdose. 7th ed.McGraw Hll; 2018: 544-545.

FDA Warns About Serious Problems With High Doses Of The Allergy Medicine Diphenhydramine (Benadryl).(09/24/2020). CDC website. Accessed December 01, 2020. https://www.fda.gov/drugs/drug-safety-and-availability/fda-warns-about-serious-problems-high-doses-allergy-medicine-diphenhydramine-benadryl.
Su M, Goldman M. Anticholinergic Poisoning. UpToDate. https://www.uptodate.com/contents/anticholinergic-poisoning?search=diphenhydramine overdose&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1. Published October 6, 2020. Accessed December 26, 2020.
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                   *Summarized by Mason Tuttle*
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EMM is excited to welcome back the hosts of Millennial Mental Health Channel podcast to explain the key points of a robust suicide assessment in the ED. Dr. Justin Romano is a third year psychiatry resident in Omaha, Nebraska and Eddie Carrillo is a licensed mental health therapist currently working at partial hospitalization and IOP eating disorder program in Portland, Oregon. Their podcast Millennial Mental Health Channel seeks to explore the world of mental health from their two professional perspectives.

You can listen to their podcast on all major streaming platforms including Apple Podcasts, Spotify and Google Podcasts.

Follow them on Twitter and Instagram @millennialmhc

Contributors: Dr. Justin Romano and Eddie Carrillo, M.A., LPC

Educational Pearls:

Suicide is 10th most common cause in U.S. and the rate rose by 30% from 2000-2016 and the CDC reports that there was a 25% increase in ED visits for SI from January 2017 - December 2018
Use an objective screening tool like Columbia-Suicide Severity Rating Scale (C-SSRS) when assessing patients as they can help detect SI although ultimately it is up to your clinical impression to make a decision
Suicide reduction measures and strategies work! Take advantage of social workers when setting up outpatient resources for patients i.e. gun locks
Risk Factors include: prior attempts, substance use/abuse, mental disorders (especially depression and bipolar disorder), access to lethal means (most modifiable by risk reduction strategies), knowing someone who has died by suicide, social isolation, chronic disease or disability, lack of access to mental health resources, recent changes in social status and being a member of a high risk demographic (older caucasian men, LGBTQ+, Native Americans and Alaskan Natives)
Protective Factors include: good followup as an outpatient, good social support, life skills, purpose in life, cultural beliefs, children and sense of responsibility in the family
Sober up and reassess suicidality
If not medically cleared, admit to hospital to address these complaints and then address suicidality
If they have suicidal thoughts, plan and are reaching out for help because they don’t want to do it then send to inpatient facility
Consult psychiatry to explain inpatient psych or when you’re worried about patient safety to have them weigh in
Get collateral by talking to a family member to verify that the patient is telling the truth
At the end of the day, thorough documentation of risk and protective factors and results of screening tool in Assessment and Plan is essential to protecting yourself as a professional

References

Betz ME, Boudreaux ED. Managing Suicidal Patients in the Emergency Department. Ann Emerg Med. 2016;67(2):276-282. doi:10.1016/j.annemergmed.2015.09.001

Suicide. National Institute of Mental Health. https://www.nimh.nih.gov/health/statistics/suicide.shtml. Published September 2020. Accessed December 30, 2020.

Zwald ML, Holland KM, Annor FB, et al. Syndromic Surveillance of Suicidal Ideation and Self-Directed Violence — United States, January 2017–December 2018. MMWR Morb Mortal Wkly Rep 2020;69:103–108. DOI: http://dx.doi.org/10.15585/mmwr.mm6904a3.

Summarized by Mason Tuttle

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Educational Pearls:

The CDC has made new formal recommendations for treating Gonorrhea due to increasing resistance to Rocephin and Azithromycin.
New recommendations:
- Confirmed gonorrhea: Ceftriaxone 500 mg once
- Empiric treatment: Ceftriaxone 500 mg once followed by 7 days Doxycycline 100 mg BID
- No longer using Azithromycin due to high resistance
Second line:
- Gentamycin IM
- Cefixime 800 mg oral
Pharyngeal involvement has high resistance rates to second line agents and ceftriaxone is strongly preferred

References

St. Cyr S, Barbee L, Workowski KA, et al. Update to CDC’s Treatment Guidelines for Gonococcal Infection, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1911–1916. DOI: http://dx.doi.org/10.15585/mmwr.mm6950a6.

Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.com/cme-courses/ and create an account.

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Contributor: Tom Seibert, MD

Educational Pearls:

High altitude cerebral edema (HACE) is the end stage of acute mountain sickness and is diagnosed when patients develop neurologic dysfunction, ataxia, and altered mental status.
The pathophysiology of HACE is thought to be due to increased cerebral blood flow and increased capillary permeability causing vasogenic edema and brain swelling
HACE is linked to extreme altitude
Rapid descent should be done as soon as possible for this potentially fatal condition
Oxygen can be supportive
Dexamethasone is also typically indicated (8mg initially followed by 4 mg every 6 hours)

Editor's note: HACE can occur at altitudes as low as 8000 feet so don’t automatically assume it can’t/doesn’t happen in the US

References

Jensen JD, Vincent AL. High Altitude Cerebral Edema. 2020 Aug 26. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan–. PMID: 28613666.

Hackett PH, Yarnell PR, Weiland DA, Reynard KB. Acute and Evolving MRI of High-Altitude Cerebral Edema: Microbleeds, Edema, and Pathophysiology. AJNR Am J Neuroradiol. 2019 Mar;40(3):464-469. doi: 10.3174/ajnr.A5897. Epub 2019 Jan 24. PMID: 30679208; PMCID: PMC7028681.

Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.com/cme-courses/ and create an account.

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Contributor: Don Stader, MD

Educational Pearls:

Time can be an important factor in outcomes regarding sepsis including mortality
Emphasis has grown on early administration of antibiotics and IV fluids in sepsis
However, early initiation of vasopressors for hypotensive patients may have significant mortality benefit as well

References

Hayden GE, Tuuri RE, Scott R, et al. Triage sepsis alert and sepsis protocol lower times to fluids and antibiotics in the ED. Am J Emerg Med. 2016;34(1):1-9. doi:10.1016/j.ajem.2015.08.039

Colling KP, Banton KL, Beilman GJ. Vasopressors in Sepsis. Surg Infect (Larchmt). 2018;19(2):202-207. doi:10.1089/sur.2017.255

Colon Hidalgo D, Patel J, Masic D, Park D, Rech MA. Delayed vasopressor initiation is associated with increased mortality in patients with septic shock. J Crit Care. 2020 Feb;55:145-148. doi: 10.1016/j.jcrc.2019.11.004. Epub 2019 Nov 9. PMID: 31731173.

Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.com/cme-courses/ and create an account.

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Contributor: Tom Seibert, MD

Educational Pearls:

Acute Mountain sickness (AMS) can cause headache along with fatigue, nausea, vomiting, insomnia
Typically occurs above 6500 feet (not 65,000) in elevation
Acclimation to altitude can help prevent symptoms
if not treated, AMS can advance to severe illness involving cerebral or pulmonary edema.
Mild symptoms can be managed with rest but more severe symptoms will require descent, oxygen, acetazolamide and steroids
Acetazolamide can be used as both a preventative and therapeutic drug

References

Davis C, Hackett P. Advances in the Prevention and Treatment of High Altitude Illness. Emerg Med Clin North Am. 2017 May;35(2):241-260. doi: 10.1016/j.emc.2017.01.002. PMID: 28411926.

Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.com/cme-courses/ and create an account.

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Contributor: Thomas Seibert, MD

Educational Pearls:

High Altitude Pulmonary Edema (HAPE) typically occurs 2-4 days after arriving at elevation
Symptoms include:
- Fatigue
- Dyspnea
- Cough
Treatment includes:
- Descent to lower elevation
- Oxygen supplementation
- Nifedipine
Caused by sympathetic stimulation from hypobaric hypoxic exposure, causing uneven pulmonary vasculature constriction and when paired with a leaky endothelium, pulmonary edema. #science

References

Swenson ER, Bärtsch P. High-altitude pulmonary edema. Compr Physiol. 2012 Oct;2(4):2753-73. doi: 10.1002/cphy.c100029. PMID: 23720264.

Johnson NJ, Luks AM. High-Altitude Medicine. Med Clin North Am. 2016 Mar;100(2):357-69. doi: 10.1016/j.mcna.2015.09.002. PMID: 26900119.

Hultgren HN. High-altitude pulmonary edema: current concepts. Annu Rev Med. 1996;47:267-84. doi: 10.1146/annurev.med.47.1.267. PMID: 8712781.

Summarized by Jackson Roos, MSIV | Edited by Erik Verzemnieks, MD

The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.com/cme-courses/ and create an account.

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Contributor: Aaron Lessen, MD

Educational Pearls:

Schizophrenia typically doesn’t present until age 13 and has a prodrome
Prodrome includes months of gradual changes in behavior, starting with negative symptoms and progressing to positive symptoms
- Negative symptoms include losing concentration, poor memory, poor school performance, and personality changes
- Positive symptoms include hallucinations, which tend to be more visual in children
Sudden changes mimicking psychiatric illness should raise concern for alternative causes

References

Kendhari J, Shankar R, Young-Walker L. A Review of Childhood-Onset Schizophrenia. Focus (Am Psychiatr Publ). 2016 Jul;14(3):328-332. doi: 10.1176/appi.focus.20160007. Epub 2016 Jul 8. PMID: 31975813; PMCID: PMC6526799.

Staal M, Panis B, Schieveld JNM. Early warning signs in misrecognized secondary pediatric psychotic disorders: a systematic review. Eur Child Adolesc Psychiatry. 2019 Sep;28(9):1159-1167. doi: 10.1007/s00787-018-1208-y. Epub 2018 Jul 27. PMID: 30054738.

Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.com/cme-courses/ and create an account.

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Contributors: Rachael Duncan, PharmD and Sean McCullough, PharmD

Educational Pearls:

A 2019 Report by the National Women’s Law Center: Most common occupations for pregnant workers are elementary and middle school teachers, registered nurses, and nursing/psychiatric/home health care aides.
This raises the question: Should pregnant women, specifically front-line workers, get the Covid-19 vaccine?
According to the FDA, there is currently not enough data to make a conclusion about the safety of the newly approved Pfizer vaccine for populations that include children less than 16, pregnant and lactating women, and those that are immunocompromised.
Specifically, pregnant women were excluded from the clinical trials testing the Pfizer vaccine.
According to the CDC, additional data needs to be reviewed from the phase III clinical trials in order to provide recommendations to pregnant and breast-feeding women about taking the Covid-19 vaccine and its safety.
An Advisory Committee of Immunization Practices (ACIP) meeting will take place on 12/13/2020 and will hopefully provide formal recommendations to pregnant and lactating women.
The Society for Maternal-Fetal Medicine (SMFM) has consistently advocated for the inclusion of pregnant and lactating women into clinical trials when these criteria are met: 1) pregnancy poses increased susceptibility to or severity of a disease; 2) the best approach to protect the infant is through passive placental antibody transfer, which provides the most efficient and direct protection to the newborn before an infant can be vaccinated, and 3) there is an active outbreak.
SMFM recommends healthcare workers who are currently being prioritized to receive the vaccine to also receive the vaccine if pregnant.
Pregnant healthcare workers should take their individual situation into consideration and weigh the risks and benefits for themselves and the risk for detecting disease when considering if or when to take the Covid-19 vaccine.

References

ACIP Meeting Agenda December 13, 2020 - cdc.gov. MEETING OF THE ADVISORY COMMITTEE ON IMMUNIZATION PRACTICES (ACIP). https://www.cdc.gov/vaccines/acip/meetings/downloads/agenda-archive/agenda-2020-12-11.pdf. Published 2020. Accessed December 11, 2020.
Coronavirus (COVID-19), Pregnancy, and Breastfeeding: A Message for Patients. ACOG. https://www.acog.org/womens-health/faqs/coronavirus-covid-19-pregnancy-and-breastfeeding. Published 2020. Accessed December 11, 2020.
Interim Considerations for COVID-19 Vaccination of Healthcare Personnel and Long-Term Care Facility Residents. Centers for Disease Control and Prevention. https://www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/covid-19/clinical-considerations.html. Published December 3, 2020. Accessed December 11, 2020.
Society for Maternal-Fetal Medicine (SMFM) Statement: SARS-CoV-2 Vaccination in Pregnancy. December 2020. https://s3.amazonaws.com/cdn.smfm.org/media/2591/SMFM_Vaccine_Statement_12-1-20_(final).pdf
Vaccines and Related Biological Products Advisory Committee Meeting December 10, 2020. 2020. https://www.fda.gov/media/144245/download
VRBPAC December 10, 2020 Meeting Announcement. U.S. Food and Drug Administration. https://www.fda.gov/advisory-committees/advisory-committee-calendar/vaccines-and-related-biological-products-advisory-committee-december-10-2020-meeting-announcement. Published December 10, 2020. Accessed December 11, 2020.

Summarized by Emily Mack OMSIII | Edited by Rachael Duncan, PharmD

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Contributor: Aaron Lessen, MD

Educational Pearls:

Serum prolactin levels can be used to help differentiate epileptic seizures from non-epileptic seizures
It is also released and elevated after epileptic seizures but not non-epileptic seizures
A level must be checked 10-20 minutes after the episode and if possible a next day level should be checked to establish a baseline
Levels can also be raised after a syncopal event
Not the most useful ED also due to the long turn around time
EEG will remain superior for now

References

Nass RD, Sassen R, Elger CE, Surges R. The role of postictal laboratory blood analyses in the diagnosis and prognosis of seizures. Seizure. 2017 Apr;47:51-65. doi: 10.1016/j.seizure.2017.02.013. Epub 2017 Feb 27. PMID: 28288363.

Chen DK, So YT, Fisher RS; Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Use of serum prolactin in diagnosing epileptic seizures: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology. 2005 Sep 13;65(5):668-75. doi: 10.1212/01.wnl.0000178391.96957.d0. PMID: 16157897.

Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.com/cme-courses/ and create an account.

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Contributor: Don Stader, MD

Educational Pearls:

Zyprexa (olanzapine) is a second generation antipsychotic with multiple other uses
Excellent for treating nausea in patients undergoing chemotherapy or with THC hyperemesis syndrome
Helps with the psychological and emotional aspect of pain
Effective in treatment of headaches
Can be given under the tongue
Fewer incidences of dystonic reactions compared with first generation antipsychotics
Patients using anti-dopaminergic should not receive antipsychotics because they also work on dopaminergic receptors

References

Navari RM, Qin R, Ruddy KJ, Liu H, Powell SF, Bajaj M, Dietrich L, Biggs D, Lafky JM, Loprinzi CL. Olanzapine for the Prevention of Chemotherapy-Induced Nausea and Vomiting. N Engl J Med. 2016 Jul 14;375(2):134-42. doi: 10.1056/NEJMoa1515725. PMID: 27410922; PMCID: PMC5344450.

Jimenez XF, Sundararajan T, Covington EC. A Systematic Review of Atypical Antipsychotics in Chronic Pain Management: Olanzapine Demonstrates Potential in Central Sensitization, Fibromyalgia, and Headache/Migraine. Clin J Pain. 2018 Jun;34(6):585-591. doi: 10.1097/AJP.0000000000000567. PMID: 29077621.

Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.com/cme-courses/ and create an account.

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Contributor: Don Stader, MD

Educational Pearls:

Majority of patients experience side effects while taking opioids
Most common include nausea/vomiting, puriitis, constipation; more severe and less common include respiratory depression, addiction and overdose
Opiates can cause nausea, but ondansetron (Zofran) is the wrong treatment because it’s not antidopaminergic. Instead consider using metoclopramide (Reglan), olanzapine (Zyprexa), or haloperidol (Haldol)
Itching from opiates isn’t histamine mediated so hydroxyzine (Atarax) and diphenhydramine (Benadryl) aren’t effective - oddly ondansetron may help with itching.
Constipation is best treated with promotility agents like Senna, rather than stool softeners

References

Rogers E, Mehta S, Shengelia R, Reid MC. Four Strategies for Managing Opioid-Induced Side Effects in Older Adults. Clin Geriatr. 2013 Apr;21(4): PMID: 25949094; PMCID: PMC4418642.

Farmer AD, Holt CB, Downes TJ, Ruggeri E, Del Vecchio S, De Giorgio R. Pathophysiology, diagnosis, and management of opioid-induced constipation. Lancet Gastroenterol Hepatol. 2018 Mar;3(3):203-212. doi: 10.1016/S2468-1253(18)30008-6. PMID: 29870734.

Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.com/cme-courses/ and create an account.

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Contributor: Peter Bakes, MD

Educational Pearls:

Recent study looked at if mask wearing protects the mask wearer from infection
This group found 1.8% of mask wearers got COVID while 2.1% of non-mask wearers became infected, which was not statistically significant
This was not statistically significant and has been used to justify not wearing masks by some groups
While the numbers look small, it's close to a 20% reduction in infections for the mask wearers
The results reported had concerns for being underpowered, meaning the studies population may not be big enough to draw definitive conclusions
Many limitations of study including how wearing a mask may protect others
Unfortunately, studies like these can lead to misinterpretation and distortion

References

Bundgaard H, Bundgaard JS, Raaschou-Pedersen DET, von Buchwald C, Todsen T, Norsk JB, Pries-Heje MM, Vissing CR, Nielsen PB, Winsløw UC, Fogh K, Hasselbalch R, Kristensen JH, Ringgaard A, Porsborg Andersen M, Goecke NB, Trebbien R, Skovgaard K, Benfield T, Ullum H, Torp-Pedersen C, Iversen K. Effectiveness of Adding a Mask Recommendation to Other Public Health Measures to Prevent SARS-CoV-2 Infection in Danish Mask Wearers : A Randomized Controlled Trial. Ann Intern Med. 2020 Nov 18. doi: 10.7326/M20-6817. Epub ahead of print. PMID: 33205991.

Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.com/cme-courses/ and create an account.

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Contributor: Rachael Duncan, PharmD

Educational Pearls:

ED visits nationwide declined by 42% in April 2020 compared to the same time in 2019 largely due to the fear of the COVID-19 pandemic. The biggest decline was seen in pediatrics less than 14, women and emerging COVID hotspots like the Northeast.
In recent weeks, this trend has reversed, showing a record-breaking number of COVID cases, hospitalizations, and deaths. As hospitals reach capacity, critically ill COVID patients are being held in the ED until an inpatient bed becomes available.
A new mRNA vaccine has promising preliminary trial results to help end the COVID-19 pandemic.
While traditional vaccines contain purified proteins or weakened viruses, the mRNA vaccine is genetic material that is coded within the human body to make the viral protein.
The mRNA vaccine codes for the critical fragment of the viral protein without causing disease and leads to the production of powerful antibodies.
Although synthetic mRNA is genetic material, it cannot be passed on to further generations.
mRNA vaccines are much faster to develop and could potentially provide a more efficient process for developing future vaccines
Cold temperatures are currently needed to maintain the stability of the mRNA which has posed a challenge to the viability of the vaccines. However, developments are underway to overcome this hurdle.

References:

A Trial Investigating the Safety and Effects of Four BNT162 Vaccines Against COVID-2019 in Healthy Adults - Full Text View - ClinicalTrials.gov. Clinicaltrials.gov. https://clinicaltrials.gov/ct2/show/NCT04380701. Published 2020. Accessed November 25, 2020.

Karikó K, Buckstein M, Ni H, Weissman D. Suppression of RNA recognition by Toll-like receptors: the impact of nucleoside modification and the evolutionary origin of RNA. Immunity. 2005;23(2):165-175. doi:10.1016/j.immuni.2005.06.008

Safety and Immunogenicity Study of 2019-nCoV Vaccine (mRNA-1273) for Prophylaxis of SARS-CoV-2 Infection (COVID-19) - Full Text View - ClinicalTrials.gov. Clinicaltrials.gov. https://clinicaltrials.gov/ct2/show/NCT04283461. Published 2020. Accessed November 25, 2020.

Schlake T, Thess A, Fotin-Mleczek M, Kallen KJ. Developing mRNA-vaccine technologies. RNA Biol. 2012;9(11):1319-1330. doi:10.4161/rna.22269

Wolff JA, Malone RW, Williams P, et al. Direct gene transfer into mouse muscle in vivo. Science. 1990;247(4949 Pt 1):1465-1468. doi:10.1126/science.1690918

Summarized by Emily Mack OMSIII | Edited by Mason Tuttle

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For this episode of Mental Health Monthly, EMM is honored to collaborate with the hosts of Millennial Mental Health Channel podcast to explain Borderline Personality Disorder and tips to manage patients with this diagnosis in the Emergency Department. Dr. Justin Romano is a third year psychiatry resident in Omaha, Nebraska and Eddie Carrillo is a licensed mental health therapist currently working at partial hospitalization and IOP eating disorder program in Portland, Oregon. Their podcast Millennial Mental Health Channel seeks to explore the world of mental health from their two professional perspectives.

You can listen to their podcast on all major streaming platforms including Apple Podcasts, Spotify and Google Podcasts.

Follow them on Twitter and Instagram @millennialmhc

Contributors: Dr. Justin Romano and Eddie Carrillo, M.A., LPC

Educational Pearls:

4% of the general population has Bipolar Personality Disorder (BPD) and 9% of all emergency room visits involve patients with BPD.
BPD is defined as a pervasive pattern of instability of interpersonal relationships, self-image, affect and marked impulsivity beginning by early adulthood and present in a variety of contexts.
There are 9 symptoms of BPD. In order to meet criteria for diagnosis you need 5 of the 9.
Symptoms include:
- Frantic efforts to avoid real or imagined abandonment
- Pattern of unstable and intense interpersonal relationships, characterized by alternating between extremes of idealization and devaluation
- Identity disturbance: markedly and persistently unstable self-image or sense of self
- Impulsivity in at least two areas that are potentially self-damaging
- Recurrent suicidal behaviors, gestures, threats or self-mutilating behavior
- Affect instability due to marked reactivity of mood
- Chronic feelings of emptiness
- Inappropriate intense anger or difficulty controlling anger
- Transient stress related paranoid ideation or severe dissociative symptoms
Pathophysiology behind BPD: Overactivation of the amygdala within the limbic system which controls fear, anxiety and anger.
Often patients with BPD have dealt with an increased amount of trauma in their lives. They have one of the highest suicide rates at 10%.
Behaviors in individuals with BPD are often due to an invalidating environment in an attempt to reconnect with people they love.
Tips to managing patients in the emergency room with BPD.
Stay calm, consistent and caring and validate their feelings with:
- Body language: sit at eye level, make good eye contact, nod your head when they talk, and use repeat back clarification questions.
- Facial expressions: be cognizant of your facial expressions. Patients with BPD are more likely to interpret a neutral face as angry.
- Set boundaries and stick to your word. Patients with BPD can be described as manipulative, but often they are unaware they are doing this.
- Give validating statements. This will ensure the patient you are listening and working with them to solve their problems.

Summarized by Emily Mack, OMSIII

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Contributor: Aaron Lessen, MD

Educational Pearls:

Contrary to many assumptions, meter-dose inhalers (MDIs) are as effective as nebulizers in pediatric and adult patients
Nebulizers are associated with higher rates of tremor, tachycardia; they cost more and are associated with longer ED stays
Though it may take some convincing, in a patient that is physically able, using an MDI with spacer appears to be the better option - and that was even before COVID.

References

Snider MA, Wan JY, Jacobs J, Kink R, Gilmore B, Arnold SR. A Randomized Trial Comparing Metered Dose Inhalers and Breath Actuated Nebulizers. J Emerg Med. 2018 Jul;55(1):7-14. doi: 10.1016/j.jemermed.2018.03.002. Epub 2018 Apr 30. PMID: 29716819.

Brocklebank D, Ram F, Wright J, Barry P, Cates C, Davies L, Douglas G, Muers M, Smith D, White J. Comparison of the effectiveness of inhaler devices in asthma and chronic obstructive airways disease: a systematic review of the literature. Health Technol Assess. 2001;5(26):1-149. doi: 10.3310/hta5260. PMID: 11701099.

Dhuper S, Chandra A, Ahmed A, Bista S, Moghekar A, Verma R, Chong C, Shim C, Cohen H, Choksi S. Efficacy and cost comparisons of bronchodilatator administration between metered dose inhalers with disposable spacers and nebulizers for acute asthma treatment. J Emerg Med. 2011 Mar;40(3):247-55. doi: 10.1016/j.jemermed.2008.06.029. Epub 2008 Dec 11. PMID: 19081697.

Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.com/cme-courses/ and create an account.

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Contributor: Ryan Circh, MD

Educational Pearls:

Diabetic ketoacidosis (DKA) can be the initial presenting condition of undiagnosed diabetes type I in pediatric patients
Unlike adults, children typically need less fluid (i.e. 10 mL/kg bolus for those in shock followed by maintenance)
Cerebral edema is a concern from rapid administration of fluids
An insulin drip at 0.1 units/Kg/hr should be started but a bolus isn’t required

Editor’s note: While conceptually similar, treatment for pediatric DKA is overall less aggressive (no bolus of insulin, less fluids, slower corrections, etc.). Recent literature also continues to argue against cerebral edema being related to fluid management

References

Hsia D, Tarai S, Alimi A, Coss-Bu J, Haymond M. Fluid management in pediatric patients with DKA and rates of suspected clinical cerebral edema. Pediatr Diabetes. 2015;16(5):338-344.

Wolfsdorf J, Glaser N, Sperling M, American D. Diabetic ketoacidosis in infants, children, and adolescents: A consensus statement from the American Diabetes Association. Diabetes Care. 2006;29(5):1150-1159.

Olivieri L, Chasm R. Diabetic ketoacidosis in the pediatric emergency department. Emerg Med Clin North Am. 2013 Aug;31(3):755-73. doi: 10.1016/j.emc.2013.05.004. Epub 2013 Jul 6. PMID: 23915602.

Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.com/cme-courses/ and create an account.

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Contributor: Nick Tsipis, MD

Educational Pearls:

Perichondritis involves infection of not only the connective tissue of the ear but typically the cartilage as well
Symptoms include erythema, ear pain, and fevers
The most common bacterial cause is Pseudomonas.
Perichondritis often occurs after a wound or piercing, but trauma is not necessary for the infection to occur
Anti-pseudomonal coverage is essential with typically oral agents for milder disease and IV antibiotics for severe infections
Can have devastating outcomes if not treated aggressively and/or treated early due to poor blood supply to the cartilage of the ear

References

Prasad HK, Sreedharan S, Prasad HS, Meyyappan MH, Harsha KS. Perichondritis of the auricle and its management. J Laryngol Otol. 2007 Jun;121(6):530-4. doi: 10.1017/S0022215107005877. Epub 2007 Feb 26. PMID: 17319983.

Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.com/cme-courses/ and create an account.

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Contributor: Sam Killian, MD

Educational Pearls:

Spontaneous bacterial peritonitis (SBP) is an infection of peritoneal fluid that typically occurs in cirrhotic patients
Symptoms may include abdominal pain, fever, and/or altered mental status
Paracentesis is diagnostic test of choice.
Diagnostic criteria includes > 250 polymorphonuclear cells (PMNs) or a positive gram stain/culture
Treatment is typically a 3rd generation cephalosporin
·30-40% of SBP patients will go into renal failure and SBP associated with sepsis has an ~80% mortality

References

Dever JB, Sheikh MY. Review article: spontaneous bacterial peritonitis--bacteriology, diagnosis, treatment, risk factors and prevention. Aliment Pharmacol Ther. 2015 Jun;41(11):1116-31. doi: 10.1111/apt.13172. Epub 2015 Mar 26. PMID: 25819304.

MacIntosh T. Emergency Management of Spontaneous Bacterial Peritonitis - A Clinical Review. Cureus. 2018 Mar 1;10(3):e2253. doi: 10.7759/cureus.2253. PMID: 29721399; PMCID: PMC5929973.

Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.com/cme-courses/ and create an account.

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Contributor: Rachael Waterson, PharmD

Educational Pearls:

Drug shortages have been an ongoing issue since the 2000’s. Improvement was being made; however, several factors have exacerbated the drug supply more recently.
According to the US Food and Drug Administration (FDA) Report there are 163 drugs currently on the drug shortage list. Of the 40 drugs critical to treating COVID-19, 18 are on this list.
In comparison, according to the American Society of Health-Systems Pharmacists (ASHP), the current drug shortages have limited 29 of the 40 drugs deemed critical to treating COVID-19 patients.
COVID-19 has had an impact on the supply and demand for pharmaceuticals and has exposed the vulnerability of the US drug supply chain. The demand for drugs that are specific to treating COVID-19 patients have increased, while supply has been impacted due to closed factories, shipping delays, trade limitations, and export bans. Supply has been further limited due to COVID-19 heavily affecting 2 of the 3 main drug manufacturer areas of the world, India and Italy.
In order to combat drug shortages, the US federal government developed a contract with a company to make generics in short supply during the pandemic. There is also current discussion about creating an “America First” program to increase domestic production of active pharmaceutical ingredients.
How pharmacists combat drug shortages:
- Re-assess the definition of need; need vs convenience of a medication.
- Look to see if there is another product, manufacturer, vial size, or drug concentration of that exact medication that can be substituted.
- Substitution of a similar drug if possible.
- Placing restrictions as to which patients can receive medications, who can prescribe medications and medication use dependent on location in the hospital.

References:

American Society of Health-System Pharmacists. (2020). Drug Shortages. ASHP. https://www.ashp.org/Drug-Shortages?loginreturnUrl=SSOCheckOnly.

FDA Drug Shortages. accessdata.fda.gov. (2020, October). https://www.accessdata.fda.gov/scripts/drugshortages/.

Summarized by Emily S Mack, MSBS, OMS III | Rachael Waterson, PharmD

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Dr. Tsipis sits down with colleague Dr. Ricky Dhaliwal for some insightful conversation regarding the differences between academic and community settings as well as the various roles of advocacy in medicine.

Time Stamps

00:23 Banter and introductions

2:41 upbringing in 1st generation immigrant Indian household

14:30 losing culture as 2nd gen immigrant

7:32 Balancing family and work with a two doc family

8:32 President of EMRA

10:42 Working in academia vs community

13:29 New job advice

15:55 Nick talks about being the product of your environment and needing to be challenged

20:42 Advocacy in medicine

25:49 Legislative advocacy

27:27 Advocacy for medicine in COVID

29:44 Who are the most influential figures in your career?

33:23 What is your teaching style

38:05 What does the future hold for you?

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Contributor: Dave Rosenberg, MD

Educational Pearls:

The potential of vaccinations was first observed in the late 1600s when Jenner observed people who had cowpox never contracted smallpox, so he inoculated people with cowpox to see if it prevented smallpox, and…
Years later, Louis Pasteur inoculated chickens with cholera after his assistant accidently created the first live attenuated vaccine by creating a weakened bacteria when he left the bacteria out while he went on vacation
Pasteur observed that exposing chickens to full strength cholera after the exposure with the weakened bacteria led to minimal or no ill effects

References

Stewart AJ, Devlin PM. The history of the smallpox vaccine. J Infect. 2006 May;52(5):329-34. doi: 10.1016/j.jinf.2005.07.021. Epub 2005 Sep 19. PMID: 16176833.

Hajj Hussein I, Chams N, Chams S, El Sayegh S, Badran R, Raad M, Gerges-Geagea A, Leone A, Jurjus A. Vaccines Through Centuries: Major Cornerstones of Global Health. Front Public Health. 2015 Nov 26;3:269. doi: 10.3389/fpubh.2015.00269. PMID: 26636066; PMCID: PMC4659912.

Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.com/cme-courses/ and create an account.

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Contributor: Chris Holmes, MD

Educational Pearls:

During a typical flu season positive rates of flu tests run around ~20%
Surveillance data from Australia, South Africa, and Chile showed remarkably low rates of flu during their typical high season - only 51 total cases were reported
This overlapped with COVID, meaning extensive social distancing and other measures likely have benefit with flu

Editor’s note: at 35 cases, we are over half way there!

References

https://www.cdc.gov/mmwr/volumes/69/wr/mm6937a6.htm

https://www.cdc.gov/flu/weekly/index.htm

Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.com/cme-courses/ and create an account.

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Contributor: John Winkler, MD

Educational Pearls:

Swimmers itch is due to a flatworm parasitic infection that causes an itchy rash after the worm burrows into the skin
The flatworm is passed between bird and snail hosts
The itch is due to the death of the parasite under the skin which leads to an extremely itchy reaction.
The rash can be difficult to identify, often erythematous and macular but can develop papules and vesicles eventually scaling
The treatment is diphenhydramine for milder cases and steroids for more severe cases.

References

Kolářová L, Horák P, Skírnisson K, Marečková H, Doenhoff M. Cercarial dermatitis, a neglected allergic disease. Clin Rev Allergy Immunol. 2013 Aug;45(1):63-74. doi: 10.1007/s12016-012-8334-y. PMID: 22915284

Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.com/cme-courses/ and create an account.

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Contributor: Nick Hatch, MD

Educational Pearls:

Kratom is derived from the evergreen tree sharing the same name, found in Southeast Asia
Kratom is legal is most regions
Adverse effects of this substance are increasing in prevalence as its use becomes more widespread
At lower doses kratom has a stimulatory effect
Higher doses of kratom can cause opioid-like and psychotropic effects
Documented instances of more severe acute liver toxicity do exists

References

LiverTox: Clinical and Research Information on Drug-Induced Liver Injury [Internet]. Bethesda (MD): National Institute of Diabetes and Digestive and Kidney Diseases; 2012–. Kratom. 2020 Apr 3. PMID: 31643556.

https://www.fda.gov/news-events/public-health-focus/fda-and-kratom

Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.com/cme-courses/ and create an account.

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Contributor: Jared Scott, MD

Educational Pearls:

Lactate is a byproduct of anaerobic metabolism or tissue hypoperfusion
Though typically associated with severe sepsis, hyperlactatemia can be caused by vigorous exercise, seizures, liver failure, asthma exacerbations, albuterol, metformin, antiretroviral drugs, and propofol
Liver failure can lead to an inability to clear lactate, or convert it back to glucose byproducts, instead of an overproduction of lactate
Always remember the other causes of elevated lactic acid besides sepsis but also remember sepsis!

References:

Kraut JA, Madias NE. Lactic acidosis. N Engl J Med. 2014 Dec 11;371(24):2309-19. doi: 10.1056/NEJMra1309483. PMID: 25494270.

Wardi G, Brice J, Correia M, Liu D, Self M, Tainter C. Demystifying Lactate in the Emergency Department. Ann Emerg Med. 2020 Feb;75(2):287-298. doi: 10.1016/j.annemergmed.2019.06.027. Epub 2019 Aug 29. Erratum in: Ann Emerg Med. 2020 Apr;75(4):557. PMID: 31474479.

Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.com/cme-courses/ and create an account.

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Contributor: Don Stader, MD

Educational Pearls:

Pain is ubiquitous in the emergency department but it is not the enemy - suffering is
Nociception is the ability to feel noxious stimuli which usually causes a reaction, like pulling a limb away when you feel something painful. Nociception is really a brainstem reflex.
Pain is nociception plus cognition, meaning we process the noxious stimuli in our frontal cortex but it is not necessarily suffering.
Pain can be associated with euphoria, such as with distance running
Suffering, unlike pain, is associated with emotional distress
Nociception is a brainstem reflex, pain involves the brainstem and the frontal cortex, while suffering involves the brainstem, frontal cortex, and the limbic system attaching an emotional response
Providers should educate patients’ expectations on pain as a part of the physiologic process and emphasize the focus on alleviating suffering

References

Sneddon LU. Comparative Physiology of Nociception and Pain. Physiology (Bethesda). 2018 Jan 1;33(1):63-73. doi: 10.1152/physiol.00022.2017. PMID: 2921289

Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

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Emergency Medical Minute collaborated with CarePoint Health in early March for a night of education on Pediatric Emergencies geared towards mid-level providers at a local Denver brewery for our latest Brewcast. Pediatric patients require special considerations compared to adults when receiving medical care, and that remains true when dealing with respiratory illnesses across different age ranges.

Dr. Parisa Jamshidi, Pediatric Emergency Physician, reviews common respiratory illnesses including bronchiolitis, croup and bacterial tracheitis in pediatric patients covering their presentation on exam and via diagnostics, treatment plans and special considerations. Her lecture is complete with a case review of a patient presenting with croup and its management, differentiation of airway sounds and high flow oxygen delivery recommendations. Listen to brush up on on your knowledge of pediatric respiratory emergencies.

The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.com/cme-courses/ and create an account.

Photo by National Cancer Institute on Unsplash

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Contributor: Aaron Lessen, MD

Educational Pearls:

The use of oxygen is controversial when treating patients with certain conditions, like MI’s, stokes, or ARDS because adverse outcomes have been demonstrated with using high oxygen concentrations.
The Oxygen ICU trial looked at using higher and lower oxygen levels in treating intubated ARDS patients and found that mortality was improved when less oxygen was given allowing oxygen saturations to sit around 95% versus using high oxygen levels to obtain 100% blood oxygen saturation.
The LOCO trial tested using even lower oxygen concentrations allowing patients to have oxygen saturations around 88% compared to more oxygen with saturation goals of 96%. They found a 15% increase in mortality in the lower saturation group and had some incidences of mesenteric ischemia leading to a premature termination of the trial due to the detrimental outcomes.
This means a blood oxygen saturation rate of around 94% is probably a safe bet for patients to reduce episodes of hypoxia but limit over oxygenation injuries, especially in patients requiring longer term oxygen therapy.

References

1) Girardis M, Busani S, Damiani E, Donati A, Rinaldi L, Marudi A, Morelli A, Antonelli M, Singer M. Effect of Conservative vs Conventional Oxygen Therapy on Mortality Among Patients in an Intensive Care Unit: The Oxygen-ICU Randomized Clinical Trial. JAMA. 2016 Oct 18;316(15):1583-1589. doi: 10.1001/jama.2016.11993. PMID: 27706466.

2) Barrot L, Asfar P, Mauny F, Winiszewski H, Montini F, Badie J, Quenot JP, Pili-Floury S, Bouhemad B, Louis G, Souweine B, Collange O, Pottecher J, Levy B, Puyraveau M, Vettoretti L, Constantin JM, Capellier G; LOCO2 Investigators and REVA Research Network. Liberal or Conservative Oxygen Therapy for Acute Respiratory Distress Syndrome. N Engl J Med. 2020 Mar 12;382(11):999-1008. doi: 10.1056/NEJMoa1916431. PMID: 32160661.

Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.com/cme-courses/ and create an account.

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Contributor: Peter Bakes, MD

Educational Pearls:

Classically presents with the 6Ps: Pain, pallor, paresthesia, pulseless, poikilothermia (cold), and paralysis
Acute limb ischemia occurs by embolic or thrombotic causes
Thrombotic causes are now more common due to aging populations and advancements in vascular surgery like stents which can be a nidus for thrombosis.
Sudden onset of pain without prior symptoms is more typical of embolic causes
Preceding symptoms leading to acute ischemia are more often from thrombosis
Diagnosis can be clinical based on absent pulses, ultrasound or CT angiogram
Definitive treatment includes thrombectomy, stenting, or bypass surgery to restore the blood flow to the distal limb

References

McNally MM, Univers J. Acute Limb Ischemia. Surg Clin North Am. 2018 Oct;98(5):1081-1096. doi: 10.1016/j.suc.2018.05.002. PMID: 30243449.

Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

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Capnography is the measurement of the partial pressure of exhaled CO2 and is an indirect measurement of your cellular respiration. It is displayed visually as a block-like waveform during the exhalation phase of respiration and monitors ventilation in real-time. Capnography is the gold standard for monitoring sedated and intubated patients in the hospital and the field and can be used in many other situations to discern more information about your patient.

Our host Jordan Ourada is joined by Dr. Eric Hill who is a board certified Emergency Physician, EMS Director for 9 agencies around Colorado, a retired military physician with the Army, former paramedic firefighter and combat veteran to discuss advanced applications of capnography to monitor a range of different patients in the pre-hospital setting. Tune in to learn how to apply capnography to monitor your patients and detect serious conditions like sepsis and DKA and initiate time-sensitive interventions that reduce mortality in patients.

Quick Educational Pearls:

Normal range is between 35 - 45 mmHg
Low capnography indicates they are blowing off CO2
High capnography indicates they are retaining CO2
Normal waveform morphology is box-like with gradual expiratory plateau after expiratory upstroke
Monitor your patient’s status and interpret the capnography numbers, rate and waveforms accordingly

Time Stamps

1:32 Capnography definition

6:36 Normal range

7:40 Reading capnography waveforms

12:36 Capnography monitoring in sedated/intubated patients

13:36 Intubation monitoring

18:03 VQ match vs mismatch

21:42 Asthmatic patients

24:30 Capnography cannula

26:24 Cardiac arrest uses

31:28 Acid-base physiology

37:28 Diabetic patients

40:15 COPD patients

41:42 CHF patients

45:18 Head injury patients

52:07 Sepsis detection and subsequent prehospital management

1:08:15 Closing thoughts on using capnography in the field

REFERENCES

Brandt, P. “Current Capnography Field Uses.” JEMS. 2010, Nov.
DiCorpo,P.,etal.“CapnographyProvidesBiggerPhysiological

Picture to Maximize Patient Care.” JEMS. 2015, Nov. * Eckstein,M.,etal.“End-tidalCO2asapredictorofsurvivalinout-of- hospital cardiac arrest.” Prehosp Disaster Med. 2011 Jun;26(3):148-50 * Kodali,B.“Physicsofcapnography.”2014 * Poste,J.,etal.“Airmedicaltransportofseverelyhead-injured patients undergoing paramedic rapid sequence intubation.” Air Med J. 2004 Jul-Aug;23(4):36-40

     * Davis, D., et al. “Predictors of Intubation Success and Therapeutic Value of Paramedic Airway Management in a Large, Urban EMS System.” Prehospital Emergency Care. 2006: Vol. 10, Iss. 3.

Grmec, S. “Comparison of three different methods to confirm endotracheal tube placement in emergency intubation.” Intensive Care Medicine. 2002; 28: 701-4.
Silvestri, et al. “The Effectiveness of out of hospital use of continuous end-tidal carbon dioxide monitoring on the rate of unrecognized misplaced intubation within a regional emergency medical services system.” Ann Emerg Med. 2005; 45: 497- 503.
Hartman, et al. “Systematic Review and Meta- Analysis of End-Tidal Carbon Dioxide Values Associated With Return of Spontaneous Circulation During Cardiopulmonary Resuscitation.” Journal Intensive Care Med. 2015, Oct;30 (7) 426-35.
```
 * Levine, et al. “End-tidal carbon dioxide and outcome of out-of-hospital cardiac arrest.” N England J Med. 1997, Jul 31; 337(5): 301-6.
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- AHA 2015 Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations
- Hunter CL, et al. “A prehospital screening tool utilizing end-tidal carbon dioxide predicts sepsis and severe sepsis.” American Journal of Emergency Medicine. 2016 May; 34(5):813-819.
- Bou Chebi, R, et al. “Diagnostic value of end tidal capnography in patients with hyperglycemia in the emergency department.” BMC Emerg Med. 2016 Jan 29; 16:7
- Soleimanpour, H, et al. “Predictive value of capnography for suspected diabetic ketoacidosis in the emergency department.” West J Emerg Med. 2013;14(6): 590-4.

The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.com/cme-courses/ and create an account.

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Contributor: Erik Verzemnieks, MD

Educational Pearls:

Baclofen is used to treat muscle spasms or spasticity.
Baclofen comes in two forms: oral and intrathecal
Withdrawal is much more common with those receiving intrathecal administration from a Baclofen pump, which is typically spinal cord patients
Withdrawal symptoms usually start within 1-3 days after stopping baclofen
Symptoms include altered mental status, muscle rigidity, and fevers, which can mimic other severe illnesses
It is nearly impossible to reverse withdrawal symptoms with oral baclofen if a patient is receiving it intrathecally, so solving the pump problem is key

References

Ross JC, Cook AM, Stewart GL, Fahy BG. Acute intrathecal baclofen withdrawal: a brief review of treatment options. Neurocrit Care. 2011 Feb;14(1):103-8. doi: 10.1007/s12028-010-9422-6. PMID: 20717751.

Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.com/cme-courses/ and create an account.

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Contributor: Don Stader, MD

Educational Pearls:

Fractures and dislocations that require reduction do not necessarily require sedation
Nerve blocks are an effective alternative that can provide analgesia to reduce fractures and dislocations and provide sustained pain relief after the reduction is completed
Hematoma blocks are effective for distal radius and various ankle fractures
Shoulder dislocations can be reduced by performing a scapular nerve block

References

Tezel O, Kaldirim U, Bilgic S, Deniz S, Eyi YE, Ozyurek S, Durusu M, Tezel N. A comparison of suprascapular nerve block and procedural sedation analgesia in shoulder dislocation reduction. Am J Emerg Med. 2014 Jun;32(6):549-52. doi: 10.1016/j.ajem.2014.02.014. Epub 2014 Feb 17. PMID: 24721024.

Tseng PT, Leu TH, Chen YW, Chen YP. Hematoma block or procedural sedation and analgesia, which is the most effective method of anesthesia in reduction of displaced distal radius fracture? J Orthop Surg Res. 2018 Mar 27;13(1):62. doi: 10.1186/s13018-018-0772-7. PMID: 29580286; PMCID: PMC5869786.

Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.com/cme-courses/ and create an account.

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Contributor: Donald Stader, MD

Educational Pearls:

Not uncommon for patients presenting after opiate overdose and narcan administration to be observed for 4-6 hours
This has been based more on tradition than evidence
Observation periods for overdose may vary based on the opiate(s) used
Fentanyl and heroin have half lives of about 2 hours, while oxycodone and methadone have significantly longer half lives.
HOUR trial attempted to externally validate a scoring tool for stratification of low risk patients appropriate for discharge after 1 hour

References

Clemency BM, Eggleston W, Shaw EW, Cheung M, Pokoj NS, Manka MA, Giordano DJ, Serafin L, Yu H, Lindstrom HA, Hostler D. Hospital Observation Upon Reversal (HOUR) With Naloxone: A Prospective Clinical Prediction Rule Validation Study. Acad Emerg Med. 2019 Jan;26(1):7-15. doi: 10.1111/acem.13567. Epub 2018 Dec 28. PMID: 30592101.

Summarized by Will Dewispelaere, MD | Edited by Erik Verzemnieks, MD

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Contributor: Sam Killian, MD

Educational Pearls:

Droperidol (Inapsine) is an antipsychotic drug with efficacy for nausea, vomiting, headaches, and treating agitation
In the early 2000’s, Droperidol received a black box warning for QT prolongation
This caused a precipitous drop of in administration and ultimately led to a stop in production
More careful analysis since has called into question the true incidence of QT prolongation in typical dosing
Retrospective review published this year looked at 15,374 non-critical and 1,172 critical patients who received droperidol with only a single episode of Torsades des pointes (which was attributed to multiple other risk factors)
Of the 2,431 non-critical patients, and 396 critical patients, who received an ECG before and after administration, there were no changes to the mean QTc
Droperidol is being manufactured again and the prior black box warning being called into question, so it will likely begin to become more widely available for use

References

Cole JB, Lee SC, Martel ML, Smith SW, Biros MH, Miner JR. The Incidence of QT Prolongation and Torsades des Pointes in Patients Receiving Droperidol in an Urban Emergency Department. West J Emerg Med. 2020 Jul 2;21(4):728-736. doi: 10.5811/westjem.2020.4.47036. PMID: 32726229; PMCID: PMC7390553.

Perkins J, Ho JD, Vilke GM, DeMers G. American Academy of Emergency Medicine Position Statement: Safety of Droperidol Use in the Emergency Department. J Emerg Med. 2015 Jul;49(1):91-7. doi: 10.1016/j.jemermed.2014.12.024. Epub 2015 Mar 30. PMID: 25837231.

Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

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Dr. Leslie Tourangeau, Pediatric Emergency Medicine Physician, breaks down what qualifies as a fever and how they should be managed for different development ranges of pediatric patients. It's important to consider the timeline of the patient's fever and the patient's vaccination history to inform your differential diagnoses and guide your workup. Tune in for a full run-down on how to proceed with pediatric fever patients you may encounter in the Emergency Department, complete with workup, consultation and disposition recommendations.

References: Up To Date

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Contributor: Aaron Lessen, MD

Educational Pearls:

True allergies to penicillin compared to reported allergies from patients ranges around 10%
Recent study took patients undergoing sensitivity tests and developed the PEN(icillin)-FAST score to address reported penicillin allergies
PEN-FAST has four components for a total score of 0-4:

o F = five years or less since prior reaction.

o A = Angioedema/Anaphylaxis.

o S = Severe cutaneous reaction (rash).

o T = Treatment, did they require treatment for a reaction?

Patients with a score of 0 had <1% incidence of penicillin allergy
Even a score of 1-2 points had around 5% incidence of a true allergy

References

Trubiano JA, Vogrin S, Chua KYL, Bourke J, Yun J, Douglas A, Stone CA, Yu R, Groenendijk L, Holmes NE, Phillips EJ. Development and Validation of a Penicillin Allergy Clinical Decision Rule. JAMA Intern Med. 2020 May 1;180(5):745-752. doi: 10.1001/jamainternmed.2020.0403. PMID: 32176248; PMCID: PMC7076536.

Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Don Stader, MD

Educational Pearls:

Local anesthetics injected directly into wounds can cause distortion - especially important in facial lacerations
Several blocks can be helpful to help numb branches of the trigeminal nerve (CN V) which innervates the face:
- Supraorbital nerve block: blocks distribution of V1 (most of the forehead) through injection above the eyebrow
- External nasal nerve block: blocks superficial innervation of nose through injection along the nasal dorsum
- Infraorbital nerve block: blocks innervation to lip and cheek by injection below the eye
- Mental nerve block: blocks innervation to chin and lower lip by injection at the mandible
Zygomatic nerve block: blocks innervation to temporal scalp and lateral aspect of forehead by injection at the temple
Greater auricular nerve block: blocks innervation to on and around the lower ear by injection across the sternocleidomastoid

References

http://highlandultrasound.com/facial-blocks

https://www.nysora.com/techniques/head-and-neck-blocks/nerve-blocks-face/

Moskovitz JB, Sabatino F. Regional nerve blocks of the face. Emerg Med Clin North Am. 2013 May;31(2):517-27. doi: 10.1016/j.emc.2013.01.003. Epub 2013 Feb 18. PMID: 23601486.

Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

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General Counsel attorney, Debi Smith, joins Dr. Nick Tsipis to discuss the ins and outs of healthcare law. Many people forget that a subpoena only compels attendance to a court date, it does not compel one to provide any information on a case without a specific HIPAA compliant authorization for use and disclosure of protected health information. Tune in for more details, perspective on the intricacies of the legal world as it pertains to medicine and for tips on how to navigate different general situations from contracts to litigation.

Time Stamps

0:47 Legal Disclaimer

3:14 Evolution of healthcare law

5:00 Contracts

9:36 Independent medical decision making without influence from a corporation

11:00 Importance of protecting your ideas

12:30 How to navigate litigation

15:09 Choosing to be an expert witness

15:56 Malpractice

17:22 common mistakes with subpoenas

18:56 COVID

22:01 Advice to getting involved in healthcare law

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Contributor: Aaron Lessen, MD

Educational Pearls:

Early antibiotics have been shown to improve outcomes in septic patients time after time
Emerging evidence challenges the concept of one-size-fits-all large fluid boluses for septic shock patients and fluid may worsen patients who have underlying sepsis-induced pulmonary capillary leak
Starting peripheral vasopressors early, and relaxing if fluid resuscitation is successful, is appearing to be a more appropriate strategy than fluids first, then vasopressors

References

CLASSIC Trial Group; Scandinavian Critical Care Trials Group. Restricting volumes of resuscitation fluid in adults with septic shock after initial management: the CLASSIC randomised, parallel-group, multicentre feasibility trial. Intensive Care Med. 2016 Nov;42(11):1695-1705. doi: 10.1007/s00134-016-4500-7. Epub 2016 Sep 30. PMID: 27686349.

Permpikul C, Tongyoo S, Viarasilpa T, Trainarongsakul T, Chakorn T, Udompanturak S. Early Use of Norepinephrine in Septic Shock Resuscitation (CENSER). A Randomized Trial. Am J Respir Crit Care Med. 2019 May 1;199(9):1097-1105. doi: 10.1164/rccm.201806-1034OC. PMID: 30704260.

Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Sam Killian, MD

Educational Pearls:

One study found that patients presented with headaches more frequently when there was high temperatures and low humidity, while higher humidity is correlated to lower incidence of headache. Moon phases had no effect on headache frequency.
A Canadian study looking at over 100,000 ED visits for headaches found increased incidence of headaches when there were higher levels of air pollution/particulates, like smoke.

References

Yilmaz M, Gurger M, Atescelik M, Yildiz M, Gurbuz S. Meteorologic parameters and migraine headache: ED study. Am J Emerg Med. 2015;33(3):409-413. doi:10.1016/j.ajem.2014.12.056

Szyszkowicz M, Stieb DM, Rowe BH. Air pollution and daily ED visits for migraine and headache in Edmonton, Canada. Am J Emerg Med. 2009;27(4):391-396. doi:10.1016/j.ajem.2008.03.013

Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

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Dr. Christine Darr, Pediatric Emergency Medicine Physician, discusses a range of traumatic injuries in pediatric patients and how to appropriately perform a physical exam, order radiographic diagnostics to further assess and identify injuries and key steps for management. She reviews growth plate injuries as well as considerations at different developmental stages that can mask the presence of more serious injuries like blunt internal organ trauma without rib fractures and SCIWORA (spinal cord injury without radiographic abnormality). Common injuries associated with abuse at different ages are also addressed to help you identify concerning signs of maltreatment of pediatric patients. Listen for a deep dive into the intricacies of pediatric trauma!

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Contributor: Aaron Lessen, MD

Educational Pearls:

Traditional teaching has shied away from using vasopressors through peripheral IVs
Tissue necrosis from extravasation is cited as a risk of use of vasopressors through a peripheral site
However, risk of extravasation is low (2-4%) and even more rarely results in significant complications
Using an IV that is more proximal and larger bore with monitoring can further minimize these risks
Starting with peripheral vasopressors in a critically ill patient appears to be without significant increased cutaneous complications compared to using a central line alone

References

Loubani OM, Green RS. A systematic review of extravasation and local tissue injury from administration of vasopressors through peripheral intravenous catheters and central venous catheters. J Crit Care. 2015;30(3):653.e9-653.e6.53E17. doi:10.1016/j.jcrc.2015.01.014

Cardenas-Garcia J, Schaub KF, Belchikov YG, Narasimhan M, Koenig SJ, Mayo PH. Safety of peripheral intravenous administration of vasoactive medication. J Hosp Med. 2015;10(9):581-585. doi:10.1002/jhm.2394

Lewis T, Merchan C, Altshuler D, Papadopoulos J. Safety of the Peripheral Administration of Vasopressor Agents. J Intensive Care Med. 2019;34(1):26-33. doi:10.1177/0885066616686035

Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Don Stader, MD

Educational Pearls:

On average, smoking reduces life expectancy by 13.2 years for men and for 14.5 years for women
Nicotine is highly addictive and has both stimulant and calming effects
Having a newborn can be a strong motivator to quit so take advantage and educate new (or expecting) parents to the risks of smoking and benefits of quitting
Smoking has been associated with sudden infant death
Biggest predictor of children smoking is seeing their parents smoking
Side effects of smoking that can be discussed with patients are cataracts/blindness, cancers (lung and throat), coronary artery disease, early menopause, osteoporosis/fractures, and impotency

References

Haug S, Schaub MP, Schmid H. Predictors of adolescent smoking cessation and smoking reduction. Patient Educ Couns. 2014;95(3):378-383. doi:10.1016/j.pec.2014.03.004

Mays D, Gilman SE, Rende R, Luta G, Tercyak KP, Niaura RS. Parental smoking exposure and adolescent smoking trajectories. Pediatrics. 2014;133(6):983-991. doi:10.1542/peds.2013-3003

Anderson TM, Lavista Ferres JM, Ren SY, et al. Maternal Smoking Before and During Pregnancy and the Risk of Sudden Unexpected Infant Death. Pediatrics. 2019;143(4):e20183325. doi:10.1542/peds.2018-3325

Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

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Dr. Glenda Quan, esteemed Trauma Surgeon at Swedish Medical Center, discusses cases related to limb injury and reviews their management. Topics include proper tourniquet application as well as alternatives to commercially available devices how to manage pain or a difficult patient with significant limb injury. We also explore the use of new “hybrid ORs” where multiple surgical teams can care for various injuries simultaneously and briefly chat about the use of blood products in the prehospital setting. Thought we were done? Nope. We finish with pearls on temperature management as part of trauma resuscitation and find the answer to when you consider reduction of a joint or mid-shaft fracture?

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Contributor: Ricky Dhaliwal, MD, JD

Educational Pearls:

Topical anesthetization can allow for an awake intubation, which substantially decreases chance of loss of airway or respiratory drive because sedatives/paralytics are not necessary
Lidocaine treatments like URO-JET (2% lidocaine jelly) can be applied through the nare followed by LMX cream (4% lidocaine) which should be applied to the back of the tongue to anesthetize the tongue and larynx.
Good topicalization can be confirmed by testing for lack of a gag reflex

References

Simmons ST, Schleich AR. Airway regional anesthesia for awake fiberoptic intubation. Reg Anesth Pain Med. 2002;27(2):180-192. doi:10.1053/rapm.2002.30659

Ducharme J, Matheson K. What is the best topical anesthetic for nasogastric insertion? A comparison of lidocaine gel, lidocaine spray, and atomized cocaine. J Emerg Nurs. 2003;29(5):427-430. doi:10.1016/s0099-1767(03)00295-2

Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Ricky Dhaliwal, MD, JD

Educational Pearls:

Tranexamic acid (TXA) as shown to have mortality benefit to patients with traumatic GI hemorrhage but should it be used to achieve hemostasis in atraumatic GI bleeding?
HALT-IT study looked at TXA for the treatment of upper and lower GI hemorrhage and found no 5 day mortality benefit
Patients given TXA also had higher occurrences of DVT and PE

References

Roberts I, Coats T, Edwards P, et al. HALT-IT--tranexamic acid for the treatment of gastrointestinal bleeding: study protocol for a randomised controlled trial. Trials. 2014;15:450. Published 2014 Nov 19. doi:10.1186/1745-6215-15-450

Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Ramnik Dhaliwal, MD, JD

Educational Pearls:

Nitrates
- Nitroprusside: becomes effective in under a minute, and becomes ineffective 10 minutes after stopping it.
- - Nitroprusside can metabolize into cyanide leading to toxicity, however this is rare.
- Nitroglycerin: predominately causes vasodilation but some arterial dilation as well; preferred agent in patients with volume overload/CHF
Adrenergic Blocking Agents
- Labetalol: alpha/beta-blocking agent with a rapid onset of 5 minutes or less given as bolus or intravenous drip
- Esmolol: cardioselective beta blocker with rapid onset and short duration of action making it easily titratable
- Hydralazine: direct arterial dilator; patient dependent response that can be unpredictable. Use with caution in patients with CAD or an aortic dissection because there will be a reflexive increase in heart rate to combat the arteriolar dilation.
Calcium Channel Blockers
- Nicardipine: Given as an IV infusion starting at 5g/hr up to 15g/hr. This drug has a slower onset of action making it difficult to titrate and it has a longer serum elimination half-life (3-6 hours)
- Clevidipine: rapid onset and short duration of action; Reduces BP without affecting cardiac filling pressures but can cause reflex tachycardia

References

)Wani-Parekh P, Blanco-Garcia C, Mendez M, Mukherjee D. Guide of Hypertensive Crisis Pharmacotherapy. Cardiovasc Hematol Disord Drug Targets. 2017;17(1):52-57. doi:10.2174/1871529X16666161220142020

Suneja M, Sanders ML. Hypertensive Emergency. Med Clin North Am. 2017;101(3):465-478. doi:10.1016/j.mcna.2016.12.007

Maloberti A, Cassano G, Capsoni N, et al. Therapeutic Approach to Hypertension Urgencies and Emergencies in the Emergency Room. High Blood Press Cardiovasc Prev. 2018;25(2):177-189. doi:10.1007/s40292-018-0261-4

Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

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Emergency Medical Minute collaborated with CarePoint Health in early March for a night of education on Pediatric Emergencies at a local Denver brewery for our latest Brewcast. Pediatric patients require special considerations compared to adults when receiving medical care, and that remains true in the ED and pre-hospital settings. As such, it's important to be careful with the documentation of these patients to maintain accuracy and avoid inclusion of common normal findings that may populate in "normal patient" macros that are inappropriate for pediatric patients.

Dr. Karen Woolf, Pediatric Emergency Medicine Physician, shares some key areas to be wary of in your documentation for pediatric patients. Some examples include the description of vital signs and whether they fall within normal ranges, general appearance descriptors as well as developmental stage specific findings i.e AAOx3, normal gait and fontanelle description etc. Listen for a rundown of the key pointers for keeping pediatric documentation accurate and informative.

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The penicillin and cephalosporin drug classes include many first line drug options for infectious disease although high rates of self-reported allergies may cause physicians to seek alternative options. In part two of our dive into antibiotics use for infectious disease, listen as Dr. Rachael Duncan, Emergency Medicine Clinical Pharmacist, addresses the need to investigate the validity of these reported allergies and their severity to avoid us elf riskier alternatives, like fluoroquinolones. Cross-reactivity between cephalosporins is most often dictated by side chain of cephalosporins rather than the beta-lactam ring. Refer to the chart included for cross-reactivity tips.

References:

 1. Li M, Krishna MT, Razaq S, Pillay D. A real-time prospective evaluation of clinical pharmaco-economic impact of diagnostic label of 'penicillin allergy' in a UK teaching hospital. J Clin Pathol 2014; 67(12): 1088-92.

Romano A, Gueant-Rodriguez RM, Viola M, Pettinato R, Gueant JL. Cross-reactivity and tolerability of cephalosporins in patients with immediate hypersensitivity to penicillins. Ann Intern Med 2004; 141(1): 16-22.
Macy E, Contreras R. Health care use and serious infection prevalence associated with penicillin "allergy" in hospitalized patients: A cohort study. J Allergy Clin Immunol 2014; 133(3): 790-6

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Trauma and loss are common issues faced by emergency personnel and first responders. These challenges have since been heightened by the COVID-19 pandemic. On this installment of Mental Health Monthly, Anat ‘Nati’ Geva, PsyD, LP joins us to discuss the stages of grief in response to loss and trauma and how they pertain to first responders and frontline workers in particular. Each of the five stages of grief: denial, anger, bargaining, despair and acceptance are addressed and explained so you can expand your understanding of the natural process of grieving, identify signs and symptoms and take steps towards moving forward.

If you or a love one is struggling through the grieving process and need more support, we encourage you to utilize the resources below:

My Strengths - https://mystrength.com/ passcode: TMCAProfessional

Responder Strong - https://you.responderstrong.org/

Jason’s Foundation - https://jasonfoundation.com/

Rocky Mountain Crisis Partners (also known as “the crisis line”) – 1-844-493-8255 (TALK) https://rmcrisispartners.org/

HCAT – 1-844-556-2012

Anat ‘Nati’ Geva, PsyD, LP

Anat.A.Geva@gmail.com

If you are interested in taking part in a personalized experiential application of the content, there will be a Webex webinar session tomorrow, August 27th from 10 - 11 am MST.

The focus group follow-up is a complimentary experiential component for individuals who want to deepen their understanding of the material from this podcast. It will benefit those who want to take the opportunity to make the content personal to their situation. In this session, participants will discuss the prominent experiences for participants, have more extended time for Q&A, and then explore (a facet of) the primary model used. Time allowing, participants will be invited to join and share insights for the benefit of all participants.

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Contributor: Aaron Lessen, MD

Educational Pearls:

Carbonated beverages have shown efficacy in helping patients spontaneously pass esophageal food impactions
Glucagon, while historically used for treatment, has been shown to have significant side effects without any clinical benefit
Definitive treatment is with endoscopy performed typically by a gastroenterologist

References

Long B, Koyfman A, Gottlieb M. Esophageal Foreign Bodies and Obstruction in the Emergency Department Setting: An Evidence-Based Review. J Emerg Med. 2019;56(5):499-511. doi:10.1016/j.jemermed.2019.01.025

Peksa GD, DeMott JM, Slocum GW, Burkins J, Gottlieb M. Glucagon for Relief of Acute Esophageal Foreign Bodies and Food Impactions: A Systematic Review and Meta-Analysis. Pharmacotherapy. 2019;39(4):463-472. doi:10.1002/phar.2236

Akram J, Amin FM, Toft JG, Rømeling F. Håndtering af fremmedlegeme i øsofagus med synkestop [Treatment of foreign body impactions in oesophagus]. Ugeskr Laeger. 2013;175(10):640-643.

Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Peter Bakes, MD

Educational Pearls:

Dental fractures are described by the Ellis classifications, which are based on the involvement of layers of the teeth:
- Ellis I: involvement of the enamel
- Ellis II: involvement of the enamel and dentin
- Ellis III: involvement of the enamel, dentin, and pulp
While Ellis I injuries can be sent for dental follow up without intervention, Ellis II/III injuries require covering of the exposed dental layers, particularly because bacteria can more easily enter into the pulp
- Calcium hydroxide (Dycal) is used to cover teeth until patients can get to a dentist.
Dental avulsions, or displacement of the tooth from the socket, are time sensitive. Every minute the tooth is not put back in place carries an increased risk of permanent loss. After the tooth is replanted, it requires fixation or bracing
Dental subluxations can also be secured or braced with dental follow up

References

Marte, D, and B Robinson. Dental Trauma. Core EM, 7 Oct. 2019, coreem.net/core/dental-trauma/#ellis-classification-system-for-dental-fractures.

Rosenberg H, Rosenberg H, Hickey M. Emergency management of a traumatic tooth avulsion. Ann Emerg Med. 2011;57(4):375-377.

Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

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Welcome to EMM’s first Pharmacy Friday where we dive deeper on a certain pharmacological topic as it pertains to emergency medicine. Dr. Rachael Duncan, emergency medicine clinical Pharmacist, joins us today to talk about antibiotics use for infectious disease, specifically fluoroquinolones. Special thanks to Dr. Nichole Neville, infectious disease pharmacist, for much of the information presented in this podcast.

Educational Pearls:

Levofloxacin and other fluoroquinolones used to be relied upon heavily due to key upsides including ease of use and wide spectrum coverage of common bacteria. Overuse over the past decade has resulted in the discovery of 3 concerns that have led to their use being advised against in most patients These concerns are patient adverse reactions, safety concerns and drug resistance.
Patient adverse reactions include potential QTc prolongation, neurologic symptoms including worsening of myasthenia gravis or peripheral neuropathy and severe hypoglycemia.
Due to these adverse effects, a new term was coined: fluoroquinolone-associated disability. In an FDA report, they looked at the percentage of disability reports among all serious outcome reports of selected antibiotics and found that the top 5 antibiotics that led to disability reports were fluoroquinolones. Safety concerns have led to several black box warnings as well.
Drug resistance due to overuse has also severely decreased the susceptibility rates of fluoroquinolones at many institutions. Check out your facility’s antibiograms to get an idea of what susceptibility rates are for different drugs.
Common infections that are inappropriately given fluoroquinolones when other options would be better suited are PNA, UTI and intra-abdominal infections.

Tune in next week for more on cross-reactivity of cephalosporins and penicillins

References:

Fda.gov. 2017. Fluoroquinolone Safety Labeling Changes. [online] Available at: https://www.fda.gov/media/104060/download [Accessed 21 August 2020].

Idsociety.org. 2018. Practice Guidelines. [online] Available at: https://www.idsociety.org/practice-guideline/practice-guidelines/#/date_na_dt/DESC/0/+/ [Accessed 18 August 2020].

U.S. Food and Drug Administration. 2018. FDA Updates Warnings For Oral And Injectable Fluoroquinolone. [online] Available at: https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-fda-updates-warnings-oral-and-injectable-fluoroquinolone-antibiotics [Accessed 18 August 2020].

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EMM would like to extend a large thank you to the Pain Management and Addiction Medicine section of the American College of Emergency Physicians for allowing us to post their webinar panel discussion facilitated by EMM’s own Don Stader, MD, FACEP on Buprenorphine use after Naloxone. This episode discusses the nuances of emergency physicians inducing patients on Buprenorphine following an opioid overdose and covers key considerations including dosing, precipitated withdrawal and contraindications to Buprenorphine administration.

Panelists include:

Rachel Haroz, MD - EM physician boarded in Medical Toxicology and Addiction working in Camden, NJ

Andrew Herring, MD - EM physician boarded in Pain and Addiction working in Oakland, CA and leads California’s Bridge program that helps hospitals start Buprenorphine programs

Eric Ketcham, MD, FACEP - EM physician who is a cofounder and chair of ACEP’s Pain Management and Addiction Medicine section working in New Mexico

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Contributor: Ricky Dhaliwal, MD, JD

Educational Pearls:

Ventricular Fibrillation (VF) is a potentially fatal cardiac arrhythmia; Refractory VF even more so
Epinephrine stimulates alpha and beta receptors which increase sympathetic tone, thereby increasing cardiac oxygen demand and myocardial calcium levels which can cause new arrhythmias, particularly a problem during resuscitation
Esmolol (or any beta blocker) can be used in VF refractory to defibrillation, epinephrine and amiodarone in a last-ditch effort.
Esmolol in the setting of epinephrine can help prevent some of these known effects from repeated beta stimulation
Dosing esmolol for refractory VF: 500mcg/kg bolus, followed by drip (max typically 1000 mcg/kg/min)
Esmolol is associated with improved mortality in ACLS care in refractory VF

References

Long DA, Long B, April MD. Does β-Blockade for Treatment of Refractory Ventricular Fibrillation or Pulseless Ventricular Tachycardia Improve Outcomes?. Ann Emerg Med. 2020;76(1):42-45. doi:10.1016/j.annemergmed.2020.01.025

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 Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Jared Scott, MD

Educational Pearls:

Burnout happens. This study reminds us to take a few minutes on shift to take care of yourself.
A new study looked at burnout in ER nurses, residents, and attending physicians where they were asked to take a 5-minute break on shift to color or play with a therapy dog.
Researchers measured stress levels and checked salivary cortisol levels after the breaks to see if the therapies were working against a control group who did not have the breaks.
Those who colored reported increased stress levels at the end of their shifts, while those who played with dogs reported decreased stress. Cortisol levels dropped in both coloring and pet therapy groups. Interestingly, patients couldn’t see any difference in their providers' stress level.
Those who conducted the study believe maybe coloring increased stress only because those who colored were denied the chance to play with a dog. Go figure.

References

1) Kline JA, VanRyzin K, Davis JC, et al. Randomized Trial of Therapy Dogs Versus Deliberative Coloring (Art Therapy) to Reduce Stress in Emergency Medicine Providers . Acad Emerg Med. 2020; doi:10.1111/acem.13939

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Burns are low-volume, high-acuity injuries that require special attention and care from the pre-hospital team to the Emergency Department and finally to a dedicated burn unit and ICU. As a first responder in the pre-hospital setting, there are a couple things that need to remain at the forefront of your mind when dealing with burn patients.

On this episode of On the Streets, host Jordan Ourada sits down with Board Certified Plastic Surgeon and Hand Surgeon Dr. Benson Pulikkottil, who is the Medical Director for Swedish Medical Center's Burn Unit and Sean McConnell RN, former flight nurse and current charge nurse at Swedish's burn clinic to review the most important pearls to pre-hospital practice when it comes to burns. They discuss the in-depth importance of the details surrounding the mechanism of injury, field treatments and surface area estimation among many other nuances related to burn care. Tune in to hear from the experts about how to provide the best possible care for your burn patients when they present themselves.

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Contributor: Don Stader, MD

Educational Pearls:

Toxic shock syndrome (TSS) is a rare cause of shock typically caused by Staph aureus or Strep pyogenes, that produces a toxin that leads to rapid onset hypotension with a diffuse erythematous rash.
Signs of TSS may include rapid onset of altered mental status, dizziness, nausea, abdominal discomfort, hypotension, and rash
TSS is associated with foreign bodies, such as tampons or nasal packing - make sure to remove any offending object
Clindamycin is the drug of choice because it stops protein synthesis which helps treat toxic shock because toxic shock is caused by a protein (TSST-1) made by the bacteria.
TSS is associated iwth high morbidity and mortality despite treatments
Despite the association with TSS, there is little supporting evidence for prophylactic antibiotics when placing nasal packing

References

Gottlieb M, Long B, Koyfman A. The Evaluation and Management of Toxic Shock Syndrome in the Emergency Department: A Review of the Literature. J Emerg Med. 2018;54(6):807-814. doi:10.1016/j.jemermed.2017.12.048

Lange JL, Peeden EH, Stringer SP. Are prophylactic systemic antibiotics necessary with nasal packing? A systematic review. Am J Rhinol Allergy. 2017;31(4):240-247. doi:10.2500/ajra.2017.31.4454

Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Don Stader, MD

Educational Pearls:

Gout is an arthritis caused by the deposition of urate crystals into the joint space
Colchicine works by disrupting microtubules and prevents white blood cells from getting into the joint space which stops the inflammatory response
Colchicine has a high rate of adverse events, in particular explosive diarrhea
The drug also has a very narrow therapeutic index and overdose is nearly universally fatal, with no antidote or effective treatment option available
Alternative agents such as steroids, which reduce the inflammatory response to urate crystals, along with NSAIDs may be better options for treatment

References

Angelidis C, Kotsialou Z, Kossyvakis C, et al. Colchicine Pharmacokinetics and Mechanism of Action. Curr Pharm Des. 2018;24(6):659-663. doi:10.2174/1381612824666180123110042

Finkelstein Y, Aks SE, Hutson JR, et al. Colchicine poisoning: the dark side of an ancient drug. Clin Toxicol (Phila). 2010;48(5):407-414. doi:10.3109/15563650.2010.495348

Dalbeth N, Merriman TR, Stamp LK. Gout. Lancet. 2016;388(10055):2039-2052. doi:10.1016/S0140-6736(16)00346-9

Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Jared Scott, MD

Educational Pearls:

Suicide is currently the 10th leading cause of death in the US
Low quality studies have reported ketamine as a potential promising agent in treating depression and preventing suicidal ideations or thoughts
Randomized study was performed looking at giving ketamine to depressed patients in the ED to see if they could establish a proof of concept, meaning: would looking at ketamine for treatment of acute depression or suicidality be viable?
18 suicidal patients who required hospitalization for their depression and suicidality were entered in the study. 88% of the group treated with ketamine felt like their symptoms improved for up to 3 days, while only 33% of the placebo group reported an improvement

References

Domany Y, Shelton RC, McCullumsmith CB. Ketamine for acute suicidal ideation. An emergency department intervention: A randomized, double-blind, placebo-controlled, proof-of-concept trial. Depression & Anxiety (1091-4269). 2020;37(3):224-233. doi:10.1002/da.22975.

Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Aaron Lessen, MD

Educational Pearls:

Hand raising test: a simple but effective tool to diagnose carpal tunnel
Patients hold their hands over their head and if symptoms of carpal tunnel develop within 2 minutes, it is considered positive, meaning they likely have carpel tunnel
Symptom included numbness and dull pain in the distribution of the median nerve
Treatment for carpal tunnel in the ED can include splinting in a neutral position and oral steroids with possible follow up for steroid injections or surgery

References

Padua L, Coraci D, Erra C, et al. Carpal tunnel syndrome: clinical features, diagnosis, and management. Lancet Neurol. 2016;15(12):1273-1284. doi:10.1016/S1474-4422(16)30231-9

Ma H, Kim I. The diagnostic assessment of hand elevation test in carpal tunnel syndrome. J Korean Neurosurg Soc. 2012;52(5):472-475. doi:10.3340/jkns.2012.52.5.472

Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

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Meet Adis Keric, Board Certified Pharmacotherapy Specialist and a Board Certified Critical Care pharmacist who works in the Emergency Department and ICU of level 1 trauma center Regions Hospital in Saint Paul, MN. Adis is the founder and host of a new FOAMed podcast, ER-Rx. He started the podcast to inform clinicians in the ED and ICU about up-to-date, appropriate and optimal use of medications in different clinical scenarios.

Dr. Nick Tsipis sits down with Adis to discuss some pearls in Emergency Medicine Pharmacy.

Time Stamps:

0:10 Intros

4:35 Antibiotics

8:30 Post-Intubation Sedation

12:00 Anti-coagulation reversal*

16:00 ER-Rx Plug

*Correction to figures quoted on anticoagulation reversal pricing. High-dose Andexxa regimen maxes out around $60,000 and Kcentra maxes out at $6,000. So there is still a massive price difference, but not as high as quoted in the audio.

Check out ER-Rx on iTunes, Google Podcasts, Spotify, YouTube and other major podcast hosting platforms!

Instagram: @errxpodcast

Website: http://errxpodcast.com/

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Contributor: Michael Hunt, MD

Educational Pearls:

Contrast agents are commonly used for X-rays and CT’s to better characterize disease, but contrast doesn’t work with MRI. That’s where the element Gadolinium comes into play.
Gadolinium, element 64, is ferromagnetic (attracted to iron) below 68 degrees and above that temperature it’s paramagnetic which makes it useful in MRI (Magnetic Resonance Imaging).
Gadolinium is toxic alone, but when paired with chelators it can be used in humans and allows for better characterization of tumors or abnormal tissue on MRI.
It helps identify this abnormal tissue because when MRI causes polarization of our body’s cells, the gadolinium, which has the maximum number of unpaired electrons in its orbital shells, alters the rate of decay in abnormal tissue highlighting abnormalities on imaging.
Gadolinium can also be used in the treatment of cancers because it collects in the cells of abnormal tissue, allowing for more targeted therapies.
In people exposed to gadolinium, the anaphylaxis rate is low, below 1/1000, and in rare cases there are reports of kidney injury and nephrogenic systemic fibrosis which is why it’s not recommended in renal failure patients.

References

1)Ibrahim MA, Hazhirkarzar B, Dublin AB. Magnetic Resonance Imaging (MRI) Gadolinium. [Updated 2020 Mar 9]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482487/

2)Pasquini L, Napolitano A, Visconti E, et al. Gadolinium-Based Contrast Agent-Related Toxicities [published correction appears in CNS Drugs. 2018 May 15;:]. CNS Drugs. 2018;32(3):229-240. doi:10.1007/s40263-018-0500-1

Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

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\Contributor: Don Stader, MD

Educational Pearls:

Altered mental status/confusion are major symptoms associated with both alcohol use and withdrawal.
Wernicke’s encephalopathy is a triad of symptoms of confusion, internuclear ophthalmoplegia, and confabulation
The treatment for Wernicke’s is IV thiamine or vitamin B1
Untreated Wernicke’s leads to Korsakoff's syndrome where a prolonged thiamine deficiency leads to worsening brain function
Subdural hematomas from torn bridging veins are common in alcoholics because of the combination of frequent falls and cerebral atrophy caused by alcohol.
Alcohol is a major cause of heart failure and atrial fibrillation; “holiday heart” is a-fib induced by binge drinking where high levels of acetaldehyde from the metabolism of alcohol excite the heart.
Frequent alcohol use is linked to esophageal cancer
Alcoholic cirrhosis can lead to a multitude of complications including esophageal varices that can rupture often with fatal outcomes
Aspiration pneumonia is more common in alcoholics because of a depressed gag reflex and alteration of oral flora

References

Brousse G, Geneste-Saelens J, Cabe J, Cottencin O. Alcool et urgences [Alcohol and emergencies]. Presse Med. 2018;47(7-8 Pt 1):667-676. doi:10.1016/j.lpm.2018.06.001

Chandrakumar A, Bhardwaj A, 't Jong GW. Review of thiamine deficiency disorders: Wernicke encephalopathy and Korsakoff psychosis. J Basic Clin Physiol Pharmacol. 2018;30(2):153-162. Published 2018 Oct 2. doi:10.1515/jbcpp-2018-0075

Simou E, Britton J, Leonardi-Bee J. Alcohol and the risk of pneumonia: a systematic review and meta-analysis. BMJ Open. 2018;8(8):e022344. Published 2018 Aug 22. doi:10.1136/bmjopen-2018-022344

Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

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Meet Michelle Whaley, Clinical Nurse Specialist and Stroke Program Coordinator at Sky Ridge Medical Center in Lone Tree, Colorado. Jordan and Michelle discuss advances in Artificial Intelligence technology in an app that uses algorithms to analyze CT Angiograms to alert physicians of patients with images concerning for Large Vessel Occlusions (LVOs). Listen as they discuss the sweeping implications of this technology in the realm of stroke care and how it is decreasing wait times for critical patients to receive tPA and interventional procedures.

For EMS, this technology is already improving the care given by specialized transfer teams of patients from smaller hospitals to regional stroke centers. Tune in for other applications of this technology in pre-hospital settings on the horizon.

Disclaimer: This episode of On The Streets is for educational purposes only. Emergency Medical Minute is not affiliated with VIZ AI in any way and did not receive compensation for this episode.

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Contributor: Michael Hunt, MD

Educational Pearls:

PPE, or personal protective equipment, has become a major talking point since the emergence of the novel coronavirus (COVID 19).
While ubiquitous now, there was not always equipment to protect health care providers or patients from infectious exposures.
The invention of surgical gloves are credited to surgeon William Halsted. He developed gloves because one of his assistants (and later wife), Carol Hampton, was having severe irritation due to a caustic pre-op disinfecting process. They developed the rubber glove for Hampton which garnered popularity, and by the early 20th century, half of surgeons were using rubber gloves.
Surgical masks came around during the same period as gloves. By 1919 about half of all surgeons were using masks, protecting themselves and their patients from infectious transmissions.
The simple advent of masks and gloves led to incredible reductions in morbidity and mortality in surgical cases. Now these simple barriers are key in the prevention of further transmitting of COVID-19.

References

1. Kean, Sam. “Glove at First Sight.” podbean.com, 27 Apr. 2020, disappearingspoon.podbean.com/e/glove-at-first-sight/.

Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Don Stader, MD

Educational Pearls:

Yersinia Pestis is the bacteria that caused the black plague. It was first discovered to be the cause of the bubonic plague in 1800s in China during the 3rd bubonic plague where 10-20 million people died
Causes 3 types of plague:
- Bubonic plague: characterized by severe swelling of lymph nodes called buboes, most commonly in the groin, also axillary and olecranon lymph nodes.
- Septicemic plague: characterized by severe sepsis, no lymphadenopathy. This strain famously causes disseminated intravascular coagulopathy (DIC) and can lead to limb necrosis and fingers turning black. Hence the name the Black Death.
- Pneumonic: most dangerous of the plagues and characterized by PNA on CXR with pronounced mediastinal lymphadenopathy
Fleas are the largest reservoir, although prairie dogs and squirrels have been known to carry the bacteria as well.
Yersinia Pestis creates a microfilm inside the stomach of fleas and renders them incapable of digesting your blood when they try to eat it and they vomit the bacteria into your blood.
Doxycycline and Ciprofloxacin are the mainstay of treatment.

References

Achtman M, Zurth K, Morelli G, Torrea G, Guiyoule A. Carniel E. Yersinia pestis, the cause of plague, is a recently emerged clone of Yersinia pseudotuberculosis. Proc Natl Acad Sci U S A. 1999. doi:10.1073/pnas.96.24.14043

Galimand M, Carniel E, Courvalin P. Resistance of Yersinia pestis to Antimicrobial Agents. Antimicrob Agents Chemother. 2006;50(10):3233 LP - 3236. doi:10.1128/AAC.00306-06

Sexton D, Stout J. Clinical Manifestations, Diagnosis, And Treatment Of Plague (Yersinia Pestis Infection). Waltham, MA: UpToDate; 2020.

Summarized by Mason Tuttle & Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

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Author: Eric Miller, MD

Educational Pearls:

Brown-Sequard Syndrome is a neurological deficit that results from hemisection of the spinal cord
This is usually from traumatic injury (blunt or penetrating), but can rarely be seen with cancer, disc herniation, or infection
It presents with flaccid paralysis and loss of sensation to touch/vibration/position on the same side as the injury with loss of pain/temperature sensation on the opposite side of the injury. These deficits will be below the level of injury.

References

Roth, E., Park, T., Pang, T. et al. Traumatic cervical Brown-Sequard and Brown-Sequard-plus syndromes: the spectrum of presentations and outcomes. Spinal Cord 29, 582–589 (1991).

Wagner R, Jagoda A. Spinal cord syndromes. Emerg Med Clin North Am. 1997;15(3):699.

Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Don Stader, MD

Educational Pearls:

Checkpoint inhibition normally helps our body detect abnormal cells and terminate it but cancerous cells often are able to avoid this countermeasure
Monoclonal antibodies that bind to checkpoint inhibitors can stop cancerous cells from turning off immunologic T cells and allows the immune system to continue to attack cancers.
These therapies carry risks of exacerbating autoimmune problems due to the ramped up immune response
Most often this autoimmune attack leads to skin and GI symptoms but can affect many other organ systems. In the emergency room this can present many different ways, but the mainstay of treatment is steroids to stop these exacerbations.
Chimeric Antigen Receptor (CAR) T-cell Therapy is another immunotherapy where antigens to a cancerous cell are re-introduced to spur a directed immune response
Cytokine release syndrome can occur in these patients and mimic other presentations such as septic shock, a result of tumor break down
This is treated with steroids and monoclonal antibodies that help thwart the cytokine release

References

Hay, KA. Cytokine release syndrome and neurotoxicity after CD19 chimeric antigen receptor-modified (CAR-) T cell therapy. Br J Haematol. 2018 Nov;183(3):364-374. doi: 10.1111/bjh.15644. Epub 2018 Nov 8.

Hryniewicki AT, Wang C, Shatsky RA, Coyne CJ. Management of Immune Checkpoint Inhibitor Toxicities: A Review and Clinical Guideline for Emergency Physicians. J Emerg Med. 2018;55(4):489-502. doi:10.1016/j.jemermed.2018.07.005

Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

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Dr. Steven Bradley is an active duty U.S. Naval officer practicing as a Staff Anesthesiologist in Virginia where also resides on the Medical Ethics Committee for his hospital. He serves as the Anesthesiology Residency Simulation Coordinator there and enjoys the opportunity to teach residents drawing from his experiences as a student. He just recently started The Black Doctors Podcast where he strives to tell stories of Black physicians who overcame adversity to attain their goals so that young individuals in the minority can listen and learn.

Tune in to hear Dr. Bradley discuss his experience as a minority in medicine and how systemic racism can manifest in various aspects of medicine.

Check out The Black Doctors Podcast on Apple Podcasts, Spotify, and all major streaming platforms.

Instagram: @theblackdoctorspodcast

Twitter: @StevenBradleyMD

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Author: Charlene Gnisci Melton, PharmD

Educational Pearls:

Status Epilepticus is defined as continuous seizure activity for >5 minutes, or 2 or more seizures without full return to consciousness between events
Status epilepticus is a true neurologic emergency with significant morbidity and mortality
Aggressive, early treatment of status epilepticus is essential as GABA receptors will regress over time and make benzodiazepines less effective as time elapses
Go large with doses of benzodiazepines and repeat doses if necessary: In adults this means lorazepam 4 mg IV push or Midazolam 10 mg intramuscular if no IV access
Second line agents include:
- Levetiracetam (Keppra) 60 mg/kg up to 4500mg
- Valproic Acid (40 mg/kg up to 3000 mg)
- Keppra has an arguably better side effect profile and compatibility compared to other second-line agents
Third line agents include intubation and sedation with propofol, benzodiazepines, or even ketamine

Editor’s note: from a time management perspective, call for your second-line treatment early to get it from pharmacy while you slam the benzodiazepines, then it will be arriving hopefully when you need it, and no harm if you don’t. Oh, and don’t forget a fingerstick glucose.

References

Glauser T, Shinnar S, Gloss D, et al. Evidence-Based Guideline: Treatment of Convulsive Status Epilepticus in Children and Adults: Report of the Guideline Committee of the American Epilepsy Society. Epilepsy Curr. 2016;16(1):48–61. doi:10.5698/1535-7597-16.1.48

Walker, M.C. Pathophysiology of status epilepticus. Neuroscience Letters. 2018:667:84-91. https://doi.org/10.1016/j.neulet.2016.12.044

Summarized by Jackson Roos, MS3 | Edited by Erik Verzemnieks, MD

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This limited series will investigate how the nation’s opioid epidemic has been impacted by the COVID-19 pandemic. Over the course of this series, we will hear from a harm reductionist, an addiction medicine physician, a Denver Police narcotics sergeant and two people currently in recovery.

Unfortunately, the opioid epidemic and the COVID-19 pandemic are likely not going anywhere soon. Emergency Medical Minute remains committed to providing education to help combat these health crises.

In the final episode of this series, we are fortunate enough to speak with Chris Espinoza and Ashley Parsons, two individuals currently in recovery. Chris and Ashley bravely share the origins of their substance use disorders, the challenges that COVID has presented during their recovery process as well as their current life goals and hopes for the future.

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Illustration by Kelly Caminero/The Daily Beast/Shutterstock

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Contributor: Aaron Lessen, MD

Educational Pearls:

Studies have shown that patients who are under deeper sedation in the ICU have worse outcomes.
Recent study compared lighter vs heavier sedation of patients in the emergency department receiving mechanical ventilation
Patients receiving lighter sedation in the ED were often continued in the ICU
Patients who had lighter sedation also tended to do better, meaning less days on the ventilator, less days in the ICU, and lower mortality supporting prior observations.
Though purely observational, interesting suggestion that lighter sedation starting in the emergency department could have significant impact on important clinical outcomes

References

Fuller BM, Roberts BW, Mohr NM, et al. The ED-SED Study: A Multicenter, Prospective Cohort Study of Practice Patterns and Clinical Outcomes Associated With Emergency Department SEDation for Mechanically Ventilated Patients. Crit Care Med. 2019;47(11):1539‐1548. doi:10.1097/CCM.0000000000003928

Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

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Unfortunately, the opioid epidemic and the COVID-19 pandemic are likely not going anywhere soon. Emergency Medical Minute remains committed to providing education to help combat these health crises.

In this episode, we speak with Lex Jorge -- a Denver Police Narcotics Sergeant -- to gain insight into how drug trafficking has been impacted by COVID. We also discuss law enforcement’s role in the recovery process and touch on social issues currently afflicting the country.

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Illustration by Kelly Caminero/The Daily Beast/Shutterstock

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Unfortunately, the opioid epidemic and the COVID-19 pandemic are likely not going anywhere soon. Emergency Medical Minute remains committed to providing education to help combat these health crises.

In this episode, we talk to Dr. Steven Young -- board certified emergency physician and addiction medicine physician -- to discover how his clinic has had to adapt and overcome the challenges presented by COVID.

Resources:

https://www.cotreatment.com/

https://www.samhsa.gov/medication-assisted-treatment

https://www.ernaloxone.org/

https://cha.com/opioid-safety/coloradomat/

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Illustration by Kelly Caminero/The Daily Beast/Shutterstock

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Unfortunately, both the opioid epidemic and the COVID-19 pandemic are likely not going anywhere soon. Emergency Medical Minute remains committed to providing education to help combat these health crises.

In the first episode, we catch up with Lisa Raville -- executive director of the Harm Reduction Action Center in Denver -- to learn how COVID has impacted her facility’s daily operations as well as the lives of her clients.

For more information about HRAC:

http://harmreductionactioncenter.org/

Get In touch with HRAC:

Email: HRAC.Denver@gmail.com

Facebook: @harmreductionactioncenter

Twitter: @HRAC_Denver

Instagram: @harmreductionactioncenter

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Illustration by Kelly Caminero/The Daily Beast/Shutterstock

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Taken from 'UnfilterED #8: Dr. Christopher Hoyte'.

“This current sars-coV-2 / COVID-19 situation should really be a wake-up call for not just a pandemic, but for a biological attack...One of the things I would like to do when we bring our attention back from COVID and get through this pandemic is to really start to prepare for disaster preparedness on the level and scale that we need to for a biological attack and get our hospitals ready, my poison center ready, state and local governments ready so that we can meet that challenge when it happens.” - Dr. Chris Hoyte

Dr. Chris Hoyte is an ED physician, toxicologist and researcher based in Denver, CO. He was featured in Bring Em’ All: Chaos. Care. Stories from Medicine’s Front Line, a book celebrating emergency physicians through personal testimonies and photography on the frontlines captured by legendary photographer, Eugene RIchards.

Photo © courtesy Eugene Richards

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Time Stamps:

01:25 - Dr. Hoyte’s Origin Story

05:01 - What Drew Dr. Hoyte to Medical Toxicology?

08:22 - Dr. Hoyte’s Most Interesting Toxicology Cases

08:52 - King Cobra Bite
13:31 - Verapamil Overdose
16:47 - Mass Cyanide Poisoning

19:16 - The Looming Threat of Biological Warfare and the Need for Emergency Preparedness

25:07 - How COVID-19 Affected Dr. Hoyte’s Job as a Toxicologist

30:19 - How Does the Rocky Mountain Poison and Drug Center Handle Its Large Workload

35:56 - Cannabinoid Exposures

42:05 - The Future of Toxicology

Publications from Dr. Hoyte:

A Characterization of Synthetic Cannabinoid Exposures Reported to the National Poison Data System in 2010

https://pubmed.ncbi.nlm.nih.gov/22575211/

An Outbreak of Exposure to a Novel Synthetic Cannabinoid

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3983965/

The Continued Impact of Marijuana Legalization on Unintentional Pediatric Exposures in Colorado

https://pubmed.ncbi.nlm.nih.gov/30288992/

Pediatric Death Due to Myocarditis After Exposure to Cannabis

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5965161/

Anaphylaxis to Black Widow Spider Antivenom

https://pubmed.ncbi.nlm.nih.gov/21641165/

Intro Music:

Backbay Lounge Kevin MacLeod (incompetech.com)

Licensed under Creative Commons: By Attribution 3.0 License

http://creativecommons.org/licenses/by/3.0/

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Contributor: Nick Tsipis, MD

Educational Pearls:

Significant cyanide exposure most commonly occurs from fire/smoke exposure particularly when plastics are involved
Cyanide binds to cytochrome oxidase leading to the use of anaerobic metabolism which causes a profound lactic acidosis
Classic toxicity includes a rapid loss of consciousness, hypotension, bradycardia, respiratory depression, and seizures
Mild exposures can lead to nausea/vomiting, headaches, and other nonspecific symptoms.
Sometimes patients will complain of an almond taste.
Cyanide toxicity will manifest on labs by a profound anion gap acidosis with elevated lactate (but don't wait for them to ponder the diagnosis)
Antidote is hydroxocobalamin and sodium thiosulfate
Severe cyanide exposure will likely need ICU level care until the blood gas levels return to their baselines and the lactic acidosis resolves

References

Nickson Chris C, Australian Centre for Health Innovation at Alfred Health. Cyanide Poisoning • LITFL • CCC Toxicology. Life in the Fast Lane • LITFL • Medical Blog. https://litfl.com/cyanide-poisoning-ccc/. Published April 2, 2019. Accessed June 11, 2020.

Parker-Cote JL, Rizer J, Vakkalanka JP, Rege SV, Holstege CP. Challenges in the diagnosis of acute cyanide poisoning. Clin Toxicol (Phila). 2018;56(7):609‐617. doi:10.1080/15563650.2018.1435886

MacLennan L, Moiemen N. Management of cyanide toxicity in patients with burns. Burns. 2015;41(1):18‐24. doi:10.1016/j.burns.2014.06.001

Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Nick Tsipis, MD

Educational Pearls:

Arsenic is a heavy metal that binds to multiple cellular enzymes and inhibits aerobic metabolism
It is primarily absorbed through the skin, respiratory and GI tract.
The classic symptoms of heavy metal exposure are GI irritation (watery diarrhea, vomiting and abdominal pain) with multisystem organ failure.
Neuropathy can present insidiously
Initial work up includes EKG, and basic lab work (expect a delayed rise in liver function tests).
Acute arsenic ingestions can sometimes show up on imaging as it is radioapaque
Diagnosis is usually made with the history and evidence of multisystem organ failure.
Treatment should be coordinated with your local Poison Control or toxicologist and involves predominantly supportive care along with chelating agents succimer (oral) or dimercaprol (intramuscular)

References

Long N. Arsenic toxicity • LITFL • Toxicology Library Toxicant. Life in the Fast Lane • LITFL • Medical Blog. https://litfl.com/arsenic-toxicity/. Published August 25, 2019.

Kuivenhoven M, Mason K. Arsenic (Arsine) Toxicity. [Updated 2019 Apr 29]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK541125/

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In addition to producing our own content, we believe in using our platform to amplify other voices and perspectives in medicine. With that in mind, check out 'The Black Doctor Podcast' from Dr. Steven Bradley which features interviews with leading minority professionals of the current generation as well as stories of how they overcame adversity and attained their goals. "Listen and be inspired."

Podcasts available on Apple Podcasts, Spotify and all other major streaming platforms

Twitter: @StevenBradleyMD

Instagram: @theblackdoctorspodcast

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Contributor: Aaron Lessen, MD

Educational Pearls:

Locked in syndrome results typically from an infarct of the basilar artery leading to infarction of the brainstem but typically preservation of the higher structures
The result is complete paralysis with preserved cognitive function, hence the name
Because of their location within the brainstem, ocular movements are sometimes preserved, allowing a patient who recovers from the initial injury to communicate
Patients typically do not regain any motor function and have a poor prognosis of recovery
Thrombectomy of the basilar artery is sometimes considered even late after the initial presentation given the devastating prognosis

References

Smith E, Delargy M. Locked-in syndrome. BMJ. 2005;330(7488):406‐409. doi:10.1136/bmj.330.7488.406

Buchman SL, Merkler AE. Basilar Artery Occlusion: Diagnosis and Acute Treatment. Curr Treat Options Neurol. 2019;21(10):45. Published 2019 Sep 26. doi:10.1007/s11940-019-0591-0

Meinel TR, Kaesmacher J, Chaloulos-Iakovidis P, et alMechanical thrombectomy for basilar artery occlusion: efficacy, outcomes, and futile recanalization in comparison with the anterior circulationJournal of NeuroInterventional Surgery 2019;11:1174-1180.

Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Jared Scott, MD

Educational Pearls:

Traditional digital block involves dorsal approach on either side of the digit, injecting local anesthetic along each side to numb all four nerves of the digit
Newer approach involves a single injection along the palmar surface at MCP joint
Recent study further compared a proximal vs distal single palmar (volar) injection with sites at the MCP and PIP joints
Injection sites achieved similar anesthesia between groups but PIP injection site had faster time of onset - 2.5 minutes compared to 3.8 minutes

References

Choi S, Cho YS, Kang B, Kim GW, Han S. The difference of subcutaneous digital nerve block method efficacy according to injection location. Am J Emerg Med. 2020;38(1):95‐98. doi:10.1016/j.ajem.2019.04.031

Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Aaron Lessen, MD

Educational Pearls:

Supplemental oxygen is not a completely benign intervention.
A recent meta-analysis found that O2 saturations above 96% while on supplemental O2 were associated with worse outcomes.
Only start a patient on supplemental oxygen if absolutely necessary and aim for a goal of no higher than 96%

References

Derek K Chu, Lisa H-Y Kim, Paul J Young, Nima Zamiri, Saleh A Almenawer, Roman Jaeschke, Wojciech Szczeklik, Holger J Schünemann, John D Neary, Waleed Alhazzani. Mortality and morbidity in acutely ill adults treated with liberal versus conservative oxygen therapy (IOTA): a systematic review and meta-analysis. The Lancet. Volume 391, Issue 10131. 2018. Pages 1693-1705,

Summarized by Will Dewispelaere, MD | Edited by Erik Verzemnieks, MD

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Contributor: Aaron Lessen, MD

Educational Pearls:

Supplemental oxygen is not a completely benign intervention.
A recent meta-analysis found that O2 saturations above 96% while on supplemental O2 were associated with worse outcomes.
Only start a patient on supplemental oxygen if absolutely necessary and aim for a goal of no higher than 96%

References

Summarized by Will Dewispelaere, MD | Edited by Erik Verzemnieks, MD

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Contributor: Aaron Lessen, MD

Educational Pearls:.

Focused assessment with Sonography for Trauma (FAST) exam and the extended-FAST (eFAST) are essential components of current trauma care and evaluation
There has been an accumulation of research to provide an estimate of effectiveness of identifying certain injuries with ultrasound:
- For identifying a pneumothorax, the sensitivity ~70% and specificity ~99%.
- For pericardial effusions, sensitivity 90% and specificity ~ 94%.
- For hemoperitoneum, sensitivity ~74% and the specificity ~98%.
While ultrasound is excellent for identifying many injuries, it may not be adequate alone to rule out serious injuries if the clinical suspicion is high based on these pooled studies

References

Netherton S, Milenkovic V, Taylor M, Davis PJ. Diagnostic accuracy of eFAST in the trauma patient: a systematic review and meta-analysis. CJEM. 2019;21(6):727‐738. doi:10.1017/cem.2019.381

Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Aaron Lessen, MD

Educational Pearls:.

Focused assessment with Sonography for Trauma (FAST) exam and the extended-FAST (eFAST) are essential components of current trauma care and evaluation
There has been an accumulation of research to provide an estimate of effectiveness of identifying certain injuries with ultrasound:
- For identifying a pneumothorax, the sensitivity ~70% and specificity ~99%.
- For pericardial effusions, sensitivity 90% and specificity ~ 94%.
- For hemoperitoneum, sensitivity ~74% and the specificity ~98%.
While ultrasound is excellent for identifying many injuries, it may not be adequate alone to rule out serious injuries if the clinical suspicion is high based on these pooled studies

References

Netherton S, Milenkovic V, Taylor M, Davis PJ. Diagnostic accuracy of eFAST in the trauma patient: a systematic review and meta-analysis. CJEM. 2019;21(6):727‐738. doi:10.1017/cem.2019.381

Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: John Winkler, MD

Educational Pearls:

Unstable ventricular tachycardia (VT) typically manifests with syncope, shortness of breath, diaphoresis and/or chest pain with hemodynamic instability
Electrical cardioversion of unstable ventricular tachycardia is first line treatment
Starting with a higher energy level (or just using the maximum) when performing cardioversion may set you up for better success as many providers feel the first shock has the highest likelihood of success

References

Dresen, W.F. Ferguson, J.D. Ventricular Arrhythmias. Cardiol Clin. 2018 Feb;36(1):129-139. doi: 10.1016/j.ccl.2017.08.007. Epub 2017 Oct 27.

Goyal, A. et al. Synchronized Electrical Cardioversion.StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020-. 2020 Feb 13.

Summarized by Jackson Roos, MS3 | Edited by Erik Verzemnieks, MD

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Contributor: Aaron Lessen, MD

Educational Pearls:

Mechanical CPR (machine assisted compression devices) remains a hot topic of debate in emergency medicine
Machine assisted CPR has been advocated to provide more consistent compressions in cardiac arrest and free up staff for other tasks.
However, multiple studies have shown mechanical CPR provides no significant survival benefit yet increased rates of injury to the chest and abdomen from the devices.
Unless a clear benefit can be found, mechanical CPR devices should not routinely replace traditional CPR in most situations
For prolonged transport as well as resource-limited settings, these devices still may provide the only option for sustained resuscitations

References

Bonnes, J. et al. Manual Cardiopulmonary Resuscitation Versus CPR Including a Mechanical Chest Compression Device in Out-of-Hospital Cardiac Arrest: A Comprehensive Meta-analysis From Randomized and Observational Studies. Ann Emerg Med. 2016 Mar;67(3):349-360.e3. doi: 10.1016/j.annemergmed.2015.09.023. Epub 2015 Nov 19.

Wang, P. Brooks, S. Mechanical Versus Manual Chest Compressions for Cardiac Arrest. Cochrane Database Syst Rev. 2018 Aug 20;8(8):CD007260. doi: 10.1002/14651858.CD007260.pub4.

Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

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"Go unafraid! And also know that you got to reach out to the right people and hold on to those people no matter what they look like, no matter what background they come from...Find people who are positive in your life who can help you. If I'm one of those people, reach out to me."

Russell J. Ledet hails from Lake Charles, Louisiana. After serving in the U.S. Navy, he attended Southern University and A&M College for his undergraduate degrees in biology and chemistry. Afterwards, he went on to complete his Ph.D. in molecular oncology at New York University. He is currently a second-year MD-MBA student at Tulane University School of Medicine and A.B. Freeman School of Business. He is the co-founder and president of 'The 15 White Coats', a non profit organization focused on helping people of color get into medical school and improving the cultural literacy of our learning spaces.

The 15 White Coats website:

https://www.the15whitecoats.org/

Get in touch with Russell:

E-Mail: Russell.ledet@gmail.com

Twitter: @theguywithyes

Instagram: @maleahandmahlinasbaba

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In this very special episode of UnfilterED, Russell speaks candidly about his childhood, the challenges that made him the man he is today and his plans for the future, including The 15 White Coats' goal to put an individual of color through medical school debt-free.

Time Stamps:

1:53 - Russell’s Introduction

6:50 How have you learned from your experiences and where you came from?

9:30 - Entrepreneurship at a young age

14:15 - Russell's Faith

16:20 - Joining the Navy

20:30 - Role Models

32:40 - Visiting the Whitney Plantation and the origin of The 15 White Coats

44:40 - The future of The 15 White Coats

53:00 - What is your take home message for a young person of color listening to this interview?

The 15 White Coats website:

https://www.the15whitecoats.org/

Get in touch with Russell:

E-Mail: Russell.ledet@gmail.com

Twitter: @theguywithyes

Instagram: @maleahandmahlinasbaba

Intro Music:

Backbay Lounge Kevin MacLeod (incompetech.com)

Licensed under Creative Commons: By Attribution 3.0 License

http://creativecommons.org/licenses/by/3.0/

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Contributor: Jared Scott, MD

Educational Pearls:

Cholera has been responsible for 6 previous global pandemics and currently the world is in the seventh pandemic of cholera, ongoing since 1961.
Cholera originated in the Ganges Delta of India and spread worldwide but largely is unseen in the US and other developed countries due to water sanitation
Cholera is a bacterial illness that is water borne and causes severe diarrhea
Estimates say that there are 1.3-4 million cases annually and up to 143,000 people die each year from Cholera.
Treatment is largely supportive and can be done with oral rehydration therapy consisting of water, salt, and sugar.
There are three oral vaccinations for Cholera but unfortunately are not widely available
Cholera has been responsible for ushering in public health initiatives. Most famously when John Snow was able to isolate a single water source causing Cholera infections in London and by shutting it off eradicated the bacteria

References

“Cholera.” World Health Organization, World Health Organization, 17 Jan. 2019, https://www.who.int/news-room/fact-sheets/detail/cholera

Clemens JD, Nair GB, Ahmed T, Qadri F, Holmgren J. Cholera. Lancet. 2017;390(10101):1539‐1549. doi:10.1016/S0140-6736(17)30559-7

Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Nick Hatch, MD

Educational Pearls:

A cesarean scar ectopic pregnancy occurs when the pregnancy implants along the scar tissue deep in the myometrium from a prior cesarean surgery, felt to be precipitated by a small fissure or fistula residual in the scar
Diagnosis can be challenging and ultrasound may not clearly show this type of ectopic pregnancy
MRI has been successfully used for diagnosis as well
Various treatment options exist including medical and surgical management but if left untreated, cesarean ectopic pregnancies are life threatening

References

Gonzalez N, Tulandi T. Cesarean Scar Pregnancy: A Systematic Review. J Minim Invasive Gynecol. 2017;24(5):731‐738. doi:10.1016/j.jmig.2017.02.020

Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

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Host: Elizabeth Esty, MD.

At this point, with so many of the studies we’ve digested exploring correlations, associations, observational studies and anecdotal reports and speculation, we could subtitle the show: what we don’t know about COVID. And so, today, we’ll look at what we don’t know about Vitamin D and COVID. There have been a number of studies and a fair amount of media coverage in recent weeks that look at a possible link between low Vitamin D levels and severity of COVID.

Vitamin D plays a role in both adaptive and innate immunity, which we discussed at some length in our episode on the BCG vaccine and COVID. Macrophages starved for Vitamin D can’t produce peroxide to kill microbes, and some of the toll-like receptors crucial to innate immunity that recognize pathogen molecules don't work right without Vitamin D. Finally, Vitamin D modulates the immune response, preventing release of too many cytokines.

The potential for Vitamin D to play a role in preventing severe COVID-19 seems plausible, but what does the science say?

Research By: Elizabeth Esty and Nathan Novotny.

Sound Editing By: Nathan Novotny.

References:

[1] Institute of Medicine (US) Committee to Review Dietary Reference Intakes for Vitamin D and Calcium; Ross AC, Taylor CL, Yaktine AL, et al., editors. Dietary Reference Intakes for Calcium and Vitamin D. Washington (DC): National Academies Press (US); 2011. 3, Overview of Vitamin D. Available from: https://www.ncbi.nlm.nih.gov/books/NBK56061/

[2] Helming L, Böse J, Ehrchen J, et al. 1α,25-dihydroxyvitamin D3 is a potent suppressor of interferon γ–mediated macrophage activation. Blood. 2005;106(13):4351-4358. doi:10.1182/blood-2005-03-1029

[3] Parva NR, Tadepalli S, Singh P, et al. Prevalence of Vitamin D Deficiency and Associated Risk Factors in the US Population (2011-2012). Cureus. 10(6). doi:10.7759/cureus.2741

[4] Sizar O, Khare S, Goyal A, Bansal P, Givler A. Vitamin D Deficiency. In: StatPearls. StatPearls Publishing; 2020. Accessed May 21, 2020. http://www.ncbi.nlm.nih.gov/books/NBK532266/

[5] Ilie PC, Stefanescu S, Smith L. The role of vitamin D in the prevention of coronavirus disease 2019 infection and mortality. Aging Clin Exp Res. Published online May 6, 2020. doi:10.1007/s40520-020-01570-8

[6] Vitamin D and Inflammation – Potential Implications for Severity of Covid-19 – Irish Medical Journal. Accessed May 21, 2020. http://imj.ie/vitamin-d-and-inflammation-potential-implications-for-severity-of-covid-19/

[7] Raharusun P, Priambada S, Budiarti C, Agung E, Budi C. Patterns of COVID-19 Mortality and Vitamin D: An Indonesian Study. Social Science Research Network; 2020. doi:10.2139/ssrn.3585561

[8] The Center for Evidence Based Medicine. Vitamin D: A rapid review of the evidence for treatment or prevention in COVID-19. CEBM. Accessed May 21, 2020. https://www.cebm.net/covid-19/vitamin-d-a-rapid-review-of-the-evidence-for-treatment-or-prevention-in-covid-19/

[9] Hastie CE, Mackay DF, Ho F, et al. Vitamin D concentrations and COVID-19 infection in UK Biobank. Diabetes & Metabolic Syndrome: Clinical Research & Reviews. 2020;14(4):561-565. doi:10.1016/j.dsx.2020.04.050

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Jordan sits down to discuss trauma with Dr. Kaysie Banton, the Trauma Services Medical Director at Level 1 Trauma Center Swedish Medical Center in Englewood, Colorado. In this laid back interview, Dr. Banton discusses how the COVID-19 has affected trauma volumes at Swedish. While trauma as an aggregate hasn’t decreased, the types of trauma for the time of year have shifted as well as the acuity of injuries that present. This episode focuses on how public opinion surrounding the pandemic has shifted the way patients seek care, how delays to seeking care changes her role as a trauma surgeon and what is being done at hospitals to emphasize the safety of patients amidst COVID. Jordan and Dr. Banton talk about how EMS can shift their interview and examinations with this type of behavior in mind. As people delay their care for fear of contracting COVID-19, traumatic injuries that might only require a day or two in the hospital are worsening while untreated and progress to stages that are unnecessary. Dr. Banton leaves medical practitioners with a call to action to educate the public about the benefits of seeking medical care as one normally would outside the pandemic to avoid the worsening of an injury.

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Contributor: Nick Tsipis, MD

Educational Pearls:

Recent randomized controlled trial compared early intervention (PCI/CABG) to medical management for those diagnosed with moderate to severe cardiac ischemia on stress testing
Primary outcome was a composite of death from cardiovascular causes, myocardial infarction, or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest
Secondary outcome was death from cardiovascular causes or myocardial infarction.
The study reported that patients who had more aggressive invasive procedures early on in treatment had a 2% increase in poor outcomes in the immediate period after intervention (6 months) but long term had a 2% decrease in poor outcomes.
Overall the mortality was essentially identical between the two groups

References

1) Maron, D.J., et al. Initial Invasive or Conservative Strategy for Stable Coronary Disease. N Engl J Med. 2020 Apr 9;382(15):1395-1407. doi: 10.1056/NEJMoa1915922. Epub 2020 Mar 30.

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Contributor: Nick Hatch, MD

Educational Pearls:

An AC (acromioclavicular joint) separation in the shoulder is a common traumatic injury
XRs can help rule out other injuries as well as help with grading the injury
There are six different grades for AC separations:
- Grade I: is stretching of the AC ligament without disruption or displacement of the clavicle and recovers with time.
- Grade II: is partial tearing of the AC ligament with some displacement but will also heal with time.
- Grade III: is a full separation with ligament rupture and may require surgery but is not always indicated. Surgery is more common in active patients.
- Grades IV, V, and VI are severe separations and all require surgery.
Other ligament damage or tears, like a slap injury, can mimic an AC separation and often require surgery but should remain on the differential diagnosis when working up shoulder trauma.
Setting expectations is key. Patients with a grade 1 or 2 separation should expect 6+ weeks of limited range of motion and up to 12 weeks until return to full function.
Cosmetically there may be a persistent bump on the shoulder.

References

van Bergen CJA, van Bemmel AF, Alta TDW, van Noort A. New insights in the treatment of acromioclavicular separation. World J Orthop. 2017;8(12):861‐873. Published 2017 Dec 18. doi:10.5312/wjo.v8.i12.861

Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

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Host: Elizabeth Esty, MD.

Smoking is known to increase both susceptibility and severity of all manner of colds and pneumonias, so you’d think the world's 1.1 billion smokers would be at risk in this pandemic of what at first seemed to be a just a respiratory virus.

What’s more, tobacco smoking increases risk for COPD, diabetes and coronary disease, so it may increase risk for more severe COVID indirectly. So it’s remarkable that preliminary evidence suggests that smokers may be less likely to be harmed by COVID than non-smokers. A story that’s gotten a fair amount of attention in the media concerns reports from France that smoking may be protective against COVID. We took a closer look and found that similar reports are coming in from across the globe, including the US. We decided to take some time to look at papers and attempt to explain this relationship.

Research By: Elizabeth Esty, MD.

Sound Editing By: Nathan Novotny.

References:

[1] Miyara M, Tubach F, Pourcher V, et al. Low incidence of daily active tobacco smoking in patients with symptomatic COVID-19. Qeios. April 2020. doi:10.32388/WPP19W.3

[2] Guan W, Ni Z, Hu Y, et al. Clinical Characteristics of Coronavirus Disease 2019 in China. New England Journal of Medicine. 2020;382(18):1708-1720. doi:10.1056/NEJMoa2002032

[3] Chow N, Fleming-Dutra K, Gierke R, et al. Preliminary Estimates of the Prevalence of Selected Underlying Health Conditions Among Patients with Coronavirus Disease 2019 — United States, February 12–March 28, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(13):382-386. doi:10.15585/mmwr.mm6913e2

[4] Richardson S, Hirsch JS, Narasimhan M, et al. Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area. JAMA. April 2020. doi:10.1001/jama.2020.6775

[5] Berlin I, Thomas D, Le Faou A-L, Cornuz J. COVID-19 and Smoking. Nicotine Tob Res. doi:10.1093/ntr/ntaa059

[6] Farsalinos K, Niaura R, Houezec JL, et al. Editorial: Nicotine and SARS-CoV-2: COVID-19 may be a disease of the nicotinic cholinergic system. Toxicology Reports. doi:10.1016/j.toxrep.2020.04.012

Photo Sourced From:

https://www.henryford.com/blog/2020/04/smoking-and-vaping-increase-covid-risks

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Contributor: Nick Tsipis, MD

Educational Pearls:

Case series reported 5 cases of generally young and healthy patients with COVID-19 who presented to the ER with acute stroke
Now several case series showing cardiovascular involvement or complications related to COVID-19
While these case series may shed light on the nature of COVID-19 complications, it's worth remembering that so far these cases represent a few unique instances and we need more studies and data to pronounce COVID-19 infected patients at higher risk of thromboembolic events like strokes and heart attacks

References

Oxley, T. et al. Large-Vessel Stroke as a Presenting Feature of Covid-19 in the Young. April 28, 2020. DOI: 10.1056/NEJMc2009787

Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Don Stader, MD

Educational Pearls:

Buprenorphine has been shown to decrease morbidity and mortality in opioid use disorder
Buprenorphine used in naloxone-induced withdrawals can displace naloxone at opioid receptors, leading to reduced withdrawal symptoms and lessen the chance of using after discharge
Patients in acute withdrawal due to naloxone after an overdose should be given Buprenorphine. Data shows that withholding Buprenorphine leads to increased mortality rates of 5% within the following month, and 10% in the following year.

References

Herring, Andrew. “Emergency Department Medication-Assisted Treatment of Opioid Addiction.” Chcf.org, Aug. 2016, www.chcf.org/wp-content/uploads/2017/12/PDF-EDMATOpioidProtocols.pdf.
D.H. Cisewski et al. Approach to buprenorphine use for opioid withdrawal treatment in the emergency setting. American Journal of Emergency Medicine 37 (2019) 143–150

Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

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In the US, few people receive vaccination for tuberculosis (TB), a disease that hasn’t been a major killer here for many decades. But while we in the US mostly experience TB as a relatively rare but real threat in its multidrug resistant form, particularly in pts with HIV--or in Victorian novels--TB still kills 2 million people a year. There is a vaccine for TB, a live attenuated vaccine called BCG for Bacille Calmette-Guerin. In fact it’s the most widely used vaccine on earth, and an estimated 4 billion people have received it since was first administered to a baby whose mother died of TB a few hours after giving birth in the summer of 1921.

This connection of this vaccine to COVID caught our attention when a friend suggested a few weeks ago that Russia and other parts of the world where BCG vaccination is routine might be shielded from the worst COVID outbreaks. In the intervening weeks, as Russia grapples with its own COVID epidemic, that possibilty seems less tenable, but it did lead us down an interesting research path.

Host: Elizabeth Esty, MD

Research By: Elizabeth Esty, MD

Sound Editing By: Nate Novotny

References:

Miller A, Reandelar MJ, Fasciglione K, Roumenova V, Li Y, Otazu GH. Correlation between Universal BCG Vaccination Policy and Reduced Morbidity and Mortality for COVID-19: An Epidemiological Study. Epidemiology; 2020. doi:10.1101/2020.03.24.20042937
Kleinnijenhuis J, Quintin J, Preijers F, et al. Bacille Calmette-Guerin induces NOD2-dependent nonspecific protection from reinfection via epigenetic reprogramming of monocytes. Proceedings of the National Academy of Sciences. 2012;109(43):17537-17542. doi:10.1073/pnas.1202870109
Arts RJW, Moorlag SJCFM, Novakovic B, et al. BCG Vaccination Protects against Experimental Viral Infection in Humans through the Induction of Cytokines Associated with Trained Immunity. Cell Host & Microbe. 2018;23(1):89-100.e5. doi:10.1016/j.chom.2017.12.010

Further Reading:

https://www.who.int/news-room/commentaries/detail/bacille-calmette-gu%C3%A9rin-(bcg)-vaccination-and-covid-19

https://clinicaltrials.gov/ct2/show/NCT04328441

https://www.mpg.de/14491738/0219-mpin-116799-modified-tuberculosis-vaccine-as-a-therapy-for-cancer-of-the-bladder

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Contributor: Don Stader, MD

Educational Pearls:

COVID-19 commonly appears as a bilateral patchy infiltrate on chest radiograph, but this is a non-specific finding
- Sensitivities range from 17-70% for COVID-19
- Many other viral pneumonias such as RSV and influenza can have similar findings
Point-of-care ultrasound (POCUS) demonstrates B-lines, water-fall sign, or hepatization of the lung, but these are also non-specific
Computerized tomography (CT) appears to be one of the more sensitive tests for detecting COVID-19, demonstrating ground-glass opacities - often before or without the patient having symptoms
- However, routine use of CT for diagnosis COVID-19 is strongly discouraged by many medical societies and the CDC
Imaging may not be necessary in most patients presenting with suspected COVID-19 for multiple reasons:
- Diagnosis is often clinical suspicion, with or without confirmatory PCR testing (if available)
- Imaging does little to change the management in the majority of patients with COVID-19
- Obtaining imaging exposes additional healthcare workers
- Cleaning protocols for units (especially CT) can be extensive and require significant downtime of the machine, thereby leading to delays in care

References

Farkas, Josh. “COVID-19.” EMCrit Project, 21 Apr. 2020, emcrit.org/ibcc/covid19/#labs.
Guan W. et al. Clinical Characteristics of Coronavirus Disease 2019 in China. February 28, 2020, updated on March 6, 2020, at NEJM.org. DOI: 10.1056/NEJMoa2002032

Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

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In this timely installment of Mental Health Monthly, mental health expert Lexi Eliades shares useful tips for identifying burnout and mental health decline as well as ways to maintain mental wellness amidst adversity and significant stress. We at Emergency Medical Minute know many of our listeners are on the frontlines of the COVID-19 pandemic. We hope this piece is helpful and that it reaches someone who needs to hear it!

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Contributor: Dylan Luyten, MD

Educational Pearls

Acidosis can be caused by a respiratory, metabolic, or mixed source
A respiratory acidosis will have a low serum pH and elevated bicarbonate if it’s chronic, but most importantly end tidal CO2 or arterial CO2 will be high.
With a metabolic acidosis we expect to see a low serum pH and low serum bicarbonate.
Once it’s determined a patient is in a metabolic acidosis, we need to determine if it’s an elevated anion gap or normal anion gap acidosis. Anion gap is calculated by subtracting the serum anions from the cations, or serum sodium minus the serum chloride and CO2 (Na-(Cl+CO2)). A normal gap is 6-10, gaps over 10 have an elevated anion gap acidosis.
The causes of an elevated anion gap acidosis can be remembered with MUDPILES mnemonic (Methanol, Uremia (renal failure), Diabetes/DKA, Paraldehyde, Isoniazid, Lactate, Ethanol/Ethylene glycol, salicylates/aspirin).
So when you suspect an elevated gap acidosis you need to evaluate for all causes, so you need to get an venous or arterial blood gas along with lactate, salicylate, and Tylenol levels.

References

Vanmassenhove J. Lameire N. Approach to the patient presenting with metabolic acidosis. Acta Clin Belg. 2019 Feb;74(1):21-27. doi: 10.1080/17843286.2018.1547245. Epub 2018 Nov 24.
Burger MK, Schaller DJ. Physiology, Acidosis, Metabolic. [Updated 2019 Jun 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482146/

Summarized by Jackson Roos, MS3 | Edited by Erik Verzemnieks, MD

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Contributor: Don Stader, MD

Educational Pearls:

Acute respiratory distress syndrome (ARDS) is a catch all term for when lung injury leads to fluid collection in the air spaces of the lungs
Ventilatory management in ARDS patients involves lower FiO2 and PEEP than other patients and relies on lung protective ventilation strategies to prevent barotrauma
Proning these patients has also been utilized with the goal of matching V/Q, or getting good blood flow to areas of the lung which are well ventilated.

References

1. Higher versus Lower Positive End-Expiratory Pressures in Patients with the Acute Respiratory Distress Syndrome. N Engl J Med 2004; 351:327-336. DOI: 10.1056/NEJMoa032193

Howell MD, Davis AM. Management of ARDS in Adults. JAMA. 2018;319(7):711–712. doi:10.1001/jama.2018.0307
Scholten, E.L. et al. Treatment of ARDS With Prone Positioning. Chest. 2017 Jan;151(1):215-224. doi: 10.1016/j.chest.2016.06.032. Epub 2016 Jul 8.

Summarized by Jackson Roos, MS3 | Edited by Erik Verzemnieks, MD

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Last week we looked at neurologic presentations of COVID-19; this week we’ll look more closely at strokes in young people with COVID. A letter published 2 days ago in the NEJM with lead author Thomas Oxley, the Neuro ICU director at Mt Sinai, presents five case studies of relatively young patients who had strokes at home and presented to Mt Sinai between 23 March and 7 April. In pre-COVID days, Mt Sinai saw on about 3 patients under the age of 50 with strokes per month, so 5 in 2 weeks represents a 7-fold increase. The authors call this one of the clearest and most profound correlations” they’ve come across. Though strokes in other COVID case reports are also occurring in older pts, other centers are reporting similar increases in young people with few or no risk factors presenting with major strokes. Right now there are at least 3 US centers preparing to publish data on the stroke in young people phenomenon.

Host: Elizabeth Esty, MD

Research By: Elizabeth Esty and Nate Novotny

Sound Editing By: Stephen Bahmani

References:

Oxley TJ, Mocco J, Majidi S, et al. Large-Vessel Stroke as a Presenting Feature of Covid-19 in the Young. New England Journal of Medicine. 2020;0(0):e60. doi:10.1056/NEJMc2009787
Cha AE. Young and middle-aged people, barely sick with covid-19, are dying of strokes. Washington Post. https://www.washingtonpost.com/health/2020/04/24/strokes-coronavirus-young-patients/. Published April 25, 2020.
Klok FA, Kruip MJHA, van der Meer NJM, et al. Incidence of thrombotic complications in critically ill ICU patients with COVID-19. Thromb Res. April 2020. doi:10.1016/j.thromres.2020.04.013

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Contributor: Don Stader, MD

Educational Pearls:

COVID-19 is diagnosed with a nasopharyngeal swab (q-tip). This unfortunately can be painful, but if the swab doesn’t go deep into the nasal cavity the sample can be inadequate leading to false negatives (missed infections).
The sensitivity of the COVID-19 RT PCR test is low, ranging from 66-80% in various studies. Another study has shown 23% of patients who initially tested negative but had COVID-19 symptoms will test positive when re-tested. So test highly suspicious patients twice.
COVID has shown to have an effect on CBC. White blood cell counts are often normal (no leukocytosis), but there is often lymphopenia, or low lymphocytes, and thrombocytopenia. Interestingly, low platelets have appeared to have prognostic value in that lower platelets often indicate worse patient outcomes.
Coagulation studies are showing very elevated D-Dimers which has sparked the debate as to whether COVID-19 causes a hypercoagulable state. The increased incidence of MI/heart attacks and strokes in COVID patients supports this argument.
While D-Dimers can help point towards a diagnosis of pulmonary embolism, in the setting of highly likely COVID-19 infections, getting a CTA looking for a PE is probably unnecessary unless there’s also suspicion for PE.
C-reactive protein (CRP) and procalcitonin are two common inflammatory markers. A CRP can help indicate how sick a patient is and procalcitonin can help determine if the infection is bacterial or viral in nature.
CRP levels are often elevated in COVID patients, and studies are showing a high CRP is linked to worse patient outcomes.
Elevations in procalcitonin can be used to see if there’s a concomitant bacterial infection, meaning patients need antibiotics in addition to supportive care for the COVID-19.
Flu season is coming to a close, but data has shown a 5-10% co-infection rate of COVID-19 with influenza. As expected patient outcomes have been worse in those with both infections.

References

1) Farkas, Josh. “COVID-19.” EMCrit Project, 21 Apr. 2020, emcrit.org/ibcc/covid19/#labs.

2) Guan W. et al. Clinical Characteristics of Coronavirus Disease 2019 in China. February 28, 2020, updated on March 6, 2020, at NEJM.org. DOI: 10.1056/NEJMoa2002032

3)Young BE, Ong SWX, Kalimuddin S, et al. Epidemiologic Features and Clinical Course of Patients Infected With SARS-CoV-2 in Singapore. JAMA. 2020;323(15):1488–1494. doi:10.1001/jama.2020.3204

4) Wang M. et al. Clinical diagnosis of 8274 samples with 2019-novel coronavirus in Wuhan. medRxiv 2020.02.12.20022327; doi: https://doi.org/10.1101/2020.02.12.20022327

Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Eric Miller, MD

Educational Pearls:

A cell count is performed on tubes 1 and 4 to account for changes that may occur from blood entering the first sample from the needle insertion
Tube 2 and 3 are usually used for the other studies like protein levels, glucose levels and gram staining
Protein levels are often elevated in bacterial meningitis but can be helpful in diagnosis conditions like multiple sclerosis
Glucose levels are typically low in bacterial meningitis due to the use of glucose by bacteria
Cell counts above 3-5 cells are typically abnormal, but cell counts can vary widely depending on the type of meningitis (viral vs. bacterial) and how long the infection has been present.
Cell type and differential can indicate viral vs. bacterial meningitis
- Neutrophils are more associated with bacterial causes
- Lymphocytes are more associated with viral etiologies
CSF cultures are used to identify the cause of bacterial meningitis but can take days to result.
A gram stain can help determine if any bacteria are present as well as cell types present.

References

Jain, R. Chang, WW. Emergency Department Approach to the Patient with Suspected Central Nervous System Infection. Emerg Med Clin North Am. 2018 Nov;36(4):711-722. doi: 10.1016/j.emc.2018.06.004.

Summarized by Jackson Roos, MS3 | Edited by Erik Verzemnieks, MD

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Contributor: Don Stader, MD

Educational Pearls:

When do we give antiplatelet drugs or anti-coagulation drugs?
- Arterial issues get antiplatelet therapy
- Venous issues, or slow flow states, get anticoagulation therapy.
High flow areas (arteries) are more prone to platelet clotting while the venous system is more prone to allowing blockages caused by coagulation factors.
The main side effect with antiplatelet and anticoagulants is bleeding. Typically antiplatelet drugs cause more bleeding issues because platelets are made in the bone marrow, while coagulation factors are made in the liver, so it takes longer for the bone marrow to replete platelets versus the liver which is a fast synthesizer of clotting factors.
Reversal of antiplatelet drugs can take a while, so patients on these drugs (ex. Plavix) may need a week of withholding the drug to get surgery, while anti-coagulation drugs (ex. Xarelto) can be stopped a day or two prior to surgery.

References

Altiok, E. Marx, N. Oral Anticoagulation: Update on Anticoagulation With Vitamin K Antagonists and Non–Vitamin K–Dependent Oral Anticoagulants. Dtsch Arztebl Int. 2018 Nov; 115(46): 776–783. Published online 2018 Nov 16. doi: 10.3238/arztebl.2018.0776
Kapil, N. Et al. Antiplatelet and Anticoagulant Therapies for Prevention of Ischemic Stroke.

Clin Appl Thromb Hemost. 2017 May;23(4):301-318. doi: 10.1177/1076029616660762. Epub 2016 Jul 26.

Ostergaard, L. Fosbol EL. Roe MT. The Role of Antiplatelet Therapy in Primary Prevention. A Review. Curr Pharm Des. 2017;23(9):1294-1306. doi: 10.2174/1381612822666161205115540.

Summarized by Jackson Roos, MS3 | Edited by Erik Verzemnieks, MD

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Accumulating clinical evidence suggests that many patients with COVID have neurological symptoms and that some may even present with neurologic manifestations of the disease. Most COVID patients have a cough, respiratory distress, and while clinicians often speak about how similar the presentations of patients with respiratory COVID are, it’s worth looking at the possibility that COVID has atypical presentations, too.There’s very good evidence that coronaviruses can infect all sorts of human cells--not just those in the respiratory tract. A few weeks ago we discussed ACE inhibitors and NSAIDs and SARS COV2 and you may remember that the virus attaches to the ACE2 receptor--a receptor which is found on a wide range of human cells. What are the chances the virus can infect a patients brain cells, cranial nerves, peripheral nerves?

Host: Elizabeth Esty, MD

Research By: Tanisha Crosby-Attipoe & Mason Tuttle

Sound Editing By: Stephen Bahmani

Time Stamps:

0:23 - Numbers

1:25 - Possible Neurological Manifestations of COVID

4:15 - What are the chances the virus can infect a patients brain cells, cranial nerves, peripheral nerves?

4:55 - The neuroinvasive potential of SARS‐CoV2 may play a role in the respiratory failure of COVID‐19 patients

8:24 - early neurological research from NEJM in February

9:10 - some early research indicated possible neurological manifestations

10:05 - COVID and serious CV incidents

10:40 - Italian Neurologists urge other nations to be alert for neuro presentations of COVID

11:11 - Case report in Radiology, COVID patient with encephalopathy

12:06 - Possible link with Guillain-Barré

References:

Li Y-C, Bai W-Z, Hashikawa T. The neuroinvasive potential of SARS-CoV2 may play a role in the respiratory failure of COVID-19 patients. Journal of Medical Virology. 2020;92(6):552-555. doi:10.1002/jmv.25728
Poyiadji N, Shahin G, Noujaim D, Stone M, Patel S, Griffith B. COVID-19–associated Acute Hemorrhagic Necrotizing Encephalopathy: CT and MRI Features. Radiology. March 2020:201187. doi:10.1148/radiol.2020201187
Mao L, Jin H, Wang M, et al. Neurologic Manifestations of Hospitalized Patients With Coronavirus Disease 2019 in Wuhan, China. JAMA Neurol. April 2020. doi:10.1001/jamaneurol.2020.1127
Li Y, Wang M, Zhou Y, et al. Acute Cerebrovascular Disease Following COVID-19: A Single Center, Retrospective, Observational Study. Rochester, NY: Social Science Research Network; 2020. doi:10.2139/ssrn.3550025
Zhao H, Shen D, Zhou H, Liu J, Chen S. Guillain-Barré syndrome associated with SARS-CoV-2 infection: causality or coincidence? The Lancet Neurology. 2020;19(5):383-384. doi:10.1016/S1474-4422(20)30109-5

Further reading and listening:

https://www.medscape.com/viewarticle/928069

http://emguidewire.libsyn.com/rss

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In this organic conversation, Nick and Dr. Helman establish a warm rapport early on as they discuss musical beginnings, life-changing mentors and the origins of Emergency Medicine Cases. Their banter includes Dr. Helman’s views on FOAMed and multimodal learning and treatment hacks learned on the frontlines of COVID-19.

Intro Music:

Backbay Lounge Kevin MacLeod (incompetech.com)

Licensed under Creative Commons: By Attribution 3.0 License

http://creativecommons.org/licenses/by/3.0/

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In this episode of the COVID-19 Digest, we revisit the airborne vs droplet transmission debate and analyze a highly publicized study on Remdesivir from the New England Journal of Medicine.

Host: Elizabeth Esty, MD & Dylan Luyten, MD

Research By: Tanisha Crosby-Attipoe & Nathan Novotny

Sound Editing By: Stephen Bahmani

Time Stamps:

0:00 - Numbers

0:58 - "Transmission Potential of SARS-CoV-2 in Viral Shedding Observed at the University of Nebraska Medical Center"

6:53 - "Compassionate Use of Remdesivir for Patients with Severe Covid-19"

References:

[1] Santarpia, J. L., Rivera, D. N., Herrera, V., Morwitzer, M. J., Creager, H., Santarpia, G. W., Lowe, J. J. (2020). Transmission Potential of SARS-CoV-2 in Viral Shedding Observed at the University of Nebraska Medical Center doi:10.1101/2020.03.23.20039446

[2]Grein J, Ohmagari N, Shin D, et al. Compassionate Use of Remdesivir for Patients with Severe Covid-19. New England Journal of Medicine. 2020;0(0):.doi:10.1056/NEJMoa2007016

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In part 2 of our interview with Dr. Adam Graham, Jordan takes a deep dive into posterior circulation strokes and how to identify them in the field.

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Contributor: Dave Rosenberg, MD

Educational Pearls:

White noise is all the surrounding sound frequencies mixed together that your brain tunes down so you don’t get distracted while you're sleeping
Pink noise, or deep soothing noises, is the accentuated bass sounds like falling rain or waves crashing your brain keys into while sleeping.
Brain electrical waves during stage 4 sleep (the deepest of sleeps), cause sudden increases and decreases in cerebral blood flow allowing for CSF washing of the brain, which helps eliminate beta amyloid - the misfolded protein linked to Alzheimers
Pink noise during sleep has been shown to increase stage 4, creating more CSF washout of beta amyloid.

References

Spinedi, E. Cardinali, DP. Neuroendocrine Metabolic Dysfunction and Sleep Disturbances in Neurodegenerative Disorders: Focus on Alzhimer's Disease and Melatonin. Neuroendocrinology. 2019;108(4):354-364. doi: 10.1159/000494889. Epub 2018 Oct 28.
Zee, P. Papalambros NA. et al. Acoustic Enhancement of Sleep Slow Oscillations and Concomitant Memory Improvement in Older Adults. Front Hum Neurosci. 2017 Mar 8;11:109. doi: 10.3389/fnhum.2017.00109. eCollection 2017.

Summarized by Jackson Roos, MS3 | Edited by Erik Verzemnieks, MD

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The circumstances that led to the national shortage in PPE for healthcare workers, the inspiring work of New Orleans med students to equip medical providers with PPE and the science behind personal use of cloth masks are all topics covered in this special edition of the Emergency Medical Minute.

Host: Elizabeth Esty, MD

Research By: Julia Luyten

Sound Editing By: Stephen Bahmani

Time Stamps:

0:00 - The scope of the mask shortage

1:04 - What led to the shortage

5:01 - Interview with Taylor Hopper, med student from Tulane University School of Medicine (TUSOM), who's part of TUSOM COVID Response Group - an organization frantically working to adequately supply hospitals with PPE in New Orleans.

16:23 - The science behind personal use of cloth masks

References and Further Reading:

https://www.fda.gov/medical-devices/personal-protective-equipment-infection-control/faqs-shortages-surgical-masks-and-gowns

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2190272/?smid=nytcore-ios-share

https://www.sciencedirect.com/science/article/pii/S0140673620305201?via%3Dihub

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7118603/

https://www.msn.com/en-us/news/us/how-the-worlds-richest-country-ran-out-of-a-75-cent-face-mask/ar-BB11GgLi?li=BBnbcA1

https://www.vox.com/the-goods/2020/3/20/21188369/face-masks-short-supply-coronavirus-donations

https://www.nytimes.com/2020/03/26/opinion/coronavirus-doctors-hoarding.html

https://columbiasurgery.org/donate-ppe

https://www.vox.com/policy-and-politics/2020/3/27/21194402/coronavirus-masks-n95-respirators-personal-protective-equipment-ppe

https://www.nytimes.com/article/face-masks-coronavirus.html?smid=nytcore-ios-share

Photo Credit: https://flickr.com/photos/91499534@N00/49432443047

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Contributor: Dylan Luyten, MD

Educational pearls:

Clinical management of COVID-19 is rapidly evolving, relying on case reports and clinical experience
In just a month, the consensus around management of COVID patients with severe hypoxia has shifted from an early intubation strategy to other, non-invasive means
Intubating early can quickly consume ventilator resources, require increased intensive care monitoring, and likely leads to longer hospital stays and once COVID patients are intubated, extubation can take days to weeks.
In Italy, ventilator supplies were depleted leading to the use of helmet CPAP machines, which appeared to be effective in management of respiratory distress in COVID, though not available for use in the US
Non-invasive ventilation such as CPAP/BiPAP is thought to increase risk to staff for infection via aerosolization, and has often been avoided in COVID patients
High flow nasal cannulas appear to pose less of a risk of aerosolization of viral particles (especially when a surgical mask is placed over the patient’s nose, mouth and apparatus)
Anecdotal evidence from NYC has shown success allowing conscious patients to maintain hypoxia on HFN, where they will self prone to help with lung recruitment, and seemingly do well despite persistent saturations in the 80s or less
Hospitals around the country are moving away from the intubate early methodology in favor of high flow oxygen therapy as long as they are not having issues with work of breathing or other complications
The pathophysiology of respiratory distress and hypoxia in COVID patients is evolving as well, and some presentations appear similar to disease processes such as high altitude pulmonary edema (HAPE) rather than acute respiratory distress syndrome (ARDS), in that patients are quite well appearing despite phenomenally low oximetry readings.
- These select patients appear to be excellent candidates for non-invasive means rather than an early intubation strategy

Editor’s note: do not take lightly that intubation is one of the highest risk aerosolization generating procedures, along with many peri-intubation procedures like suctioning, BVM, etc.

References

[1]. Sorbello, M. et al. The Italian coronavirus disease 2019 outbreak: recommendations from clinical practice. Anaesthesia. 2020 Mar 27.

[2]. Giwa, AL. Desai A. Duca A. Novel 2019 coronavirus SARS-CoV-2 (COVID-19): An updated overview for emergency clinicians. Emerg Med Pract. 2020 May 1;22(5):1-28.

[3]. Ather B, Edemekong PF. Airborne Precautions. [Updated 2020 Feb 17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan.

Summarized by Jackson Roos, MS3 | Edited by Erik Verzemnieks, MD

Photo Credit: New England Journal of Medicine

https://www.nejm.org/doi/full/10.1056/NEJMc2007589?query=RP

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In our coverage of COVID-19 this week, we’ve investigated the shakey evidence for NSAID use making COVID worse, heard first-hand accounts from ED clinicians with COVID, and looked at the status of testing in the United States. Before capping our week of coverage off, we wanted to analyze some of the most recent literature on clinical interventions for COVID, particularly the recently FDA approved hydroxychloroquine.

Host: Elizabeth Esty, MD

Research By: Elizabeth Esty and Nathan Novotny

Sound Editing By: Stephen Bahmani

References

Wang M, Cao R, Zhang L, et al. Remdesivir and chloroquine effectively inhibit the recently emerged novel coronavirus (2019-nCoV) in vitro. Cell Research. 2020;30(3):269-271. doi:10.1038/s41422-020-0282-0
Gautret P, Lagier J-C, Parola P, et al. Hydroxychloroquine and azithromycin as a treatment of COVID-19: results of an open-label non-randomized clinical trial. Int J Antimicrob Agents. March 2020:105949. doi:10.1016/j.ijantimicag.2020.105949
Molina JM, Delaugerre C, Goff JL, et al. No Evidence of Rapid Antiviral Clearance or Clinical Benefit with the Combination of Hydroxychloroquine and Azithromycin in Patients with Severe COVID-19 Infection. Médecine et Maladies Infectieuses. March 2020. doi:10.1016/j.medmal.2020.03.006
Chen Z, Hu J, Zhang Z, et al. Efficacy of hydroxychloroquine in patients with COVID-19: results of a randomized clinical trial. medRxiv. March 2020:2020.03.22.20040758. doi:10.1101/2020.03.22.20040758

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A dive into how the United States responded to an emerging pandemic and the pitfalls along the way that led to stalled testing capacity across the country before community transmission was confirmed. Hear what led us to our current situation, what continues to be an issue and new technologies on the horizon as well as how the rest of the world has responded.

Host: Elizabeth Esty, MD

Research By: Mason Tuttle

Sound Editing By: Stephen Bahmani

References:

Shear M, Goodnough A, Kaplan S, Fink S, Thomas K, Weiland N. The Lost Month: How a Failure to Test Blinded the U.S. to Covid-19. The New York Times. https://www.nytimes.com/2020/03/28/us/testing-coronavirus-pandemic.html?smid=nytcore-ios-share. Published March 28, 2020.
Topol E. US Betrays Healthcare Workers in Coronavirus Disaster. MedScape. https://www.medscape.com/viewarticle/927811. Published March 30, 2020.
Abbott. DETECT COVID-19 IN AS LITTLE AS 5 MINUTES. https://www.abbott.com/corpnewsroom/product-and-innovation/detect-covid-19-in-as-little-as-5-minutes.html. Published March 27, 2020.
Abdelmalek M, David E, Margolin J. Why coronavirus antibody testing in one Colorado town could provide a way forward. ABC News. https://abcnews.go.com/Health/antibody-testing-colorado-town-provide-forward/story?id=69856623. Published March 28, 2020.
Kuznia R, Devine C, Griffin D. Severe shortages of swabs and other supplies hamper coronavirus testing. CNN. https://www.cnn.com/2020/03/18/us/coronovirus-testing-supply-shortages-invs/index.html. Published March 18, 2020.
Judd D, Zaslav A, Diaz D. America is ramping up Covid-19 testing, but a shortage of basic supplies is limiting capabilities. CNN. https://www.cnn.com/2020/03/28/politics/coronavirus-swabs-supplies-shortage-states/index.html. Published March 28, 2020.
Haug G. “A game changer”: FDA authorizes Abbott Labs’ portable, 5-minute coronavirus test the size of a toaster. USA Today. https://www.usatoday.com/story/news/health/2020/03/28/coronavirus-fda-authorizes-abbott-labs-fast-portable-covid-test/2932766001/. Published March 28, 2020.
Hasell J, Roser M, Ortiz-Ospina E. Data on COVID-19 testing. Our World In Data. https://ourworldindata.org/covid-testing. Published March 28, 2020.
Hale T. Iceland’s Prolific COVID-19 Testing Is Telling Us A Lot About The Outbreak. IFLScience! https://www.iflscience.com/health-and-medicine/icelands-prolific-covid19-testing-is-telling-us-a-lot-about-the-outbreak/. Published March 27, 2020.

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Long time friends of EMM, Aaron and Bree, share their experiences on the frontlines in the ED, coping with COVID, managing anxiety and quarantining with their family.

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In the past two weeks, warnings, questions, and misinformation concerning COVID-19 and NSAID use have been spreading...no pun intended..virally. The pace of this evolving pandemic and the equally quick pace of the news and social media news cycle have meant that information and misinformation travel equally fast. Today we bring to you the story of how a letter in The Lancet led to a world of confusion.

Host: Elizabeth Esty, MD

Research By: Elizabeth Esty & Nathan Novotny

Sound Editing By: Stephen Bahmani

Time Stamps:

0:00 - COVID-19 Statistics

2:55 - The Lancet Letter: What Started the Rumor

4:10 - ACE Inhibitors & ARB's

5:00 - What The Lancet Letter Got Wrong

6:25 - Treatment of HTN and DM in China vs. the U.S.

9:13 - Do ACE Inhibitors Actually Increase ACE-2 Expression?

11:00 - The French Ministry of Health and Their Warning About NSAIDs

14:09 - Misinformation in the Age of COVID-19

15:09 - Potential Harms of Tylenol Use

16:11 - The Need for High-Quality Science to Overcome COVID-19

References:

Fang L, Karakiulakis G, Roth M. Are patients with hypertension and diabetes mellitus at increased risk for COVID-19 infection? The Lancet Respiratory Medicine. March 2020:S2213260020301168. doi:10.1016/S2213-2600(20)30116-8
Kane S. Ibuprofen - Drug Usage Statistics, ClinCalc DrugStats Database. ClinCalc DrugStats Database. https://clincalc.com/DrugStats/Drugs/Ibuprofen. Published December 23, 2019. Accessed March 30, 2020.
Hoffmann M, Kleine-Weber H, Schroeder S, et al. SARS-CoV-2 Cell Entry Depends on ACE2 and TMPRSS2 and Is Blocked by a Clinically Proven Protease Inhibitor. Cell. March 2020. doi:10.1016/j.cell.2020.02.052
Lu J, Lu Y, Wang X, et al. Prevalence, awareness, treatment, and control of hypertension in China: data from 1·7 million adults in a population-based screening study (China PEACE Million Persons Project). The Lancet. 2017;390(10112):2549-2558. doi:10.1016/S0140-6736(17)32478-9
Wang Zengwu, Chen Zuo, Zhang Linfeng, et al. Status of Hypertension in China. Circulation. 2018;137(22):2344-2356. doi:10.1161/CIRCULATIONAHA.117.032380
Hu C, Jia W. Diabetes in China: Epidemiology and Genetic Risk Factors and Their Clinical Utility in Personalized Medication. Diabetes. 2018;67(1):3-11. doi:10.2337/dbi17-0013
Yuan H, Li X, Wan G, et al. Type 2 diabetes epidemic in East Asia: a 35-year systematic trend analysis. Oncotarget. 2018;9(6). doi:10.18632/oncotarget.22961
Woo KS, Nicholls MG. High prevalence of persistent cough with angiotensin converting enzyme inhibitors in Chinese. Br J Clin Pharmacol. 1995;40(2):141-144.
Chen X, Hu W, Ling J, et al. Hypertension and Diabetes Delay the Viral Clearance in COVID-19 Patients. medRxiv. March 2020:2020.03.22.20040774. doi:10.1101/2020.03.22.20040774
Perico L, Benigni A, Remuzzi G. Should COVID-19 Concern Nephrologists? Why and to What Extent? The Emerging Impasse of Angiotensin Blockade. NEF. March 2020:1-9. doi:10.1159/000507305
Qiao Y, Shin J-I, Chen TK, et al. Association Between Renin-Angiotensin System Blockade Discontinuation and All-Cause Mortality Among Persons With Low Estimated Glomerular Filtration Rate. JAMA Intern Med. March 2020. doi:10.1001/jamainternmed.2020.0193
The Local. UPDATE - Coronavirus: French health minister and WHO issue warning over taking anti-inflammatories. https://www.thelocal.fr/20200314/coronavirus-french-health-minister-issues-warning-over-anti-flammatories. Published March 14, 2020. Accessed March 30, 2020.
ScienceAlert. Updated: WHO Now Doesn’t Recommend Avoiding Ibuprofen For COVID-19 Symptoms. https://www.sciencealert.com/who-recommends-to-avoid-taking-ibuprofen-for-covid-19-symptoms. Accessed March 30, 2020.
European Medicines Agency. Coronavirus disease (COVID-19). https://www.ema.europa.eu/en/human-regulatory/overview/public-health-threats/coronavirus-disease-covid-19#advice-on-using-non-steroidal-anti-inflammatory-medicines-such-as-ibuprofen--section. Published March 18, 2020.
U.S. Food and Drug Administration. FDA advises patients on use of non-steroidal anti-inflammatory drugs (NSAIDs) for COVID-19. https://www.fda.gov/drugs/drug-safety-and-availability/fda-advises-patients-use-non-steroidal-anti-inflammatory-drugs-nsaids-covid-19. Published March 19, 2020.
BBC Reality Check team and BBC Monitoring. Coronavirus and ibuprofen: Separating fact from fiction. BBC News. https://www.bbc.com/news/51929628. Published March 17, 2020.
Mosbergen D. Tylenol Overdose Risk Is Staggering; Acetaminophen Safeguards Remain Insufficient: Report. HuffPost. https://www.huffpost.com/entry/tylenol-overdose_n_3976991. Published September 24, 2013.

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Contributor: Dylan Luyten, MD

Educational Pearls:

After you diagnose a pulmonary embolism (PE) via CT or VQ scan, we need to categorize the PE as massive, sub-massive, or just PE to dictate treatment.
Massive PE: shock with hypotension due to an embolism, and the treatment of choice is thrombolysis with IV tPA with anticoagulation after lysis. Catheter thrombolysis is not used in the hemodynamically unstable patient but can be done after they are stable.
Sub-massive: signs of right heart strain/failure but hemodynamically stable. This can be EKG changes, positive biomarkers, or imaging findings. These patients can be treated with IV heparin as there may benefit from catheter directed thrombolysis which has been shown to lead to better functional outcomes.
Everything else can be stratified to determine whether inpatient even outpatient treatment is necessary
Pulmonary Embolism Severity Index (PESI) or Hestia criteria and can help determine if the patient is better suited for in or outpatient management.
Non massive or sub-massive PEs are treated with heparin/Lovenox bridged to Warfarin, a factor Xa inhibitor (ex. Xarelto), or direct oral anticoagulants (DOAC).

Editor’s note: intravenous heparin is preferable to other anticoagulants when considering interventional radiology as it can be shut off and/or reversed if necessary prior to procedure

References

Sista, A. et al. Stratification, Imaging, and Management of Acute Massive and Submassive Pulmonary Embolism. 2017 Jul;284(1):5-24
Aujesky D, Obrosky DS, Stone RA, Auble TE, Perrier A, Cornuz J, Roy PM, Fine MJ. Derivation and validation of a prognostic model for pulmonary embolism. Am J Respir Crit Care Med. 2005 Oct 15;172(8):1041-6
Jimenez, D. et al. Risk stratification of patients with acute symptomatic pulmonary embolism. Intern Emerg Med. 2016 Feb;11(1):11-8.

Summarized by Jackson Roos, MS3 | Edited by Erik Verzemnieks, MD

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Host: Elizabeth Esty, MD

Research By: Elizabeth Esty and Nathan Novotny

References:

Osumi M. Questions raised over COVID-19 reinfection after Japanese woman develops illness again. The Japan Times. https://www.japantimes.co.jp/news/2020/02/28/national/coronavirus-reinfection/#.Xn4coZNKhQI. Published February 28, 2020.
Bao L, Deng W, Gao H, et al. Reinfection could not occur in SARS-CoV-2 infected rhesus macaques. bioRxiv. March 2020:2020.03.13.990226. doi:10.1101/2020.03.13.990226
Steinbuch Y. Doctor asks recovered coronavirus patients to be tested for antibodies. New York Post. https://nypost.com/2020/03/26/doctor-asks-recovered-coronavirus-patients-to-be-tested-for-antibodies/. Published March 26, 2020.
Casadevall A. How a Boy’s Blood Stopped an Outbreak. The Wall Street Journal. https://www.wsj.com/articles/how-a-boys-blood-stopped-an-outbreak-11582847330. Published February 27, 2020.
U.S. Food and Drug Administration. Investigational COVID-19 Convalescent Plasma - Emergency INDs.https://www.fda.gov/vaccines-blood-biologics/investigational-new-drug-ind-or-device-exemption-ide-process-cber/investigational-covid-19-convalescent-plasma-emergency-inds. Published March 24, 2020.
Carmichael T. Takeda Pharmaceutical Announces a Plasma-Derived Coronavirus Therapy. Nasdaq. https://www.nasdaq.com/articles/takeda-pharmaceutical-announces-a-plasma-derived-coronavirus-therapy-2020-03-04. Published March 4, 2020.
Maxmen A. How blood from coronavirus survivors might save lives. Nature. March 2020. https://www.nature.com/articles/d41586-020-00895-8.
Amanat F, Nguyen T, Chromikova V, et al. A serological assay to detect SARS-CoV-2 seroconversion in humans. medRxiv. March 2020:2020.03.17.20037713. doi:10.1101/2020.03.17.20037713
Steinbuch Y. Mount Sinai researchers develop test for coronavirus antibodies. New York Post. https://nypost.com/2020/03/24/mount-sinai-researchers-develop-test-for-coronavirus-antibodies/. Published March 24, 2020.

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Recorded 3/26/20

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The circumstances surrounding the COVID-19 virus are quickly evolving and that means that EMM will have to as well. For the foreseeable future, EMM will be releasing COVID-19 updates. In this series, we will report the most recent statistics, summarize the newest literature and answer YOUR burning questions. Submit your questions through comments on this post or through private messages on any of our social media platforms.

Host: Elizabeth Esty, MD

Research By: Elizabeth Esty, Jackson Roos, Nathan Novotny & Mason Tuttle

Time Stamps:

0:00 - COVID-19 by the numbers

2:50 - Hydroxychloroquine and Azithromycin

6:05 - Ongoing Anti-Viral Therapy Research

7:47 - Anosmia

9:31 - Viability of COVID-19 Aerosolized vs. on Surfaces

10:49 - Listener Questions

References:

[1] The Center for Systems Science and Engineering (CSSE) at Johns Hopkins University Interactive Map

[2] Gautret et al. (2020) Hydroxychloroquine and azithromycin as a treatment of COVID‐19: results of an open‐label nonrandomized clinical trial. International Journal of Antimicrobial Agents – In Press 17 March 2020 –DOI : 10.1016/j.ijantimicag.2020.105949

[3] Belhadi D, Peiffer-Smadja N, Yazdanpanah Y, Mentré F, Laouénan C. A brief review of antiviral drugs evaluated in registered clinical trials for COVID-19. medRxiv. March 2020:2020.03.18.20038190.doi:10.1101/2020.03.18.20038190

[4] Hopkins C, Kumar N, ENT UK at The Royal College of Surgeons of England. Loss of sense of smell as marker of COVID-19 infection. https://www.entuk.org/sites/default/files/files/Loss%20of%20sense%20of%20smell%20as%20marker%20of%20COVID.pdf.

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Contributor: Don Stader, MD

Educational Pearls:

PPIs (Proton pump inhibitors) reduce stomach acid levels and are commonly prescribed in patients with GERD or peptic ulcer disease
Stopping a PPI after sustained use for a month or longer can lead to withdrawal - causing a rebound indigestion or reflux due to a surge in acid production
Long term PPI use has noteworthy side effects including increased incidence of bacterial GI infections and pneumonia
Be cautious in prescribing a PPI for over 2 weeks. If continued indigestion control is needed, transition to a H2 blocker or OTC antacids if prolonged treatment is needed.

References

1)Haastrup PF, Thompson W, Søndergaard J, Jarbøl DE (2018) Side effects of long-term proton pump inhibitor use: a review. Basic Clin Pharmacol Toxicol 123(2):114–121. https://doi.org/10.1111/bcpt.13023 Review

2) Helgadottir, H.; Bjornsson, E.S. Problems Associated with Deprescribing of Proton Pump Inhibitors. Int. J. Mol. Sci. 2019, 20, 5469.

Summarized by Jackson Roos, MS3 | Edited by Erik Verzemnieks, MD

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In this special edition of our On the Streets podcast, we discuss COVID-19 as well as what first responders and emergency providers need to know to keep themselves and their patients safe during this pandemic.

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Contributor: Sam Killian, MD

Educational Pearls:

Agitation can be due to a number of causes, but regardless of the cause, sedation often plays a key role in patient and provider safety. But what is the best sedative agent?
A study looked at control of agitation with intramuscular medication. Specifically, 5 different IM sedative agents were compared to see which one best provides “adequate” sedation in 15 minutes or less.
Haldol 5mg, Haldol 10mg, Versed 5mg, Zyprexa 10mg, and Geodon 20mg were all compared, and by far Versed provided the best sedative results. All medications had approximately the same amount of adverse effects.
There are so many sedative options, but time and time again large dose benzodiazepines have demonstrated great effectiveness in treating acute agitation

References

1) Klein, Lauren R. et al. Intramuscular Midazolam, Olanzapine, Ziprasidone, or Haloperidol for Treating Acute Agitation in the Emergency Department. Annals of Emergency Medicine. 2018. 72(4), 374 - 385

Summarized by Jackson Roos, MS3 | Edited by Erik Verzemnieks, MD

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Contributor: Sam Killian, MD

Educational Pearls:

Classic dogma teaching that epinephrine should not be used in the fingers, nose, penis, and toes when performing local anesthesia due to concerns for ischemia is wrong
This has been well documented in multiple literature reviews
A prospective, randomized double-blind study compared lidocaine vs lidocaine with epinephrine for finger injuries and the use of epinephrine was associated with less bleeding and better anesthesia

Editor’s note: in the lidocaine without epinephrine group, 5 (not 7) needed additional dosing of local anesthesia. The groups were also split 29 for lidocaine alone and 31 for lidocaine with epinephrine but we’re in a pandemic so who is noticing anyways

References

1. Wilhelmi, B.J., et al. Do not use epinephrine in digital blocks: myth or truth? Plast Reconstr Surg. 2001 Feb;107(2):393-7.
1. Ilicki, J. Safety of Epinephrine in Digital Nerve Blocks: A Literature Review. J Emerg Med. 2015 Nov;49(5):799-809. doi: 10.1016/j.jemermed.2015.05.038. Epub 2015 Aug 4.
1. Walsh, K., Baker, B.G., Iyer, S. Adrenaline Auto-injector injuries to digits; a systematic review and recommendations for emergency management. 2020 Feb 8. pii: S1479-666X(20)30016-0. doi: 10.1016/j.surge.2020.01.005.

Summarized by Jackson Roos, MS3 | Edited by Erik Verzemnieks, MD

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Part 1 of 2: Dr. Adam Graham dishes out the essentials of identifying concerning neurological deficits on the scene, predicting what they mean and how to best care for patients with neurological deficits in the pre-hospital setting.

About Dr. Adam Graham:

Adam Graham, MD, is a board-certified neurologist with Blue Sky Neurology in Denver. His professional interests include treatment of diseases of the peripheral nerves and muscles, for example ALS, myasthenia gravis and peripheral neuropathy. He works to make EMG procedures as comfortable as possible for patients. Dr. Graham earned his medical degree from Creighton University. He then completed a residency in neurology and a fellowship in neuromuscular medicine and EMG, both at the University of Colorado.

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Contributor: Nick Tsipis, MD

Educational Pearls:

Congenital adrenal hyperplasia (CAH) is a group of enzyme deficiencies in the adrenals leading to a deficiency of hormones normally synthesized by the adrenals (mineralocorticoids, glucocorticoids, androgens)
21-hydroxylase is most commonly the deficient enzyme.
21-hydroxylase is needed to produce aldosterone and cortisol, and those with chronic cortisol deficiencies need daily steroid replacement
Aldosterone, made in the kidney as part of the renin-angiotensin-aldosterone system (RAAS), increases blood pressure via salt and water retention to maintain adequate organ perfusion
Adrenal crisis results in a loss of cortisol leading to hypoglycemia and potential CNS depression with hypotension, hypoglycemia, and hyponatremia
Patients in adrenal crisis need salt, volume, and glucose replacement

References

Martin-Grace, J., et al. Adrenal insufficiency: physiology, clinical presentation and diagnostic challenges. Clin Chim Acta. 2020 Feb 6.

Dineen, R., Thompson, C.J., Sherlock, M. Adrenal crisis: prevention and management in adult patients. Ther Adv Endocrinol Metab. 2019 Jun 13;10:2042018819848218.

El-Maouche, D., Arlt, W., Merke, D.P. Congenital Adrenal Hyperplasia. Lancet. 2017 Nov 11;390(10108):2194-2210.

Summarized by Jackson Roos, MS3 | Edited by Erik Verzemnieks, MD

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Author: Aaron Lessen, MD

Educational Pearls:

A recent retrospective study looked capsaicin cream in treating cannabinoid hyperemesis syndrome in regards to length of stay, cost analysis, use of rescue therapies, and adverse events
Results showed a trend towards reduced length of stay but did not reach statistical significance
Use of opioids was reduced in the capsaicin group
Capsaicin remains a potential treatment option in this often difficult disease

References

Samantha Wagner, Jason Hoppe, Matthew Zuckerman, Kerry Schwarz & Julie McLaughlin (2019) Efficacy and safety of topical capsaicin for cannabinoid hyperemesis syndrome in the emergency department, Clinical Toxicology, DOI: 10.1080/15563650.2019.1660783

Summarized by Jackson Roos, MS3 | Edited by Erik Verzemnieks, MD

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Author: Jared Scott, MD

Educational Pearls:

Differentiating symptomatic bradycardia from asymptomatic may be essential in determining workup and treatment
Airway, breath, circulation always hold true
Symptoms may include dizziness, syncope, or weakness
An EKG is essential in the majority of cases
Complete heart block can be a cause of symptomatic bradycardia and requires immediate attention
Complete heart block can be caused by drugs (beta-blockers, calcium channel blockers), Lyme disease, infiltrative disease, or degeneration of the conduction system

References:

Kusumoto FM, Schoenfeld MH, Barrett C, Edgerton JR, Ellenbogen KA, Gold MR, Goldschlager NF, Hamilton RM, Joglar JA, Kim RJ, Lee R, Marine JE, McLeod CJ, Oken KR, Patton KK, Pellegrini CN, Selzman KA, Thompson A, Varosy PD. 2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2019;74(7):e51. Epub 2018 Nov 6.

Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

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Author: Aaron Lessen, MD

Educational Pearls:

New data shows within 5 years of smoking cessation, the risk of cardiovascular disease becomes half of those who continue to smoke
After 10-15 years of cessation, cardiovascular disease rates return to rates seen in non-smokers.
Lung disease, COPD, and cancer rates do not decrease quite as rapidly, but do decrease
It’s important to remind patients of the long-term health benefits associated with smoking cessation when counseling them.

References

Duncan MS, Freiberg MS, Greevy RA, Kundu S, Vasan RS, Tindle HA. Association of Smoking Cessation With Subsequent Risk of Cardiovascular Disease. JAMA. 2019;322(7):642–650. doi:10.1001/jama.2019.10298

Summarized by Jackson Roos, MS3 | Edited by Erik Verzemnieks, MD

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Recorded remotely in the highest hospital in the world, Nick sits down to talk with Dr. Lisa Zwerdlinger, a small-town physician who's worn many different hats both in the hospital and her community.

Intro Music:

Backbay Lounge Kevin MacLeod (incompetech.com)
Licensed under Creative Commons: By Attribution 3.0 License
http://creativecommons.org/licenses/by/3.0/

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Author: Aaron Lessen, MD

Educational Pearls:

Previously, trials had shown promising evidence that vitamin C may improve mortality rates in patients with sepsis or septic shock.
A 2017 retrospective before-after study gave a “cocktail” of hydrocortisone, vitamin C, and thiamine to patients with severe sepsis or in septic shock and reported a decrease in mortality from 40% to 8%.
A 2020 randomized controlled trial demonstrated that giving patients hydrocortisone, vitamin C, and thiamine showed no benefits in improving sepsis outcomes.
Currently use of Vitamin C in sepsis and septic shock remains controversial due to lack of sufficient data

References

1) Marik PE, Khangoora V, Rivera R, Hooper MH, Catravas J. Hydrocortisone, Vitamin C, and Thiamine for the Treatment of Severe Sepsis and Septic Shock: A Retrospective Before-After Study. Chest. 2017;151(6):1229. Epub 2016 Dec 6.

2) Fujii T, Luethi N, Young PJ, et al. Effect of Vitamin C, Hydrocortisone, and Thiamine vs Hydrocortisone Alone on Time Alive and Free of Vasopressor Support Among Patients With Septic Shock: The VITAMINS Randomized Clinical Trial. JAMA. 2020;323(5):423–431. doi:10.1001/jama.2019.22176

Summarized by Jackson Roos, MS3 | Edited by Erik Verzemnieks, MD

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Author: Nick Tsipis, MD

Educational Pearls:

Aortic injury caused by blunt trauma is very rare
Chest x-ray findings might include widening of the mediastinum
Ligamentum arteriosum (remnant of the ductus arteriosus) tethers the aorta to the chest wall, potentially causing injury with abrupt decelerations and motion
XR lacks significant sensitivity (around 75%) to be utilized in many cases
CT angiogram (CTA) of the chest is typically the preferred test but comes with potential risks including radiation exposure
NEXUS Decision Instrument (NEXUS DI) is a scoring tool that may provide value in determining the need for additional imaging

References

Yu L, Baumann BM, Raja AS, Mower WR, Langdorf MI, Medak AJ, Anglin DR, Hendey GW, Nishijima D, Rodriguez RM. Blunt Traumatic Aortic Injury in the Pan-scan Era. Acad Emerg Med. 2019 Dec 7. doi: 10.1111/acem.13900.

Summarized and edited by Erik Verzemnieks, MD

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Non Epileptic Seizures (NES) is perhaps one of the most misunderstood and overlooked disorders that emergency medicine professionals encounter. Dr. Randi Libbon & Dr. Laura Strom, both experts on NES, explain the ongoing research surrounding the topic as well as how to best manage patients with NES in the emergency setting.

To learn more about Dr. Randi Libbon:

https://www.cudoctors.com/Find_A_Doctor/Profile/25375

To learn more about Dr. Laura Strom:

http://www.ucdenver.edu/academics/colleges/medicalschool/departments/neurology/Faculty/Pages/Strom.aspx

References & Further Reading:

[1] Baslet G, Seshadri A, Bermeo-Ovalle A, Willment K, Myers L. Psychogenic Non-epileptic Seizures: An Updated Primer. Psychosomatics. 2016;57(1):1-17. doi:10.1016/j.psym.2015.10.004

[2] Perez DL, LaFrance WC. Nonepileptic Seizures: An Updated Review. CNS Spectr. 2016;21(3):239-246. doi:10.1017/S109285291600002X

[3] Libbon R, Gadbaw J, Watson M, et al. The feasibility of a multidisciplinary group therapy clinic for the treatment of nonepileptic seizures. Epilepsy Behav. 2019;98:117-123. doi:10.1016/j.yebeh.2019.06.032

[4] Ding J-R, An D, Liao W, et al. Altered Functional and Structural Connectivity Networks in Psychogenic Non-Epileptic Seizures. PLoS ONE. 2013;8(5). doi:10.1371/journal.pone.0063850

[5] Allendorfer JB, Nenert R, Hernando KA, et al. FMRI response to acute psychological stress differentiates patients with psychogenic non-epileptic seizures from healthy controls – A biochemical and neuroimaging biomarker study. NeuroImage Clin. 2019;24:101967. doi:10.1016/j.nicl.2019.101967

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Author: Don Stader, MD

Educational Pearls:

Nasogastric tubes (NGT) are very uncomfortable for all those involved but some simple tricks and tips may help:
Topical lidocaine can be inserted into the nasal passage for local analgesia
Afrin may help shrink the mucosal tissue of the nasal turbinates as well
Molding the tube with cold/ice water can help - putting it in an ice bath with an endotracheal tube stylet will allow you to mold the tip to your preference

References

Lor YC, Shih PC, Chen HH, et al. The application of lidocaine to alleviate the discomfort of nasogastric tube insertion: A systematic review and meta-analysis. Medicine (Baltimore). 2018;97(5):e9746. doi:10.1097/MD.0000000000009746

https://www.acepnow.com/article/making-ng-tube-placement-less-horrendous/

https://www.aliem.com/trick-of-trade-making-ng-and-np-painless/

Summarized and edited by Erik Verzemnieks, MD

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Author: Aaron Lessen, MD

Educational Pearls:

Traditional technique of needle thoracostomy for tension penumothorax is along the 2nd intercostal space at the midclavicular line
Inserting a large angiocatheter along the 4th or 5th intercostal space at the mid-axillary line may provide a thinner area that is more easily identified, overcoming many of the obstacles of the traditional approach
The 10th Edition of ATLS now recommends this location as well
A finger thoracostomy, where a scalpel and then the finger are used to penetrate the pleural cavity at the same location, is another method to provide quick decompression of a traumatic tension pneumothorax, allowing a tube thoracostomy to be performed later

References

Laan DV, Vu TD, Thiels CA, et al. Chest wall thickness and decompression failure: A systematic review and meta-analysis comparing anatomic locations in needle thoracostomy. Injury. 2016;47(4):797–804. doi:10.1016/j.injury.2015.11.045

Inaba K, Branco BC, Eckstein M, Shatz DV, Martin MJ, Green DJ, Noguchi TT, Demetriades D. Optimal positioning for emergent needle thoracostomy: a cadaver-based study. J Trauma. 2011 Nov;71(5):1099-103; discussion 1103. doi: 10.1097/TA.0b013e31822d9618.

Summarized and edited by Erik Verzemnieks, MD

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EMM is proud to present the pilot episode of our new monthly series, “On the Streets”. This will be an informative podcast for all of our listeners, but this one was designed specifically for our EMS listeners.

Each month, we will consult medical experts on topics pertinent to prehospital care: Identifying a posterior circulation stroke in the field; Knowing when to do a 12-lead and what to look for; How to use capnography for a variety of datapoints; How to give an effective handoff report. And much much more...

On our first episode, we are proud to welcome long-time friend of EMM, now retired Emergency Physician and current Medical Director of the ACC EMS program, Dr. Michael Hunt. This episode focuses exclusively on the Do's and Don'ts of giving handoff report.

As we all know, knowledge and timing can make a world of difference when treating acutely ill patients. Like all of our content, we aim to equip you with the resources to forge your medical knowledge while keeping it relevant and time-efficient. Tune into “On the Streets” for real, raw and relevant EMS education.

Photo Credit: https://www.flickr.com/photos/sc-axman/2327963351/

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Contributor: Don Stader, MD

Educational Pearls:

Olanzapine (Zyprexa) is an atypical antipsychotic that can be used in a similar fashion to haloperidol for pain and nausea, including that with abdominal pain and headaches
Olanzapine can be administered as an oral disolving tablets, intramuscular or intravenous injection
Because Zyprexa is an atypical antipsychotic, it has a lower risk for tardive dyskinesia and akathisia
Olanzapine may cause transient rises in glucose and should be considered when contemplating use in a diabetic

References

Olanzapine for the prevention and treatment of cancer-related nausea and vomiting in adults.Sutherland A, Naessens K, Plugge E, Ware L, Head K, Burton MJ, Wee B. Cochrane Database Syst Rev. 2018;9:CD012555. Epub 2018 Sep 21.

Silberstein, S.D., Peres, M.F., Hopkins, M.M., Shechter, A.L., Young, W.B. and Rozen, T.D. (2002), Olanzapine in the Treatment of Refractory Migraine and Chronic Daily Headache. Headache: The Journal of Head and Face Pain, 42: 515-518. doi:10.1046/j.1526-4610.2002.02126.

Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Rachel Beham, PharmD

Educational Pearls:

Coricidin HBP Cough & Cold (dextromethorphan and chlorpheniramine) is one of the more commonly abused over-the-counter medications
Dextromethorphan, binds to multiple receptors, particularly at high doses
- Opioid receptors, causing respiratory depression, CNS depression
- NMDA receptors, causing agitation and hallucinations
- Serotonin-reuptake inhibition, which may lead to serotonin syndrome, especially when combined with other agents
Dextromethorphan also contains bromide, which when chronically abused can lead to bromism (behavioral changes, hallucinations, weight loss, and neurologic changes)
Chlorpheniramine is an antihistamine and can cause anticholinergic effects in overdose, such agitation, hyperthermia, and hallucinations
Acute treatment of Coricidin abuse is mostly supportive, which may include benzodiazepines, naloxone, dialysis, sodium bicarbonate, and physostigmine depending on the predominate toxidrome and symptoms present

References

Ritter D, Ouellette L, Sheets JD, Riley B, Judge B, Cook A, Houseman J, Jones JS. "Robo-tripping": Dextromethorphan toxicity and abuse. Am J Emerg Med. 2019 Nov 17. pii: S0735-6757(19)30655-2. doi: 10.1016/j.ajem.2019.10.001.

Bryner JK, Wang UK, Hui JW, Bedodo M, MacDougall C, Anderson IB. Dextromethorphan abuse in adolescence: an increasing trend: 1999-2004. Arch Pediatr Adolesc Med. 2006;160(12):1217–1222. doi:10.1001/archpedi.160.12.1217

Monks S, Yen M, Myers J. Bromism: An overlooked and elusive toxidrome from chronic dextromethorphan abuse. Am J Emerg Med. 2019 Nov 15:158491. doi: 10.1016/j.ajem.2019.158491.

Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Jared Scott, MD

Educational Pearls:

A distal 5th metacarpal neck fracture is often referred to as a “boxer’s fracture” and a common fracture encountered in the emergency department
Splinting with an ulnar gutter splint is the typical management of uncomplicated boxer’s fractures
A recent study randomized patients to buddy taping or ulnar gutter splint for uncomplicated Boxer’s fractures.
Similar functional and pain outcomes were found at follow-up, and those in the buddy taping group returned to work more quickly.
One limitation was nearly 20% of study patients were lost to follow up

Editor’s note: remember - this only applies to a true boxer’s fracture, which is a distal 5th metacarpal neck fracture, not just any 5th metacarpal shaft fracture

References

Richard Pellatt, Igor Fomin, Carli Pienaar, Randipsingh Bindra, Michael Thomas, Ezekiel Tan, Cindy Mervin, Ping Zhang, Gerben Keijzers. Is Buddy Taping as Effective as Plaster Immobilization for Adults With an Uncomplicated Neck of Fifth Metacarpal Fracture? A Randomized Controlled Trial, Annals of Emergency Medicine, Volume 74, Issue 1, 2019, Pages 88-97,

Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Don Stader, MD

Educational Pearls:

High-quality compressions are an essential, and probably one of the most important, part of cardiac arrest
Actual evidence for drugs in cardiac arrest included in ACLS are limited, including epinephrine, bicarbonate, amiodarone, etc.
Early defibrillation for ventricular tachycardia (VT) or ventricular fibrillation (VF) has a plethora of supporting evidence
Double-sequential defibrillation (nearly simultaneous defibrillation using 2 machines) may be considered for refractory dysrhythmias like VF
tPA during a cardiac arrest can be considered in the setting of massive PE (although the evidence supporting this practice is poor)
Ending a cardiac arrest resuscitation is a difficult decision and use of ultrasound may be helpful to assess for meaningful cardiac function/activity

References

Link MS, Berkow LC, Kudenchuk PJ, Halperin HR, Hess EP, Moitra VK, Neumar RW, O'Neil BJ, Paxton JH, Silvers SM, White RD, Yannopoulos D, Donnino MW . Part 7: Adult Advanced Cardiovascular Life Support: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015 Nov;132(18 Suppl 2):S444-64.

Wang Y, Wang M, Ni Y, Liang B, Liang Z. Can Systemic Thrombolysis Improve Prognosis of Cardiac Arrest Patients During Cardiopulmonary Resuscitation? A Systematic Review and Meta-Analysis.J Emerg Med. 2019;57(4):478. Epub 2019 Oct 5.

Eric Cortez, William Krebs, James Davis, David P. Keseg, Ashish R. Panchal. Use of double sequential external defibrillation for refractory ventricular fibrillation during out-of-hospital cardiac arrest. Resuscitation. Volume 108. 2016. Pages 82-86,

Atkinson PR, Beckett N, French J, Banerjee A, Fraser J, Lewis D. Does Point-of-care Ultrasound Use Impact Resuscitation Length, Rates of Intervention, and Clinical Outcomes During Cardiac Arrest? A Study from the Sonography in Hypotension and Cardiac Arrest in the Emergency Department (SHoC-ED) Investigators. Cureus. 2019;11(4):e4456. Published 2019 Apr 13. doi:10.7759/cureus.4456

Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

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Dr. Vivek Tayal of Carolinas Medical Center, a pioneer of using ultrasound in the emergency department, reflects on his role in establishing ultrasound use in emergency medicine and much more!

Ultrasound Program Management:

https://www.amazon.com/Ultrasound-Program-Management-Point-Care/dp/3319631411

Intro Music:

Backbay Lounge Kevin MacLeod (incompetech.com)
Licensed under Creative Commons: By Attribution 3.0 License
http://creativecommons.org/licenses/by/3.0/

Ultrasound Program Management: A Comprehensive Resource for Administrating Point-of-Care, Emergency, and Clinical Ultrasound

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Contributor: Dylan Luyten, MD

Educational Pearls:

Clear the nasal passages - have the patient, if stable, blow their nose to dislodge any clot that might be in the way
Searching for the source of bleeding can be tough. Majority of anterior bleeding is from Kesselbach’s plexus
Placing a clamp to provide direct pressure is a mainstay of treatment
Application of a topical agent, which may include lidocaine epinephrine tetracaine (LET), tranexamic acid (TXA), or oxymetazoline
Nasal packing with a nasal balloon or merocel may be necessary if bleeding persists
Posterior epistaxis can be potentially devastating - for all practical purposes are epistaxis that does not resolve with anterior packing
Interventional radiology can be a helpful consultant for controlling of posterior epistaxis, and may be just as or more helpful than ENT

References

Supriya M, Shakeel M, Veitch D, Ah-See K. Epistaxis: prospective evaluation of bleeding site and its impact on patient outcome. J Laryngol Otol. 2010;124(7):744-749.

Shargorodsky J, Bleier B, Holbrook E, et al. Outcomes analysis in epistaxis management: development of a therapeutic algorithm. Otolaryngol Head Neck Surg. 2013;149(3):390-398.

Singer A, Blanda M, Cronin K, et al. Comparison of nasal tampons for the treatment of epistaxis in the emergency department: a randomized controlled trial. Ann Emerg Med. 2005;45(2):134-139.

Womack JP, Kropa J Jimenez Stabile M. Epistaxis: Outpatient Management. Am Fam Physician. 2018 Aug 15;98(4):240-245.

Liu WH, Chen YH, Hsieh CT, Lin EY, Chung TT, Ju DT. Transarterial embolization in the management of life-threatening hemorrhage after maxillofacial trauma: a case report and review of literature. Am J Emerg Med. 2008 May;26(4):516.e3-5. doi: 10.1016/j.ajem.2007.07.036.

Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Aaron Lessen, MD

Educational Pearls:

Emergency department evaluation of falls, particularly in the elderly, should include an assessment of risk factors
Common causes of falls in the elderly include medications. Review medication list for sedating medications amongst others
Consult with your hospital physical therapist to discuss fall prevention techniques with the patient
One study has shown that a comprehensive interdisciplinary approach to geriatric falls in the ED can reduce return visits and hospital admissions.

References

Caplan GA, Williams AJ, Daly B, Abraham K. A randomized, controlled trial of comprehensive geriatric assessment and multidisciplinary intervention after discharge of elderly from the emergency department--the DEED II study. J Am Geriatr Soc. 2004;52(9):1417–23.

Albert M, Rui P, McCaig LF. Emergency department visits for injury and illness among adults aged 65 and over: United States, 2012-2013. NCHS Data Brief. 2017;(272):1–8.

Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

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In the first episode of this new series, the complexities of decision making capacity are discussed.

References and Further Reading:

[1] Appelbaum, P. S. (2007). Assessment of patients' competence to consent to treatment. New England Journal of Medicine, 357(18), 1834-1840.

[2] Etchells, E., Darzins, P., Silberfeld, M., Singer, P. A., McKenny, J., Naglie, G., ... & Strang, D. (1999). Assessment of patient capacity to consent to treatment. Journal of general internal medicine, 14(1), 27-34.

Joint Centre for Bioethics - Aid to Capacity Evaluation (ACE)

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Author: Michael Hunt, MD

Educational Pearls:

Organophosphate “nerve agents” were developed in the 1930’s
These agents have cholinergic effects, which can be remembered by the mnemonic “SLUDGE”
- Salivation
- Lacrimation
- Urination
- Defecation
- GI cramping
- Emesis
The “SLUDGE” toxidrome is mediated through the muscarinic acetylcholine receptors. Nerve agents also affect the nicotinic acetylcholine receptors, which leads to muscle paralysis
Death in these cases is from respiratory collapse due to secretions (bronchorrhea) and diaphragmatic paralysis
Treatment includes atropine to reduce secretions (often in incredibly high doses) and pralidoxime (2-PAM) to treat muscle paralysis
Benzodiazepines may be necessary for seizures

References

https://www.osha.gov/SLTC/emergencypreparedness/guides/nerve.html

Michael Eddleston Novel Clinical Toxicology and Pharmacology of Organophosphorus Insecticide Self-Poisoning. Annual Review of Pharmacology and Toxicology 2019 59:1, 341-360

Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Dylan Luyten, MD

Educational Pearls:

Insulin related hypoglycemia can vary from a brief transient effect from short-acting forms (i.e. insulin lispro) to prolonged from long acting (i.e. insulin glargine), and will require different treatment and/or observation
Of oral glycemic agents, sulfonylureas are a common culprit while metformin is rarely a cause
Sulfonylureas also deserve attention because in pediatric patients, they can be lethal even with a single ingestion, but also can cause severe hypoglycemia in adults
Hypoglycemia in non-diabetics usually occurs in the malnourished, or in those with liver or adrenal disease

References

Klein-Schwartz W, Stassinos GL, Isbister GK. Treatment of sulfonylurea and insulin overdose. Br J Clin Pharmacol. 2016;81(3):496–504. doi:10.1111/bcp.12822

Tourkmani AM, Alharbi TJ, Rsheed AMB, AlRasheed AN, AlBattal SM, Abdelhay O, Hassali MA, Alrasheedy AA, Al Harbi NG, Alqahtani A. Hypoglycemia in Type 2 Diabetes Mellitus patients: A review article. Diabetes Metab Syndr. 2018 Sep;12(5):791-794. doi: 10.1016/j.dsx.2018.04.004. Epub 2018 Apr 12.

Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Jared Scott, MD

Educational Pearls:

Superior vena cava (SVC) syndrome is caused by physical compression of the SVC and can present with facial swelling, upper extremity swelling, flushing, and parasthesias
Common causes of SVC syndrome include lung cancer, lymphoma, and thymoma
Keep SVC syndrome on the differential for all patients with facial or upper extremity swelling

References

The superior vena cava syndrome: clinical characteristics and evolving etiology. Rice TW, Rodriguez RM, Light RW. Medicine (Baltimore). 2006;85(1):37.

Diagnosis and management of superior vena cava syndrome. Markman M. Cleve Clin J Med. 1999;66(1):59.

Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Don Stader, MD

Educational Pearls:

The classic migraine cocktail includes: Reglan (or other dopamine antagonist), Benadryl, Toradol, Decadron, and IV fluids.
The most effective agent in the cocktail is a dopaminergic agent
Routine IV fluids have not shown efficacy
There is no evidence for pre-treatment of akathisia with diphenhydramine (Benadryl)
Decadron reduces rebound headache
Consider trigger point injections for those with migraine attributable to cervical neck pain.

References

Jones CW, Remboski LB, Freeze B, Braz VA, Gaughan JP, McLean SA..Intravenous Fluid for the Treatment of Emergency Department Patients With Migraine Headache: A Randomized Controlled Trial. Ann Emerg Med. 2019 Feb;73(2):150-156. doi: 10.1016/j.annemergmed.2018.09.004. Epub 2018 Oct 26.

Friedman BW, Cabral L, Adewunmi V, et al. Diphenhydramine as Adjuvant Therapy for Acute Migraine: An Emergency Department-Based Randomized Clinical Trial. Ann Emerg Med. 2016;67(1):32–39.e3. doi:10.1016/j.annemergmed.2015.07.495

Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Don Stader, MD

Educational Pearls:

The common causes of anion gap metabolic acidosis include (MUDPILES)
- Metformin, Methanol
- Uremia
- DKA
- Paraldehyde
- INH/Iron
- Lactate
- Ethylene Glycol
- Salicylate
Metformin is a very common drug used to treat type 2 diabetes, however in the right setting, it can cause a profound lactic acidosis. There is a very high mortality rate.
Treatment of metformin toxicity includes fluids, bicarb, and dialysis
Most commonly, metformin toxicity is in the setting of kidney injury or overdose.
Always consider acidosis in those with tachypnea!

References

Re-evaluation of a biguanide, metformin: mechanism of action and tolerability. Sirtori CR, Pasik C Pharmacol Res. 1994;30(3):187.

Bicarbonate haemodialysis as a treatment of metformin overdose.Heaney D, Majid A, Junor B. Nephrol Dial Transplant. 1997;12(5):1046.

Extracorporeal Treatment for Metformin Poisoning: Systematic Review and Recommendations From the Extracorporeal Treatments in Poisoning Workgroup.Calello DP, Liu KD, Wiegand TJ, Roberts DM, Lavergne V, Gosselin S, Hoffman RS, Nolin TD, Ghannoum M, Extracorporeal Treatments in Poisoning Workgroup Crit Care Med. 2015;43(8):1716.

Metformin accumulation: lactic acidosis and high plasmatic metformin levels in a retrospective case series of 66 patients on chronic therapy.Vecchio S, Giampreti A, Petrolini VM, Lonati D, Protti A, Papa P, Rognoni C, Valli A, Rocchi L, Rolandi L, Manzo L, Locatelli CA Clin Toxicol (Phila). 2014;52(2):129.

Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Aaron Lessen, MD

Educational Pearls:

Hemophilia is characterized by bleeding (A /B) A is is 8, B (chrstmas, 9)
Hemophilia refers to a group of bleeding disorders caused by a deficiency in a certain clotting factor. The two most common are hemophilia A (caused by a lack of factor VIII), and B (caused by a lack of factor 9)
Most cases are inherited in an X-linked recessive manner. Therefore, males are the most commonly affected. However, spontaneous cases do occur in all sexes.
People with hemophilia can present to the ED with a variety of bleeding complications including hemarthrosis, intracranial hemorrhage, and GI bleeds.
Treatment is guided by the type of hemophilia and the degree of bleeding, with the most severe cases being treated with replacement of 100% of that person’s deficient clotting factor.
Timely treatment improves outcomes, so consider empiric therapy in those with known hemophilia

References

Hemophilia A in the third millennium.Franchini M, Mannucci PM Blood Rev. 2013 Jul;27(4):179-84. Epub 2013 Jun 28.

Rheumatic manifestations of hematologic disorders.Aviña-Zubieta JA, Galindo-Rodriguez G, Lavalle C Curr Opin Rheumatol. 1998;10(1):86.

The molecular genetics of hemophilia: blood clotting factors VIII and IX.Lawn RM Cell. 1985;42(2):405.

Guidelines for the management of hemophilia.Srivastava A, Brewer AK, Mauser-Bunschoten EP, Key NS, Kitchen S, Llinas A, Ludlam CA, Mahlangu JN, Mulder K, Poon MC, Street A, Treatment Guidelines Working Group on Behalf of The World Federation Of Hemophilia Haemophilia. 2013 Jan;19(1):e1-47. Epub 2012 Jul 6.

Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Michael Hunt, MD

Educational Pearls:

Cirrhosis is the end stage of chronic structural damage to the liver. This is most commonly due to alcohol but other causes viral hepatitis and hepatotoxic drugs
Cirrhotic patients are very prone to GI bleeding and infections, partially due to the role the liver plays in producing immune and clotting factors
These patients can easily become “sick”. Use the shock index (heart rate / systolic blood pressure) as a rapid assessment of hemodynamic status. >0.7 is worrisome, >1 should prompt resuscitation.
Because cirrhotic patients are immunocompromised, do not rely on the presence of fever and peritonitis to diagnose spontaneous bacterial peritonitis (SBP), and have a low threshold to perform a diagnostic paracentesis
Polymorphonuclear (PMN) count > 250 in the ascitic fluid suggests SBP
With GI bleeding in cirrhotics, antibiotics have a mortality benefit, while PPIs and octreotide have limited benefit

References

Chinnock B, Hendey GW, Minnigan H, Butler J, Afarian H. Clinical impression and ascites appearance do not rule out bacterial peritonitis. J Emerg Med. 2013 May;44(5):903-9. doi: 10.1016/j.jemermed.2012.07.086. Epub 2013 Mar 7.

Pericleous M, Sarnowski A, Moore A, Fijten R, Zaman M. The clinical management of abdominal ascites, spontaneous bacterial peritonitis and hepatorenal syndrome: a review of current guidelines and recommendations. Eur J Gastroenterol Hepatol. 2016 Mar;28(3):e10-8. doi: 10.1097/MEG.0000000000000548.

Chavez-Tapia NC, Barrientos-Gutierrez T, Tellez-Avila F, Soares-Weiser K, Mendez-Sanchez N, Gluud C, Uribe M.Meta-analysis: antibiotic prophylaxis for cirrhotic patients with upper gastrointestinal bleeding - an updated Cochrane review. Aliment Pharmacol Ther. 2011 Sep;34(5):509-18. doi: 10.1111/j.1365-2036.2011.04746.x. Epub 2011 Jun 27.

Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Erik Verzemnieks, MD

Educational Pearls:

Knee dislocations are most common in high energy trauma, such as a motor vehicle accident
The knee may appear grossly normal on initial inspection since dislocations can spontaneously reduce - Look for such findings as hemarthrosis, instability, or ecchymosis, as clues to an occult dislocation.
Knee dislocations are often associated with damage to the popliteal artery that runs behind the knee.
Assess for pulse deficit on exam. If you are concerned - use the ankle-brachial index (normal >0.9). If the ABI is abnormal, evaluate with CT angiogram and a vascular surgery consult.

References

Mills WJ, Barei DP, McNair P. The value of the ankle-brachial index for diagnosing arterial injury after knee dislocation: a prospective study. J Trauma. 2004 Jun;56(6):1261-5.

Steele HL, Singh A. Vascular injury after occult knee dislocation presenting as compartment syndrome. J Emerg Med 2012; 42:271.

Sillanpää PJ, Kannus P, Niemi ST, et al. Incidence of knee dislocation and concomitant vascular injury requiring surgery: a nationwide study. J Trauma Acute Care Surg 2014; 76:715.

Summarized and written by myself

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Contributor: Charleen Melton, PharmD

Educational Pearls:

Desmopressin (DDAVP) is an analogue of anti-diuretic hormone (ADH) that has been used for the treatment of intracranial hemorrhage. It works by increasing the release of Von Willebrand factor, helping to stabilize clots.
The use of DDAVP for intracranial hemorrhage in patients on antiplatelet agents (mainly Aspirin and Plavix) was recently reviewed
In this retrospective review, they found an 88% decreased likelihood of hemorrhage expansion, in those who received DDAVP, compared to those who did not. Furthermore, they found no significant increase in adverse effects like hyponatremia or thrombosis
However, no difference in mortality or neurological status was found
DDAVP for intracranial hemorrhage in the setting of antiplatelet agents may be safe and reduce the expansion of intracranial bleeds but not change important patient outcomes

References

Feldman EA et al. Retrospective assessment of desmopressin effectiveness and safety in patients with antiplatelet-associated intracranial hemorrhage. Crit Care Med 2019 Sep 24; [e-pub]

Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Jared Scott, MD

Educational Pearls:

The ED is full of painful procedures. One of the most commonly dreaded procedures is nasal packing for epistaxis, as it is quite uncomfortable for the patient.
A recent study compared TXA with compression, saline with compression, and traditional nasal packing for the treatment of epistaxis.
Hemostasis was achieved in 91% with TXA and compression, 93% with nasal packing, and 71% with saline and compression. There was no statistically significant difference between the packing and TXA groups.
Furthermore, there was no difference in rates of rebleeding between the TXA and packing groups. However, 15% of nasal packing patients demanded removal of the packing due to pain.
Consider TXA (on gauze or atomized) for your next patient with epistaxis!

References

Akkan, Sedat et al.. Evaluating Effectiveness of Nasal Compression With Tranexamic Acid Compared With Simple Nasal Compression and Merocel Packing: A Randomized Controlled Trial. Annals of Emergency Medicine, Volume 74, Issue 1, 72 - 78 Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Sue Chilton, MD

Educational Pearls:

More intracardiac devices and injection drug abuse are thought to be increasing incidence of endocarditis
Classic signs of endocarditis have included: Osler nodes (painful hemorrhagic lesions on hands and feet), Janeway lesions (painless hemorrhagic lesions on the hands and feet), and splinter hemorrhages in the nail beds
Other classic findings like fever and murmur are variable
More non-specific symptoms can include flu-like symptoms
Patients who inject drugs are at higher risk for this diagnosis

References

Pant S, Patel NJ, Deshmukh A, Golwala H, Patel N, Badheka A, Hirsch GA, Mehta JL Trends in infective endocarditis incidence, microbiology, and valve replacement in the United States from 2000 to 2011. J Am Coll Cardiol. 2015;65(19):2070.

Infective endocarditis. Cahill TJ, Prendergast BD Lancet. 2016;387(10021):882. Epub 2015 Sep 1.

Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Don Stader, MD

Educational Pearls:

It can be difficult to distinguish between central and peripheral causes of vertigo. Cerebellar stroke should be considered with any dizzy patient.
Signs and symptoms that suggest stroke as the cause of vertigo include: ataxia, cranial nerve deficits, and rapid onset of symptoms
When cerebellar stroke is being considered, MRI is the imaging modality of choice since CT does not adequately visualize the posterior fossa.

References

Kim J, Lee H. Vertigo due to posterior circulation stroke. Semin Neurol. 2013 Jul;33(3):179-84. doi: 10.1055/s-0033-1354600. Epub 2013 Sep 21.

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Husband and wife Pete and Katie Bakes, both emergency physicians in the Denver-Metro area, reflect on their upbringings, the many lessons learned over their twenty year careers, and how they've evolved as physicians and as a couple in this very special episode of UnfilterED.

Time Stamps:

00:25 - Intros

03:05 - How did you two meet?

08:20 - (P) How have you seen Katie develop and change over the course of her medical career?

12:00 - (K) As a young woman, how did you balance your professional aspirations with your desire to start a family?

17:04 - (K) How have you seen Pete develop and change over the course of his medical career?

21:41 - Fostering and maintaining empathy over the course of a medical career

33:55 - How has medicine impacted the way you raise your children?

38:55 - Pete's experience as a 1st generation American

53:04 - How medicine has shaped Katie's faith and spirituality

1:00:24 - What is the purpose of suffering?

1:05:02 - Community vs. Academic medicine

1:09:40 - "The Award Winning Dr. Bakes"

1:12:40 - Extra-Clinical Pursuits

Intro Music:

Backbay Lounge Kevin MacLeod (incompetech.com)
Licensed under Creative Commons: By Attribution 3.0 License
http://creativecommons.org/licenses/by/3.0/

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Contributor: John Winkler, MD

Educational Pearls:

Vaping-related lung injury initially presents with flu-like symptoms and can progress to respiratory failure requiring aggressive resuscitation including ECMO
It is thought to be related to the contents of homemade vaping fluid, mostly in THC-containing products (“brands” include DankVapes, PaxPen)
Ask patients with vague constitutional or respiratory symptoms about their vape use

References

What are the respiratory effects of e-cigarettes? Gotts JE, Jordt SE, McConnell R, Tarran R BMJ. 2019;366:l5275. Epub 2019 Sep 30.

Pulmonary Illness Related to E-Cigarette Use in Illinois and Wisconsin - Preliminary Report.Layden JE, Ghinai I, Pray I, Kimball A, Layer M, Tenforde M, Navon L, Hoots B, Salvatore PP, Elderbrook M, Haupt T, Kanne J, Patel MT, Saathoff-Huber L, King BA, Schier JG, Mikosz CA, Meiman J N Engl J Med. 2019;

Vaping-Associated Acute Lung Injury: A Case Series. Triantafyllou GA, Tiberio PJ, Zou RH, Lamberty PE, Lynch MJ, Kreit JW, Gladwin MT, Morris A, Chiarchiaro J. Am J Respir Crit Care Med. 2019;

Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

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Author: Jared Scott, MD

Educational Pearls:

A hyphema is blood in the anterior chamber of the eye, typically caused by trauma
While there is a spectrum of disease, blurred vision and eye pain are common presenting complaints after direct trauma to the eye
Hyphema are graded between Grade 1 and Grade 5, depending on the amount of blood in the anterior chamber. Higher grades are associated with worse outcomes and more complications
Other important diagnoses to consider include globe rupture and retrobulbar hematoma
Complications of a hyphema can include glaucoma and vision loss

References

Brandt MT, Haug RH.Traumatic hyphema: a comprehensive review. J Oral Maxillofac Surg. 2001 Dec;59(12):1462-70.

Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Peter Bakes, MD

Educational Pearls:

Peri-arrest patients present a particular challenge to ED providers, as the differential is broad and time is critical
The differential for near cardiac arrest includes the “H’s and T’s”, just as in true cardiac arrest
The 6 H’s include: hypoxia, hypo/hyperkalemia, hypovolemia (including shock states), hydrogen (acidosis), hypothermia
The 6 T’s include: tension pneumothorax, cardiac tamponade, thrombus (PE/MI), toxins, trauma
Use your history skills to narrow down this list (i.e renal failure leads to hyperkalemia, trauma leads to tension pneumothorax or tamponade)

Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

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From DU's 1st annual Colorado Behavioral Health and Wellness Summit:

Contributor:

Michael Miller, Strategic Initiatives Coordinator, Jefferson County Public Health

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From DU's 1st annual Colorado Behavioral Health and Wellness Summit:

Contributors: Judith Shlay, MD, MSPH, Associate Director, Denver Public Health, and Brooke Bender, MPH, Center for Addiction Medicine Planner, Denver Health

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From DU's 1st annual Colorado Behavioral Health and Wellness Summit:

Contributor: Christopher Urbina, MD, MPH, Colorado Consortium for Prescription Drug Abuse Prevention

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From DU's 1st annual Colorado Behavioral Health and Wellness Summit:

Contributor:

Jason Vitello, MSW, Behavioral Health Coordinator, Denver Public Health/CPHA

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From DU's 1st annual Colorado Behavioral Health and Wellness Summit:

Contributors: Sarah Davidon, EdD, Director of Research & Child and Adolescent Strategy, Mental Health Colorado, and Sarah Younggren, LCSW, Child & Adolescent Specialist, Mental Health Colorado

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From DU's 1st annual Colorado Behavioral Health and Wellness Summit:

Contributor: Carl Clark, MD, President & Chief Executive Officer, Mental Health Center of Denver

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From DU's 1st annual Colorado Behavioral Health and Wellness Summit:

Contributor:

Karen Prestia, MBA, Director, Marketing & Communications, Mental Health Center of Denver

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From DU's 1st annual Colorado Behavioral Health and Wellness Summit:

Contributors:

Allison Miller, LCSW, LAC, Program Manager of Child and Family Outpatient Services, Mental Health Center of Denver, and Jon Roberts, LCSW, CAC II, Licensed Mental Health Therapist, Mental Health Center of Denver

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From DU's 1st annual Colorado Behavioral Health and Wellness Summit:

Contributors: Tracy Vozar, Ph.D., Director of the Infant and Early Childhood Mental Health Specialty, and Jennifer M. Tippett, Psy.D., Director of the Substance Use Disorder Specialty, both at the University of Denver’s Graduate School for Professional Psychology

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From DU's 1st annual Colorado Behavioral Health and Wellness Summit:

Contributors:

Marion Rorke, MPH, Substance Use Resource Coordinator, City and County of Denver, and Maggie Kauffman, MPH, Health Equity Data Analyst, City and County of Denver, and Jean Finn, RN, Substance Misuse Manager, City and County of Denver

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From DU's 1st annual Colorado Behavioral Health and Wellness Summit:

Contributors:

Lesley Brooks, MD, Chief Medical Officer, Sunrise Community Health Center; Medical Director – Quality, North Colorado Health Alliance, and Heather Ihrig, RN, CO-SLAW Program Director, North Colorado Health Alliance, and Meredith Silverstein, PhD, Sr. Research Associate, Butler Institute for Families, Graduate School of Social Work, University of Denver, and Kali Jefferson, MSW, Research Assistant, Butler Institute for Families, Graduate School of Social Work, University of Denver

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From DU's 1st annual Colorado Behavioral Health and Wellness Summit:

Contributor: Khara Croswaite Brindle, MA, LPC, ACS, Croswaite Counseling, PLLC

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From DU's 1st annual Colorado Behavioral Health and Wellness Summit:

Contributor: Steven Wright, MD, Colorado Consortium for Prescription Drug Abuse Prevention

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Contributor: John Winkler

Educational Pearls:

There is increasing resistance to antimalarial drugs, especially in P. falciparum. This trend started with chloroquine, but is now spreading to the other first-line drugs.
Resistant strains have been identified in Cambodia and Thailand
220 million people were infected last year
The best treatment of malaria is prevention from bites - DEET and permethrin are typical effective options.
Permethrin may be applied to clothing items before travel, and will last through 6-8 wash cycles.
While malaria is rare in the US, it should be considered in those having recently travelled

References

Hamilton WL, Amato R, van der Pluijm RW, et al. Evolution and expansion of multidrug-resistant malaria in southeast Asia: a genomic epidemiology study. Lancet Infect Dis. 2019;19(9):943–951. doi:10.1016/S1473-3099(19)30392-5

Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Jared Scott, MD

Educational Pearls

In a 4 yr period at 2 hospital systems, unprofessional behavior of surgeons was monitored via a complaint system. Number of complaints was compared with surgical complications.
In 13000 patients over this period, the number of surgical complications was found to vary with the number of complaints. Surgeons with with zero complaints had a 10% complication rate, 1-3 complaints had a 14% rate, and those with >4 and an 11.9% rate.
There was statistical significance that persisted after adjustment for a variety of patient factors
It never hurts to be professional!

References

Cooper WO, Spain DA, Guillamondegui O, et al. Association of Coworker Reports About Unprofessional Behavior by Surgeons With Surgical Complications in Their Patients. JAMA Surg. 2019;154(9):828–834. doi:https://doi.org/10.1001/jamasurg.2019.1738

Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Dylan Luyten, MD

Educational Pearls:

Bag-valve masks (BVM) typically have a port to connect O2 to. Unfortunately room air becomes entrained in the mask, reducing the FiO2 delivered to the patient. This can be overcome by using a PEEP (positive end-expiratory pressure) valve on the BMV
PEEP valves function by keeping alveoli open in the lungs at the end of expiration. This increases the oxygen diffusing ability of the lungs, keeping patients’ oxygen saturations higher.
Patients who are critically ill can become quickly hypoxic after RSI meds due to reduced functional residual lung capacity - an issue that can be overcome with a PEEP valve
PEEP also will reduce work of breathing in COPD and CHF patients

References

Bucher JT, Cooper JS. Bag Mask Ventilation (Bag Valve Mask, BVM) [Updated 2019 Jul 30]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441924/

Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

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Lisa Raville and Dr. Josh Blum, two pioneers of harm reduction in Denver, discuss the addiction crisis, the current state of harm reduction and how it will evolve in the future.

Intro Music:

Backbay Lounge Kevin MacLeod (incompetech.com)
Licensed under Creative Commons: By Attribution 3.0 License
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Contributor: Erik Verzemnieks, MD

Educational Pearls:

Important to realize complications can occur in the post-opioid overdose patient regardless of cause
Narcan administration has been associated with non-cardiogenic pulmonary edema, although the mechanism of this is not quite known
Symptoms include progressive shortness of breath and hypoxia.
Treatment is with positive-pressure ventilation and diuresis, similar to cardiogenic causes
Though rare, it would appear this typically resolves with treatment

Reference

Jiwa N, Sheth H, Silverman R. Naloxone-Induced Non-Cardiogenic Pulmonary Edema: A Case Report. Drug Saf Case Rep. 2018;5(1):20. Published 2018 May 10. doi:10.1007/s40800-018-0088-x

All by Erik Verzemnieks, MD

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Contributor: Jared Scott, MD

Educational Pearls:

Non-accidental trauma (NAT) to children is commonly missed by medical providers
Try to remember TEN-4-FACES as a useful aide for concerning patterns that may reflect NAT:
- Torso, ears, neck and any bruising in child 4 months or longer
- Frenulum, angle of the mandible, cheek, eyes, sclera

References

Pierce MC, Magana JN, Kaczor K, Lorenz DJ, Meyers G, Bennett BL, Kanegaye JT. The Prevalence of Bruising Among Infants in Pediatric Emergency Departments. Ann Emerg Med. 2016 Jan;67(1):1-8. PMID: 26233923.

Pierce MC, Kaczor K, Aldridge S, O’Flynn J, Lorenz DJ. Bruising characteristics discriminating physical child abuse from accidental trauma. Pediatrics. 2010 Jan;125(1):67-74. PMID: 19969620.

Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

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Author: Don Stader, MD

Educational Pearls:

Suboxone, methadone, and naltrexone are commonly used as treatments for opiate use disorder.
Naltrexone is a full mu-opiate receptor antagonist, making acute pain control difficult in patients taking it.
Options for pain control in patients on naltrexone include nerve blocks, NSAIDS, ketamine, and high doses of opiates.
Of the opiates, Dilaudid (hydromorphone) has the highest affinity for mu-opiate receptors, and will be the most effective.

References

Vickers AP, Jolly A. Naltrexone and problems in pain management. BMJ. 2006;332(7534):132–133. doi:10.1136/bmj.332.7534.132

Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

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Author: John Winkler, MD

Educational Pearls:

The plague (black death) is caused by the Yersinia Pestis bacteria. This bacteria is spread by fleas and carried by rats. It is very contagious and only needs ~ 100 bacteria to cause an infection.
The pulmonary form presents with cough, fever, night sweats, hemoptysis and has a near 100% fatality rate if not treated in the first day of symptoms
The bubonic form causes buboes, which are necrotic, purulent lymph nodes that can lead to sepsis.
Prairie dogs are a common carrier in modern times

References

https://www.cdc.gov/plague/index.html

Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

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Author: Don Stader, MD

Educational Pearls:

Abstinence from substances such as tobacco or alcohol are effective strategies to achieve long term sobriety
However, abstinence is not an effective strategy for achieving sobriety with opiate use disorder (OUD)
Up to 90% of those who use an abstinence-only strategy for OUD will relapse within a month.
Attending a rehabilitation facility increases mortality in those with OUD due to decreased tolerance and higher rates of overdose.
Medication-assisted therapy (MAT) with naltrexone, buprenorphine or methadone for OUD is supported by evidence, and is the preferred method for achieving remission

References

Nielsen S, Larance B, Degenhardt L, Gowing L, Kehler C, Lintzeris N. Opioid agonist treatment for pharmaceutical opioid dependent people. Cochrane Database Syst Rev. 2016 May 9;(5):CD011117. doi: 10.1002/14651858.CD011117.pub2. Review. PubMed PMID: 27157143.

Medications for Opioid Use Disorder Save Lives. 2019 Mar 30;. doi: 10.17226/25310. Review. PubMed PMID: 30896911.

Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

Music credit: “Smooth Lovin” by Kevin MacLoed (incompetech.com). Licensed under Creative Commons By Attribution 3.0 License. http://creativecommons.org/licenses/by/3.0/

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Author: Rachel Beham, PharmD

Educational Pearls:

There are currently many Ebola vaccines that are being studied, and one (recombinant VZV-Ebola vaccine) is currently being used in Africa. This vaccine has so far shown good efficacy in reducing Ebola infections and mortality from Ebola in those who do become infected.
There are antibody-based treatments that are currently under investigation for the treatment of Ebola. They have been well tolerated in phase 1 trials and show some promise of efficacy.

References

Shcheblyakov D et. al. Development and characterization of two GP-specific monoclonal antibodies, which synergistically protect non-human primates against Ebola lethal infection. Antiviral Res. 2019 Oct 5:104617. doi: 10.1016/j.antiviral.2019.104617. [Epub ahead of print]

Fries L et. al. A Randomized, Blinded, Dose-Ranging Trial of an Ebola Virus Glycoprotein (EBOV GP) Nanoparticle Vaccine with Matrix-M™ Adjuvant in Healthy Adults. J Infect Dis. 2019 Oct 11. pii: jiz518. doi: 10.1093/infdis/jiz518. [Epub ahead of print]

Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

Music credit: “Smooth Lovin” by Kevin MacLoed (incompetech.com). Licensed under Creative Commons By Attribution 3.0 License. http://creativecommons.org/licenses/by/3.0/

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Author: John Winkler, MD

Educational Pearls:

There is a new outbreak of Ebola in The Congo. This is likely due to civil war and rebel attacks on healthcare workers in the area.
Ebola is now spreading from the Congo into neighboring Uganda, but vaccination efforts are staving off the spread across the border
Early symptoms of Ebola are similar to the flu
Spread occurs through close contact with bodily fluids. Proper PPE is required when treating patients with suspected ebola

References

https://wwwnc.cdc.gov/travel/notices/alert/ebola-democratic-republic-of-the-congo

https://www.cdc.gov/vhf/ebola/symptoms/index.html

Malvy D, McElroy AK, de Clerck H, Günther S, van Griensven J. Ebola virus disease. Lancet. 2019 Mar 2;393(10174):936-948. doi: 10.1016/S0140-6736(18)33132-5. Epub 2019 Feb 15.

Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

Music credit: “Smooth Lovin” by Kevin MacLoed (incompetech.com). Licensed under Creative Commons By Attribution 3.0 License. http://creativecommons.org/licenses/by/3.0/

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Contributor: Jared Scott, MD

Educational Pearls:

Sleep deprivation and disturbed sleep cycles increases the risk of many acute and chronic medical issues such as motor vehicle accidents, diabetes, cardiovascular disease, psychiatric disease, and shift work sleep disorder (difficulty sleeping, fatigue, interference with daily activities)
Stages of sleep
- Stage 1: 5-10 minutes (light sleep, may not recognize).
- Stage 2: Spindle waves, mostly unstudied
- Stage 3: Restorative sleep
- Stage 4 (REM): Paralysis, memory consolidation
One sleep cycle takes about 120 minutes
Light is critical for regulating sleep cycles. Exposure to light (especially blue light) inhibits melatonin release from the pineal gland, which influences the suprachiasmatic nucleus (master sleep controller in the brain)
How can you optimize sleep before your night shifts? On the day of your first night shift, sleep until you wake naturally, then take a 90min nap between 2-6pm before you start your shift
Sleepy on shift? A 5 minute nap is helpful to increase your attention span and thinking. A 30 minute nap is good for achieving more restorative sleep. Naps between 30 and 60 minutes are not recommended due to increased sleep inertia
How do I optimize myself on shift? Keep active and take a 5 minute nap if needed. Do not use caffeine within the last 4 hours of your shift (it will interfere with your sleep!). More than 200-300mg a caffeine are not recommended, if you do use it.Use built in checks to reduce errors, as errors are increased during night shifts!
Leaving your shift, reduce exposure to light by wearing sunglasses, avoid screens and alcohol, and get to sleep ASAP
Got things to do? Remember that some sleep is better than none!

References

Kuhn G et al. Circadian rhythm, shift work, and emergency medicine. Ann Emerg Med. (2001) 37:1, 88-98.

McKenna Helen, Wilkes Matt. Optimising sleep for night shifts BMJ (2018). 360:j5637

Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

Music credit: “Smooth Lovin” by Kevin MacLoed (incompetech.com). Licensed under Creative Commons By Attribution 3.0 License. http://creativecommons.org/licenses/by/3.0/

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Contributor: Chris Holmes, MD

Educational Pearls:

In ancient Egypt, pregnant women would urinate over barley and wheat seeds to help determine the sex of thier fetus, as well as if they were pregnant. Amazingly, this has 70% accuracy (!!) for determining pregnancy (not sex).
Piss Prophets in the middle ages would examine urine for changes in color to determine if a woman was pregnant or not.
In the early 1900’s, after discovering progesterone, and it’s associated with pregnancy, the A-Z pregnancy urine test was created. Urine was collected from the woman of interest and injected into an immature rat or rabbit. If the urine put the animal into heat (due to the presence of progesterone in the urine), this was interpreted as a positive test.

References

https://history.nih.gov/exhibits/thinblueline/timeline.html

Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

Music credit: “Smooth Lovin” by Kevin MacLoed (incompetech.com). Licensed under Creative Commons By Attribution 3.0 License. http://creativecommons.org/licenses/by/3.0/

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Contributor: Nick Tsipis, MD

Educational Pearls:

Communication proves time and time again to be most helpful in preventing surprises after patient admission
Frequent re-evaluations and repeat vital signs can be important to evaluating a patient’s risk for deterioration once admitted as well as selecting the proper level of care at admission
Broad categories of patients who most commonly have a change in condition after admission are septic patients and those admitted for respiratory complaints

References

Kennedy M, Joyce N, Howell MD, et al. Identifying infected ED patients admitted to the hospital ward at risk of clinical deterioration and intensive care unit transfer. Acad Emerg Med. 2010;17(10):1080–1085.

Caterino JM, Jalbuena T, Bogucki B. Predictors of acute decompensation after admission in ED patients with sepsis. Am J Emerg Med. 2010;28(5):631–636. doi: 10.1016/j.ajem.2009.04.020.

Wardi G, Wali AR, Villar J, et al. Unexpected intensive care transfer of admitted patients with severe sepsis. J Intensive Care. 2017;5:43. Published 2017 Jul 12. doi:10.1186/s40560-017-0239-7

Boerma LM, Reijners EPJ, Hessels RAPA, V Hooft MAA. Risk factors for unplanned transfer to the intensive care unit after emergency department admission. Am J Emerg Med. 2017;35(8):1154–1158.

Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

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On the first installment of this new series, Dr. Michael Hunt shares stories, lessons and advice as he reflects on his 35 year career as an emergency physician.

Intro Music:

Backbay Lounge Kevin MacLeod (incompetech.com)
Licensed under Creative Commons: By Attribution 3.0 License
http://creativecommons.org/licenses/by/3.0/

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Contributor: Don Stader, MD

Educational Pearls:

Seymour fracture is an eponym for a Salter-Harris I/II fracture of the distal phalanx of the finger or toe in children, associated with a nailbed inury
These may present and subtle as a subungal hematoma with a fracture on x-ray but carry a significant risk of complications
While in adults a hammer-finger deformity indicates an avulsion injury of the extensor tendon, in children it can indicate disruption of the growth plate. This is coupled with disruption of the proximal nail bed.
Because these fractures affect the growth plate, they can lead to arrest of the growth plate or chronic osteomyelitis
These injuries require orthopedic consultation for possible debridement and fixation

Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Don Stader, MD

Educational Pearls:

Only 10% of patients receiving antibiotics for strep throat actually have the diesease
Treatment of strep with antibiotics only slightly reduces the duration of illness. Most studies say the reduction is between 16 and 24 hours
Antibiotic treatment may reduce complications such as peritonsilar abscess and otitis media but antibiotics also increase the risk of diarrhea and yeast infection
Rheumatic fever is caused by a specific serotype of strep that is no longer prevalent in the United States, so treating strep throat likely has no effect on preventing this complication

References

Anand Swaminathan, "Do Patients with Strep Throat Need to Be Treated with Antibiotics?", REBEL EM blog, January 5, 2015. Available at: https://rebelem.com/patients-strep-throat-need-treated-antibiotics/.

Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

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...coming October 2019

Music:

emotional by Barradeen | https://soundcloud.com/barradeen
Music promoted by https://www.free-stock-music.com
Creative Commons Attribution-ShareAlike 3.0 Unported
https://creativecommons.org/licenses/by-sa/3.0/deed.en_US

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Contributor: Don Stader, MD

Educational Pearls:

The eye is surrounded by relatively inflexible tissues such as the bone of the orbit and the fibrous tissue of the eye. This makes it relatively susceptible to damage from outside compression, which is most common from trauma. This phenomenon is called ocular compartment syndrome (OCS)
Look for OCS when patients have face, head or direct eye trauma
OCS will present with a swollen, bulging eye associated with pain and blurry vision. Typically diagnosed with an elevated intraocular pressure (>40)
OCS needs to be treated with a lateral canthotomy to help expand the area around the eye, reducing the pressure.
Can’t see the eye due to swelling? Use paper clips to make eyelid retractors!

References

Lima V, Burt B, Leibovitch I, Prabhakaran V, Goldberg RA, Selva D. Orbital compartment syndrome: the ophthalmic surgical emergency. Surv Ophthalmol. 2009 Jul-Aug;54(4):441-9. doi: 10.1016/j.survophthal.2009.04.005. Review. PubMed PMID: 19539832.

Rowh AD, Ufberg JW, Chan TC, Vilke GM, Harrigan RA. Lateral canthotomy and cantholysis: emergency management of orbital compartment syndrome. J Emerg Med. 2015 Mar;48(3):325-30. doi: 10.1016/j.jemermed.2014.11.002. Epub 2014 Dec 16. PubMed PMID: 25524455.

Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Dylan Luyten, MD

Educational Pearls:

Those that are hypokalemic are often hypomagnesemic, and should receive magnesium (Mg) supplementation if repleting potassium
Mg levels are typically not necessary - if someone is suspect to have hypomagnesemia, just given them Mg
Mg increases the AV node refractory period and therefore may be helpful as an adjunct to those in atrial fibrillation with a rapid ventricular response
Mg is the preferred treatment for seizure prophylaxis in preeclampsia. All patients with suspected preeclampsia should get 4g Mg IV over 20 min
Mg may reduce hospital admissions in those with severe asthma, though it has not shown to have mortality or other benefits in acute exacerbations

Editor’s note: and we didn’t even touch on magnesium in headaches

References

Huang CL, Kuo E. Mechanism of hypokalemia in magnesium deficiency. J Am Soc Nephrol. 2007 Oct;18(10):2649-52. doi: 10.1681/ASN.2007070792. Epub 2007 Sep 5. Review. PubMed PMID: 17804670.

Ismail Y, Ismail AA, Ismail AA. The underestimated problem of using serum magnesium measurements to exclude magnesium deficiency in adults; a health warning is needed for "normal" results. Clin Chem Lab Med. 2010 Mar;48(3):323-7. doi: 10.1515/CCLM.2010.077. PubMed PMID: 20170394.

Heitz C, Morgenstern J, Bond C, Milne WK. Hot Off the Press: Low-dose Magnesium Sulfate Versus High Dose in the Early Management of Rapid Atrial Fibrillation: Randomized Controlled Double-blind Study. Acad Emerg Med. 2019 Sep;26(9):1093-1095. doi: 10.1111/acem.13720. Epub 2019 Mar 18. PubMed PMID: 30815951.

Levy Z, Slesinger TL. Does intravenous magnesium reduce the need for hospital admission among adult patients with acute asthma exacerbations?. Ann Emerg Med.2015 Jun;65(6):702-3. doi: 10.1016/j.annemergmed.2014.07.019. Epub 2014 Aug 13. PubMed PMID: 25128007.

Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Aaron Lessen, MD

Educational Pearls:

Patients with psychiatric complaints are often complicated to disposition from the main ED, and many will require inpatient psychiatric stays
Some health systems have dedicated psychiatric ED’s that are specialized in taking care of these patients
For example, in Oakland, CA, EMS are permitted to “clear” a patient for transport to a psych-only facility.
5-year retrospective study of this system showed 40% of psych patients were cleared by EMS for transfer directly to a psychiatric facility
- Only 0.3% of these patients “bounced back" and required an emergency department visit
This technique could be used elsewhere to provide the most appropriate care for psych patients

References

Trivedi TK, Glenn M, Hern G, Schriger DL, Sporer KA. Emergency Medical Services Use Among Patients Receiving Involuntary Psychiatric Holds and the Safety of an Out-of-Hospital Screening Protocol to "Medically Clear" Psychiatric Emergencies in the Field, 2011 to 2016. Ann Emerg Med. 2019 Jan;73(1):42-51. doi: 10.1016/j.annemergmed.2018.08.422. Epub 2018 Sep 28. PubMed PMID: 30274946.

Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

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Author: Jared Scott, MD

Educational Pearls:

Study from Hennepin County EM studied the efficacy of different drugs for agitation, which included 737 patients
Most patients in this study were male and surprise drunk
Compared doses of common sedatives with primary outcome of sedation at 15 minutes (all intramuscular)
- haloperidol 5 mg
- ziprasidone 20 mg
- olanzapine 10 mg
- midazolam 5 mg
- haloperidol 10 mg with the main outcome of agitation at 15 minutes
Intramuscular midazolam resulted in the lowest level of agitation at 15 minutes, followed by ziprasidone. There were no differences in adverse effects.

References

Klein LR, Driver BE, Miner JR, Martel ML, Hessel M, Collins JD, Horton GB, Fagerstrom E, Satpathy R, Cole JB. Intramuscular Midazolam, Olanzapine, Ziprasidone, or Haloperidol for Treating Acute Agitation in the Emergency Department. Ann Emerg Med. 2018 Oct;72(4):374-385. doi: 10.1016/j.annemergmed.2018.04.027. Epub 2018 Jun 7. PubMed PMID: 29885904.

Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

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Treatment with buprenorphine is easier, less time consuming and far more effective for management of opioid withdrawal and OUD than standard care with clonidine, IVF, haldol and other symptomatic therapies.
Induction with buprenorphine is easy, requires no IV or labs, and is usually accomplished in 1-2 hours. It requires a chair, not a hospital bed.
To identify patients who are candidates, be sure they’re in sufficient opioid withdrawal using clinical impression or the COWS scale, obtain a history of type of opioid use and time of last use and any prior experience with buprenorphine, and confirm patient consent for buprenorphine induction.
Precipitated withdrawal is a risk with induction if a patient is not sufficiently in withdrawal. Consensus on the treatment of precipitated withdrawal will require further study. Some protocols recommend stopping buprenorphine if withdrawal symptoms worsen, while others recommend treatment with additional doses of buprenorphine in addition to symptomatic meds.
Patients should be discharged with overdose education, naloxone and a plan for close follow-up with a warm handoff to an OTP or OBOT.
For adolescents 16 years old or older with OUD, buprenorphine is an option. For pregnant women, buprenorphine is a life-saver for both fetus and mother.
ED providers can be part of the solution to the opioid epidemic. Consistent appropriate use of buprenorphine in the ED has the potential to transform ED care of patients with OUD.

Click HERE for more information.

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There are three MAT drugs available to treat addiction: naltrexone (brand name Vivitrol), methadone (brand names Dolophine or Methadose) & buprenorphine (brand name Suboxone, Subutex, and Sublicade).
The only MAT drug appropriate for initiation in the ED is buprenorphine.
Buprenorphine is a semi-synthetic opioid which acts as partial agonist at the mu receptor. Buprenorphine does not produce as much euphoria or as much of the respiratory depression seen with other opioids. It has a quick onset and long half-life and is usually administered sublingually. The most commonly used formulation of buprenorphine is mixed with naloxone for one reason and one reason only - to prevent diversion and IV drug use. When taken orally, the buprenorphine effect is predominant; when taken IV, the naloxone effect is predominant
Any ED provider can administer buprenorphine in the ED for up to 3 consecutive days in order to bridge a patient to addiction services.
X-Waivers allow you to prescribe buprenorphine from the ED, which is a great service you can provide your patients, particularly in rural communities. In 2019 ACEP will be producing an ED physician specific X-Waiver training which will focus exclusively on ED-based care.

Click HERE for more information

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Medication Assisted Treatment or (Medication for Addiction Treatment) is an important frontier in ED care of patients with Opioid Use Disorder. Naltrexone, methadone and buprenorphine are the medications approved for the treatment of OUD.
Addiction is a disease that is widely misunderstood and rarely taught in medical school.
It is a dangerous myth that the best treatment of all addictions is simply abstinence.
The evolving consensus around OUD is that is best treated with medication. An opioid addiction should be treated with an opioid agonist.
MAT is shown to substantially decrease mortality and morbidity for OUD.
The treatment gap for OUD is egregious--as high as 75% in Colorado.
Emergency department providers can be part of the solution to this problem by understanding and, when indicated, initiating proper treatment for OUD.

Click HERE for more information

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Addiction is widely misunderstood by the public and by many healthcare providers. It is not taught in most medical schools.
Combating the opioid epidemic will require providers to understand Opioid Use Disorder (OUD) and its treatment.
Addiction is a chronic, relapsing disease with extraordinarily high morbidity and mortality. It is the transition from controlled to impulsive and compulsive drug intake.
Physiologic dependence is just one aspect of addiction. The behavioral and social derangements seen in addiction are the major source of harm for people with substance use disorders.
Addiction is not a personal failure of will. The role of genetics and environment are enormous.
It is more useful to think of addiction as a kind of “brain failure.” Dopamine and different dopaminergic systems are severely affected by drug use, resulting in chronic changes and even death to areas of the brain.
We do not stigmatize patients with diabetes or CHF for life choices contributing to their disease, nor do we refuse them care or make their care conditional on their behavior. We treat them.
Opioid use disorder is a treatable disease. It is time that ED providers start treating it.

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Author: Dave Saintsing

Educational Pearls:

Poor sleep is an independent risk factor for development of health problems such as type 2 diabetes. A 2019 study, randomized participants to 3 groups: 9 hours of sleep, 5 hours of sleep with weekend catch-up sleep, and 5 hours of sleep without catch-up sleep. In the sleep deprived (5 hour) groups, there was significantly more insulin resistance, calorie intake, and weight gain regardless of catch-up sleep.
Tramadol is prescribed 25 million times a year in the USA, usually to avoid prescribing traditional opiates such as Percocet or Oxycodone. Tramadol has complex pharmacology in that is is both an SNRI and mu-opiate agonist after metabolism in the liver. The pharmacogenetics of this vary greatly between people. Many people have rapid metabolism that will lead to increased opiate effects. Other medications interfere with metabolism (such as SSRI’s). A recent study demonstrated increased risk of hypoglycemia in diabetics taking Tramadol. Use caution when prescribing this drug.
Sepsis resuscitation has traditionally been gauged by following lactate levels on the presumption that lactate is an adequate marker of organ perfusion. Unfortunately, lactate levels are often elevated by medications and other health conditions such as kidney or liver disease, making lactate an often ineffective biomarker for perfusion. The Andromeda-Shock trial compared using capillary refill to lactate as guides for resuscitation with the primary endpoint of reducing 28-day mortality. The capillary refill group had a 9% absolute risk reduction in mortality, but this did not reach statistical significance. However, capillary refill can be used as another data point while resuscitating your septic patients.
When should you start pressors for patients in septic shock? A 2019 study compared routine resuscitation (30cc/kg fluid bolus) to initiation of norepinephrine with the first 30cc/kg crystalloid. They found that the early pressor group had significantly more “shock control” (MAP>65) at 6 hours, compared to the control group. While there was a trend towards less mortality in the early pressor group, it was not statistically significant. Keep an eye out for more studies in this area!
A recent study in JAMA found that 88% of deaths from sepsis were unavoidable, due to severe chronic comorbidities. Remember that patients will still die from septic shock despite your best efforts and knowledge of the newest literature.

References

Depner CM, Melanson EL, Eckel RH, Snell-Bergeon JK, Perreault L, Bergman BC, Higgins JA, Guerin MK, Stothard ER, Morton SJ, Wright KP Jr. Curr Biol. 2019 Feb 11. pii: S0960-9822(19)30098-3. doi: 10.1016/j.cub.2019.01.069. [Epub ahead of print]. PMID:30827911.

Fournier J, Azoulay L, Yin H, Montastruc J, Suissa S. Tramadol Use and the Risk of Hospitalization for Hypoglycemia in Patients With Noncancer Pain. JAMA Intern Med. 2015;175(2):186–193. doi:10.1001/jamainternmed.2014.6512

Hernández G, Ospina-Tascón GA, Damiani LP, et al. Effect of a Resuscitation Strategy Targeting Peripheral Perfusion Status vs Serum Lactate Levels on 28-Day Mortality Among Patients With Septic Shock: The ANDROMEDA-SHOCK Randomized Clinical Trial. JAMA. Published online February 17, 2019321(7):654–664. doi:10.1001/jama.2019.0071

Rhee C, Jones TM, Hamad Y, et al. Prevalence, Underlying Causes, and Preventability of Sepsis-Associated Mortality in US Acute Care Hospitals. JAMA Netw Open. Published online February 15, 20192(2):e187571. doi:10.1001/jamanetworkopen.2018.7571

Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

From CarePoint PA Academy, 2019

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Podcast # 499: Posterior Circulation Strokes

Contributor: Neal O’Connor, MD

Educational Pearls:

Dizziness is a very common complaint in the emergency department, but how can we find patients with a dangerous cause of their symptoms, namely a posterior circulation stroke?
Consider a posterior circulation stroke in those with an abrupt onset of headache with neck pain, balance problem, blurred vision, or dysphagia
Thorough cranial nerve exam can be important to screen for posterior circulation stroke, as much of the brainstem is supplied by the posterior circulation.
The most common posterior circulation stroke is a lateral medullary infarct (Wallenberg Syndrome), which produces dysphagia due to cranial nerve IX and XII involvement
Other physical exam findings include truncal ataxia, extremity ataxia, visual field cuts, and Horner syndrome (Ptosis, Miosis, Anhidrosis)
The HINTS exam (Head Impulse - Nystagmus - Test of Skew)can be used to differentiate between peripheral and central causes of dizziness
Concerning exam findings for central cause may include vertical nystagmus, gaze skew, or inability to track with head impulse

References

Áine Merwick, David Werring. Posterior circulation ischaemic stroke. BMJ 2014;348:g3175 doi: 10.1136/bmj.g3175

Kattah JC, Talkad AV, Wang DZ, Hsieh YH, Newman-Toker DE. HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging. Stroke. 2009;40(11):3504–3510. doi:10.1161/STROKEAHA.109.551234

Nouh A, Remke J, Ruland S. Ischemic posterior circulation stroke: a review of anatomy, clinical presentations, diagnosis, and current management. Front Neurol. 2014;5:30. Published 2014 Apr 7. doi:10.3389/fneur.2014.00030

From CarePoint PA Academy, 2019

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Author: Susan Ryan, DO

Educational Pearls:

General orthopedic principles:
- Examine above and below the injury
- Document neurovascular status
- X-ray imaging typically requires three different views
Fracture description should include name the bone, location of fracture, degree of displacement, and if it is closed or open
Osgood-Schlatter (tibia) and Sever’s (calcaneus) disease are apophyseal injuries caused by ligaments that are “stronger” than the bones they attach to
When looking for scaphoid injuries, get extra (turned) views of the wrist. Remember that the scaphoid has a reverse blood flow and is prone to avascular necrosis
Acute carpal tunnel syndrome can occur in forearm fractures. Again, don’t forget your neuro exam.
Distal radial-ulnar joint (DRUJ) injuries are caused by tears in the ligaments that stabilize the wrist. They cause chronic pain with pronation and supination.
Posterior effusions in the elbow in the 90 degree view nearly always indicate a fracture
Lisfranc injuries are commonly missed, especially if the mechanism is perceived as low energy. Look for the “fleck sign”, which is an avulsion fracture at the base of 2nd metatarsal
Syndesmotic injuries of the ankle (a high ankle sprain) can be identified through the squeeze test
Knee dislocations are neurovascular emergencies

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Author: Dylan Luyten, MD

Educational Pearls:

While certain aspects of the history, exam, and EKG may increase likelihood of ACS, there is no one element that performs well on its own
Elements of the history have been found to have different likelihood ratios, which can increase or decrease the probability of a patient having ACS
Likelihood ratios greater than one increase the chance of the patient having the disease. Ratios less than one decrease it
Bilateral arm radiation is one of very few historical features that increases the likelihood of ACS
ST depressions are one of the few EKG findings with a high LR for ACS
Scoring systems such as the HEART score can be useful to risk stratify your patients

References

Fanaroff AC, Rymer JA, Goldstein SA, Simel DL, Newby LK. Does This Patient With Chest Pain Have Acute Coronary Syndrome?: The Rational Clinical Examination Systematic Review. JAMA. 2015 Nov 10;314(18):1955-65. doi: 10.1001/jama.2015.12735. Review. PubMed PMID: 26547467.

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. PubMed PMID: 23465250.

From CarePoint PA Academy, 2019

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Author: David Holland, MD

Educational Pearls:

Hallucinogenics have been used for a variety of cultural and religious reasons for thousands of years
In the 1960’s a Harvard professor began experimenting with psilocybin mushrooms. There was resulting public outcry, eventually leading to all hallucinogens being listed as schedule I drugs
Common hallucinogens include: LSD (acid), Mescaline (peyote), DMT (ayahuasca), Psilocybin (mushrooms), MDMA (ecstacy)
Effects vary by specific drug but may include auditory/visual hallucinations, increased empathy, loss of fear
Physiologic effects often include mydriasis, tachycardia, hyperthermia and hypertension
Recent neuroimaging studies have shown increased neural connectivity in people after administration of hallucinogens
Each hallucinogen has a specific dose and duration, some can last half a day or more

References

Heal DJ, Gosden J, Smith SL. Evaluating the abuse potential of psychedelic drugs as part of the safety pharmacology assessment for medical use in humans.Neuropharmacology. 2018 Nov;142:89-115. doi: 10.1016/j.neuropharm.2018.01.049. Epub 2018 Feb 8. Review. PubMed PMID: 29427652.

Garcia-Romeu A, Kersgaard B, Addy PH. Clinical applications of hallucinogens: A review. Exp Clin Psychopharmacol. 2016 Aug;24(4):229-68. doi: 10.1037/pha0000084. Review. PubMed PMID: 27454674; PubMed Central PMCID: PMC5001686.

Bogenschutz MP, Johnson MW. Classic hallucinogens in the treatment of addictions.Prog Neuropsychopharmacol Biol Psychiatry. 2016 Jan 4;64:250-8. doi: 10.1016/j.pnpbp.2015.03.002. Epub 2015 Mar 14. Review. PubMed PMID: 25784600.

From CarePoint PA Academy

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Author: Rachel Brady, MD

Educational Pearls:

Elderly patients (>65 years old) have a higher trauma mortality compared to younger patients, even though they have lower mechanisms of injury
Elder trauma is often under-triaged due to low-energy mechanisms and lack of physiologic response due to age and medications such as beta-blockers. Do not be reassured by normal vital signs.
Image elderly patients with head injury aggressively since they are at high risk of intracranial bleeds
Be sure to ask about anticoagulation use. Up to 15% of asymptomatic head injury patients on warfarin will have intracranial bleeds on CT.
Be on the lookout for unstable C-spine injuries such as type II odontoid fractures
Central cord syndrome is a possibility with any neck extension injury
Rib fractures are common, with mortality increasing greatly with more than 2 ribs involved
The elderly are more prone to musculoskeletal injuries due to loss of bone density
Always discuss goals of care with these patients

References

Rathlev NK, Medzon R, Lowery D, Pollack C, Bracken M, Barest G, Wolfson AB, Hoffman JR, Mower WR. Intracranial pathology in elders with blunt head trauma. Acad Emerg Med. 2006 Mar;13(3):302-7. doi: 10.1197/j.aem.2005.10.015. PubMed PMID: 16514123.

Keller JM, Sciadini MF, Sinclair E, O'Toole RV. Geriatric trauma: demographics, injuries, and mortality. J Orthop Trauma. 2012 Sep;26(9):e161-5. doi: 10.1097/BOT.0b013e3182324460. PubMed PMID: 22377505.

Bulger EM, Arneson MA, Mock CN, Jurkovich GJ. Rib fractures in the elderly. J Trauma.2000 Jun;48(6):1040-6; discussion 1046-7. doi: 10.1097/00005373-200006000-00007. PubMed PMID: 10866248.

Hashmi A, Ibrahim-Zada I, Rhee P, Aziz H, Fain MJ, Friese RS, Joseph B. Predictors of mortality in geriatric trauma patients: a systematic review and meta-analysis. J Trauma Acute Care Surg. 2014 Mar;76(3):894-901. doi: 10.1097/TA.0b013e3182ab0763. Review. PubMed PMID: 24553567.

Brooks SE, Peetz AB. Evidence-Based Care of Geriatric Trauma Patients. Surg Clin North Am. 2017 Oct;97(5):1157-1174. doi: 10.1016/j.suc.2017.06.006. Review. PubMed PMID: 28958363.

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Contributor: JP Brewer, MD

Educational Pearls:

Obtaining collateral is often vital to determine the potential drugs accessible to the patient - this may include
After this, use ancillary sources such as EMS, family/friends, and police to determine the patient’s last normal, PMH and medications
To help separate toxidromes, pupillary exam and skin exam are helpful
Important physical exam clues in toxicology include the pupils and the skin
Adjunct laboratory evaluation may include liver function tests, acetaminophen level, salicylate levels, urine drug screens, particularly in unknown ingestions
Your local toxicologist (if you are fortunate to have one) or the Poison Center can always provide assistance in treatment and workup - consider involving them early

References

Erickson TB, Thompson TM, Lu JJ. The approach to the patient with an unknown overdose. Emerg Med Clin North Am 2007; 25:249.

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Contributor: JP Brewer, MD

Educational Pearls:

Because of their smaller size, there are a variety of adult-dose pills that are potentially toxic to children.
The most common categories of medications that may be toxic include cardiac, diabetic, pain, psychiatric, anti-malarial, and herbals/caustics
Oral hypoglycemics such as sulfonylureas can be particularly dangerous in children.
Opiates and benzodiazepines have the potential for respiratory arrest
Anti-malarial medications are arrhythmogenic to children
Camphor, batteries, oil of wintergreen (for the salicylate), and household caustic materials are dangerous non-pharmacologic ingestions to think about in children
If you encounter any of the above situations, consult your local poison control center 1-800-222-1222 or your toxicologist if you are lucky enough to have one on call

References

https://www.acep.org/how-we-serve/sections/toxicology/news/march-2016/one-pill-or-sip-can-kill/

Schillie SF, Shehab N, Thomas KE, Budnitz DS. Medication overdoses leading to emergency department visits among children. Am J Prev Med 2009;37:181-7.

Oz B, Levichek Z, Koren G. Medications That Can Be Fatal For a Toddler with One Tablet or Teaspoonful A 2004 Update. Pediatric Drugs, 2004; 6(2): 123-126

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Contributor: Don Stader, MD

Educational Pearls:

Buprenorphine is a partial Mu-agonist and binds with higher affinity than most opioids
Pain management with opioids therefore can be difficult in patients taking buprenorphine
Ketamine is a good option for pain control in these patients
You can also consider using additional buprenorphine
Intravenous buprenorphine is dosed differently than oral formulations
Consider receptor availability - patients on high doses of buprenorphine (32mg) will have few Mu receptors available, and thus will likely not benefit from opiate pain meds of any kind

References

Alford DP, Compton P, Samet JH. Acute pain management for patients receiving maintenance methadone or buprenorphine therapy. Ann Intern Med. 2006;144(2):127–134.

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

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Educational Pearls:

Buprenorphine is a semi-synthetic derivative of the opium poppy
FDA approved for the treatment of opiate use disorder and chronic pain
Benefit in emergency department use is the ceiling effect - producing less euphoria as well as respiratory depression with higher doses
It has an onset of 30-60 minutes, peak effect at 1-4 hours
Duration of action depends is dose dependent, typically 6-12 hours, but can be as long as 24-72 hours in doses over 16 mg
Use buprenorphine in those in moderate to severe opiate withdrawal
Clinical Opioid Withdrawal Scale (COWS) can be used to assess and score severity of withdrawal
A reasonable starting dose is 8mg. A second dose can be given after an hour, ranging from 8-24 mg depending on symptoms still present
Buprenorphine can induce withdrawals so someone needs to be in true withdrawals for it to provide benefit

References

https://www.mdcalc.com/cows-score-opiate-withdrawal

https://ed-bridge.org

Herring AA, Perrone J, Nelson LS. Managing Opioid Withdrawal in the Emergency Department With Buprenorphine. Ann Emerg Med. 2019 May;73(5):481-487. doi: 10.1016/j.annemergmed.2018.11.032. Epub 2019 Jan 5. Review. PubMed PMID: 30616926.

Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Don Stader, MD

Educational Pearls:

Syncope is usually benign but can be caused by serious etiologies which include: PE, certain cardiac arrhythmias, AAA, intracranial bleed/stroke
The Canadian Syncope Rule appears to identify those patients with syncope and low risk of serious outcomes
The score is based on vital signs, EKG and history
Negative scores preclude a very low risk of adverse events
A calculated score greater than 1 are considered medium risk
Scores greater than 4 are high risk
Anyone with a medium risk or higher should have their cause thoroughly investigated - which may involve admission or a shared decision making utilizing this rule if discharged

Editor’s note: just remember this rule has not been externally validated… yet

References

https://www.mdcalc.com/canadian-syncope-risk-score

Thiruganasambandamoorthy V, Kwong K, Wells GA, et al. Development of the Canadian Syncope Risk Score to predict serious adverse events after emergency department assessment of syncope. CMAJ. 2016;188(12):E289–E298. doi:10.1503/cmaj.151469

Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Jared Scott, MD

Educational Pearls:

The CDC recommends rabies prophylaxis if there was a direct encounter with a possibly rabid animal except...
Bats are treated differently since their bites may be very superficial and not seen/felt. All people with possible close encounters with a bat should receive rabies prophylaxis
From 1990-2007 there were 34 rabies cases associated with bats:
- 6 of these had a reported bat bite
- 15 there was a reported exposure but no reported bite
- 11 had no reported bat exposure but DNA testing revealed that the rabies came from a bat

References

Pieracci EG, Pearson CM, Wallace RM, Blanton JD, Whitehouse ER, Ma X, Stauffer K, Chipman RB, Olson V. Vital Signs: Trends in Human Rabies Deaths and Exposures - United States, 1938-2018. MMWR Morb Mortal Wkly Rep. 2019 Jun 14;68(23):524-528. doi: 10.15585/mmwr.mm6823e1. PubMed PMID: 31194721; PubMed Central PMCID: PMC6613553.

https://www.cdc.gov/rabies/specific_groups/doctors/index.html

Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Nick Hatch, MD

Educational Pearls:

Dalbavancin (Dalvance®) is an antibiotic that can be used for skin and soft tissue infections, providing MRSA coverage
It cannot be used in other infections or sepsis
Dalbavancin may be appealing as a single dose lasts about 2 weeks
Expense is currently a large barrier to use
Patients with a vancomycin allergy will likely be allergic to Dalbavancin as the two are related

References

Patel M, Smalley S, Dubrovskaya Y, Siegfried J, Caspers C, Pham V, Press RA, Papadopoulos J. Dalbavancin Use in the Emergency Department Setting. Ann Pharmacother. 2019 Jun 3;:1060028019855159. doi: 10.1177/1060028019855159. [Epub ahead of print] PubMed PMID: 31155916.

Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Michael Hunt, MD

Educational Pearls:

Due to the efficacy of vaccination, epiglottitis is now more common in adults than children
Risk factors include smoking and other immunocompromising co-morbidities, such as diabetes
Epiglottitis can present with sore throat and fever, with potential rapid progression to respiratory distress and stridor
Diagnosis can include x-ray to look for the “thumbprint sign," nasofiberoptics, and/or CT
Antibiotics are mainstay of treatment but severe cases may need establishment of a definitive airway, typically done with fiberoptics in the operating room due to the potential to irritate the epiglottitis with traditional laryngoscopy

References

Li RM, Kiemeney M. Infections of the Neck. Emerg Med Clin North Am. 2019 Feb;37(1):95-107. doi: 10.1016/j.emc.2018.09.003. Review. PubMed PMID: 30454783.

Tsai YT, Huang EI, Chang GH, Tsai MS, Hsu CM, Yang YH, Lin MH, Liu CY, Li HY. Risk of acute epiglottitis in patients with preexisting diabetes mellitus: A population-based case-control study. PLoS One. 2018;13(6):e0199036. doi: 10.1371/journal.pone.0199036. eCollection 2018. PubMed PMID: 29889887; PubMed Central PMCID: PMC5995441.

Guerra AM, Waseem M. Epiglottitis. [Updated 2018 Nov 15]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430960/

Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Nick Hatch, MD

Educational Pearls:

True morel mushrooms are commonly foraged
The false morel mushroom (Gyromitra esculenta) looks similar to the true morel, but is toxic
False morel mushroom toxicity can cause gastrointestinal symptoms as well as liver failure, rhabdomyolysis, and seizures
Seizures can be refractory to benzodiazepine therapy and may require use of vitamin B6 and propofol

References

Horowitz KM, Horowitz BZ. Gyromitra Mushroom Toxicity. [Updated 2019 May 12]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470580/

Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Jared Scott, MD

Educational Pearls:

Cerebellar strokes make up a disproportionate number of missed or delayed diagnosis for stroke likely due to the subtle nature of the presentation
Cerebellar strokes can present with vomiting, dizziness, and ataxia.
Unlike anterior circulation stroke, exam findings in a cerebellar stroke are ipsilateral to the lesion
On neuro exam, findings may include:
- Dysmetria: lack of coordination with overshooting/undershooting intended position of limb
- Dysdiadochokinesia: difficulty with rapid alternating movements
- Ataxia
- Nystagmus
Consider a cerebellar stroke in patients presenting with vomiting and dizziness without an alternative diagnosis

References

Edlow JA, Newman-Toker DE, Savitz SI. Diagnosis and initial management of cerebellar infarction. Lancet Neurol. 2008 Oct;7(10):951-64. doi: 10.1016/S1474-4422(08)70216-3. Review. PubMed PMID: 18848314.

Datar S, Rabinstein AA. Cerebellar infarction. Neurol Clin. 2014 Nov;32(4):979-91. doi: 10.1016/j.ncl.2014.07.007. Epub 2014 Sep 13. Review. PubMed PMID: 25439292.

Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Charleen Gnisci, PharmD

Educational Pearls:

Causes of increased intracranial pressure may include intracranial hemorrhage, malignancy, and trauma.
While definite treatment is to remove the offending cause, there are emergency medicine
Non-pharmacologic methods include elevating head of bed and removing noxious stimuli
Pharmacologic options include mannitol and hypertonic saline
Hypertonic saline is best delivered through a central line but not required
Both these agents benefit from adequate renal function
Before using mannitol, be sure to inspect the bag to ensure that it has not precipitated. If it has, try warming the bag before administration.

References

https://pulmccm.org/critical-care-review/hyperosmolar-therapy-for-increased-intracranial-pressure-review-nejm/

Burgess S, Abu-Laban RB, Slavik RS, Vu EN, Zed PJ. A Systematic Review of Randomized Controlled Trials Comparing Hypertonic Sodium Solutions and Mannitol for Traumatic Brain Injury: Implications for Emergency Department Management. Ann Pharmacother. 2016 Apr;50(4):291-300. doi: 10.1177/1060028016628893. Epub 2016 Jan 29. Review. PubMed PMID: 26825644.

Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Don Stader, MD

Educational Pearls:

Antiplatelets include aspirin and clopidogrel, and are generally used for arterial clotting (MI, stroke)
Anticoagulants such as coumadin, Xarelto, Eliquis are generally used for venous clotting (DVT/PE)
Growing data suggests that dual antiplatelet therapy (aspirin+clopidogrel) is superior to aspirin alone in reducing stroke for diagnosed with TIA

References:

Kheiri B, Osman M, Abdalla A, Haykal T, Swaid B, Ahmed S, Chahine A, Hassan M, Bachuwa G, Al Qasmi M, Bhatt DL. Clopidogrel and aspirin after ischemic stroke or transient ischemic attack: an updated systematic review and meta-analysis of randomized clinical trials. J Thromb Thrombolysis. 2019 Feb;47(2):233-247. doi: 10.1007/s11239-018-1786-z. PubMed PMID: 30511260.

Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Michael Hunt, MD

Educational Pearls:

Tetracycline antibiotics such as minocycline can cause greyish hyperpigmentation
This hyperpigmentation can sometimes be reversible but not always
Minocycline has been used for its effects in autoimmune and neurological diseases, where it is often taken chronically, which can lead to increased pigmentation

References

La Placa M, Infusino SD, Balestri R, Vincenzi C. Minocycline-Induced Blue-Gray Discoloration. Skin Appendage Disord. 2017 Aug;3(3):161-162. doi: 10.1159/000469712. Epub 2017 Apr 22. PubMed PMID: 28879193; PubMed Central PMCID: PMC5582477.

Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

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Contributor: Peter Bakes, MD

Educational Pearls:

While there are many different types of medical error, one of the most common errors in emergency medicine is failure to diagnose
Systematic error in thinking that negatively affects judgement
Medical errors are often driven by cognitive biases, which include anchoring, attribution, and availability
Anchoring bias occurs when early information leads to premature closure on a single diagnosis. There is subsequent failure to consider alternative diagnoses, even in the face of conflicting new data and test results.
Attribution bias occurs when assumptions about personal and medical characteristics are made about a specific group of people.
Availability bias occurs when recent experiences drive providers to over or under consider diagnoses.

References

Croskerry P. Cognitive forcing strategies in clinical decisionmaking. Ann Emerg Med. 2003 Jan;41(1):110-20. doi: 10.1067/mem.2003.22. PubMed PMID: 12514691.

Redelmeier DA. Improving patient care. The cognitive psychology of missed diagnoses. Ann Intern Med. 2005 Jan 18;142(2):115-20. doi: 10.7326/0003-4819-142-2-200501180-00010. PubMed PMID: 15657159.

https://www.nuemblog.com/blog/cognitive-bias

Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

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Author: Sam Killian, MD

Educational Pearls:

Abuse occurs by breathing in volatile substances such as solvents, glues, paints, butane, and propane
Inhalants are generally depressants
Estimated that 100-125 people die every year in the US from acute inhalant abuse.
Short-term effects include memory impairment, slurred speech, diplopia, seizures, and cardiac arrhythmias
Long term effects include renal dysfunction, neuropathy, blindness and cognitive blunting
Evaluation includes a detailed lung exam, cardiac monitoring, and assessments of oxygenation and renal function
Treatment is generally supportive.

References

Lipari RN. Understanding Adolescent Inhalant Use. 2013;. Review. PubMed PMID: 28722849.

Howard MO, Bowen SE, Garland EL, Perron BE, Vaughn MG. Inhalant use and inhalant use disorders in the United States. Addict Sci Clin Pract.2011 Jul;6(1):18-31. Review. PubMed PMID: 22003419; PubMed Central PMCID: PMC3188822.

Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

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Author: Nick Hatch, MD

Educational Pearls:

Pregnancy is a hypercoagulable state, which predisposes women to venous thromboembolism, but also elevates levels of circulating d-dimer
A recent study evaluated the YEARS protocol in combination of adjusted d-dimer cutoffs in pregnant women to evaluate for DVT and PE
Using this protocol, only 1 DVT was missed. No PE’s were missed.
This protocol has growing evidence as an option in pregnant women in whom you must rule out a DVT/PE but more validating studies are likely necessary

References

van der Pol LM, Tromeur C, Bistervels IM, Ni Ainle F, van Bemmel T, Bertoletti L, Couturaud F, van Dooren YPA, Elias A, Faber LM, Hofstee HMA, van der Hulle T, Kruip MJHA, Maignan M, Mairuhu ATA, Middeldorp S, Nijkeuter M, Roy PM, Sanchez O, Schmidt J, Ten Wolde M, Klok FA, Huisman MV. Pregnancy-Adapted YEARS Algorithm for Diagnosis of Suspected Pulmonary Embolism. N Engl J Med. 2019 Mar 21;380(12):1139-1149. doi: 10.1056/NEJMoa1813865. PubMed PMID: 30893534.

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

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Author: Chris Holmes, MD

Educational Pearls:

Hallucinogenic drugs have been in use since ancient times for both medical and recreational purposes
Ayahausca is an ancient psychedelic with origins in Bolivia that causes intense vomiting followed by a psychedelic experience
This and other hallucinogens are gaining gaining interest for their use in depression with some startling positive initial results

References

https://www.nationalgeographic.com/culture/2019/05/ancient-hallucinogens-oldest-ayahuasca-found-shaman-pouch/

Carhart-Harris RL et. al. Psilocybin with psychological support for treatment-resistant depression: six-month follow-up. Psychopharmacology (Berl). 2018 Feb;235(2):399-408. doi: 10.1007/s00213-017-4771-x. Epub 2017 Nov 8. PubMed PMID: 29119217; PubMed Central PMCID: PMC5813086.

Palhano-Fontes F et. al. Rapid antidepressant effects of the psychedelic ayahuasca in treatment-resistant depression: a randomized placebo-controlled trial. Psychol Med. 2019 Mar;49(4):655-663. doi: 10.1017/S0033291718001356. Epub 2018 Jun 15. PubMed PMID: 29903051; PubMed Central PMCID: PMC6378413.

Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

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Author: Nick Hatch, MD

Educational Pearls:

Postpolypectomy electrocoagulation syndrome (PES) is a rare complication of polypectomy and electrocautery during colonoscopy
Occurs when cautery causes transmural thickening from a contact burn
Patients can present as if they have peritonitis, with guarding, leukocytosis, fever, etc.
CT is the imaging of choice mainly to evaluate for bowel perforation as PES may not be seen on imaging
Treatment is often with antibiotics and supportive care - in severe cases, hospitalization may be required.

References

Benson BC, Myers JJ, Laczek JT. Postpolypectomy electrocoagulation syndrome: a mimicker of colonic perforation. Case Rep Emerg Med. 2013;2013:687931. doi: 10.1155/2013/687931. Epub 2013 Jul 15. PubMed PMID: 23956889; PubMed Central PMCID: PMC3728495.

Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

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Author: Dylan Luyten, MD

Educational Pearls:

Actual wait times are weakly correlated to patient satisfaction but the difference between perceived/expected wait times and actual wait times is strongly correlated
Having others in the room or with the patient while they wait also has a positive effect
Under-promising and over-delivering can result in better patient experience
Managing up others and services provided also is demonstrated to improve satisfaction
Perceived time with health care members (physicians, APPs, nurses, etc) also is supported to improve satisfaction
Sitting with patients increases the perception of time

References

Trout A, Magnusson AR, Hedges JR. Patient satisfaction investigations and the emergency department: what does the literature say?. Acad Emerg Med. 2000 Jun;7(6):695-709. Review. PubMed PMID: 10905652.

Sonis JD, Aaronson EL, Lee RY, Philpotts LL, White BA. Emergency Department Patient Experience: A Systematic Review of the Literature. J Patient Exp. 2017;5(2):101–106. doi:10.1177/2374373517731359

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

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Author: Michael Hunt, MD

Educational Pearls:

A recent study evaluated the relationship between abnormal orthostatic vital signs and serious outcomes within 30 days in patients over 60 presenting to the ED with syncope
Of the roughly 2000 patients enrolled, about ⅓ had abnormal orthostatic vital signs
There was no statistically significance between orthostatic vital signs and serious outcomes in 30 days

Editor's note: study used a composite end-point of multiple serious outcomes

References

White JL, Hollander JE, Chang AM, Nishijima DK, Lin AL, Su E, Weiss RE, Yagapen AN, Malveau SE, Adler DH, Bastani A, Baugh CW, Caterino JM, Clark CL, Diercks DB, Nicks BA, Shah MN, Stiffler KA, Storrow AB, Wilber ST, Sun BC. Orthostatic vital signs do not predict 30 day serious outcomes in older emergency department patients with syncope: A multicenter observational study. Am J Emerg Med. 2019 Mar 25;. doi: 10.1016/j.ajem.2019.03.036. [Epub ahead of print] PubMed PMID: 30928476.

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

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Author: Peter Bakes, MD

Educational Pearls:

The differential diagnosis for pedal edema includes issues in the heart, kidney, and liver
Obesity hypoventilation syndrome (OHS) is an important and common cause of right heart failure. Nighttime hypoventilation leads to pulmonary hypertension, causing right heart strain followed by right heart failure
OHS criteria includes obesity, sleep disordered breathing, and alveolar hypoventilation (PaCO2 > 45 mmHg)
The causes of OHS are multifactorial, and include mechanical problems with breathing and hormonal changes

References

Balachandran JS, Masa JF, Mokhlesi B. Obesity Hypoventilation Syndrome Epidemiology and Diagnosis. Sleep Med Clin. 2014;9(3):341–347. doi:10.1016/j.jsmc.2014.05.007

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

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Author: Sam Killian, MD

Educational Pearls:

A recent study in Pediatrics compared the rates of antibiotic prescriptions for acute respiratory infections (ARIs) between direct to consumer (DTC) telemedicine, urgent care, and primary care providers
Among the nearly 530,000 visits studied, the rate of antibiotic prescription was 52%, 42% and 31% for telemedicine, urgent care, and primary care providers, respectively
Nearly 4/10 antibiotic prescriptions from telemedicine visits were not indicated based on antibiotics guideline recommendations

References

Ray KN, Shi Z, Gidengil CA, Poon SJ, Uscher-Pines L, Mehrotra A. Antibiotic Prescribing During Pediatric Direct-to-Consumer Telemedicine Visits. Pediatrics. 2019 May;143(5). doi: 10.1542/peds.2018-2491. Epub 2019 Apr 8. PubMed PMID: 30962253.

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

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Author: Gretchen Hinson, MD

Educational Pearls:

In most healthcare settings, normal saline (NS) has become ubiquitous as an intravenous fluid despite some potential drawbacks
Compared to normal saline, a balanced crystalloid (either lactated Ringer’s or Plasma-Lyte) was associated with a lower composite endpoint of mortality, renal replacement therapy, and renal injury in SMART (Isotonic Solutions and Major Adverse Renal Events Trial)
Balanced crystalloids such as lactate Ringer’s may be preferable in more critically ill populations

References

Yau YW, Kuan WS. Choice of crystalloids in sepsis: a conundrum waiting to be solved. Ann Transl Med. 2016;4(6):121. doi:10.21037/atm.2016.02.09

Semler MW, Self WH, Wanderer JP, et al. Balanced Crystalloids versus Saline in Critically Ill Adults. N Engl J Med. 2018;378(9):829–839. doi:10.1056/NEJMoa1711584

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

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Author: Don Stader, MD

Educational Pearls:

Cyclic vomiting syndrome (CVS) is different than cannabis hyperemesis syndrome (CHS). It is important to differentiate the two.
CHS is thought to be caused by activation of THC receptors in the gut
CVS is associated with migraines and therefore responds to similar medications
Olanzapine (Zyprexa) is an alternative to haloperidol (Haldol)
Amitriptyline, as well as anti-epileptics can be used to prevent CVS
Opioids worsen CVS

References

Lapoint J, Meyer S, Yu CK, Koenig KL, Lev R, Thihalolipavan S, Staats K, Kahn CA.Cannabinoid Hyperemesis Syndrome: Public Health Implications and a Novel Model Treatment Guideline. West J Emerg Med. 2018 Mar;19(2):380-386. doi: 10.5811/westjem.2017.11.36368. Epub 2017 Nov 8. PubMed PMID: 29560069; PubMed Central PMCID: PMC5851514.

Boles RG, Lovett-Barr MR, Preston A, Li BU, Adams K. Treatment of cyclic vomiting syndrome with co-enzyme Q10 and amitriptyline, a retrospective study. BMC Neurol. 2010;10:10. Epub 2010 Jan 28.

Hikita T, Kodama H, Kaneko S, Amakata K, Ogita K, Mochizuki D, Kaga F, Nakamoto N, Fujii Y, Kikuchi A. Sumatriptan as a treatment for cyclic vomiting syndrome: a clinical trial. Cephalalgia. 2011;31(4):504. Epub 2010 Dec 8.

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

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Author: Jared Scott, MD

Educational Pearls:

Ondansetron (Zofran) is one of the latest drugs that has had concerns raised about side effects, particularly in pregnancy
2018 study probed two birth defect databases to assess increases in 51 major birth defects with increased exposure to ondansetron
Only two of the 51 had even a modest increase, which is unclear in causation (cleft palate and renal agenesis)
When administering ondansetron (or any drug) to pregnant women, be able to discuss any potential risks for an informed decision by the patient

Editor's note: in this study, adjusted odds ratios for risk of birth defects from exposure to ondansetron were: cleft palate 1.6 (95% CI 1.1-2.3) and renal agenesis 1.8 (95% CI 1.1-3.0)

References

Parker SE, Van Bennekom C, Anderka M, Mitchell AA. Ondansetron for Treatment of Nausea and Vomiting of Pregnancy and the Risk of Specific Birth Defects. Obstet Gynecol. 2018 Aug;132(2):385-394. doi: 10.1097/AOG.0000000000002679. PubMed PMID: 29995744.

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

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Author: Dave Rosenberg, MD

Educational Pearls:

Nothing by mouth (NPO) status routinely used before surgery to reduce the theoretical risk of aspiration
However, surgery poses a large physiological stress. Calories and fluid are needed to overcome stresses like these
Patients who drank 1/2 strength Gatorade up to 2 hours before surgery did better than those who did not

References

Alyssa Cheng-Cheng Zhu, Aalok Agarwala, Xiaodong Bao. Perioperative Fluid Management in the Enhanced Recovery after Surgery (ERAS) Pathway. Clinics in Colon and Rectal Surgery 2019; 32(02): 114-120. DOI: 10.1055/s-0038-1676476

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

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Educational Pearls:

Tiflitis refers to the presence of enterocolitis in the setting of neutropenia - also known as neutropenic enterocolitis
Commonly a result of chemotherapy for hematologic malignancies.
The infection is usually polymicrobial/fungal and can lead to septic shock
Usually presents with fever, abdominal pain, with associated GI complaints
Workup includes CBC for the ANC (usually <500), and a CT abdomen (look for bowel thickening)
Treatment typically with broad-spectrum antibiotics with or without anti-fungal agents
Mortality can be as high as 50%

References

Cloutier RL. Neutropenic enterocolitis. Emerg Med Clin North Am. 2009 Aug;27(3):415-22. doi: 10.1016/j.emc.2009.04.002. PubMed PMID: 19646645.

Rodrigues FG, Dasilva G, Wexner SD. Neutropenic enterocolitis. World J Gastroenterol.2017 Jan 7;23(1):42-47. doi: 10.3748/wjg.v23.i1.42. Review. PubMed PMID: 28104979; PubMed Central PMCID: PMC5221285.

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

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Author: Erik Verzemnieks, MD

Educational Pearls:

Cauda equina syndrome is caused by the compression of the nerve roots that extend beyond the termination of the spinal cord
Trauma, infection, hematoma, disc rupture/herniation can cause this - basically anything that can cause pressure and fill space
Symptoms can include saddle anesthesia, lower extremity pain, numbness, incontinence, and constipation
Post-void residual that is abnormally high may be an indicator
MRI is diagnostic modality of choice
Emergent surgical decompression is treatment

References

Jalloh I, Minhas P. Delays in the treatment of cauda equina syndrome due to its variable clinical features in patients presenting to the emergency department. Emerg Med J. 2007 Jan;24(1):33-4. doi: 10.1136/emj.2006.038182. PubMed PMID: 17183040; PubMed Central PMCID: PMC2658150.

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Author: Nicholas Hatch, MD

Educational Pearls:

Measles has a period of infectivity starts before the appearance of the characteristic rash, up to 4-5 days
A devastating consequence of measles is Subacute Sclerosing Panencephalitis (SSPE), which manifests 7-10 years after the initial measles infection
SSPE is a central nervous system disease that has no cure and is nearly universally fatal
Educating patients on the importance of vaccination should include discussion of these long term consequences

References

Pallivathucal LB, Noymer A. Subacute sclerosing panencephalitis mortality, United States, 1979-2016: Vaccine-induced declines in SSPE deaths. Vaccine. 2018 Aug 23;36(35):5222-5225. doi: 10.1016/j.vaccine.2018.07.030. Epub 2018 Jul 26. PubMed PMID: 30057285.

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

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Author: Ryan Circh, MD

Educational Pearls:

The 2019 ANDROMEDA-SHOCK trial compared using serum lactates to capillary refill assessment in septic shock patients to guide resuscitation
Capillary refill time was standardized (this is not straightforward):
- A glass microscope slide was pressed on the ventral side of the right index finger
- Pressure was increased until the skin was blanched
- This pressure was sustained for another 10 seconds
- After pressure was removed, the time to return to normal skin color was timed
- Greater than three seconds was considered abnormal.
No difference between the two groups for mortality at 28-days

Editor’s note: lactates have become so ingrained in our practice it will be tough to change habits but this is an excellent quiver for those of us that hate the over reliance on this lab value alone, despite some of the limitations of the study.

References

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

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Author: Aaron Lessen, MD

Educational Pearls:

A problem of take-home-naloxone is the administration of it by an able-bodied bystander
Australian study looked at consecutive opioid overdose deaths in a single year to identify characteristics of overdose and potential for bystander administered naloxone
Of the 235 fatal heroin overdoses reviewed, 83% were alone with only 17% (38 cases) having another person present
Half of those in the presence of others had a bystander that was not impaired
Take-home-naloxone needs a competent person to administer it. Make sure to review this along with other harm reduction strategies when prescribing/dispensing it to patients

References

Stam NC, Gerostamoulos D, Smith K, Pilgrim JL, Drummer OH. Challenges with take-home naloxone in reducing heroin mortality: a review of fatal heroin overdose cases in Victoria, Australia. Clin Toxicol (Phila). 2019 May;57(5):325-330. doi: 10.1080/15563650.2018.1529319. Epub 2018 Nov 17. PubMed PMID: 30451007.

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

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Author: Erik Verzemnieks, MD

Educational Pearls:

Buproprion is used as an antidepressant and for smoking cessation
Severe buproprion overdoses can cause seizures and lead to cardiac dysrhythmias
Benzodiazepines are treatment of choice for seizures
Bicarbonate and Interlipid are also possible treatment options with less evidence

References

Stall N, Godwin J, Juurlink D. Bupropion abuse and overdose. CMAJ. 2014 Sep 16;186(13):1015. doi: 10.1503/cmaj.131534. Epub 2014 Apr 28. PubMed PMID: 24778361; PubMed Central PMCID: PMC4162783.

Balit CR, Lynch CN, Isbister GK. Bupropion poisoning: a case series. Med J Aust. 2003 Jan 20;178(2):61-3. PubMed PMID: 12526723.

Bruccoleri RE, Burns MM. A Literature Review of the Use of Sodium Bicarbonate for the Treatment of QRS Widening. J Med Toxicol. 2016 Mar;12(1):121-9. doi: 10.1007/s13181-015-0483-y. Review. PubMed PMID: 26159649; PubMed Central PMCID: PMC4781799.

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Author: Don Stader, MD

Educational Pearls:

10% of patients seen in the emergency department for opioid overdose patients will die within a year
Half of these overdoses will occur in the next month
This mortality rate is higher than patients with STEMI, of which 7% will die within one year
Take-home naloxone, as well as medication assisted treatment like buprenorphine can save lives

References

Olfson M, Crystal S, Wall M, Wang S, Liu SM, Blanco C. Causes of Death After Nonfatal Opioid Overdose. JAMA Psychiatry. 2018 Aug 1;75(8):820-827. doi: 10.1001/jamapsychiatry.2018.1471. PubMed PMID: 29926090; PubMed Central PMCID: PMC6143082.

Olfson M, Wall M, Wang S, Crystal S, Blanco C. Risks of fatal opioid overdose during the first year following nonfatal overdose.Drug Alcohol Depend. 2018 Sep 1;190:112-119. doi: 10.1016/j.drugalcdep.2018.06.004. Epub 2018 Jul 4. PubMed PMID: 30005310.

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

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Author: Gretchen Hinson, MD

Educational Pearls:

Breath stacking occurs when a patient is unable to expire fully before another inspiration
In intubated/ventilated patients, this is because adequate time has not passed before exhalation
Asthmatics are susceptible due to the prolonged expiratory phase
Complications can include reduction in cardiac preload and cardiovascular collapse
Pursed-lip breathing can help in the spontaneously breathing patient
Intubation may be required when patients present with status asthmaticus and breath stacking

References

Phipps P, Garrard CS. The pulmonary physician in critical care . 12: Acute severe asthma in the intensive care unit. Thorax. 2003 Jan;58(1):81-8. Review. PubMed PMID: 12511728; PubMed Central PMCID: PMC1746457.

Pohlman MC, McCallister KE, Schweickert WD, Pohlman AS, Nigos CP, Krishnan JA, Charbeneau JT, Gehlbach BK, Kress JP, Hall JB. Excessive tidal volume from breath stacking during lung-protective ventilation for acute lung injury. Crit Care Med. 2008 Nov;36(11):3019-23. doi: 10.1097/CCM.0b013e31818b308b. PubMed PMID: 18824913.

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

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Author: Michael Hunt, MD

Educational Pearls:

Most causes of syncope are benign
Pulmonary embolism can result in syncope and is life threatening
A recent study of Canadian and US ED patients with syncope showed that 0.4% of patients had a PE at 30 day follow-up
PE should always be considered in cases of syncope but overall is a rare cause

Editor’s note: this study puts to rest a previous study from 2016 that reported a rate of PE in syncope as high as 1 in 6 in patients admitted to syncope - which was met with much skepticism based on clinical practice.

References

Roncon L, Zuin M, Casazza F, Becattini C, Bilato C, Zonzin P. Impact of syncope and pre-syncope on short-term mortality in patients with acute pulmonary embolism. Eur J Intern Med. 2018 Aug;54:27-33. doi: 10.1016/j.ejim.2018.04.004. Epub 2018 Apr 11. PubMed PMID: 29655808.

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

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Author: Julian Orenstein, MD

Educational Pearls:

Severe clonidine ingestion can present as a fluctuating mental status between typically accompanied by changes in vital signs (hypotension/bradycardia)
Respiratory depression requiring intubation is not uncommon

References

Isbister GK, Heppell SP, Page CB, Ryan NM. Adult clonidine overdose: prolonged bradycardia and central nervous system depression, but not severe toxicity. Clin Toxicol (Phila). 2017 Mar;55(3):187-192. doi: 10.1080/15563650.2016.1277234. Epub 2017 Jan 20. PubMed PMID: 28107093.

Spiller HA, Klein-Schwartz W, Colvin JM, Villalobos D, Johnson PB, Anderson DL. Toxic clonidine ingestion in children. J Pediatr. 2005 Feb;146(2):263-6. PubMed PMID: 15689921.

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

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Author: Nick Hatch, MD

Educational Pearls:

A recent study investigated the effect of scheduled IV acetaminophen on the incidence of delirium in post-CABG patients in the ICU
The use of scheduled IV acetaminophen reduced the rate of delirium in these patients compared to placebo
This may be due to the analgesic effect of acetaminophen and/or less requirement on other deliriogenic medications (opiates)

References

Subramaniam B, Shankar P, Shaefi S, Mueller A, O'Gara B, Banner-Goodspeed V, Gallagher J, Gasangwa D, Patxot M, Packiasabapathy S, Mathur P, Eikermann M, Talmor D, Marcantonio ER. Effect of Intravenous Acetaminophen vs Placebo Combined With Propofol or Dexmedetomidine on Postoperative Delirium Among Older Patients Following Cardiac Surgery: The DEXACET Randomized Clinical Trial. JAMA. 2019 Feb 19;321(7):686-696. doi: 10.1001/jama.2019.0234. PubMed PMID: 30778597.

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

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Author: Jared Scott, MD

Educational Pearls:

Modified Rankin Score: measure of disability often used to qualify outcomes following stroke = no disability, 6=dead, 0-1 indicate good outcome)
- 0-6 Scale
- 0-1 indicative of good outcome
ASPECT score: uses CT to quantify the extent of changes in the brain due to ischemia
- 0-10 Scale
- 10 areas are assessed on non-contrast CT to assess for early stroke changes
- -1 for each area with these findings
- 8-10 is indicative of better outcomes

References

Aviv RI, Mandelcorn J, Chakraborty S, Gladstone D, Malham S, Tomlinson G, Fox AJ, Symons S. Alberta Stroke Program Early CT Scoring of CT perfusion in early stroke visualization and assessment. AJNR Am J Neuroradiol. 2007 Nov-Dec;28(10):1975-80. Epub 2007 Oct 5. PubMed PMID: 17921237.

https://manual.jointcommission.org/releases/TJC2018A/DataElem0569.html

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

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Author: Jared Scott, MD

Educational Pearls:

Beta-blockers can mask the effects of hypoglycemia
Prolonged/refractory hypoglycemia should raise a suspicion for sulfonylurea (or other oral hypoglycemic) overdose
Interventions to reverse hypoglycemia include feeding the patient, IV dextrose, glucagon
Octreotide can be used as an antidote with sulfonylurea ingestion

Editor’s note: Here is an interesting case report on using steroids for severe hypogylcemia caused by insulin overdose. Perhaps another treatment modality to keep in your back pocket?

References

Alsahli M, Gerich JE. Hypoglycemia. Endocrinol Metab Clin North Am. 2013 Dec;42(4):657-76. doi: 10.1016/j.ecl.2013.07.002. Review. PubMed PMID: 24286945.

Moore C, Woollard M. Dextrose 10% or 50% in the treatment of hypoglycaemia out of hospital? A randomised controlled trial.Emerg Med J. 2005 Jul;22(7):512-5. PubMed PMID: 15983093; PubMed Central PMCID: PMC1726850.

Fasano CJ, O'Malley G, Dominici P, Aguilera E, Latta DR. Comparison of octreotide and standard therapy versus standard therapy alone for the treatment of sulfonylurea-induced hypoglycemia. Ann Emerg Med. 2008 Apr;51(4):400-6. Epub 2007 Aug 30. PubMed PMID: 17764782.

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

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Author: Michael Hunt, MD

Educational Pearls:

Like all tests, urine toxicology (utox) screens can have false positives
Prescription medications such as demerol, antipsychotics, ketamine, and tramadol can all produce a false positive utox for PCP
Over-the-counter medication such as dextromethorphan also mimic PCP on utox

References

Doyon S. (January 2014). False Positive Urine Screens for Phencyclidine. ToxTidbits. Retrieved from https://www.mdpoison.com/media/SOP/mdpoisoncom/ToxTidbits/2014/January%202014%20ToxTidbits.pdf

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

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Educational Pearls:

Acetaminophen overdose can also present in patients taking too much over the course of days to weeks - not just intentional ingestions
If acute overdose is suspected, refer to the Rumak-Matthew nomogram to guide treatment based on time of ingestion and the time of level
In chronic overdose, Tylenol levels will not guide treatment
NAPQI is the toxic metabolite of acetaminophen
N-acetylcysteine (NAC) can be effective treatment in both acute and chronic overdoses
7.5 g is the daily toxic dose of Tylenol in adults, 150mg/kg in children

References:

Smilkstein MJ. Acetaminophen. In: Goldfrank's Toxicologic Emergencies, Goldfrank LR, Flomenbaum NE, Lewin NA, et al (Eds), Appleton & Lange, Stamford 1998. P.541.

Chiew AL, Gluud C, Brok J, Buckley NA. Interventions for paracetamol (acetaminophen) overdose. Cochrane Database Syst Rev. 2018 Feb 23;2:CD003328. doi: 10.1002/14651858.CD003328.pub3. Review. PubMed PMID: 29473717.

Lancaster EM, Hiatt JR, Zarrinpar A. Acetaminophen hepatotoxicity: an updated review. Arch Toxicol. 2015 Feb;89(2):193-9. doi: 10.1007/s00204-014-1432-2. Epub 2014 Dec 24. Review. PubMed PMID: 25537186.

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

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Author: Sam Killian, MD

Educational Pearls:

Headache is a common complaint in the ED. It’s plausible that headaches could be correlated with environmental factors
A 2015 study ED visits for headache found that temperature was associated with an increase visits, while higher humidity led to fewer
A retrospective study looking over a 10-year period for headache found that there was an increase headache presentations during days with high air pollution

References:

Yilmaz M, Gurger M, Atescelik M, Yildiz M, Gurbuz S. Meteorologic parameters and migraine headache: ED study. Am J Emerg Med. 2015 Mar;33(3):409-13. doi: 10.1016/j.ajem.2014.12.056. Epub 2014 Dec 31. PubMed PMID: 25601162.

Szyszkowicz M, Stieb DM, Rowe BH. Air pollution and daily ED visits for migraine and headache in Edmonton, Canada. Am J Emerg Med. 2009 May;27(4):391-6. doi: 10.1016/j.ajem.2008.03.013. PubMed PMID: 19555607.

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

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Author: Sam Killian, MD

Educational Pearls:

Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy (CADASIL) occurs in 1:100000 individuals
The disease is caused by a defect in the NOTCH3 gene on chromosome 19
It is an important cause of stroke in young patients
Features include ischemia, cognitive deficits, migraines, psychiatric disease, coma, and seizure, all of which is worse with pregnancy
Migraine with aura is often the first presenting symptom with onset by age 30
Strokes typically can occur by age 50
Diagnosis is with MRI for characteristic lesions
Unfortunately there is no cure, and treatment is focused on stroke prevention with aspirin and statins

References:

Chabriat H, Joutel A, Dichgans M, Tournier-Lasserve E, Bousser MG. Cadasil. Lancet Neurol. 2009 Jul;8(7):643-53. doi: 10.1016/S1474-4422(09)70127-9. Review. PubMed PMID: 19539236.

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

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Author: Don Stader, MD

Educational Pearls:

Non-steroidal anti-inflammatory drugs (NSAIDs) are effective pain relievers but come with important side effects
NSAIDs inhibit COX-1 and/or COX-2, which decreases the production of prostaglandins, which reduce pain and inflammation
Side effects of NSAIDS include increased rates myocardial infarction, stroke, and gastrointestinal bleeding, CVA
Effective pain reliever doses of many NSAIDs are lower than typically prescribed (i.e. ibuprofen 400 mg is as effective as 800 mg but with less risk of side effects)
Topical NSAIDs can be an alternative to reduce systemic effects
Selective Cox-2 inhibitors have less GI side effects

Editor note: What is ALTO? It’s alternative to opioids and consists of multi-modal pain control to reduce exposure to opioids. Check out more here and here.

References:

Derry S, Wiffen PJ, Kalso EA, Bell RF, Aldington D, Phillips T, Gaskell H, Moore RA. Topical analgesics for acute and chronic pain in adults - an overview of Cochrane Reviews. Cochrane Database Syst Rev. 2017 May 12;5:CD008609. doi: 10.1002/14651858.CD008609.pub2. Review. PubMed PMID: 28497473.

Coxib and traditional NSAID Trialists' (CNT) Collaboration., Bhala N, Emberson J, Merhi A, Abramson S, Arber N, Baron JA, Bombardier C, Cannon C, Farkouh ME, FitzGerald GA, Goss P, Halls H, Hawk E, Hawkey C, Hennekens C, Hochberg M, Holland LE, Kearney PM, Laine L, Lanas A, Lance P, Laupacis A, Oates J, Patrono C, Schnitzer TJ, Solomon S, Tugwell P, Wilson K, Wittes J, Baigent C. Vascular and upper gastrointestinal effects of non-steroidal anti-inflammatory drugs: meta-analyses of individual participant data from randomised trials. Lancet. 2013 Aug 31;382(9894):769-79. doi: 10.1016/S0140-6736(13)60900-9. Epub 2013 May 30. PubMed PMID: 23726390; PubMed Central PMCID: PMC3778977.

Kaufman DW, Kelly JP, Battista DR, Malone MK, Weinstein RB, Shiffman S. Exceeding the daily dosing limit of nonsteroidal anti-inflammatory drugs among ibuprofen users. Pharmacoepidemiol Drug Saf. 2018 Mar;27(3):322-331. doi: 10.1002/pds.4391. Epub 2018 Jan 26. PubMed PMID: 29372579.

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

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Author: Sam Killian, MD

Educational Pearls:

Viral gastroenteritis alters the gut microbiome and it is theorized that probiotics may help reduce the duration and severity of the disease.
Double-blind randomized controlled trial involving almost 900 children with viral gastroenteritis compared 5 days of probiotics to a control group.
There was no difference in the rates of severe gastroenteritis between the two groups
Probiotics are likely unhelpful for kid with viral gastroenteritis

References:

Freedman SB, Williamson-Urquhart S, Farion KJ, Gouin S, Willan AR, Poonai N, Hurley K, Sherman PM, Finkelstein Y, Lee BE, Pang XL, Chui L, Schnadower D, Xie J, Gorelick M, Schuh S; PERC PROGUT Trial Group.. Multicenter Trial of a Combination Probiotic for Children with Gastroenteritis. N Engl J Med. 2018 Nov 22;379(21):2015-2026. doi: 10.1056/NEJMoa1802597. PubMed PMID: 30462939.

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

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Author: Dylan Luyten, MD

Educational Pearls:

A “banana bag” is a bag of IV fluid that contains various vitamins and minerals including folate and thiamine
IV fluids do not alter intoxicated patients recovery in the emergency department
Folate deficiency is rare in the intoxicated patient
Some intoxicated patients may be thiamine deficient, and those that would benefit the most need significantly more daily thiamine supplementation than provided in a banana bag

References:

Perez SR, Keijzers G, Steele M, Byrnes J, Scuffham PA. Intravenous 0.9% sodium chloride therapy does not reduce length of stay of alcohol-intoxicated patients in the emergency department: a randomised controlled trial. Emerg Med Australas. 2013 Dec;25(6):527-34. doi: 10.1111/1742-6723.12151. Epub 2013 Nov 8. PubMed PMID: 24308613; PubMed Central PMCID: PMC4253317.

Li SF, Jacob J, Feng J, Kulkarni M. Vitamin deficiencies in acutely intoxicated patients in the ED. Am J Emerg Med. 2008 Sep;26(7):792-5. doi: 10.1016/j.ajem.2007.10.003. PubMed PMID: 18774045.

ay E, Bentham PW, Callaghan R, Kuruvilla T, George S. Thiamine for prevention and treatment of Wernicke-Korsakoff Syndrome in people who abuse alcohol. Cochrane Database Syst Rev. 2013 Jul 1;(7):CD004033. doi: 10.1002/14651858.CD004033.pub3. Review. PubMed PMID: 23818100.

Summarized by Will Dewsipelaere, MS3 | Edited by Erik Verzemnieks, MD

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Author: Ryan Circh, MD

Educational Pearls:

Chronic salicylate (ASA) toxicity can present in elderly patients as altered mental status
Consider chronic toxicity in patients with an unexplained anion gap acidosis
Treatment for chronic ingestion typically includes IV fluids and urine alkalinization

References:

O'Malley GF. Emergency department management of the salicylate-poisoned patient. Emerg Med Clin North Am. 2007 May;25(2):333-46; abstract viii. Review. PubMed PMID: 17482023.

Durnas C, Cusack BJ. Salicylate intoxication in the elderly. Recognition and recommendations on how to prevent it. Drugs Aging. 1992 Jan-Feb;2(1):20-34. Review. PubMed PMID: 1554971.

Summarized by Will Dewsipelaere, MS3 | Edited by Erik Verzemnieks, MD

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Author: Dylan Luyten, MD

Educational Pearls:

Recent randomized controlled trial compared intravenous to oral acetaminophen in emergency department patients
There was no difference in pain relief between the groups
While the actual acquisition cost of these drugs are not significant, the cost multipliers that are passed onto patients lead to real dollars
With the significant cost of IV acetaminophen, it may not be the best choice given the lack of superiority to other formulations

References:

Furyk J, Levas D, Close B, Laspina K, Fitzpatrick M, Robinson K, Vangaveti VN, Ray R. Intravenous versus oral paracetamol for acute pain in adults in the emergency department setting: a prospective, double-blind, double-dummy, randomised controlled trial.Emerg Med J. 2018 Mar;35(3):179-184. doi: 10.1136/emermed-2017-206787. Epub 2017 Dec 15. PubMed PMID: 29247042.

Summarized by Will Dewsipelaere, MS3 | Edited by Erik Verzemnieks, MD

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Author: Dylan Luyten, MD

Educational Pearls:

1:500 patients will experience a retinal detachment
Consider stroke on your differential (central retinal arterial occlusion)
Flashes and floaters are a common complaint with retinal detachments
Though patients may report fields of vision loss, visual acuity is often spared
Ocular ultrasound is an effective way to diagnosis retinal detachment in the ED
These require urgent ophthalmologic consultation for surgical repair

References:

https://www.aliem.com/2014/03/ocular-ultrasound-retinal-detachment-posterior-vitreous-detachment/

Gottlieb M, Holladay D, Peksa GD. Point-of-Care Ocular Ultrasound for the Diagnosis of Retinal Detachment: A Systematic Review and Meta-Analysis. Acad Emerg Med. 2019 Jan 13. doi: 10.1111/acem.13682. [Epub ahead of print] PubMed PMID: 30636351.

Summarized by Will Dewsipelaere, MS3 | Edited by Erik Verzemnieks, MD

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Author: Michael Hunt, MD

Educational Pearls:

Bedside transtracheal ultrasound to confirm proper endotracheal intubation is simple and effective
Review of 17 studies showed transtracheal ultrasound was was 98.7% sensitive and 97.1% specific
Curvilinear probe may be preferable as it provides a larger field of view

Editor’s Note: rather than explain what you’re looking for… just go here

References:

Gottlieb M, Holladay D, Peksa GD. Ultrasonography for the Confirmation of Endotracheal Tube Intubation: A Systematic Review and Meta-Analysis. Ann Emerg Med. 2018 Dec;72(6):627-636. doi: 10.1016/j.annemergmed.2018.06.024. Epub 2018 Aug 14. PubMed PMID: 30119943.

Summarized and edited by Erik Verzemnieks, MD

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Author: Aaron Lessen, MD

Educational Pearls:

Dyspnea can occur in up to 50% of intubated patients
Dyspnea is associated with prolonged mechanical intubation
Often goes undiagnosed as these patients have difficulty communicating
Expert opinion on reducing sensation of dyspnea
- Reduce stimulation of respiratory drive like fever and acidosis
- Give bronchodilators for patients with wheezing
- Optimize the ventilator settings
- Use medications for comfort (i.e. opioids, benzodiazepines)

References:

Decavèle M, Similowski T, Demoule A. Detection and management of dyspnea in mechanically ventilated patients. Curr Opin Crit Care. 2019 Feb;25(1):86-94. doi: 10.1097/MCC.0000000000000574. PubMed PMID: 30531366.

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

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Author: Sue Chilton, MD

Educational Pearls:

Measles is highly contagious
Typically patients just look sick
Remember 4 & 4, 14, and 4-C’s:
- Contagious 4 days before and after onset of rash
- 14 days for rash to appear
- Cough, coryza, conjunctivitis (non-purulent), and Koplik’s spots
Under 2 and over 20 are highest risk groups
1 in 1000 will die
Subacute sclerosing panencephalitis is one of the most feared, degenerative, 100% fatal complications that can occur up to two decades after initial infection

Editor’s Note: Don’t be pro-plague - if you can, vaccinate your children.

References:

https://www.denverpost.com/2019/01/16/denver-measles-exposure/

Moss WJ. Measles. Lancet. 2017 Dec 2;390(10111):2490-2502. doi: 10.1016/S0140-6736(17)31463-0. Epub 2017 Jun 30. Review. PubMed PMID: 28673424.

Bester JC. Measles and Measles Vaccination: A Review. JAMA Pediatr. 2016 Dec 1;170(12):1209-1215. doi: 10.1001/jamapediatrics.2016.1787. Review. PubMed PMID: 27695849.

Summarized and edited by Erik Verzemnieks, MD

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Author: Jared Scott, MD

Educational Pearls:

CXR is 40-90% sensitive for detecting pneumonia when compared to CT
Patients with a high degree of suspicion for pneumonia may still warrant treatment despite a negative CXR

References:

Self WH, Courtney DM, McNaughton CD, Wunderink RG, Kline JA. High discordance of chest x-ray and computed tomography for detection of pulmonary opacities in ED patients: implications for diagnosing pneumonia. Am J Emerg Med. 2013 Feb;31(2):401-5. doi: 10.1016/j.ajem.2012.08.041. Epub 2012 Oct 18. PubMed PMID: 23083885; PubMed Central PMCID: PMC3556231.

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

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Author: Don Stader, MD

Educational Pearls:

Recent study demonstrated patients with non-STEMI treated with heparin had no difference in survival, but had an increased risk of major bleeding
Heparin may be an outdated medication in the era of dual anti-platelet therapy and PCI
Heparin may fall to the wayside like other former treatments for ACS such as morphine, oxygen and nitroglycerin as far as mortality benefit

References:

Chen JY, He PC, Liu YH, Wei XB, Jiang L, Guo W, Duan CY, Guo YS, Yu XP, Li J, Li WS, Zhou YL, Lin CY, Luo JF, Yu DQ, Chen ZJ, Chen W, Chen YY, Guo ZQ, Geng QS, Tan N. Association of Parenteral Anticoagulation Therapy With Outcomes in Chinese Patients Undergoing Percutaneous Coronary Intervention for Non-ST-Segment Elevation Acute Coronary Syndrome. JAMA Intern Med. 2019 Feb 1;179(2):186-194. doi: 10.1001/jamainternmed.2018.5953. PubMed PMID: 30592483

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

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Author: Katie Sprinkle, MD

Educational Pearl:

Carbon monoxide (CO) is the leading cause of death from poison world-wide
CO forms from the combustion of any carbon based product
Patients often present with non specific symptom like headache, vomiting, and malaise
Consider this diagnosis with multiple people presenting with similar symptoms from a single location
Treatment is with high flow oxygen (i.e. non-rebreather)
Hyperbaric therapy is controversial and up for debate - discussion with local consultants may help guide this management/transfer
Tobacco smokers typically have elevated levels of carbon monoxide at baseline

Editor’s Note: *smoking hookah for one hour may be the equivalent of smoking nearly 100 cigarettes*

References:

Jacob P, Abu Raddaha AH, Dempsey D, et al. Nicotine, carbon monoxide, and carcinogen exposure after a single use of a water pipe. Cancer Epidemiol Biomarkers Prev. 2011;20(11):2345-53.

Ng PC, Long B, Koyfman A. Clinical chameleons: an emergency medicine focused review of carbon monoxide poisoning. Intern Emerg Med. 2018 Mar;13(2):223-229. doi: 10.1007/s11739-018-1798-x. Epub 2018 Feb 12. Review. Erratum in: Intern Emerg Med. 2018 Mar 22;:. PubMed PMID: 29435715.

American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Carbon Monoxide Poisoning:., Wolf SJ, Maloney GE, Shih RD, Shy BD, Brown MD. Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Acute Carbon Monoxide Poisoning. Ann Emerg Med. 2017 Jan;69(1):98-107.e6. doi: 10.1016/j.annemergmed.2016.11.003. PubMed PMID: 27993310.

Guzman JA. Carbon monoxide poisoning. Crit Care Clin. 2012 Oct;28(4):537-48. doi: 10.1016/j.ccc.2012.07.007. Review. PubMed PMID: 22998990.

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

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Author: Aaron Lessen, MD

Educational Pearls:

Several studies have shown administration of tPA can improve outcomes and reduce need for amputation
tPA is considered in grade III and IV frostbite
tPA cannot be given until after the warming process
Administration is systemically, not catheter directed or intra-arterial

References:

Jones LM, Coffey RA, Natwa MP, Bailey JK. The use of intravenous tPA for the treatment of severe frostbite. Burns. 2017 Aug;43(5):1088-1096. doi: 10.1016/j.burns.2017.01.013. Epub 2017 Jan 31. PubMed PMID: 28159151.

Wexler A, Zavala S. The Use of Thrombolytic Therapy in the Treatment of Frostbite Injury. J Burn Care Res. 2017 Sep/Oct;38(5):e877-e881. doi: 10.1097/BCR.0000000000000512. PubMed PMID: 28296671.

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

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Author: Aaron Lessen, MD

Educational Pearl:

A double ingestion of a single pill is typically a benign event but several drug classes may cause problems
A published review of 10 years of single medication double dose ingestion found 12 out of 876 cases had adverse events. The drugs and events were:
- Propafenone ingestion leading to ventricular tachycardia
- Beta blocker ingestion leading to bradycardia and hypotension
- Calcium channel blocker leading to bradycardia and hypotension
- Bupropion ingestion leading to seizures
- Tramadol ingestion leading to ventricular tachycardia

Editor’s Note:

References:

Correia MS, Whitehead E, Cantrell FL, Lasoff DR, Minns AB. A 10-year review of single medication double-dose ingestions in the nation's largest poison control system. Clin Toxicol (Phila). 2019 Jan;57(1):31-35. doi: 10.1080/15563650.2018.1493205. Epub 2018 Nov 28. PubMed PMID: 30484705.

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

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Podcast # 437 : Myasthenia Gravis

Author: Gretchen Hinson, MD

Educational Pearls:

Myasthenia gravis (MG) is an antibody mediated autoimmune disorder against the acetylcholine receptors at the neuromuscular junctions.
Bimodal age distribution (20’s-30’s: women; 60’s-70’s: men)
Presents with fluctuating muscle weakness typically worse at the end of the day with upper extremities affected more than lower and typically involving facial muscles.
Myasthenia crisis occurs when muscle fatigue begins to cause respiratory depression
MG was historically diagnosed with the Tensilon test but now often by EMG
Treatment of MG crisis involves plasma exchange and IVIG. Those in crisis often require intubation and ICU admission

References:

Gilhus NE. Myasthenia Gravis. N Engl J Med. 2016 Dec 29;375(26):2570-2581. doi: 10.1056/NEJMra1602678. Review. PubMed PMID: 28029925.

Roper J, Fleming ME, Long B, Koyfman A. Myasthenia Gravis and Crisis: Evaluation and Management in the Emergency Department. J Emerg Med. 2017 Dec;53(6):843-853. doi: 10.1016/j.jemermed.2017.06.009. Epub 2017 Sep 12. PubMed PMID: 28916122.

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

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Author: Charleen Gnisci, PharmD

Educational Pearls:

Between 2011 to 2016, Mylan increased EpiPen prices by 400% ($700 for 2 packs)
AUVI-Q was recalled in 2012, which left the market share to the EpiPen until recently
Teva announced last year it will be making a generic version of the EpiPen retailing around $300 but expected to decrease

References:

Kaplan, S. F.D.A. Approves Generic EpiPen That May Be Cheaper. The New York Times, The New York Times, 2018. Retrived from www.nytimes.com/2018/08/16/health/epipen-generic-drug-prices.html.

Tirrell, M. FDA approves Teva's generic EpiPen after yearslong delay. 2018. Retrieved from https://www.cnbc.com/2018/08/16/fda-approves-tevas-generic-epipen-after-years-long-delay.html

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

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Author: Ryan Circh, MD

Educational Pearls:

Ulnar collateral ligament injury is often called gamekeeper’s thumb or skier’s thumb
Can results from traumatic deviating the thumb radially (abduction)
Poor rabbits
Have a low threshold for referral to hand surgery for follow up - treatment for minor injuries can be conservative but more severe require surgery to preserve function
This injury should be placed in a thumb spica splint
Radiographs are often negative unless an avulsion fracture is present

Editor’s note: to test for UCL injuries, I like this.

References:

Schroeder NS, Goldfarb CA. Thumb ulnar collateral and radial collateral ligament injuries. Clin Sports Med. 2015 Jan;34(1):117-26. doi: 10.1016/j.csm.2014.09.004. Epub 2014 Oct 11. Review. PubMed PMID: 25455399.

Madan SS, Pai DR, Kaur A, Dixit R. Injury to ulnar collateral ligament of thumb. Orthop Surg. 2014 Feb;6(1):1-7. doi: 10.1111/os.12084. Review. PubMed PMID: 24590986.

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

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Author: Peter Bakes, MD

Educational Pearl:

Transient ischemic attack (TIA) is defined as neurologic symptoms that resolve in 24 hours with no new changes on head imaging
Mimics include complex migraine, carotid dissection, seizure (Todd’s paralysis)
Typical presentation is with sudden onset of negative symptoms such as numbness, weakness, etc.
Mimics tend to have positive symptoms such as photophobia, pain, etc.

References:

Kernan WN, Ovbiagele B, Black HR, et al. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2014; 45:2160.

Simmons B, et al. Transient Ischemic Attack: Part I. Diagnosis and Evaluation. American Family Physician 2012; 86(6):521-526.

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

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Author: Michael Hunt, MD

Educational Pearls:

Recent study compared ketamine to morphine in elderly patient
Ketamine (IV dose 0.3 mg /kg) provided equivalent pain control to morphine (IV dose 0.1 mg / kg)
However, etamine group had much higher rate of side effects, including psychoperceptual
A lower does of 0.1 mg / kg given intravenously over 15 minutes might be a better option to start in the elderly population - you can always add more!

References

Motov S, Mann S, Drapkin J, Butt M, Likourezos A, Yetter E, Brady J, Rothberger N, Gohel A, Flom P, Mai M, Fromm C, Marshall J. Intravenous subdissociative-dose ketamine versus morphine for acute geriatric pain in the Emergency Department: A randomized controlled trial. Am J Emerg Med. 2019 Feb;37(2):220-227. doi: 10.1016/j.ajem.2018.05.030. Epub 2018 May 16. PubMed PMID: 29807629.

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Author: Michael Hunt, MD

Educational Pearls:

As many as 20% of women in assisted living have asymptomatic bacteriuria
This can present a diagnostic conundrum when seeing these patients in the emergency department, particularly for altered mental status and deciding whether to treat
True diagnosis of UTI in the emergency department is difficult as true diagnoses required culture results and repeated positive samples
Procalcitonin is an emerging biomarker that may be helpful in determining the presence of infection

References:

Cortes-Penfield NW, Trautner BW, Jump RLP. Urinary Tract Infection and Asymptomatic Bacteriuria in Older Adults. Infect Dis Clin North Am. 2017 Dec;31(4):673-688. doi: 10.1016/j.idc.2017.07.002. Review. PubMed PMID: 29079155; PubMed Central PMCID: PMC5802407.

Huang DT, Angus DC, Chang CH, Doi Y, Fine MJ, Kellum JA, Peck-Palmer OM, Pike F, Weissfeld LA, Yabes J, Yealy DM; ProACT Investigators.. Design and rationale of the Procalcitonin Antibiotic Consensus Trial (ProACT), a multicenter randomized trial of procalcitonin antibiotic guidance in lower respiratory tract infection. BMC Emerg Med. 2017 Aug 29;17(1):25. doi: 10.1186/s12873-017-0138-1. PubMed PMID: 28851296; PubMed Central PMCID: PMC5576372.

Summarized by Erik Verzemnieks, MD

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Author: Rachel Brady, MD

Educational Pearls:

Medication errors are estimated to be the 3rd leading cause of death
A 2016 study estimated 250,000 errors occur per year, with 7000-9000 leading to death
About 50% are in the ordering/prescribing phase; 25-30% during administration phase.
Overworked and distracted providers are the most common underlying reasons for medication error
A 2017 study found 40% of ED nurses witnessed a medication error in the last year

Editor’s Note: This is a reasonable counterpoint

References

Farag A, Blegen M, Gedney-Lose A, Lose D, Perkhounkova Y. Voluntary Medication Error Reporting by ED Nurses: Examining the Association With Work Environment and Social Capital. J Emerg Nurs. 2017 May;43(3):246-254. doi: 10.1016/j.jen.2016.10.015. Epub 2017 Mar 28. PubMed PMID: 28359712.

Makary MA, Daniel M. Medical error-the third leading cause of death in the US. BMJ. 2016 May 3;353:i2139. doi: 10.1136/bmj.i2139. PubMed PMID: 27143499.

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

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Author: Aaron Lessen, MD

Educational Pearls:

Choose the longest needle for the humeral IO
Internally rotate and adduct the patients hand (resting on umbilicus) for best access to the site
Aim 1 cm superior to the greater tuberosity of the humerus with the needle angled 45 degrees inferiorly
Maintaining the line is critical - keep arm internally rotated with sling, tape or whatever works

References

Kovar J, Gillum L. Alternate route: the humerus bone - a viable option for IO access. JEMS. 2010 Aug;35(8):52-9. doi: 10.1016/S0197-2510(10)70207-2. PubMed PMID: 20708143.

http://epmonthly.com/article/get-humeral-io-access/

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

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Author: Chris Holmes, MD

Educational Pearls:

In WWI, the 2nd leading cause of soldier disability were STDs.
An early treatment of syphilis included topical and inhaled mercury
Bloodletting, vitriol, arsenic, and bismuth were other treatments for syphilis.
Infecting patients with Malaria and treating the Malaria was also tried
Thankfully penicillin was discovered for our syphilis woes

References

Frith J. . Syphilis – Its early history and Treatment until Penicillin and the Debate on its Origins. Journal of Military and Veterans Health. 2012. 20(4): 49-58 https://jmvh.org/article/syphilis-its-early-history-and-treatment-until-penicillin-and-the-debate-on-its-origins/

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

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Author: Gretchen Hinson, MD

Educational Pearls:

Clinical manifestations of severe hypothyroidism may include:
- Pale, cool, diaphoretic skin
- Myxedema is the non-pitting edema seen in hypothyroidism
- Hypothermia, heart failure, hypotension and shock
- Shortness of breath
- Cholestasis, constipation
- Encephalopathy and coma

Mortality is 30-50%

Specific treatment includes thyroid hormone (T3, T4, or both) and glucocorticoids (for potential adrenal insufficiency)

References:

Kwaku MP, Burman KD. Myxedema coma. J Intensive Care Med. 2007 Jul-Aug;22(4):224-31. Review. PubMed PMID: 17712058.

Ono Y, Ono S, Yasunaga H, Matsui H, Fushimi K, Tanaka Y. Clinical characteristics and outcomes of myxedema coma: Analysis of a national inpatient database in Japan. J Epidemiol. 2017 Mar;27(3):117-122. doi: 10.1016/j.je.2016.04.002. Epub 2017 Jan 5. PubMed PMID: 28142035; PubMed Central PMCID: PMC5350620.

Lee CH, Wira CR. Severe angioedema in myxedema coma: a difficult airway in a rare endocrine emergency. Am J Emerg Med. 2009 Oct;27(8):1021.e1-2. doi: 10.1016/j.ajem.2008.12.027. PubMed PMID: 19857436.

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

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Author: Eric Miller, MD

Educational Pearls:

Recent CDC statement warms against consumption of cookie dough
Two common ingredients can pose risk: eggs and flour
Flour in dough is a raw agricultural product not treated to kill E. coli
A 2016 E. coli outbreak was linked to flour

References:

https://www.cdc.gov/features/no-raw-dough/index.html

https://www.cdc.gov/ecoli/2016/o121-06-16/index.html

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

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Author: Katrina Iverson, MD

Educational Pearls:

The winter holiday months present a unique picture of patient presentations to the emergency department
- Some of the unique presentations include:
- Children falling off Santa’s lap
- Sledding injuries
- Falling off ladders
- Lacerations, ingestion, and insertion of broken ornaments (pediatrics)
Parents tend to hurt themselves on their children’s toys

References:

Lauche R, et al. (2018). ‘Santa baby, hurry [extra carefully] down the chimney tonight’ – Prevalence of Christmas related injuries 2007–2016 in the United States: Observational study. Advances in Integrative Medicine. https://doi.org/10.1016/j.aimed.2018.11.004

https://areyouawellbeing.texashealth.org/common-winter-injuries/

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

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Author: Aaron Lessen, MD

Educational Pearls:

Recent meta-analysis reviewed efficacy oseltamivir (Tamiflu) in pediatric populations treated for influenza, showing an 18 hour reduction in duration of illness for those with laboratory confirmed influenza
Those with suspected influenza unsurprisingly had less effect
Subgroup analysis showed most benefit in those treated within the first 24 hours of symptom onset
Patients with confirmed influenza treated with oseltamivir had a 34% reduction in risk of otitis media

Editor’s note: Vomiting was higher in the treatment groups; There were no significantly different outcomes in regards to other endpoints, such as lower respiratory tract infections and hospitalizations

References:

Malosh RE, Martin ET, Heikkinen T, Brooks WA, Whitley RJ, Monto AS. Efficacy and Safety of Oseltamivir in Children: Systematic Review and Individual Patient Data Meta-analysis of Randomized Controlled Trials. Clin Infect Dis. 2018 May 2;66(10):1492-1500. doi: 10.1093/cid/cix1040. PubMed PMID: 29186364.

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

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Author: Mike Hunt, MD

Educational Pearls:

Measles is highly contagious and successfully infects 90% of those at risk exposed to the virus.
10 day prodrome where patients are asymptomatic.
3 day period of characteristic cough, coryza, conjunctivitis, fever and Koplick spots with a maculopapular rash that moves from head through trunk
Infection risk extends three to four days after the onset of rash but also three to four days prior to onset. Have fun with that.
A potential exposure, say in an emergency department waiting room, needs review of any exposed patient’s immunization history to contain spread

References:

Moss WJ. Measles. Lancet. 2017 Dec 2;390(10111):2490-2502. doi: 10.1016/S0140-6736(17)31463-0. Epub 2017 Jun 30. Review. PubMed PMID: 28673424.

Bester JC. Measles and Measles Vaccination: A Review. JAMA Pediatr. 2016 Dec 1;170(12):1209-1215. doi: 10.1001/jamapediatrics.2016.1787. Review. PubMed PMID: 27695849.

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

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Author: Mike Hunt, MD

Educational Pearls:

Blunt cardiac injuries most commonly occur in motor vehicle collisions, auto-pedestrian collisions, and from sports injuries
The more anterior right ventricle is the most commonly injured structure
Look for new EKG changes such as bundle branch blocks, ST changes, or other arrhythmias
New EKG abnormalities should prompt consideration of further workup and admission for telemetry
Patients may have an elevated troponin - but it is unclear when exactly this should be drawn after the injury

References:

Bellister SA, Dennis BM, Guillamondegui OD. Blunt and Penetrating Cardiac Trauma. Surg Clin North Am. 2017 Oct;97(5):1065-1076. doi: 10.1016/j.suc.2017.06.012. Review. PubMed PMID: 28958358.

Marcolini EG, Keegan J. Blunt Cardiac Injury. Emerg Med Clin North Am. 2015 Aug;33(3):519-27. doi: 10.1016/j.emc.2015.04.003. Epub 2015 Jun 10. Review. PubMed PMID: 26226863.

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

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Author: Jared Scott, MD

Educational Pearls:

From 1996 to 2012, the total quantity of opioids prescribed increased 647% for non-cancer pain
Office based prescriptions accounted for 84% of the total opioid prescriptions, up from 64%
The total share of opioids prescribed from the emergency department declined from 10% to 3.9% but
Total opioids prescribed from the ED still increased 219% over this same time frame

References:

Axeen S, Seabury SA, Menchine M. Emergency Department Contribution to the Prescription Opioid Epidemic. Ann Emerg Med. 2018 Jun;71(6):659-667.e3. doi: 10.1016/j.annemergmed.2017.12.007. Epub 2018 Jan 16. PubMed PMID: 29373155

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

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Author: Gretchen Hinson, MD

Educational Pearls:

Diabetic ketoacidosis patients are subject to electrolyte derangements
Potassium should be monitored closely:
- K < 3.3 = Do not give insulin and replete K first
- 3.3 < K < 5.3 = give 20-30mEq K for each L of IVF
- K > 5.3 = delay potassium replacement
- Adult patients are typically severely volume depleted and can require 50 cc/kg bolus or more
- Insulin typically given in bolus of 0.1 units/kg followed by drip at 0.1 units/kg/hr

References:

Fayfman M, Pasquel FJ, Umpierrez GE. Management of Hyperglycemic Crises: Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar State. Med Clin North Am. 2017 May;101(3):587-606. doi: 10.1016/j.mcna.2016.12.011. Review. PubMed PMID: 28372715.

Nyenwe EA, Kitabchi AE. The evolution of diabetic ketoacidosis: An update of its etiology, pathogenesis and management.Metabolism. 2016 Apr;65(4):507-21. doi: 10.1016/j.metabol.2015.12.007. Epub 2015 Dec 19. Review. PubMed PMID: 26975543.

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

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Author: Don Stader, MD

Educational Pearls:

Recent meta-analysis has demonstrated that there is no significant risk for kidney injury from CT contrast
Most kidney injury seen after contrast CTs were due to other underlying illnesses (sepsis, hypovolemia, etc.)
Older contrast agents likely did have nephrotoxic effects but this appears to be a thing of the past

References:

Aycock RD, Westafer LM, Boxen JL, Majlesi N, Schoenfeld EM, Bannuru RR. Acute Kidney Injury After Computed Tomography: A Meta-analysis. Ann Emerg Med. 2018 Jan;71(1):44-53.e4. doi: 10.1016/j.annemergmed.2017.06.041. Epub 2017 Aug 12. Review. PubMed PMID: 28811122.

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

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Author: Don Stader, MD

Educational Pearls:

Etripamil is an intranasal calcium channel blocker in development for use in SVT
A recent study showed that etripamil has an SVT conversion rate of around 80%
Etripamil does not have the same feeling of “impending doom” that can occur with adenosine

Editor's note: Etripamil is still in development and these results are from a phase II clinical trial.

References:

Stambler BS, Dorian P, Sager PT, Wight D, Douville P, Potvin D, Shamszad P, Haberman RJ, Kuk RS, Lakkireddy DR, Teixeira JM, Bilchick KC, Damle RS, Bernstein RC, Lam WW, O'Neill G, Noseworthy PA, Venkatachalam KL, Coutu B, Mondésert B, Plat F. Etripamil Nasal Spray for Rapid Conversion of Supraventricular Tachycardia to Sinus Rhythm. J Am Coll Cardiol. 2018 Jul 31;72(5):489-497. doi: 10.1016/j.jacc.2018.04.082. PubMed PMID: 30049309.

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

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Author: Don Stader, MD

Educational Pearls:

Vertebral artery dissection (VAD) contributes to just 2% of strokes overall but ~25% of strokes for patients < 30
VAD is associated with minor trauma (chiropractic manipulation, yoga), typically with neck extension and rotation.
VAD can cause posterior stroke symptoms (vertigo, diplopia, Horner’s Syndrome, Wallenberg Syndrome)
Overall a good prognosis with around 50% of patients recovering without lasting neurologic deficits.

References:

Debette S, Leys D. Cervical-artery dissections: predisposing factors, diagnosis, and outcome. Lancet Neurol. 2009 Jul;8(7):668-78. doi: 10.1016/S1474-4422(09)70084-5. Review. PubMed PMID: 19539238.

Gottesman RF, Sharma P, Robinson KA, et al. Clinical characteristics of symptomatic vertebral artery dissection: a systematic review. Neurologist. 2012;18(5):245-54.

Schievink WI. Spontaneous dissection of the carotid and vertebral arteries. N Engl J Med. 2001 Mar 22;344(12):898-906. Review. PubMed PMID: 11259724.

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

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Author: Katie Sprinkle, MD

Educational Pearls:

Hyponatremia results when patients over hydrate and dilute their sodium with too much free water
Symptoms of hyponatremia can mimic symptoms of dehydration (dizziness, lightheadedness, general malaise)
With severe hyponatremia patients can progress to seizure, coma, and death
Hypernatremia results from dehydration and is more common

References:

Bennett BL, Hew-Butler T, Hoffman MD, Rogers IR, Rosner MH; Wilderness Medical Society.. Wilderness Medical Society practice guidelines for treatment of exercise-associated hyponatremia: 2014 update. Wilderness Environ Med. 2014 Dec;25(4 Suppl):S30-42. doi: 10.1016/j.wem.2014.08.009. PubMed PMID: 25498260.

Braun MM, Barstow CH, Pyzocha NJ. Diagnosis and management of sodium disorders: hyponatremia and hypernatremia. Am Fam Physician. 2015 Mar 1;91(5):299-307. PubMed PMID: 25822386.

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

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Author: Aaron Lessen, MD

Educational Pearls:

Defined as QRS over 120 ms and rate over 120
Two major rhythms = Vetricular tachycardia (VT) or SVT with aberrancy
Safest approach is to assume it is VT
Synchronized Cardioversion is preferred even for stable VT for multiple reasons including safety and efficacy
Procainamide is preferred pharmacologic option
Amiodarone is less preferred third option
Calcium channel blockers (i.e. diltiazem) can worsen certain rhythms and should be avoided

References:

Long B, Koyfman A. Best Clinical Practice: Emergency Medicine Management of Stable Monomorphic Ventricular Tachycardia. J Emerg Med. 2017 Apr;52(4):484-492. doi: 10.1016/j.jemermed.2016.09.010. Epub 2016 Oct 15. Review. PubMed PMID: 27751700.

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

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Author: Ryan Circh, MD

Educational Pearls:

Myofascial pain syndrome (MFPS) is typically unilateral with discrete points of palpable pain
Often secondary to repeated use and poor posture.
MFPS typically responds very well to trigger point injections.
Fibromyalgia is bilateral and diffuse and is thought to have a psychological component
Some of the best pharmacological treatments for fibromyalgia are Tramadol and Flexeril

References:

Tofferi JK, Jackson JL, O'Malley PG. Treatment of fibromyalgia with cyclobenzaprine: A meta-analysis. Arthritis Rheum. 2004 Feb 15;51(1):9-13. PubMed PMID: 14872449.

Goldenberg DL, Burckhardt C, Crofford L. Management of fibromyalgia syndrome. JAMA. 2004 Nov 17;292(19):2388-95. Review. PubMed PMID: 15547167.

Giamberardino MA, Affaitati G, Fabrizio A, Costantini R. Myofascial pain syndromes and their evaluation. Best Pract Res Clin Rheumatol. 2011 Apr;25(2):185-98. doi: 10.1016/j.berh.2011.01.002. Review. PubMed PMID: 22094195.

Borg-Stein J, Iaccarino MA. Myofascial pain syndrome treatments. Phys Med Rehabil Clin N Am. 2014 May;25(2):357-74. doi: 10.1016/j.pmr.2014.01.012. Epub 2014 Mar 17. Review. PubMed PMID: 24787338

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

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Author: Dylan Luyten, MD

Educational Pearls:

Symptoms of acute limb ischemia are the 5 P’s: Pulselessness, pain, pallor, paresthesias, and poikilothermia
Sudden onset of non-traumatic extremity pain should raise concern for this diagnosis
Obtaining an ankle brachial index (ABI) can help confirm the diagnosis
Consultation with vascular surgery should be immediately after the clinical diagnosis and before any further delays to obtain further imaging

References:

Santistevan JR. Acute Limb Ischemia: An Emergency Medicine Approach. Emerg Med Clin North Am. 2017 Nov;35(4):889-909. doi: 10.1016/j.emc.2017.07.006. Epub 2017 Aug 23. Review. PubMed PMID: 28987435.

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

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Author: Katie Sprinkle, MD

Educational Pearls:

The fascia iliaca block is useful for hip and proximal femur fractures.
Typically involves injecting 40-60 mL of diluted bupivacaine (0.25%) under the fascia iliaca (or other anesthetic)
Anesthesia is achieved of the femoral, obturator, and lateral femoral cutaneous nerves.
Monitor for signs of bupivacaine toxicity (paresthesias, AMS, seizures, arrhythmias)
Intralipid can be an effective treatment for life-threatening toxicity

References:

Hoegberg LC, Bania TC, Lavergne V, Bailey B, Turgeon AF, Thomas SH, Morris M, Miller-Nesbitt A, Mégarbane B, Magder S, Gosselin S; Lipid Emulsion Workgroup.. Systematic review of the effect of intravenous lipid emulsion therapy for local anesthetic toxicity. Clin Toxicol (Phila). 2016 Mar;54(3):167-93. doi: 10.3109/15563650.2015.1121270. Epub 2016 Feb 6. Review. PubMed PMID: 26853119.

https://www.acepnow.com/article/control-hip-fracture-pain-without-opioids-using-ultrasound-guided-fascia-iliaca-compartment-block/?singlepage=1&theme=print-friendly

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

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Author: Aaron Lessen, MD

Educational Pearls:

Patients with "minor" strokes with NIHSS 0 to 5 can still end up having poor long-term outcomes
Recent study compared use of alteplase vs. aspirin for these patients and saw no difference in regards to favorable neurologic outcome at 90 days
Study was ended early due to patient recruitment difficulties

Editor's note: though ended early, it is debatable whether even if appropriately powered there would have been an identifiable benefit

References:

Khatri P, Kleindorfer DO, Devlin T, Sawyer RN Jr, Starr M, Mejilla J, Broderick J, Chatterjee A, Jauch EC, Levine SR, Romano JG, Saver JL, Vagal A, Purdon B, Devenport J, Pavlov A, Yeatts SD; PRISMS Investigators. Effect of Alteplase vs Aspirin on Functional Outcome for Patients With Acute Ischemic Stroke and Minor Nondisabling Neurologic Deficits: The PRISMS Randomized Clinical Trial. JAMA. 2018 Jul 10;320(2):156-166. doi: 10.1001/jama.2018.8496. PubMed PMID: 29998337.

Summary by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

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Author: Dylan Luyten, MD

Educational Pearls:

Early recognition that the current situation is a mass casualty incident (MCI) is essential with establishing a sole provider/nurse to oversee
Team members labeling themselves by name and role is also helpful
Practice and prepare for these unfortunate events

Editor’s note: This podcast comes at the end of a MCI drill over several days

References:

http://epmonthly.com/article/not-heroes-wear-capes-one-las-vegas-ed-saved-hundreds-lives-worst-mass-shooting-u-s-history/

Summary by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

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Author: Aaron Lessen, MD

Educational Pearls:

Retrospective study looking at type of transportation and mortality outcomes for patients with penetrating trauma
Mortality was 2.2 % for those brought in by private vehicle compared to 11.6% by EMS

Editor’s note: the above is raw mortality - even after risk adjustments the odds ratio of death was statistically significant for penetrating injuries, which held true even over multiple trauma systems. Shout out to Dr Haut as well!

References:

Wandling MW, Nathens AB, Shapiro MB, Haut ER. Association of Prehospital Mode of Transport With Mortality in Penetrating Trauma: A Trauma System-Level Assessment of Private Vehicle Transportation vs Ground Emergency Medical Services. JAMA Surg. 2018 Feb 1;153(2):107-113. doi: 10.1001/jamasurg.2017.3601. PubMed PMID: 28975247; PubMed Central PMCID: PMC5838586.

Summary by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

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Author: Nick Hatch, MD

Educational Pearls:

Quick review on typical treatments for acute CHF:
- Nitrates are a mainstay to reduce preload
- Furosemide has fallen out of favor in regards to urgency but still essential; it can also be utilized in those with poor renal function
Before going into the weeds:
- Phlebotomy can be used to remove volume and may be helpful in certain clinical scenarios
- Trapping venous blood by using blood pressure cuffs on three of four extremities was a very early treatment of CHF

References:

Alzahri MS, Rohra A, Peacock WF. Nitrates as a Treatment of Acute Heart Failure. Card Fail Rev. 2016 May;2(1):51-55. doi: 10.15420/cfr.2016:3:3. PubMed PMID: 28785453; PubMed Central PMCID: PMC5490950.

Paterna S, Di Gaudio F, La Rocca V, Balistreri F, Greco M, Torres D, Lupo U, Rizzo G, di Pasquale P, Indelicato S, Cuttitta F, Butler J, Parrinello G. Hypertonic Saline in Conjunction with High-Dose Furosemide Improves Dose-Response Curves in Worsening Refractory Congestive Heart Failure. Adv Ther. 2015 Oct;32(10):971-82. doi: 10.1007/s12325-015-0254-9. Epub 2015 Oct 31. PubMed PMID: 26521190; PubMed Central PMCID: PMC4635178.

Huijskes RV, Hoogenberg K, Wiesfeld AC, Pijl ME, van Gelder IC. Phlebotomies as a treatment of serious heart failure due to haemochromatosis: a case report. Neth Heart J. 2009;17(11):438-41.

Burch, George E., and Nicholas P. DePasquale. "Congestive Heart Failure—Acute Pulmonary Edema." JAMA 208.10 (1969): 1895-1897.

Summary by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

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Author: Don Stader, MD

Educational Pearls:

Recent study showed efficacy 5mg IM midazolam > 10mg IM olanzapine > 10mg IM haloperidol for quickly sedating an agitated patient
If you have access, ketamine intravenous is the fastest
Olanzapine should be used with caution in elderly patients because of its anticholinergic properties
Ketamine can transiently worsen psychosis in some mental illness
Haloperidol is contraindicated in patients with prolonged QT
Olanzapine can be safely given intravenous as another option to your sedating arsenal

References:

Chew ML, Mulsant BH, Pollock BG, Lehman ME, Greenspan A, Kirshner MA, Bies RR, Kapur S, Gharabawi G. A model of anticholinergic activity of atypical antipsychotic medications. Schizophr Res. 2006 Dec;88(1-3):63-72. Epub 2006 Aug 22. PubMed PMID: 16928430.

Mankowitz SL, Regenberg P, Kaldan J, Cole JB. Ketamine for Rapid Sedation of Agitated Patients in the Prehospital and Emergency Department Settings: A Systematic Review and Proportional Meta-Analysis. J Emerg Med. 2018 Nov;55(5):670-681. doi: 10.1016/j.jemermed.2018.07.017. Epub 2018 Sep 7. PubMed PMID: 30197153.

Summary by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

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Author: Don Stader, MD

Educational Pearls:

Three options for a blister in partial thickness burns: do nothing, unroof it, or poke a hole in it
Recent study suggest that aspirating the blister may be more effective in regards to wound healing
The overlying skin acts as a bio-band-aid and patients recover slightly faster

References:

Ro HS, Shin JY, Sabbagh MD, Roh SG, Chang SC, Lee NH. Effectiveness of aspiration or deroofing for blister management in patients with burns: A prospective randomized controlled trial. Medicine (Baltimore). 2018 Apr;97(17):e0563. doi: 10.1097/MD.0000000000010563. PubMed PMID: 29703044; PubMed Central PMCID: PMC5944508.

Summary by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

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Author: Don Stader, MD

Educational Pearls:

Intravenous Tylenol currently is many times more expensive than oral
Single ED study comparing the two has methodology flaws and there is a lack of additional evidence to support intravenous over oral formulations solely for pain control
Oral Tylenol appears to be at least equally efficacious, though with a slightly slower onset of action

References:

Furyk J, Levas D, Close B, Laspina K, Fitzpatrick M, Robinson K, Vangaveti VN, Ray R. Intravenous versus oral paracetamol for acute pain in adults in the emergency department setting: a prospective, double-blind, double-dummy, randomised controlled trial. Emerg Med J. 2018 Mar;35(3):179-184. doi: 10.1136/emermed-2017-206787. Epub 2017 Dec 15. PubMed PMID: 29247042.

Jibril F, Sharaby S, Mohamed A, Wilby KJ. Intravenous versus Oral Acetaminophen for Pain: Systematic Review of Current Evidence to Support Clinical Decision-Making. Can J Hosp Pharm. 2015 May-Jun;68(3):238-47. Review. PubMed PMID: 26157186; PubMed Central PMCID: PMC4485512.

Summary by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

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Author: Don Stader, MD

Educational Pearls:

Recent study has revealed that infant walkers are more harmful than helpful
Infant walkers can also delay motor function
The American Academy of Pediatrics calls for a ban on walkers as they are a preventable cause of injury

References:

Siegel AC, Burton RV. (1999).Effects of baby walkers on motor and mental development in human infants. Journal of Developmental and Behavioral Pediatrics. 20:355–361.

Sims A, et al. (2018). Infant Walker-Related Injuries in United States. Pediatrics 142(4).

Summary by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

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Author: Sam Killian, MD

Educational Pearls:

Recent news articles are showing an increase in injuries related to riding electric scooters
Year-to-year, scooter injuries have increased as high as three to four times
More definitive evidence still to come

Editor’s note: don’t follow birdgraveyard on instagram

References:

https://www.washingtonpost.com/business/economy/scooter-use-is-rising-in-major-cities-so-are-trips-to-the-emergency-room/2018/09/06/53d6a8d4-abd6-11e8-a8d7-0f63ab8b1370_story.html?noredirect=on&utm_term=.a6e46ff35bdc

https://kutv.com/news/local/er-doctors-report-161-increase-in-scooter-injuries-in-downtown-salt-lake-city

Summary by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

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Author: Mark Hinton, MD

Educational Pearls:

Meniscus lock can occur with a tear leading to inability to extend the knee
Treatment can include an intra-articular joint block followed by straightening
Medial meniscus injuries are more common

References:

Allum RL, Jones JR. The locked knee. Injury. 1986 Jul;17(4):256-8. PubMed PMID: 3770920.

Critchley IJ, Bracey DJ. The acutely locked knee--is a manipulation worth while? Injury. 1985 Jan;16(4):281-3. PubMed PMID: 3967919.

Summary by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

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Educational Pearls:

RSI includes induction agent (sedative) and a paralytic
Succinylcholine is a depolarizing paralytic of rapid onset and short duration with contraindications in hyperkalemic states and muscular dystrophy
Rocuronium and vecuronium are longer acting, non-depolarizing paralytic, more commonly
Common induction agents are etomidate and ketamine
Ketamine can be particularly beneficial for bronchodilator effects in those with reactive airway disease

References:

Stollings JL, Diedrich DA, Oyen LJ, Brown DR. Rapid-sequence intubation: a review of the process and considerations when choosing medications. Ann Pharmacother. 2014 Jan;48(1):62-76. doi: 10.1177/1060028013510488. Epub 2013 Nov 4. Review. PubMed PMID: 24259635.

Summary by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

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Author: Gretchen Hinson, MD

Educational Pearls:

Diagnosis can be difficult and often delayed
Asymmetric breath sounds, choking, stridor may be present, but children also present asymptomatically
Peak incidence around one to two years of age
Hot dogs, nuts, popcorn – round and smooth objects are most commonly aspirated

References:

Green SS. Ingested and Aspirated Foreign Bodies. Pediatr Rev. 2015 Oct;36(10):430-6. doi: 10.1542/pir.36-10-430. Review. PubMed PMID: 26430203.

Sink JR, Kitsko DJ, Georg MW, Winger DG, Simons JP. Predictors of Foreign Body Aspiration in Children. Otolaryngol Head Neck Surg. 2016 Sep;155(3):501-7. doi: 10.1177/0194599816644410. Epub 2016 Apr 12. PubMed PMID: 27071446.

Summary by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

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Author: Dylan Luyten, MD

Educational Pearls:

Extracorporeal membrane oxygenation (ECMO) is similar to bypass
ECMO is being utilized routinely at some centers and even prehospital in cardiac arrest
There are two general types of ECMO:
- Venovenous (VV-ECMO) is useful when the patient cannot oxygenate but has adequate heart function.
- Venoarterial (VA-ECMO) is more like typical bypass and can be used in a pulseless patient

References:

Ouweneel DM, Schotborgh JV, Limpens J, Sjauw KD, Engström AE, Lagrand WK, Cherpanath TGV, Driessen AHG, de Mol BAJM, Henriques JPS. Extracorporeal life support during cardiac arrest and cardiogenic shock: a systematic review and meta-analysis. Intensive Care Med. 2016 Dec;42(12):1922-1934. doi: 10.1007/s00134-016-4536-8. Epub 2016 Sep 19. Review. PubMed PMID: 27647331; PubMed Central PMCID: PMC5106498.

Tonna JE, Johnson NJ, Greenwood J, Gaieski DF, Shinar Z, Bellezo JM, Becker L, Shah AP, Youngquist ST, Mallin MP, Fair JF 3rd, Gunnerson KJ, Weng C, McKellar S; Extracorporeal REsuscitation ConsorTium (ERECT) Research Group.. Practice characteristics of Emergency Department extracorporeal cardiopulmonary resuscitation (eCPR) programs in the United States: The current state of the art of Emergency Department extracorporeal membrane oxygenation (ED ECMO). Resuscitation. 2016 Oct;107:38-46. doi: 10.1016/j.resuscitation.2016.07.237. Epub 2016 Aug 11. PubMed PMID: 27523953; PubMed Central PMCID: PMC5475402.

Summary by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

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Author: Michael Hunt, MD

Educational Pearls:

Alcohol and gallstones are most common causes of pancreatitis
Diagnosis is not simply based on lipase alone - must have at least two the the three criteria:
- Elevated lipase (greater than 3x upper limit of reference range)
- Typical pain (epigastric pain, radiating to back, etc.)
- Radiographic findings suggestive of pancreatitis (CT, MRI, US)
BISAP criteria can help risk stratify mortality in pancreatitis. You get 1 point for each of the following:
- BNP > 25
- Impaired mental status
- SIRS criteria, more than 2
- AGE > 60
- Pleural effusion
BISAP score of 0 has < 1% mortality

Editor’s note: The severity of pancreatitis does not correlate with serum lipase levels - notice how it is not used in the BISAP criteria, as an example. Even a mild elevation in serum testing can result in severe pancreatitis.

References:

Banks PA, Bollen TL, Dervenis C, Gooszen HG, Johnson CD, Sarr MG, Tsiotos GG, Vege SS; Acute Pancreatitis Classification Working Group.. Classification of acute pancreatitis--2012: revision of the Atlanta classification and definitions by international consensus. Gut. 2013 Jan;62(1):102-11. doi: 10.1136/gutjnl-2012-302779. Epub 2012 Oct 25. PubMed PMID: 23100216.

Papachristou GI, Muddana V, Yadav D, O'Connell M, Sanders MK, Slivka A, Whitcomb DC. Comparison of BISAP, Ranson's, APACHE-II, and CTSI scores in predicting organ failure, complications, and mortality in acute pancreatitis. Am J Gastroenterol. 2010 Feb;105(2):435-41; quiz 442. doi: 10.1038/ajg.2009.622. Epub 2009 Oct 27. PubMed PMID: 19861954.

Wu BU, Johannes RS, Sun X, Tabak Y, Conwell DL, Banks PA. The early prediction of mortality in acute pancreatitis: a large population-based study. Gut. 2008 Dec;57(12):1698-703. doi: 10.1136/gut.2008.152702. Epub 2008 Jun 2. PubMed PMID: 18519429.

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Author: Erik Verzemnieks, MD

Educational Pearls:

Recent study provides at least some evidence to help predict antibiotic failure for cellulitis, which is not necessarily straight forward
Intuitive risk factors such as recent cellulitis, chronic ulcers, history of MRSA are associated with antibiotic treatment failure
Oddly, tachypnea at triage was associated with the highest odds ratio for treatment failure

References:

Yadav K, Suh KN, Eagles D, MacIsaac J, Ritchie D, Bernick J, Thiruganasambandamoorthy V, Wells G, Stiell IG. Predictors of Oral Antibiotic Treatment Failure for Nonpurulent Skin and Soft Tissue Infections in the Emergency Department. Acad Emerg Med. 2018 Jun 5. doi: 10.1111/acem.13492.

Summarized and edited by Erik Verzemnieks, MD

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Author: Aaron Lessen, MD

Educational Pearls:

Injuries from penetrating pharyngeal trauma are often subtle on examination in children
Potentially serious complications including carotid artery injury, mediastinitis from spreading infection, or airway compromise from hematoma formation
Imaging choice is typically CTA to assess for vascular injuries
These injuries may require antibiotics

References:

Zonfrillo MR, Roy AD, Walsh SA. Management of pediatric penetrating oropharyngeal trauma. Pediatr Emerg Care. 2008 Mar;24(3):172-5. doi: 10.1097/PEC.0b013e3181669072. PubMed PMID: 18347498.

Sasaki T, Toriumi S, Asakage T, Kaga K, Yamaguchi D, Yahagi N. The toothbrush: a rare but potentially life-threatening cause of penetrating oropharyngeal trauma in children. Pediatrics. 2006 Oct;118(4):e1284-6. PubMed PMID: 17015515.

Summary by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

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Author: Rachel Brady, MD

Educational Pearls:

Hypercalcemia of malignancy:

Hypercalcemia of malignancy can present with lethargy, muscle weakness, hyperreflexia, altered mental status, cardiac dysrhythmias, and even cardiac arrest.
Treatment is based both on calcium level and symptoms
Intravenous rehydration is first line treatment
Other options include steroids, bisphosphonates and calcitonin.

Tumor Lysis Syndrome

Occurs due to the breakdown of tumor cells after chemotherapy/radiation
Presents as hyperkalemia, hyperuricemia, hyperphosphatemia, and hypocalcemia
Treatment is very similar to severe hypercalcemia - hydration with crystalloids
Hyperuricemia can be treated using rasburicase or allopurinol

References:

Ñamendys-Silva SA, Arredondo-Armenta JM, Plata-Menchaca EP, Guevara-García H, García-Guillén FJ, Rivero-Sigarroa E, Herrera-Gómez A. Tumor lysis syndrome in the emergency department: challenges and solutions. Open Access Emerg Med. 2015 Aug 20;7:39-44. doi: 10.2147/OAEM.S73684. eCollection 2015. Review. PubMed PMID: 27147889; PubMed Central PMCID: PMC4806807.

Zagzag J, Hu MI, Fisher SB, Perrier ND. Hypercalcemia and cancer: Differential diagnosis and treatment. CA Cancer J Clin. 2018 Sep;68(5):377-386. doi: 10.3322/caac.21489. Epub 2018 Sep 21. Review. PubMed PMID: 30240520.

Summary by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

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Author: Aaron Lessen, MD

Educational Pearls:

In patients without indications for aspirin, three recent studies looked at prevention of several end points in the elderly
These showed no benefit in preventing cardiovascular events (stroke, MI, hear failure), disability, or death in elderly
These studies also demonstrated higher mortality and increased bleeding risk in patients who were taking aspirin without clear indications

Editor's note: the increased all cause mortality is intriguing - but attributed to an increase in cancer mortality. Unclear why but will be important to see if this trend is seen in other studies.

References:

McNeil JJ, Woods RL, Nelson MR, et al., on behalf of the ASPREE Investigator Group. Effect of Aspirin on Disability-free Survival in the Healthy Elderly. N Engl J Med. 2018 Oct 18;379(16):1499-1508. doi: 10.1056/NEJMoa1800722. Epub 2018 Sep 16. PubMed PMID: 30221596.

McNeil JJ, Woods RL, Nelson MR, et al., on behalf of the ASPREE Investigator Group. Effect of Aspirin on Cardiovascular Events and Bleeding in the Healthy Elderly. N Engl J Med. 2018 Oct 18;379(16):1509-1518. doi: 10.1056/NEJMoa1805819. Epub 2018 Sep 16. PubMed PMID: 30221597.

McNeil JJ, Woods RL, Nelson MR, et al., on behalf of the ASPREE Investigator Group. Effect of Aspirin on All-Cause Mortality in the Healthy Elderly. N Engl J Med. 2018 Oct 18;379(16):1519-1528. doi: 10.1056/NEJMoa1803955. Epub 2018 Sep 16. PubMed PMID: 30221595.

Summary by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

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Author: Katie Sprinkle, MD

Educational Pearls:

Medication Assisted Treatment (MAT) is the treatment of addiction with medications, commonly used for opioid use disorders
A long held belief is MAT simply replaces one addiction for another, which is patently false
MAT is one of the most affective methods to treat a patient with opioid addiction
Unfortunately, outdated requirements for prescribers along further prevent its widespread use

References:

Salsitz E, Wiegand T. Pharmacotherapy of Opioid Addiction: “Putting a Real Face on a False Demon.” Journal of Medical Toxicology. 2016;12(1):58-63. doi:10.1007/s13181-015-0517-5.

Duber HC, Barata IA, Cioè-Peña E, Liang SY, Ketcham E, Macias-Konstantopoulos W, Ryan SA, Stavros M, Whiteside LK. Identification, Management, and Transition of Care for Patients With Opioid Use Disorder in the Emergency Department. Ann Emerg Med. 2018 Oct;72(4):420-431. doi: 10.1016/j.annemergmed.2018.04.007. Epub 2018 Jun 5. Review. PubMed PMID: 29880438.

Summary by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

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Author: Peter Bakes, MD

Educational Pearls:

Important historical information to elicit is the birth history, feeding habits, stooling habits, associated symptoms, presence of bile, and presence of trauma.
Volvulus is a common etiology of intestinal obstruction and is often due to malrotation in utero.

Editor’s note: get an upper GI series if there is any bilious vomiting in a neonate. Any time of the night. Wake people up. Transfer if necessary to get the study. This can diagnose volvulus and save bowel.

References:

Ratnayake K, Kim TY. Evidence-based management of neonatal vomiting in the emergency department. Pediatr Emerg Med Pract. 2014 Nov;11(11):1-20; Review. PubMed PMID: 25928976.

Burge DM. The management of bilious vomiting in the neonate. Early Hum Dev. 2016 Nov;102:41-45. doi: 10.1016/j.earlhumdev.2016.09.002. Epub 2016 Sep 12. Review. PubMed PMID: 27634337.

Summary by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

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Author: Jared Scott, MD

Educational Pearls:

Interest started as it was noticed soldiers who had wounds infected with maggots had better outcomes than those without maggots
Studies have shown that wound care with maggots is essentially equivalent to traditional therapy with oxygen, antibiotics, and debridement
Maggots debride the wound with proteolytic enzymes, sterilize the wound, and stimulate wound healing

References:

Sherman RA. Maggot therapy takes us back to the future of wound care: new and improved maggot therapy for the 21st century. J Diabetes Sci Technol. 2009 Mar 1;3(2):336-44. Review. PubMed PMID: 20144365; PubMed Central PMCID: PMC2771513.

Baer WS. The treatment of chronic osteomyelitis with the maggot (larva of the blow fly) J Bone & Joint Surg. 1931;13:438–475. DOI: 10.1007/s11999-010-1416-3

Summary by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

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Author: Peter Bakes, MD

Educational Pearls:

Necrotizing fasciitis is an infection of the deep soft tissues with destruction of the muscle fascia and overlying fat
Think of it if pain is out of proportion to your exam
Polymicrobial and Clostridium species typically cause condition in susceptible individuals (immunocompromised, diabetics, obese, penetrating injury)
Group A strep typically is less specific and can cause necrotizing infections in otherwise healthy individuals
Treatment is typically rapid surgical debridement in addition to broad spectrum antibiotics in addition to clindamycin

References:

Breyre A, Frazee BW. Skin and Soft Tissue Infections in the Emergency Department. Emerg Med Clin North Am. 2018 Nov;36(4):723-750. doi: 10.1016/j.emc.2018.06.005. Review. PubMed PMID: 30297001.

Stevens DL, Bryant AE. Necrotizing Soft-Tissue Infections. N Engl J Med. 2017 Dec 7;377(23):2253-2265. doi: 10.1056/NEJMra1600673. Review. PubMed PMID: 29211672.

Summary by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

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Author: Gretchen Hinson, MD

Educational Pearls:

Reasonable approach of haloperidol 10 mg IM (or 5 mg IV) for pain relief in opioid-dependent patients; can repeat once
Chronic opioid use results in hyperalgesia and a narrow therapeutic window in the long-term so alternatives are essential
Consider the risk of QTc prolongation with haloperidol, particularly if the patient is on other drugs that may do so

Editor's note: Interested in more alternatives to opioids? Check out the Colorado ACEP Opioid Prescribing & Treatment Guidelines and the impact these have had in Colorado

References:

http://ercast.libsyn.com/haloperidol-for-analgesia

Ramirez R, Stalcup P, Croft B, Darracq MA. Haloperidol undermining gastroparesis symptoms (HUGS) in the emergency department. Am J Emerg Med. 2017 Aug;35(8):1118-1120. doi: 10.1016/j.ajem.2017.03.015. Epub 2017 Mar 12. PubMed PMID: 28320545.

Seidel S, Aigner M, Ossege M, Pernicka E, Wildner B, Sycha T. Antipsychotics for acute and chronic pain in adults. Cochrane Database Syst Rev. 2013 Aug 29;(8):CD004844. doi: 10.1002/14651858.CD004844.pub3. Review. PubMed PMID: 23990266.

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Educational Pearls:

BRUE (Brief Resolved Unexplained Event) replaces what was previously called ALTE
BRUE describes an event in a child less than one year of age with one or more of the following:
- cyanosis or pallor
- absent, decreased, or irregular breathing
- decreased or increased tone
- altered responsiveness
These must be sudden, brief, and now resolved and without an alternative explanation after a history and physical exam
Low risk patients can be safely discharged with reassurance
Low risk criteria must all be present:
- Age over 60 days old
- 32 weeks gestational age at birth and adjusted gestational age > 45 weeks)
- No CPR was performed (by a trained medical professional)
- First event
- Duration less than 1 minute of event
Patients who satisfy above criteria can be considered low risk and may be discharged after minimal/no workup

References:

Tieder JS, Bonkowsky JL, Etzel RA, et al. Clinical Practice Guideline: Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants: Executive Summary. Pediatrics. 2016:137(5):e20160591. Pediatrics. 2016 Aug;138(2). pii: e20161488. doi: 10.1542/peds.2016-1488. PubMed PMID: 27474017.

Summary by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

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Author: Aaron Lessen, MD

Educational Pearls:

5-year follow up study on antibiotic treatment for uncomplicated appendicitis showed 39.1% recurrence rate requiring appendectomy by 5 years
Nearly 60% chance then of preventing an appendectomy by using antibiotics only for uncomplicated appendicitis

Editor’s note: not surprisingly, complications were much higher in the group receiving surgery, which reiterates why an antibiotic-only approach is attractive for the right patient population

References:

Salminen P, Tuominen R, Paajanen H, Rautio T, Nordström P, Aarnio M, Rantanen T, Hurme S, Mecklin JP, Sand J, Virtanen J, Jartti A, Grönroos JM. Five-Year Follow-up of Antibiotic Therapy for Uncomplicated Acute Appendicitis in the APPAC Randomized Clinical Trial. JAMA. 2018 Sep 25;320(12):1259-1265. doi: 10.1001/jama.2018.13201. PubMed PMID: 30264120.

Summary by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

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Author: Don Stader, MD

Educational Pearls:

Fluoroquinolones can cause connective tissue disruption leading not only to tendon rupture but also aortic dissection
Retrospective study from Taiwan showed over a 2x higher rate of dissection when exposed to fluoroquinolones (1.6% vs 0.6%)
Remember to think about aortic dissection when you have a patient with chest pain that travels and/or involves neurologic symptoms
Try to use fluoroquinolones when no other appropriate antibiotic exists as they have significant other side effects as well

Editor’s note: In July 2018, the FDA required strengthening of warning labels on fluoroquinolones about the risks of mental health effects and hypoglycemia

References:

Lee CC, Lee MG, Hsieh R, Porta L, Lee WC, Lee SH, Chang SS. Oral Fluoroquinolone and the Risk of Aortic Dissection. J Am Coll Cardiol. 2018 Sep 18;72(12):1369-1378. doi: 10.1016/j.jacc.2018.06.067. PubMed PMID: 30213330.

Khaliq Y, Zhanel GG. Fluoroquinolone-associated tendinopathy: a critical review of the literature. Clin Infect Dis. 2003 Jun 1;36(11):1404-10. Epub 2003 May 20. Review. PubMed PMID: 12766835.

https://www.fda.gov/downloads/Drugs/DrugSafety/UCM612834.pdf

Summary by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

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Author: Kasey Champion, MD

Educational Pearls:

Transgender populations are frequent victims of discrimination in healthcare
Ask transgender patients what their preferred pronoun is
It is sometimes important to ask about transition status (i.e. on hormones, surgery)

References:

Chisolm-Straker M, Willging C, Daul AD, McNamara S, Sante SC, Shattuck DG 2nd, Crandall CS. Transgender and Gender-Nonconforming Patients in the Emergency Department: What Physicians Know, Think, and Do. Ann Emerg Med. 2018 Feb;71(2):183-188.e1. doi: 10.1016/j.annemergmed.2017.09.042. Epub 2017 Nov 3. PubMed PMID: 29103796.

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Author: John Winkler, MD

Educational Pearls:

Probiotics are bacteria that are ingested to promote gut health but recent research casts doubt on their effectiveness.
Recent study suggests that most probiotics that are ingested are killed by stomach acid. Those that remain are not very healthy and are outcompeted by the normal gut flora.
Probiotics should not be given as a one-size-fits-all treatment.

References:

Zmora N, Zilberman-Schapira G, Suez J, Mor U, Dori-Bachash M, Bashiardes S, Kotler E, Zur M, Regev-Lehavi D, Brik RB, Federici S, Cohen Y, Linevsky R, Rothschild D, Moor AE, Ben-Moshe S, Harmelin A, Itzkovitz S, Maharshak N, Shibolet O, Shapiro H, Pevsner-Fischer M, Sharon I, Halpern Z, Segal E, Elinav E. Personalized Gut Mucosal Colonization Resistance to Empiric Probiotics Is Associated with Unique Host and Microbiome Features. Cell. 2018 Sep 6;174(6):1388-1405.e21. doi: 10.1016/j.cell.2018.08.041. PubMed PMID: 30193112.

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Author: Don Stader, MD

Educational Pearls:

Recent study suggests we may not need to drain uncomplicated peritonsillar abscesses
Patients who received medical therapy alone had no difference in complications and failure compared to those who received surgical drainage plus medical therapy
Medical therapy in study was ceftriaxone, clindamycin, and dexamethasone
Medical therapy was also associated with fewer opioid prescriptions, sore days, and days off from work.

References:

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Author: Sam Killian, MD

Educational Pearls:

Two high quality randomized control trials published in 2018 demonstrated no difference in mortality or neurologic outcomes when using a supraglottic airway compared to endotracheal intubation in out of hospital cardiac arrest
These two trials enrolled over a combined 12000 patients
Supraglottic airways have a higher success rate than intubations

References:

Benger JR, Kirby K, Black S, Brett SJ, Clout M, Lazaroo MJ, Nolan JP, Reeves BC, Robinson M, Scott LJ, Smartt H, South A, Stokes EA, Taylor J, Thomas M, Voss S, Wordsworth S, Rogers CA. Effect of a Strategy of a Supraglottic Airway Device vs Tracheal Intubation During Out-of-Hospital Cardiac Arrest on Functional Outcome: The AIRWAYS-2 Randomized Clinical Trial. JAMA. 2018 Aug 28;320(8):779-791. doi: 10.1001/jama.2018.11597. PubMed PMID: 30167701

Wang HE, Schmicker RH, Daya MR, Stephens SW, Idris AH, Carlson JN, Colella MR, Herren H, Hansen M, Richmond NJ, Puyana JCJ, Aufderheide TP, Gray RE, Gray PC, Verkest M, Owens PC, Brienza AM, Sternig KJ, May SJ, Sopko GR, Weisfeldt ML, Nichol G. Effect of a Strategy of Initial Laryngeal Tube Insertion vs Endotracheal Intubation on 72-Hour Survival in Adults With Out-of-Hospital Cardiac Arrest: A Randomized Clinical Trial. JAMA. 2018 Aug 28;320(8):769-778. doi: 10.1001/jama.2018.7044. PubMed PMID: 30167699.

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Author: Ryan Circh, MD

Educational Pearls:

A “shoulder separation” is when the clavicle separates from the scapula - also referred to as an acromio-clavicular (AC) separation
Diagnosis is clinical: pain over AC joint, pain with adduction, and difficulty raising harm past horizontal
Early range of motion can be critical for recovery

References:

Lemos MJ. The evaluation and treatment of the injured acromioclavicular joint in athletes. Am J Sports Med. 1998 Jan-Feb;26(1):137-44. Review. PubMed PMID: 9474415.

Monica J, Vredenburgh Z, Korsh J, Gatt C. Acute Shoulder Injuries in Adults. Am Fam Physician. 2016 Jul 15;94(2):119-27. Review. PubMed PMID: 27419328.

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Author: Sam Killian, MD

Educational Pearls:

MRI machines can generate enough heat from the radiofrequency to cause thermal burns
Patients with EKG stickers, medication patches, clothing impregnated with metallic ions, etc., can all increase risk of burns
Even skin-to-skin contact within the patient can cause a misinterpretation from the software and increased energy, leading to burn

References:

Cross NM, Hoff MN, Kanal KM. Avoiding MRI-Related Accidents: A Practical Approach to Implementing MR Safety. J Am Coll Radiol. 2018 Aug 24. pii: S1546-1440(18)30762-2. doi: 10.1016/j.jacr.2018.06.022. [Epub ahead of print] PubMed PMID: 30149951.

Takahashi T, Fujimoto N, Hamada Y, Tezuka N, Tanaka T. MRI-related thermal injury due to skin-to-skin contact. Eur J Dermatol. 2016 Jun 1;26(3):296-8. doi: 10.1684/ejd.2016.2740. PubMed PMID: 26987101.

Pietryga JA, Fonder MA, Rogg JM, North DL, Bercovitch LG. Invisible metallic microfiber in clothing presents unrecognized MRI risk for cutaneous burn. AJNR Am J Neuroradiol. 2013 May;34(5):E47-50. doi: 10.3174/ajnr.A2827. Epub 2011 Dec 15. PubMed PMID: 22173750.

Dempsey MF, Condon B. Thermal injuries associated with MRI. Clin Radiol. 2001 Jun;56(6):457-65. Review. PubMed PMID: 11428795.

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Author: Ryan Circh, MD

Educational Pearls:

Review of 25 randomized control trials encompassing 16,037 acutely ill hospitalized patients
Patients given oxygen with saturations > 94% on room air were found to have associated increased mortality in-hospital, at 30-days, and at long-term follow up
It may seem intuitive, but do not give oxygen to patients that do not need it

References:

Chu DK, et al (2018). Mortality and morbidity in acutely ill adults treated with liberal versus conservative oxygen therapy (IOTA): a systematic review and meta-analysis. Lancet. 391(10131):1693-1705

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Author: Sam Killian, MD

Educational Pearls:

Patients may have certain fears or expectations about the flu based on hearsay and other less reliable sources
Taking extra time explaining the risks of the flu may help base these expectations more in reality
This includes providing good return precautions and acknowledging that the disease can still be unpredictable

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Author: Michael Hunt, MD

Educational Pearls:

Use the mnemonic NOT RECLUSE to rule out a brown recluse spider bite:
Numerous bites (recluse spiders will bite once)
Occurence (recluse bites between April- October)
Timing (recluse spiders are… get this… reclusive)
Red (recluse bites are white/pale)
Elevated (recluse bites are flat)
Chronic (recluse bites are acute)
Large (recluse wounds are small)
Ulceration, early (recluse bites ulcerate between 7-14 days)
Swollen (recluse bites are flat)
Exudative (recluse bites are dry)

References:

Stoecker WV, Vetter RS, Dyer JA. NOT RECLUSE-A Mnemonic Device to Avoid False Diagnoses of Brown Recluse Spider Bites. JAMA Dermatol. 2017 May 1;153(5):377-378. doi: 10.1001/jamadermatol.2016.5665. PubMed PMID: 28199453.

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Author: Nick Tsipis, MD

Educational Pearls:

Persistent fever or positive blood cultures should raise suspicion for endocarditis
Patients with recent dental procedures, recent cardiac surgeries are at risk, or who inject drugs are at higher risk
Physical exam findings may include fever with a new murmur, Janeway lesions, Osler nodes, and/or splinter hemorrhages

References:

Long B, Koyfman A. Infectious endocarditis: An update for emergency clinicians. Am J Emerg Med. 2018 Sep;36(9):1686-1692. doi: 10.1016/j.ajem.2018.06.074. Epub 2018 Jul 2. Review. PubMed PMID: 30001813.

Murdoch DR, Corey GR, Hoen B et. al. International Collaboration on Endocarditis-Prospective Cohort Study (ICE-PCS) Investigators. Clinical presentation, etiology, and outcome of infective endocarditis in the 21st century: the International Collaboration on Endocarditis-Prospective Cohort Study. Arch Intern Med. 2009 Mar 9;169(5):463-73. doi: 10.1001/archinternmed.2008.603

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Educational Pearls:

Blood concentrations over 0.4 mg/dL is associated with respiratory depression and possible death in alcohol naive patients
Alcohol overdose accounts to 2,200 deaths per year
Don’t forget about checking for hypoglycemia in severe alcohol intoxication
Consider ketamine for agitation to prevent further respiratory depression

Editor’s note: check out our podcast on ketamine for alcohol withdrawal here

References:

Jung YC, Namkoong K. Alcohol: intoxication and poisoning - diagnosis and treatment. Handb Clin Neurol. 2014;125:115-21. doi: 10.1016/B978-0-444-62619-6.00007-0.

Centers for Disease Control and Prevention (CDC). "Vital signs: binge drinking prevalence, frequency, and intensity among adults-United States, 2010." MMWR. Morbidity and mortality weekly report 61.1 (2012): 14.

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Author: Jared Scott, MD

Educational Pearls:

Blood at urethral meatus in trauma can be a sign of bladder/urethral injury
Blind placement of a Foley catheter can make an undiagnosed urethral injury worse
Urethral injury is evaluated using a retrograde urethrogram (RUG)
If urethra is confirmed to be intact, Foley catheter can be placed to allow additional tests

References:

Avery, L. (2012). Imaging of male pelvic trauma. Radiologic Clinics of North America., 50(6), 1201-1217.

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Author: Sue Chilton, MD

Educational Pearls:

An unusual cause of leg pain that can mimic sciatica/claudication
Predominantly occurring in high endurance athletes, particularly cyclists and runners
More common in men
Check supine ABIs 1 minute after activity in the ED: a value < 0.5 is 80% sensitive

References:

Mansour A, Murney S, Jordan K, Laperna L. Endofibrosis: an unusual cause of leg pain in an athlete. J Sports Med Phys Fitness. 2016 Jan-Feb;56(1-2):157-61. Epub 2015 Jul 3. PubMed PMID: 26140352.

Peach G, Schep G, Palfreeman R, Beard JD, Thompson MM, Hinchliffe RJ. Endofibrosis and kinking of the iliac arteries in athletes: a systematic review. Eur J Vasc Endovasc Surg. 2012;43(2):208–17.

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Author: Gretchen Hinson, MD

Educational Pearls:

Legionnaires disease refers to a severe pneumonia caused by Legionella pneumophilia and occurs typically at the extremes of age
Associated gastrointestinal symptoms (nausea/vomiting/diarrhea) may be present
Hyponatremia is a common laboratory finding
Legionella urinary antigen can be a convenient test to identify the infection
Treatment is with fluoroquinolones, macrolides and/or tetracyclines

References

Pierre DM, Baron J, Yu VL, Stout JE. Diagnostic testing for Legionnaires’ disease. Annals of Clinical Microbiology and Antimicrobials. 2017;16:59. doi:10.1186/s12941-017-0229-6.

Cunha BA, Cunha CB. Legionnaire's Disease and its Mimics: A Clinical Perspective. Infect Dis Clin North Am. 2017 Mar;31(1):95-109. doi: 10.1016/j.idc.2016.10.008. Review.

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Author: Don Stader, MD

Educational Pearls:

8014 patients with out-of-hospital cardiac arrest randomized to epinephrine vs placebo
30-day survival was not dramatically better between groups (3.2%in the epinephrine group and 2.4% in the placebo group)
Functional neurological outcome was nearly identical at 2.2% and 1.9% of patients
Adds to literature that epinephrine provides little important benefit in cardiac arrest - focus on chest compressions and early defibrillation

Editor’s note: NNT for epinephrine to prevent one death in this study was 115 - compared to bystander CPR (NNT 15) and defibrillation (NNT 5) from prior studies.

References

Perkins GD et. al. . A Randomized Trial of Epinephrine in Out-of-Hospital Cardiac Arrest. N Engl J Med. 2018 Aug 23;379(8):711-721. doi: 10.1056/NEJMoa1806842. Epub 2018 Jul 18.

Kitamura T, Kiyohara K, Sakai T, et al. Public-access defibrillation and out-of-hospital cardiac arrest in Japan. N Engl J Med 2016;375:1649-1659.

Hasselqvist-Ax I, Riva G, Herlitz J, et al. Early cardiopulmonary resuscitation in out-of-hospital cardiac arrest. N Engl J Med 2015;372:2307-2315.

Hagihara A, Hasegawa M, Abe T, Nagata T, Wakata Y, Miyazaki S. Prehospital epinephrine use and survival among patients with out-of-hospital cardiac arrest. JAMA. 2012 Mar 21;307(11):1161-8. doi: 10.1001/jama.2012.294. PubMed PMID: 22436956.

Sanghavi P, Jena AB, Newhouse JP, Zaslavsky AM. Outcomes after out-of-hospital cardiac arrest treated by basic vs advanced life support. JAMA Intern Med. 2015 Feb;175(2):196-204. doi: 10.1001/jamainternmed.2014.5420.

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Author: Jared Scott, MD

Educational Pearls:

EKG changes do not necessarily correlate to degree of hyperkalemia
Traditional progression through peaked T-waves, flattened p-waves, QRS widening, and then sine-waves before asystole

References

Mattu A, Brady WJ, Robinson DA. Electrocardiographic manifestations of hyperkalemia. Am J Emerg Med. 2000;18:721–729.

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Author: Erik Verzemnieks, MD

Educational Pearls:

In the panic of a precipitous ED delivery, remember: Warm. Dry. Stim. It will solve most of your problems in most scenarios
Start compressions if heart rate is less than 60
Put the pulse ox on the right hand - it may make a difference as it is preductal

Editor’s note: detecting a heart rate can be tough in a newborn - you can feel the umbilical stump or just listen with your stethoscope

References

Gary Weiner & Jeanette Zaichkin. Textbook of Neonatal Resuscitation (NRP), 7th Ed, 2016. American Academy of Pediatrics & American Heart Association.

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Author: Michael Hunt, MD

Educational Pearls:

Here is a list of some very toxic natural substances:

#5: Tetrodotoxin: Found in pufferfish and other aquatic species

#4: Ricin: made from castor beans

#3: Mercury: natural element absorbable through skin and gloves

#2: Batrachotoxin: found on poison dart frogs

#1: Botulinum toxin: produced by Clostridium botulinum and causes a descending paralysis

Editor's note: batrachotoxin is thought to be accumulated by the beatles and other insects dart frogs eat - those in captivity therefore are not poisonous

References

https://theconversation.com/handle-with-care-the-worlds-five-deadliest-poisons-56089

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Author: Aaron Lessen, MD

Educational Pearls:

Non-blinded randomized study assessing 30-day mortality benefit from plasma-first resuscitation in patients at risk hemorrhagic shock
Study involved aeromedical transport of trauma patients
30-day mortality 23.2 % in intervention group vs. 33.0% in standard care group

Editor's note: a similar study published in Lancet at the same time showed no mortality benefit from prehospital administration of plasma in a slightly different population which had much shorter ground transport times a major trauma center

References

Sperry JL, Guyette FX, Brown JB, Yazer MH, Triulzi DJ, Early-Young BJ, Adams PW, Daley BJ, Miller RS, Harbrecht BG, Claridge JA, Phelan HA, Witham WR, Putnam AT, Duane TM, Alarcon LH, Callaway CW, Zuckerbraun BS, Neal MD, Rosengart MR, Forsythe RM, Billiar TR, Yealy DM, Peitzman AB, Zenati MS; PAMPer Study Group.. Prehospital Plasma during Air Medical Transport in Trauma Patients at Risk for Hemorrhagic Shock. N Engl J Med. 2018 Jul 26;379(4):315-326. doi: 10.1056/NEJMoa1802345.

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Podcast # 367: Digital Necrosis after Epinephrine Drip

Author: Jared Scott, MD.

Educational Pearls:

Make sure to monitor for limb ischemia in all patients on vasopressors
Good reminder that vasopressors are not risk free - use them only on patients that need them!

References

Daroca-Pérez, R., & Carrascosa, M. F. . Digital necrosis: a potential risk of high-dose norepinephrine. Therapeutic Advances in Drug Safety. 2017. 8(8), 259–261. http://doi.org/10.1177/2042098617712669.

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Podcast # 366: Ehlers Danlos

Author: Gretchen Hinson, MD.

Educational Pearls:

Heritable mutation in collagen synthesis and expression commonly resulting in joint hyperextension and skin elasticity.
Vascular type can result in aneurysm formation and rupture in young patients.
Patients are also at risk for spontaneous bowel rupture.
Pregnant women can present with uterine rupture.

References

Byers PH, Murray ML (2012). "Heritable collagen disorders: the paradigm of Ehlers–Danlos syndrome". Journal of Investigative Dermatology. 132 (E1): E6–11.

Pepin MG, Byers PH. Ehlers-Danlos Syndrome Type IV. In: Pagon RA, Bird TD, Dolan CR, et al., eds. GeneReviews [Internet]. Seattle (WA): University of Washington, Seattle; 1993-.

Yoneda, A., Okada, K., Okubo, H., Matsuo, M., Kishikawa, H., Naing, B. T., … Shimada, T. (2014). Spontaneous Colon Perforations Associated with a Vascular Type of Ehlers-Danlos Syndrome. Case Reports in Gastroenterology, 8(2), 175–181. http://doi.org/10.1159/000363373

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Author: Erik Verzemnieks, MD

Educational Pearls:

Single study in Japan demonstrated possible effectiveness of renal colic trigger point
Patients had injection at the area of maximal tenderness on palpation of the flank
Compared to a muscle relaxer, injection of local anesthetic at the trigger point had faster time to pain relief and fewer rescue therapies

References

Iguchi, M et al. Randomized trial of trigger point injection for renal colic. International Journal of Urology. 2002. 9(9): 475-479

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Author: Peter Bakes, MD

Educational Pearls:

Pericarditis, LBBB, LVH and left ventricular aneurysms can all present with ST elevation.
Ventricular aneurysm will present days after a cardiac event with ST elevation and Q waves in the affected leads.
Ventricular aneurysms may cause papillary muscle dysfunction with a resultant holosystolic murmur and even heart failure.

References

Victor F. Froelicher; Jonathan Myers (2006). Exercise and the heart. Elsevier Health Sciences. pp. 138–. ISBN 978-1-4160-0311-3.

Nagle RE, Williams DO. (1974) Proceedings: Natural history of ventricular aneurysm without surgical treatment. British Heart Journal, 36:1037.

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Educational Pearls:

Recent study has shown adjunctive ketamine can be useful in setting of alcohol withdrawal.
Ketamine was associated with a decrease in the amount of benzodiazepines needed, likelihood of intubation, and a decrease in ICU length of stay by 3 days.
For patients with benzodiazepine resistance, ketamine was shown to have symptom relief in an hour and decreased rate of benzodiazepine infusion.

References

Pizon A, Lynch M, Benedict N, et al. 2018. Adjunct Ketamine Use in the Management of Severe Ethanol Withdrawal. Critical Care Medicine. 46(8):e768-e771.

Shah, P., McDowell, M., Ebisu, R. et al. J. Med. Toxicol. (2018). https://doi.org/10.1007/s13181-018-0662-8

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Author: John Winkler, MD

Educational Pearls:

Tall flowering plant with phototoxic sap
Direct skin contact with the sap can cause the skin to become photosensitive
Severe blisters and even burns can result

References

Diebel, Matthew (18 June 2018). "Giant Hogweed, a Plant That Can Cause Burns and Blindness, Found in Virginia". USA Today.

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Author: Peter Bakes, MD

Educational Pearls:

Important to find out if patients mean dysequilibrium, lightheadedness, or vertigo when patients say they are “dizzy.”
Differentiate central vs. peripheral vertigo
Central vertigo typically present with bulbar syndromes (difficulty swallowing, facial nerve palsy) and cerebellar symptoms (ataxia).
Peripheral vertigo typically present with sudden onset vertigo with nausea and vomiting in the absence of bulbar symptoms.
Episodic? BPPV or Meniere’s Disease. BPPV has not auditory symptoms and is associated with head position; Meniere’s has hearing loss, tinnitus, and ear fullness.
Constant? Neuronitis has no auditory symptoms, while labyrinthitis has associated hearing loss/tinnitus and is associated with a recent infection (OM).

References

Baloh RW. Differentiating between peripheral and central causes of vertigo. Otolaryngol Head Neck Surg 1998; 119:55.

Chase M, Goldstein JN, Selim MH, et al. A prospective pilot study of predictors of acute stroke in emergency department patients with dizziness. Mayo Clin Proc 2014; 89:173.

Kerber KA, Brown DL, Lisabeth LD, et al. Stroke among patients with dizziness, vertigo, and imbalance in the emergency department: a population-based study. Stroke 2006; 37:2484.

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Author: Dylan Luyten, MD.

Educational Pearls:

Dangerous causes of back pain: AAA, cauda equina syndrome, epidural abscess.
Young person with back pain needs to be evaluated for injection drug use (major risk factor).
Patient with focal neurologic deficits (FND) require an MRI. Patients without FND can be screened with ESR and CRP. An ESR < 20 & CRP < 1 can effectively rule out epidural abscess as it has a 90% sensitivity for epidural abscess.
Treatment is IV antibiotics and surgical debridement.

References

Davis DP et al. Prospective evaluation of a clinical decision guideline to diagnose spinal epidural abscess in patients who present to the emergency department with spine pain, Journal of Neurosurgery: Spine. 2011. 14:765-770.

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Author: Sam Killian, MD.

Educational Pearls:

Computer interpretation has a very good negative predictive value of a normal EKG (99%).
Of 222 interpreted as “normal,” 13 were deemed to have some abnormality by a cardiologist in a recent study.
Those 13 EKG’s were read by 2 ER docs, and only 1 missed interpretation warranted a move from triage to a bed.

References

Katie E. Hughes KE., Scott M. Lewis SM., Laurence Katz and Jonathan Jones Safety of Computer Interpretation of Normal Triage Electrocardiograms. 2017. Academic Emergency Medicine 24(1):120-124. http://onlinelibrary.wiley.com/doi/10.1111/acem.13067/full.

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Author: Erik Verzemnieks, MD

Educational Pearls:

Otic (ear) specific antibiotic drops can be expensive
Opthalmic (eye) versions are basically identical and can be used as an affordable substitute as many are on the $4 drug lists
But don’t do the reverse (don't use ear drops on the eye)
Use caution when administering aminoglycoside if tympanic membrane rupture is present

References

https://tgtfiles.target.com/pharmacy/WCMP02-032536_RxGenericsList_NM7.pdf

http://i.walmart.com/i/if/hmp/fusion/four_dollar_drug_list.pdf

https://www.uptodate.com/contents/external-otitis-treatment

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Author: Michael Hunt, MD

Educational Pearls:

Toxicity happens from local anesthetics being given too fast, too much, or in the unintended spot
Systemic toxicity manifests first with neurologic symptoms like circumoral numbness, tinnitus, blurred vision, nausea, and even seizures. Severe toxicity can then progress to arrhythmias and cardiac arrest.
Maximum doses of lidocaine: 4 mg/kg; and with epinephrine: 7mg/kg.
Maximum dose of bupivacaine: 2mg/kg; with epinephrine 3mg/kg

Editor note: treat seizures with benzodiazepines and avoid propofol for sedation; severe toxicity can also be treated with a 20% lipid emulsion, though there is debate on its efficacy

References

Dickerson DM, Apfelbaum JL. Local anesthetic systemic toxicity. Aesthet Surg J. 2014 Sep;34(7):1111-9. doi: 10.1177/1090820X14543102.

Neal JM, Mulroy MF, Weinberg GL; American Society of Regional Anesthesia and Pain Medicine.. American Society of Regional Anesthesia and Pain Medicine checklist for managing local anesthetic systemic toxicity: 2012 version. Reg Anesth Pain Med. 2012 Jan-Feb;37(1):16-8. doi: 10.1097/AAP.0b013e31822e0d8a.

Vasques F, Behr AU, Weinberg G, Ori C, Di Gregorio G. A Review of Local Anesthetic Systemic Toxicity Cases Since Publication of the American Society of Regional Anesthesia Recommendations: To Whom It May Concern. Reg Anesth Pain Med. 2015 Nov-Dec;40(6):698-705. doi: 10.1097/AAP.0000000000000320.

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Author: Don Stader, MD.

Educational Pearls:

A baby can be born dependent on opioids but not addicted to them.
Opioid addiction (Opioid Use Disorder) is a disease of mature brains and is characterized by compulsive drug use despite adverse consequences.
Opioid addiction is a disease that affects the reward center of the brain
Pregnant patients struggling with addiction do better when started on buprenorphine or methadone. This treatment will cause opioid withdrawal syndrome in newborns, but not the long term morbidity and mortality of illicit opioids.

References

Gowing L, Farrell MF, Bornemann R, Sullivan LE, Ali R. Oral substitution treatment of injecting opioid users for prevention of HIV infection. Cochrane Database of Systematic Reviews 2011, Issue 8: CD004145. DOI: 10.1002/14651858.CD004145.pub4.

Volkow ND, Koob GF, McLellan AT ( 2016). "Neurobiologic Advances from the Brain Disease Model of Addiction." New England Journal of Medicine. 374 (4): 363–371.

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Author: Aaron Lessen, MD

Educational Pearls:

Re-emerging STI.
Progresses through distinct phases if untreated:
Primary syphilis: frequently overlooked because initial chancre is painless.
Secondary syphilis: viral syndrome, rash on trunk, palms, and soles.
Latent syphilis: asymptomatic period, lasting 5-20 years.
Tertiary syphilis: includes neurosyphilis (dementia, encephalitis, etc.) and cardiovascular syphilis (aortitis, etc).
Treatment penicillin G 2.4 million units once for primary or secondary treatment; once weekly for 3 weeks for latent/tertiary.

References

Mattei, P., Beachkofsky, T., Gilson, R., Wisco, O. Syphilis: A reemerging infection. 2012. American Family Physician., 86(5), 433-440.

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Author: Sam Killian, MD

Educational Pearls:

Hematometra: uterus filled with blood due to obstruction of outflow tract.
Most commonly a result congenital abnormalities (imperforate hymen, transverse vaginal septum, etc.) but can be acquired due to cervical stenosis, intrauterine adhesions, neoplasms, and post-surgical scarring.
Symptoms include: pain, abnormal bleeding, enlarged uterus
Diagnosis: commonly achieved by ultrasound and physical exam.
Treatment is surgical (cervical dilatation, hysteroscopy, etc.).

References

U Nayak A, Swarup A, G S J, N S. Hematometra and acute abdomen. Journal of Emergencies, Trauma and Shock. 2010;3(2):191-192. doi:10.4103/0974-2700.62117.

Kotter HC, Weingrow D, Canders CP. Hematometrocolpos in a Pubescent Girl with Abdominal Pain. Clinical Practice and Cases in Emergency Medicine. 2017;1(3):218-220. doi:10.5811/cpcem.2017.3.33369.

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Author: Sam Killian, MD

Educational Pearls:

Japan recently approved baloxavir marboxil (Xofluza), which may potentially "kill" Flu A/B within 24 hours
Recent RCT trial showed superiority over oseltamavir (Tamiflu) in cessation of viral shedding (24 vs 72 hours)
Compared to placebo, superior in time to symptom resolution (53.7 vs 80.7 hours)
Administered as single dose
Yet to be considered for FDA approval

References

Portsmouth S, Kawaguchi K, Arai M, Tsuchiya K, Uehara T. Cap-dependent Endonuclease Inhibitor S-033188 for the Treatment of Influenza: Results from a Phase 3, Randomized, Double-Blind, Placebo- and Active-Controlled Study in Otherwise Healthy Adolescents and Adults with Seasonal Influenza. Open Forum Infectious Diseases. 2017;4(Suppl 1):S734. doi:10.1093/ofid/ofx180.001.

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Podcast #352: TXA for Epistaxis

Author: Chris Holmes, M.D.

Educational Pearls:

TXA: tranexamic acid; used in control of bleeding in major trauma, postpartum hemorrhage, etc.
In study of 216 patients with epistaxis, TXA placed on a pledget was compared to anterior cotton nasal packing.
The TXA group had faster time to bleeding control, quicker time to discharge, better patient satisfaction, and lower rates of re-bleeding.

References:

Zahed R, Moharamzadeh P, Alizadeharasi S, Ghasemi A, Saeedi M. A new and rapid method for epistaxis treatment using injectable form of tranexamic acid topically: a randomized controlled trial. Am J Emerg Med. 2013 Sep;31(9):1389-92. doi: 10.1016/j.ajem.2013.06.043.

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Author: Pete Bakes, MD

Educational Pearls:

AICD: Automated Implantable Cardioverter-Defibrillator.
Can be placed for secondary prevention of cardiac arrest (i.e. history of cardiac arrest not from reversible cause).
Also indications for primary prevention: EF 35% or less; ventricular tachycardia with underlying structural heart disease; Brugada; genetic-induced prolonged QT-syndromes.

References:

Al-Khatib SM et. al. 2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Heart Rhythm. 2017 Oct 30. pii: S1547-5271(17)31249-3. doi: 10.1016/j.hrthm.2017.10.035.

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Author: Nick Hatch, MD.

Educational Pearls:

A common concern using vasopressors is the risk of digital and mesenteric ischemia.
The absolute risk of digital ischemia and/or mesenteric ischemia is pretty low. Norepinephrine at its highest doses carries a 5% digital ischemia rate and a 2% mesenteric ischemia rate.
The studies demonstrating this complication were predominately patients with pre-existing liver disease.
Providers commonly mistake purpura fulminans, a common complication of sepsis, for digital ischemia.

References

Brown, SM. et al. Survival After Shock Requiring High-Dose Vasopressor Therapy. Chest. 2013. 143(3), 664–671. http://doi.org/10.1378/chest.12-1106.

Malay MB et al. Heterogeneity of the vasoconstrictor effect of vasopressin in septic shock. Critical Care Medicine. 2004. 32(6), 1327-31.

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Author: Sue Chilton, MD

Educational Pearls:

Triad of fat emboli syndrome is a petechial rash, AMS, and respiratory distress.
Petechiae usually start in the axilla.
90% of patients with long bone fractures will shed fat.
May see ground-glass opacities on imaging, but perfusion defects will not be seen on CTA or V/Q scan
Patients with a PFO can have cerebral involvement.

References

Newbigin K, Souza CA, Torres C, Marchiori E, Gupta A, Inacio J, Armstrong M, Peña E. Fat embolism syndrome: State-of-the-art review focused on pulmonary imaging findings. Respir Med. 2016.113:93-100. doi: 10.1016/j.rmed.2016.01.018.

Kosova E, Bergmark B, Piazza G. Fat embolism syndrome. Circulation. 2015. 20;131(3):317-20. doi: 10.1161/CIRCULATIONAHA.114.010835.

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Author: Don Stader, MD

Educational Pearls:

Steakhouse syndrome is an impacted esophageal food bolus.
Occurs because they have an esophageal stricture (schatzki ring, scarring, esophagitis).
Classic treatments have consisted of effervescents, glucagon, and/or sublingual nitroglycerin (NTG).
Recent case series has shown oral 400mcg tablet of NTG dissolved in 10cc tap water was 100% successful.
Complications of NTG are hypotension and headache.

References

Kirchner GI, Zuber-Jerger I, Endlicher E, et al. (2011) Causes of bolus impaction in the esophagus. Surgical Endoscopy. 25:3170.

Willenbring BA, et al. (2018). Oral Nitroglycerin Solution May Be Effective for Esophageal Food Impaction. Journal of Emergency Medicine. 54(5):678-680.

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Author: Sam Killian, MD

Educational Pearls:

Recent study examining fasting and adverse events during procedural sedation found no association between fasting duration and any type of adverse event.
Of the 6,183 children in the study, about 6 vomited during the procedure, and about 300 vomited recently after the procedure, and there were no episodes of aspiration.

References

Bhatt, M, et al. (2018). Association of Preprocedural Fasting With Outcomes of Emergency Department Sedation in Children. JAMA Pediatrics, doi: 10.1001/jamapediatrics.2018.0830. [Epub ahead of print]

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Author: Chris Holmes, MD

Educational Pearls:

There is a risk of cerebral edema in pediatrics with DKA if over resuscitated.
Recent study comparing normal saline vs. ½ normal saline showed no difference in rates of cerebral edema regardless of rate of infusion.
Recommend sticking with a fluid resuscitation protocol you are familiar with (i.e., 2 rounds of 10cc/kg bolus of NS).

References

Glaser, N. S., Ghetti, S., Casper, T. C., Dean, J. M., & Kuppermann, N. (2013). Pediatric Diabetic Ketoacidosis, Fluid Therapy and Cerebral Injury: The Design of a Factorial Randomized Controlled Trial. Pediatric Diabetes, 14(6), 435–446. http://doi.org/10.1111/pedi.12027

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Author: Sue Chilton, MD

Educational Pearls:

IV drug use and spinal procedures are major risk factors.
Classic triad of back pain, focal neurological deficit and fever. However, presence of fever is highly variable. Neurologic deficits may not present until later, but then they can have a rapid progression of neurological decline.
MRSA is most common organism, but GNR and MSSA are also possible.

References

Chen WC, Wang JL, Wang JT, et al. (2008). Spinal epidural abscess due to Staphylococcus aureus: clinical manifestations and outcomes. Journal of Microbiology, Immunology and Infection. 41:215.

Danner RL, Hartman BJ. (1987).Update on spinal epidural abscess: 35 cases and review of the literature. Review of Infectious Disease. 9:265.

Pfister H-W, Klein M, Tunkel AR, Scheld WM. Epidural abscess. In: Infections of the Central Nervous System, Fourth Edition, Scheld WM, Whitley RJ, Marra CM (Eds), Wolters Kluwer Health, Philadelphia 2014. p.550.

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Author: Aaron Lessen, MD.

Educational Pearls:

When foley is stuck, balloon may not have deflated.
Make sure balloon is not in the urethra, which can block drainage.
Cut off the port as it may be obstructed.
If still not draining, pass guide wire through port to unclog catheter.
Other techniques have been described using mineral oil to dissolve, rupturing the balloon through over-inflation, and transcutaneous guided drainage.
Crystallization can be a cause of catheter obstruction - sterile water may be a better solution to inflate the ballon than saline when it is first placed.

References

Khan SA, Landes F, Paola AS, Ferrarotto L. Emergency management of the nondeflating Foley catheter balloon. Am J Emerg Med. 1991 May;9(3):260-3. PubMed PMID: 2018599.

Hollingsworth M, Quiroz F, Guralnick ML. The management of retained Foley catheters. Can J Urol. 2004 Feb;11(1):2163-6. PubMed PMID: 15003159.

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Educational Pearls:

Snake bites commonly occur between April and October.
Rattlesnake bites are the most common.
Venom contains proteins/enzymes that cause local inflammation, coagulopathy, and systemic effects (hypotension, angioedema, renal failure, etc.) along with neurotoxins may cause fasciculations, ptosis, drooling, or hyporeflexia.
Management:
Mark site for swelling.
Monitor progression.
Elevate and immobilize injured limb and treat pain.
Check basic labs including coagulation studies, and update tetanus.
Antidote is CroFab and use if patient has systemic symptoms. Anaphylaxis is a known complication of CroFab
Avoid: ice, tourniquets, and incision and drainage.

References

Hifumi T et. al.. Venomous snake bites: clinical diagnosis and treatment. J Intensive Care. 2015 Apr 1;3(1):16. doi: 10.1186/s40560-015-0081-8.

Warrell DA. Snake bite. Lancet. 2010. 375(9708):77-88. doi: 10.1016/S0140-6736(09)61754-2.

Warrell DA. Envenoming and injuries by venomous and nonvenomous reptiles worldwide. In: Wilderness Medicine, 6th Edition, Auerbach PS (Ed), Elsevier Mosby, Philadelphia 2012. p.1040.

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Author: Jared Scott, MD

Educational Pearls:

Scombroid is a type of food poisoning associated with dark fish (i.e. tuna, salmon, mackerel) that mimics anaphylaxis.
Occurs through conversion of histidine to histamine by bacteria in the fish.
Symptoms include flushing, lips swelling, nausea, diarrhea in setting of recent fish consumption.
Treat with antihistamines.

References

Ridolo E, Martignago I, Senna G, Ricci G. Scombroid syndrome: it seems to be fish allergy but... it isn't. Curr Opin Allergy Clin Immunol. 2016. 16(5):516-21. doi: 10.1097/ACI.0000000000000297.

Patterson R, Little B, Tolan J, Sweeney C. How to manage a urinary catheter balloon that will not deflate. Int Urol Nephrol. 2006;38(1):57-61. Review. PubMed PMID: 16502053.

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Author: Rachel Beham, PharmD

Educational Pearls:

Tenecteplase is more specific for fibrin and has a longer half-life than alteplase.
In setting of ischemic stroke, tenecteplase before thrombectomy was associated with a statistically higher incidence of reperfusion and better functional outcome than alteplase.

References

Bruce C.V. Campbell B et al (2018). Tenecteplase versus Alteplase before Thrombectomy for Ischemic Stroke. New England Journal of Medicine. 378:1573-1582

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Author: Chris Holmes, MD

Educational Pearls:

Epidemiology: 80% male, ages 1-4 at greatest risk, African-American > Caucasian.
Freshwater and ocean water may have more bacteria than pool water.
Salt water is hyperosmolar, which theoretically increases risk of pulmonary edema.
Greatest physiologic insult is from hypoxia secondary to fluid aspiration or laryngeal spasm. Patient survival is related to presentation on arrival.
Workup includes CXR and ABG; consider C-spine immobilization/imaging when cervical injury is strongly suspected (i.e. diving injury).
Treatment consists of supplemental oxygen therapy. Consider CPAP or intubation.

References

Szpilman D, Bierens JJ, Handley AJ, Orlowski JP. Drowning. N Engl J Med. 2012. 366(22):2102-10. doi: 10.1056/NEJMra1013317.

Schmidt A, Sempsrott J. Drowning In The Adult Population: Emergency Department Resuscitation And Treatment. Emerg Med Pract. 2015. 17(5):1-18.

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Author: Jared Scott, MD

Educational Pearls:

Data is mixed, but some studies show 1-2% of pregnancies are ectopic.
Risk factors for ectopic pregnancies include: pelvic inflammatory disease, prior ectopic pregnancy, prior abdominal surgery, prior abortion, advanced maternal age, IUD, tubal blockage, and smoking (including spouse).
Greatest risk factor is a prior ectopic pregnancy, which carries a 17x higher risk.
Patients with histories of PID and cigarette smoking present educational opportunities.

References

Moini, A., Hosseini, R., Jahangiri, N., Shiva, M., & Akhoond, M. R. (2014). Risk factors for ectopic pregnancy: A case–control study. Journal of Research in Medical Sciences : The Official Journal of Isfahan University of Medical Sciences, 19(9), 844–849.

Rana, P; Kazmi, I; Singh, R; Afzal, M; Al-Abbasi, FA; Aseeri, A; Singh, R; Khan, R; Anwar, F (2013). "Ectopic pregnancy: a review". Archives of Gynecology and Obstetrics. 288 (4): 747–57. doi: 10.1007/s00404-013-2929-2.

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Author: Chris Holmes, MD

Educational Pearls:

Symptoms commonly seen with mononucleosis are palatal petechiae, posterior cervical lymphadenopathy, inguinal/axillary lymphadenopathy, splenomegaly, and/or atypical lymphocytes > 10% on CBC.
Among these, posterior cervical lymphadenopathy and atypical lymphocytes > 10% were the most sensitive (sensitivities of 0.64 and 0.66 respectively).

References

Welch, JL et al. What Elements Suggest Infectious Mononucleosis? Annals of Emergency Medicine. 2018. 71(4): 521-522. Doi: 10.1016/j.annemergmed.2017.06.014

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Author: John Winkler, MD

Educational Pearls:

Singed nasal hairs, soot around mouth, hoarse voice, drooling, and burns to head/face are signs suggestive of inhalation injury.
Early intubation is critical for these patients as the airway changes rapidly.
With inhalation injuries, the upper airway is burned while the lower airway is damaged by inhaled chemicals in the soot and can cause ARDS.
Carbon monoxide (CO) and cyanide (CN) poisoning can occur with inhalation injuries.
Treatment for CO poisoning is 100% oxygen and possible hyperbarics. Treatment for CN poisoning is cyanocobalamin.

References

Rehberg S, Maybauer MO, Enkhbaatar P, et al. Pathophysiology, management and treatment of smoke inhalation injury. Expert Rev Respir Med 2009; 3:283.

Woodson CL. Diagnosis and treatment of inhalation injury. In: Total Burn Care, 4 ed, Herndon DN (Ed), 2009.

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Author: Dylan Luyten, MD

Educational Pearls:

Most important questions to answer with low potassium are 1. What are their symptoms? 2. Can they take potassium by mouth?
Oral repletion is faster, cheaper, and more effective than IV repletion.
Give IV potassium when patients have K < 2.5 mmol/L or present with arrhythmias and/or characteristic EKG changes (flattened T waves).
Most patients who are hypokalemic are hypomagnesemic and require magnesium supplementation. Checking a level is unnecessary.

References

Ashurst J, Sergent SR, Wagner BJ, Kim J. Evidence-based management of potassium disorders in the emergency department. Emerg Med Pract. 2016 Nov 22;18(Suppl Points & Pearls):S1-S2

Whang R, Flink EB, Dyckner T, et al. Magnesium depletion as a cause of refractory potassium repletion. Arch Intern Med 1985; 145:1686.

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Author: Peter Bakes, M.D.

Educational Pearls:

Epidural hematomas have a characteristic convex appearance on CT while a subdural hematoma will have a concave appearance.
Indications for operative intervention for subdural hematoma may include: >5 mm midline shift, over 10 mm in thickness, comatose with ICP >20, or patient neurologic deterioration.

References

Bullock, M. R. et. al. . Surgical management of acute subdural hematomas. 2006. Neurosurgery, 58(SUPPL. 3). DOI: 10.1227/01.NEU.0000210364.29290.C9.

Huang KT, Bi WL, Abd-El-Barr M, Yan SC, Tafel IJ, Dunn IF, Gormley WB. The Neurocritical and Neurosurgical Care of Subdural Hematomas. Neurocrit Care. 2016. 24(2):294-307. doi: 10.1007/s12028-015-0194-x.

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Author: Dylan Luyten, MD

Educational Pearls:

Resuscitative thoracotomies are most commonly used for treatment of cardiac tamponade and to selectively perfuse the brain and heart in setting of hemorrhage control.
Resuscitative thoracotomies are indicated in patients with penetrating injuries who lose vitals in the ED or those who had vitals within the last 10 minutes.
Do not perform resuscitative thoracotomies on patients who have no signs of life on scene, asystole as their presenting rhythm, or no vitals > 10 minutes.
Resuscitative thoracotomies are not indicated in patients with blunt trauma unless vitals are present in ED.
Do not perform CPR on trauma patients.

References:

Karmy-Jones R, Namias N, Coimbra R, et al. (2014).Western Trauma Association critical decisions in trauma: penetrating chest trauma. Journal of Trauma Acute Care Surgery. 77:994.

Seamon MJ, Shiroff AM, Franco M, et al. (2009) Emergency department thoracotomy for penetrating injuries of the heart and great vessels: an appraisal of 283 consecutive cases from two urban trauma centers. Journal of Trauma. 67:1250.

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Author: Michael Hunt, MD

Educational Pearls:

Studies have shown that patients with decreasing GCS scores have worse outcomes, however GCS of 4 has worse outcome than GCS 3.
Alternative scoring system is the GCS-P score which is GCS score - number of non-reactive pupils.
GCS3 50% mortality 70% poor outcome at 6 months; GCS-P of 1 had mortality 74% and poor outcome at about 90% at 6 months.
GCS-P score is a better prognostic indicator than GCS score.

References:

Han J, et al (2014). External validation of the CRASH and IMPACT prognostic models in severe traumatic brain injury. Journal of Neurotrauma. 31(13):1146-52.

Maas AI, et al. (2007). Prognosis and clinical trial design in traumatic brain injury: the IMPACT study. Journal of Neurotrauma. 24(2):232-8.

The CRASH trial management group, & the CRASH trial collaborators. (2001). The CRASH trial protocol (Corticosteroid randomisation after significant head injury) [ISRCTN74459797]. BMC Emergency Medicine, 1, 1. http://doi.org/10.1186/1471-227X-1-1.

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Author: Nick Hatch, MD

Educational Pearls:

Recent study argues that CHF patients receiving furosemide within 60 minutes of arrival had a lower in-hospital mortality than those receiving it after (2.3% vs. 6.0%, p=0.002).
Flaw in study is that there were significant baseline differences between groups.

References:

Matsue Y et al. Time-to-Furosemide Treatment and Mortality in Patients Hospitalized With Acute Heart Failure. JACC 2017. PMID: 28641794

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Author: Nick Hatch, MD

Educational Pearls:

The sodium-glucose cotransporter in the gut is essential for rehydration.
Oral rehydration therapies require an equimolar concentration of glucose and sodium to be effective.
ORT has saved millions of lives globally.
Consider using ORT in patients with dehydration. Especially useful in resource limited settings.

References:

Victora CG, Bryce J, Fontaine O, Monasch R. Reducing deaths from diarrhoea through oral rehydration therapy. Bull World Health Organ. 2000; 78:1246.

Santillanes G, Rose E. Evaluation and Management of Dehydration in Children. Emerg Med Clin North Am. 2018. 36(2):259-273. doi: 10.1016/j.emc.2017.12.004.

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Author: Nick Hatch, MD

Educational Pearls:

Behcet Disease is an autoimmune disease that can affect any organ system.
Typical symptoms include recurrent oral and genital ulcers, but more concerning features include skin rashes, ocular problems, and strokes.
Patients with Behcet disease with hypotension should have low threshold for giving steroids.

References:

Arlt W, Allolio B. Adrenal insufficiency. Lancet, 2003; 361:1881.

Sakane T, Takeno M, Suzuki N, Inaba G. Behçet's disease. New England Journal of Medicine. 1999; 341:1284.

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Author: Dylan Luyten , MD

Educational Pearls:

Rare autosomal dominant condition that is often misdiagnosed as a psychiatric illness.
Presents as profound muscle weakness with frank paralysis that is often precipitated by vigorous exercise, high carb diet, high sodium load, or by high temperatures.
Supplemental potassium can rapidly reverse symptoms.
Important to rule out thyrotoxicosis (get a TSH!).
Prevention is key: adhering to a low carb and low sodium diet with supplemental potassium can help prevent episodes.

References:

Vicart S, Sternberg D, Arzel-Hézode M, et al. Hypokalemic Periodic Paralysis. 2002 Apr 30 [Updated 2014 Jul 31]. In: Adam MP, Ardinger HH, Pagon RA, et al., editors. GeneReviews® [Internet]. Seattle (WA): University of Washington, Seattle; 1993-2018. Available from: https://www.ncbi.nlm.nih.gov/books/NBK1338/?report=classic

Statland JM, Fontaine B, Hanna MG, et al. Review of the Diagnosis and Treatment of Periodic Paralysis. Muscle & Nerve. 2018;57(4):522-530. doi:10.1002/mus.26009.

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Author: Sam Killian, MD

Educational Pearls:

Insufficient sleep and disrupted circadian rhythms are a major health problem today
Millions of dollars, thousands of deaths, and millions of injuries are related to sleep deprivation every year
56 billion dollars - 24,000 deaths - 2.5 million disabiling injuries related to a sleep-type deprivation
Exxon valdez, challanger, chyrnobel linked to sleep deprivation- at least partially
Data has shown that in the Spring (when people lose an hour of sleep) there were 8% more traffic accidents on the Monday immediately after daylight savings. Conversely, in the Fall (when people gain an hour of sleep), there were 8% fewer traffic accidents on the Monday immediately after daylight savings.
Studies have also shown an increased risk of myocardial infarction in Spring immediately after daylight savings, and a decreased risk of myocardial infarction in the Fall immediately after daylight savings.

References:

Corren S. Traffic Accidents and Daylight Saving Time. New England Journal of Medicine. 1996;335(5):355-357. doi:10.1056/nejm199608013350517

Janszky I, Ljung R. Shifts to and from Daylight Saving Time and Incidence of Myocardial Infarction. New England Journal of Medicine. 2008;359(18):1966-1968. doi:10.1056/nejmc0807104.

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Author: Don Stader, MD

Educational Pearls:

The use of fecal occult blood tests is falling out of favor in emergency departments
These tests have strong evidence suggesting their efficacy in colon cancer screening but clinical significance in ED is limited
They have relatively high false positive and false negative rates
Small/microscopic bleeding are often not clinically significant in the ED but can lead to increased costs from over-testing and other harms from fecal occult blood testing

References:

Gupta A, Tang Z, Agrawal D. Eliminating In-Hospital Fecal Occult Blood Testing: Our Experience with Disinvestment. American Journal of Medicine. (2018). 10.1016/j.amjmed.2018.03.002

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Author: Michael Hunt, MD

Educational Pearls:

Valley fever is a fungal infection known as Coccidiomycosis that can present with vague symptoms like cough, fever, myalgias.
A thorough history is critical to the diagnosis. Disease is localized to the Southwestern US (California, New Mexico, Arizona, Nevada, Utah) and parts of Central/South America.
Disease is caused by inhaling fungal spores which damage the lung. Rarely, the disease can disseminate and cause infections that require systemic anti fungal therapy.

References:

Centers for Disease Control and Prevention (CDC). Increase in reported coccidioidomycosis--United States, 1998-2011. MMWR Morb Mortal Wkly Rep 2013; 62:217.

Saubolle MA, McKellar PP, Sussland D. (2007). Epidemiologic, clinical, and diagnostic aspects of coccidioidomycosis. Journal of Clinical Microbiology. 45:26.

Taylor AB, Briney AK. (1949). Observations on primary coccidioidomycosis. Annals of Internal Medicine. 30:1224.

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Author: Sam Killian, MD

Educational Pearls:

Being exposed to E-cigarette vapor may increase risk of pneumonia.
Recent study has shown e-cigarette vapor increases quantities of Platelet-activating-receptor factor in epithelial cells, which may aid pneumococcal bacteria in entering pneumocytes.

References:

Miyashita L, et al. (2018). E-cigarette vapour enhances pneumococcal adherence to airway epithelial cells. The European Respiratory Journal. 7;51(2).

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Author: Rachel Beham, PharmD

Educational Pearls:

Some synthetic cannabinoids have been contaminated with Brodifacoum. Brodifacoum is a Vitamin K antagonist and can present with a severe coagulopathy.
Brodifacoum is commonly known as “superwarfarin” and has a very long half life of 120+ days.
Check PT/INR in patients with a bleeding diathesis in setting of synthetic cannabinoid use.
Treatment is activated charcoal and large doses of Vitamin K (10mg Q6H for months).

References:

Lipton R.A.; Klass E.M. (1984). "Human ingestion of a 'superwarfarin' rodenticide resulting in a prolonged anticoagulant effect". JAMA. 252: 3004–3005.

La Rosa F; Clarke S; Lefkowitz J. B. (1997). "Brodifacoum intoxication with marijuana smoking". Archives of Pathology & Laboratory Medicine. 121: 67–69

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Author: Jared Scott, M.D.

Educational Pearls:

Cardiac myocytes and vascular smooth muscle are dependent on an intracellular calcium influx for contraction. Pancreatic beta cells rely on calcium to release insulin.
Calcium channel blockers will decrease cardiac contractility and heart rate, but will also cause vascular smooth muscle relaxation with a subsequent decrease in systemic vascular resistance.
Resultant cardiac depression and hypotension.
Pancreatic beta cells also use calcium to release insulin, so calcium channel blockade can cause hyperglycemia.
Treatment for calcium channel toxicity include: fluid resuscitation, calcium gluconate, vasopressors, and high dose insulin.
Dosing for insulin therapy is usually 1-5 Units/kg/hr. Make sure to add dextrose!

References:

Boyer EW, Shannon M. (2001).Treatment of calcium-channel-blocker intoxication with insulin infusion. New England Journal of Medicine. 344:1721.

Proano L, Chiang WK, Wang RY. (1995).Calcium channel blocker overdose. American Journal of Emergency Medicine. 13:444.

St-Onge M, Dubé PA, Gosselin S, et al. (2014). Treatment for calcium channel blocker poisoning: a systematic review. Clinical Toxicology. 52:926.

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Author: Nick Hatch, M.D.

Educational Pearls:

Methemoglobinemia is when the iron in hemoglobin is in the Fe3+ (ferric) state rather than the normal Fe2+ (ferrous) state. Methemoglobin cannot release oxygen at the tissues.
Symptoms include cyanosis, headache, tachycardia, dyspnea, and lethargy.
Suspect in setting of hypoxia that does not improve with oxygenation, and clinical cyanosis with a normal PaO2 on ABG.
Treatment is methylene blue which reduces the iron back to the ferrous state.
Causes can be Dapsone, Lidocaine, Benzocaine.

References:

Agarwal N, Nagel RL, Prchal JT. Dyshemoglobinemias. In: Disorders of Hemoglobin: Genetics, Pathophysiology, and Clinical Management, 2nd ed, Steinberg M (Ed), 2009. P.607

Cortazzo JA, Lichtman AD. (2014). Methemoglobinemia: a review and recommendations for management. Journal of Cardiothoracic and Vascular Anesthesia. 28:1043.

Darling R, Roughton F. (1942). The effect of methemoglobin on the equilibrium between oxygen and hemoglobin. American Journal of Physiology. 137:56.

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Author: Jared Scott, M.D.

Educational Pearls:

Recent study compared Compazine with Benadryl vs. Dilaudid for acute migraine management in the ED.
Compazine + Benadryl demonstrated migraine relief in 60% of patients compared to the 31% of patients who were relieved with Dilaudid.
Compazine + Benadryl is a superior migraine treatment than Dilaudid.

References:

Friedman BW, et. al. (2017). Randomized study of IV prochlorperazine plus diphenhydramine vs IV hydromorphone for migraine. Neurology. 89(20):2075-2082

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Author: Don Stader, M.D.

Educational Pearls:

Pulmonary embolism is one of the leading causes of maternal mortality.
There is disagreement among different medical societies about the value of D-dimer as a screening modality. If you use it, consider the rational D-dimer approach whereby you add 250 to your cut-off for every trimester.
A useful screening modality is an ultrasound of bilateral lower extremities looking for DVT.
Keep in mind, both a V/Q scan and CT scan have a significant amount of radiation. CTA is probably the right diagnostic test (less radiation than CT w&w/o).
Always use the shared decision-making model and clinical acumen to choose your tests.

References:

Leung AN, et. al. (2011). An official American Thoracic Society/Society of Thoracic Radiology clinical practice guideline: evaluation of suspected pulmonary embolism in pregnancy. American Journal of Respiratory and Critical Care Medicine. 184(10):1200-8

Polak JF, Wilkinson DL. (1991). Ultrasonographic diagnosis of symptomatic deep venous thrombosis in pregnancy. American Journal of Obstetrics and Gynecology. 165(3):625-9.

Sachs BP, et. al. (1987). Maternal mortality in Massachusetts. Trends and prevention. New England Journal of Medicine. 316(11):667-72.

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Author: Aaron Lessen, MD

Educational Pearls:

Shockable rhythms like V-fib or V-tach have a better prognosis than patients with PEA or asystole.
Recent study has shown an initial electrical frequency in PEA between 10-24/min had worse outcomes than PEA with initial rhythm over 60/min.
Patients with an initial electrical frequency in PEA over 60/min did just as well as patients with shockable rhythms. Of them, there was a 22% survival rate with 15% having a good neurologic outcome.

References:

Weiser, C., et al. (2018). Initial electrical frequency predicts survival and neurological outcome in out of hospital cardiac arrest patients with pulseless electrical activity. Resuscitation. 125:34-38

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**Author: Erik Verzemnieks, M.D.**

Educational Pearls:

● Common causes of nystagmus: Congenital disorders, CNS diseases (MS, CVA), Intoxication

● Drugs associated (ETOH, Ketamine, PCP, SSRI, MDMA, Lithium, Phenytoin, Barbiturates)

● If a patient has nystagmus and is intoxicated, consider other drugs and etiologies as potential sources

References:
Alpert JN. (1978). Downbeat nystagmus due to anticonvulsant toxicity. Annals of

Neurology. 4(5):471-3.
Rosenberg, ML. (1987) Reversible downbeat nystagmus secondary to excessive

alcohol intake. Journal of Clinical Neuroophthalmology. 7(1):23-5.

Weiner AL, Vieira L, McKay CA, Bayer MJ. (2000). Ketamine abusers presenting to the emergency department: a case series. Journal of Emergency Medicine. 18(4):447-51.

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**Author: John Winkler, M.D.**

Educational Pearls:

● Lower mechanisms of injury have a lower chance of an associated fracture or major ligament injury

● One major concern is having a fracture fragment in the joint (can lead to chronic arthritic pain)

● Evaluation should involve checking the neurovascular status of the arm and reduce the fracture as soon as possible. Immobilize arm in a sling and consult orthopedics if there is intra-articular involvement.

References:

https://orthoinfo.aaos.org/en/diseases--conditions/elbow-dislocation/

Mehta, JA; Bain, GI. (2004). Elbow dislocations in adults and children. Clinics in Sports Medicine. 23(4):609-27.

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Author: Michael Hunt, M.D.

Educational Pearls:

1% of patients presenting to ED with alcohol intoxication end up going to the ICU
Most common critical illnesses were acute hypoxic respiratory failure, sepsis, and intracranial hemorrhage
Predictive markers: Vital abnormalities (hypoxia, tachycardic, tachypneic, hypothermic, hyperthermia, hypoglycemia) and patients receiving parenteral sedatives had higher incidence of ICU admission

References:

Klein, LR; et al. (2018). Unsuspected Critical Illness Among Emergency Department Patients Presenting for Acute Alcohol Intoxication. Annals of Emergency Medicine. 71(3):279-288

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Author: Dr. Karen Woolf, MD

Educational Pearls:

Anatomy : base of skull to posterior mediastinum, anteriorly bounded by middle layer of deep cervical fascia and posteriorly by the deep layer, communicates to lateral pharyngeal space bounded by carotid sheath. Lymph node chains draining nasopharynx, sinuses, middle ear, etc. run through it.
Epidemiology & Microbiology: most common kids 2-4, (neonates too). Polymicrobial (GAS, MSSA, MRSA, respiratory anaerobes).
Signs and symptoms can include pharyngitis, dysphagia, odynophagia, drooling, torticollis, muffled voice, respiratory distress, stridor, neck swelling, and trismus.
Exam may show drooling, posterior pharyngeal swelling, anterior cervical LAD, or a neck mass.
Imaging: Get CT neck w/IV contrast!
DDx: epiglottis, croup, bacterial tracheitis, peritonsillar abscess, trauma, foreign body, angioedema, cystic hygroma, meningitis, osteomyelitis, tetanus toxin.
Tx: Unasyn, if not responding add Vancomycin or Linezolid; surgical drainage if airway is compromised.
Complications: airway obstruction, sepsis, aspiration pneumonia, IJ thrombosis, carotid artery rupture, mediastinitis.

References:

Craig FW, Schunk JE. Retropharyngeal abscess in children: clinical presentation, utility of imaging, and current management. Pediatrics 2003; 111:1394.

Fleisher GR. Infectious disease emergencies. In: Textbook of Pediatric Emergency Medicine, 5th ed, Fleisher GR, Ludwig S, Henretig FM (Eds), Lippincott Williams & Wilkins, Philadelphia 2006. p.783.

Goldstein NA, Hammersclag MR. Peritonsillar, retropharyngeal, and parapharyngeal abscesses. In: Textbook of Pediatric Infectious Diseases, 6th ed, Feigin RD, Cherry JD, Demmler-Harrison GJ, Kaplan SL (Eds), Saunders, Philadelphia 2009. P.177

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Author: Gretchen Hinson, M.D.

Educational Pearls:

PNES vs. epilepsy: postictal state is diagnostic of an epileptic seizure (sonorous respirations and/or confusion, lasting typically 20-30 minutes); Epileptiform seizures show decrease in convulsion frequency, but increase in convulsion amplitude while PNES convulsions demonstrate episodic convulsion amplitudes; and epileptiform seizures usually do not pause.
PNES is a form of conversion disorder and can be associated with underlying personality disorder; however there are patients with epilepsy that also can have PNES which complicates the diagnosis and treatment.
Patients that are malingering may have flailing movements and might talk during the episodes - both not typical of epileptic seizures or PNES.
Treatment for PNES is with psychotropic medications and psychotherapy as opposed to antiepileptic medications

References:

Avbersek, A; Sisodiya, S. (2010). Does the primary literature provide support for clinical signs used to distinguish psychogenic nonepileptic seizures from epileptic seizures?. Journal of neurology, neurosurgery, and psychiatry. 81(7):719-25.

Devinsky, O; Gazzola, D; LaFrance, W. Curt (2011). Differentiating between nonepileptic and epileptic seizures. Nature Reviews. Neurology. 7 (4): 210–220.

Lesser, RP. (2003). Treatment and Outcome of Psychogenic Nonepileptic Seizures. Epilepsy Currents. 3(6):198-200. doi:10.1046/j.1535-7597.2003.03601.x.

Pillaia, JA; Hautab SR. (2012). Patients with epilepsy and psychogenic non-epileptic seizures: An inpatient video-EEG monitoring study. Seizure. 21(1): 24-27.

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Author: Dr. Peter Bakes

Educational Pearls:

High risk patients: underlying lung disease, immunocompromised, extremes of age (<2 or >65), underlying cardiac/renal/neurologic disease, and pregnant women
Testing: RT-PCR (RNA based test that is both sensitive and specific)
Workup: comorbidities dictate whether or not they are screened; CXR indicated in high risk patients with respiratory symptoms
Morbidity from flu comes from secondary pneumonia, sepsis, and septic shock
Treatment options are Tamiflu and Relenza (Relenza is contraindicated in patients with lung disease)
High risk patients see average of 2.5 days shortening of illness and a decrease in illness severity. Low risk patients see average of 1.5 days shortening of illness.

References:

https://www.cdc.gov/flu/about/disease/high_risk.htm

Binnicker MJ, Espy MJ, Irish CL, Vetter EA. Direct Detection of Influenza A and B Viruses in Less Than 20 Minutes Using a Commercially Available Rapid PCR Assay. J Clin Microbiol. 2015 Jul; 53(7): 2353-4.

Longo, Dan L. (2012). "187: Influenza". Harrison's principles of internal medicine (18th ed.). New York: McGraw-Hill. ISBN 9780071748896.

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Author: Sam Killian, M.D.

Educational Pearls:

Spinal cord injury without radiographic abnormality (SCIWORA) is a diagnosis defined as traumatic injury to spine with clinical sx of traumatic myelopathy (paraplegia, paresthesias, FND) without radiographic abnormalities.
Term was established in 1970’s before MRI and accounted for about 15% of injuries at the time (mainly children). Today SCIWORA accounts for about 10% of spinal injuries.
Belief is that injury causes subtle movement of the spinal cord from its natural position with resultant contusion or ischemia with subsequent deficits.
Treatment involves prolonged immobilization (up to 12 weeks).

References:

Walecki, J. (2014). Spinal Cord Injury Without Radiographic Abnormality (SCIWORA) – Clinical and Radiological Aspects. Polish Journal of Radiology,79, 461-464. doi:10.12659/pjr.890944

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Author: Aaron Lessen, M.D.

Educational Pearls:

Recurrence rate for first time unprovoked seizures - 5% after 48 hours, 14% at 2 weeks , 30% after 4 months.
Higher risk for recurrence: age under 3; patients with multiple seizures at initial presentation, focal neurologic findings on initial presentation.
Useful for counseling patients and recommending follow up.

References:

Shinnar S, Berg AT, Moshé SL, et al. Risk of seizure recurrence following a first unprovoked seizure in childhood: a prospective study. Pediatrics 1990; 85:1076.

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Author: Gretchen Hinson, M.D.

Educational Pearls:

Controversial topic.
Pathophysiology - acidosis leads to an extracellular potassium shift. Patients in DKA will be intracellularly potassium deplete, but will have a falsely normal/elevated serum potassium.
3 risk of giving bicarb in DKA - alkalosis will drive potassium intracellularly but can overshoot (hypokalemia) and increase risk of arrhythmias; bicarb slows clearance of ketones and will transiently increase their precursors; bicarb can cause elevated CSF acidosis.
3 instances when appropriate to give bicarb in DKA: DKA in arrest; hyperkalemic in DKA with arrhythmia; fluid and vasopressor refractory hypotension.

References:

Bratton, S. L., & Krane, E. J. (1992). Diabetic Ketoacidosis: Pathophysiology, Management and Complications. Journal of Intensive Care Medicine, 7(4), 199-211. doi:10.1177/088506669200700407

Chua, H., Schneider, A., & Bellomo, R. (2011). Bicarbonate in diabetic ketoacidosis - a systematic review. Annals of Intensive Care, 1(1), 23. doi:10.1186/2110-5820-1-23

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Author: Alicia Oberle, MD

Educational Pearls:

Recent study has shown risk factors for return included patients at high risk for resistance (nursing home, obstructive uropathy), patient where diagnogsis of pyelonephritis was missed, but the biggest risk factor was the existence of bug-drug mismatches.
Cephalexin (Keflex) was associated with highest rate of return, while nitrofurantoin (Macrobid) was associated with lowest return rate.
Recommendation is to continue to detect between pyelonephritis and cystitis, broaden coverage for patients with complications, and utilize your facilities antibiogram.

References:

Jorgensen S, et al. ( 2018). Risk factors for early return visits to the emergency department in patients with urinary tract infection. American Journal of Emergency Medicine. 36(1):12-17

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Author: Aaron Lessen, M.D.

Educational Pearls:

There is currently debate within the medical community about what constitutes cardiac activity on ultrasound in the setting of cardiac arrest. A recent study has shown there providers looking at the same clips from an echo will disagree about what constitutes cardiac activity.
Some of the confusion stems from movement that is not cardiac in etiology. For example, some alvular movement can be due to IV fluids and some cardiac motion can be due to the patient being bagged.
Cardiac activity is defined as “Any intrinsic motion of the myocardium.” However, even if this is present, it is important to ask if it clinically significant cardiac activity.
Despite disagreement, ultrasound can be useful for clinical decision making.

References:

Gaspari R et al. (2016) Emergency Department Point-Of-Care Ultrasound in Out-Of-Hospital and in-ED Cardiac Arrest. Resuscitation; 109: 33 – 39.

Hu K et al. (2017) Variability in Interpretation of Cardiac Standstill Among Physician Sonographers. Ann Emerg Med.

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Author: Peter Bakes, M.D.

Educational Pearls:

Rare disease with 1-2 patients out of 100,000. About 60% of patients report a preceding diarrheal illness and classically presents with an ascending motor weakness.
Pathophysiology is likely due to molecular mimicry where the immune system creates antibodies against a pathogen (C. jejuni ) which appears similar to the myelin of peripheral nerves resulting in autoimmune demyelination.
Diagnosis is made by clinical presentation +/- a spinal tap with a characteristic high protein count but without cells.
Treatment is IVIG or plasmapharesis. It is important to monitor respiratory function because about 15% of patients progress to respiratory failure.

References:

Sejvar, James J.; Baughman, Andrew L.; Wise, Matthew; Morgan, Oliver W. (2011). "Population incidence of Guillain–Barré syndrome: a systematic review and meta-analysis"

van den Berg, Bianca; Walgaard, Christa; Drenthen, Judith; Fokke, Christiaan; Jacobs, Bart C.; van Doorn, Pieter A. (15 July 2014). "Guillain–Barré syndrome: pathogenesis, diagnosis, treatment and prognosis". Nature Reviews Neurology. 10 (8): 469–482.

Yuki, Nobuhiro; Hartung, Hans-Peter (14 June 2012). "Guillain–Barré Syndrome". New England Journal of Medicine. 366 (24): 2294–2304.

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Author: Nick Hatch, M.D.

Educational Pearls

Tramadol acts at multiple receptors and is a partial agonist at the mu opioid receptor, but also blocks reuptake of serotonin and norepinephrine throughout the body among others.
One major side effect to be aware of is that it lowers the seizure threshold.
Useful in setting of pain control in patients with contraindications to NSAIDs who are poor opioid candidates.
Use with caution as it potential for abuse.

References

Hennies HH, Friderichs E, Schneider J (July 1988). "Receptor binding, analgesic and antitussive potency of tramadol and other selected opioids". Arzneimittel-Forschung. 38 (7): 877–80.

"Tramadol Hydrochloride". The American Society of Health-System Pharmacists. Retrieved Dec 1, 2014.

"Withdrawal syndrome and dependence: tramadol too". Prescrire Int. 12 (65): 99–100. 2003

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Author: Aaron Lessen, M.D.

Educational Pearls

A “stuffer” is a term for someone who hastily and conceals a bag of drugs orally/rectally/vaginally in an unplanned situation. A “packer” is someone who is planning to smuggle drugs, and does so in a similar manner.
“Stuffers”are more likely to have the drug container open up in their system, while packers tend to have more reliable containment, but typically have larger quantities on-board.
Be on look out for symptoms associated with the drug’s exposure (drug dependent) as well as mechanical symptoms (perforation; obstruction).
If suspicious, order CT as X-rays underestimate severity.
Management: treat symptoms of intoxication appropriately, observe if packets are intact, consider surgery/endoscopy if necessary.

References

Dueñas-Laita A, Nogué S, Burillo-Putze G (2004). "Body packing". New England Journal of Medicine. 350 (12): 1260–1

Hergan K, Kofler K, Oser W (2004). "Drug smuggling by body packing: what radiologists should know about it". Eur Radiology. 14 (4): 736–42.

Traub SJ, Hoffman RS, Nelson LS (2003). "Body packing—the internal concealment of illicit drugs". New England Journal of Medicine. 349 (26): 2519–26.

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Author: Dylan Luyten, MD

Educational Pearls

Johannes Hoffer coined term Nostalgia in 1688 in his medical dissertation.
Nostalgia was a formal medical diagnosis, and one that dates back to 17th century when soldiers had longing for home and melancholy with a constellation of symptoms including lethargy, sadness, disturbed sleep, heart palpitations, GI complaints, and/or skin findings for which the only cure was to return home.
In the civil war, over 5000 soldiers were given medical leave for nostalgia.
Always remember to view your patient in the appropriate context (psychosocial, cultural, historical, etc.)

References

Beck, J. (2013, August 14). When Nostalgia Was a Disease. Retrieved March 08, 2018, from https://www.theatlantic.com/health/archive/2013/08/when-nostalgia-was-a-disease/278648/

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Author: Dylan Luyten, M.D.

Educational Pearls

The Lazarus phenomenon is the delayed return of spontaneous circulation after cessation of CPR.
A prospective study in Finland found 5 out of 840 patients where CPR was attempted in the setting of cardiac arrest experienced the Lazarus effect (about 0.6%).
3 of these patients died on scene, and the other 2 died in the hospital at 1.5 and 26 hours respectively.
Ultimately, the Lazarus effect is rare, but it does occur and providers and family members should be aware that signs such as gasping or twitching may be seen after cardiac arrest, but the prognosis is still dismal.

References

Kuisma, M, et al. (September 2017) “Delayed return of spontaneous circulation (the Lazarus phenomenon) after cessation of out-of-hospital cardiopulmonary resuscitation”. Resuscitation. 118: 107-111

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Author: Jared Scott, M.D.

Educational Pearls

Flu is widespread throughout the US (through Jan 20th 2018).
All age groups have seen surge in hospitalizations, but 65 + age group has seen the largest surge in hospitalizations due to flu.
New recommendations for treating with Tamiflu! Treat the following high-risk groups at any stage of illness: Children under age 2, Adults 65 and older, patients with comorbidities such as chronic lung disease, heart disease, blood disorders, kidney disorders, liver disorders, neurological disorders, immunosuppressed, pregnant women, American Indians, extreme obesity, women under 19 on long-term aspirin, and nursing home residents.

References:

https://www.cdc.gov/flu/about/disease/high_risk.htm

https://www.cdc.gov/flu/weekly/summary.htm

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Author: Don Stader, M.D.

Educational Pearls

Common pathologies include cholecystitis, choledocholithiasis, and in concerningly ascending cholangitis.
Cholecystitis is obstruction at the cystic duct leading to inflammation of gallbladder wall, while choledocholithiasis is a distal obstruction of the biliary tree, and ascending cholangitis is an ascending infection of the biliary tree secondary to obstruction.
Risk factors for Cholecystitis are the 5 F’s (Fat, Forty, Female, Fertile, Family Hx).
Classic symptoms seen in ascending cholangitis are Charcot’s Triad of fever, RUQ pain, and jaundice, or Reynold’s pentad which is more severe and has the addition of
altered mental status and hypotension.
Porcelain gallbladder is a radiographic finding showing calcification of the gallbladder that is associated with cancer of the gallbladder.

References:

Kimura Y, Takada T, Kawarada Y, et al. (2007). "Definitions, pathophysiology, and epidemiology of acute cholangitis and cholecystitis: Tokyo Guidelines". J Hepatobiliary Pancreat Surg.

Strasberg, SM (26 June 2008). "Clinical practice. Acute calculous cholecystitis". The New England Journal of Medicine. 358 (26): 2804–11.

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Since the tragic overdose of his son, Admiral Winnefeld has developed an intriguing strategy on how to combat the Opioid Epidemic.

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Sam Quinones, American journalist and author of the critically acclaimed book, Dreamland: The True Tale of America's Opiate Epidemic, shares the story of how he discovered the truth about the Opiate Epidemic.

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Lisa Raville, executive director of The Harm Reduction Action Center in Denver, shares tales from her perspective as a Harm Reductionist.

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Emergency Medical Minute's very own Donald Stader, MD explains Medicine's contribution to the catastrophe that is the Opioid Epidemic.

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Dr. Robert Valuck, director of the Colorado Consortium, presents 10 fallacies that have fueled the Opioid Epidemic.

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The Honorable Alby Zweig shares his impactful first-hand experience with addiction, recovery and triumph.

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Admiral James Winnefeld and Mary Winnefeld speak publicly for the first time about the tragic overdose of their son, Jonathon, and how 'No Family is S.A.F.E...yet'.

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Author: Peter Bakes, M.D.

Educational Pearls

Probiotics are living bacteria that are taken as an oral supplement.
Most of the data to support their use is in the prevention of antibiotic-related diarrhea and the reduction of the symptoms of ulcerative colitis (UC).
Some studies have some a reduction of the incidence of antibiotic-related diarrhea in children of up to 12% with the use of probiotics.
There may be a reduction of up to 60% in the incidence of antibiotic-related C. diff infection in adults with probiotic use
Studies have shown a 10% or more reduction in the duration and severity of the symptoms of UC with probiotic use.
Proposed mechanisms of probiotics include a decrease in gut permeability and a decrease in pathogenic gut bacteria due to resource competition.

References: http://www.cochrane.org/CD006095/IBD_use-probiotics-prevent-clostridium-difficile-diarrhea-associated-antibiotic-use

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Author: Chris Holmes, M.D.

Educational Pearls

It’s estimated that about 25 million people died during the Black Plaque. Researchers have confirmed this number by assessing how much old, broken pottery was buried in front of homes and churches from that time period.
Traditional thinking has been that the Black Plague was spread primarily by flea bites. However, using mathematical modeling, researchers have theorized that person-to-person spread was more common.

References: https://www.washingtonpost.com/news/speaking-of-science/wp/2016/05/24/broken-pottery-reveals-the-sheer-devastation-caused-by-the-black-death/

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Author: Sam Killian, M.D.

Educational Pearls

The availability of antiepileptic treatment has changed in the last 30 years.
A recent study in JAMA followed 18,000 pts with epilepsy for 30 years to assess the effectiveness of looked at seizure control.
The study found that although there have been new drugs introduced over the last 30 years, there has not been much of an improvement in seizure control.
Side effect profiles and medicine compliance may have improved in this time period, but the main goal of reducing seizure frequency has not been reached.

References: Chen Z, Brodie MJ, Liew D, Kwan P. Treatment Outcomes in Patients with Newly Diagnosed Epilepsy Treated With Established and New Antiepileptic DrugsA 30-Year Longitudinal Cohort Study. JAMA Neurol. Published online December 26, 2017. doi:10.1001/jamaneurol.2017.3949

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Educational Pearls

Truvada (Emtricitabine/tenofovir) is a combination nucleotide reverse transcriptase inhibitor that can be used as pre-exposure prophylaxis (PrEP) for HIV. It has been shown to dramatically reduce the risk of contracting HIV.
It is used in high-risk patients, like the MSM community or those who are in a relationship with someone with HIV.
Side effects include nausea, vomiting, headache, and liver damage.
HIV testing should be performed every 3 months while taking it, since it is not meant to fight an actual infection.
Since 2012, there have only been 3 confirmed cases of transmission while using Truvada.
It costs between 50-60$ dollars per pill, but it is covered by most insurances, including Medicaid.
Generic version has recently been FDA approved.

References: https://www.cdc.gov/hiv/pdf/prep_gl_patient_factsheet_truvada_english.pdf

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Author: Rachael Duncan, PharmD

Educational Pearls

A NEJM study report in July 2016 discussed a situation in New York during which 30 people became “zombie-like” after ingesting synthetic cannabinoids (aka “Spice).
The ER managed to coordinate with the CDC to evaluate blood samples from 18 patients who were transported to the hospital.
Of those who went to the ER, the mean age was 36.8, many of them were homeless, all of them were male. Mass spectrometry was used to confirm the presence of synthetic cannabinoid in their blood.
Compared to normal THC, synthetic cannabinoids have a much lower EC50 and LD50.
Spice intoxication presents in a variety of ways -patients may be hyperthermic, combative, delirious and/or seizing.
Treatment is supportive, including fluids, cooling, electrolyte management, and sedatives.

References: Adams, A. J., Banister, S. D., Irizarry, L., Trecki, J., Schwartz, M., & Gerona, R. (2017). “Zombie” Outbreak Caused by the Synthetic Cannabinoid AMB-FUBINACA in New York. New England Journal of Medicine, 376(3), 235-242. doi:10.1056/nejmoa1610300

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Author: Sam Killian, M.D.

Educational Pearls

Traditionally, UTI diagnosis has been dependent on urine culture, urinalysis and clinical symptoms. But a recent study casts some doubt on the utility of urine cultures.
A study in the Journal of Clinical Microbiology did urine cultures and E. coli PCR in 220 women with UTI symptoms and 86 women without UTI symptoms.
In the symptomatic women, 67% had positive E. Coli PCR and 98% had a pathogenic bacteria in their urine culture.
In the asymptomatic women, 10% had positive E. coli PCR and/or urine culture.
Therefore, this study suggests that urine culture may be of limited utility, since symptoms alone seemed to predict bacteriuria.

References: Burd EM, Kehl KS. A Critical Appraisal of the Role of the Clinical Microbiology Laboratory in the Diagnosis of Urinary Tract Infections. Journal of Clinical Microbiology. 2011;49(9 Supplement). doi:10.1128/jcm.00788-11.

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Author: Michael Hunt, M.D.

Educational Pearls

Rhabdomyolysis is caused by the destruction of skeletal muscle that leads to the release of myoglobin, which causes renal failure. It presents with pain and weakness in the affected muscle, as well as dark urine.
Diagnosis is made with creatinine kinase levels
It can happen to extreme athletes after competition, but the most common presentation is in people who fall and are immobilized for long periods of time.
Other causes include burns, crush injuries, viral infections (influenza), bacterial infections (Legionella), and medications (statins in adults, propofol in kids)
Treatment is aggressive fluids

References: Huerta-Alardín AL, Varon J, Marik PE. Bench-to-bedside review: Rhabdomyolysis – an overview for clinicians. Critical Care. 2005;9(2):158-169. doi:10.1186/cc2978.

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Author: Sam Killian, M.D.

Educational Pearls

Transient global amnesia is a paroxysmal, transient memory issue. Remote and immediate memory is preserved, but new memories cannot be made.
Patients will have a normal neurological exam and usually no other complaints.
The episode will last less than 24 hours, but they usually resolve after 1-2 hours.
This is relatively common. It happens in 5/100000 people, mostly men over 50. Recurrence is rare.
There is no known cause, but it is associated with migraines and classically occurs after heavy physical exertion or emotional stress.
Workup includes a full neuro exam, imaging for ongoing symptoms, and labs to rule out other causes.
Patients can be sent home with reassurance after symptoms resolve. Instruct them to follow up with neurology. Patients with continuing symptoms should be admitted.

References: Owen D, Paranandi B, Sivakumar R, Seevaratnam M. Classical diseases revisited: transient global amnesia. Postgraduate Medical Journal. 2007;83(978):236-239. doi:10.1136/pgmj.2006.052472.

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Author: John Winkler, M.D.

Educational Pearls

Normally, the parathyroid is the master regulator of serum Ca levels. It secretes PTH, which stimulates calcium uptake from the bone and gut.
Causes of hypercalcemia include: parathyroid tumor, lytic bone lesions (multiple myeloma), breast cancer, renal injury, and some lung cancers.
Hypercalcemia can lead to poor bone quality and pathological fractures. It can also cause heart arrhythmias.
It is important to order an ionized calcium to quantify the level of hypercalcemia, since calcium binds to albumin.
Treatment for hypercalcemia includes fluids and loop diuretics.

References: https://emedicine.medscape.com/article/766373-treatment

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Author: Nick Hatch, M.D.

Educational Pearls

The Cincinnati Stroke Scale uses 3 measures to screen for ischemic stroke. The measures are: facial asymmetry, speech quality and arm drift.
This scale is used commonly in EMS systems as a screening tool.
Studies show that having one out of the 3 elements correlates with a 72% chance of having an ischemic stroke, while having all 3 of the elements correlates with an 85% chance. Overall the scale is highly sensitive but not very specific (92% and 48%, respectively, in one study).
The measures focus on anterior circulation function, and often misses posterior circulation strokes.
The Cincinnati Stroke Scale is good for EMS, but not necessarily for emergency physicians.

References: http://onlinelibrary.wiley.com/store/10.1002/9781118783467.app5/asset/app5.pdf?v=1&t=jcf2yn71&s=3c2341ba472c1fcc88003dc0af7eac28691dd980

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Author: Dave Rosenberg, M.D.

Educational Pearls

DKA commonly causes hyperkalemia, leading to peaked T-waves on ECG. However, DKA causes hypokalemia at the same time.
In DKA, glucose cannot be taken into the cells. This signals the body to create and use acidic ketones for energy. This leads to acidosis. To compensate for increased acid, H ions are pumped into cells. To maintain electroneutrality, K is pumped out of the cell. At the kidney, K is lost in the urine.
Overall, while serum K is high in DKA, total body K is low. The derangement in K can lead to life-threatening arrhythmias.
Treatment for DKA can induce hypokalemia, as the K will shift back into the cells with insulin administration. Therefore, treatment for DKA needs to include K.

References: http://www.merckmanuals.com/professional/endocrine-and-metabolic-disorders/diabetes-mellitus-and-disorders-of-carbohydrate-metabolism/diabetic-ketoacidosis-dka

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Author: Dylan Luyten, M.D.

Educational Pearls

Cannabinoid Hyperemesis syndrome is a relatively new diagnosis that presents with vomiting and abdominal pain without a clear etiology in the setting of daily marijuana use.
The pathophysiology is not well-understood well, but may involve cannabinoid receptors in the gut.
Treatment is abstinence from marijuana, fluids, dextrose, and antiemetics (haldol, ondansetron, etc). Opioids should be avoided.
Capsaicin cream on the abdomen may be helpful, as it can distract from the pain and vomiting. Milk can be used to reverse its effects.

References:Galli JA, Sawaya RA, Friedenberg FK. Cannabinoid Hyperemesis Syndrome. Current drug abuse reviews. 2011;4(4):241-249.

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Author: Peter Bakes, M.D.

Educational Pearls

Chronic diarrhea is defined as 3 or more loose, watery stools lasting more than 2-3 weeks.
Look for clues in the history, including travel (could suggest infectious etiology), antibiotic use (could suggest C. Diff), and family history.
Irritable Bowel Disease (Crohn’s/Ulcerative Colitis) is an autoimmune disorder that affects 1.3 million Americans and is a leading cause of chronic diarrhea.
Crohn’s always involves the terminal ileum, but can present anywhere along the GI tract. It causes transmural inflammation of the bowel wall and can lead to adhesions, perforations, and fistulas. Ulcerative colitis usually involves the rectum and causes mucosal inflammation only.
Workup for IBD includes colonoscopy and tissue biopsy.
Treatment for IBD includes dietary changes, 5-ASA/Mesalamine, steroids, and infliximab (anti-TNF alpha).

References: https://www.aafp.org/afp/2011/1115/p1119.html

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Author: Aaron Lessen, M.D.

Educational Pearls

Treatment “bundles” are a popular approach to the rapid resuscitation of septic patients. A recent study in New York, where sepsis bundles are mandatory, sought to figure out which aspects of the bundle had impacts on mortality.
In a study of 40,000 septic patients, the study found that early antibiotics were associated with better outcomes, while early IV fluids were not associated with better outcomes.
This study affirms the important role of early antibiotics in sepsis. IV fluids may play an important role in the treatment of sepsis in some patients, but its role is less clear than antibiotics.

References: Time to Treatment and Mortality during Mandated Emergency Care for Sepsis Christopher W. Seymour, M.D., Foster Gesten, M.D., Hallie C. Prescott, M.D., Marcus E. Friedrich, M.D., Theodore J. Iwashyna, M.D., Ph.D., Gary S. Phillips, M.A.S., Stanley Lemeshow, Ph.D., Tiffany Osborn, M.D., M.P.H., Kathleen M. Terry, Ph.D., and Mitchell M. Levy, M.D. N Engl J Med 2017; 376:2235-2244 June 8, 2017 DOI: 10.1056/NEJMoa1703058

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Author: Don Stader, M.D.

Educational Pearls

While we usually associate the coronary vasculature with STEMIs, there are other pathologies that can affect the heart’s blood supply.
Kounis syndrome: an allergic vasospasm of the coronary arteries. This can happen post anaphylaxis or be caused by a stent allergy. It is best treated with aggressive management of the allergic reaction.
Kawasaki disease: An autoimmune condition that presents in kids as conjunctivitis, lymphadenopathy, hand/foot swelling, rash, and fever. It can also cause coronary aneurysms, which can rupture and be rapidly fatal.
Prinzmetal angina: Caused by coronary vasospasm. Presents with transient chest pain at rest. Treat with CCBs.
Cocaine: Causes coronary vasospasm. Cocaine-induced vasospasm is best treated with BZDs.
Coronary artery dissection: increased risk in pregnant women and those with connective tissue disorders.

References: Memon S, Chhabra L, Masrur S, Parker MW. Allergic acute coronary syndrome (Kounis syndrome). Proceedings (Baylor University Medical Center). 2015;28(3):358-362.

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Author: Aaron Lessen, M.D.

Educational Pearls

While C. difficile infections are generally thought of as nosocomial, there is a subset of patients who acquire the infection in the community.
One recent study showed that about 10% of patients presenting to the ED with diarrhea and without vomiting had a C. diff infection.
Another study found risk factors for community-acquired C. diff included recent ED/Urgent care visits and antibiotic use. However, 36% of the patients in that study had no identifiable risk factors.

References: Gupta A, Khanna S. Community-acquired Clostridium difficile infection: an increasing public health threat. Infection and Drug Resistance. 2014;7:63-72. doi:10.2147/IDR.S46780.

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Author: Erik Verzemneicks, M.D.

Educational Pearls

1/600 flights has an on-board request for medical assistance.
Most common complaints on board include: syncope, respiratory complaints, and GI complaints. Most of the time, these are exacerbations of underlying chronic conditions.
Except for situations involving gross negligence, the Aviation Assistance Act protects providers from legal action as long as they are acting within their scope of practice.
Flight crew are CPR and AED trained.
The onboard medical kit includes: epinephrine, dextrose, nitroglycerin, NSAIDs, injectable antihistamine, antiemetic, steroids, beta-blocker, aspirin, stethoscope, BP cuff, airway tools, thermometer and more.
There is ground-based medical control for consult and guidance.

References: https://www.acep.org/Clinical---Practice-Management/Emergency-at-30,000-Feet---What-You-Can-Do/#sm.0001eqpidqrpoczltzg1epg0m0aqu

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Author: John Winkler, M.D.

Educational Pearls

Photokeratitis is a UV burn of the sclera and cornea, which can cause blindness.
UV light causes eyelid swelling with diffuse scarring of the eye (widespread, punctate uptake of fluorescein dye). While this can eventually heal, it is incredibly painful.
Snow reflects light underneath sunglasses, so wrap-around goggles are the best form of prevention.
This can happen to welders, sunbathers or any other person with prolonged UV light exposure.

References: https://emedicine.medscape.com/article/799025-treatment

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Author: Dave Rosenberg, M.D.

Educational Pearls

EKG changes that can be seen in DKA include ST elevation and peaked T-waves secondary to derangements in K levels.
In DKA, serum K is high, but total body K is low, which can cause said EKG abnormalities.
Many things cause ST elevation besides MI, so think beyond STEMI.
When someone in in DKA, think about the “Three I’s” for underlying cause: (not taking) insulin, ischemia, infection.

References:Nageswara Rao Chava. ECG in Diabetic Ketoacidosis. Arch Intern Med. 1984;144(12):2379–2380. doi:10.1001/archinte.1984.00350220101022

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Author: John Winkler, M.D.

Dr. Winkler shares his knowledge of wilderness medicine and provides insight on how to prevent and treat conditions such as hypothermia, frostbite and sun blindness. More importantly, he gives us tips on how to stay safe while doing our favorite wintertime activities!

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Podcast #281: Intracranial Hemorrhage Treatment

Author: Don Stader, M.D.

Educational Pearls

Types of traumatic bleeds include subdural, epidural, and subarachnoid.
Treatment for a traumatic bleed includes maintenance of systolic BP above 120 and seizure prophylaxis with phenytoin.
In atraumatic bleeds, treatment should focus on lowering blood pressure to reduce bleeding.

References: https://www.aliem.com/2017/09/intracranial-hemorrhage-management/

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Author: Aaron Lessen, M.D.

Educational Pearls

Patients with an ischemic stroke from occlusion of the left middle cerebral artery often present with aphasia in addition to other neurological deficits.
A recent study looked at patients presenting with suspected stroke. Of the 700 patients recruited, 3% had isolated aphasia on exam. On follow-up, none of the 3% had evidence of stroke on imaging. Underlying causes of the isolated aphasia in these patients included syncope, infections, seizures were the underlying cause.

References: Gabriel Casella, Rafael H. Llinas, Elisabeth B. Marsh, Isolated aphasia in the emergency department: The likelihood of ischemia is low, Clinical Neurology and Neurosurgery, Volume 163, 2017, Pages 24-26, ISSN 0303-8467, https://doi.org/10.1016/j.clineuro.2017.10.013.

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Author: Aaron Lessen, M.D.

Educational Pearls

Post-intubation care should always include pain control and adequate sedation.
Commonly used sedation agents include propofol, ketamine and versed.
However, too much sedation is harmful. Deep sedation (RASS -4 to -5) is associated with worse long-term outcomes. RASS of 0 to -2 is ideal, as long as the patient is comfortable.

References: https://coreem.net/core/post-intubation/

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Educational Pearls

Subdural hematomas can happen in the elderly because of brain atrophy, and can manifest with neurological deficit.
Subdural hematomas are caused by rupture of the bridging veins of the brain. This can be caused by trauma, brain atrophy, or possibly by anticoagulant use. They are crescent-shaped on head CT.
Epidural hematomas, in contrast, are caused by rupture of meningeal arteries secondary to trauma. They are usually lens-shaped on head CT.
Subdurals are difficult to pick up on head CT because they may be isodense to brain tissue.

References: Management of Recurrent Subdural Hematomas Desai, Virendra R. et al. Neurosurgery Clinics , Volume 28 , Issue 2 , 279 - 286

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Author: Don Stader, M.D.

Educational Pearls

Mucor/Rhizopus fungal infections usually present in diabetic or immunocompromised patients as a black, necrotic lesion on the face.
The fungus invades the vasculature of the face, causing tissue ischemia and necrosis.
The infection is more common in the diabetic population because the fungus prefers more acidic and glucose-rich environments.
This is a surgical emergency since it is cured only with excision of the affected tissue

References: Vijayabala GS, Annigeri RG, Sudarshan R. Mucormycosis in a diabetic ketoacidosis patient. Asian Pacific Journal of Tropical Biomedicine. 2013;3(10):830-833. doi:10.1016/S2221-1691(13)60164-1.

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Author: John Winkler, M.D.

Educational Pearls

Angioedema is immediately life-threatening due to airway obstruction.
Mechanisms include allergic reaction (histamine-related) or bradykinin-related (ACE-inhibitor, C1 esterase inhibitor deficiency).
The bradykinin-related mechanism will not respond to the traditional meds used for anaphylaxis. Instead, use FFP to replace depleted factors.
If a patient displays signs of respiratory compromise, intubation is indicated. Anesthesia should be consulted as this will be a very difficult airway.

References: https://emcrit.org/pulmcrit/treatment-of-acei-induced-angioedema/

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Author: Nick Hatch, M.D.

Educational Pearls

Unlike coin ingestions, button batteries can cause necrosis of the GI tract.
If lodged in the esophagus, removal within 2 hours is important, because they can cause problems such as strictures or esophago-aortic fistula.
If the battery is in the stomach or beyond, it may be ok to let it pass but give strict return precautions.
Small hearing aid batteries are not as dangerous, but still require close follow-up to ensure the battery passes.
Delayed effects (after passage of the battery) are possible.

References: https://www.poison.org/battery/guideline

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Author: Aaron Lessen, M.D.

Educational Pearls

A recent prospective observational study was performed to examine the safety of different sedation medications in the pediatric ED.
This study included 6000 children, and looked at the rate of serious adverse events following administration of different sedatives.
Overall, the safest drug to use was ketamine alone, with an adverse event rate of about 1%.
Propofol, BZDs, and opiates had increased rates of adverse events.

References: https://lifeinthefastlane.com/pediatric-procedural-sedation-with-ketamine/

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Author: Sam Killian, M.D.

Educational Pearls

Difficulty with bag valve mask (BVM) ventilation can be addressed using the MOANS mnemonic.
Mask seal, Obesity/obstruction, Age, No teeth, Sleep apnea.
Often BVM difficulty can be addressed by an extra set of hands.

References: https://www.aliem.com/2012/10/mnemonics-for-difficult-airway/

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Author: David Rosenberg, M.D.

Educational Pearls

A study of 20,000 subjects found that reducing fever in sepsis did not improve outcomes such as morbidity, mortality, or length of stay.
However, correcting fever may help for patient comfort.

References: Zhang Z, Chen L, Ni H. Antipyretic Therapy in Critically Ill Patients with Sepsis: An Interaction with Body Temperature. Azevedo LCP, ed. PLoS ONE. 2015;10(3):e0121919. doi:10.1371/journal.pone.0121919.

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Author: Chris Holmes, M.D.

Educational Pearls

The nexus chest CT scan rule is based on an 11,000 subject, multicenter study that looked for signs following a trauma that predicted significant findings on subsequent chest CT.
Findings that were associated with abnormal chest CT included: abnormal CXR, distracting injury, chest wall, sternal, thoracic spine or scapular tenderness. Furthermore, a mechanism of injury that includes rapid deceleration was also associated.
If a patient has none of the above findings, then there is only a small chance that there will be an abnormal chest CT.

References: https://www.mdcalc.com/nexus-chest-ct-decision-instrument-ct-imaging

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Author: Don Stader, M.D.

Educational Pearls

Wound botulism should be considered in patients with cutaneous lesions and neuromuscular weakness.
The toxin produced by clostridium botulinum is the causative agent. It forms spores, so it is very resistant to killing by heat.
It presents with weakness, most often in the extraocular muscles.
Treatment includes wound care and respiratory support. Anti-toxin is rarely used as it is stored at the CDC and must be flown in.

References: Kalka-Moll WM, Aurbach U, Schaumann R, Schwarz R, Seifert H. Wound Botulism in Injection Drug Users. Emerging Infectious Diseases. 2007;13(6):942-943. doi:10.3201/eid1306.061336.

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Author: Michael Hunt, M.D.

Educational Pearls

Tattoo ink is applied below the skin, and because of this, they can lead to keloids, granulomas, tetanus, hepatitis B and C, and skin infections.
Tattoo pigment has been found to contain substances like lead, cadmium, chromium, and arsenic; however, there are no long-term studies of the health effects of tattoos.
In one study 14% of inks had ingredients that were banned in cosmetics.
Nanoparticles of tattoo pigment can be found in the lymph nodes, and laser removal can precipitate their spread.
Those with tattoos could experience complications with MRI because of the metal content of the ink.

References: Khunger N, Molpariya A, Khunger A. Complications of Tattoos and Tattoo Removal: Stop and Think Before you ink. Journal of Cutaneous and Aesthetic Surgery. 2015;8(1):30-36. doi:10.4103/0974-2077.155072.

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Author: Dave Rosenberg, M.D.

Educational Pearls

Poiseuille’s Law addresses the flow of a fluid through a tube.
Many common ED presentations involve alterations in flow: asthma, MI, ischemic stroke, etc.
According to the law, flow increases with the 4th power of the radius. That is to say, doubling the radius of the tube will increase the flow by 16x.
Therefore, in situations that require re-opening of an anatomic tube (artery, airway), small changes in the size of the opening will result in dramatic effects.

References: https://www.openanesthesia.org/poiseuilles_law_iv_fluids/

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Author: Dylan Luyten, M.D.

Educational Pearls

Lactate is a byproduct of anaerobic metabolism, a sign of dying tissue. Dangerous causes of high lactates will not normalize with repeat labs.
Crush injuries, seizures, bowel necrosis, end-stage liver disease, and metformin toxicity are common causes of highly elevated lactate.

References: https://lifeinthefastlane.com/ccc/lactic-acidosis/

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Author: John Winkler, M.D.

Educational Pearls

Some risk factors for MI in the young are history of CAD, stimulant drug use, coronary spasm and diabetes.
In those with diffuse ST elevations on EKG, think pericarditis. Troponin will also be elevated.

References: Egred M, Viswanathan G, Davis GK Myocardial infarction in young adults Postgraduate Medical Journal 2005;81:741-745.

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Author: Rachel Beham, PharmD, Advanced Clinical Pharmacist - Emergency Medicine

Educational Pearls

CDC recommends using the inactivated, injectable flu vaccine in those 6 months and older. The live attenuated vaccine is not used because of low efficacy.
Pregnant women should be vaccinated, and can receive the vaccine at any stage of their pregnancy.
The vaccine is contraindicated ONLY in those with a history of a severe anaphylactic reaction to the injection in the past.
Antivirals (oseltamivir, zanamivir) are useful for Flu A and B. Their dosing needs to be adjusted for renal function, and it is contraindicated in those with ESRD who are not receiving dialysis. It should be used for prophylaxis in those with exposure and/or for the very young, very old, morbidly obese, nursing home residents, and those who are immunocompromised. They may be effective as long as 72 hours after symptom onset.

References: https://www.cdc.gov/flu/professionals/index.htm

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Author: Aaron Lessen, M.D.

Educational Pearls

For patients with in-hospital cardiac arrest, intubation in the 1st 15 minutes of resuscitation was associated with worse outcomes (mortality, neurologic outcome). This is likely due to cessation of high-quality CPR and defibrillation during the intubation sequence.
In those with an in-hospital, shockable, cardiac arrest, administration of epinephrine before the 2nd defibrillatory shock was associated with worse outcome. This was likely due to the cessation of high-quality CPR.
For in-hospital cardiac arrest, resuscitation should focus on high-quality CPR.

References: Andersen LW, Granfeldt A, Callaway CW, Bradley SM, Soar J, Nolan JP, Kurth T, Donnino MW, for the American Heart Association’s Get With The Guidelines–Resuscitation Investigators. Association Between Tracheal Intubation During Adult In-Hospital Cardiac Arrest and Survival. JAMA. 2017;317(5):494–506. doi:10.1001/jama.2016.20165

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Educational Pearls

After the first hour, every 1 hour delay in antibiotics in a patient with septic shock patient is associated with a 4% increase in mortality.
In patients with high suspicion for septic shock (fever and hypotension), antibiotics should be initiated ASAP. Rocephin (ceftriaxone) should be used for those with community-acquired sepsis, zosyn for nosocomial or IV-associated sepsis.

References: https://lifeinthefastlane.com/ccc/antibiotic-timing/

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Author: Julian Orenstein, M.D.

Educational Pearls

Colorado has a high population of unvaccinated children, and is at increased risk for pertussis outbreaks.
The causative organism is Bordetella pertussis. It causes causes respiratory epithelial necrosis leading to congestion of the bronchioles, leading to cough.
The cough is unique - it is usually a series of expiratory coughs followed by one deep inspiration
The clinical presentation is divided into 3 phases:
- Catarrhal: cough and congestion with low-grade fever and coryza.
- Whooping: characteristic cough.
- Resolution: recovery with persistent cough.
Infants may not get this presentation, but may get apnea and nonspecific cough.
Tongue depressor can be used to elicit cough for diagnosis.

References: Tozzi AE, Pastore Celentano L, Ciofi degli Atti ML, Salmaso S. Diagnosis and management of pertussis. CMAJ : Canadian Medical Association Journal. 2005;172(4):509-515. doi:10.1503/cmaj.1040766.

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Authors:

Katie Sprinkel, MD Emergency Medicine Physician SANE Medical Director, Medical Center of Aurora Amy Ferrin, Senior Deputy District Attorney County Court Supervisor Office of the District Attorney, 18th Judicial District
Amy Ferrin and Dr. Katie Sprinkel speak about the medical and legal aspects of domestic violence.

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Author: Aaron Lessen, M.D.

Educational Pearls

Icatibant was introduced to treat ACE-inhibitor induced angioendema.
This type of angioedema is refractory to epinephrine and antihistamines, and is likely mediated by elevated bradykinin.(which is inactivated by ATII and ACE).
Icatibant initially was shown to reduce facial swelling and airway obstruction in the setting of ACE-I angioedema, but later, better-powered studies showed that it had no benefit compared to standard treatment.

References: Sinert R et al. Randomized Trial of Icatibant for Angiotensin-Converting Enzyme Inhibitor-Induced Upper Airway Angioedema. J Allergy Clin Immunol Pract 2017. PMID: 28552382

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Author: David Rosenberg, M.D.

Educational Pearls

Preoxygenation is done before rapid sequence intubation, and should be done even if SaO2 is at 100%.
Preoxygenation is done to fill the lungs with oxygen rather than ambient air, which is only 20% O2. While the patient is paralyzed, the O2-filled lungs will continue to oxygenate venous blood, buying you more time for intubation.
BiPAP is an effective tool for pre-oxygenation.

References: https://lifeinthefastlane.com/ccc/preoxygenation/

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Podcast #259: TIA

Author: Peter Bakes, M.D.

Educational Pearls

A TIA is defined as focal neurological deficit that resolves within 24 hours and has negative imaging. The etiology is a transient thrombus, embolus, or narrowing of a branch of a cerebral artery.
Screening tests are generally negative and low-yield. MRI and vascular imaging are usually done to look for reversible causes.
Patients presenting with TIA are usually admitted because of a higher risk for stroke. However, there are some patients that are low-risk and do not require admission. Risk can be assessed using the “ABCD” mnemonic: Age>60, BP (history of HTN), Clinical presentation (area of deficit), Diabetes/Duration of symptoms. See reference link for scoring sheet.
Patients with a low enough score may be eligible for outpatient follow-up.

References: http://www.stroke.org/sites/default/files/resources/tia-abcd2-tool.pdf?docID

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Author: Dylan Luyten, M.D.

Educational Pearls

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA).
Exsanguination is a major cause of mortality in trauma
One temporizing technique to buy time to definitive hemorrhage control is to occlude the aorta thereby shunting blood away from pelvis and lower extremities, increasing cardiac afterload to increase myocardial and brain perfusion.
Rather than perform a thoracotomy to cross clamp aorta, a REBOA catheter may be introduced into the aorta via the common femoral artery and a balloon inflated in the descending aorta to occlude it.
The indications for REBOA include PEA arrest of brief duration attributable to exsanguination for sub-diaphragmatic source in a young, healthy patient, or severe hypovolemic shock or those in an agonal state due to non-compressible hemorrhage not responding to volume and in whom obstructive cause of shock has been ruled out.
Contraindicated in prolonged arrest, suspected proximal aortic injury, advanced age/comorbidities.
Controversies and evidence:
- High quality evidence is lacking - as it is for much of what we do and even consider standard of care in trauma. It has not been shown to improve survival, which is hard to demonstrate.
- Role in remote settings vs trauma centers unclear.
- Further refinements of indication for use are likely to occur with time and experience.
Summarize - REBOA is a promising relatively new technology that may have potential to improve outcomes in the sickest of trauma patients.

Reference: https://lifeinthefastlane.com/ccc/resuscitative-endovascular-balloon-occlusion-aorta-reboa/

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Educational Pearls

Strangulation is common in cases of domestic violence and sexual assault, and it is associated with higher mortality
People who have been strangled have a higher rate of stroke due to vascular damage to carotid artery
Only 50% of people who die from strangulation show external signs of trauma
CTA should be done in all those who experience LOC or incontinence from strangulation
50-60sec of strangulation is all that is required to produce LOC

References: http://epmonthly.com/article/clinical-focus-strangulation-and-hanging-injuries/

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Authors:

Don Stader, M.D & Rachael Duncan, PharmD BCPS BCCCP

Educational Pearls

Fentanyl patches may be abused in many ways, including changing the patches more frequently, chewing them, extracting the fentanyl in a tea, and administering them rectally.
Fentanyl is very lipophilic and has a fast onset, but it has a very low bioavailability when given enterally, because it does not survive the stomach and 1st pass metabolism. It can be given IV, intranasal, through the buccal mucosa, or transdermal.
When patients present with fentanyl overdose due to ingestion of a patch, it is more important to find out how long the patient had the patch in their mouth, since that is the principal form of absorption.

References: http://www.medscape.org/viewarticle/518441_3

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Author: Heidi Wald, MD, MSPH

Associate Professor of Medicine - University of Colorado School of Medicine, Physician Advisor - Colorado Hospital Association

Dr. Heidi Wald explains common misconceptions of UTI's in elderly patients and provides tips on how to properly identify them.

References:

Trestioreanu , Adi Lador , May-Tal Sauerbrun-Cutler and Leonard Leibovici Antibiotics for asymptomatic bacteriuria Cochrane Collaborative Online Publication Date: April 2015.

Trautner BW, Bhimani RD, Amspoker AB, et al. Development and validation of an algorithm to recalibrate mental models and reduce diagnostic errors associated with catheter-associated bacteriuria. BMC Med Inform Decis Mak 2013;13:48.

Trautner BW, Grigoryan L, Petersen NJ, et al. Effectiveness of an Antimicrobial Stewardship Approach for Urinary Catheter Associated Asymptomatic Bacteriuria. JAMA Intern Med 2015.

D'Agata E, Loeb MB, and Mitchell. Challenges in assessing nursing home residents with advanced dementia for suspected urinary tract infections. J Am Geriatr Soc.2013 Jan;61(1):62-6. doi: 10.1111/jgs.12070.

Stone ND, Ashraf MS, Calder J, et al. Surveillance definitions of infections in long-term care facilities: revisiting the McGeer criteria. Infect Control Hosp Epidemiol 2012;33:965-77.

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Author: Erik Verzemnieks, M.D.

Educational Pearls

Posterior vitreous detachment is the tearing of the lining in the back of of the eye.
Patients often present with loss of vision and floaters.
Diagnosis can be made with US.
This is a benign diagnosis, but 10-15% can progress to retinal detachment , so follow up with ophthalmology is recommended.

References: http://www.medscape.com/viewarticle/513226

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Author: Chris Holmes, M.D.

Educational Pearls

There’s little/no data about the necessary length of an antibiotic course, nor has it proven that stopping a course of antibiotics early selects for the most resistant bugs.
There’s little incentive for drug companies to fund this type of study.
Pro-calcitonin levels have been used in some settings to distinguish if an infection has resolved or not, but this may not be feasible in an outpatient setting.

References: Llewelyn, Martin J et al. The antibiotic course has had its day. 2017. BMJ

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Author: Nick Hatch, M.D.

Educational Pearls

Photic or solar retinitis occurs when you stare at the sun. The refractive power of the lens of the eye concentrates the light of the sun on the retina, stimulating the production of free radicals, damaging photoreceptors.
Solar retinitis may present hours-days after light exposure.
Patients will present with patchy loss of vision without pain, since the retina has no pain receptors.
In one study during an eclipse in the UK, of those who initially presented with vision loss due to solar retinitis, 92% recovered full vision.

References: Dobson R. UK hospitals assess eye damage after solar eclipse. BMJ : British Medical Journal. 1999;319(7208):469.

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Author: Sam Killian, M.D.

Educational Pearls

The tongue blade test is done for mandible fractures, which make up 40-60% of facial fractures.
The test is done by having the patient bite down on a tongue depressor on one side of the mouth. The provider then tries to snap the tongue depressor. This is repeated on the other side of the mouth. The test is positive if the patient complains of pain before the depressor can be broken on either side.
It has been compared to CT and X-ray and has a similar sensitivity and specificity (95% and 65%, respectively).

References: J. Neiner, et al. Tongue Blade Bite Test Predicts Mandible Fractures. Craniomaxillofac Trauma Reconstr. 2016

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Author: Rachel Beham, PharmD, Advanced Clinical Pharmacist – Emergency Medicine

Educational Pearls

Cyanide poisoning is suspected in patients who present with lactic acidosis after being trapped around burning household objects. It affects our ability to metabolize and can quickly lead to CV collapse and death.
Because cyanide blood levels are not quickly available, the diagnosis is made by history and lactic acidosis on ABG.
The cyanokit is the key treatment. It contains hydroxocobalamin, which binds to cyanide so it can be excreted.
One side effect to be aware of is that the cyanokit will turn everything red, including mucous membranes, saliva, urine, and skin. This will interfere with some lab values, so make sure to get labs before administration.

References: Mégarbane B, et al. Antidotal treatment of cyanide poisoning. J Chin Med Assoc. 2003

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Author: Rachael Duncan, PharmD BCPS BCCCP

Educational Pearls

Desmopressin is an ADH mimetic and helps retain water, release von Willibrand Factor (in high doses), and treat diabetes insipidus (in low doses).
It can also be used in renal colic, because it may reduce muscle spasm in the ureters.
The dosing for renal colic is very small (40 micrograms).

References: http://reference.medscape.com/drug/ddavp-stimate-noctiva-desmopressin-342819

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Author: Jared Scott, M.D.

Educational Pearls

Overall, medical providers are bad at detecting pulses.
However, only 2% of patients do not have a detectable DP pulse.
In one study, for patients with limb claudication, there was only about 50% agreement on the presence of a DP pulse.

References: Brearley et al. Peripheral pulse palpation: an unreliable physical sign. Annals of the Royal College of Surgeons of England. 1992

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Author: Aaron Lessen, M.D.

Educational Pearls

Traditionally the family is removed from the room during procedures and codes, but recent research shows that family presence may be beneficial.
50% patients want family present during a code.
Family-related outcomes were improved with presence.
There was no change in medical outcomes, and no increased incidence of medicolegal issues.

References: Jabre et al. Family Presence during Cardiopulmonary Resuscitation. NEJM. 2013.

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Author: Michael Hunt, M.D.

Educational Pearls

In the recent YEARS study, investigators checked every patient with suspicion for PE with a D-dimer, using a modified Wells score for risk stratification. The goal of the study was to show that CT scan usage could safely reduced using this screening method.
The Wells Criteria measures they used to stratify risk were: PE mostly likely dx, hemoptysis, and evidence of DVT. If the d-dimer was 1, but the patient had none of the Wells criteria, the patient did not get a CT. If the patient had any of the criteria, but the d-dimer was only 0.5, the patient did not get a CT scan.
The investigators reduced CT usage by 14% using the new criteria, with no significant increase in morbidity and mortality.

References: van der Hulle et al. Simplified diagnostic management of suspected pulmonary embolism (the YEARS study): a prospective, multicentre, cohort study. The Lancet. 2017

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Author: Jared Scott, M.D.

Educational Pearls

The foramen ovale (FO) connects the left and right atria to allow oxygenated blood to bypass the developing lungs, it usually closes at birth but for some it remains patent (PFO).
A PFO allows clots to cross from the venous to arterial circulation, increasing the likelihood of stroke.
PFO is present in 25% of general population, present in 50% of those with stroke of unknown cause, and very common those with stroke under 50 years old.
Treat with anticoagulation or surgical correction.

References: http://www.heart.org/HEARTORG/Conditions/More/CardiovascularConditionsofChildhood/Patent-Foramen-Ovale-PFO_UCM_469590_Article.jsp#.WarsZZN95E4

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Author: Don Stader, M.D.

Educational Pearls

Ear pain is a common complaint in adults and kids.
A red, hot, painful ear with involvement of the pinna could indicate perichondritis - an infection of the cartilage that is usually caused by pseudomonas.
A painful, swollen ear with involvement of the mastoid process could be mastoiditis, which needs to be treated with IV antibiotics to avoid cerebellar abscess.
Ear pain with significant drainage and a cranial nerve deficit points to malignant otitis externa, which needs to be treated with IV antibiotics.

References: John W. Ely, Marlan R. Hansen, Elizabeth C. Clark. Diagnosis Of Ear Pain. 2008. American Family Physician.

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Author: Nick Hatch, M.D.

Educational Pearls

A recent observational cohort study found that the biggest predictor for sepsis survival was fever. Those with higher fevers had better outcomes.
Some possible explanations for this finding are that high fevers indicate good immune response or that high fever cued providers to treat sepsis more aggressively.

References: Paul J Young, Rinaldo Bellomo. Fever in Sepsis: is it cool to be hot?. 2014. Critical Care

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Author: Dylan Luyten, M.D.

Educational Pearls

Hypoglycemia is very common in type 2 diabetics, and is often caused by insulin overdose or missed meals. Knowing the peak time of action for common diabetes medications can help inform treatment and disposition.
Regular insulin’s action peaks around 60 minutes. By the time most of these patients present to the ED, the drug has had most of its effect.
Lantis’ action does not peak, and will continue to exert its effect for 12 or more hours.
Levamir has a peak around 6-8 hours.
Metformin sensitizes tissues to insulin, so it cannot cause hypoglycemia alone.
Glipizides have half-lives over 12 hours and work by increasing insulin release by the pancreas. Hypoglycemia in a patient taking a glipizide usually indicates there is another medical issue interfering with clearance

References: http://emedicine.medscape.com/article/122122-workup

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Author: Nick Hatch, M.D.

Educational Pearls

The force required to break a clavicle is significant, so clavicle fracture may be associated with other injury (pneumothorax, vascular injury).
Most fractures occur in the middle 1/3 of the clavicle.
Traditionally, clavicle fractures have been managed without surgery. However, recent studies have shown that surgery may be beneficial in a larger population than previously thought.

References: http://emedicine.medscape.com/article/398799-overview

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Author: Don Stader, M.D.

Educational Pearls

Cluster headaches are usually intense, unilateral, and involve the periorbital area.
CN V (Trigeminal) provides sensory and autonomic innervation the face and eyes, which play roles in headache pathology.
Cluster headaches can be treated with high flow oxygen, but a new treatment involves blocking the sphenopalatine ganglion (SPG) with lidocaine. Because sensory and autonomic branches of the trigeminal traverse the SPG, lidocaine will effectively treat a cluster headache.
To block the ganglion, intranasal lidocaine may be used, or a Q-tip soaked in 4% lidocaine can be applied to the most posterior aspect of the pharynx for 10-15 minutes.

References: https://www.aliem.com/2017/03/trick-sphenopalatine-ganglion-block-primary-headaches/

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Author: Suzanne Chilton, M.D.

Educational Pearls

Pott’s puffy tumor is a subperiosteal abscess of the frontal bone that arises from hematologic spread or direct infection via the frontal sinuses. The primary symptom is facial swelling.
It is much more common in children and adolescents.
Treatment involves removal of the frontal bone, reconstructive surgery, and 6-8 weeks of IV antibiotics.

References: Grewal HS, Dangaych NS, Esposito A. A tumor that is not a tumor but it sure can kill! The American Journal of Case Reports. 2012;13:133-136. doi:10.12659/AJCR.883236.

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Author: Dave Rosenberg, M.D.

Educational Pearls

MI and GERD can present similarly. For example, 47% with angina report increased belching with an anginal attack, and 20% of people with an MI describe symptoms of indigestion that are relieved by antacids.
Overall, GERD is more common in those with CAD, so don’t be “reassured” by GERD symptoms in the setting of chest pain.

References: http://www.mdedge.com/ecardiologynews/article/82215/cad-atherosclerosis/gerd-may-boost-risk-mi

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Podcast #240: Honey and Burns

Author: Nick Hatch, M.D.

Educational Pearls

Honey can be used to treat burns because it has antibacterial properties. In one study, honey outperformed silver sulfadiazine for burn treatment, but more research is needed in this area.
In practice, honey is likely more useful outside the ER than inside the ER.

References: Gupta SS, Singh O, Bhagel PS, Moses S, Shukla S, Mathur RK. Honey Dressing Versus Silver Sulfadiazene Dressing for Wound Healing in Burn Patients: A Retrospective Study. Journal of Cutaneous and Aesthetic Surgery. 2011;4(3):183-187. doi:10.4103/0974-2077.91249.

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Author: Rachel Beham, PharmD, Advanced Clinical Pharmacist - Emergency Medicine

Educational Pearls

Tetanus Ig is indicated in those who have no or unknown tetanus vaccination history who present with contaminated cuts that or dirty puncture wounds
The tetanus vaccine is a 5 shot series (DTAP) for children, TDAP is used for adults
There is no harm is receiving the TDAP more than once if vaccination history is unknown

References: https://www.cdc.gov/features/tetanus/index.html

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Author: Aaron Lessen M.D.

Educational Pearls

Ultrasound is helpful in the setting of cardiac arrest for finding a cause like cardiac tamponade or PE, but also for predicting outcomes for non-shockable rhythms.
One study showed that in those that presented with asystole or PEA and cardiac activity on US had a 4% survival rate, while those without cardiac activity had almost no chance.

References: Philip Salen, Larry Melniker, Carolyn Chooljian, John S. Rose, Janet Alteveer, James Reed, Michael Heller, Does the presence or absence of sonographically identified cardiac activity predict resuscitation outcomes of cardiac arrest patients?, The American Journal of Emergency Medicine, Volume 23, Issue 4, 2005, Pages 459-462, ISSN 0735-6757, http://dx.doi.org/10.1016/j.ajem.2004.11.007.

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Author: Susan Brion, M.D.

Dr. Brion enlightens us on the ever-evolving standard of sepsis management.

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Author: Sam Killian, M.D.

Educational Pearls

Phimosis refers to the inability to retract the distal foreskin over the glans penis in uncircumcised males. Paraphimosis is the entrapment of the foreskin proximal to the glans penis in these patients.
Phimosis is rarely a medical emergency, but requires follow up with urology. Paraphimosis, on the other hand, can cause venous and lymphatic insufficiency, leading to infarction, necrosis and autoamputation. Therefore, paraphimosis requires emergent treatment with manual reduction of the foreskin or surgery.

References:

Aaron Vunda, M.D., Laurence E. Lacroix, M.D., Franck Schneider, Sergio Manzano, M.D., and Alain Gervaix, M.D. Reduction of Paraphimosis in Boys. N Engl J Med 2013; 368:e16

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Author: Nick Hatch, M.D.

Educational Pearls

When peripheral or central IV access is difficult, sometimes providers will try to use a peripheral IV setup at an IJ site using US guidance.
Case studies have shown that this method is often successful, with the most common complication being the loss of access.

References: Ash AJ, Raio C. Seldinger Technique for Placement of “Peripheral” Internal Jugular Line: Novel Approach for Emergent Vascular Access. Western Journal of Emergency Medicine. 2016;17(1):81-83. doi:10.5811/westjem.2015.11.28726.

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Author: Pete Bakes, M.D.

Educational Pearls

One of the roles of the ER provider is to discharge patients only after life-threatening conditions have been ruled out. However, some patients that are discharged from the ED die within days of their discharge. One recent study sought to investigate the factors and diagnoses associated with death within 7 days of discharge.
This study was a retrospective study in 10 million medicare recipients that presented to the ER over 10 years. They excluded palliative, hospice and SNF patients.
0.12% of these patients died within 7 days of ER discharge. Signs and symptoms such as altered mental status, general malaise and fatigue, and nonspecific dyspnea had relative risks of 3-5 for death following discharge.
Think carefully before discharge in patients with the signs/symptoms above.

References: Obermeyer Ziad, Cohn Brent, Wilson Michael, JenaAnupam B, Cutler David M. Early death after discharge from emergency departments: analysis of national US insurance claims data BMJ 2017;356 :j239

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Author: Dylan Luyten, M.D.

Educational Pearls

Around 30% of patients in the ER receive CT imaging, and the sensitivity of CT imaging may be improved with IV contrast. However, contrast is often withheld for fear of contrast-induced nephropathy.
A recent, single-center, retrospective cohort study compared the rates of nephropathy between contrast CT, non-contrast CT, and no CT control patients, and found no differences.
This study confirms what many have believed to be true - that the dangers of modern contrast may be overstated. However, the results should be interpreted with caution, as this was a retrospective, single-center study.

References: Hinson, Jeremiah S. et al.. Risk of Acute Kidney Injury After Intravenous Contrast Media Administration. Annals of Emergency Medicine , Volume 69 , Issue 5 , 577 - 586.e4

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Author: Don Stader, M.D. andRachael Duncan, PharmD BCPS BCCCP

Educational Pearls

Carfentanil is an opioid elephant tranquilizer that can be used recreationally. It is 1000 times stronger than fentanyl, and looks like a white powder.
Healthcare workers must be cautious when carfentanil overdose is suspected, as the drug can be absorbed through caregivers’ skin if it is present on the patient’s clothes.
Overdose may require large amounts of naloxone, and a drip may be started at a rate equivalent to the bolus dose that the patient responded to. For example, if the patient responded to a 10mg bolus dose of naloxone, he would then be started on a 10mg/hr naloxone drip.

References: https://www.dea.gov/divisions/hq/2016/hq092216.shtml

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Author: Gretchen Hinson, M.D.

Educational Pearls

High-Altitude Pulmonary Edema (HAPE) is caused when hypoxemia due to low ambient pO2 leads to breakdown and constriction of the pulmonary vasculature leading to edema.
HAPE is very rare under 8000 ft, but common over 10000 ft (6%). Over 18,000 ft the incidence is very high (12-15%).
Symptoms include dyspnea, cough, weakness and chest tightness.
Signs include hypoxemia, crackles, wheezing, central cyanosis, tachypnea and tachycardia.
Drugs that reduce pulmonary resistance have been shown to help, but increased oxygenation and descent are the best treatments.

References: http://emedicine.medscape.com/article/300716-overview

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Author: Jared Scott, M.D.

Educational Pearls

Boerhaave syndrome (aka effort rupture of the esophagus) accounts for 10% of esophageal ruptures and is usually caused by strain during vomiting episodes. It can also be caused by childbirth, seizure, or prolonged coughing or laughing.
Food and water swallowed after the tear end up in the mediastinum, eventually causing infection. Therefore, Boerhaave syndrome is a surgical emergency.
Best diagnostic techniques are CT or endoscopy.
Mallory-Weiss syndrome may present similarly, however it is less serious since it involves only a small tear through the mucosa at the gastroesophageal junction. This can be managed on an outpatient basis with PPI’s.

References: https://radiopaedia.org/articles/boerhaave-syndrome

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Author: Aaron Lessen, M.D.

Educational Pearls

2 studies this past year looked at pediatric and adolescent patients following a concussion. They found people who returned to activity sooner did better than those who went on “brain rest”.
While patients should still follow up with their PCP following a concussion, it is ok for patients to return to physical activity as tolerated.

References: Grool AM, Aglipay M, Momoli F, Meehan WP, Freedman SB, Yeates KO, Gravel J, Gagnon I, Boutis K, Meeuwisse W, Barrowman N, Ledoux A, Osmond MH, Zemek R, for the Pediatric Emergency Research Canada (PERC) Concussion Team. Association Between Early Participation in Physical Activity Following Acute Concussion and Persistent Postconcussive Symptoms in Children and Adolescents. JAMA. 2016;316(23):2504-2514. doi:10.1001/jama.2016.17396

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Author: Sam Killian, M.D.

Educational Pearls

Andrew Jackson was the 7th president of the USA. He served 2 terms from 1829-1837.
He had had many medical issues during his presidency. He was said to be chronically underweight with rotting teeth. Furthermore, he had chronic infections and lead poisoning from bullets lodged in his arm and chest.
He suffered from smallpox that he contracted while in a British prison during the Revolutionary War.
He died from “dropsy” (CHF).

References: http://www.doctorzebra.com/prez/g07.htm

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Author: Jared Scott, M.D.

Educational Pearls

BB gun eye injuries are most common in August and September. They most often happen to males aged 16-17 year old. Around 10% of the BB eye injuries lead to eye loss.
Accidental firearm injury is common in children and is a common cause of mortality. One-third of homes with children have a firearm.
Most accidental pediatric gun injuries happen to young, male children with guns owned by family members. It is important to educate gun owners about proper gun storage.

References: Childhood Firearm Injuries in the United States Katherine A. Fowler, Linda L. Dahlberg, Tadesse Haileyesus, Carmen Gutierrez, Sarah Bacon. Pediatrics Jun 2017, e20163486; DOI: 10.1542/peds.2016-3486

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Author: Nick Hatch, M.D.

Educational Pearls

CPR-induced consciousness is a phenomenon that occurs when someone who was previously unconscious and is undergoing CPR regains consciousness and makes purposeful movements.
Studies have shown that this phenomenon is increasing, likely because of increased quality of CPR.
Many people use a sedative such as ketamine to keep patients unconscious to reduce the psychologic trauma of CPR.
39% of people who survive CPR with good neurologic details remember the process of CPR .

References:

Joshua Pound, P. Richard Verbeek, and Sheldon Cheske. CPR Induced Consciousness During Out-of-Hospital Cardiac Arrest: A Case Report on an Emerging Phenomenon. 2017. Prehospital Emergency Care Vol. 21.

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Author: Sam Killian, M.D.

Educational Pearls

Anaphylaxis is common in the ED. These patients are treated and then usually watched for 4-6 hours.
Biphasic happens in patients that have a complete resolution of their anaphylaxis for at least an hour, but then have a recurrence that requires pharmacologic intervention. Most of the time this happens 3-6 hours later, but can happen more than 10 hours later.
More commonly happens in patients that have a delayed presentation, a wide pulse pressure, need multiple doses of epi, require the use of a beta agonist, or are ages 6-9 years old.
Educate patients about the possibility of Biphasic anaphylaxis before discharge.

References: http://www.medscape.org/viewarticle/583328_7

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Author: Dylan Luyten, M.D.

Educational Pearls

Rhogam is commonly used when an Rh negative woman has an Rh positive fetus. It is commonly used in the ER in the setting of a miscarriage.
Rh(+) fetal blood can enter the Rh(-) maternal circulation, sensitizing the woman to the Rh antigen. During a subsequent pregnancy, if the fetus is Rh(+), the woman may mount an immune response to the fetus, lead to fetal demise. Rhogam is used to block this process.
Use of Rhogam has reduced this complication from 16% of Rh(+) pregnancies in the 1960’s to less than 1% today.
Under 10 weeks, the amount of maternal-fetal blood exchange is very small, so the use of Rhogam in a 1st trimester miscarriage is unnecessary. It should be used in patients with a miscarriage after 12 weeks, or women undergoing a surgical D&C.
Rhogam is expensive and in limited supply, so it is important to only use it when necessary.

References: Hannafin, Blaine et al. Do Rh-negative women with first trimester spontaneous abortions need Rh immune globulin? 2006. The American Journal of Emergency Medicine, Volume 24 , Issue 4 , 487 - 489

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Author: Justin Harper

Justin Harper, a paramedic married to a pediatric nurse, discovered his own son had type I diabetes 2 years ago. Despite their medical experience, this diagnosis came as surprise to Justin and his wife. This is the compelling story about how their son was diagnosed with type I diabetes and how this has impacted their lives.

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Author: Dr. Larry Wolk,Executive Director and Chief Medical Officer for the Colorado Department of Public Health and Environment.

Topic:Dr. Larry Wolk educates us on how cannabis has affected Colorado since medical and recreational legalization.

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Authors: Don Stader, M.D. & Lauren Gibbs

Topic:Lauren breaks the stoner stereotype and explains how marijuana has positively impacted her life.

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Author: Erik Verzemnieks, M.D.

Topic: Erik speaks about how slightly altering the chemical composition of marijuana can create a drug with drastic effects on the human body.

WARNING: Explicit Language

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Author: Sophie Yorkwilliams

-B.A. (Psychology)

-Dual Ph.D. Candidate, Clinical Psychology and Neuroscience. Expected graduation: 2020

Topic: Studying cannabis comes with its own set of challenges. Find out how Sophie and her team have overcome obstacles to get accurate data on marijuana.

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Authors: Don Stader, M.D. & Peter Pryor, M.D.

Topic:What caused Dr. Pryor to leave emergency medicine and enter the realm of medical marijuana?

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Author: Rachael Duncan, PharmD BCPS BCCCP

Topic: Rachel explainsthe science behind one of the most common maladies thought to be induced by chronic cannabis use.

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Author: Brett Marlin, M.D.

Topics:Brett explains the biochemical and physiological properties of cannabis.

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Author: Don Stader, M.D

Topic:Don kicks things off with an overview of the history of marijuana and how it has made its way into medicine.

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Author: Sam Killian, M.D.

Educational Pearls

Not every troponin elevation is an MI.
Trop elevates in about an hour in ACS and stays elevated for days.
Non-MI conditions that cause elevated troponin: Critical illness (sepsis), increased cardiac demand, right heart strain, LV dysfunction, hypotension, pressor use, acute PE, SAH, chronic renal failure, CHF, aortic dissection, and peri/myocarditis.
Elevated troponin in settings other than MI is correlated with increased mortality.

References: Korff S, Katus HA, Giannitsis E. Differential diagnosis of elevated troponins. Heart. 2006;92(7):987-993. doi:10.1136/hrt.2005.071282.

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Author: Nick Hatch, M.D.

Educational Pearls

Acyclovir toxicity can uncommonly cause altered mental status, low blood glucose, hallucinations and myoclonic jerks.
Toxicity often occurs in the setting of renal insufficiency, as it is cleared by the kidneys.
Acyclovir is often used to treat shingles, which can also cause similar symptoms as acyclovir toxicity due to encephalitis - rule this out in the setting of a concomitant shingles infection.

References: http://www.rxlist.com/zovirax-drug.htm

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Author: Michael Hunt, M.D.

Educational Pearls

Wells Criteria was initially designed to screen patients for further workup for PE.
Aspects of the Wells Criteria include: signs and symptoms of DVT (3 points), PE most likely dia (3 points), HR > 100 (1.5 points), immobility for > 3 days or surgery in last 4 weeks (1.5 points), documented history of PE (1.5), hemoptysis (1), treatment for cancer in last 6 mo (1).
ACEP uses a score of less than or equal to 4 to define “low risk.” Greater than 4 is “high risk”.
Use Wells to guide clinical decisions about PE workup.

References: http://www.ebmedicine.net/media_library/files/1212%20Pulmonary%20Embolism

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Podcast #221: Walking Corpse Syndrome

Author: Erik Verzemnieks, M.D.

Educational Pearls

Walking Corpse Syndrome (aka Cotard Delusion) is a very rare psychiatric disorder that leads to the belief that one is a “walking corpse”.
Often co-presents with depression, schizophrenia, and starvation.
Responds to ECT.

References: https://en.wikipedia.org/wiki/Cotard_delusion

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Author: Aaron Lessen, M.D.

Educational Pearls

Atrial fibrillation is common.
One of the best treatments for a fib is cardioversion back into sinus rhythm.
Cardioversion may increase stroke risk if A-Fib duration is greater than 48 hours, but some new data suggests that this risk may happen as soon as 12 hours.
However, newer studies show that cardioversion is generally safe as a treatment for A-Fib.

References: Aatish Garg, Monica Khunger, Sinziana Seicean, Mina K. Chung, Patrick J.Tchou Incidence of Thromboembolic Complications Within 30 Days of Electrical Cardioversion Performed Within 48 Hours of Atrial Fibrillation Onset. JACC: Clinical Electrophysiology Aug 2016, 2 (4) 487-494; DOI: 10.1016/j.jacep.2016.01.018

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Author: Chris Holmes, M.D.

Educational Pearls

“Sepo’ is a term from Homer (author of The Iliadand The Odyssey), and means “I rot”.
Hippocrates in 400 BC identified sepsis as a “dangerous decay within the body”.
Galen in 200 AD believed pus was “laudable”.
The Greeks and Romans used the term “myasma” to describe the smell of swamp and rotting flesh.
Dr. Emmanuel Rivers in Detroit did one of the the first big studies about sepsis and was an advocate for goal-directed therapy.
Now, Vitamin C cocktails are in use, but new sepsis treatments should be investigated carefully before implementation.

References: Funk, Duane J. et al. Sepsis and Septic Shock: A History. Critical Care Clinics , Volume 25 , Issue 1 , 83 - 101

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Author:Aaron Lessen, M.D.

Educational Pearls

Asking parents and Broselow Tape are common options for estimating pediatric weight.
Equipment sizes should not be adjusted for under/overweight kids based on Broselow Tape estimates.
The finger counting method (see reference) is just as accurate as Broselow Tape method, according to one study.

References: http://handtevy.com/images/Casestudies/Americanjournalofemergencymedicine.pdf

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Author: John Winkler, M.D.

Educational Pearls:

Designer, or “synthetic” drugs include bath salts, synthetic THC, and many others.
Many of these drugs are originally manufactured in China and are shipped globally.
Treatment usually involves airway control and sedation - ketamine may be useful.
Traditional tox screens do not test for these drugs.

References: https://www.drugabuse.gov/related-topics/trends-statistics/national-drug-early-warning-system-ndews

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Author: Aaron Lessen, M.D.

Educational Pearls:

Anecdotal evidence suggests that roller coasters may help with kidney stones.
A recent study used a model of a kidney and ureter with different sized stones and put it on Thunder Mountain roller coaster in Disney World.
There was “dramatic passage” of the kidney stones at the rear of the roller coaster.

References: Marc A. Mitchell, DO; David D. Wartinger, DO, JD. Validation of a Functional Pyelocalyceal Renal Model for the Evaluation of Renal Calculi Passage While Riding a Roller Coaster. The Journal of the American Osteopathic Association, October 2016, Vol. 116, 647-652. doi:10.7556/jaoa.2016.128. http://jaoa.org/article.aspx?articleid=2557373

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PRACTICE RECOMMENDATIONS

Patients who abuse opioids should be managed without judgement; addiction is a medical condition and not a moral failing. Caregivers should endeavor to meet patients “where they are,” infusing empathy and understanding into the patient/medical provider relationship.
Every emergency clinician should be well-versed in the safe injection of heroin and other intravenous (IV) drugs, and understand the practical steps for minimizing the dangers of overdose, infection, and other complications. When treating patients with complications of IV drug use, injection habits should be discussed and instruction should be given about safe practices.
Emergency department patients who inject drugs should be referred to local syringe access programs, where they can obtain sterile injection materials and support services such as counseling, HIV/hepatitis testing, and referrals.
Emergency departments should provide naloxone to high-risk patients at discharge. If the drug is unavailable at the time of release, patients should receive a prescription and be informed about the over-the-counter availability of the drug in most Colorado pharmacies.
Emergency clinicians should be familiar with Colorado’s regulations pertaining to naloxone. State laws eliminate liability risk for prescribing the drug, encourage good samaritan reporting of overdose, and make naloxone legal and readily available over the counter in most pharmacies.
Emergency department patients who receive prescriptions for opioids should be educated on their risks, safe storage methods, and the proper disposal of leftover medications.

POLICY RECOMMENDATIONS

Harm reduction agencies and community programs that provide resources for people who inject drugs (PWID) should be made readily available.
When local programs are unavailable for PWID, emergency departments should establish their own programs to provide services such as safe syringe exchanges.

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PRACTICE RECOMMENDATIONS

All emergency departments should implement ALTO programs and provide opioid-free pain treatment pathways for

the following conditions:

a. Acute on chronic opioid-tolerant radicular lower back pain

b. Opioid-naive musculoskeletal pain

c. Migraine or recurrent primary headache

d. Extremity fracture or joint dislocation

e. Gastroparesis-associated or chronic functional abdominal pain

f. Renal colic

Emergency departments should integrate ALTO into their computerized physician order entry systems to facilitate a seamless adoption by clinicians.
Low-dose, subdissociative ketamine (0.1-0.3 mg/kg) is an effective analgesic that can be opioid-sparing for many acute pain syndromes. Institutional guidelines and policies should be in place to enable clinicians and nurses who administer this agent for pain.
For musculoskeletal pain, consider a multimodal treatment approach using acetaminophen, NSAIDs, steroids, topical medications, trigger-point injections, and (for severe pain) ketamine.
For headache and migraine, consider a multimodal treatment approach that includes the administration of antiemetic agents, NSAIDs, steroids, valproic acid, magnesium, and triptans. Strongly consider cervical trigger-point injection.
For pain with a neuropathic component, consider gabapentin.
For pain with a tension component, consider a muscle relaxant.
For pain caused by renal colic, consider an NSAID, lidocaine infusion, and desmopressin nasal spray.
For chronic abdominal pain, consider low doses of haloperidol, diphenhydramine, and lidocaine infusion.
For extremity fracture or joint dislocation, consider the immediate use of nitrous oxide and low-dose ketamine while setting up for ultrasound-guided regional anesthesia.
For arthritic or tendinitis pain, consider an intra-articular steroid/anesthetic injection.

POLICY RECOMMENDATIONS

Hospitals should update institutional guidelines and put policies in place that enable clinicians to order and nurses to administer dose-dependent ketamine and IV lidocaine in non-ICU areas.
Emergency departments are encouraged to assemble an interdisciplinary pain management team that includes clinicians, nurses, pharmacists, physical therapists, social workers, and case managers.
Reimbursement should be available for any service directly correlated to pain management, the reduction of opioid use, and treatment of drug-addicted patients.

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RACTICE RECOMMENDATIONS

Opioids are inherently dangerous, highly addictive drugs with significant abuse potential, numerous side effects, lethality in overdose, rapid development of tolerance, and debilitating withdrawal symptoms. They should be avoided whenever possible and, in most cases, initiated only after other modalities of pain control have been trialed.
Prior to prescribing an opioid, physicians should perform a rapid risk assessment to screen for abuse potential and medical comorbidities. Alternative methods of pain control should be sought for patients at increased risk for abuse, addiction, or adverse reactions.
Emergency physicians should frequently consult Colorado’s prescription drug monitoring program (PDMP) to assess a patient’s history of prescription drug abuse, misuse, or diversion.
Emergency physician groups should strongly consider tracking, collecting, and sharing individual opioid prescribing patterns with their clinicians to decrease protocol variabilities.
Strongly consider removing prepopulated doses of opioids from order sets in computerized provider order entry (CPOE) systems.
Opioid alternatives and nonpharmacological therapies should be used to manage patients with acute low back pain, in whom opioids are particularly detrimental. Opioids should be prescribed only after alternative treatments have failed.
Potential drug interactions must be evaluated, and opioids should be avoided in patients already taking benzodiazepines, barbiturates, or other narcotics.
Patients with chronic pain should receive opioid medications from one practice, preferably their primary care provider or pain specialist. Opioids should be avoided in the emergency department treatment of most chronic conditions. Emergency physicians should coordinate care with a patient’s primary care or pain specialist whenever possible, and previous patient-physician contracts regarding opioid use should be honored.
Clinicians should abstain from adjusting opioid dosing regimens for chronic conditions and avoid routinely prescribing opioids for acute exacerbations of chronic noncancer pain.
“Long-acting” or “extended-release” opioid products should be avoided for the relief of acute pain.
Patients receiving controlled medication prescriptions should be able to verify their identity.
Patients who receive opioids should be educated about their side effects and potential for addiction, particularly when being discharged with an opioid prescription.
When considering opioids, clinicians should prescribe the lowest possible effective dose in the shortest appropriate duration (eg, <3 days).
Emergency departments should refuse to refill lost or stolen opioid prescriptions.

POLICY RECOMMENDATIONS

As has been done in other states, the Colorado PDMP should develop an automated query system that can be more readily integrated into electronic health records and accessed by emergency clinicians.
Pain control should be removed from patient satisfaction surveys, as they may unfairly penalize physicians for exercising proper medical judgement.
Opioid prepacks should be avoided or eliminated in the emergency department if 24-hour pharmacy support is available.
Pain should not be considered the “fifth vital sign.”

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The Emergency Medical Minute proudly presents an educational podcast series sponsored by the Colorado Hospital Association addressing our the United States' opioid epidemic.

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Author: Donald Stader, M.D.

Educational Pearls:

The most common ankle injury mechanism is an inversion.
Most common broken bone in the ankle is the fibula.
During exam, it is important to palpate over the fibular head, medial and lateral malleoli, over the 5th metatarsal and over the cuboid bone. If no tenderness in these areas and the patient is walking - they have a sprain and can be sent home without imaging.
In calcaneal fractures, make sure to image the lumbar spine since up to 30% of calcaneal fractures are associated with lumbar spine injury.

References: http://orthosurg.ucsf.edu/oti/patient-care/divisions/sports-medicine/physical-examination-info/ankle-physical-examination/

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Author: Aaron Lessen, M.D.

Educational Pearls:

We can differentiate verto into benign problems such as vestibular problem (peripheral problem), or something more worrisome that originates in the brain (central problem).
Dizziness + other symptoms makes us think about origination in the CNS. Symptoms include Dizziness, Diplopia, Dysarthria, Dysphagia, Dysmetria.

References: http://www.medicalnewstoday.com/knowledge/160900/vertigo-causes-symptoms-treatments

http://www.mayoclinic.org/diseases-conditions/dizziness/basics/causes/con-20023004

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Author: Michael Hunt, M.D.

Educational Pearls:

Oats have been shown to lower LDL.
Oat bran is the most effective way to consume oats to lower LDL.
A Swedish study of 69,000 people who ate at least 3 servings of potatoes a week showed no increased risk of a MI or stroke associated with potato consumption.

References: Larsson SC, Wolk A. Potato consumption and risk of cardiovascular disease: 2 prospective cohort studies. Am J Clin Nutr. 2016

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Author: Jared Scott, M.D.

Educational Pearls:

A pessary is a device inserted into the vagina for medical purposes. Examples include birth control and mechanical support of the pelvic structures.
In older women, collapse of the pelvic structures is common, and many may have pessaries to aid in treatment.

References: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2876320/

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Author: Michael Hunt, M.D.

Educational Pearls:

Children under age of 6 are at greatest risk of accidental nicotine overdose from ingestion.
Biphasic presentation:
- Hyperadrenergic = nausea, vomiting, tachycardia, flushing.
- Bradycardia and respiratory depression.

References:

http://www.aapcc.org/alerts/e-cigarettes/

Mayer B. How much nicotine kills a human? Tracing back the generally accepted lethal dose to dubious self-experiments in the nineteenth century. Archives of Toxicology. 2013;88(1):5-7. doi:10.1007/s00204-013-1127-0.

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Author: Jared Scott M.D.

Educational Pearls:

Bear mauling is not a common issue in the ED.
The Ursus americanus (black bear) is the most common in Colorado, but Ursus arctos horribilis (grizzly bear) attacks are more frequent because they are more aggressive.
Head and neck lacerations are the most common injuries. Complications include infection and long term PTSD.
Most bear attacks are defensive in nature.
If a bear attacks you - lay face down and cover your neck with your hands.

References: Frank RC, Mahabir RC, Magi E, Lindsay RL, de Haas W. Bear maulings treated in Calgary, Alberta: Their management and sequelae. The Canadian Journal of Plastic Surgery. 2006;14(3):158-162. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2539044/

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Author: Sam Killian, M.D.

Educational Pearls:

“The Rabbit Has Died” is a lesser used phrase to denote finding out one is pregnant.
During a test used in the 1930s, the “Rabbit’s Test,” a rabbit was injected with a potentially pregnant woman’s urine. If the woman was pregnant, the rabbit would begin displaying signs of pregnancy itself.
This test required killing the rabbits to visualize the ovaries, hence the term “Rabbit Done Died”.

References: https://www.early-pregnancy-tests.com/history

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Author: Martin O’Bryan M.D.

Educational Pearls:

Vocal cord dysfunction can mimic other causes of stridor, such as asthma and upper airway obstruction.
Patients are often very anxious because of the difficulty of inspiration.
The definitive diagnosis is laryngoscopy that must be done by a pulmonologist.
The treatment is general reassurance, asthma medications will not help. CPAP and heliox can be used to help with the stridor.
Benzodiazepines can be used to reduce the associated anxiety.

References: https://asthmarp.biomedcentral.com/articles/10.1186/s40733-015-0009-z

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Author: Sam Killian, M.D.

Educational Pearls:

Defined as fracture of neck (distal segment) of 5th metacarpal.
Intrinsic muscles of hand pull segment to palmar aspect of hand.
30 degrees of angulation is allowed. Any more increases risk of chronic pain, grip strength and grasping deficits, and rotational deformities.
Reduce fracture if more than 30 degrees of angulation or if rotation is present.
Splint fracture in “ulnar gutter” with goal being flexion at MCP and extension at DIP and PIP.

References: http://www.emedicinehealth.com/boxers_fracture/article_em.htm

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Author: Jared Scott, M.D.

Educational Pearls:

DDx for blood at urethral meatus includes: pelvic fracture, ruptured bladder, kidney laceration, penile trauma.
Retrograde Urethrogram (RUG) must be performed before placing foley and is critical for diagnosis.

References:https://www.ncbi.nlm.nih.gov/pubmed/16488282

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Author: Michael Hunt, M.D.

Educational Pearls:

Research has shown that the higher temperatures post-cardiac arrests may lead to poorer outcomes.
Initially, 33 deg C was the target temp. However, more research is being done to find therapeutic temperature levels.
New studies have shown that the cooling protocol differs for inpatient cardiac arrests vs. outpatient cardiac arrests. The results show that it may not be necessary to cool inpatient cardiac arrests.

References:http://www.hopkinsmedicine.org/healthlibrary/test_procedures/cardiovascular/therapeutic_hypothermia_after_cardiac_arrest_135,393/

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Authors:Rebecca van Vliet MS, APN;Michelle Whaley MSN, CNS, CCNS, ANVP-VC

The Stroke Team at Swedish Medical Center gives us a taste of how they are breaking records with door-to-needle time in management of acute cerebrovascular accidents.

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Author: Aaron Lessen M.D.

Educational Pearls:

Thoracotomy is a potentially life-saving procedure. However, outcomes are often poor and the procedure itself poses many risks to provider and patient.
Chance of surviving a thoracotomy when there is no cardiac activity on ultrasound is 0%.
Performing a thoracotomy is unlikely to benefit patients with no cardiac activity on ultrasound or patients that lost vital signs greater than 10 minutes before starting the procedure.
A thoracotomy is maximally beneficial in patients with a penetrating chest injury that occurred less than 10 minutes before the procedure.

References: K. Inaba et al, “FAST Ultrasound Examination as a Predictor of Outcomes After Resuscitative Thoracotomy: A Prospective Evaluation” Ann. of Surgery, 2015. https://www.ncbi.nlm.nih.gov/pubmed/26258320

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Author: Dave Rosenberg M.D.

Educational Pearls:

Louis Pasteur developed the technique that is now known as pasteurization. It was first used in the wine-producing regions of France, and eventually in dairy products like milk.
Pasteur also investigated infectious disease. During one experiment, Pasteur’s lab assistant accidentally infected chickens with a weakened form of cholera. When none of the chickens died, Pasteur re-infected them with a stronger strain. This time, none of the chickens became sick because they had been inoculated against the disease. This experiment paved the way for modern vaccination.

References: Smith KA. Louis Pasteur, the Father of Immunology? Frontiers in Immunology. 2012;3:68. doi:10.3389/fimmu.2012.00068.

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Author: Susan Brion M.D.

Educational Pearls:

Laundry and dishwasher detergent pods resemble candy and can be ingested by children.
These tide pods are very highly concentrated and can cause chemical burns of the lips, airway, eyes, mouth and esophagus.
The strong bases in detergent pods (pH>12) can cause liquefactive necrosis, which can cause immediate perforation of the esophagus.
Common symptoms associated with ingestion of detergent pods include pain, dysphagia, drooling, mediastinal pain, upper airway inflammation. The presence or absence of symptoms does not indicate severity - suspected ingestions should be admitted and undergo bronchoscopy.
Mental status should be assessed rapidly because detergent ingestion can lead to CNS depression and aspiration.

References: Bonney AG, Mazor S, Goldman RD. Laundry detergent capsules and pediatric poisoning. Canadian Family Physician. 2013;59(12):1295-1296.

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Author: Mark Kozlowski M.D.

Educational Pearls:

Humans cannot “multitask” effectively - a more accurate term is “task interruption.”
When doing more than one task at once, we are more likely to forget key details and perform both tasks more slowly overall.
Do not interrupt people who are focusing on critical tasks - programming a pump or drawing up doses.
Think about ways to reduce task interruption in your hospital for a better clinical practice.

References: Westbrook JI, Woods A, Rob MI, Dunsmuir WTM, Day RO. Association of Interruptions With an Increased Risk and Severity of Medication Administration Errors. Arch Intern Med. 2010;170(8):683-690. doi:10.1001/archinternmed.2010.65

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Author: Don Stader M.D.

Educational Pearls:

Non-traumatic back pain is a very common complaint in the Emergency Department.
Conditions that can manifest with back pain include: ruptured abdominal aortic aneurysm, retroperitoneal bleeding, cauda equina syndrome, epidural abscess or cancer.
Patients with cauda equina syndrome or epidural abscess prefer to sit forward, while people with disc issues tend to sit upright.

References: https://emergencymedicinecases.com/episode-26-low-back-pain-emergencies/

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Author: Arthur Lessen M.D.

Educational Pearls:

Zofran (ondansetron) is generally safe to use for the treatment of nausea and vomiting. However, it can prolong the QT interval and increase the chance for torsades.
Low doses of Zofran are not likely to be an issue. However, when multiple doses are given, especially in the setting of a preexisting LQTS, clinical concern should be raised.
When giving Zofran to a patient with an increased risk for torsades, consider continuous cardiac monitoring or an alternate anti-emetic.

References:https://www.fda.gov/Drugs/DrugSafety/ucm310190.htm

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Author: Aaron Lessen M.D.

Educational Pearls:

Imodium (loperamide) is a mu-opioid receptor agonist. Traditionally, it is used as an anti-diarrheal. It is also abused recreationally for an opioid high and to self-treat opioid withdrawal.
40 or more pills are often ingested. People often co-ingest with cimetidine to potentiate the desired effects.
Patients will present with opioid overdose symptoms (narrow pupils, respiratory depression).
Narcan is effective in reversing an overdose of Imodium.
Imodium prolongs QT and predisposes to Torsades, so monitor rhythm and then treat like any other opioid OD.

References: http://www.tandfonline.com/doi/abs/10.3109/15563650.2016.1159310

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Author: Dylan Luyten M.D.

Educational Pearls:

Ashman’s Phenomenon occurs in the setting atrial fibrillation and mimics ventricular tachycardia, but is harmless.
On ECG, the pattern of Ashman Phenomenon is a long cycle, followed a short cycle, followed by a complex wide complex beat.
The wide complex beats have right BBB morphology. The long R-R followed by a short R-R leads to conduction down the left bundle branch while the right bundle branch is still in a refractory period.

References: https://lifeinthefastlane.com/ecg-library/atrial-fibrillation/

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Author: Samuel Killian M.D.

Educational Pearls:

Lower extremity DVTs are extremely common. There are more left lower extremity DVT due to anatomical variation.
May-Thurner Syndrome is a form of anatomical variation in which the left iliac artery compresses the left iliac vein.
Anticoagulation may not be sufficient to treat those with May-Thurner syndrome - endovascular stenting may be needed
Patients with with recurrent LLE DVT, especially those in whom anticoagulation fails, should be referred to a specialist.

References: Peters M, Syed RK, Katz M, et al. May-Thurner syndrome: a not so uncommon cause of a common condition. Proceedings (Baylor University Medical Center). 2012;25(3):231-233. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3377287/

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Author: Don Stader, M.D

Educational Pearls:

It is important for providers to know how to use IV drugs properly so that they can instruct their patients on how to avoid injury. Heroin use is increasing.
Hepatitis, HIV and infection are possible complications of improper IV drug use
The first step of heroin use is to dissolve the solid heroin in water using heat - a spoon and lighter are often used for this step. Next, the heroin is drawn into the syringe through a filter (cotton is often used).
Heroin concentration often varies widely - counsel patients to test their heroin first.
Sterility of the needle, water, cooker, cotton and syringe is paramount. Refer patients to a needle exchange program where they can get clean supplies.
Hepatitis C can live outside the body for 4 days - NEVER share ANY supplies.
Sterile procedure is important - needles should not be licked.

References: http://drugsense.org/flyers/10_tips_for_safer_use.pdf

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Author: Peter Bakes, M.D

Educational Pearls

Intracerebral hemorrhage is an intracranial bleed within the brain tissue or ventricles.
Subarachnoid aneurysm causes about 50% of all ICH.
Amyloid deposition can lead to ICH in elderly patients.
Hypertension is another common cause of atraumatic ICH, commonly leading to pontine, cerebellar, or basal ganglial bleeding. Bleeding in other locations is suggestive of a different etiology.
ICH will often present with depressed mental status, but specifically a patient with a systolic BP > 220 is suggestive of hypertensive ICH.
CT is the first diagnostic step. CTA should be considered when the bleeding is in an atypical area. Significant edema on imaging can be suggestive of a tumor.
Treatment should include hemostatic measures and BP control. Transfuse platelets if necessary and reverse any anticoagulation. BP target is <140 systolic. Monitor ICP if patient has AMS. Neurosurgical intervention is indicated when there is significant expansion of the hematoma with AMS or if the bleed is cerebellar.

References: Sahni R, Weinberger J. Management of intracerebral hemorrhage. Vascular Health and Risk Management. 2007;3(5):701-709. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2291314/

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Author: JP Brewer M.D.

Educational Pearls:

The “Quick Wee” was a method to get urine out of infants who need to have a UA in the Emergency Department.
A randomized-controlled experiment was done with 350 infants between the ages of 1 to 12 months.
The “Quick Wee” method is taking a sterile saline gauze with cool saline and rubbing it over the suprapubic abdomen for five minutes. The results were significant, with 31% in the treatment group voided after five minutes, 12% in the control group voided after five minutes.

References:http://www.bmj.com/content/357/bmj.j1341

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Author: Jared Scott M.D.

Educational Pearls:

There are two anatomical triangles on the back, the inferior lumbar triangle and the superior lumbar triangle.
Herniation occurs whenever something moves to a place where it is not supposed to be, often through a fascial weakness.
A “back hernia” can happen when the contents of of the abdominal cavity herniate into the back, usually through the superior lumbar triangle. This is also known as a Grynfeltt-Lesshaft hernia.
Back hernias can be traumatic or congenital.
These hernias are typically treated surgically.

References: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3959346/

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Author: Chris Holmes M.D.

Educational Pearls:

Mechanism of injury involves hyperextension/hyperflexion
Pathophysiology: inside of the arteries in the neck becomes disrupted, similar to a dissection. This is thrombogenic and leads to cerebral infarction
Neurologic deficit is common.
Other risk factors include facial fracture and cervical-spine fracture.
Treat with anticoagulation - aspirin or other antiplatelet agents are appropriate.
Increase clinical suspicion when patient presents with neurological deficit and has a negative CT.

References: https://www.east.org/education/practice-management-guidelines/blunt-cerebrovascular-injury

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Author: Michael Hunt M.D.

Dr. Hunt shares his wealth of experience with biological terrorism over the course of his career.

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Author: Rachel Duncan, PharmD BCPS

Educational Pearls:

Toradol (Ketorolac) is an NSAID used for its anti-inflammatory properties
In practice, the common dosages are 30mg IV or 60mg IM.
Clinical concerns arise in patients with renal insufficiency or bleeding, but the risks are small (<1%).
Studies have found that doses over 7.5mg have the same efficacy in pain control as higher doses.
Consider lower-dose Toradol (15mg) and decrease dose in the elderly and those with a CrCl<50.

References: Motov S, Yasavolian M, Likourezos A, et al. “Comparison of Intravenous Ketorolac at Three Single-Dose Regimens for Treating Acute Pain in the Emergency Department: A Randomized Controlled Trial”. Ann Emerg Med 2016. http://www.annemergmed.com/article/S0196-0644(16)31244-6/fulltext

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Author:Donald Stader M.D.

Educational Pearls:

Coffee originates from Ethiopia. Its “active ingredient” is caffeine.
Caffeine is a xanthine alkaloid used in medicine to control headache and as a neonatal stimulant.
Studies have shown that coffee may increase lifespan.
Overdose can be encountered in those using diet pills or concentrated caffeine pills and is treated with dialysis.

References: Juliano, LM et al. “A critical review of caffeine withdrawal: empirical validation of symptoms and signs, incidence, severity, and associated features.” Psychopharmacology, 2004. https://www.ncbi.nlm.nih.gov/pubmed?term=15448977

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Author: Peter Bakes M.D.

Educational Pearls:

Some common causes of monoarticular arthritis include: crystal arthropathies (gout and pseudogout), infection (septic joint), reactive arthritis and acute presentations of chronic arthritides.
Lyme disease usually presents with a targetoid lesion associated with constitutional symptoms.
The common triad of symptoms associated with reactive arthritis (aka Reiter’s Syndrome) consists of conjunctivitis, urethritis, and arthritis.
Reactive arthritis commonly presents with a history of a GU infection (often chlamydia) or GI infection (Shigella, Campylobacter, Yersinia, Salmonella). It is more common in men and those between 20 and 40 years old.
Treatment for reactive arthritis is usually supportive.

References: www.emedicine.medscape.com/article/331347-overview

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Are you super duper sad you missed our event? Did you make it to the event, but want to relive it? Well no worries! We have compiled a summary of the event with some amazing photographs of our speakers in action. Check it out here: https://emergencymedicalminute.com/?page_id=2578

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Author: Gretchen Hinson M.D.

Educational Pearls:

The key imaging of a mumps patient is “chipmunk cheeks” or parotitis.
The swelling can extend almost to the ears and can be extremely painful - in about 25% of cases the swelling is unilateral.
Other organs can be involved as well including: testicles, ovaries, breast tissue, other salivary glands, and the brain/spinal cord.
Mumps is transmitted through droplets in the air.
Two immunizations will get you 88% probability immunity and one immunization will get you 78% probability of immunity. Yet, immunity can wane and there can be viral strains not covered by the immunization.
Mumps outbreaks are common in the winter season because of close quarters.
You can test for Mumps using an IGM blood test, (more likely to see a spike in this if the patient is not vaccinated) Buckle swabs, & Urine test.

References: https://www.cdc.gov/mumps/index.html

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Author: Aaron Lessen M.D.

Educational Pearls:

Regularly a patient’s creatinine level is an important factor in determining whether a patient will receive IV contrast with a CT because it is thought that contrast can harm the kidneys and could worsen underlying kidney disease.
A recent retrospective study compared the rates of worsening kidney problems between patients who received a CT scan with contrast, a CT without contrast, and no CT.
The study even included patients with creatinines of up to 4 before excluding patients.
The study suggested that there is no difference in the rate of worsening kidney problems between the three groups.

References: http://www.annemergmed.com/article/S0196-0644(16)31388-9/fulltext

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Author: Peter Bakes M.D.

Dr. Peter Bakes takes us through how he developed his interest in travel medicine as well as some of the more interesting aspects of the specialty.

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Author: Peter Bakes

Educational Pearls:

The Neuromuscular Junction (NMJ) is a neuronal synapse in skeletal muscle mediated by nicotinic acetylcholine receptors.
Paralytic agents, commonly used in the ED for intubation, include succinylcholine and rocuronium/vecuronium.
Succinylcholine is a depolarizing paralytic while rocuronium is a non-depolarizing agent.
A newly developed reversing agent, sugammadex, can be used to counter the effects of curonium based paralytics. This is especially helpful due to the long duration of action of rocuronium (45 minutes to 1 hour) as compared to succinylcholine (<15 minutes).

References: https://www.acep.org/Physician-Resources/Clinical/Thoracic-Respiratory/Rocuronium-vs--Succinylcholine--Which-Is-Best-/

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There are many causes of syncope and a pulmonary embolism may be a commonly missed reason.

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Electrolytes it's what your bodies crave.

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What's the difference between an Aortic Dissection and an Aortic Aneurysm?

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New information about concussion precautions for patients

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A case presentation of an abnormal rhythm in a younger patient with Lupus.

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Probably not what Def Leppard were thinking about when they wrote "Pour Some Sugar on Me".

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Learning about football injuries may not make you a pro bowl player, but it can help you treat patients like one.

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A discussion on the clinical features and testing for preeclampsia in the ER.

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Are cervical collars disappearing? Probably not soon, but there are a few reasons why collars may not be as helpful as we think.

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A few quick tips to help increase the success of defibrillating a patient in persistent ventricular fibrillation.

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A permutation of the Cincinnati pre-hospital stroke scale to help EMS decide when to take patients to a comprehensive stroke center.

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A unique disease with a bizarre presentation is discussed.

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Learn about the dangers of synthetic marijuana and why it is a huge problem for emergency rooms.

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What are the symptoms of Lyme and why is it becoming a more frequent occurrence in the New England and upper Midwest.

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A case of neurogenic shock in patient with a GSW of the spine is discussed.

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Some of the possible side effects of suppressing or completely removing the adrenal glands.

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A discussion about the presentation and treatments for SDH, both chronic and acute.

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The clinical presentation of a critical illness that can become fatal if not treated properly.

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Need a drug to convert a stable wide complex tachycardia patient? Why not procainamide?

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We all know what a dollar is right? But what about a gray? Let Dr. Scott explain how to approach radiation in pregnancy.

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Ludwig's Angina, what it presents as and what to be prepared for.

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Some interested questions and comments from some lovely folks.

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From our friend, the famed Mark Rosenberg MD.

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From our fearless leader Donald Stader MD.

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From our friend Adam Lembitz MD.

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From our friend, the brave Tiffany Middleton.

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From our friend Lisa Rizzo from the Denver Harm Reduction Action Center.

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From our friend Dana Bushell RN.

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From our friend Robert Valuck PhD RPh.

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From our friend, Steve Cantrill MD.

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Donald Stader MD and Dylan Luyten MD lead in a transformative night discussing opiates and medicine.

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Haunted houses, headaches, and hyperbaric chambers.

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An overview of a study that scrutinizes the effectiveness of platelet transfusions in patients with spontaneous intracranial hemorrhage.

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Complications and treatment for a true knee dislocation.

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The process of identification and treatment for GI bleeds in the year 1966.

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Preparing for a patient that is actively choking, and the steps that can be taken in the ER to get the patient to the operating room.

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Eye trauma is never fun! Iridodialysis is one example of a bad time.

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A discussion about a specific type of brain bleed.

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A quick discussion on the mechanism of Calcaneal fractures and how they are managed in the ED.

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The toxin from Clostridium Botulinum is the deadliest toxin known to man and can now be found in heroin in Colorado!

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Complications from staying out in high heat for too long, including a serious medical emergency.

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Just look at that pose! Luckily there is an easy way to look just like him. Simply fall asleep on your arm...whether you're drunk or not is up to you.

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It brings tears to even the most manly men, but what causes it?

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Another journey back in time to look at bromide and how it can cause altered mentation.

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Who knew you could milk a snake?

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A glimpse into the history of how James Lind saved the lives of pirates everywhere.

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Recognition and treatment methods for an abnormally fast heart rate.

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So you and your pet don't end up in a modern rendition of Old Yeller.

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A reminder about the legal ability of a minor to consent for medical treatment in Colorado.

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A discussion a rare, but morbid sub-type of stroke seen in the emergency room.

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How to choose which antibiotics work best for patients with an uncomplicated UTI

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A description of a patient with a serious medical emergency where clotting proteins are overactive.

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Serious complications that can occur in the water, even for experienced and well conditioned swimmers.

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Have you ever wondered why the medical professionals also use this house hold cleaning product? Well wonder no more.

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What to do...what to do when the ol' standby, zofran, can't be used?

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An interview with pain research extraordinaire, Dr. Peter Grace.

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Dr. Holmes takes us back in time to the era or free love and Pulp Fiction style management of cardiac arrest.

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A great success...with some unintended consequences.

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Apple juice or pedialyte for the dehydrated toddlers? Though the real question is which t drink in the morning after you have a few too many.

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Are we accurate guessers? And what does it matter if we are wrong?

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A look into the drug vault for the inexpensive methadone replacement.

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A blast from the past with relevance to the present day treatment of a common ED issue.

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What do you if a patient just won't stop seizing?

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Dr. Hunt through some old school and some new school methods of managing SVT.

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Description and treatment of different types of nose bleeds.

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A discussion about reducing unnecessary urinary catheterizations in infants.

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A discussion on one of the most common causes of C. Diff and the relative likelihood of infection.

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Dr. Luyten is a thrifty guy, turns out he can save about 66 million dollars with one simple trick.

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Does a patient need antibiotics for a positive Urinalysis? Here is an algorithm that could help.

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Those high rise apartments have great views, but poor prognosis for heart attacks.

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A discussion of cranial nerve palsies.

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Why not all that is elevated lactate is sepsis.

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Discussion of EKG findings after Benadryl overdose.

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A full review of pericarditis from Dr. Hinson.

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Although it may not be sexy, it does save lives.

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New update on the Zika Virus.

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Emergency Medical Minute: Recent Episodes

Emergency Medical Minute