Emergency Medical Minute (Emergency Medical Minute)

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 

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!

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

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.

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.

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

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

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. 

Donate to EMM today!

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.

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

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.

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

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

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. 

Donate to EMM today!

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/

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. 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.
2. 2. 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.
3. 3. 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

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

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.

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

1. 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.

2. 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.

3. 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

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

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. 

Donate to EMM today!

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

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

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:

1. 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
2. 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
3. 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

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

1. 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

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.

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

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. 

Donate to EMM today!

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. 

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

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

1. 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.

2. 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.

3. Health Outreach for Latin America Foundation - HOLA Foundation. (n.d.). http://www.hola-foundation.org/

4. 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

*********************

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

From DU's 1st annual Colorado Behavioral Health and Wellness Summit:

Contributor:

Karen Prestia, MBA, Director, Marketing & Communications, Mental Health Center of Denver

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

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!

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

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

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

1. 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.

2. 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

3. Walker, M. Chapter 13: iPads, Factory Whistles, and Nightcaps In: Walker, M, Why We Sleep. Scribner; 2017, pg. 272. 

4. Zarcone V. Alcoholism and sleep. Adv Biosci. 1978;21:29-38.

Summarized & Edited by Jorge Chalit, OMSII

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

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!

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

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:

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 Feb;158(2):280-286. doi: 10.1177/0194599817739277. Epub 2017 Nov 7. PubMed PMID: 29110574.

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

2. Howell MD, Davis AM. Management of ARDS in Adults. JAMA. 2018;319(7):711–712. doi:10.1001/jama.2018.0307

3. 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

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. 

Donate to EMM today!

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

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/

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.

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

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
http://creativecommons.org/licenses/by/3.0/

​​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

1. 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

2. 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

3. 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

4. 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

5. 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

6. 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

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

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/

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

1. 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

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

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

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.

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.

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/

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

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. 

Donate to EMM today!

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

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

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

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. 

Donate to EMM today!

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. 

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

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.

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, only one occurrence in a 24-hour period, ABSENCE of focal features, ABSENCE of Todd’s paralysis

• Complex: 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: 

1. 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. 

2. Schuchmann S, Vanhatalo S, Kaila K. Neurobiological and physiological mechanisms of fever-related epileptiform syndromes. Brain Dev. 2009 May;31(5):378–82. 

3. 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. 

4. 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. 

5. Pavlidou E, Panteliadis C. Prognostic factors for subsequent epilepsy in children with febrile seizures. Epilepsia. 2013 Dec;54(12):2101–7. 

6. 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. 

7. 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. 

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

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

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.

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. 

Contributor: Aaron Lessen, MD

Educational Pearls:

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

1. 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

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

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

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

1. 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

2. 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

3. 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/

4. 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

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

Contributor: Aaron Lessen MD

Educational Pearls:

• 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

1. ACOG Practice Bulletin No. 211 Summary: Critical Care in Pregnancy. Obstetrics & Gynecology. 2019;133(5)

2. 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

3. Jeejeebhoy FM, Zelop CM, Lipman S, et al. Cardiac Arrest in Pregnancy. Circulation. 2015;132(18):1747-1773. doi:doi:10.1161/CIR.0000000000000300

4. 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 

Summarized & Edited by Jorge Chalit, OMS3

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

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

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

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

1. 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

2. 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

3. 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

4. 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

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

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

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

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.

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

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

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. 

Donate to EMM today!

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.

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

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.

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

*********************

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:

1. 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
2. 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.
3. 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

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.

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

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/

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

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

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].

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