Emergency Medical Minute

Dr. Meghan Hurley, a pediatric expert, discusses a complex case of myopericarditis in a 17-year-old patient. She highlights how COVID and flu vaccinations, along with high caffeine intake, played a role in the patient’s condition. The conversation covers key diagnostic techniques, such as ultrasound and troponin levels, and emphasizes the need for prompt diagnosis and treatment. Dr. Hurley also addresses the relative safety of vaccinations compared to the risks of COVID-19, shedding light on this critical health issue.

The podcast discusses the causes of Bradyarrhythmias such as complete heart block, medication side effects, electrolyte imbalances, heart attack, and hypothermia.

In this podcast, they discuss the use of intravesical tranexamic acid for patients with gross hematuria. The study shows that using intravesical TXA resulted in a shorter length of stay in the emergency department, shorter duration of Foley catheter placement, and fewer revisits after ED discharge.

The podcast discusses preseptal and orbital cellulitis, two bacterial skin infections. It highlights the seriousness of preseptal cellulitis and its prompt treatment to prevent progression. Treatment options for preseptal cellulitis are mentioned along with the importance of checking immunization status. Orbital cellulitis is explained, including its symptoms and potential complications like orbital compartment syndrome and meningitis.

Contributors: Andrew White MD - Outpatient Psychiatrist; Fellowship Trained in Addiction Psychiatry; Denver Health Travis Barlock MD - Emergency Medicine Physician; Swedish Medical Center Summary In this episode of Mental Health Monthly, Dr. Travis Barlock hosts Dr. Andrew White to discuss the elements of mania that may be encountered in the emergency department. The discussion includes a helpful mnemonic to assess mania, work-up and treatment in the ED, underlying causes of mania, mental health holds, inpatient treatment, and the role of sleep in mania. Educational Pearls Initial assessment of suspected mania can be done via DIGFAST: Distractibility - Individual that is unable to carry a linear, goal-directed conversation Impulsivity - Executive functioning is impaired and patients are unable to control their behaviors Grandiosity - Elevated mood and sense of self to delusions of grandeur Flight of ideas - Usually described as racing thoughts Agitation - Increase in psychomotor activity; start several projects of which they have little previous knowledge Sleep decrease - Typically, manic episodes start with insomnia and can devolve into multiday sleeplessness Talkativeness - More talkative than usual with pressured speech and a tangential thought process Interviewing patients requires an understanding of mood-based mania vs. psychosis-based mania An individual with mood-based mania will more likely be restless, whereas a patient with psychosis-based mania will be more relaxed from a psychomotor standpoint Treatment of manic patients in the ED includes the use of antipsychotics to manage acute symptomatology Management can be informed and directed by the patient's history i.e. known medications that have worked for the patient ED management of manic patients involves a work-up for a broad differential including agitated delirium, substance-induced mania, metabolic disorders, and autoimmune diseases. Some individuals experience manic episodes from marijuana and other illicit substances Antidepressants used in bipolar patients for suspected depression may induce mania Important to avoid using antidepressants as first-line therapy Mental health holds can be beneficial in patients with grave disabilities from mania Oftentimes, undertreatment of manic episodes leads to re-hospitalization Inpatient treatment: Environment is important - ensure that patients get solo rooms if possible to minimize stimulation Antipsychotics, including risperidone and olanzapine, with or without a benzodiazepine, are useful for short-term agitation Long-term treatment involves coupled pharmacological treatments with non-pharmacological treatments Sleep Fractured sleep is one of the earliest warning signs that someone has an imminent manic episode Poor sleep can be an inciting factor for mania, which then turns into a cycle that further propagates a patient's manic episode Summarized and edited by Jorge Chalit, OMSII | Studio production by Jeffrey Olson, MS2

Contributor: Travis Barlock MD Education Pearls: The Cushing Reflex is a physiologic response to elevated intracranial pressure (ICP) Cushing's Triad: widened pulse pressure (systolic hypertension), bradycardia, and irregular respirations Increased ICP results from systolic hypertension, which causes a parasympathetic reflex to drop heart rate, leading to Cushing's Triad. The Cushing Reflex is a sign of herniation Treatment includes: Hypertonic saline is comparable to mannitol and preferable in patients with hypovolemia or hyponatremia Give 250-500mL of 3%NaCl 20% Mannitol - given at a dose of 0.5-1 g/kg Each additional dose of 0.1 g/kg reduces ICP by 1 mm Hg 23.4% hypertonic saline is more often given in the neuro ICU 8.4% Sodium bicarbonate lowers ICP for 6 hours without causing metabolic acidosis Non-pharmacological interventions: Raise the head of the bed to 30-45 degrees Remove the c-collar to improve blood flow to the head Hyperventilation induces hypocapnia, which will vasoconsrict the cerebral arterioles You hyperventilate on the way to the OR. Otherwise, maintain normocapnia. References Alnemari AM, Krafcik BM, Mansour TR, Gaudin D. A Comparison of Pharmacologic Therapeutic Agents Used for the Reduction of Intracranial Pressure After Traumatic Brain Injury. World Neurosurg. 2017;106:509-528. doi:10.1016/j.wneu.2017.07.009 Bourdeaux C, Brown J. Sodium bicarbonate lowers intracranial pressure after traumatic brain injury. Neurocrit Care. 2010;13(1):24-28. doi:10.1007/s12028-010-9368-8 Dinallo S, Waseem M. Cushing Reflex. [Updated 2023 Mar 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK549801/ Godoy DA, Seifi A, Garza D, Lubillo-Montenegro S, Murillo-Cabezas F. Hyperventilation therapy for control of posttraumatic intracranial hypertension. Front Neurol. 2017;8(JUL):1-13. doi:10.3389/fneur.2017.00250 Summarized by Jorge Chalit, OMSII | Edited by Meg Joyce & Jorge Chalit, OMSII

Contributors: Kalen Abbott, MD - EM Physician and Medical Director for AirLife Denver Brendan Reiss - Flight Nurse AirLife Denver Matt Spoon - Flight Paramedic AirLife Denver Jordan Ourada - EMS Coordinator at Swedish Medical Center and Paramedic Summary: In this episode, hosted by Jordan Ourada, Brendan Reiss and Matt Spoon present a first-hand experience case of hydrofluoric acid exposure in a pediatric patient. Commentary and educational pearls are provided by EM Physician, Kalen Abbott. The case: The patient was a male infant who had spilled a large amount of heavy-duty acid aluminum wheel cleaner on himself while playing in his parent's garage. Unclear if he had ingested any fluid. The cleaning fluid contained a large percentage of hydrofluoric acid. He was brought by EMS to his local hospital, who quickly decided to transport the infant by helicopter to a large Denver hospital. Initial labs were unremarkable and the EKG was normal. Heart rate was in the 140s. Blood pressure was 110/73. Respirations were around 30 and non-labored. Chest and abdominal x-rays were unremarkable. The patient had received a water-based decontamination and 1 gram of calcium gluconate IV. Complications: Immediately before leaving a nurse informed Brendan and Matt that the serum calcium was 6.8 mg/dl (normal range: 8.5 to 10.2). During the flight, the patient went into cardiac arrest. The patient achieved ROSC after CPR was administered in the helicopter. Once on the ground, an I/O line was started and calcium chloride, sodium bicarb, and normal saline were administered. Within the first 2 hours that patient received the equivalent of 310 mg/kg of calcium (the pediatric dose is 20 mg/kg) Care resolution: The patient ended up having a several-week stay in the pediatric ICU. There were some complications such as pulmonary hemorrhage. Calcium gluconate was continued via nebulization for several days. Ultimately, the child was weaned off the ventilator and spontaneous respirations resumed. They were able to wean the child off vasopressors and sedation over the course of several days. A gastric lavage with calcium gluconate was completed as well during the inpatient stay. The child was able to leave the hospital, neurologically intact after about 14 days. Pearls: Lower concentrations of acids can be more dangerous because they don't immediately burn but rather can be absorbed systemically through the skin. Calcium is the antidote to hydrofluoric acid exposure. Calcium chloride has 3 times the elemental calcium as calcium gluconate. The maximum infusion rate of calcium chloride through a peripheral line is 1 gram every 10 minutes, calcium gluconate can be infused at 1 gram every 5 minutes. When intubating a patient with acid exposure, avoid succinylcholine because of the risk of hyperkalemia. References Caravati EM. Acute hydrofluoric acid exposure. Am J Emerg Med. 1988 Mar;6(2):143-50. doi: 10.1016/0735-6757(88)90053-8. PMID: 3281684. Pepe J, Colangelo L, Biamonte F, Sonato C, Danese VC, Cecchetti V, Occhiuto M, Piazzolla V, De Martino V, Ferrone F, Minisola S, Cipriani C. Diagnosis and management of hypocalcemia. Endocrine. 2020 Sep;69(3):485-495. doi: 10.1007/s12020-020-02324-2. Epub 2020 May 4. PMID: 32367335. Strayer RJ. Succinylcholine, rocuronium, and hyperkalemia. Am J Emerg Med. 2016 Aug;34(8):1705-6. doi: 10.1016/j.ajem.2016.05.039. Epub 2016 May 19. PMID: 27241569. Vallentin MF, Granfeldt A, Meilandt C, Povlsen AL, Sindberg B, Holmberg MJ, Iversen BN, Mærkedahl R, Mortensen LR, Nyboe R, Vandborg MP, Tarpgaard M, Runge C, Christiansen CF, Dissing TH, Terkelsen CJ, Christensen S, Kirkegaard H, Andersen LW. Effect of Intravenous or Intraosseous Calcium vs Saline on Return of Spontaneous Circulation in Adults With Out-of-Hospital Cardiac Arrest: A Randomized Clinical Trial. JAMA. 2021 Dec 14;326(22):2268-2276. doi: 10.1001/jama.2021.20929. PMID: 34847226; PMCID: PMC8634154. Summarized by Jeffrey Olson MS2 | Edited by Jeffrey Olson, Meg Joyce, & Jorge Chalit, OMSII

Discussion on the flaws of ATLS protocol including intubating unstable patients, the drawbacks of cervical collars, and the importance of resuscitation before intubation. Critique of the practice of cutting clothes off trauma patients and the need for adapting trauma care practices to align with patient needs.

Contributor: Meghan Hurley MD Educational Pearls: Shift work is defined as anything that takes place outside of a 9-5 schedule, not exempting day-shift medical workers Various ill effects of shift work on overall health: Increased all-cause mortality Increased number of accidents Glucose metabolism dysregulation Increased BMI Fertility impacts for men and women Increased breast cancer risk Decreased cognitive functioning Mitigation strategies Work at the same time every day Anchor Sleep - always try to be asleep at the same time of day Progressive shifts: day- into swing- into night shift instead of the other way around Three days off after a stretch of nights can help reset sleep schedule Shorter night shifts Morning shifts should start no earlier than 8 AM Sleep hygiene Ensure an ideal sleep environment; cool, dark, and damp Avoid bright lights when going to sleep Exposure to bright lights when waking up Hydration throughout your shift Stop caffeine at midnight if you are working a night shift Eat healthy meals and avoid junk food Avoid eating 2-3 hours before going to sleep References Boivin, D. B., Boudreau, P., & Kosmadopoulos, A. (2022). Disturbance of the Circadian System in Shift Work and Its Health Impact. Journal of biological rhythms, 37(1), 3–28. https://doi.org/10.1177/07487304211064218 Jang TW. Work-Fitness Evaluation for Shift Work Disorder. Int J Environ Res Public Health. 2021;18(3):1294. Published 2021 Feb 1. doi:10.3390/ijerph18031294 Minors DS, Waterhouse JM. Anchor sleep as a synchronizer of rhythms on abnormal routines. Int J Chronobiol. 1981;7(3):165-188. Reinganum MI, Thomas J. Shift Work Hazards. [Updated 2023 Jan 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK589670/ Summarized by Jorge Chalit, OMSII | Edited by Meg Joyce & Jorge Chalit, OMSII

Contributor: Aaron Lessen MD Educational Pearls: Why is airway management more difficult in obesity? Larger body habitus causes the chest to be above the head when the patient is lying supine, creating difficult angles for intubation. Reduced Functional Residual Capacity (FRC) causes these patients to deoxygenate much more quickly, reducing the amount of time during which the intubation can take place. What special considerations need to be made? Positioning. The auditory canal and sternal notch should be aligned in a horizontal plane. Do this by stacking blankets to lift the neck and head. Also, try to make the head itself parallel to the ceiling. Pre-oxygenation. Use Bi-level Positive Airway Pressure (BiPAP) with Positive End Expiratory Pressure (PEEP) or a Bag-Valve-Mask (BVM) with a PEEP valve. PEEP helps prevent alveoli from collapsing after every breath and improves oxygenation. Dosing of paralytics. Succinylcholine is dosed on total body weight so the dose will be much larger for the obese patient. Rocuronium is dosed on ideal body weight, but adjusted body weight may also be used in obese cases. References De Jong A, Wrigge H, Hedenstierna G, Gattinoni L, Chiumello D, Frat JP, Ball L, Schetz M, Pickkers P, Jaber S. How to ventilate obese patients in the ICU. Intensive Care Med. 2020 Dec;46(12):2423-2435. doi: 10.1007/s00134-020-06286-x. Epub 2020 Oct 23. PMID: 33095284; PMCID: PMC7582031. Langeron O, Birenbaum A, Le Saché F, Raux M. Airway management in obese patient. Minerva Anestesiol. 2014 Mar;80(3):382-92. Epub 2013 Oct 14. PMID: 24122033. Sharma S, Arora L. Anesthesia for the Morbidly Obese Patient. Anesthesiol Clin. 2020 Mar;38(1):197-212. doi: 10.1016/j.anclin.2019.10.008. Epub 2020 Jan 2. PMID: 32008653. Singer BD, Corbridge TC. Basic invasive mechanical ventilation. South Med J. 2009 Dec;102(12):1238-45. doi: 10.1097/SMJ.0b013e3181bfac4f. PMID: 20016432. Summarized by Jeffrey Olson, MS2 | Edited by Jorge Chalit, OMSII