Emergency Medical Minute

Educational Pearls: Most common sexually transmitted disease (STD) in North America: Human Papillomavirus (HPV) From the emergency department patients should be connected to follow-up care and educated on vaccine series Most common non-viral STD in North America: Trichomonas Vaginalis While men may be asymptomatic, they can transmit the disease to women who may experience irritation leading to increased likelihood of PID and contraction of other STDs and HIV Trichomonas is diagnosed via wet preparation with visualization of motile parasites Similarly, men's urine can be tested for visualized motile parasites Expedite lab as parasites are motile for about one hour PCR test is becoming more available Most common bacterial STD in North America: Chlamydia trachomatis Neisseria gonorrhoeae is a less common bacterial STD but does have high rates of drug resistance Empiric STD treatment includes IM Ceftriaxone and PO Doxycycline Providers should consider adding Flagyl for Trichomonas Vaginalis coverage ReferencesSexually transmitted disease surveillance, 2020. Centers for Disease Control and Prevention. https://www.cdc.gov/std/statistics/2020/default.htm. Published August 22, 2022. Accessed November 21, 2022. Workowski KA, Bachmann LH, Chan PA, et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep. 2021;70(4):1-187. Published 2021 Jul 23. doi:10.15585/mmwr.rr7004a1 Summarized by Kirsten Hughes, MS4 | Edited by John Spartz, MD, & Erik Verzemnieks, MD In an effort to promote diversity, equity, and inclusion in Emergency Medicine, The Emergency Medical Minute is proud to present our 2nd annual Diversity and Inclusion Award. We support increasing the representation of underrepresented groups in medicine and extend this award to individuals applying to emergency medicine residencies during the 2022-2023 cycle. For information on award eligibility and the application process, visit https://emergencymedicalminute.com/edi-award/ Donate to EMM today!

Contributor: Aaron Lessen,MD Educational Pearls: Recent study looked at mechanically ventilated patients in ED and ICU to determine if O2 saturation level impacted patient outcomes 2541 patients randomized to one of three target O2 saturation levels Low: 90% (Range: 88-92%) Intermediate: 94% (Range: 92-96%) High: 98% (Range: 96-100%) Outcome indicators Primary: Number of days alive and ventilator free by day 28 of hospital admission Secondary: Mortality at 28 days No significant difference was seen for either primary or secondary outcomes between all three groups at 28 days This study shows that the target oxygenation level is not likely to significantly impact outcomes in mechanically ventilated patients in the ED References Semler MW, Casey JD, Lloyd BD, et al. Oxygen-Saturation Targets for Critically Ill Adults Receiving Mechanical Ventilation. N Engl J Med. Nov 10 2022;387(19):1759-1769. doi:10.1056/NEJMoa2208415 Summarized by Mark O'Brien, MS4 | Edited by John Spartz, MD, & Erik Verzemnieks, MD In an effort to promote diversity, equity, and inclusion in Emergency Medicine, The Emergency Medical Minute is proud to present our 2nd annual Diversity and Inclusion Award. We support increasing the representation of underrepresented groups in medicine and extend this award to individuals applying to emergency medicine residencies during the 2022-2023 cycle. For information on award eligibility and the application process, visit https://emergencymedicalminute.com/edi-award/ Donate to EMM today!

Contributor: Travis Barlock, MD Educational Pearls: Gauge and length of catheter are determinants of flow rate Smaller gauges produce higher flow rate Longer catheters reduce flow rate Common IV gauges produce predictable rates of flow: 20 gauge = 60 cc/min 18 gauge = 105 cc/min 16 gauge = 220 cc/min Central lines typically have two 18 gauge and one 16 gauge lumen, both with long catheters, producing the following slower flow rates: 18 gauge = 26 cc /min 16 gauge = 55 cc/min Sheath Introducers, such as Cordis brand catheters, are wider and shorter than classic central lines. Flow rates are 150 cc/min, or 130 cc/min with pressure bag Maximal flow allows for one unit of blood to be delivered over one minute It is important to consider length and gauge of catheter when patients require fluids References Greene N, Bhananker S, Ramaiah R. Vascular access, fluid resuscitation, and blood transfusion in pediatric trauma. International Journal of Critical Illness and Injury Science. 2012;2(3):135. doi:10.4103/2229-5151.100890 Khoyratty SI, Gajendragadkar PR, Polisetty K, Ward S, Skinner T, Gajendragadkar PR. Flow rates through intravenous access devices: an in vitro study. J Clin Anesth. 2016;31:101-105. doi:10.1016/j.jclinane.2016.01.048 Summarized by Kirsten Hughes, MS4 | Edited by John Spartz, MD, & Erik Verzemnieks, MD In an effort to promote diversity, equity, and inclusion in Emergency Medicine, The Emergency Medical Minute is proud to present our 2nd annual Diversity and Inclusion Award. We support increasing the representation of underrepresented groups in medicine and extend this award to individuals applying to emergency medicine residencies during the 2022-2023 cycle. For information on award eligibility and the application process, visit https://emergencymedicalminute.com/edi-award/ Donate to EMM today!

Contributor: Aaron Lessen, MD Educational Pearls: Monkeypox transmission is still occurring in the United States Transmitted by contact to exposed lesion MSM are a high-risk group for monkeypox infection Symptoms include rash and flu like symptoms Monkeypox lesions are often described as blister-like, firm, clear, and rubbery Most commonly develop on the face and/or anogenital regions Patients with potential monkeypox infection should be moved to isolation to reduce risk of transmission Providers should use full PPE including N95, facial covering, gown, and gloves when interacting with a potential case of monkeypox Diagnosis involves swabbing the lesion and sending it for analysis People at risk for severe disease (i.e. immunocompromised) or who have severe symptoms (i.e. eye involvement) should begin treatment with Tecovirimat (TPOXX) in the ED Infectious Disease (ID) should be consulted, and the patient will need to follow up with ID regardless of symptom severity References Rizk JG, Lippi G, Henry BM, Forthal DN, Rizk Y. Prevention and Treatment of Monkeypox. Drugs. Jun 2022;82(9):957-963. doi:10.1007/s40265-022-01742-y Thornhill JP, Barkati S, Walmsley S, et al. Monkeypox Virus Infection in Humans across 16 Countries - April-June 2022. N Engl J Med. Aug 25 2022;387(8):679-691. doi:10.1056/NEJMoa2207323 Summarized by Mark O'Brien, MS4 | Edited by John Spartz, MD, & Erik Verzemnieks, MD In an effort to promote diversity, equity, and inclusion in Emergency Medicine, The Emergency Medical Minute is proud to present our 2nd annual Diversity and Inclusion Award. We support increasing the representation of underrepresented groups in medicine and extend this award to individuals applying to emergency medicine residencies during the 2022-2023 cycle. For information on award eligibility and the application process, visit https://emergencymedicalminute.com/edi-award/ Donate to EMM today!

Contributor: Nick Hatch, MD Educational Pearls: In the setting of traumatic injury, tranexamic acid (TXA) is given to stabilize clots which minimizes bleeding and decreases risk of hemorrhagic shock Current TXA dose for trauma is 1 g bolus followed by a 1 g infusion; both doses should be given within 3 hours from time of injury Due to the split dose and narrow window, patients with complicated care, particularly if they require transfer may miss the infusion dose Various smaller studies have shown that dosing 2 g initially or 2 g followed by a 1 g infusion produces the same patient outcomes and no additional harm Receiving hospitals should strive to acquire accurate information regarding previous doses of TXA given and confirm timeline of injury References Roberts I, Shakur H, Coats T, et al. The CRASH-2 trial: a randomised controlled trial and economic evaluation of the effects of tranexamic acid on death, vascular occlusive events and transfusion requirement in bleeding trauma patients. Health Technol Assess. 2013;17(10):1-79. doi:10.3310/hta17100 Ramirez RJ, Spinella PC, Bochicchio GV. Tranexamic Acid Update in Trauma. Crit Care Clin. 2017;33(1):85-99. doi:10.1016/j.ccc.2016.08.004 Spinella PC, Thomas KA, Turnbull IR, et al. The Immunologic Effect of Early Intravenous Two and Four Gram Bolus Dosing of Tranexamic Acid Compared to Placebo in Patients With Severe Traumatic Bleeding (TAMPITI): A Randomized, Double-Blind, Placebo-Controlled, Single-Center Trial. Front Immunol. 2020;11:2085. Published 2020 Sep 8. doi:10.3389/fimmu.2020.02085 Summarized by Kirsten Hughes, MS4 | Edited by John Spartz, MD, & Erik Verzemnieks, MD In an effort to promote diversity, equity, and inclusion in Emergency Medicine, The Emergency Medical Minute is proud to present our 2nd annual Diversity and Inclusion Award. We support increasing the representation of underrepresented groups in medicine and extend this award to individuals applying to emergency medicine residencies during the 2022-2023 cycle. For information on award eligibility and the application process, visit https://emergencymedicalminute.com/edi-award/ Donate to EMM today!

Contributor: Aaron Lessen, MD Educational Pearls: Recent study evaluated if early exposure to an allergen impacted the rate of allergy development later in childhood Children were exposed to peanut, milk, wheat, and egg allergens at 3 months of age and then followed for 3 years 2.5-3% of children who were not exposed developed allergies to these allergens 1% of children exposed to the allergens developed allergies to these allerrgens Exposing 63 children to allergens at 3 months would prevent the development of food allergy in one child with no significant adverse events Future recommendations will likely be to gradually introduce allergens to children starting around 3 months References Skjerven HO, Lie A, Vettukattil R, et al. Early food intervention and skin emollients to prevent food allergy in young children (PreventADALL): a factorial, multicentre, cluster-randomised trial. Lancet. Jun 25 2022;399(10344):2398-2411. doi:10.1016/s0140-6736(22)00687-0 Summarized by Mark O'Brien, MS4 | Edited by John Spartz, MD, & Erik Verzemnieks, MD In an effort to promote diversity, equity, and inclusion in Emergency Medicine, The Emergency Medical Minute is proud to present our 2nd annual Diversity and Inclusion Award. We support increasing the representation of underrepresented groups in medicine and extend this award to individuals applying to emergency medicine residencies during the 2022-2023 cycle. For information on award eligibility and the application process, visit https://emergencymedicalminute.com/edi-award/ Donate to EMM today!

Contributor: Travis Barlock, MD Educational Pearls: The presence of a STEMI has traditionally been used to determine if a patient with acute chest pain requires urgent cath lab management STEMI indicates an occluded coronary artery, and urgent intervention is needed to restore perfusion to ischemic tissue Patients with occluded coronary arteries can present with EKG findings other than STEMI 2022 ACC Expert Consensus Decision Pathway on the Evaluation and Disposition of Acute Chest Pain in the Emergency Department was recently published in the Journal of the American College of Cardiology Recognizes STEMI equivalents that necessitate cath lab management ST depression in precordial leads Indicates a posterior infarct/possible RCA occlusion LBBB c ST elevation meeting modified Sgarbossa criteria Hyperacute and/or De Winter T wave First indication of coronary artery occlusion Most beneficial time to initiate cath lab because more tissue is salvageable These recommendations will likely alter clinical practice for ED management of acute chest pain References Kontos MC, de Lemos JA, Deitelzweig SB, et al. 2022 ACC Expert Consensus Decision Pathway on the Evaluation and Disposition of Acute Chest Pain in the Emergency Department: A Report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol. Oct 6 2022;doi:10.1016/j.jacc.2022.08.750 Meyers HP, Bracey A, Lee D, et al. Comparison of the ST-Elevation Myocardial Infarction (STEMI) vs. NSTEMI and Occlusion MI (OMI) vs. NOMI Paradigms of Acute MI. J Emerg Med. Mar 2021;60(3):273-284. doi:10.1016/j.jemermed.2020.10.026 Tziakas D, Chalikias G, Al-Lamee R, Kaski JC. Total coronary occlusion in non ST elevation myocardial infarction: Time to change our practice? Int J Cardiol. Apr 15 2021;329:1-8. doi:10.1016/j.ijcard.2020.12.082 Summarized by Mark O'Brien, MS4 | Edited by John Spartz, MD, & Erik Verzemnieks, MD In an effort to promote diversity, equity, and inclusion in Emergency Medicine, The Emergency Medical Minute is proud to present our 2nd annual Diversity and Inclusion Award. We support increasing the representation of underrepresented groups in medicine and extend this award to individuals applying to emergency medicine residencies during the 2022-2023 cycle. For information on award eligibility and the application process, visit https://emergencymedicalminute.com/edi-award/ Donate to EMM today!

Contributor: Aaron Lessen, MD Educational Pearls: In urban settings, it is becoming more common for police to transport critical patients from scene to hospital A 2022 multicenter observational study compared mortality rates in patients with penetrating injury to torso and/or proximal extremity when transported by EMS versus police Approximately 18% of patients were transported by police Overall mortality was approximately 15% in both groups In patients with more severe injury, mortality was still similar at approximately 36% and 38% respectively References Taghavi S, Maher Z, Goldberg AJ, et al. An analysis of police transport in an Eastern Association for the Surgery of Trauma multicenter trial examining prehospital procedures in penetrating trauma patients. J Trauma Acute Care Surg. 2022;93(2):265-272. doi:10.1097/TA.0000000000003563 Jacoby SF, Branas CC, Holena DN, Kaufman EJ. Beyond survival: the broader consequences of prehospital transport by police for penetrating trauma. Trauma Surg Acute Care Open. 2020;5(1):e000541. Published 2020 Nov 26. doi:10.1136/tsaco-2020-000541 Summarized by Kirsten Hughes, MS4 | Edited by John Spartz, MS4 & Erik Verzemnieks, MD In an effort to promote diversity, equity, and inclusion in Emergency Medicine, The Emergency Medical Minute is proud to present our 2nd annual Diversity and Inclusion Award. We support increasing the representation of underrepresented groups in medicine and extend this award to individuals applying to emergency medicine residencies during the 2022-2023 cycle. For information on award eligibility and the application process, visit https://emergencymedicalminute.com/edi-award/ Donate to EMM today!

Contributor: Travis Barlock, MD Educational Pearls: Catheter related blood infections were thought to be caused by skin flora seeding the catheter. Thus, significant effort is applied to sterility and skin preparation. However, studies have shown that bacteria growing on the tip of the catheter is not consistent with growth on cultures of skin. Staphylococcus epidermidis is commonly found on cultures of catheter sites. It has also been found in the gut flora of >50% of ICU patients. Rates of catheter related blood infections have been decreased through oral decontamination and early feeding. These findings suggest enteral bacterial translation as a major source of blood stream infection. References O'Grady NP, Alexander M, Burns LA, et al. Guidelines for the prevention of intravascular catheter-related infections. Clin Infect Dis. 2011;52(9):e162-e193. doi:10.1093/cid/cir257 von Eiff C, Becker K, Machka K, Stammer H, Peters G. Nasal carriage as a source of Staphylococcus aureus bacteremia. Study Group. N Engl J Med. 2001;344(1):11-16. doi:10.1056/NEJM200101043440102 ALTEMEIER WA, HUMMEL RP, HILL EO. Staphylococcal enterocolitis following antibiotic therapy. Ann Surg. 1963;157(6):847-858. doi:10.1097/00000658-196306000-00003 Marshall JC, Christou NV, Horn R, Meakins JL. The microbiology of multiple organ failure. The proximal gastrointestinal tract as an occult reservoir of pathogens. Arch Surg. 1988;123(3):309-315. doi:10.1001/archsurg.1988.01400270043006 Mrozek N, Lautrette A, Aumeran C, et al. Bloodstream infection after positive catheter cultures: what are the risks in the intensive care unit when catheters are routinely cultured on removal?. Crit Care Med. 2011;39(6):1301-1305. doi:10.1097/CCM.0b013e3182120190 Atela I, Coll P, Rello J, et al. Serial surveillance cultures of skin and catheter hub specimens from critically ill patients with central venous catheters: molecular epidemiology of infection and implications for clinical management and research. J Clin Microbiol. 1997;35(7):1784-1790. doi:10.1128/jcm.35.7.1784-1790.1997 Tani T, Hanasawa K, Endo Y, et al. Bacterial translocation as a cause of septic shock in humans: a report of two cases. Surg Today. 1997;27(5):447-449. doi:10.1007/BF02385710 Summarized by Kirsten Hughes, MS4 | Edited by John Spartz, MS4 & Erik Verzemnieks, MD In an effort to promote diversity, equity, and inclusion in Emergency Medicine, The Emergency Medical Minute is proud to present our 2nd annual Diversity and Inclusion Award. We support increasing the representation of underrepresented groups in medicine and extend this award to individuals applying to emergency medicine residencies during the 2022-2023 cycle. For information on award eligibility and the application process, visit https://emergencymedicalminute.com/edi-award/ Donate to EMM today!

Jared Scott, MD, a contributor with a wealth of knowledge in emergency medicine, dives into the high-stakes world of immediate resuscitative thoracotomy. He discusses how this urgent procedure can be a lifesaver in traumatic cardiac arrest cases. The conversation highlights the crucial criteria for performing the surgery, particularly in cases like a young woman struck by a car. Scott also shares impactful findings on survival rates from recent studies, emphasizing the importance of timely medical intervention in trauma care.