Emergency Medical Minute

Contributor: Nick Tsipis, MD Educational Pearls: PO medications are less frequently used in the ED due to their longer onset of action The position the patient is in when given PO medications may affect how quickly the medication is absorbed The quicker the medication passes through the stomach into the small intestine, the quicker it can be absorbed and metabolized Recent study used in silico gastric biomechanics model to compare the length of time it took PO medications to pass through the stomach based on the patient's positioning Compared the medication transit time in a stomach model placed in right lateral, left lateral, upright, and supine positions Right lateral positioning resulted in the fastest time for medication to pass through the stomach and enter the duodenum Likely due to the direction of gravity aligning with the antrum and pylorus of the stomach Left lateral positioning had the slowest time for the pill to enter the small intestine Likely due to gravity not aligning with stomach anatomy The time to absorption in the right and left lateral position were significantly faster and slower respectively than that seen in the upright and supine positions These results indicate that placing a patient in the right lateral position when giving PO medications may result in faster rate of medication onset than if the patient is in another position References Lee JH, Kuhar S, Seo JH, Pasricha PJ, Mittal R. Computational modeling of drug dissolution in the human stomach: Effects of posture and gastroparesis on drug bioavailability. Phys Fluids (1994). 2022;34(8):081904. Summarized by Mark O'Brien, MS4 | Edited by John Spartz MD & Erik Verzemnieks, MD 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: Lessen, Aaron MD Educational Pearls: Ketamine can be given at 0.2-0.3 mg/kg as subdissociative doses for pain control in the ED Ketamine coadministered with Haldol may reduce agitation A recent study in Iran compared subdissociative Ketamine given with 2.5 mg Haldol to 1 mg/kg Fentanyl for pain control in the ED Ketamine with Haldol had better pain control than Fentanyl at 5, 10, 15 and 30 minutes Ketamine with Haldol less frequently required rescue medication Ketamine with Haldol did have increased agitation at only the 10 minute mark Of note, there was not a Ketamine only group to compare Ketamine with Haldol is a viable alternative combination for pain control References Moradi MM, Moradi MM, Safaie A, Baratloo A, Payandemehr P. Sub dissociative dose of ketamine with haloperidol versus fentanyl on pain reduction in patients with acute pain in the emergency department; a randomized clinical trial. Am J Emerg Med. 2022;54:165-171. doi:10.1016/j.ajem.2022.02.012 Sin B, Ternas T, Motov SM. The use of subdissociative-dose ketamine for acute pain in the emergency department. Acad Emerg Med. 2015;22(3):251-257. doi:10.1111/acem.12604 Summarized by Kirsten Hughes, MS4 | Edited by John Spartz, MD & Erik Verzemnieks, MD 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: Jarod Scott, MD Educational Pearls: There is a 1-hour window for tooth replantation in ED Cold milk is often best transport media unless there is access to specialized solutions (Hank's Balanced Solution) Goal is to preserve periodontal ligament Soaking in tap water should be avoided as it will lyse cells of periodontal ligament If oral surgeon is rapidly available, have them perform replantation Do not delay replantation to wait for an oral surgeon to become available Steps in tooth reimplantation Disturb the socket as little as possible Handle tooth only by crown, don't touch root Rinse tooth gently with tap water or saline, do not scrub it Tooth should click back in place and remain stable Don't manipulate after reimplantation It may take weeks to determine if the tooth will survive Studies have shown that replantation performed within one hour has a significantly better prognosis than those taking place after a greater amount of time has passed References Alotaibi S, Haftel A, Wagner ND. Avulsed Tooth. In: StatPearls. Treasure Island (FL): StatPearls Publishing. Copyright © 2022, StatPearls Publishing LLC.; 2022. Andreasen JO, Andreasen FM, Skeie A, Hjørting-Hansen E, Schwartz O. Effect of treatment delay upon pulp and periodontal healing of traumatic dental injuries – a review article. Dent Traumatol. 2002;18(3):116-128. De Brier N, O D, Borra V, Singletary EM, Zideman DA, De Buck E. Storage of an avulsed tooth prior to replantation: A systematic review and meta-analysis. Dent Traumatol. 2020;36(5):453-476. Summarized by Mark O'Brien, MS4 | Edited by John Spartz, MD & Erik Verzemnieks, MD 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: Aaron Lessen, MD Educational Pearls: Achilles tendon rupture usually presents in younger, healthy patients after a sports injury Patients typically present complaining of an abrupt onset ankle pain after feeling a "pop" Pain can be localized to posterior ankle and patient's lack the ability to plantarflex Achilles rupture is a clinical diagnosis and does not usually require imaging in the ED Thompson test Having patient lay on their stomach and squeezing the calf on the injured side should result in plantarflexion If the Achilles is ruptured, no plantarflexion will occur Treatment in the ED is to place the patient in a short leg posterior splint with some mild plantarflexion to aid in healing After discharge patients should follow up with orthopedics Recent study compared those who underwent the traditional open surgery, a minimally invasive surgery, and no surgery No difference in functionality was noted between the groups 3 months to 1 year post injury Those in the nonoperative group had slightly higher rates of repeat rupture (6%) than those in the surgical groups ( Patients undergoing minimally invasive surgery had the highest risk of nerve injury (5.2%), followed by traditional surgery (2.8%), and then nonoperative (0.6%) References Cuttica DJ, Hyer CF, Berlet GC. Intraoperative value of the thompson test. J Foot Ankle Surg. 2015;54(1):99-101. Kauwe M. Acute Achilles Tendon Rupture: Clinical Evaluation, Conservative Management, and Early Active Rehabilitation. Clin Podiatr Med Surg. 2017;34(2):229-243. Myhrvold SB, Brouwer EF, Andresen TKM, et al. Nonoperative or Surgical Treatment of Acute Achilles' Tendon Rupture. N Engl J Med. 2022;386(15):1409-1420. Summarized by Mark O'Brien, MS4 | Edited by John Spartz MD & Erik Verzemnieks, MD 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: Dylan Luyten, MD Educational Pearls: Positive End Expiratory Pressure (PEEP) is positive pressure within the lungs and maintained throughout the entire respiratory cycle. It is the pressure preventing alveoli from collapsing at the end of exhalation. When using a bag valve mask (BVM) to ventilate patients, always attach the PEEP valve to prevent intrathoracic pressure from returning to atmospheric pressure which would allow alveoli collapse. A BVM with a good seal to patients face and with an attached PEEP valve provides the same support as BiPAP or CPAP. A generally acceptable PEEP setting is 5 cmH2O. References Mora Carpio AL, Mora JI. Positive End-Expiratory Pressure. In: StatPearls. Treasure Island (FL): StatPearls Publishing; August 27, 2021. Harrison MJ. PEEP and CPAP. Br Med J (Clin Res Ed). 1986;292(6521):643-644. doi:10.1136/bmj.292.6521.643 Summarized by Kirsten Hughes, MS4 | Edited by John Spartz, MD & Erik Verzemnieks, MD 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: Jared Scott, MD Educational Pearls: If a patient is in significant pain, a digital block can be helpful. Pain management alone may allow for manual ring removal. Ring cutters and trauma shears with specialized ring cutters can be attempted but will destroy the ring and some materials may be resistant to cutting. 2 alternative options are presented which aim to reduce edema above the ring to assist removal: Move the ring as proximally as possible. Wrap large size suture from the ring distally beyond PIP joint. Slide the ring over the suture and off the finger. Wrap a tourniquet from distal to proximal including over the ring. Have the patient hold the tourniquet in place while they elevate their hand above the head for 15 minutes. Take down the tourniquet then remove the ring. References Asher CM, Fleet M, Bystrzonowski N. Ring removal: an illustrated summary of the literature. Eur J Emerg Med. 2020;27(4):268-273. doi:10.1097/MEJ.0000000000000658 Walter J, DeBoer M, Koops J, Hamel LL, Rupp PE, Westgard BC. Quick cuts: A comparative study of two tools for ring tourniquet removal. Am J Emerg Med. 2021;46:238-240. doi:10.1016/j.ajem.2020.07.039 Summarized by Kirsten Hughes, MS4 | Edited by John Spartz, MD & Erik Verzemnieks, MD 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: Jared Scott, MD Educational Pearls: Physicians are typically advised not to trust computer interpretation of ECGs Retrospective study was done of computer interpreted normal ECGs to evaluate the accuracy of such an interpretation 989 ECGs were interpreted as "Normal sinus rhythm, Normal ECG" by proprietary cardiology software on MUSE Cardiology Information System These EKGs received follow up interpretation by cardiologists which was considered the "gold standard" for interpretation 18.6% of "normal ECG" had at least one abnormality identified by the cardiologist 6.1% of these discrepant interpretations were deemed potentially clinically significant Only 1% were classified as possible ischemia On retrospective chart review: Six patients underwent non-emergent cardiac catheterization Two had cardiac interventions One had three PCI stents to a prior CABG graft One had a scheduled outpatient cardiac catheterization but was admitted and ended up receiving a CABG graft Study showed that discrepancies between computer interpretation of "Normal ECG" and cardiologist re-interpretation were not clinically significant Emergency physicians should still screen ECGs per AHA guidelines References Winters LJ, Dhillon RK, Pannu GK, Terrassa P, Holmes JF, Bing ML. Emergent cardiac outcomes in patients with normal electrocardiograms in the emergency department. Am J Emerg Med. 2022;51:384-387. Summarized by Mark O'Brien, MS4 | Edited by John Spartz MD & Erik Verzemnieks, MD 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: Aaron Lessen, MD Educational Pearls: Patients with recurrent ascites may need frequent outpatient or emergency department paracentesis which can be time consuming and uncomfortable for patients. Tunneled peritoneal catheters are a permanent alternative therapy which allows fluid drainage at home by patient or caregiver. There has been theoretical concern that long term placement of tunneled peritoneal catheters may increase risk of infection, thus they are more commonly placed as a palliative measure for patients with end stage cancer and malignant ascites with shorter anticipated life spans. However, a recent small study found that in both patients with malignant ascites and recurrent ascites from cirrhosis, tunneled peritoneal catheter placement reduced symptoms from ascites and did not increase risk of infection or leakage at catheter site, or spontaneous bacterial peritonitis after four weeks. More research is emerging and tunneled peritoneal catheters may become more common. References Kimer N, Riedel AN, Hobolth L, et al. Tunneled Peritoneal Catheter for Refractory Ascites in Cirrhosis: A Randomized Case-Series. Medicina (Kaunas). 2020;56(11):565. Published 2020 Oct 27. doi:10.3390/medicina56110565Petzold G, Bremer SCB, Heuschert FC, et al. Tunnelled Peritoneal Catheter for Malignant Ascites-An Open-Label, Prospective, Observational Trial. Cancers (Basel). 2021;13(12):2926. Published 2021 Jun 11. doi:10.3390/cancers13122926Corrigan M, Thomas R, McDonagh J, et al. Tunnelled peritoneal drainage catheter placement for the palliative management of refractory ascites in patients with liver cirrhosis. Frontline Gastroenterol. 2020;12(2):108-112. Published 2020 Feb 28. doi:10.1136/flgastro-2019-101332 Summarized by Kirsten Hughes, MS4 | Edited by John Spartz, MD & Erik Verzemnieks, MD 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: Peter Bakes, MD Educational Pearls: Tachycardia describes a heart rate of >120 beats per minute Wide Complex describes a QRS duration of >120 ms or 3 small boxes on a standard EKG The major differential for a wide complex tachycardia is Ventricular Tachycardia (VT), aka "V Tach", or Supraventricular Tachycardia (SVT) with Aberrancy SVT alone is a narrow complex tachycardia, but as rate increases a right or left bundle branch block pattern may emerge, creating SVT with Aberrancy seen as a wide complex on EKG It is important to distinguish the rhythms as treatment for stable VT differs from treatment(s) for stable SVT Brugada Criteria is an algorithm for determining if wide complex tachycardia is VT with a high degree of sensitivity and specificity. Following is a simple ED approach based on brugada criteria to determine VT on EKG. If either condition is true, suspect and treat VT: Concordance: All precordial leads have QRS complexes that are either all positive or all negative. R-S interval: >100 ms in any one precordial lead. Also note that VT is more common in patients who are elderly and/or have cardiac comorbidities of ischemic or structural heart disease References Reithmann C. Tachykardien mit breiten QRS-Komplexen [Differential diagnosis of wide QRS complex tachycardia]. MMW Fortschr Med. 2019;161(13):48-56. doi:10.1007/s15006-019-0022-x Ding WY, Mahida S. Wide complex tachycardia: differentiating ventricular tachycardia from supraventricular tachycardia. Heart. 2021;107(24):1995-2003. doi:10.1136/heartjnl-2020-316874 Brugada P, Brugada J, Mont L, Smeets J, Andries EW. A new approach to the differential diagnosis of a regular tachycardia with a wide QRS complex. Circulation. 1991;83(5):1649-1659. doi:10.1161/01.cir.83.5.1649 Summarized by Kirsten Hughes, MS4 | Edited by John Spartz, MD & Erik Verzemnieks, MD 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: Aaron Lessen, MD Educational Pearls: Awareness with recall of paralysis can occur in intubated and ventilated patients receiving paralytic medications Patients who suffer from this effect are at high risk of developing severe PTSD, depression, and suicidal ideations Occurs in approximately 0.1-0.2% of patients undergoing general anesthesia in an OR setting 2021 study showed patients intubated in the ED have a much higher rate of experiencing awareness during intubation 2.6% chance of awareness in patients undergoing intubation and mechanical ventilation in the ED Higher rates with rocuronium likely due to its longer duration of action New follow up study from 2022 showed 3.4% of patients aware when paralyzed for mechanical ventilation in ED 5.5% of patients receiving rocuronium had awareness occur Patients who received other paralytics had a Important to be proactive with sedation and pain medications to decrease risk of awareness with recall of paralysis, especially in patients receiving rocuronium References Fuller BM, Pappal RD, Mohr NM, et al. Awareness With Paralysis Among Critically Ill Emergency Department Patients: A Prospective Cohort Study. Crit Care Med. 2022. Leslie K, Davidson AJ. Awareness during anesthesia: a problem without solutions? Minerva Anestesiol. 2010;76(8):624-628. Pappal RD, Roberts BW, Mohr NM, et al. The ED-AWARENESS Study: A Prospective, Observational Cohort Study of Awareness With Paralysis in Mechanically Ventilated Patients Admitted From the Emergency Department. Ann Emerg Med. 2021;77(5):532-544. Summarized by Mark O'Brien, MS4 | Edited by John Spartz, MD & Erik Verzemnieks, MD 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!