Emergency Medical Minute

Contributor: Jarod Scott, MD Educational Pearls: Rectal prolapse is an evagination of the rectal tissue through the anal opening Factors that weaken the pelvic floor muscles increase the risk of rectal prolapse These include age > 40, female, multiple pregnancies, constipation, diarrhea, cystic fibrosis, prior pelvic floor surgeries, or other pelvic floor abnormalities Noninvasive treatment options include increasing fluid and fiber intake to soften stools as well as using padding/taping to reinforce the perineum Surgery is an option to repair the prolapse so long as the patient is a good surgical candidate Medical sugar can be used as a desiccant to dry out and shrink the prolapse thus allowing for easier manual replacement References Coburn WM, 3rd, Russell MA, Hofstetter WL. Sucrose as an aid to manual reduction of incarcerated rectal prolapse. Ann Emerg Med. 1997;30(3):347-349. 2Gachabayov M, Bendl R, Flusberg M, et al. Rectal prolapse and pelvic descent. Curr Probl Surg. 2021;58(9):100952. Segal J, McKeown DG, Tavarez MM. Rectal Prolapse. In: StatPearls. Treasure Island (FL): StatPearls Publishing. Copyright © 2022, StatPearls Publishing LLC.; 202 Summarized by Mark O'Brien, 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!

Contributor: Aaron Lessen, MD Educational Pearls: Hyperglycemic Hyperosmolar State (HHS) is less common than Diabetic Ketoacidosis (DKA) but is associated with a mortality rate up to 10 times greater than that seen in DKA Typically seen in elderly patients with severely elevated blood glucose levels (>1000 mg/dL) and an increased plasma osmolality Unlike in DKA, patients with HHS do not have elevated ketones Treatment of HHS includes insulin administration along with correcting fluid and electrolyte abnormalities When treating HHS, it is important to monitor and follow osmolality regularly because over-rapid correction can result in the development of cerebral edema References Fayfman M, Pasquel FJ, Umpierrez GE. Management of Hyperglycemic Crises: Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar State. Med Clin North Am. 2017;101(3):587-606. Gosmanov AR, Gosmanova EO, Kitabchi AE. Hyperglycemic Crises: Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar State. In: Feingold KR, Anawalt B, Boyce A, et al., eds. Endotext. South Dartmouth (MA): MDText.com, Inc. Copyright © 2000-2022, MDText.com, Inc.; 2000. Long B, Willis GC, Lentz S, Koyfman A, Gottlieb M. Diagnosis and Management of the Critically Ill Adult Patient with Hyperglycemic Hyperosmolar State. J Emerg Med. 2021;61(4):365-375. Summarized by Mark O'Brien, MS4 | Edited by John Spartz MS4 & Erik Verzemnieks, MD 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!

The Emergency Medical Minute is excited to announce that we our upcoming event, Palliative. Check out our event page for more information and to buy tickets: Palliative Eventbrite Page

Contributor: Aaron Lessen, MD Educational Pearls: NSAIDs are a potential alternative to opioids for pain management and are associated with decreased rates of adverse effects A recent study evaluated the effectiveness of ibuprofen and oxycodone for pain management in pediatric patients with isolated, acute-limb fractures Participants were discharged home with either ibuprofen or oxycodone and followed for six weeks There was no difference in pain scores between those taking ibuprofen and those taking oxycodone indicating that they had comparable analgesic effects Those in the ibuprofen group experienced significantly less adverse events compared to those taking oxycodone The participants in the ibuprofen group showed quicker return to their normal activities and improved quality of life In pediatric patients with fracture-related pain, ibuprofen is a safer alternative to oxycodone that is equally effective for pain control References Ali S, Manaloor R, Johnson DW, et al. An observational cohort study comparing ibuprofen and oxycodone in children with fractures. PLoS One. 2021;16(9):e0257021. Cooney MF. Pain Management in Children: NSAID Use in the Perioperative and Emergency Department Settings. Paediatr Drugs. 2021;23(4):361-372. Yin X, Wang X, He C. Comparative efficacy of therapeutics for traumatic musculoskeletal pain in the emergency setting: A network meta-analysis. Am J Emerg Med. 2021;46:424-429. Summarized by Mark O'Brien, MS4 | Edited by John Spartz MS4 & Erik Verzemnieks, MD The Emergency Medical Minute is excited to announce that we our upcoming event, Palliative. Check out our event page for more information and to buy tickets: Palliative Eventbrite Page Donate to EMM today!

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!

Substance-Induced Psychosis (Part I) In this first episode of a two-part mini-series, we feature Dr. Nadia Haddad, a Colorado psychiatrist, and Dr. Ricky Dhaliwal, an emergency medicine physician, as they discuss the different substances that cause psychosis and their unique presentations in the ED and in the psychiatric world. First, Dr. Haddad establishes a medical definition of psychosis. Then, Dr. Haddad and Dr. Dhaliwal partake in a fruitful discussion, each providing their unique perspective on the drugs that affect our patient populations today. Key Points: Psychosis is a cognitive processing disorder, which leads to auditory hallucinations, visual hallucinations, and delusions. Axis one psychosis like that from schizophrenia or mania typically produces auditory hallucinations, not visual hallucinations. Delusions are also common in underlying psychiatric psychosis. One of the most common substances that cause psychosis today is methamphetamine. Meth-induced psychosis can mimic schizophrenia symptoms, though tactile hallucinations are very common with methamphetamine use. Methamphetamine is active for up to about 8 hours but can vary depending on underlying mental health predispositions, which can be exacerbated for several days or a week before neurotransmitters right themselves after meth use. Cannabis can lead to psychosis and paranoia for people - especially young people - with a predisposition to schizophrenia or bipolar. Alcohol-related psychosis comes primarily from withdrawal, though acute alcohol intoxication may cause mild alcoholic hallucinosis. The hallmark of delirium tremens is a fluctuating, waxing-and-waning consciousness, which can occur 72 hours after the last drink. DTs can occur after treatment of the physical withdrawal symptoms. Alcohol withdrawal can occur even at high BALs relative to a patient's baseline. Cocaine psychosis is similar to methamphetamine-induced psychosis. Recorded, Summarized, and Edited By: Jorge Chalit

Contributor: Aaron Lessen, MD Educational Pearls: Tracheostomy bleeding is a rare but potentially life-threatening complication that usually occurs within the first month of tracheostomy tube placement No matter how severe the bleeding, every patient should be evaluated to rule out a tracheo-innominate fistula between the tracheostomy and the innominate artery If the patient is currently bleeding and has a cuffed tracheostomy tube, over-inflate the balloon to compress the bleeding vessel Consider replacing an uncuffed tracheostomy tube with a cuffed tube or an ET tube If the tracheostomy was performed in the last seven days, use a bougie or bronchoscope to replace the uncuffed tube due to increased risk of opening a false track into the subcutaneous tissue If bleeding cannot be controlled, follow mass-transfusion protocols, and as a last resort, remove the tube and insert a finger into the stoma to manually compress the artery References Bontempo LJ, Manning SL. Tracheostomy Emergencies. Emerg Med Clin North Am. 2019;37(1):109-119. Khanafer A, Hellstern V, Meißner H, et al. Tracheoinnominate fistula: acute bleeding and hypovolemic shock due to a trachea-innominate artery fistula after long-term tracheostomy, treated with a stent-graft. CVIR Endovasc. 2021;4(1):30. Manning Sara, Bontempo Laura. Complications of Tracheostomies. In: Mattu A and Swadron S, ed. ComPendium. Burbank, CA: CorePendium, LLC. https://www.emrap.org/corependium/chapter/reckOdDn9Ljn7sBLy/Complications-of-Tracheostomies. Updated August 17, 2021. Accessed June 5, 2022. Summarized by Mark O'Brien, MS4 | Edited by John Spartz, MD, MPH & Erik Verzemnieks, MD 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: Nick Hatch, MD Educational Pearls: Transcatheter aortic valve replacement (TAVR) is an increasingly common endovascular procedure to treat aortic stenosis TAVR is an alternative to the open approach surgical aortic valve replacement (SAVR) for patients who are inoperable or are high risk surgical candidates Following TAVR, there is increased risk of stroke, particularly in the first 30 days TAVR-related strokes are due to embolic debris left on the valve root, which is generally cleaned out during SAVR Further, following the procedure many patients are anticoagulated which increases the risk for conversion to hemorrhagic stroke Isolated, unexplained nausea and vomiting in elderly patients should prompt concern for a neurologic workup with imaging - even more so if they have recently undergone TAVR References Davlouros PA, Mplani VC, Koniari I, Tsigkas G, Hahalis G. Transcatheter aortic valve replacement and stroke: a comprehensive review. J Geriatr Cardiol. 2018;15(1):95-104. doi:10.11909/j.issn.1671-5411.2018.01.008 Gleason TG, Reardon MJ, Popma JJ, et al. 5-Year Outcomes of Self-Expanding Transcatheter Versus Surgical Aortic Valve Replacement in High-Risk Patients. J Am Coll Cardiol. 2018;72(22):2687-2696. doi:10.1016/j.jacc.2018.08.2146 Siontis GCM, Overtchouk P, Cahill TJ, et al. Transcatheter aortic valve implantation vs. surgical aortic valve replacement for treatment of symptomatic severe aortic stenosis: an updated meta-analysis. Eur Heart J. 2019;40(38):3143-3153. doi:10.1093/eurheartj/ehz275 Summarized by Kirsten Hughes, MS4 | Edited by John Spartz MS4 & Erik Verzemnieks, MD 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: Nick Hatch, MD Educational Pearls: "Smiling Death" describes the prehospital phenomenon of a person who is happy to be extricated from an extended period of crush injury, but dies suddenly soon after the rescue. Smiling Death is caused by Crush Syndrome. Crush Syndrome begins when large areas of tissue are damaged by compression and subsequent impeded blood flow. Resultant cell death is followed by release of myoglobin and efflux of electrolytes including potassium. Upon removal of the crushing force, high levels of potassium enter circulation and cause cardiac arrhythmias leading to sudden death. Prevention measures include aggressive hydration using normal saline before extrication. An acceptable starting rate is 1L per hour, but providers should take patient status into consideration and titrate appropriately. Standard techniques for controlling hyperkalemia by intracellular shifting may be less effective. Early dialysis may be useful. References Gonzalez D. Crush syndrome. Crit Care Med. 2005;33(1 Suppl):S34-S41. doi:10.1097/01.ccm.0000151065.13564.6f Better OS. Rescue and salvage of casualties suffering from the crush syndrome after mass disasters. Mil Med. 1999;164(5):366-369. Summarized by Kirsten Hughes, MS4 | Edited by John Spartz MS4 & Erik Verzemnieks, MD 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: Pepper spray is a chemical irritant derived from oleoresin capsicum (OC), an extract from pepper plants. It can be used by police for riot or crowd control, or by individuals for self defense. In the event of an exposure, those affected should immediately disperse from the area, remove contact lenses with clean or gloved hands, and remove contaminated clothing. Pepper spray can spread from patients to providers by contact. When caring for those exposed, providers should use PPE including gloves and should double bag personal belongings. For patient management consider the following: If the eyes are affected, first remove contacts then irrigate with clean water. Use proparacaine drops for relief. Clean exposed skin thoroughly with soap and water. Inhalation and ingestion may cause nausea, vomiting, shortness of breath and generalized anxiety from discomfort. Treatment can include antiemetics and anxiolytics. Symptoms may persist for many days. References Schep LJ, Slaughter RJ, McBride DI. Riot control agents: the tear gases CN, CS and OC-a medical review. J R Army Med Corps. 2015;161(2):94-99. doi:10.1136/jramc-2013-000165 Tidwell RD, Wills BK. Tear Gas and Pepper Spray Toxicity. [Updated 2022 Jan 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK544263/ Summarized by Kirsten Hughes, MS4 | Edited by John Spartz MS4 & Erik Verzemnieks, MD 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! *********************