Emergency Medical Minute

Contributor: Jared Scott, MD Educational Pearls: About 50% of those infected with SARS-CoV-2 will shed the virus in their feces Wastewater surveillance can be used to track COVID burden, which may be easier than collating test data from multiple hospitals across a region Viral shedding begins 5-7 days prior to symptom onset, so wastewater data can be used to anticipate outbreaks and inform policy and public health initiatives Some existing limitations to wastewater surveillance include: Reporting by counties were water sources may be mixed Septic tanks and other closed water systems will not be counted Not all those infected will shed the virus References Weidhaas J, Aanderud ZT, Roper DK, et al. Correlation of SARS-CoV-2 RNA in wastewater with COVID-19 disease burden in sewersheds. Sci Total Environ. 2021;775:145790. doi:10.1016/j.scitotenv.2021.145790 Kirby AE, Walters MS, Jennings WC, et al. Using Wastewater Surveillance Data to Support the COVID-19 Response — United States, 2020–2021. MMWR Morb Mortal Wkly Rep 2021;70:1242–1244. DOI: http://dx.doi.org/10.15585/mmwr.mm7036a2 Covid-19 monitoring in wastewater. Colorado COVID-19 Updates. https://covid19.colorado.gov/covid-19-monitoring-in-wastewater. Accessed May 21, 2022. 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!

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!

Contributor: Aaron Lessen, MD Educational Pearls: Tidal volume is the amount of breath a patient receives in a single ventilation Traditional tidal volume (TV) setting was 10 ml/kg but studies showed lower TV had less incidence of respiratory distress, ARDS, and overall better outcomes ED ventilation settings may get carried on for hours or days when a patient is admitted, making this an important part of patient care Recent large systematic review shows that low TV setting in the ED leads to decreased incidence of ARDS, shorter ICU and hospital length of stay, shorter duration of mechanical ventilation, and decreased mortality Consider an ED low tidal volume ventilation setting at around 6 ml/kg of predicted body weight References De Monnin K, Terian E, Yaegar LH, et al. Low Tidal Volume Ventilation for Emergency Department Patients: A Systematic Review and Meta-Analysis on Practice Patterns and Clinical Impact [published online ahead of print, 2022 Feb 7]. Crit Care Med. 2022;10.1097/CCM.0000000000005459. doi:10.1097/CCM.0000000000005459 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!

Explore the intriguing connections between the foxglove plant and its historical use for heart failure, known as dropsy. Discover how digoxin, derived from foxglove, enhances heart function but carries risks of toxicity. The conversation takes a unique turn, linking the effects of digoxin on EKGs to Salvador Dali's artistic style. Tune in for captivating insights into the intersection of medicine, history, and art, along with a personal patient story that adds depth to the discussion.

Contributor: Aaron Lessen, MD Educational Pearls: Recent study looking at a pediatric emergency department to determine what percentage of patients after intubation received sedation within 10 minutes after intubation About 25% of the patients in the study received sedation within 10 minutes after intubation Only 75% of the patients in the study received sedation in the ED at some point after intubation Those who received rocuronium were less likely to received sedation post-intubation References Berg K, Gregg V, Cosgrove P, Wilkinson M. The Administration of Postintubation Sedation in the Pediatric Emergency Department. Pediatr Emerg Care. 2021;37(11):e732-e735. doi:10.1097/PEC.0000000000001744 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: Aaron Lessen, MD Educational Pearls: Pulse pressure is the difference between the systolic and diastolic blood pressure, normal is about 40 A narrow pulse pressure is generally thought of as less than 30 mmHg which may signal peripheral vasoconstriction in response to lower blood volumes 2020 study examined hypotension and narrow pulse pressure in trauma and outcomes 37% of patients who were hypotensive on ED arrival had a severe injury, 22% of patients who had a narrow pulse pressure had a severe injury, and 11% of patients with normal blood pressure and normal pulse pressure had a severe injury Need for thoracotomy, death, cardiac arrest, and need for other interventions was highest in the hypotensive group, the lowest in the normal blood pressure/normal pulse pressure group, and narrow pulse pressure group outcomes fell in the middle Narrow pulse pressure in the setting of trauma may be a helpful vital sign to incorporate into trauma care in the ED References Schellenberg M, Owattanapanich N, Getrajdman J, Matsushima K, Inaba K. Prehospital Narrow Pulse Pressure Predicts Need for Resuscitative Thoracotomy and Emergent Intervention After Trauma [published correction appears in J Surg Res. 2021 Oct 6;270:1]. J Surg Res. 2021;268:284-290. doi:10.1016/j.jss.2021.06.051 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: Peter Bakes, MD Educational Pearls: Mild frostbite injury usually only requires supportive care In severe frostbite injury, patients should receive an immediate angiogram, be admitted, and receive tPA if there is evidence of vascular occlusion Salvage rate is around 80% for appropriate patients who receive tPA in phalangeal frostbite injury References Paine RE, Turner EN, Kloda D, Falank C, Chung B, Carter DW. Protocoled thrombolytic therapy for frostbite improves phalangeal salvage rates. Burns Trauma. 2020;8:tkaa008. Published 2020 Apr 10. doi:10.1093/burnst/tkaa008 Basit H, Wallen TJ, Dudley C. Frostbite. In: StatPearls. Treasure Island (FL): StatPearls Publishing; November 5, 2021. Wexler A, Zavala S. The Use of Thrombolytic Therapy in the Treatment of Frostbite Injury. J Burn Care Res. 2017;38(5):e877-e881. doi:10.1097/BCR.0000000000000512 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: Chris Holmes, MD Educational Pearls: Antiemetics were used in ancient Rome to help with sea-sickness and included toxic substances such as wine and wormwood and white hellborn The first antihistamine used for nausea, dramamine, was introduced in 1947 for motion sickness After this chlorpromazine, prochlorperazine, and promethazine came about in the 1950s and 1960s Cannabis, colloquially referred to as weed, isolates like THC used in the 1970s to help with chemotherapy-induced After this in the 1980s, ondansetron and metoclopramide were introduced for more severe chemotherapy-induced nausea Lastly, NK-1 inhibitors were introduced to treat nausea References Sanger GJ, Andrews PLR. A History of Drug Discovery for Treatment of Nausea and Vomiting and the Implications for Future Research. Front Pharmacol. 2018;9:913. Published 2018 Sep 4. doi:10.3389/fphar.2018.00913 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!

In this special episode of MHM, we feature Dr. Nadia Haddad, a Colorado psychiatrist, and Dr. Ricky Dhaliwal, an emergency medicine physician, as they discuss the implications of OUD in Colorado. As a substance use disorder specialist, Dr. Haddad provides an invaluable perspective on various treatment modalities for OUD in the outpatient and inpatient settings. Finally, Dr. Haddad and Dr. Dhaliwal discuss the implications of the newly introduced Colorado legislation affecting patients with OUD and their providers. Key Points: The classic Suboxone therapy for heroin or prescription opioid detox can precipitate severe withdrawal in street fentanyl users. The three FDA-approved MATs include methadone (full opioid agonist), buprenorphine (partial opioid agonist), and naltrexone (opioid antagonist). Street fentanyl does not behave like pharmaceutical-grade fentanyl; a recent study found that the chemical composition of a street pill varied and included opioid analogs and benzodiazepines Fentanyl attaches and detaches to/from the receptor more easily and quickly than buprenorphine. Dr. Haddad suspects that as fentanyl weans from the patient's system, there is not enough to compete with Suboxone, therefore precipitating withdrawal. Suboxone vs. naltrexone: Suboxone can be started sooner to treat post-acute withdrawal. Naltrexone helps to prevent relapse but may slow a patient's emotional return to baseline. Dr. Haddad recently developed a new home induction program to provide patients with supportive measures for the withdrawal period, which include pharmacologic interventions like clonidine, trazodone, dicyclomine, or loperamide. Resources after discharge in Colorado include mental health centers, Front Range Clinic, Magnolia Mental Health The criminalization of substance use disorders moves people from treatment-focused settings to punitive settings and leads to prison population expansion without adequate mental healthcare resources.

Contributor: Aaron Lessen, MD Educational Pearls: Traditionally, blood cultures are drawn from two separate sites despite no data to suggest this is better than drawing blood from one site Recent study evaluated multi-site versus single-site blood cultures to determine if there was a difference in accuracy or contamination Positive yield was 20% in the single-site year and 17% in the multi-site year No difference in contamination between the two groups References Ekwall-Larson A, Yu D, Dinnétz P, Nordqvist H, Özenci V. Single-Site Sampling versus Multisite Sampling for Blood Cultures: a Retrospective Clinical Study. J Clin Microbiol. 2022;60(2):e0193521. doi:10.1128/JCM.01935-21 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!