Emergency Medical Minute

Contributor: Sam Killian, MD Educational Pearls: Transaminitis refers to the elevation of transaminases, enzymes of the liver (AST and ALT) Elevation of ALT is relatively specific to the liver, but AST is found in more organs than the liver including the muscle If AST is significantly greater than ALT, consider a musculoskeletal origin such as rhabdomyolysis Transaminitis is not always a liver specific issue References Lala V, Goyal A, Minter DA. Liver Function Tests. [Updated 2021 Aug 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482489/ Lim AK. Abnormal liver function tests associated with severe rhabdomyolysis. World J Gastroenterol. 2020;26(10):1020-1028. doi:10.3748/wjg.v26.i10.1020 Jo KM, Heo NY, Park SH, et al. Serum Aminotransferase Level in Rhabdomyolysis according to Concurrent Liver Disease. Korean J Gastroenterol. 2019;74(4):205-211. doi:10.4166/kjg.2019.74.4.205 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: Tramadol is often thought of as a mild-opiate to use for analgesia, but it is a more complicated drug Tramadol needs to be metabolized into an effective drug making it not pharmacologically reliable 3-10% of people cannot metabolize tramadol and it does not work Some others over-metabolize tramadol and it causes greater effect Studies have shown it is not any better as a acetaminophen or ibuprofen for analgesia, it can lower a seizure threshold, and it acts to inhibit serotonin reuptake Recent study evaluated all-cause mortality of tramadol compared to codeine and found tramadol had nearly double the all-cause mortality as those prescribed codeine Overall tramadol has many risks and should be critically evaluated before prescribing References Dhesi M, Maldonado KA, Maani CV. Tramadol. [Updated 2021 May 25]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK537060/ Association of tramadol vs codeine prescription dispensation with mortality and other adverse clinical outcomes Xie J, Strauss VY, Martinez-Laguna D, et al. JAMA. 2021;326(15):1504-1515. 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: Retrospective cohort study looked at return rate of discharged patients after receiving either phenobarbital or benzodiazepines or both in the ED for treatment of alcohol withdrawal Patients who received benzodiazepines had a 25% chance of returning in 3 days versus a 10% chance of returning in 3 days for those who received phenobarbital 13% of patients returned in 3 days after receiving both phenobarbital and benzodiazepines Phenobarbital may make it less likely for patients to come back to the ED after receiving treatment for alcohol withdrawal References Lebin JA, Mudan A, Murphy CE 4th, Wang RC, Smollin CG. Return Encounters in Emergency Department Patients Treated with Phenobarbital Versus Benzodiazepines for Alcohol Withdrawal. J Med Toxicol. 2022;18(1):4-10. doi:10.1007/s13181-021-00863-2 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: Many are taught that patients with cocaine chest pain should not receive beta-blockers due to unopposed alpha agonism, but is this true? 363 consecutive admissions for chest pain with positive cocaine on urine toxicology were reviewed in a retrospective cohort study 60 patients in this cohort received a beta-blocker and multivariate analysis demonstrated a reduction in myocardial infarction risk Another retrospective cohort study demonstrated no association of negative outcomes with beta-blocker administration in those with a recent positive result on cocaine urine toxicology Two more recent meta-analyses were performed finding no association between adverse clinical outcomes and beta-blocker administration for cocaine chest pain No prospective randomized-controlled trials have been performed to evaluate the use of beta-blockers for treatment of cocaine chest pain in the ED setting References Dattilo PB, Hailpern SM, Fearon K, Sohal D, Nordin C. Beta-blockers are associated with reduced risk of myocardial infarction after cocaine use [published correction appears in Ann Emerg Med. 2008 Jul;52(1):90]. Ann Emerg Med. 2008;51(2):117-125. doi:10.1016/j.annemergmed.2007.04.015 Rangel C, Shu RG, Lazar LD, Vittinghoff E, Hsue PY, Marcus GM. Beta-blockers for chest pain associated with recent cocaine use. Arch Intern Med. 2010;170(10):874-879. doi:10.1001/archinternmed.2010.115 Pham D, Addison D, Kayani W, et al. Outcomes of beta blocker use in cocaine-associated chest pain: a meta-analysis. Emerg Med J. 2018;35(9):559-563. doi:10.1136/emermed-2017-207065 Lo KB, Virk HUH, Lakhter V, et al. Clinical Outcomes After Treatment of Cocaine-Induced Chest Pain with Beta-Blockers: A Systematic Review and Meta-Analysis. Am J Med. 2019;132(4):505-509. doi:10.1016/j.amjmed.2018.11.041 Richards JR, Hollander JE, Ramoska EA, et al. β-Blockers, Cocaine, and the Unopposed α-Stimulation Phenomenon. J Cardiovasc Pharmacol Ther. 2017;22(3):239-249. doi:10.1177/1074248416681644 Lange RA, Cigarroa RG, Flores ED, et al. Potentiation of cocaine-induced coronary vasoconstriction by beta-adrenergic blockade. Ann Intern Med. 1990;112(12):897-903. doi:10.7326/0003-4819-112-12-897 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: Septic arthritis can occur at any joint, including the sternoclavicular joint Sternoclavicular joint infections comprise 1% of all bone and joint infections Patients who use intravenous drugs have a higher occurrence of this type of infection compared to the general population, accounting for 17% of all sternoclavicular joint infections Usual treatment includes intravenous antibiotics and, in some cases, surgery References Tapscott DC, Benham MD. Sternoclavicular Joint Infection. [Updated 2021 Dec 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK551721/ 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!

Tune in for a double feature with our Equity, Diversity and Inclusion Award winners from this fall as Nick asks them about their backgrounds, what brought them into medicine and Emergency Medicine specifically. Patricia is a 4th year medical student at PennMed. As a first-generation immigrant, college, and medical student, she is committed to actively promoting and being an advocate for diversity, equity, and inclusion because she sees the value in having a diverse workforce to build a more equitable health care system. In diversity, there is beauty, there is growth and there is strength. Leyanet is an MS4 at Caribbean Medical University. As a Cuban refugee, she strives to facilitate better rapport & cultural sensitivity to those who are underrepresented. She believes in the importance of having a workforce paradigm that comprehensively represents the community. Leyanet aspires to be a transformational leader & be a role model for others pursuing medicine to demonstrate that shattering glass ceilings and creating an inclusive workplace is important & possible.

Contributor: Jared Scott, MD Educational Pearls: Variability of organisms in infecting the myocardial valves Duke Criteria for Infective Endocarditis includes three categories that can be used to definitively diagnose endocarditis Pathologic Criteria pathological evidence of infection Major Clinical Criteria positive blood cultures positive echocardiogram findings (TEE is more sensitive than a TTE) Minor Clinical Criteria (must include all of the below criteria) Fever Underlying heart condition or IV drug use Vascular phenomena (includes Janeway's lesions) Immunologic phenomena (includes Osler's nodes, Roth spots) Positive blood cultures or serologic evidence of infection with bacteria known to cause endocarditis Some studies show up to a 33% one-year mortality of people diagnosed with endocarditis This criteria was developed by David Durack, MD and he was affiliated with Duke University, shout out to Dr. Pete Bakes! References https://www.mdcalc.com/duke-criteria-infective-endocarditis https://www.youtube.com/watch?v=3NLtNg-pqv0 Holland TL, Baddour LM, Bayer AS, Hoen B, Miro JM, Fowler VG Jr. Infective endocarditis. Nat Rev Dis Primers. 2016;2:16059. Published 2016 Sep 1. doi:10.1038/nrdp.2016.59 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: Jared Scott, MD Educational Pearls: Often present with complaints of sore throat, pain with swallowing, difficulty swallowing, voice change, and possible fever Retrospective study from 2018 evaluated outcomes of peritonsillar abscess with two management arms, surgical vs. non-surgical treatment Non-surgical treatment only included IV fluids as well as IV ceftriaxone + clindamycin; Surgical treatment included either needle aspiration or incision and drainage of the abscess as well as the medical treatment from the non-surgical arm Failure rate in both arms were statistically equivalent, but patients in the surgical arm had more days missed from work and more use of opioid medications for pain References Battaglia A, Burchette R, Hussman J, Silver MA, Martin P, Bernstein P. Comparison of Medical Therapy Alone to Medical Therapy with Surgical Treatment of Peritonsillar Abscess. Otolaryngol Head Neck Surg. 2018;158(2):280-286. doi:10.1177/0194599817739277 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: Don Stader, MD Educational Pearls: Fentanyl's common administration route through pills has lowered the psychological barrier of using opioid compared to injecting and smoking heroin Fentanyl is showing up in all illicit drugs with documented cases even in marijuana Testing for fentanyl is difficult and requires a send out test because UA does not show up not common in ED but can better inform our care Fentanyl doesn't show up on UA drug screen and requires a send out test, thus we should ask patients if they're using fentanyl specifically Send any patient using an illicit drug home with Narcan to protect them from potential opioid overdoses Start patients on buprenorphine for opioid withdrawal in the ED Fentanyl is very lipophilic, thus patients require longer washout times (sometimes over 24 hours) before buprenorphine induction to avoid precipitated withdrawal References: Adams, K.K., Machnicz, M. & Sobieraj, D.M. Initiating buprenorphine to treat opioid use disorder without prerequisite withdrawal: a systematic review. Addict Sci Clin Pract 16, 36 (2021). https://doi.org/10.1186/s13722-021-00244-8 Moustaqim-Barrette, A., Dhillon, D., Ng, J. et al. Take-home naloxone programs for suspected opioid overdose in community settings: a scoping umbrella review. BMC Public Health 21, 597 (2021). https://doi.org/10.1186/s12889-021-10497-2 *Image from NIDA Summarized by Mason Tuttle

Contributor: Nick Tsipis, MD Educational Pearls: Acute hyperkalemia is characterized as serum K of 5.4 or higher in non-hemolyzed samples Hyperkalemia is commonly associated with end stage renal disease, acute kidney injury or acute renal failure Cardiac dysrhythmias are the primary concern with hyperkalemia, common EKG changes (and approximate serum levels) can include: Peaked T waves that start to show at serum K of 6 Second sign is lengthening of PR and QRS intervals due to extended repolarization Severe hyperkalemia manifests as a sine wave around serum of 8-9 Three approaches to treat hyperkalemia: Stabilize cardiac membrane with calcium Shift potassium back into the cell, insulin and albuterol are common agents used. Potassium binding for excretion Cochrane review showed no significant effects of Kayexalate on serum K in 4 hours Bowel necrosis is a rare adverse event that can occur with Kayexalate More myths and misconceptions about hyperkalemia addressed in reference below! References: Gupta AA, Self M, Mueller M, Wardi G, Tainter C. Dispelling myths and misconceptions about the treatment of acute hyperkalemia. Am J Emerg Med. 2022;52:85-91. doi:10.1016/j.ajem.2021.11.030 Mahoney BA, Smith WA, Lo DS, Tsoi K, Tonelli M, Clase CM. Emergency interventions for hyperkalaemia. Cochrane Database Syst Rev. 2005;2005(2):CD003235. Published 2005 Apr 18. doi:10.1002/14651858.CD003235.pub2 Li T, Vijayan A. Insulin for the treatment of hyperkalemia: a double-edged sword?. Clin Kidney J. 2014;7(3):239-241. doi:10.1093/ckj/sfu049 Summarized by Mason Tuttle| Edited by Nick Tsipis, MD