Emergency Medical Minute

Dr. Kim Nordstrom, a practicing emergency psychiatrist and associate professor with the University of Colorado, discusses various work-up models alongside valuable bedside tools for elderly patients with acute psychosis. In this podcast, she explores the methods to differentiate primary psychiatric psychosis from medically mediated psychosis in the elderly using an empirical bedside tool. Furthermore, Dr. Nordstrom educates our listeners on the treatment modalities available and currently recommended for new psychosis in the elderly. Key Points: Non-psychiatric causes of psychosis include lobar degeneration, sensory deficits, pharmacologic mediators, and others. ADEPT tool, developed by CPE under an ACEP sponsorship, is a useful guideline for rapid and reliable assessment of psychosis in the elderly. DTS (delirium triage screen) tool, embedded in the ADEPT, is 98% sensitive to rule-out delirium. BCAM (brief concussion assessment method) is used if DTS is positive to rule-in delirium with high specificity. ADEPT Tool: https://www.acep.org/patient-care/adept DTS Tool: http://eddelirium.org/delirium-assessment/dts-calculator/ BCAM Tool: http://eddelirium.org/delirium-assessment/bcam-calculator/ Source: Shen​vi C, Kennedy M, et al. Managing delirium and agitation in the older emergency department patient: The ADEPT Tool. Ann Emerg Med. 2020 Feb; 75(2): 136–145.

Contributor: Nick Tsipis, MD Educational Pearls: Observational study in Israel evaluated cohort of vaccinated pregnant women receiving the initial Pfizer-BioNTech COVID-19 mRNA vaccine Looked at 24,288 newborns with about 16,697 exposed to maternal vaccination in utero Longitudinal follow up showed no significant difference in preterm births, neonatal hospitalizations, post-natal hospitalizations, congenital abnormalities, or mortality While this is not a randomized-controlled trial, this observational trial has a very large population that was studied supporting the safety profile of birth outcomes relating to receiving COVID mRNA vaccines during pregnancy References Goldshtein I, Steinberg DM, Kuint J, et al. Association of BNT162b2 COVID-19 Vaccination During Pregnancy With Neonatal and Early Infant Outcomes [published online ahead of print, 2022 Feb 10]. JAMA Pediatr. 2022;e220001. doi:10.1001/jamapediatrics.2022.0001 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: Dr. Carl Reinhold August Wunderlich, of the mid-1800s, was the first physician to suggest temperature was related to disease processes and his measurements set the 37˚C (98.6˚F) as the baseline temperature Thermometers were adapted to be sold to the public with guidelines for temperature measurement interpretation Taller and thinner individuals, anyone taking a temperature in the morning, and the elderly have decreased temperatures Temperature averages have been decreased and the actual average temperature appears to be closer to 97.5˚ currently References Wright WF. Early evolution of the thermometer and application to clinical medicine. J Therm Biol. 2016;56:18-30. doi:10.1016/j.jtherbio.2015.12.003 Geneva II, Cuzzo B, Fazili T, Javaid W. Normal Body Temperature: A Systematic Review. Open Forum Infect Dis. 2019;6(4):ofz032. Published 2019 Apr 9. doi:10.1093/ofid/ofz032 Chen W. Thermometry and interpretation of body temperature [published correction appears in Biomed Eng Lett. 2019 Feb 25;9(1):19]. Biomed Eng Lett. 2019;9(1):3-17. Published 2019 Feb 9. doi:10.1007/s13534-019-00102-2 Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

Contributor: Jared Scott, MD Educational Pearls: ACEP survey was done in 2018 looking at violence towards staff in the ED with only 10% of those solicited responding Survey found 47% of respondents were assaulted and 71% had witnessed violence towards staff Regarding what was done about the violence, 28% said patients were flagged by the hospital, 21% said patient was arrested by police/hospital security, 6% of the cases resulted in the hospital pressing charges, and in 3% of cases the staff were advised to press charges Analyzing the type of violence that occurred, it was found that in 44% of the incidents staff were hit/slapped, 30% were spit on, 28% were punched, 27% were kicked, 17% were scratched, 6% were bitten, 2% were assaulted with a weapon, and 1% were sexually assaulted ED violence is a very serious matter and you can learn more about the survey and initiatives at the links below References https://www.acep.org/administration/violence-in-the-emergency-department-resources-for-a-safer-workplace/ https://www.emergencyphysicians.org/press-releases/2018/10-2-2018-violence-in-emergency-departments-is--increasing-harming-patients-new-research-finds https://stopedviolence.org/ 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: Tubo-ovarian abscess is a rare complication of pelvic inflammatory disease Usually presents with chief complaint of abdominal pain and is often diagnosed by CT of the abdomen/pelvis Hospitalization is indicated 60-80% of patients improve with an IV anaerobic cephalosporin (cefoxitin or cefotetan) with doxycycline or using clindamycin and gentamicin Mortality can occur in up to 5% of patients, often as a result of progression to septic shock References Kairys N, Roepke C. Tubo-Ovarian Abscess. [Updated 2021 Jul 18]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448125/ 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.

Contributor: Aaron Lessen, MD Educational Pearls: Normal saline is thought to interfere with renal function and cause an acidosis and balanced fluids (like lactated ringers) are a better option The SALT-ED trial and SMART trial showed a small benefit with renal injury and need for dialysis using balanced fluid in critically ill patients Recent multicenter RCT in Brazil evaluated balanced fluids versus normal saline and looked at 90-day mortality Found no difference in 90-day mortality or secondary outcomes like renal function PLUS trial is currently being done in Australia and New Zealand to further evaluate fluid choice Larger trials don't show a major difference at this point, keep an eye out for future trials References Semler MW, Wanderer JP, Ehrenfeld JM, et al. Balanced Crystalloids versus Saline in the Intensive Care Unit. The SALT Randomized Trial. Am J Respir Crit Care Med. 2017;195(10):1362-1372. doi:10.1164/rccm.201607-1345OC Semler MW, Self WH, Wanderer JP, et al. Balanced Crystalloids versus Saline in Critically Ill Adults. N Engl J Med. 2018;378(9):829-839. doi:10.1056/NEJMoa1711584 Zampieri FG, Machado FR, Biondi RS, et al. Effect of Intravenous Fluid Treatment With a Balanced Solution vs 0.9% Saline Solution on Mortality in Critically Ill Patients: The BaSICS Randomized Clinical Trial [published online ahead of print, 2021 Aug 10]. JAMA. 2021;326(9):1-12. doi:10.1001/jama.2021.11684 https://clinicaltrials.gov/ct2/show/NCT02721654 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: Techniques regarding ring removal in the ED were evaluated in a recent study which looked at using trauma shears versus the motorized ring cutters A certain type of trauma shear has a ring-cutter attached to it, 7 seconds to remove vs. about 70 seconds for motorized ring cutters Both the users of the devices and the patients preferred the ring-cutter shears References 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 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: Recent study evaluated budesonide for outpatient COVID-19 infection treatment to see if there was a decrease in length of illness or hospitalization rates Found patients who received a budesonide inhaler had recovery times that were about 3 days shorter and there was a slight (non-significant) decrease in hospitalizations References Berezowski I, Patel J, Shaw M, Pourmand A. High-dose budesonide for early COVID-19. Lancet. 2021;398(10317):2146-2147. doi:10.1016/S0140-6736(21)02441-7 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: An endotracheal tube introducer or bougie are often used as a rescue device during difficult intubations as they are small and can be placed blindly Large randomized-controlled trial looked at first-pass bougie use versus standard intubation to determine if there was improvement in first-pass success rate No difference in first-pass success rate, about 80% for both techniques This does not mean that bougies are not great rescue devices or options for managing an airway References Driver BE, Semler MW, Self WH, et al. Effect of Use of a Bougie vs Endotracheal Tube With Stylet on Successful Intubation on the First Attempt Among Critically Ill Patients Undergoing Tracheal Intubation: A Randomized Clinical Trial. JAMA. 2021;326(24):2488–2497. 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!

Dr. Kim Nordstrom discusses a valuable bedside tool for evidence-based assessment in patients that visit the ED and are at risk for suicidality. Dr. Nordstrom is a practicing emergency psychiatrist and associate professor with the University of Colorado. As a developer and user of the tool, Dr. Nordstrom gives us invaluable insight into a new avenue for psychiatric care in emergency medicine. Educational Pearls: An app-based tool made in conjunction with ACEP Identifying suicidal risk for each patient, including assessment of clues like bodily injuries Communicating with patients to create a safe space and enhance rapport Assessing for threats such as environmental or personal objects Risk assessment; previous attempts, mental state, life stressors, etc. Risk reduction once discharge is thought possible Extension of care once patients leave the ED Link to Access the ICAR2E Tool References Wilson MP, Moutier C, et al. Emergency department recommendations for suicide prevention in adults: The ICAR2E mnemonic and a systematic review of the literature. Am J Emerg Med. 2020; 38:571-581. Summarized by Jorge Chalit 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!