Emergency Medical Minute

Contributor: Aaron Lessen, MD Educational Pearls: Think about giving take home naloxone kits for anyone on long-term opioids as well as anyone with an opioid use disorder, those in opioid withdrawal, or those who recently overdosed on opioids Also consider for individuals with non-opioid substance use disorders For patients seen in the ED with an opioid overdose the 1-year mortality is about 5% and 1-month mortality is about 1% Also 50% of accidental pediatric overdose deaths are due to opioids, so ensuring naloxone is present in the household can save lives Prescriptions have a very low fill rate, so getting naloxone in the hands of people before they leave is important References Strang J, McDonald R, Campbell G, et al. Take-Home Naloxone for the Emergency Interim Management of Opioid Overdose: The Public Health Application of an Emergency Medicine. Drugs. 2019;79(13):1395-1418. doi:10.1007/s40265-019-01154-5 Katzman JG, Takeda MY, Greenberg N, et al. Association of Take-Home Naloxone and Opioid Overdose Reversals Performed by Patients in an Opioid Treatment Program. JAMA Netw Open. 2020;3(2):e200117. Published 2020 Feb 5. doi:10.1001/jamanetworkopen.2020.0117 Weiner SG, Baker O, Bernson D, Schuur JD. One-Year Mortality of Patients After Emergency Department Treatment for Nonfatal Opioid Overdose. Ann Emerg Med. 2020;75(1):13-17. doi:10.1016/j.annemergmed.2019.04.020 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: Nick Tsipis, MD Educational Pearls: Prothrombin complex concentrate (Kcentra) and Vitamin K are used to reverse life-threatening bleeds in patients on warfarin (Coumadin) Factors II, VII, IX, and X are included in four-factor PCC PCC/Kcentra dosing is 500-2000 units based on INR and patient weight PROPER3 RCT was a non-inferiority trial done to evaluate standardized dosing of PCC/Kcentra versus variable dosing based on INR and weight Looked at end-points to assess hemostasis, but ultimately this trial did not show non-inferiority of standardized dosing compared to variable dosing References Abdoellakhan RA, Khorsand N, Ter Avest E, et al. Fixed Versus Variable Dosing of Prothrombin Complex Concentrate for Bleeding Complications of Vitamin K Antagonists-The PROPER3 Randomized Clinical Trial. Ann Emerg Med. 2022;79(1):20-30. doi:10.1016/j.annemergmed.2021.06.016 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: Nick Hatch, MD Educational Pearls: Botulism requires a prompt clinical diagnosis as lab results can take about 5 days to return Whale blubber, honey, home fermented foods, homemade wine (especially the wine made in prison), and improperly stored canned food can all contain the toxin The botulinum toxin is create by a Clostridium botulinum that is prevalent on our food and in the soil, but the toxin is readily degraded with heat and light Blocks release of acetylcholine at the neuromuscular junction preventing release of neurotransmitter and therefore the propagation of an electrical nerve potential Descending paralysis, often first including bulbar muscles, and anticholinergic symptoms can be present on exam Infantile botulism, classically seen as floppy baby syndrome, occurs up to a week after ingestion, because the infant GI tract is not acidic enough to deactivate the toxin Antitoxin is available to neutralize the botulism toxin present, but it cannot prevent the already established symptoms References Jeffery IA, Karim S. Botulism. [Updated 2021 Jul 19]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459273/ 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: Ricky Dhaliwal, MD Educational Pearls: Esophageal food impaction can be managed in the ED prior to calling GI for endoscopy Coca-cola, glucagon, benzodiazepines, calcium channel blockers, and dissolved nitroglycerin are all options to try For pediatric patients, weighted bougies can be used under sedation to attempt retrieval of the food bolus Always evaluate airway status, especially if the patient cannot maintain secretions References Long B, Koyfman A, Gottlieb M. Esophageal Foreign Bodies and Obstruction in the Emergency Department Setting: An Evidence-Based Review. J Emerg Med. 2019;56(5):499-511. doi:10.1016/j.jemermed.2019.01.025 Khayyat YM. Pharmacological management of esophageal food bolus impaction. Emerg Med Int. 2013;2013:924015. doi:10.1155/2013/924015 Schimmel J, Slauson S. Swallowed Nitroglycerin to Treat Esophageal Food Impaction. Ann Emerg Med. 2019;74(3):462-463. doi:10.1016/j.annemergmed.2019.04.003 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: Biggest study to date examined new protocol for repeat head CT in anticoagulated elderly patients with head trauma and an initial negative head CT 0.5%-6% of patients in this category will get a delayed ICH and this can occur up to a week out from initial injury 18% of the study group had an ICH on initial head CT, but the rest who had negative head CT initially received a repeat head CT at 6 hours 0.9% had a bleed identified on repeat head CT 6 hours after initial imaging, but of this group no one had an intervention for this bleed Suggests repeat head CT may not be needed and that good counseling for return precautions and discharge is a reasonable disposition in caring for these patients Supratherapeutic INR was a risk factor for delayed bleed, so they should be treated as a higher risk group of patients References Borst J, Godat LN, Berndtson AE, Kobayashi L, Doucet JJ, Costantini TW. Repeat head computed tomography for anticoagulated patients with an initial negative scan is not cost-effective. Surgery. 2021;170(2):623-627. doi:10.1016/j.surg.2021.02.024 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: Alicia Oberle, MD Educational Pearls: Nitrous oxide (N2O) can cause a vitamin B12 deficiency in patients after regular use N2O is used in procedural sedation but also as a popular recreational drug N2O binds and inactivate B12 in the body, therefore decreasing usable supply Lack of B12, which is essential for myelinating nerves, can lead to subacute combined degeneration of the spinal cord Presentation may include paresthesias, ataxia, gait changes, or bilateral lower extremity motor weakness B12 can be normal on labs, as the B12 is present but inactivated Treatment is daily B12 injections and oral supplementation References Stockton L, Simonsen C, Seago S. Nitrous oxide-induced vitamin B12 deficiency. Proc (Bayl Univ Med Cent). 2017;30(2):171-172. doi:10.1080/08998280.2017.11929571 Samia AM, Nenow J, Price D. Subacute Combined Degeneration Secondary to Nitrous Oxide Abuse: Quantification of Use With Patient Follow-up. Cureus. 2020;12(10):e11041. Published 2020 Oct 19. doi:10.7759/cureus.11041 Edigin E, Ajiboye O, Nathani A. Nitrous Oxide-induced B12 Deficiency Presenting With Myeloneuropathy. Cureus. 2019;11(8):e5331. Published 2019 Aug 6. doi:10.7759/cureus.5331 *Image obtained from Wikimedia author Hansmuller and licensed under Creative Commons Attribution-Share Alike 4.0 International license. 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!

Educational Pearls: Glucagon can be used to treat hypoglycemia and esophageal foreign body, but it can also be used in beta-blocker toxicity to bypass cardiac beta-blockade The superior option for treating bradycardia due to beta-blocker toxicity is glucagon Glucagon has decreased efficacy in patients with heart failure, so increased doses up to 10 mg might be required in the event of beta-blocker toxicity References Khalid MM, Galuska MA, Hamilton RJ. Beta-Blocker Toxicity. [Updated 2021 Jul 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448097/ Rotella JA, Greene SL, Koutsogiannis Z, et al. Treatment for beta-blocker poisoning: a systematic review. Clin Toxicol (Phila). 2020;58(10):943-983. doi:10.1080/15563650.2020.1752918 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: A rust ring can occur after a metallic foreign body is left in the eye for a prolonged period of time Issues occur when the rust ring is left as it can epithelialize and become a permanent spot in the patient's vision An eye burr or Alger brush can help to gouge out the rust ring in the emergency setting These tools have a failsafe mechanism to prevent the eye burr from going through layers past the cornea (though this does not work if the foreign body is already through the cornea) Referral to ophthalmology, antibiotic drops, and dilating drops are recommended options upon discharge Complications include poor wound healing, scarring, and infection References Camodeca AJ, Anderson EP. Corneal Foreign Body. [Updated 2021 Apr 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK536977/ https://www.reviewofoptometry.com/article/no-insult-to-injury-managing-foreign--body-removal 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 checks are necessary during CPR to check for return of spontaneous circulation (ROSC) Previous studies have shown that assessing ROSC with palpating for pulse are not a very consistent Study compared palpating pulses at carotid/femoral artery versus a newly contrived gold standard for pulse checks The gold standard used was an increase in end tidal CO2 + cardiac activity on ultrasound + perfusing rhythm on ECG Carotid artery palpation was the best location to confirm pulse during pulse check, although femoral artery palpation Carotid artery palpation was 92% accurate versus 82% accuracy with femoral pulse check Regardless of chosen site, remember 10 seconds is the maximum amount of time for a pulse check before resuming CPR References Yılmaz G, Bol O. Comparison of femoral and carotid arteries in terms of pulse check in cardiopulmonary resuscitation: A prospective observational study. Resuscitation. 2021;162:56-62. doi:10.1016/j.resuscitation.2021.01.042 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: Study of nearly 400 patients evaluating giving calcium during cardiac arrest with the endpoint as return of spontaneous circulation (ROSC) Compared giving 1 amp calcium chloride with each round of epinephrine for the first two rounds of epinephrine versus saline placebo ROSC occurred in 19% of patients in the calcium groups versus 27% in saline placebo group No magic drugs in cardiac arrest, good CPR and early defibrillation are still the most important factors for ROSC in cardiac arrest References Vallentin MF, Granfeldt A, Meilandt C, et al. Effect of Intravenous or Intraosseous Calcium vs Saline on Return of Spontaneous Circulation in Adults With Out-of-Hospital Cardiac Arrest: A Randomized Clinical Trial. JAMA. 2021;326(22):2268-2276. doi:10.1001/jama.2021.20929 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!