Emergency Medical Minute

Contributor: Peter Bakes, MD Educational Pearls: High concern causes of third trimester vaginal bleeding include placenta previa, placental abruption, or vasa previa In placenta previa, the placenta implants over the cervix and this condition Often noted during routine prenatal care on transabdominal ultrasound Patients present with painful vaginal bleeding, usually in the absence of trauma Avoid pelvic exam, transvaginal ultrasound, or digital vaginal exam in placenta previa Risk factors for placenta previa include multiple gestations, previous medical abortions, advanced maternal age, and previous placenta previa Management usually includes admission to the hospital >37 weeks: admission for c-section 34-37 weeks: judgment call based on maternal/fetal stability <34 weeks: steroids for fetal lung maturation and delay delivery References Anderson-Bagga FM, Sze A. Placenta Previa. [Updated 2021 Jun 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK539818/ Young JS, White LM. Vaginal Bleeding in Late Pregnancy. Emerg Med Clin North Am. 2019;37(2):251-264. doi:10.1016/j.emc.2019.01.006 Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD *Image from BruceBlaus via Wikimedia Commons licensed under Creative Commons license 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 examined patient perceptions of providers wearing traditional white coats, fleece coats and soft-shell jackets Found that white coats were seen as more professional than other types of dress Also found that female physicians were viewed as less professional than their male counterparts regardless of dress Older respondents thought more of white coats than younger respondents Patient perspective should be considered and reiterating roles may help build relationships with patients References Xun H, Chen J, Sun AH, Jenny HE, Liang F, Steinberg JP. Public Perceptions of Physician Attire and Professionalism in the US. JAMA Netw Open. 2021;4(7):e2117779. Published 2021 Jul 1. doi:10.1001/jamanetworkopen.2021.17779 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: Ian Gillman, PA-C Educational Pearls: Acute mesenteric ischemia is a condition where bowel loses blood supply from an acute occlusion of the mesenteric arteries A frequent sign is abdominal pain that is out of proportion to the exam Atrial fibrillation is one risk factor for mesenteric ischemia Treatment includes anticoagulation and possible surgical intervention depending on the extent of the ischemia References Monita MM, Gonzalez L. Acute Mesenteric Ischemia. [Updated 2021 Jun 29]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Kühn F, Schiergens TS, Klar E. Acute Mesenteric Ischemia. Visc Med. 2020;36(4):256-262. doi:10.1159/000508739 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 evaluating patient outcomes after traumatic brain injury (TBI) over 1 year Trial followed patients with severe TBI (GCS 3-8) and moderate TBI (GCS 9-12) At 1 year out ½ of the severe TBI group were able to be independent for at least 8 hours per day; ⅔ were independent to this level at one year in the moderate TBI group ¼ of the patient who were in a vegetative state 2 weeks after the traumatic brain injury had good outcomes at 1 year References McCrea MA, Giacino JT, Barber J, et al. Functional Outcomes Over the First Year After Moderate to Severe Traumatic Brain Injury in the Prospective, Longitudinal TRACK-TBI Study. JAMA Neurol. 2021;78(8):982-992. doi:10.1001/jamaneurol.2021.2043 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: Adam Barkin, MD Educational Pearls: Seasonal Affective Disorder (SAD) a form of seasonal depression which can result in trouble sleeping, concentration difficulties, changes in appetite, and decreased mood SAD is a common condition affecting millions of people in the US Coupling this with the stresses of COVID, these affects may be compounded To reduce the effects of SAD: Stick to a routine Exercise Light therapy Engage with your community Meditation Tangible bucket list to set goals for the winter Nostalgic activity References Melrose S. Seasonal Affective Disorder: An Overview of Assessment and Treatment Approaches. Depress Res Treat. 2015;2015:178564. doi:10.1155/2015/178564 Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD The Emergency Medical Minute offers 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: End tidal CO2 is accurate to 1-4 mmHg in intubated patient but use with those on positive pressure ventilation like BiPAP is unclear Study looked at patients on BiPAP for COPD or CHF and found end tidal CO2 measurements were significantly underestimated when compared to VBG levels End tidal CO2 measurements for those on positive pressure ventilation appears to be inaccurate References Uzunay H, Selvi F, Bedel C, Karakoyun OF. Comparison of ETCO2 Value and Blood Gas PCO2 Value of Patients Receiving Non-invasive Mechanical Ventilation Treatment in Emergency Department [published online ahead of print, 2021 Apr 27]. SN Compr Clin Med. 2021;1-5. doi:10.1007/s42399-021-00935-y Casati A, Gallioli G, Scandroglio M, Passaretta R, Borghi B, Torri G. Accuracy of end-tidal carbon dioxide monitoring using the NBP-75 microstream capnometer. A study in intubated ventilated and spontaneously breathing nonintubated patients. Eur J Anaesthesiol. 2000;17(10):622-626. doi:10.1046/j.1365-2346.2000.00731.x 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! Diversity and Inclusion Award

Contributor: Aaron Lessen, MD Educational Pearls: Recent study at a hospital in Chicago with a shortage of normal saline decided to push IV ceftriaxone rather than the typical infusion of the antibiotic Retrospective chart analysis of about 800 patients to determine safety of giving a push dose of ceftriaxone Only 1 complication due to the ceftriaxone causing a patient to vomit References Agunbiade A, Routsolias JC, Rizvanolli L, Bleifuss W, Sundaresan S, Moskoff J. The effects of ceftriaxone by intravenous push on adverse drug reactions in the emergency department. Am J Emerg Med. 2021;43:245-248. doi:10.1016/j.ajem.2020.03.022 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: Inhaled nitric oxide or Flolan may be considered in COVID Flolan is a prostaglandin can be inhaled or given IV These medications are classically used for right-sided heart failure, but may be used in COVID Causes pulmonary vasodilation to reduce the resistance against the right ventricle Complications include hypotension and hemolysis, but nitric oxide can be turned off very quickly if needed Be careful and wean patients on nitric oxide for pulmonary hypertension References Lotz C, Muellenbach RM, Meybohm P, et al. Effects of inhaled nitric oxide in COVID-19-induced ARDS - Is it worthwhile?. Acta Anaesthesiol Scand. 2021;65(5):629-632. doi:10.1111/aas.13757 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! Diversity and Inclusion Award

Educational Pearls: Organophosphates affect the cholinergic system by inhibiting acetylcholinesterase affecting muscarinic and nicotinic receptors Symptoms include lacrimation, salivation, bronchoconstriction, blurred vision, bradycardia, bronchorrhea, emesis, and diarrhea Initially, the patient should be decontaminated to prevent further organophosphate exposure Treatment consists of atropine every 5 minutes, 1-3 mg to start and doubling the dose each time it is given until reversal of symptoms is seen Atropine only works on muscarinic receptors, so nicotinic receptor activation continues despite atropine administration resulting in muscle contractions and eventually respiratory arrest Pralidoxime (2-PAM) should also be given to prevent the nicotinic effects and maturation of the organophosphate-acetylcholinesterase complex References Robb EL, Baker MB. Organophosphate Toxicity. [Updated 2021 Jul 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470430/ 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! Diversity and Inclusion Award

Contributor: Chris Holmes, MD Educational Pearls: Parkland Formula: 4 mL x [Total Body Surface Area Burned (%)] x [body weight (kg)] given in 24 hours 50% given over 8 hours and 50% given over the next 16 hours Brooke Formula: 2 mL x [Total Body Surface Area Burned (%)] x [body weight (kg)] given in 24 hours 50% given over 8 hours and 50% given over the next 16 hours 2009 military study evaluated Parkland vs. Brooke formulas for severe burn patients and found the outcomes were the same Guidelines are in flux on which formula to use, but reducing the overall volume using the Brooke formula can be done without significant change in morbidity or mortality Using fluid responsiveness by measuring urine output and signs of fluid overload can help guide overall resuscitative approach in burn patients References Chung KK, Wolf SE, Cancio LC, et al. Resuscitation of severely burned military casualties: fluid begets more fluid. J Trauma. 2009;67(2):231-237. doi:10.1097/TA.0b013e3181ac68cf Schaefer TJ, Nunez Lopez O. Burn Resuscitation And Management. [Updated 2021 Aug 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430795/ 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! Diversity and Inclusion Award