Emergency Medical Minute

Educational Pearls: Recent updates to treatment guidelines increased the 250 mg ceftriaxone IM dose to 500 mg ceftriaxone IM IM dosing can be very painful, so other methods of administration can help decrease pain for patients Using IV ceftriaxone instead of IM has no significant difference in pharmacokinetics or bioavailability, so it can be considered in patients with an IV already placed References St Cyr S, Barbee L, Workowski KA, et al. Update to CDC's Treatment Guidelines for Gonococcal Infection, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(50):1911-1916. Published 2020 Dec 18. doi:10.15585/mmwr.mm6950a6 Product Information: ROCEPHIN(R) IV, IM injection, ceftriaxone sodium IV, IM injection. Genentech USA, Inc. (per Manufacturer), South San Francisco, CA, 2010. 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: Jared Scott, MD Educational Pearls: A press release from Merck introduced Molnupiravir for treatment of mild to moderate COVID-19 The yet to be published study is a randomized control trial at around 100 different sites Reported outcomes were hospitalization and mortality from COVID and mortality from COVID Molnupiravir was found to be twice as effective as placebo looking at these two endpoints (7% vs. 14%) 5 day course of the drug taken twice per day costs $700, but cost-saved from using this drug was $32,000 per patient References https://www.merck.com/news/merck-and-ridgebacks-investigational-oral-antiviral-molnupiravir-reduced-the-risk-of-hospitalization-or-death-by-approximately-50-percent-compared-to-placebo-for-patients-with-mild-or-moderat/ https://www.merck.com/news/merck-and-ridgebacks-molnupiravir-an-oral-covid-19-antiviral-medicine-receives-first-authorization-in-the-world/ 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: Nick Tsipis, MD Educational Pearls: Meaningful survival under 10% for out of hospital cardiac arrest The most common cause of out-of-hospital cardiac arrest is due to cardiac ischemia Study looked at whether taking patients without ST elevation who had an out-of-hospital cardiac arrest with return of spontaneous circulation (ROSC) should receive angiography upon arrival to the hospital Took 530 patients and randomized to early vs. delayed angiography after resuscitation from out-of-hospital arrest Found no benefit to early angiography using 30-day all-cause risk of death as the primary endpoint References Desch S, Freund A, Akin I, et al. Angiography after Out-of-Hospital Cardiac Arrest without ST-Segment Elevation [published online ahead of print, 2021 Aug 29]. N Engl J Med. 2021;10.1056/NEJMoa2101909. doi:10.1056/NEJMoa2101909 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: Classically, diverticulitis is diagnosed via CT scan and patients are discharged home on antibiotics if they are without complication The DINAMO study is a multicenter open-label RCT that evaluated if it is safe to not give antibiotics to patients with mild acute diverticulitis Found no difference in readmission, return visits to ED, pain control, or likelihood of surgical intervention between the group that was sent home with antibiotics and the group without Medical societies have not reached a consensus on this issue, likely further studies need to be completed References Mora-López L, Ruiz-Edo N, Estrada-Ferrer O, et al. Efficacy and Safety of Nonantibiotic Outpatient Treatment in Mild Acute Diverticulitis (DINAMO-study): A Multicentre, Randomised, Open-label, Noninferiority Trial. Ann Surg. 2021;274(5):e435-e442. doi:10.1097/SLA.0000000000005031 *Image from Hellerhoff, CC BY-SA 3.0 https://creativecommons.org/licenses/by-sa/3.0>, via Wikimedia Commons 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: Peter Bakes, MD Educational Pearls: Ophthalmia Neonatorum encompasses any conjunctivitis that presents within the first 28 days of life Neonates often receive prophylactic silver nitrate eye drops for gonorrhea prophylaxis, but the drops can cause chemical conjunctivitis Etiology & Timing of Presentation: Silver nitrate conjunctivitis presents 0-2 days after birth Neisseria gonorrhae presents 2-5 days after birth Chlamydia trachomatis presents 5 days to 5 weeks Neisseria gonorrhoeae conjunctivitis is vision-threatening, typically requiring admission and IV antibiotics with a 3rd generation cephalosporin References Castro Ochoa KJ, Mendez MD. Ophthalmia Neonatorum. [Updated 2021 Jul 22]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK551572/ US Preventive Services Task Force, Curry SJ, Krist AH, et al. Ocular Prophylaxis for Gonococcal Ophthalmia Neonatorum: US Preventive Services Task Force Reaffirmation Recommendation Statement. JAMA. 2019;321(4):394-398. doi:10.1001/jama.2018.21367 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: Preterm deliveries in the ED can be complex and preventing hypothermia is essential to the health of the baby Recent meta-analysis examined methods for warming preterm deliveries to prevent hypothermia The most effective way to warm the baby is by wrapping them in plastic References Abiramalatha T, Ramaswamy VV, Bandyopadhyay T, et al. Delivery Room Interventions for Hypothermia in Preterm Neonates: A Systematic Review and Network Meta-analysis. JAMA Pediatr. 2021;175(9):e210775. doi:10.1001/jamapediatrics.2021.0775 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: Don Stader, MD Educational Pearls: Ivermectin is a Nobel-Prize winning antiparasitic used to treat filariasis and onchocerciasis Ivermectin is receiving press due to a scientific study examining ivermectin on COVID-19 viral replication in vitro, but the dosages needed for this effect were much higher than is safe for human use Ivermectin has since been studied in humans with no evidence suggesting it is a viable treatment for COVID-19 Ivermectin is a neurotoxin but at normal levels it does not cross the blood-brain barrier Ivermectin toxicity can include altered mental status, seizures, coma, tachycardia, hypotension, nausea, vomiting and diarrhea Treatment of suspected ivermectin overdose is predominately supportive References Caly L., Druce J.D., Catton M.G., Jans D.A., Wagstaff K.M. The FDA-approved drug ivermectin inhibits the replication of SARS-CoV-2 in vitro. Antivir Res. 2020;178:104787. doi: 10.1016/j.antiviral.2020.104787 López-Medina E, López P, Hurtado IC, et al. Effect of Ivermectin on Time to Resolution of Symptoms Among Adults With Mild COVID-19: A Randomized Clinical Trial. JAMA. 2021;325(14):1426–1435. doi:10.1001/jama.2021.3071 Roder JD, Stair EL. An overview of ivermectin toxicosis. Vet Hum Toxicol. 1998;40(6):369-370. Roman YM, Burela PA, Pasupuleti V, Piscoya A, Vidal JE, Hernandez AV. Ivermectin for the treatment of COVID-19: A systematic review and meta-analysis of randomized controlled trials [published online ahead of print, 2021 Jun 28]. Clin Infect Dis. 2021;ciab591. doi:10.1093/cid/ciab591 Chandler RE. Serious Neurological Adverse Events after Ivermectin-Do They Occur beyond the Indication of Onchocerciasis?. Am J Trop Med Hyg. 2018;98(2):382-388. doi:10.4269/ajtmh.17-0042 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: Alec Coston, MD Educational Pearls: Flash pulmonary edema or Sympathetic Crash Acute Pulmonary Edema (SCAPE) is a severe illness that requires aggressive treatment Often in patients with heart failure and a sympathetic surge increasing heart rate, decreased diastolic filling, increased preload, and increased afterload causing pulmonary edema Clinical diagnosis: acute onset diaphoresis and respiratory distress, hypoxia and tachypnea on exam Bedside lung ultrasound will demonstrate B-lines, indicative of pulmonary edema Treatment is nitroglycerin and BiPAP Nitroglycerin drip can be started at 80 micrograms/minute, which is similar to the dose delivered by sublingual nitroglycerin References Stemple K, DeWitt KM, Porter BA, Sheeser M, Blohm E, Bisanzo M. High-dose nitroglycerin infusion for the management of sympathetic crashing acute pulmonary edema (SCAPE): A case series. Am J Emerg Med. 2021;44:262-266. doi:10.1016/j.ajem.2020.03.062 Agrawal N, Kumar A, Aggarwal P, Jamshed N. Sympathetic crashing acute pulmonary edema. Indian J Crit Care Med. 2016;20(12):719-723. doi:10.4103/0972-5229.195710 Wilson SS, Kwiatkowski GM, Millis SR, Purakal JD, Mahajan AP, Levy PD. Use of nitroglycerin by bolus prevents intensive care unit admission in patients with acute hypertensive heart failure. Am J Emerg Med. 2017;35(1):126-131. doi:10.1016/j.ajem.2016.10.038 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 podcast, we are back again with host, Jordan Ourada, and neurosurgeon, Dr. Eddie Tsvankin as they discuss an exciting and mind-blowing array of topics pertaining to neurosurgery. Listen as Dr. Tsvankin shares his views on not only the history of neurosurgery, but also the medical, surgical, and engineering advancements that are taking place today. You'll also hear Dr. Tsvankin give intriguing details into how neurosurgeries are performed with cutting-edge technology including the exoscopes that are presently utilized at Swedish Medical Center. Finally, Jordan and Dr. Tsvankin delve into predictions for future advancements in neurosurgery and neurooncology, as well as why cancer seems more prevalent today than ever. 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: Donald Stader, MD Educational Pearls: Hip Dislocation Prolonged dislocations can impair blood supply to femoral head Hip dislocation for >6 hours puts patient at high risk for needing a hip replacement in the next two year Knee Dislocation High mechanism Often looks anatomically normal on knee x-ray Vascular injuries of the popliteal artery can cause significant morbidity with some studies suggesting an 80% amputation rate if not treated within 6 hours Ankle Dislocation Common dislocation and often co-occurs with ankle fractures (bimalleolar/trimalleolar) Pressure on the skin from the displaced joint can cause skin tenting, which can lead to skin necrosis Hematoma blocks work well for ankle reductions as an adjunct to or substitute for procedural sedation References Arnold C, Fayos Z, Bruner D, Arnold D. Managing dislocations of the hip, knee, and ankle in the emergency department. Emerg Med Pract. 2017;19(12):1-28. Dawson-Amoah K, Raszewski J, Duplantier N, Waddell BS. Dislocation of the Hip: A Review of Types, Causes, and Treatment. Ochsner J. 2018;18(3):242-252. doi:10.31486/toj.17.0079 Patterson BM, Agel J, Swiontkowski MF, Mackenzie EJ, Bosse MJ; LEAP Study Group. Knee dislocations with vascular injury: outcomes in the Lower Extremity Assessment Project (LEAP) Study. J Trauma. 2007;63(4):855-858. doi:10.1097/TA.0b013e31806915a7 Ross A, Catanzariti AR, Mendicino RW. The hematoma block: a simple, effective technique for closed reduction of ankle fracture dislocations. J Foot Ankle Surg. 2011;50(4):507-509. doi:10.1053/j.jfas.2011.04.037 Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD