Emergency Medical Minute

Contributor: Chris Holmes, MD Educational Pearls: Medicine is cyclical and practice is always evolving A description of recommended treatment for CHF from 1966 Give oxygen Give one dose morphine then switch to demerol Decrease venous return and start PPV Immediately apply tourniquet to 3 extremities rotating tourniquets every 20 minutes Phlebotomy of 350-500 cc blood into a donor bag and draw off plasma as RBCs settle down Give aminophylline (make sure it is warmed) Induce hypotension with nitroglycerin and trimethoprim camphorsulfonate (infused at 10 drips/minute) Start digitalis Don't use any diuretics as they are ineffective If in shock, release tourniquets and hang the phlebotomized blood Isoproterenol might be beneficial References Messer JV. Management of emergencies. 13. Acute cardiac decompensation. N Engl J Med. 1966;274(26):1491-1493. doi:10.1056/NEJM196606302742608 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 www.emergencymedicalminute.com/cme-courses/ and create an account. Donate to EMM today! Photo Credit: Photo presented without modification courtesy of Kipp Teague , CC license

Contributor: Aaron Lessen, MD Educational Pearls: Facial nerve palsy (Bell's palsy) can occur in pediatric patients with Lyme disease, viral infection, or even leukemia One trial sought out to find if steroids and acyclovir would benefit pediatric patients with facial nerve palsy However, during screening process, around 1% of enrollees had leukemia (5 of the 644 patients) This is important as steroids can partially treat the leukemia thereby prolonging diagnosis and put the patient at risk for tumor lysis syndrome References Babl FE, Kochar A, Osborn M, et al. Risk of Leukemia in Children With Peripheral Facial Palsy. Ann Emerg Med. 2021;77(2):174-177. doi:10.1016/j.annemergmed.2020.06.029 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 www.emergencymedicalminute.com/cme-courses/ and create an account. Donate to EMM today!

Contributor: Don Stader, MD Educational Pearls: Patients are more likely to survive an opioid overdose if they have naloxone 10% risk of death in the year following an opioid overdose of patients seen in the ED Those who receive naloxone: Have better survival rates Are more likely to enter recovery Are more likely to use the naloxone on another person who has overdosed Better to give the patient naloxone at discharge from the ED as rates of filling prescriptions are low Any patient who uses illicit drugs, chronic opioid medications, or opioids with benzodiazepines are good candidates for naloxone at discharge Remember to instruct the patient and those who live with them on how to use it References Gunn AH, Smothers ZPW, Schramm-Sapyta N, Freiermuth CE, MacEachern M, Muzyk AJ. The Emergency Department as an Opportunity for Naloxone Distribution. West J Emerg Med. 2018;19(6):1036-1042. doi:10.5811/westjem.2018.8.38829 Olfson M, Wall M, Wang S, Crystal S, Blanco C. Risks of fatal opioid overdose during the first year following nonfatal overdose. Drug Alcohol Depend. 2018;190:112-119. doi:10.1016/j.drugalcdep.2018.06.004 Olfson M, Crystal S, Wall M, Wang S, Liu SM, Blanco C. Causes of Death After Nonfatal Opioid Overdose [published correction appears in JAMA Psychiatry. 2018 Aug 1;75(8):867]. JAMA Psychiatry. 2018;75(8):820-827. doi:10.1001/jamapsychiatry.2018.1471 http://naloxoneproject.com/ Summarized by John Spartz, MS3 | 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 www.emergencymedicalminute.com/cme-courses/ and create an account. Donate to EMM today!

Contributor: Aaron Lessen , MD Educational Pearls: Patients on 10L or more of oxygen per minute in the ICU were randomized to oxygen goals of 90% or 96% to compare 90-day mortality rates Mortality rates were about 42% for both of oxygen target groups, indicating no significant difference References Schjørring OL, Klitgaard TL, Perner A, et al. Lower or Higher Oxygenation Targets for Acute Hypoxemic Respiratory Failure. N Engl J Med. 2021;384(14):1301-1311. doi:10.1056/NEJMoa2032510 Summarized by John Spartz, MS3 | 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 www.emergencymedicalminute.com/cme-courses/ and create an account. Donate to EMM today!

Contributor: Adam Barkin, MD Educational Pearls: Represents less than 1% of all fractures that occur, although it has a significant mortality rate of 2-5% Typically occurs in high-energy trauma and are commonly associated with high injury severity scores and other fractures Concomitant Injuries: 50% have rib fracture 25% have clavicle fracture 30% have a spine fracture 5% have a brachial plexus injury 40% have a pulmonary contusion 30% have a pneumothorax 34% have a head injury 11% have a vascular injury References Cole PA, Freeman G, Dubin JR. Scapula fractures. Curr Rev Musculoskelet Med. 2013;6(1):79-87. doi:10.1007/s12178-012-9151-x Summarized by John Spartz, MS3 | 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 www.emergencymedicalminute.com/cme-courses/ and create an account. Donate to EMM today!

Contributor: Dave Rosenberg, MD Educational Pearls: In 1951, Operation Tat-Type began tattooing adults with their blood type in an effort to prepare for rapid transfusions in the time of the Cold War and the Korean War School children in northern Indiana and areas in Utah were tattooed with their blood type beginning in 1952 under the same operation Based on tattoos given to SS officers during WWII This wasn't to identify who needed what blood but rather to identify who could give what blood in the event of a massive attack References Wolf EK, Laumann AE. The use of blood-type tattoos during the Cold War. J Am Acad Dermatol. 2008;58(3):472-476. doi:10.1016/j.jaad.2007.11.019 Summarized by John Spartz, MS3 | 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 www.emergencymedicalminute.com/cme-courses/ and create an account. Donate to EMM today!

Contributor: Gretchen Hinson, MD Educational Pearls: Three episodes of ventricular tachycardia within 24 hours or two episodes back-to-back Treat with IV amiodarone and IV beta-blockers initially as well as IV lidocaine Correct underlying causes: IV magnesium for QT prolongation Replete potassium in hypokalemia Urgent revascularization in ischemia For refractory vtach, urgent radiofrequency ablation or stellate ganglion block can be done Last resort is placing on the patient on ECMO References Muser D, Santangeli P, Liang JJ. Management of ventricular tachycardia storm in patients with structural heart disease. World J Cardiol. 2017;9(6):521-530. doi:10.4330/wjc.v9.i6.521 Eifling M, Razavi M, Massumi A. The evaluation and management of electrical storm. Tex Heart Inst J. 2011;38(2):111-121. Summarized by John Spartz, MS3 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 www.emergencymedicalminute.com/cme-courses/ and create an account. Donate to EMM today!

Contributor: Donald Stader, MD Educational Pearls: Opioids target kappa and NMDA receptors that can lead to central nervous system sensitization and therefore increased pain For patients with opioid-induced hyperalgesia (OIH), oral ketamine (25-50 mg) can be used to treat their pain as it targets the NMDA receptor Other treatments is IV magnesium, NSAIDs, tylenol, and clonidine Buprenorphine and methadone are options for chronic pain management in the setting of OIH References Lee M, Silverman SM, Hansen H, Patel VB, Manchikanti L. A comprehensive review of opioid-induced hyperalgesia. Pain Physician. 2011;14(2):145-161. Summarized by John Spartz, MS3 | 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 www.emergencymedicalminute.com/cme-courses/ and create an account. Donate to EMM today!

Contributor: Aaron Lessen, MD Educational Pearls: Recent study looked at whether lactated ringers might be a better choice for fluid resuscitation in patients with DKA compared to normal saline Normal saline can cause a hyperchloremic metabolic acidosis Time to resolution of acidosis was 4 hours less with lactated ringers compared to normal saline Time on an insulin drip decreased by about 4 hours with lactated ringers compared to normal saline LR might be a better choice for fluid resuscitation in patients with DKA References Self WH, Evans CS, Jenkins CA, et al. Clinical Effects of Balanced Crystalloids vs Saline in Adults With Diabetic Ketoacidosis: A Subgroup Analysis of Cluster Randomized Clinical Trials. JAMA Netw Open. 2020;3(11):e2024596. doi:10.1001/jamanetworkopen.2020.24596 Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD

Contributor: Jared Scott, MD Educational Pearls: About ½ of the patients in the ED present with some form of pain One study looked at patients presenting in pain and followed up two days after discharge to determine if their pain was addressed, asking if the patient received anything for pain and if the patient refused pain medication Non-analgesic pain management: About 30% discordance between patient reports and documentation Conventional analgesic pain management: About 15% discordance between patient reports and documentation References Taylor DM, Valentine S, Majer J, Grant N. Discordance between patient-reported and actual emergency department pain management. Emerg Med Australas. 2020 Nov 22. doi: 10.1111/1742-6723.13690. Epub ahead of print. PMID: 33225600. Summarized by John Spartz, MS3 | 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 www.emergencymedicalminute.com/cme-courses/ and create an account. Donate to EMM today!