Emergency Medical Minute

Contributor: Peter Bakes, MD Educational Pearls: Incidence 2.5-10 per million people occurring primarily in those with environmental allergens Typically occurs with mRNA vaccines in lipid nanoparticles (Moderna/Pfizer) rather than the adenovirus vaccine (J&J) Recommendation is to forego 2nd dose of the mRNA vaccine and instead get the adenovirus vaccine after weighing the risks and benefits References Kounis NG, Koniari I, de Gregorio C, Velissaris D, Petalas K, Brinia A, Assimakopoulos SF, Gogos C, Kouni SN, Kounis GN, Calogiuri G, Hung MY. Allergic Reactions to Current Available COVID-19 Vaccinations: Pathophysiology, Causality, and Therapeutic Considerations. Vaccines (Basel). 2021 Mar 5;9(3):221. doi: 10.3390/vaccines9030221. PMID: 33807579; PMCID: PMC7999280. Blumenthal KG, Robinson LB, Camargo CA, et al. Acute Allergic Reactions to mRNA COVID-19 Vaccines. JAMA. Published online March 08, 2021. doi:10.1001/jama.2021.3976 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: Jared Scott, MD Educational Pearls: 1-3 cases of rabies per year in US with 55,000 people per year receiving rabies prophylaxis 90% of rabies cases come from wildlife, most commonly by racoons, bats, foxes, and skunks Because of rabies prophylaxis, domesticated pets almost never have rabies in the United States Rabies is typical transmitted via a bite, but direct contact with saliva or brain tissue on an open wound can transmit the virus Some people exposed to rabies from bats will never report a bite References Kessels J, Tarantola A, Salahuddin N, Blumberg L, Knopf L. Rabies post-exposure prophylaxis: A systematic review on abridged vaccination schedules and the effect of changing administration routes during a single course. Vaccine. 2019 Oct 3;37 Suppl 1:A107-A117. doi: 10.1016/j.vaccine.2019.01.041. Epub 2019 Feb 5. PMID: 30737043. Centers for Disease Control and Prevention. Rabies Postexposure Prophylaxis (PEP). Published June 11, 2019. https://www.cdc.gov/rabies/medical_care/index.html 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: Alicia Oberle, MD Educational Pearls: Down Syndrome with Trisomy 21 have three copies of chromosome 21 Current birth rates are around 1 in 700 births Average life span 25 years in 1980, today the average life span is 60 years of age Patients with Down syndrome require additional therapies in the first 3 years due to developmental delays They also have increased risk for childhood leukemias, seizures, hypothyroidism, celiac disease, and early-onset Alzheimers Half have a cardiac defect requiring surgery at birth References Tsou AY, Bulova P, Capone G, et al. Medical Care of Adults With Down Syndrome: A Clinical Guideline. JAMA. 2020;324(15):1543–1556. doi:10.1001/jama.2020.17024 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!

This week's episode features a fascinating conversation with Dr. Nadia Tremonti, medical director for the pediatric palliative care program at Children's Hospital of Michigan in Detroit. Dr. Tremonti was the featured physician in an independent short film Palliative and subsequent New York Times shorter excerpt Dying in your Mother's Arms that explore her work with terminally ill pediatric patients. From conversations of religion's role in processing disease to the physician's role in alleviating suffering for patients and their families, Nick and Nadia explore the existential ground in this thought-provoking segment. Time Stamps 00:47 Introductions 3:50 How patients led her to pursue palliative care 14:32 Dr. Tremonti's approach to palliative care 21:42 Understanding patients' and family's language to guide counseling 31:38 Most frequent anxieties and fears of families of pediatric palliative care patients 37:21 How emergent interventions can shift burden of decision to continue life-sustaining measures to families 47:45 Navigating existential questions of life or death with patients and their families 55:38 Saddest part of palliative care 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: Droperidol for sedation in agitated patients in the emergency department was studied compared to ziprasidone (Geodon) and lorazepam (Ativan) Double-blinded RCT showed droperidol was 65% effective to get patients to a good level of sedation in 15 minutes compared to ativan and geodon which were 25-35% effective Droperidol had less respiratory depression and prolongation of the QT compared to Ativan and Geodon References Martel ML, Driver BE, Miner JR, Biros MH, Cole JB. Randomized Double-blind Trial of Intramuscular Droperidol, Ziprasidone, and Lorazepam for Acute Undifferentiated Agitation in the Emergency Department. Acad Emerg Med. 2021 Apr;28(4):421-434. doi: 10.1111/acem.14124. Epub 2020 Oct 5. PMID: 32888340. Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD

Contributor: Ricky Dhaliwal, MD Educational Pearls: Primarily affects children Caused by staph aureus releasing exotoxins that result in erythema and sloughing of the skin Present with significant pain, dehydration and underlying staph infection Treatment typically oxacillin/nafcillin with admission for wound care with petroleum gel and xeroform Burn centers may be treatment centers of choice for this condition Most patients recover in 2-3 days with treatment References Patel GK, Finlay AY. Staphylococcal scalded skin syndrome: diagnosis and management. Am J Clin Dermatol. 2003;4(3):165-75. doi: 10.2165/00128071-200304030-00003. PMID: 12627992. Jordan KS. Staphylococcal Scalded Skin Syndrome: A Pediatric Dermatological Emergency. Adv Emerg Nurs J. 2019 Apr/Jun;41(2):129-134. doi: 10.1097/TME.0000000000000235. PMID: 31033660. 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: Ricky Dhaliwal, MD Educational Pearls: Rhabdomyolysis occurs when high levels of myoglobin are released from dying muscle tissue into the blood Severe levels of myoglobin cause renal injury Causes include elevated temperature, excessive exercise, toxins, infection, muscle ischemia, crush injury, and prolonged immobilization Can also be caused by medications, like antipsychotics, statins, SSRIs, colchicine, lithium Workup typically includes creatinine kinase, potassium, creatinine levels and serial EKGs Firstline treatment is with IV fluids with a goal urine output of 300 ml/hr Sodium bicarbonate and mannitol have had some use in treatment but weak evidence References Long B, Koyfman A, Gottlieb M. An evidence-based narrative review of the emergency department evaluation and management of rhabdomyolysis. Am J Emerg Med. 2019 Mar;37(3):518-523. doi: 10.1016/j.ajem.2018.12.061. Epub 2019 Jan 2. PMID: 30630682. 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.

Contributor: Aaron Lessen, MD Educational Pearls: Study in NEJM looked at occult hypoxemia, when oxygen saturation reads at >92% when the actual saturation is Rate of occult hypoxemia was 3 times higher in those who identified as black (12% vs 4%) Keep this disparity in mind when providing care to patients of all backgrounds and incorporate into clinical decision-making References Sjoding MW, Dickson RP, Iwashyna TJ, Gay SE, Valley TS. Racial Bias in Pulse Oximetry Measurement. N Engl J Med. 2020;383(25):2477-2478. doi:10.1056/NEJMc2029240 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: Peter Bakes, MD Educational Pearls: Febrile Seizure clinical criteria 6 months - 5 years of age Rapid rise in temp No preexisting seizure disorder No other explanation for the seizure Nonfocal seizure lasting less than 15 minutes If the seizure does not meet the above criteria, a full workup needs to be completed Regardless of cause, treat the seizure with IV/IO benzodiazepines or IN versed if unable to obtain access Risk of developing epilepsy after a simple febrile seizure roughly doubles References Leung AK, Hon KL, Leung TN. Febrile seizures: an overview. Drugs Context. 2018;7:212536. Published 2018 Jul 16. doi:10.7573/dic.212536 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: Acid and alkali ingestions have differing prognosis and immediate concerns Immediate issues can include superficial irritation, severe burns, esophageal perforation, and even airway compromise from edem Long term morbidity can include strictures Supportive care is typically all that can be provided in the emergency department Diagnostics may include imaging and endoscopy For more severe ingestions without immediate issues,, patients may be monitored for up to 24 hours References Hoffman RS, Burns MM, Gosselin S. Ingestion of Caustic Substances. N Engl J Med. 2020 Apr 30;382(18):1739-1748. doi: 10.1056/NEJMra1810769. PMID: 32348645. Summarized 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!