Emergency Medical Minute

Contributor: Peter Bakes, MD Educational Pearls: Lyme disease gives a single expanding target lesion with central clearing called erythema chronicum migrans Erythema multiforme is another targetoid rash that presents with multiple target lesions Characterized into erythema minor and major based on severity but typically resolves More severe hypersensitivity reactions include Stevens-Johnson Syndrome (30% skin involvement) SJS and TEN is associated with NSAIDS including aspirin, antiemetics like phenergan, anticonvulsants like dilantin or phenobarbital, and antibiotics like penicillin or sulfa drugs Other causes include viral illnesses like Herpes simplex virus or mycoplasma pneumoniae Treat by removing offending agent and treat supportively with monitoring for rash progression to SJS or TEN References Trayes KP, Love G, Studdiford JS. Erythema Multiforme: Recognition and Management. Am Fam Physician. 2019 Jul 15;100(2):82-88. PMID: 31305041. Read J, Keijzers GB. Pediatric Erythema Multiforme in the Emergency Department: More Than "Just a Rash". Pediatr Emerg Care. 2017 May;33(5):320-324. doi: 10.1097/PEC.0000000000000618. PMID: 26555305. 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: Fever is an adaptive response to infection, but elderly and immunocompromised patients may not be able to mount a hyperthermic response in sepsis Patients with fever in sepsis end up receiving treatment earlier and have better outcomes Hypothermic patients with severe sepsis admitted to the ICU had a 32% mortality versus 21% mortality in those who had a fever on presentation 3-hour sepsis bundle compliance was less frequent in hypothermic patients than in febrile patients (56% versus 71%) Early broad spectrum antibiotics were administered less in patients who were hypothermic than those that were febrile (77% versus 87%) References Blair E, Buxton RW, Cowley RA, Mansberger AR. The Use of Hypothermia in Septic Shock. JAMA. 1961;178(9):916–919. doi:10.1001/jama.1961.73040480005008b Kushimoto S, Abe T, Ogura H, et al. Impact of Body Temperature Abnormalities on the Implementation of Sepsis Bundles and Outcomes in Patients With Severe Sepsis: A Retrospective Sub-Analysis of the Focused Outcome Research on Emergency Care for Acute Respiratory Distress Syndrome, Sepsis and Trauma Study. Crit Care Med. 2019;47(5):691-699. 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: Survey study compared depression symptom prevalence in the United States at the beginning of COVID compared to data acquired by a similar survey for 2017-2018 and found it was three-fold higher Mild symptoms: 25% during pandemic; 16% before Moderate: 15% during pandemic; 6% before Moderately Severe symptoms: 8% during pandemic; 2% before Severe symptoms: ~5% during pandemic; 1% before Those with lower income, less savings, and exposure to more stressors were at greater risk for developing depression symptoms References Ettman CK, Abdalla SM, Cohen GH, Sampson L, Vivier PM, Galea S. Prevalence of Depression Symptoms in US Adults Before and During the COVID-19 Pandemic. JAMA Netw Open. 2020;3(9):e2019686. doi:10.1001/jamanetworkopen.2020.19686 Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD

Contributor: Ricky Dhaliwal, MD, JD Educational Pearls: Glucagon administered intravenously has a high rate of adverse events (nausea/vomiting) with very weak evidence NItroglycerin too has very limited evidence but a much better adverse event profile Mix 0.4 mg (1 sublingual tablet) nitro in 10 mL of water and administer orally Nothing beats upper endoscopy for effectiveness but in settings where GI is not immediately available, nitroglycerin may be worth an attempt given its better safety profile to other medications References Arora S, Galich P. Myth: glucagon is an effective first-line therapy for esophageal foreign body impaction. CJEM 2015;11:169–71 Schimmel J, Slauson S. Swallowed Nitroglycerin to Treat Esophageal Food Impaction. Ann Emerg Med. 2019 Sep;74(3):462-463. Summarized/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: While it is rare to have a native hip dislocation, it is relatively common to dislocate a prosthetic hip The mechanism for dislocation is usually adduction, flexion, and internal rotation the hip which can occur when walking Arthroplasty in the setting of trauma or fracture, posterior approach during surgery, and using a small femoral head increase the likelihood of later dislocation If a patient with a total hip arthroplasty says they were walking and then developed hip pain, do not discount a potential dislocation References Zahar A, Rastogi A, Kendoff D. Dislocation after total hip arthroplasty. Curr Rev Musculoskelet Med. 2013;6(4):350-356. doi:10.1007/s12178-013-9187-6 Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD

A heartfelt excerpt from our most recent UnfilterED episode with Dr. Don Stader.

Contributor: Katie Sprinkel, MD Educational Pearls: Hereditary angioedema (HA) is an autosomal dominant bradykinin-mediated disease affecting the airway, skin or gastrointestinal tract and typically presents with swelling in the absence of pruritus HA episodes last 3-5 days, typically occur first in childhood or adolescence, and decrease in frequency with aging Airway angioedema is the most dangerous but least common Skin angioedema is usually uncomfortable and should be monitored if involving the face GI angioedema involves nausea, vomiting, and severe abdominal pain No definitive triggers, but episodes may be preceded by a variable prodrome but can include headache, GI symptoms, and even a rash Treatment can include infusion of a C-1 inhibitor, such as Berinert but it is very expensive References Busse PJ, Christiansen SC. Hereditary Angioedema. N Engl J Med. 2020 Mar 19;382(12):1136-1148. doi: 10.1056/NEJMra1808012. PMID: 32187470. Longhurst HJ, Bork K. Hereditary angioedema: an update on causes, manifestations and treatment. Br J Hosp Med (Lond). 2019 Jul 2;80(7):391-398. doi: 10.12968/hmed.2019.80.7.391. PMID: 31283393. Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD

Contributor: Katie Sprinkel, MD Educational Pearls: Psychogenic Non-Epileptic Seizures (PNES) are due to a psychogenic rather than an epileptic cause Despite common assumption, PNES are not always volitional 20-40% of those with PNES can also have true epileptic seizures 20-40% True diagnosis requires a video EEG Characteristics of PNES include: Waxing and waning of the seizure intensity Eyes clenched shut Pelvic thrusting, rolling from side-to-side Ability to respond to verbal stimuli during the seizure Ability to recall information during the seizure Weeping or stuttering Guarding the face on passive hand drop Characteristics of epileptic seizures: Tongue biting Prolonged postictal state Incontinence Haldol or Zyprexa may be better for PNES and benzodiazepines tend to be better for epileptic seizures References Huff JS, Murr N. Psychogenic Nonepileptic Seizures. 2021 Jan 28. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan–. PMID: 28722901. Asadi-Pooya AA. Psychogenic nonepileptic seizures: a concise review. Neurol Sci. 2017 Jun;38(6):935-940. doi: 10.1007/s10072-017-2887-8. Epub 2017 Mar 8. PMID: 28275874. Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD

High in the mountains of Colorado, a crew of unsuspecting docs stumble upon the EMS scene of a head-on collision after an arduous mountain bike ride. Trauma is a Journey is a four part rural trauma mini series that recounts this tale as this group springs into action to assist the EMS crews dealing with two critical patients. Elizabeth Esty hosts a panel discussion with the key players: Dr. Dylan Luyten, Dr. JP Brewer, Dr. Madison Macht, Dr. Glenda Quan and Jeremiah Grantham as this story unfolds. This final episode explores how addressing psychological and emotional trauma is the final step in a patient's journey once their physical illnesses have been addressed. The group discusses how this can take time and how they support patients through these tough journeys. Dr. Luyten brings everything full circle as he recounts his own story of being a patient in a rural car crash and how that experience affected him and ultimately set him on a path to become an ER physician. This episode also emphasizes the need for healthcare professionals to support each other through debriefs to prevent burnout and remain resilient themselves when providing care. Thank you all for listening!

High in the mountains of Colorado, a crew of unsuspecting docs stumble upon the EMS scene of a head-on collision after an arduous mountain bike ride. Trauma is a Journey is a four part rural trauma mini series that recounts this tale as this group springs into action to assist the EMS crews dealing with two critical patients. Elizabeth Esty hosts a panel discussion with the key players: Dr. Dylan Luyten, Dr. JP Brewer, Dr. Madison Macht, Dr. Glenda Quan and Jeremiah Grantham as this story unfolds. The third episode opens up with an ode to ATLS and how important those training protocols really are to real-world applications like the one in this story. The group segues into discussion of the various opinions on the essentials for emergency first aid supplies you should have on hand. Dr. JP Brewer circles back to the role of teamwork and establishing roles in order to accomplish a successful resuscitation and the others chime in based on their experiences.