Emergency Medical Minute

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 second episode follows the patients as they arrive to St. Vincent, a small critical access hospital in Leadville, the next stop on their journey. Teamwork is the main theme throughout this episode as these doctors work to stabilize these patients and coordinate air transport to definitive care at Level 1 Trauma Center Swedish Medical Center. Dr. Quan goes into detail about the extent of the patients' internal injuries, the role of damage control surgery in their management and how appropriate pre-hospital management is crucial for these critical trauma patients.

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. In this first episode, the scene is set for the arc of this storyline and while the journey of these patients is the primary focus, the doctors involved come to realize that this experience also took them on a journey as they debrief the events following their ride. Tune in for discussion of the pre-hospital management and insightful commentary on the situation as a whole.

Contributor: Samuel Killian, MD Educational Pearls: Anecdotally, when the computer reads a triage EKG as normal it is most often normal One study tested this theory by examining 855 computer-read EKGS (222 of which were read as normal) Two cardiologists reviewed these 222 normal EKGs and only found 13 EKGs that were slightly abnormal with nonspecific abnormalities Two EM physicians then reviewed these EKGs and only one physician on one EKG said they would change the patient's course of care by rooming them faster The study may support eliminating physician review of normal triage EKGs as a safe practice that would decrease physician interruption References Hughes KE, Lewis SM, Katz L, Jones J. Safety of Computer Interpretation of Normal Triage Electrocardiograms. Acad Emerg Med. 2017 Jan;24(1):120-124. doi: 10.1111/acem.13067. PMID: 27519772. Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD

Contributor: Aaron Lessen, MD Educational Pearls: Ivermectin is an antiparasitic medication that has been used for a long time, but has sparked new interest in the past year as a potential treatment for COVID-19 In-vitro studies have shown it decreases how quickly COVID replicates and may make it less likely to adhere to cells Observational studies have found lower rates of COVID-19 infections in areas that provide ivermectin prophylaxis In several studies it was shown that it decreased severity and mortality, though there were significant methodological limitations NIH gave a statement saying there is not enough evidence to support or refute based on current trials and larger more rigorous trials are needed References Caly L, Druce JD, Catton MG, Jans DA, Wagstaff KM. The FDA-approved drug ivermectin inhibits the replication of SARS-CoV-2 in vitro. Antiviral Res. 2020 Jun;178:104787. doi: 10.1016/j.antiviral.2020.104787. Epub 2020 Apr 3. PMID: 32251768; PMCID: PMC7129059. Hellwig MD, Maia A. A COVID-19 prophylaxis? Lower incidence associated with prophylactic administration of ivermectin. Int J Antimicrob Agents. 2021 Jan;57(1):106248. doi: 10.1016/j.ijantimicag.2020.106248. Epub 2020 Nov 28. PMID: 33259913; PMCID: PMC7698683. Rajter JC, Sherman MS, Fatteh N, Vogel F, Sacks J, Rajter JJ. Use of Ivermectin Is Associated With Lower Mortality in Hospitalized Patients With Coronavirus Disease 2019: The Ivermectin in COVID Nineteen Study. Chest. 2021 Jan;159(1):85-92. doi: 10.1016/j.chest.2020.10.009. Epub 2020 Oct 13. PMID: 33065103; PMCID: PMC7550891. Chaccour C, Casellas A, Blanco-Di Matteo A, Pineda I, Fernandez-Montero A, Ruiz-Castillo P, Richardson MA, Rodríguez-Mateos M, Jordán-Iborra C, Brew J, Carmona-Torre F, Giráldez M, Laso E, Gabaldón-Figueira JC, Dobaño C, Moncunill G, Yuste JR, Del Pozo JL, Rabinovich NR, Schöning V, Hammann F, Reina G, Sadaba B, Fernández-Alonso M. The effect of early treatment with ivermectin on viral load, symptoms and humoral response in patients with non-severe COVID-19: A pilot, double-blind, placebo-controlled, randomized clinical trial. EClinicalMedicine. 2021 Feb;32:100720. doi: 10.1016/j.eclinm.2020.100720. Epub 2021 Jan 19. PMID: 33495752; PMCID: PMC7816625. Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD

If you listen to this podcast, then you're probably familiar with our founder and frequent contributor, Dr. Donald Stader, and his fascination with the intersection of Emergency Medicine, opioids and Addiction Medicine. He is board certified in both specialties and is an active clinician in the ED that is constantly working to improve systems of best practice surrounding opioid uses there and in other specialties. In this episode of UnfilterED, Nick touches on these topics briefly before diving much deeper into the evolution of Don's perspectives on life and death in the context of his mother's recent passing due to COVID-19. Tune in to hear Don's unfiltered personal account that can only be described as real, raw and relevant. Time Stamps 1:35 Don introduction 3:00 Opioid epidemic impacted by COVID 10:00 Upcoming Don projects and the role of stories 14:42 Sources of aspirational inspiration 34:07 Mother's death and learning how to die 49:12 Ending on a happier note 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: Erik Verzemnieks, MD Educational Pearls: INR measures the clotting cascade including factors II, VII, IX, and X Coumadin most commonly elevates the INR, and it is used to monitor the anticoagulant's effectiveness Liver failure can cause a similar elevation in the INR due to lack of synthesis of factors II, VII, IX, X An elevated INR in liver failure does not mean that the patient is anticoagulated, at increased risk for bleeding, or is at less risk of forming a clot There is more commonly an increased risk of clot formation due to lack of production of protein C and S, which are natural anticoagulants Lack of production of proteins C and S have a larger effect and lead to typically a net clotting risk Levels of these can be indirectly measured through albumin Portal venous thrombosis is one of the most common examples of this phenomenon References Harrison MF. The Misunderstood Coagulopathy of Liver Disease: A Review for the Acute Setting. West J Emerg Med. 2018;19(5):863-871. doi:10.5811/westjem.2018.7.37893 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: When evaluating a thunderclap headache, don't forget RCVS! RCVS: reversible cerebral vasoconstriction syndrome Due to reversible spasms of cerebral blood vessels Can sometimes be seen on CTA or MRA, but often the imaging is normal and formal angiograms only occasionally show it It can be caused by medications, intense physical activity, orgasm, and postpartum conditions, but the exact etiology is unknown Typically seen in females in their 40s Can result in bleeding, strokes, and seizures There is no good treatment, but stopping the suspected offending agent may help References Sattar A, Manousakis G, Jensen MB. Systematic review of reversible cerebral vasoconstriction syndrome. Expert Rev Cardiovasc Ther. 2010;8(10):1417-1421. doi:10.1586/erc.10.124 Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD

Contributor: Peter Bakes, MD Educational Pearls: Necrotizing Enterocolitis (NEC) Presents in the first few days of life (often in the NICU) to 3 weeks old Risk factors include prematurity, excess feeding, neonatal sepsis Pneumatosis Intestinalisis on abdominal xray caused by bacterial translocation into the bowel wall Treated with NG tube, bowel rest and surgical resection Other causes of pediatric abdominal pain Malrotation with volvulus Malrotation is caused by failure of intestinal rotation in the 8th-12th week of development Presents with bilious vomiting, which is a surgical emergency in a neonate 90% of cases present in the first year of life, with most of these presenting in the first month Diagnosed with an upper GI series Pyloric Stenosis Typically in males Diagnosed with abdominal ultrasound and treated surgically Intussusception Typically presents between 2 months and 2 years with a palpable mass in the RUQ Diagnosed with abdominal ultrasound Duodenal atresia Congenital stricture in the duodenum Presents with bilious vomiting and a double-bubble on abdominal xray References Alwan R, Drake M, Gurria Juarez J, Emery KH, Shaaban AF, Szabo S, Sobolewski B. A Newborn With Abdominal Pain. Pediatrics. 2017 Nov;140(5):e20164267. doi: 10.1542/peds.2016-4267. PMID: 29042421. Hostetler MA, Schulman M. Necrotizing enterocolitis presenting in the Emergency Department: case report and review of differential considerations for vomiting in the neonate. J Emerg Med. 2001 Aug;21(2):165-70. doi: 10.1016/s0736-4679(01)00371-7. PMID: 11489407. Summarized by John Spartz, MS3

Contributor: Aaron Lessen, MD Educational Pearls: Meta-analysis of 57,420 COVID+ patients evaluated mortality after intubation 45% mortality rate for all patients in the study 84.4% mortality in patients over 80 years old POSITIONED Trail assessed need for intubation in patients awake self-proning compared to not Risk of intubation and mortality was lower for those self-proning 0.3 hazard ratio for intubation in those self-proning References Lim ZJ, Subramaniam A, Ponnapa Reddy M, et al. Case Fatality Rates for Patients with COVID-19 Requiring Invasive Mechanical Ventilation. A Meta-analysis. Am J Respir Crit Care Med. 2021;203(1):54-66. doi:10.1164/rccm.202006-2405OC Jagan N, Morrow LE, Walters RW, Klein LP, Wallen TJ, Chung J, Plambeck RW. The POSITIONED Study: Prone Positioning in Nonventilated Coronavirus Disease 2019 Patients-A Retrospective Analysis. Crit Care Explor. 2020 Oct 1;2(10):e0229. doi: 10.1097/CCE.0000000000000229. PMID: 33063033; PMCID: PMC7531752. Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD

Contributor: Jared Scott, MD Educational Pearls: Differential Diagnosis: non-accidental trauma, febrile seizure, meningitis, hyponatremia, epilepsy Convulsions with gastroenteritis is a known entity to cause seizures in infancy Predominantly occurs in ages 6 months to 3 years Occur with diarrheal episodes No electrolyte abnormalities associated with the seizure nor severe dehydration Seizures tend to come in clusters Most have a normal EEG and do not develop epilepsy Reported incidence in gastroenteritis of 1-2% of gastroenteritis Treatment addresses the seizures but long term anti-epileptic drugs are typically not needed References Kang B, Kwon YS. Benign convulsion with mild gastroenteritis. Korean J Pediatr. 2014;57(7):304-309. doi:10.3345/kjp.2014.57.7.304 Ma X, Luan S, Zhao Y, Lv X, Zhang R. Clinical characteristics and follow-up of benign convulsions with mild gastroenteritis among children. Medicine (Baltimore). 2019;98(2):e14082. doi:10.1097/MD.0000000000014082 Image credit: Kurt Christensen Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD