Emergency Medical Minute

Contributor: Nick Tsipis, MD Educational Pearls: Epinephrine: alpha-1, alpha-2, beta-1, and beta 2 agonist - used in cardiac arrest with positive effects on ROSC in prehospital and peri-hopsital setting Norepinephrine: alpha-1 and beta-1 agonist - used in septic shock to increase cardiac output and peripheral vasoconstriction Phenylephrine: alpha-1 adrenergic agonist - used in spinal/neurogenic shock as well as medication-induced peri-procedural hypotension (propofol for RSI) as it only helps with vasoconstriction Dopamine: alpha-1, alpha-2, beta-1, beta 2, and dopamine agonist - used for sepsis in the past, but not recommended due to dysrhythmias Vasopressin: V1 agonist (vasoconstricts) - used when maxed out of norepinephrine for septic shock Milrenone: phosphodiesterase inhibitor - used in heart failure to drop preload and afterload Dobutamine: beta-2 (with minimal beta-1) adrenergic agonist - used in heart failure and cardiogenic shock to reduce afterload References Shields SH, Holland RM. Pharmacology of Vasopressors and Inotropes. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 7e. McGraw-Hill; Accessed February 14, 2021. Episode 31 - Vasopressors. FOAMcast: An Emergency Medicine Podcast. 25 July 2015. https://foamcast.org/tag/vasopressors/ Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD

Contributor: Jared Scott, MD Educational Pearls: Small capsule pacemaker (2.5 cm, 1 ml volume) resides in the heart without any associated wires or leads like a traditional pacemaker The new version has a 6 year battery life, after which it can be deactivated and a traditional pacemaker put in place Cost is around 2-4 times that of a traditional pacemaker NEJM study from 2015 showed it met the primary efficacy endpoint in 90% of patients and the primary safety endpoint in 93.3% of patients Follow up study showed 3% complication with the intracardiac pacemaker compared to 9% in traditional References Groner, Ashley PA-C; Grippe, Kristen PA-C The leadless pacemaker, Journal of the American Academy of Physician Assistants: June 2019 - Volume 32 - Issue 6 - p 48-50 doi: 10.1097/01.JAA.0000554750.85170.d4 Reddy VY, Exner DV, Cantillon DJ, Doshi R, Bunch TJ, Tomassoni GF, Friedman PA, Estes NA 3rd, Ip J, Niazi I, Plunkitt K, Banker R, Porterfield J, Ip JE, Dukkipati SR; LEADLESS II Study Investigators. Percutaneous Implantation of an Entirely Intracardiac Leadless Pacemaker. N Engl J Med. 2015 Sep 17;373(12):1125-35. doi: 10.1056/NEJMoa1507192. Epub 2015 Aug 30. PMID: 26321198. Chan KH, McGrady M, Wilcox I. A Leadless Intracardiac Transcatheter Pacing System. N Engl J Med. 2016 Jun 30;374(26):2604. doi: 10.1056/NEJMc1604852. PMID: 27355553. Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD

Contributor: Peter Bakes , MD Educational Pearls: Pediatric Fever + Rash Differential: scarlet fever, measles, rubella, chicken pox, fifth's disease, HHV-6, adenovirus, anaphylaxis, Kawasaki's disease Kawasaki's is diagnosed clinically with prolonged fever (>7 days fever in 5 days of fever >6 months with 4 of the following: Strawberry tongue/fissured lips Bilateral conjunctival injection Cervical lymphadenopathy Hand/foot edema Maculopapular rash Can develop life threatening coronary artery aneurysms Treated with aspirin/IVIG References Modesti AM, Plewa MC. Kawasaki Disease. [Updated 2020 Jul 2]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK537163/?report=classic Ramphul K, Mejias SG. Kawasaki disease: a comprehensive review. Arch Med Sci Atheroscler Dis. 2018;3:e41-e45. Published 2018 Mar 21. doi:10.5114/amsad.2018.74522 Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD

Contributor: Rachael Duncan, PharmD BCPS Educational Pearls: According to the Department of Public Health and Environment who puts out a weekly report on the influenza virus in Colorado, there appears to be less influenza in Colorado than previous years A milder influenza outbreak is likely due to mask wearing and social distancing practices There have only been 22 hospitalizations for influenza in Colorado since the start of the flu season back in September and 0 outbreaks in long-term care facilities Xofluza (baloxavir marboxil) is an antiviral PA endonuclease inhibitor and was approved by the FDA in 2018 for uncomplicated influenza in patients 12 years and older that have been symptomatic for less than 48 hours Patient's getting Xofluza must be otherwise healthy or at risk of developing influenza-related complications Due to limited data, Xofluza would not be a good option for those that are inpatient or critically ill and is best utilized for patients who are being seen in the emergency department and will be sent home Currently Xofluza is not approved for complicated patients, pregnant patients or those that are breast-feeding which limits its use When compared with Tamiflu in phase 3 studies, Xofluza was superior to placebo and similar to Tamiflu in shortening the duration of illness Xofluza is a single dose that is weight based and appears to be very well tolerated with some adverse effects including headache, nausea and diarrhea Xofluza showed a quicker recovery compared to Tamiflu by 8 hours which could be related to its one-time dosing Cost is a limiting factor for the use of Xofluza. Tamiflu costs around $25 where as Xofluza (only available as brand name currently) is $156 at the cheapest Pharmacists are still encouraging everyone to get their influenza vaccines despite less influenza cases this year References: Cdphe.colorado.gov. 2021. Influenza (flu) | Department of Public Health & Environment. [online] Available at: [Accessed 11 February 2021]. Ison, M., Portsmouth, S., Yoshida, Y., Shishido, T., Mitchener, M., Tsuchiya, K., Uehara, T. and Hayden, F., 2020. Early treatment with baloxavir marboxil in high-risk adolescent and adult outpatients with uncomplicated influenza (CAPSTONE-2): a randomised, placebo-controlled, phase 3 trial. The Lancet Infectious Diseases, 20(10), pp.1204-1214. Hayden, F., Sugaya, N., Hirotsu, N., Lee, N., de Jong, M., Hurt, A., Ishida, T., Sekino, H., Yamada, K., Portsmouth, S., Kawaguchi, K., Shishido, T., Arai, M., Tsuchiya, K., Uehara, T. and Watanabe, A., 2018. Baloxavir Marboxil for Uncomplicated Influenza in Adults and Adolescents. New England Journal of Medicine, 379(10), pp.913-923. Summarized by Emily Mack OMSIII 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.

This episode of Mental Health Monthly we will be discussing drugs screens in the Emergency Department with Dr. Justin Romano and Eddie Carillo. Dr. Justin Romano is a current psychiatry resident and Eddie Carillo is a licensed mental health therapist. Check out their podcast Millennial Mental Health Channel on all major podcast platforms. Shout out to Dr. Dave Marshall whose grand round presentation this was based on. Key Points: Try not to judge your patient based on the results of their drug screen Drug screens are used a lot; they are not always accurate Based on one study there was no significant change in outcome, treatment, disposition or psychiatric course when a drug screen was obtained Specific good uses for drug screens include new onset of psychiatric symptoms Educational Pearls: 1 in 8 ED visits are due to psychiatric complaints which is up 44% since mid 2000's 63% of new psychiatric complaints had a medical cause Physicians use drug screens commonly in the Emergency Department, but often do not understand their limitations and are often not using them in the most clinically effective manner Urine is by far the most commonly used in the Emergency Department UA drug screens are notorious for having false positives and false negatives Length of clearance from the urine: Alcohol 12 hours Methamphetamines/Amphetamines 48 hours Benzodiazepines 3 days Opiates 2-3 days Cocaine 2-4 days Marijuana dependent on use: 3- 15 days Phencyclidine (PCP) 8 days Urine drug screens have a false positive rate of 5-10 % and a false negative rate of 10-15% False Positive; urine drug screen positive, but drug is not in their body False positives for amphetamines: bupropion, trazodone, metformin, promethazine, pseudoephedrine, phentermine and atomoxetine False positives for benzodiazepines: sertraline False positives for cannabis: ibuprofen, naproxen, proton pump inhibitors False positives for opiates: poppy seeds, antibiotics, Benadryl False positives for PCP: venlafaxine, ibuprofen and Ambien False positives for cocaine: amoxicillin False Negative; urine drug screen negative, but drug is in the body Benzodiazepines: such as alprazolam, clonazepam, lorazepam or triazolam Cannabinoids: CBD, synthetic marijuana such as K2 Opiates: oxycodone, fentanyl, methadone and tramadol If you get a test that you don't think is accurate you can always send off for a confirmatory test References Summarized by Emily Mack OMSIII | Edited by Mason Tuttle 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: Retrospective review of 5,021 patients over 65 with 2 or more rib fractures recently published 3577 (78 %) were admitted to non-ICU setting 1.1% of these patients had unexpected intubation or ICU transfer Findings raise questions regarding current guidelines for ICU admission in elderly patients with isolated rib fractures References Naar L, El Hechi MW, van Erp IA, Mashbari HNA, Fawley J, Parks JJ, Fagenholz PJ, King DR, Mendoza AE, Velmahos GC, Kaafarani HMA, Saillant NN. Isolated rib cage fractures in the elderly: Do all patients belong to the intensive care unit? A retrospective nationwide analysis. J Trauma Acute Care Surg. 2020 Dec;89(6):1039-1045. doi: 10.1097/TA.0000000000002891. PMID: 32697447. Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD

Contributor: Aaron Lessen, MD Educational Pearls: Pyogenic liver abscesses can be caused by Intra-abdominal infection progressing to peritonitis which then drains into liver Bacteremia leading to hematogenous spead and seeding Local biliary infection with contiguous spread Patients typically present with signs of sepsis or septic shock and the abscess can be diagnosed using ultrasound or CT Treat with IV fluids, broad spectrum antibiotics, and consultation for drainage References Kurland JE, Brann OS. Pyogenic and amebic liver abscesses. Curr Gastroenterol Rep. 2004 Aug;6(4):273-9. doi: 10.1007/s11894-004-0078-2. PMID: 15245694. Rahimian J, Wilson T, Oram V, Holzman RS. Pyogenic liver abscess: recent trends in etiology and mortality. Clin Infect Dis. 2004 Dec 1;39(11):1654-9. doi: 10.1086/425616. Epub 2004 Nov 9. PMID: 15578367. Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD

Contributor: Katie Sprinkel, MD Educational Pearls: Commonly known as "acid," LSD is seeing a resurgence in the population as a recreational hallucination Onset is about 30 minutes with peak pharmacologic effects at 2-4 hours, the drug's half life is 3 hours resulting in some prolonged effects While there is not an significant addictive component of LSD, tolerance for LSD does occur and prolonged usage is associated with increased incidence of schizophreniform disorders Hallucinations and pseudo-hallucinations (sensory misperceptions) are typical of LSD intoxication, other common signs of intoxication include nausea, diaphoresis, tachycardia, mydriasis, and hypertension More serious effects can be coma, hyperthermia, seizures, cardiac arrest, serotonin syndrome (with concomitant SSRI use) and coagulopathy, although the dose to cause these effects is very high Treatment is decreasing sensory stimulation, benzodiazepines in some cases, and symptomatic treatment - no specific antidote exists References Blaho K, Merigian K, Winbery S, Geraci SA, Smartt C. Clinical pharmacology of lysergic acid diethylamide: case reports and review of the treatment of intoxication. Am J Ther. 1997 May-Jun;4(5-6):211-21. doi: 10.1097/00045391-199705000-00008. PMID: 10423613. Klock JC, Boerner U, Becker CE. Coma, hyperthermia and bleeding associated with massive LSD overdose. A report of eight cases. West J Med. 1974;120(3):183-188. Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD

Contributor: Sam Killian, MD Educational Pearls: iliac vein compression syndrome is also called May-Thurner Syndrome The left leg more frequently develops deep venous thrombosis (DVT) in part because about 1/4 of the population has May-Thurner May-Thurner syndrome anatomic variant results in a right iliac artery compresses the left iliac vein against the spine, which can promote DVT formation This is thought to be the cause of 2-3% of DVTs in patients seen in the ED and suspicion for this disease should increased in those with recurrent DVT Diagnosis is made with MRV/MRA and will typically not be seen on duplex ultrasound Typical anticoagulation treatment fails to address the underlying structural cause References Demir MC, Kucur D, Çakır E, Aksu NM, Onur MR, Sabuncu T, Akkaş M. May-Thurner syndrome: A curious syndrome in the ED. Am J Emerg Med. 2016 Sep;34(9):1920.e1-3. doi: 10.1016/j.ajem.2016.02.045. Epub 2016 Feb 19. PMID: 26971822. Sharafi S, Farsad K. Variant May-Thurner syndrome: Compression of the left common iliac vein by the ipsilateral internal iliac artery. Radiol Case Rep. 2018;13(2):419-423. Published 2018 Feb 20. doi:10.1016/j.radcr.2018.01.001 Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD

Educational Pearls: Atropine has been shown to reduce hypersalivation as well as nausea and vomiting induced by ketamine sedation. Atropine can increase the occurrence of a transient rash, as well as tachycardia. There are no guidelines that recommend for or against atropine use in pediatric patients undergoing ketamine induced sedation. Ultimately, it is the providers decision to include atropine when performing ketamine sedation. Pediatric dosing for atropine is 0.01mg/kg IM. References Heinz P, Geelhoed GC, Wee C, Pascoe EM. Is atropine needed with ketamine sedation? A prospective, randomised, double blind study. Emerg Med J. 2006 Mar;23(3):206-9. doi: 10.1136/emj.2005.028969. PMID: 16498158; PMCID: PMC2464444. Chong JH, Chew SP, Ang AS. Is prophylactic atropine necessary during ketamine sedation in children? J Paediatr Child Health. 2013 Apr;49(4):309-12. doi: 10.1111/jpc.12149. Epub 2013 Mar 15. PMID: 23495827. Shi J, Li A, Wei Z, Liu Y, Xing C, Shi H, Ding H, Pan D, Ning G, Feng S. Ketamine versus ketamine pluses atropine for pediatric sedation: A meta-analysis. Am J Emerg Med. 2018 Jul;36(7):1280-1286. doi: 10.1016/j.ajem.2018.04.010. Epub 2018 Apr 5. PMID: 29656945. Presented and Summarized by Devan Naughton, 4th year pharmacy student | Edited by Ruben Marrero-Vasquez