Emergency Medical Minute

Contributor: Peter Bakes, MD Educational Pearls: Two main differentials for wide complex tachycardia (WCT) include ventricular tachycardia (most common) and supraventricular tachycardia with aberrancy Brugada syndrome and Wolff-Parkinson White are potential causes Arrhythmogenic right ventricular dysplasia is a rare congenital cause of WCT that should be considered in younger patients presenting with WCT References B Garner J, M Miller J. Wide Complex Tachycardia - Ventricular Tachycardia or Not Ventricular Tachycardia, That Remains the Question. Arrhythm Electrophysiol Rev. 2013;2(1):23-29. doi:10.15420/aer.2013.2.1.23 Katritsis DG, Brugada J. Differential Diagnosis of Wide QRS Tachycardias. Arrhythm Electrophysiol Rev. 2020;9(3):155-160. doi:10.15420/aer.2020.20 Li KHC, Bazoukis G, Liu T, et al. Arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D) in clinical practice. J Arrhythm. 2017;34(1):11-22. Published 2017 Dec 21. doi:10.1002/joa3.12021 Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD

Contributor: Dylan Luyten, MD Educational Pearls: D10 may be a better alternative to D50 in correcting hypoglycemia Risks of D50: Can cause extravasation injury Risk of rebound hypoglycemia D10 does not have the same risks and has no significant difference in reversal time of hypoglycemia compared to D50 References Kiefer MV, Gene Hern H, Alter HJ, Barger JB. Dextrose 10% in the treatment of out-of-hospital hypoglycemia. Prehosp Disaster Med. 2014 Apr;29(2):190-4. doi: 10.1017/S1049023X14000284. Epub 2014 Apr 15. PMID: 24735872. Moore C, Woollard M. Dextrose 10% or 50% in the treatment of hypoglycaemia out of hospital? A randomised controlled trial. Emerg Med J. 2005 Jul;22(7):512-5. doi: 10.1136/emj.2004.020693. PMID: 15983093; PMCID: PMC1726850. 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: Jared Scott, MD Educational Pearls: Pathologic bone fractures occur due to weakened bones from chronic disease and with less force when compared to non-pathologic fractures Can be due to bone tumors, bone cysts, infections (osteomyelitis), osteogenesis imperfecta, Paget's disease of bone, and multiple myeloma Have moth bitten or lytic appearance and you can sometimes see the periosteum peeling away from the bone References Angelini A, Trovarelli G, Berizzi A, Pala E, Breda A, Maraldi M, Ruggieri P. Treatment of pathologic fractures of the proximal femur. Injury. 2018 Nov;49 Suppl 3:S77-S83. doi: 10.1016/j.injury.2018.09.044. PMID: 30415673. Marshall RA, Mandell JC, Weaver MJ, Ferrone M, Sodickson A, Khurana B. Imaging Features and Management of Stress, Atypical, and Pathologic Fractures. Radiographics. 2018 Nov-Dec;38(7):2173-2192. doi: 10.1148/rg.2018180073. PMID: 30422769. Unbreakable Summarized by Jackson Roos, 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.

Contributor: Jared Scott, MD Educational Pearls: Bilirubin is natural breakdown product of red blood cells but can be neurotoxic if levels become too high Fetal red blood cells are fragile and break down easier, leading to higher bilirubin levels in neonates Immature livers and increased intestinal absorption from sterile bowels also contribute to elevated levels and jaundice in all neonates Other risk factors for neonatal jaundice include: temperature instability, poor feeding, hypoxia at birth, and being of East Asian descent Neonatal bilirubin levels are referenced to time since birth using a nomogram to determine the need for light therapy (or exchange transfusion) References Mitra S, Rennie J. Neonatal jaundice: aetiology, diagnosis and treatment. Br J Hosp Med (Lond). 2017 Dec 2;78(12):699-704. doi: 10.12968/hmed.2017.78.12.699. PMID: 29240507. Woodgate P, Jardine LA. Neonatal jaundice: phototherapy. BMJ Clin Evid. 2015 May 22;2015:0319. PMID: 25998618; PMCID: PMC4440981. Colletti JE, Kothari S, Jackson DM, Kilgore KP, Barringer K. An emergency medicine approach to neonatal hyperbilirubinemia. Emerg Med Clin North Am. 2007 Nov;25(4):1117-35, vii. doi: 10.1016/j.emc.2007.07.007. Erratum in: Emerg Med Clin North Am. 2008 Feb;26(1):xi. Kothori, Samip [corrected to Kothari, Samip]. PMID: 17950138. Summarized by Jackson Roos, 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.

Contributor: Cheyenne Bean, PharmD Educational Pearls: Bactrim (TMP-SMX) is a sulfa antibiotic used for a number of infections but can have untoward effects. Hypoglycemia can be induced by the sulfa component of Bactrim, which binds receptors in the pancreas causing insulin to be secreted, dropping blood sugar levels. Oral diabetic medications, specifically sulfonylureas, when taken with Bactrim most often lead to these hypoglycemic episodes. Hyperkalemia can be induced by Trimethoprim by blocking potassium excretion in the kidney, so Bactrim in combination with ACE inhibitors/ARBs/spironolactone can induce high potassium. When prescribing Bactrim, remember to check home medications and if a patient is taking an above medication, check a baseline BGL and potassium. References 1) Khorvash F, Moeinzadeh F, Saffaei A, Hakamifard A. Trimethoprim-sulfamethoxazole Induced Hyponatremia and Hyperkalemia, The Necessity of Electrolyte Follow-up in Every Patient. Iran J Kidney Dis. 2019 Jul;13(4):277-280. PMID: 31422395. 2) Kennedy KE, Teng C, Patek TM, Frei CR. Hypoglycemia Associated with Antibiotics Alone and in Combination with Sulfonylureas and Meglitinides: An Epidemiologic Surveillance Study of the FDA Adverse Event Reporting System (FAERS). Drug Saf. 2020 Apr;43(4):363-369. doi: 10.1007/s40264-019-00901-7. PMID: 31863282; PMCID: PMC7117991. Summarized by Jackson Roos, 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.

Contributor: Gretchen Hinson, MD Educational Pearls: Viruses mutate frequently and a new variant of COVID has been found in the United Kingdom. Mutations typically occur due to transcription errors during virus replication leading to slight changes in the virus which can alter its virulence, and this UK mutation has shown more infectivity. The UK variant was first identified on 9/20/20 and sequenced in October The variant has a mutation of the spike protein with increased receptor binding capacity, making it more efficient at infecting cells Children seem to be more susceptible to this variant as compared to the prior COVID strains. References 1) Tang JW, Tambyah PA, Hui DS. Emergence of a new SARS-CoV-2 variant in the UK. J Infect. 2020 Dec 28:S0163-4453(20)30786-6. doi: 10.1016/j.jinf.2020.12.024. Epub ahead of print. PMID: 33383088. Summarized by Jackson Roos, 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.

Contributor: Peter Bakes, MD Educational Pearls: Hyperacute T waves can occur immediately and typical last less than an hour Hyperacute T waves are typically broader than peaked T-waves, which are associated with hyperkalemia ST elevation which usually starts within an hour of the inciting event and can last up to a few days, and often follows the hyperacute T-waves Q waves can begin at the time ST elevation begins and can remain permanently T waves can invert before normalizing again days later References Levis JT. ECG Diagnosis: Hyperacute T Waves. Perm J. 2015;19(3):79. doi:10.7812/TPP/14-243 Vogel B, Claessen BE, Arnold SV, Chan D, Cohen DJ, Giannitsis E, Gibson CM, Goto S, Katus HA, Kerneis M, Kimura T, Kunadian V, Pinto DS, Shiomi H, Spertus JA, Steg PG, Mehran R. ST-segment elevation myocardial infarction. Nat Rev Dis Primers. 2019 Jun 6;5(1):39. doi: 10.1038/s41572-019-0090-3. PMID: 31171787. Summarized by Jackson Roos, 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.

Contributor: Jared Scott, MD Educational Pearls: EKGs look at different angles, or vectors, of the heart's electrical conduction as it travels through the heart. Knowing how to read these vectors is essential in diagnosing locations of cardiac pathologies Leads II, III, and aVF follow an inferior path, so ST elevation in those leads indicates inferior involvement Major complications more common with inferior STEMIs can include: hypotension which can be made worse by nitroglycerin Severe bradycardia due to SA/AV node involvement Inferior STEMI, barring no hypotension or bradycardia, have better mortality than other types References Warner MJ, Tivakaran VS. Inferior Myocardial Infarction. 2020 Aug 8. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan–. PMID: 29262146. Summarized by Jackson Roos, 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.

Contributor: Peter Bakes, MD Educational Pearls: STEMI criteria is not just 1mm elevation in contiguous leads 1.5 mm in V2-V3 for women 2.0 mm in V2-V3 for men 2.5 mm in V2-V3 for men under 40 Inferior MI typically have ST elevation in leads II, III and aVF Usually inferior MI's show reciprocal changes (ST depression) in the lateral leads. Lateral MI typically elevation in V5, V6, I, and aVL Anterior MI show elevation in leads V1-4 Right sided MIs have mixed pattern, showing elevation in V1-V2 and V4 along with the inferior leads. Right sided MI's are very sensitive to nitrates, especially if they become intubated because this combination can drop pre-load significantly leading to profound hypotension References Akbar H, Foth C, Kahloon RA, et al. Acute ST Elevation Myocardial Infarction. [Updated 2020 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK532281/ Namana V, Gupta SS, Abbasi AA, Raheja H, Shani J, Hollander G. Right ventricular infarction. Cardiovasc Revasc Med. 2018 Jan;19(1 Pt A):43-50. doi: 10.1016/j.carrev.2017.07.009. Epub 2017 Jul 14. PMID: 28822687. Summarized by Jackson Roos, 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.

Contributor: Aaron Lessen, MD Educational Pearls: High flow nasal cannula (HFNC) has become more utilized with COVID pandemic Multiple studies have shown this method improves both oxygenation and ventilation Newer studies have shown the respiratory benefit of HFNC vs normal oxygen in patients suffering from CHF and those with do not intubate orders who are experiencing respiratory distress. Heated high flow is another option to provide ventilator and oxygen support to patients who either do not need or do not want to be intubated References Kang MG, Kim K, Ju S, et al. Clinical efficacy of high-flow oxygen therapy through nasal cannula in patients with acute heart failure . J Thorac Dis. 2019;11(2):410-417. doi:10.21037/jtd.2019.01.51 Peters SG, Holets SR, Gay PC. High-flow nasal cannula therapy in do-not-intubate patients with hypoxemic respiratory distress. Respir Care. 2013 Apr;58(4):597-600. doi: 10.4187/respcare.01887. PMID: 22781059. Sharma S, Danckers M, Sanghavi D, et al. High Flow Nasal Cannula. [Updated 2020 Jul 2]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK526071/ Summarized by Jackson Roos, 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.