Emergency Medical Minute

Contributor: Ruben Marrero-Vasquez, PharmD Educational Pearls: ACEP and FDA have both issued warnings about the viral Tik Tok Benadryl (diphenhydramine) challenge where individuals voluntarily overdose on diphenhydramine which can cause fatal toxicity Diphenhydramine is typically dosed at 0.5-1 mg/kg in pediatric patients Q4-6 PRN and carries a fatal dose of 20-40 mg/kg but anywhere from 3-5x recommended dose does can cause toxicity Diphenhydramine toxicity causes both central and peripheral anticholinergic toxicity Central anticholinergic toxicity symptoms: delirium, agitation, combativeness, confusion, restlessness, hallucinations, ataxia, tremor and seizures Peripheral anticholinergic toxicity symptoms: tachycardia, dry flushed skin, dry mucus membranes, thick secretions, dilation of pupils, urinary retention, and decreased bowel sounds Pneumatic to help you remember anticholinergic toxidrome: Red as a beet Dry as a bone Blind as a bat Mad as a hatter Hot as a hare Full as a flask Management typically only requires supportive care, agitation from central anticholinergic delirium can be hardest aspect to treat, IV benzodiapines are first line treatment to control and may require large doses to prevent rhabdomyolysis and hyperthermia Diphenhydramine toxicity has been associated with blockade of sodium and potentially potassium channels increasing risk of arrhythmia and seizures. Cardiac changes can include: QRS widening, myocardial depression, QT prolongation and torasades-type ventricular tachycardia. Wide QRS complexes indicate delayed ventricular depolarization caused by sodium channel blockade, bolus of sodium bicarbonate can be used dosed 1-2 mEq/kg followed by continuous infusion Prolonged QT: restoration of low serum potassium and magnesium to high normal range Benzodiazipines should be used as first line therapy for toxin induced seizures Don't use fosphenytoin or phenytoin sodium channel blockers as they can worsen cardiac conduction References Olson KR, Anderson IB, Benowitz NL, Blanc PD, Clark RF, Kearney TE, Kim-Katz SY, Wu AH. Diphenhydramine. In: Poisoning & Drug Overdose. 7th ed.McGraw Hll; 2018: 544-545. FDA Warns About Serious Problems With High Doses Of The Allergy Medicine Diphenhydramine (Benadryl).(09/24/2020). CDC website. Accessed December 01, 2020. https://www.fda.gov/drugs/drug-safety-and-availability/fda-warns-about-serious-problems-high-doses-allergy-medicine-diphenhydramine-benadryl. Su M, Goldman M. Anticholinergic Poisoning. UpToDate. https://www.uptodate.com/contents/anticholinergic-poisoning?search=diphenhydramine overdose&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1. Published October 6, 2020. Accessed December 26, 2020. Summarized by Mason Tuttle

EMM is excited to welcome back the hosts of Millennial Mental Health Channel podcast to explain the key points of a robust suicide assessment in the ED. Dr. Justin Romano is a third year psychiatry resident in Omaha, Nebraska and Eddie Carrillo is a licensed mental health therapist currently working at partial hospitalization and IOP eating disorder program in Portland, Oregon. Their podcast Millennial Mental Health Channel seeks to explore the world of mental health from their two professional perspectives. You can listen to their podcast on all major streaming platforms including Apple Podcasts, Spotify and Google Podcasts. Follow them on Twitter and Instagram @millennialmhc Contributors: Dr. Justin Romano and Eddie Carrillo, M.A., LPC Educational Pearls: Suicide is 10th most common cause in U.S. and the rate rose by 30% from 2000-2016 and the CDC reports that there was a 25% increase in ED visits for SI from January 2017 - December 2018 Use an objective screening tool like Columbia-Suicide Severity Rating Scale (C-SSRS) when assessing patients as they can help detect SI although ultimately it is up to your clinical impression to make a decision Suicide reduction measures and strategies work! Take advantage of social workers when setting up outpatient resources for patients i.e. gun locks Risk Factors include: prior attempts, substance use/abuse, mental disorders (especially depression and bipolar disorder), access to lethal means (most modifiable by risk reduction strategies), knowing someone who has died by suicide, social isolation, chronic disease or disability, lack of access to mental health resources, recent changes in social status and being a member of a high risk demographic (older caucasian men, LGBTQ+, Native Americans and Alaskan Natives) Protective Factors include: good followup as an outpatient, good social support, life skills, purpose in life, cultural beliefs, children and sense of responsibility in the family Sober up and reassess suicidality If not medically cleared, admit to hospital to address these complaints and then address suicidality If they have suicidal thoughts, plan and are reaching out for help because they don't want to do it then send to inpatient facility Consult psychiatry to explain inpatient psych or when you're worried about patient safety to have them weigh in Get collateral by talking to a family member to verify that the patient is telling the truth At the end of the day, thorough documentation of risk and protective factors and results of screening tool in Assessment and Plan is essential to protecting yourself as a professional References Betz ME, Boudreaux ED. Managing Suicidal Patients in the Emergency Department. Ann Emerg Med. 2016;67(2):276-282. doi:10.1016/j.annemergmed.2015.09.001 Suicide. National Institute of Mental Health. https://www.nimh.nih.gov/health/statistics/suicide.shtml. Published September 2020. Accessed December 30, 2020. Zwald ML, Holland KM, Annor FB, et al. Syndromic Surveillance of Suicidal Ideation and Self-Directed Violence — United States, January 2017–December 2018. MMWR Morb Mortal Wkly Rep 2020;69:103–108. DOI: http://dx.doi.org/10.15585/mmwr.mm6904a3. Summarized by Mason Tuttle

Educational Pearls: The CDC has made new formal recommendations for treating Gonorrhea due to increasing resistance to Rocephin and Azithromycin. New recommendations: Confirmed gonorrhea: Ceftriaxone 500 mg once Empiric treatment: Ceftriaxone 500 mg once followed by 7 days Doxycycline 100 mg BID No longer using Azithromycin due to high resistance Second line: Gentamycin IM Cefixime 800 mg oral Pharyngeal involvement has high resistance rates to second line agents and ceftriaxone is strongly preferred References St. Cyr S, Barbee L, Workowski KA, et al. Update to CDC's Treatment Guidelines for Gonococcal Infection, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1911–1916. DOI: http://dx.doi.org/10.15585/mmwr.mm6950a6. 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: Tom Seibert, MD Educational Pearls: High altitude cerebral edema (HACE) is the end stage of acute mountain sickness and is diagnosed when patients develop neurologic dysfunction, ataxia, and altered mental status. The pathophysiology of HACE is thought to be due to increased cerebral blood flow and increased capillary permeability causing vasogenic edema and brain swelling HACE is linked to extreme altitude Rapid descent should be done as soon as possible for this potentially fatal condition Oxygen can be supportive Dexamethasone is also typically indicated (8mg initially followed by 4 mg every 6 hours) Editor's note: HACE can occur at altitudes as low as 8000 feet so don't automatically assume it can't/doesn't happen in the US References Jensen JD, Vincent AL. High Altitude Cerebral Edema. 2020 Aug 26. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan–. PMID: 28613666. Hackett PH, Yarnell PR, Weiland DA, Reynard KB. Acute and Evolving MRI of High-Altitude Cerebral Edema: Microbleeds, Edema, and Pathophysiology. AJNR Am J Neuroradiol. 2019 Mar;40(3):464-469. doi: 10.3174/ajnr.A5897. Epub 2019 Jan 24. PMID: 30679208; PMCID: PMC7028681. 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: Don Stader, MD Educational Pearls: Time can be an important factor in outcomes regarding sepsis including mortality Emphasis has grown on early administration of antibiotics and IV fluids in sepsis However, early initiation of vasopressors for hypotensive patients may have significant mortality benefit as well References Hayden GE, Tuuri RE, Scott R, et al. Triage sepsis alert and sepsis protocol lower times to fluids and antibiotics in the ED. Am J Emerg Med. 2016;34(1):1-9. doi:10.1016/j.ajem.2015.08.039 Colling KP, Banton KL, Beilman GJ. Vasopressors in Sepsis. Surg Infect (Larchmt). 2018;19(2):202-207. doi:10.1089/sur.2017.255 Colon Hidalgo D, Patel J, Masic D, Park D, Rech MA. Delayed vasopressor initiation is associated with increased mortality in patients with septic shock. J Crit Care. 2020 Feb;55:145-148. doi: 10.1016/j.jcrc.2019.11.004. Epub 2019 Nov 9. PMID: 31731173. 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: Tom Seibert, MD Educational Pearls: Acute Mountain sickness (AMS) can cause headache along with fatigue, nausea, vomiting, insomnia Typically occurs above 6500 feet (not 65,000) in elevation Acclimation to altitude can help prevent symptoms if not treated, AMS can advance to severe illness involving cerebral or pulmonary edema. Mild symptoms can be managed with rest but more severe symptoms will require descent, oxygen, acetazolamide and steroids Acetazolamide can be used as both a preventative and therapeutic drug References Davis C, Hackett P. Advances in the Prevention and Treatment of High Altitude Illness. Emerg Med Clin North Am. 2017 May;35(2):241-260. doi: 10.1016/j.emc.2017.01.002. PMID: 28411926. 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: Thomas Seibert, MD Educational Pearls: High Altitude Pulmonary Edema (HAPE) typically occurs 2-4 days after arriving at elevation Symptoms include: Fatigue Dyspnea Cough Treatment includes: Descent to lower elevation Oxygen supplementation Nifedipine Caused by sympathetic stimulation from hypobaric hypoxic exposure, causing uneven pulmonary vasculature constriction and when paired with a leaky endothelium, pulmonary edema. #science References Swenson ER, Bärtsch P. High-altitude pulmonary edema. Compr Physiol. 2012 Oct;2(4):2753-73. doi: 10.1002/cphy.c100029. PMID: 23720264. Johnson NJ, Luks AM. High-Altitude Medicine. Med Clin North Am. 2016 Mar;100(2):357-69. doi: 10.1016/j.mcna.2015.09.002. PMID: 26900119. Hultgren HN. High-altitude pulmonary edema: current concepts. Annu Rev Med. 1996;47:267-84. doi: 10.1146/annurev.med.47.1.267. PMID: 8712781. Summarized by Jackson Roos, MSIV | 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.

Discussion on pediatric psychosis, including the prodrome of schizophrenia, negative and positive symptoms, and the importance of considering alternative causes for sudden psychiatric changes in children

Contributors: Rachael Duncan, PharmD and Sean McCullough, PharmD Educational Pearls: A 2019 Report by the National Women's Law Center: Most common occupations for pregnant workers are elementary and middle school teachers, registered nurses, and nursing/psychiatric/home health care aides. This raises the question: Should pregnant women, specifically front-line workers, get the Covid-19 vaccine? According to the FDA, there is currently not enough data to make a conclusion about the safety of the newly approved Pfizer vaccine for populations that include children less than 16, pregnant and lactating women, and those that are immunocompromised. Specifically, pregnant women were excluded from the clinical trials testing the Pfizer vaccine. According to the CDC, additional data needs to be reviewed from the phase III clinical trials in order to provide recommendations to pregnant and breast-feeding women about taking the Covid-19 vaccine and its safety. An Advisory Committee of Immunization Practices (ACIP) meeting will take place on 12/13/2020 and will hopefully provide formal recommendations to pregnant and lactating women. The Society for Maternal-Fetal Medicine (SMFM) has consistently advocated for the inclusion of pregnant and lactating women into clinical trials when these criteria are met: 1) pregnancy poses increased susceptibility to or severity of a disease; 2) the best approach to protect the infant is through passive placental antibody transfer, which provides the most efficient and direct protection to the newborn before an infant can be vaccinated, and 3) there is an active outbreak. SMFM recommends healthcare workers who are currently being prioritized to receive the vaccine to also receive the vaccine if pregnant. Pregnant healthcare workers should take their individual situation into consideration and weigh the risks and benefits for themselves and the risk for detecting disease when considering if or when to take the Covid-19 vaccine. References ACIP Meeting Agenda December 13, 2020 - cdc.gov. MEETING OF THE ADVISORY COMMITTEE ON IMMUNIZATION PRACTICES (ACIP). https://www.cdc.gov/vaccines/acip/meetings/downloads/agenda-archive/agenda-2020-12-11.pdf. Published 2020. Accessed December 11, 2020. Coronavirus (COVID-19), Pregnancy, and Breastfeeding: A Message for Patients. ACOG. https://www.acog.org/womens-health/faqs/coronavirus-covid-19-pregnancy-and-breastfeeding. Published 2020. Accessed December 11, 2020. Interim Considerations for COVID-19 Vaccination of Healthcare Personnel and Long-Term Care Facility Residents. Centers for Disease Control and Prevention. https://www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/covid-19/clinical-considerations.html. Published December 3, 2020. Accessed December 11, 2020. Society for Maternal-Fetal Medicine (SMFM) Statement: SARS-CoV-2 Vaccination in Pregnancy. December 2020. https://s3.amazonaws.com/cdn.smfm.org/media/2591/SMFM_Vaccine_Statement_12-1-20_(final).pdf Vaccines and Related Biological Products Advisory Committee Meeting December 10, 2020. 2020. https://www.fda.gov/media/144245/download VRBPAC December 10, 2020 Meeting Announcement. U.S. Food and Drug Administration. https://www.fda.gov/advisory-committees/advisory-committee-calendar/vaccines-and-related-biological-products-advisory-committee-december-10-2020-meeting-announcement. Published December 10, 2020. Accessed December 11, 2020. Summarized by Emily Mack OMSIII | Edited by Rachael Duncan, PharmD

Contributor: Aaron Lessen, MD Educational Pearls: Serum prolactin levels can be used to help differentiate epileptic seizures from non-epileptic seizures It is also released and elevated after epileptic seizures but not non-epileptic seizures A level must be checked 10-20 minutes after the episode and if possible a next day level should be checked to establish a baseline Levels can also be raised after a syncopal event Not the most useful ED also due to the long turn around time EEG will remain superior for now References Nass RD, Sassen R, Elger CE, Surges R. The role of postictal laboratory blood analyses in the diagnosis and prognosis of seizures. Seizure. 2017 Apr;47:51-65. doi: 10.1016/j.seizure.2017.02.013. Epub 2017 Feb 27. PMID: 28288363. Chen DK, So YT, Fisher RS; Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Use of serum prolactin in diagnosing epileptic seizures: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology. 2005 Sep 13;65(5):668-75. doi: 10.1212/01.wnl.0000178391.96957.d0. PMID: 16157897. 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.