Emergency Medical Minute

Contributor: Sam Killian, MD Educational Pearls: One study found that patients presented with headaches more frequently when there was high temperatures and low humidity, while higher humidity is correlated to lower incidence of headache. Moon phases had no effect on headache frequency. A Canadian study looking at over 100,000 ED visits for headaches found increased incidence of headaches when there were higher levels of air pollution/particulates, like smoke. References Yilmaz M, Gurger M, Atescelik M, Yildiz M, Gurbuz S. Meteorologic parameters and migraine headache: ED study. Am J Emerg Med. 2015;33(3):409-413. doi:10.1016/j.ajem.2014.12.056 Szyszkowicz M, Stieb DM, Rowe BH. Air pollution and daily ED visits for migraine and headache in Edmonton, Canada. Am J Emerg Med. 2009;27(4):391-396. doi:10.1016/j.ajem.2008.03.013 Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

Dr. Christine Darr, a Pediatric Emergency Medicine Physician with extensive experience in treating young patients, shares her expertise on pediatric trauma. She discusses the unique anatomical and physiological considerations for children, emphasizing tailored management approaches. Growth plate injuries and the complexities of diagnosing serious trauma without obvious signs are explored. Darr also addresses recognizing abuse in young patients and differentiating it from conditions that mimic trauma, such as arthritis, providing crucial insights for medical professionals.

Contributor: Aaron Lessen, MD Educational Pearls: Traditional teaching has shied away from using vasopressors through peripheral IVs Tissue necrosis from extravasation is cited as a risk of use of vasopressors through a peripheral site However, risk of extravasation is low (2-4%) and even more rarely results in significant complications Using an IV that is more proximal and larger bore with monitoring can further minimize these risks Starting with peripheral vasopressors in a critically ill patient appears to be without significant increased cutaneous complications compared to using a central line alone References Loubani OM, Green RS. A systematic review of extravasation and local tissue injury from administration of vasopressors through peripheral intravenous catheters and central venous catheters. J Crit Care. 2015;30(3):653.e9-653.e6.53E17. doi:10.1016/j.jcrc.2015.01.014 Cardenas-Garcia J, Schaub KF, Belchikov YG, Narasimhan M, Koenig SJ, Mayo PH. Safety of peripheral intravenous administration of vasoactive medication. J Hosp Med. 2015;10(9):581-585. doi:10.1002/jhm.2394 Lewis T, Merchan C, Altshuler D, Papadopoulos J. Safety of the Peripheral Administration of Vasopressor Agents. J Intensive Care Med. 2019;34(1):26-33. doi:10.1177/0885066616686035 Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

Contributor: Don Stader, MD Educational Pearls: On average, smoking reduces life expectancy by 13.2 years for men and for 14.5 years for women Nicotine is highly addictive and has both stimulant and calming effects Having a newborn can be a strong motivator to quit so take advantage and educate new (or expecting) parents to the risks of smoking and benefits of quitting Smoking has been associated with sudden infant death Biggest predictor of children smoking is seeing their parents smoking Side effects of smoking that can be discussed with patients are cataracts/blindness, cancers (lung and throat), coronary artery disease, early menopause, osteoporosis/fractures, and impotency References Haug S, Schaub MP, Schmid H. Predictors of adolescent smoking cessation and smoking reduction. Patient Educ Couns. 2014;95(3):378-383. doi:10.1016/j.pec.2014.03.004 Mays D, Gilman SE, Rende R, Luta G, Tercyak KP, Niaura RS. Parental smoking exposure and adolescent smoking trajectories. Pediatrics. 2014;133(6):983-991. doi:10.1542/peds.2013-3003 Anderson TM, Lavista Ferres JM, Ren SY, et al. Maternal Smoking Before and During Pregnancy and the Risk of Sudden Unexpected Infant Death. Pediatrics. 2019;143(4):e20183325. doi:10.1542/peds.2018-3325 Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

Dr. Glenda Quan, esteemed Trauma Surgeon at Swedish Medical Center, discusses cases related to limb injury and reviews their management. Topics include proper tourniquet application as well as alternatives to commercially available devices how to manage pain or a difficult patient with significant limb injury. We also explore the use of new "hybrid ORs" where multiple surgical teams can care for various injuries simultaneously and briefly chat about the use of blood products in the prehospital setting. Thought we were done? Nope. We finish with pearls on temperature management as part of trauma resuscitation and find the answer to when you consider reduction of a joint or mid-shaft fracture?

Contributor: Ricky Dhaliwal, MD, JD Educational Pearls: Topical anesthetization can allow for an awake intubation, which substantially decreases chance of loss of airway or respiratory drive because sedatives/paralytics are not necessary Lidocaine treatments like URO-JET (2% lidocaine jelly) can be applied through the nare followed by LMX cream (4% lidocaine) which should be applied to the back of the tongue to anesthetize the tongue and larynx. Good topicalization can be confirmed by testing for lack of a gag reflex References Simmons ST, Schleich AR. Airway regional anesthesia for awake fiberoptic intubation. Reg Anesth Pain Med. 2002;27(2):180-192. doi:10.1053/rapm.2002.30659 Ducharme J, Matheson K. What is the best topical anesthetic for nasogastric insertion? A comparison of lidocaine gel, lidocaine spray, and atomized cocaine. J Emerg Nurs. 2003;29(5):427-430. doi:10.1016/s0099-1767(03)00295-2 Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

Contributor: Ricky Dhaliwal, MD, JD Educational Pearls: Tranexamic acid (TXA) as shown to have mortality benefit to patients with traumatic GI hemorrhage but should it be used to achieve hemostasis in atraumatic GI bleeding? HALT-IT study looked at TXA for the treatment of upper and lower GI hemorrhage and found no 5 day mortality benefit Patients given TXA also had higher occurrences of DVT and PE References Roberts I, Coats T, Edwards P, et al. HALT-IT--tranexamic acid for the treatment of gastrointestinal bleeding: study protocol for a randomised controlled trial. Trials. 2014;15:450. Published 2014 Nov 19. doi:10.1186/1745-6215-15-450 Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

Contributor: Ramnik Dhaliwal, MD, JD Educational Pearls: Nitrates Nitroprusside: becomes effective in under a minute, and becomes ineffective 10 minutes after stopping it. Nitroprusside can metabolize into cyanide leading to toxicity, however this is rare. Nitroglycerin: predominately causes vasodilation but some arterial dilation as well; preferred agent in patients with volume overload/CHF Adrenergic Blocking Agents Labetalol: alpha/beta-blocking agent with a rapid onset of 5 minutes or less given as bolus or intravenous drip Esmolol: cardioselective beta blocker with rapid onset and short duration of action making it easily titratable Hydralazine: direct arterial dilator; patient dependent response that can be unpredictable. Use with caution in patients with CAD or an aortic dissection because there will be a reflexive increase in heart rate to combat the arteriolar dilation. Calcium Channel Blockers Nicardipine: Given as an IV infusion starting at 5g/hr up to 15g/hr. This drug has a slower onset of action making it difficult to titrate and it has a longer serum elimination half-life (3-6 hours) Clevidipine: rapid onset and short duration of action; Reduces BP without affecting cardiac filling pressures but can cause reflex tachycardia References )Wani-Parekh P, Blanco-Garcia C, Mendez M, Mukherjee D. Guide of Hypertensive Crisis Pharmacotherapy. Cardiovasc Hematol Disord Drug Targets. 2017;17(1):52-57. doi:10.2174/1871529X16666161220142020 Suneja M, Sanders ML. Hypertensive Emergency. Med Clin North Am. 2017;101(3):465-478. doi:10.1016/j.mcna.2016.12.007 Maloberti A, Cassano G, Capsoni N, et al. Therapeutic Approach to Hypertension Urgencies and Emergencies in the Emergency Room. High Blood Press Cardiovasc Prev. 2018;25(2):177-189. doi:10.1007/s40292-018-0261-4 Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

Emergency Medical Minute collaborated with CarePoint Health in early March for a night of education on Pediatric Emergencies at a local Denver brewery for our latest Brewcast. Pediatric patients require special considerations compared to adults when receiving medical care, and that remains true in the ED and pre-hospital settings. As such, it's important to be careful with the documentation of these patients to maintain accuracy and avoid inclusion of common normal findings that may populate in "normal patient" macros that are inappropriate for pediatric patients. Dr. Karen Woolf, Pediatric Emergency Medicine Physician, shares some key areas to be wary of in your documentation for pediatric patients. Some examples include the description of vital signs and whether they fall within normal ranges, general appearance descriptors as well as developmental stage specific findings i.e AAOx3, normal gait and fontanelle description etc. Listen for a rundown of the key pointers for keeping pediatric documentation accurate and informative.

The penicillin and cephalosporin drug classes include many first line drug options for infectious disease although high rates of self-reported allergies may cause physicians to seek alternative options. In part two of our dive into antibiotics use for infectious disease, listen as Dr. Rachael Duncan, Emergency Medicine Clinical Pharmacist, addresses the need to investigate the validity of these reported allergies and their severity to avoid us elf riskier alternatives, like fluoroquinolones. Cross-reactivity between cephalosporins is most often dictated by side chain of cephalosporins rather than the beta-lactam ring. Refer to the chart included for cross-reactivity tips. References: Li M, Krishna MT, Razaq S, Pillay D. A real-time prospective evaluation of clinical pharmaco-economic impact of diagnostic label of 'penicillin allergy' in a UK teaching hospital. J Clin Pathol 2014; 67(12): 1088-92. Romano A, Gueant-Rodriguez RM, Viola M, Pettinato R, Gueant JL. Cross-reactivity and tolerability of cephalosporins in patients with immediate hypersensitivity to penicillins. Ann Intern Med 2004; 141(1): 16-22. Macy E, Contreras R. Health care use and serious infection prevalence associated with penicillin "allergy" in hospitalized patients: A cohort study. J Allergy Clin Immunol 2014; 133(3): 790-6