Emergency Medical Minute

Trauma and loss are common issues faced by emergency personnel and first responders. These challenges have since been heightened by the COVID-19 pandemic. On this installment of Mental Health Monthly, Anat 'Nati' Geva, PsyD, LP joins us to discuss the stages of grief in response to loss and trauma and how they pertain to first responders and frontline workers in particular. Each of the five stages of grief: denial, anger, bargaining, despair and acceptance are addressed and explained so you can expand your understanding of the natural process of grieving, identify signs and symptoms and take steps towards moving forward. If you or a love one is struggling through the grieving process and need more support, we encourage you to utilize the resources below: My Strengths - https://mystrength.com/ passcode: TMCAProfessional Responder Strong - https://you.responderstrong.org/ Jason's Foundation - https://jasonfoundation.com/ Rocky Mountain Crisis Partners (also known as "the crisis line") – 1-844-493-8255 (TALK) https://rmcrisispartners.org/ HCAT – 1-844-556-2012 Anat 'Nati' Geva, PsyD, LP Anat.A.Geva@gmail.com If you are interested in taking part in a personalized experiential application of the content, there will be a Webex webinar session tomorrow, August 27th from 10 - 11 am MST. The focus group follow-up is a complimentary experiential component for individuals who want to deepen their understanding of the material from this podcast. It will benefit those who want to take the opportunity to make the content personal to their situation. In this session, participants will discuss the prominent experiences for participants, have more extended time for Q&A, and then explore (a facet of) the primary model used. Time allowing, participants will be invited to join and share insights for the benefit of all participants. Details for joining: Join via Webex Join from a video system or application Dial 1453267047@hcameeting.webex.com Tap to join from a mobile device (attendees only) +1-415-655-0003,,1453267047## United States TOLL Join by phone +1-415-655-0003 United States TOLL Global call-in numbers Access code: 145 326 7047 Meeting password: Meeting password: mVx3rt6Kwb

Contributor: Aaron Lessen, MD Educational Pearls: Carbonated beverages have shown efficacy in helping patients spontaneously pass esophageal food impactions Glucagon, while historically used for treatment, has been shown to have significant side effects without any clinical benefit Definitive treatment is with endoscopy performed typically by a gastroenterologist References Long B, Koyfman A, Gottlieb M. Esophageal Foreign Bodies and Obstruction in the Emergency Department Setting: An Evidence-Based Review. J Emerg Med. 2019;56(5):499-511. doi:10.1016/j.jemermed.2019.01.025 Peksa GD, DeMott JM, Slocum GW, Burkins J, Gottlieb M. Glucagon for Relief of Acute Esophageal Foreign Bodies and Food Impactions: A Systematic Review and Meta-Analysis. Pharmacotherapy. 2019;39(4):463-472. doi:10.1002/phar.2236 Akram J, Amin FM, Toft JG, Rømeling F. Håndtering af fremmedlegeme i øsofagus med synkestop [Treatment of foreign body impactions in oesophagus]. Ugeskr Laeger. 2013;175(10):640-643. Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

Contributor: Peter Bakes, MD Educational Pearls: Dental fractures are described by the Ellis classifications, which are based on the involvement of layers of the teeth: Ellis I: involvement of the enamel Ellis II: involvement of the enamel and dentin Ellis III: involvement of the enamel, dentin, and pulp While Ellis I injuries can be sent for dental follow up without intervention, Ellis II/III injuries require covering of the exposed dental layers, particularly because bacteria can more easily enter into the pulp Calcium hydroxide (Dycal) is used to cover teeth until patients can get to a dentist. Dental avulsions, or displacement of the tooth from the socket, are time sensitive. Every minute the tooth is not put back in place carries an increased risk of permanent loss. After the tooth is replanted, it requires fixation or bracing Dental subluxations can also be secured or braced with dental follow up References Marte, D, and B Robinson. Dental Trauma. Core EM, 7 Oct. 2019, coreem.net/core/dental-trauma/#ellis-classification-system-for-dental-fractures. Rosenberg H, Rosenberg H, Hickey M. Emergency management of a traumatic tooth avulsion. Ann Emerg Med. 2011;57(4):375-377. Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

Welcome to EMM's first Pharmacy Friday where we dive deeper on a certain pharmacological topic as it pertains to emergency medicine. Dr. Rachael Duncan, emergency medicine clinical Pharmacist, joins us today to talk about antibiotics use for infectious disease, specifically fluoroquinolones. Special thanks to Dr. Nichole Neville, infectious disease pharmacist, for much of the information presented in this podcast. Educational Pearls: Levofloxacin and other fluoroquinolones used to be relied upon heavily due to key upsides including ease of use and wide spectrum coverage of common bacteria. Overuse over the past decade has resulted in the discovery of 3 concerns that have led to their use being advised against in most patients These concerns are patient adverse reactions, safety concerns and drug resistance. Patient adverse reactions include potential QTc prolongation, neurologic symptoms including worsening of myasthenia gravis or peripheral neuropathy and severe hypoglycemia. Due to these adverse effects, a new term was coined: fluoroquinolone-associated disability. In an FDA report, they looked at the percentage of disability reports among all serious outcome reports of selected antibiotics and found that the top 5 antibiotics that led to disability reports were fluoroquinolones. Safety concerns have led to several black box warnings as well. Drug resistance due to overuse has also severely decreased the susceptibility rates of fluoroquinolones at many institutions. Check out your facility's antibiograms to get an idea of what susceptibility rates are for different drugs. Common infections that are inappropriately given fluoroquinolones when other options would be better suited are PNA, UTI and intra-abdominal infections. Tune in next week for more on cross-reactivity of cephalosporins and penicillins References: Fda.gov. 2017. Fluoroquinolone Safety Labeling Changes. [online] Available at: https://www.fda.gov/media/104060/download> [Accessed 21 August 2020]. Idsociety.org. 2018. Practice Guidelines. [online] Available at: https://www.idsociety.org/practice-guideline/practice-guidelines/#/date_na_dt/DESC/0/+/> [Accessed 18 August 2020]. U.S. Food and Drug Administration. 2018. FDA Updates Warnings For Oral And Injectable Fluoroquinolone. [online] Available at: https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-fda-updates-warnings-oral-and-injectable-fluoroquinolone-antibiotics> [Accessed 18 August 2020].

EMM would like to extend a large thank you to the Pain Management and Addiction Medicine section of the American College of Emergency Physicians for allowing us to post their webinar panel discussion facilitated by EMM's own Don Stader, MD, FACEP on Buprenorphine use after Naloxone. This episode discusses the nuances of emergency physicians inducing patients on Buprenorphine following an opioid overdose and covers key considerations including dosing, precipitated withdrawal and contraindications to Buprenorphine administration. Panelists include: Rachel Haroz, MD - EM physician boarded in Medical Toxicology and Addiction working in Camden, NJ Andrew Herring, MD - EM physician boarded in Pain and Addiction working in Oakland, CA and leads California's Bridge program that helps hospitals start Buprenorphine programs Eric Ketcham, MD, FACEP - EM physician who is a cofounder and chair of ACEP's Pain Management and Addiction Medicine section working in New Mexico

Contributor: Ricky Dhaliwal, MD, JD Educational Pearls: Ventricular Fibrillation (VF) is a potentially fatal cardiac arrhythmia; Refractory VF even more so Epinephrine stimulates alpha and beta receptors which increase sympathetic tone, thereby increasing cardiac oxygen demand and myocardial calcium levels which can cause new arrhythmias, particularly a problem during resuscitation Esmolol (or any beta blocker) can be used in VF refractory to defibrillation, epinephrine and amiodarone in a last-ditch effort. Esmolol in the setting of epinephrine can help prevent some of these known effects from repeated beta stimulation Dosing esmolol for refractory VF: 500mcg/kg bolus, followed by drip (max typically 1000 mcg/kg/min) Esmolol is associated with improved mortality in ACLS care in refractory VF References Long DA, Long B, April MD. Does β-Blockade for Treatment of Refractory Ventricular Fibrillation or Pulseless Ventricular Tachycardia Improve Outcomes?. Ann Emerg Med. 2020;76(1):42-45. doi:10.1016/j.annemergmed.2020.01.025 Lee YH, Lee KJ, Min YH, et al. Refractory ventricular fibrillation treated with esmolol. Resuscitation. 2016;107:150-155. doi:10.1016/j.resuscitation.2016.07.243 Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

Contributor: Jared Scott, MD Educational Pearls: Burnout happens. This study reminds us to take a few minutes on shift to take care of yourself. A new study looked at burnout in ER nurses, residents, and attending physicians where they were asked to take a 5-minute break on shift to color or play with a therapy dog. Researchers measured stress levels and checked salivary cortisol levels after the breaks to see if the therapies were working against a control group who did not have the breaks. Those who colored reported increased stress levels at the end of their shifts, while those who played with dogs reported decreased stress. Cortisol levels dropped in both coloring and pet therapy groups. Interestingly, patients couldn't see any difference in their providers' stress level. Those who conducted the study believe maybe coloring increased stress only because those who colored were denied the chance to play with a dog. Go figure. References 1) Kline JA, VanRyzin K, Davis JC, et al. Randomized Trial of Therapy Dogs Versus Deliberative Coloring (Art Therapy) to Reduce Stress in Emergency Medicine Providers . Acad Emerg Med. 2020; doi:10.1111/acem.13939

Burns are low-volume, high-acuity injuries that require special attention and care from the pre-hospital team to the Emergency Department and finally to a dedicated burn unit and ICU. As a first responder in the pre-hospital setting, there are a couple things that need to remain at the forefront of your mind when dealing with burn patients. On this episode of On the Streets, host Jordan Ourada sits down with Board Certified Plastic Surgeon and Hand Surgeon Dr. Benson Pulikkottil, who is the Medical Director for Swedish Medical Center's Burn Unit and Sean McConnell RN, former flight nurse and current charge nurse at Swedish's burn clinic to review the most important pearls to pre-hospital practice when it comes to burns. They discuss the in-depth importance of the details surrounding the mechanism of injury, field treatments and surface area estimation among many other nuances related to burn care. Tune in to hear from the experts about how to provide the best possible care for your burn patients when they present themselves.

Contributor: Don Stader, MD Educational Pearls: Toxic shock syndrome (TSS) is a rare cause of shock typically caused by Staph aureus or Strep pyogenes, that produces a toxin that leads to rapid onset hypotension with a diffuse erythematous rash. Signs of TSS may include rapid onset of altered mental status, dizziness, nausea, abdominal discomfort, hypotension, and rash TSS is associated with foreign bodies, such as tampons or nasal packing - make sure to remove any offending object Clindamycin is the drug of choice because it stops protein synthesis which helps treat toxic shock because toxic shock is caused by a protein (TSST-1) made by the bacteria. TSS is associated iwth high morbidity and mortality despite treatments Despite the association with TSS, there is little supporting evidence for prophylactic antibiotics when placing nasal packing References Gottlieb M, Long B, Koyfman A. The Evaluation and Management of Toxic Shock Syndrome in the Emergency Department: A Review of the Literature. J Emerg Med. 2018;54(6):807-814. doi:10.1016/j.jemermed.2017.12.048 Lange JL, Peeden EH, Stringer SP. Are prophylactic systemic antibiotics necessary with nasal packing? A systematic review. Am J Rhinol Allergy. 2017;31(4):240-247. doi:10.2500/ajra.2017.31.4454 Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

Contributor: Don Stader, MD Educational Pearls: Gout is an arthritis caused by the deposition of urate crystals into the joint space Colchicine works by disrupting microtubules and prevents white blood cells from getting into the joint space which stops the inflammatory response Colchicine has a high rate of adverse events, in particular explosive diarrhea The drug also has a very narrow therapeutic index and overdose is nearly universally fatal, with no antidote or effective treatment option available Alternative agents such as steroids, which reduce the inflammatory response to urate crystals, along with NSAIDs may be better options for treatment References Angelidis C, Kotsialou Z, Kossyvakis C, et al. Colchicine Pharmacokinetics and Mechanism of Action. Curr Pharm Des. 2018;24(6):659-663. doi:10.2174/1381612824666180123110042 Finkelstein Y, Aks SE, Hutson JR, et al. Colchicine poisoning: the dark side of an ancient drug. Clin Toxicol (Phila). 2010;48(5):407-414. doi:10.3109/15563650.2010.495348 Dalbeth N, Merriman TR, Stamp LK. Gout. Lancet. 2016;388(10055):2039-2052. doi:10.1016/S0140-6736(16)00346-9 Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD