Emergency Medical Minute

Contributor: Jared Scott, MD Educational Pearls: Suicide is currently the 10th leading cause of death in the US Low quality studies have reported ketamine as a potential promising agent in treating depression and preventing suicidal ideations or thoughts Randomized study was performed looking at giving ketamine to depressed patients in the ED to see if they could establish a proof of concept, meaning: would looking at ketamine for treatment of acute depression or suicidality be viable? 18 suicidal patients who required hospitalization for their depression and suicidality were entered in the study. 88% of the group treated with ketamine felt like their symptoms improved for up to 3 days, while only 33% of the placebo group reported an improvement References Domany Y, Shelton RC, McCullumsmith CB. Ketamine for acute suicidal ideation. An emergency department intervention: A randomized, double-blind, placebo-controlled, proof-of-concept trial. Depression & Anxiety (1091-4269). 2020;37(3):224-233. doi:10.1002/da.22975. Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

Contributor: Aaron Lessen, MD Educational Pearls: Hand raising test: a simple but effective tool to diagnose carpal tunnel Patients hold their hands over their head and if symptoms of carpal tunnel develop within 2 minutes, it is considered positive, meaning they likely have carpel tunnel Symptom included numbness and dull pain in the distribution of the median nerve Treatment for carpal tunnel in the ED can include splinting in a neutral position and oral steroids with possible follow up for steroid injections or surgery References Padua L, Coraci D, Erra C, et al. Carpal tunnel syndrome: clinical features, diagnosis, and management. Lancet Neurol. 2016;15(12):1273-1284. doi:10.1016/S1474-4422(16)30231-9 Ma H, Kim I. The diagnostic assessment of hand elevation test in carpal tunnel syndrome. J Korean Neurosurg Soc. 2012;52(5):472-475. doi:10.3340/jkns.2012.52.5.472 Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

Meet Adis Keric, Board Certified Pharmacotherapy Specialist and a Board Certified Critical Care pharmacist who works in the Emergency Department and ICU of level 1 trauma center Regions Hospital in Saint Paul, MN. Adis is the founder and host of a new FOAMed podcast, ER-Rx. He started the podcast to inform clinicians in the ED and ICU about up-to-date, appropriate and optimal use of medications in different clinical scenarios. Dr. Nick Tsipis sits down with Adis to discuss some pearls in Emergency Medicine Pharmacy. Time Stamps: 0:10 Intros 4:35 Antibiotics 8:30 Post-Intubation Sedation 12:00 Anti-coagulation reversal* 16:00 ER-Rx Plug *Correction to figures quoted on anticoagulation reversal pricing. High-dose Andexxa regimen maxes out around $60,000 and Kcentra maxes out at $6,000. So there is still a massive price difference, but not as high as quoted in the audio. Check out ER-Rx on iTunes, Google Podcasts, Spotify, YouTube and other major podcast hosting platforms! Instagram: @errxpodcast Website: http://errxpodcast.com/

Contributor: Michael Hunt, MD Educational Pearls: Contrast agents are commonly used for X-rays and CT's to better characterize disease, but contrast doesn't work with MRI. That's where the element Gadolinium comes into play. Gadolinium, element 64, is ferromagnetic (attracted to iron) below 68 degrees and above that temperature it's paramagnetic which makes it useful in MRI (Magnetic Resonance Imaging). Gadolinium is toxic alone, but when paired with chelators it can be used in humans and allows for better characterization of tumors or abnormal tissue on MRI. It helps identify this abnormal tissue because when MRI causes polarization of our body's cells, the gadolinium, which has the maximum number of unpaired electrons in its orbital shells, alters the rate of decay in abnormal tissue highlighting abnormalities on imaging. Gadolinium can also be used in the treatment of cancers because it collects in the cells of abnormal tissue, allowing for more targeted therapies. In people exposed to gadolinium, the anaphylaxis rate is low, below 1/1000, and in rare cases there are reports of kidney injury and nephrogenic systemic fibrosis which is why it's not recommended in renal failure patients. References 1)Ibrahim MA, Hazhirkarzar B, Dublin AB. Magnetic Resonance Imaging (MRI) Gadolinium. [Updated 2020 Mar 9]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482487/ 2)Pasquini L, Napolitano A, Visconti E, et al. Gadolinium-Based Contrast Agent-Related Toxicities [published correction appears in CNS Drugs. 2018 May 15;:]. CNS Drugs. 2018;32(3):229-240. doi:10.1007/s40263-018-0500-1 Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

\Contributor: Don Stader, MD Educational Pearls: Altered mental status/confusion are major symptoms associated with both alcohol use and withdrawal. Wernicke's encephalopathy is a triad of symptoms of confusion, internuclear ophthalmoplegia, and confabulation The treatment for Wernicke's is IV thiamine or vitamin B1 Untreated Wernicke's leads to Korsakoff's syndrome where a prolonged thiamine deficiency leads to worsening brain function Subdural hematomas from torn bridging veins are common in alcoholics because of the combination of frequent falls and cerebral atrophy caused by alcohol. Alcohol is a major cause of heart failure and atrial fibrillation; "holiday heart" is a-fib induced by binge drinking where high levels of acetaldehyde from the metabolism of alcohol excite the heart. Frequent alcohol use is linked to esophageal cancer Alcoholic cirrhosis can lead to a multitude of complications including esophageal varices that can rupture often with fatal outcomes Aspiration pneumonia is more common in alcoholics because of a depressed gag reflex and alteration of oral flora References Brousse G, Geneste-Saelens J, Cabe J, Cottencin O. Alcool et urgences [Alcohol and emergencies]. Presse Med. 2018;47(7-8 Pt 1):667-676. doi:10.1016/j.lpm.2018.06.001 Chandrakumar A, Bhardwaj A, 't Jong GW. Review of thiamine deficiency disorders: Wernicke encephalopathy and Korsakoff psychosis. J Basic Clin Physiol Pharmacol. 2018;30(2):153-162. Published 2018 Oct 2. doi:10.1515/jbcpp-2018-0075 Simou E, Britton J, Leonardi-Bee J. Alcohol and the risk of pneumonia: a systematic review and meta-analysis. BMJ Open. 2018;8(8):e022344. Published 2018 Aug 22. doi:10.1136/bmjopen-2018-022344 Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

Meet Michelle Whaley, Clinical Nurse Specialist and Stroke Program Coordinator at Sky Ridge Medical Center in Lone Tree, Colorado. Jordan and Michelle discuss advances in Artificial Intelligence technology in an app that uses algorithms to analyze CT Angiograms to alert physicians of patients with images concerning for Large Vessel Occlusions (LVOs). Listen as they discuss the sweeping implications of this technology in the realm of stroke care and how it is decreasing wait times for critical patients to receive tPA and interventional procedures. For EMS, this technology is already improving the care given by specialized transfer teams of patients from smaller hospitals to regional stroke centers. Tune in for other applications of this technology in pre-hospital settings on the horizon. Disclaimer: This episode of On The Streets is for educational purposes only. Emergency Medical Minute is not affiliated with VIZ AI in any way and did not receive compensation for this episode.

Contributor: Michael Hunt, MD Educational Pearls: PPE, or personal protective equipment, has become a major talking point since the emergence of the novel coronavirus (COVID 19). While ubiquitous now, there was not always equipment to protect health care providers or patients from infectious exposures. The invention of surgical gloves are credited to surgeon William Halsted. He developed gloves because one of his assistants (and later wife), Carol Hampton, was having severe irritation due to a caustic pre-op disinfecting process. They developed the rubber glove for Hampton which garnered popularity, and by the early 20th century, half of surgeons were using rubber gloves. Surgical masks came around during the same period as gloves. By 1919 about half of all surgeons were using masks, protecting themselves and their patients from infectious transmissions. The simple advent of masks and gloves led to incredible reductions in morbidity and mortality in surgical cases. Now these simple barriers are key in the prevention of further transmitting of COVID-19. References 1. Kean, Sam. "Glove at First Sight." podbean.com, 27 Apr. 2020, disappearingspoon.podbean.com/e/glove-at-first-sight/. Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

Contributor: Don Stader, MD Educational Pearls: Yersinia Pestis is the bacteria that caused the black plague. It was first discovered to be the cause of the bubonic plague in 1800s in China during the 3rd bubonic plague where 10-20 million people died Causes 3 types of plague: Bubonic plague: characterized by severe swelling of lymph nodes called buboes, most commonly in the groin, also axillary and olecranon lymph nodes. Septicemic plague: characterized by severe sepsis, no lymphadenopathy. This strain famously causes disseminated intravascular coagulopathy (DIC) and can lead to limb necrosis and fingers turning black. Hence the name the Black Death. Pneumonic: most dangerous of the plagues and characterized by PNA on CXR with pronounced mediastinal lymphadenopathy Fleas are the largest reservoir, although prairie dogs and squirrels have been known to carry the bacteria as well. Yersinia Pestis creates a microfilm inside the stomach of fleas and renders them incapable of digesting your blood when they try to eat it and they vomit the bacteria into your blood. Doxycycline and Ciprofloxacin are the mainstay of treatment. References Achtman M, Zurth K, Morelli G, Torrea G, Guiyoule A. Carniel E. Yersinia pestis, the cause of plague, is a recently emerged clone of Yersinia pseudotuberculosis. Proc Natl Acad Sci U S A. 1999. doi:10.1073/pnas.96.24.14043 Galimand M, Carniel E, Courvalin P. Resistance of Yersinia pestis to Antimicrobial Agents. Antimicrob Agents Chemother. 2006;50(10):3233 LP - 3236. doi:10.1128/AAC.00306-06 Sexton D, Stout J. Clinical Manifestations, Diagnosis, And Treatment Of Plague (Yersinia Pestis Infection). Waltham, MA: UpToDate; 2020. Summarized by Mason Tuttle & Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

Author: Eric Miller, MD Educational Pearls: Brown-Sequard Syndrome is a neurological deficit that results from hemisection of the spinal cord This is usually from traumatic injury (blunt or penetrating), but can rarely be seen with cancer, disc herniation, or infection It presents with flaccid paralysis and loss of sensation to touch/vibration/position on the same side as the injury with loss of pain/temperature sensation on the opposite side of the injury. These deficits will be below the level of injury. References Roth, E., Park, T., Pang, T. et al. Traumatic cervical Brown-Sequard and Brown-Sequard-plus syndromes: the spectrum of presentations and outcomes. Spinal Cord 29, 582–589 (1991). Wagner R, Jagoda A. Spinal cord syndromes. Emerg Med Clin North Am. 1997;15(3):699. Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

Contributor: Don Stader, MD Educational Pearls: Checkpoint inhibition normally helps our body detect abnormal cells and terminate it but cancerous cells often are able to avoid this countermeasure Monoclonal antibodies that bind to checkpoint inhibitors can stop cancerous cells from turning off immunologic T cells and allows the immune system to continue to attack cancers. These therapies carry risks of exacerbating autoimmune problems due to the ramped up immune response Most often this autoimmune attack leads to skin and GI symptoms but can affect many other organ systems. In the emergency room this can present many different ways, but the mainstay of treatment is steroids to stop these exacerbations. Chimeric Antigen Receptor (CAR) T-cell Therapy is another immunotherapy where antigens to a cancerous cell are re-introduced to spur a directed immune response Cytokine release syndrome can occur in these patients and mimic other presentations such as septic shock, a result of tumor break down This is treated with steroids and monoclonal antibodies that help thwart the cytokine release References Hay, KA. Cytokine release syndrome and neurotoxicity after CD19 chimeric antigen receptor-modified (CAR-) T cell therapy. Br J Haematol. 2018 Nov;183(3):364-374. doi: 10.1111/bjh.15644. Epub 2018 Nov 8. Hryniewicki AT, Wang C, Shatsky RA, Coyne CJ. Management of Immune Checkpoint Inhibitor Toxicities: A Review and Clinical Guideline for Emergency Physicians. J Emerg Med. 2018;55(4):489-502. doi:10.1016/j.jemermed.2018.07.005 Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD