Emergency Medical Minute

Contributor: Nick Tsipis, MD Educational Pearls: Arsenic is a heavy metal that binds to multiple cellular enzymes and inhibits aerobic metabolism It is primarily absorbed through the skin, respiratory and GI tract. The classic symptoms of heavy metal exposure are GI irritation (watery diarrhea, vomiting and abdominal pain) with multisystem organ failure. Neuropathy can present insidiously Initial work up includes EKG, and basic lab work (expect a delayed rise in liver function tests). Acute arsenic ingestions can sometimes show up on imaging as it is radioapaque Diagnosis is usually made with the history and evidence of multisystem organ failure. Treatment should be coordinated with your local Poison Control or toxicologist and involves predominantly supportive care along with chelating agents succimer (oral) or dimercaprol (intramuscular) References Long N. Arsenic toxicity • LITFL • Toxicology Library Toxicant. Life in the Fast Lane • LITFL • Medical Blog. https://litfl.com/arsenic-toxicity/. Published August 25, 2019. Kuivenhoven M, Mason K. Arsenic (Arsine) Toxicity. [Updated 2019 Apr 29]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK541125/

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Contributor: Aaron Lessen, MD Educational Pearls: Locked in syndrome results typically from an infarct of the basilar artery leading to infarction of the brainstem but typically preservation of the higher structures The result is complete paralysis with preserved cognitive function, hence the name Because of their location within the brainstem, ocular movements are sometimes preserved, allowing a patient who recovers from the initial injury to communicate Patients typically do not regain any motor function and have a poor prognosis of recovery Thrombectomy of the basilar artery is sometimes considered even late after the initial presentation given the devastating prognosis References Smith E, Delargy M. Locked-in syndrome. BMJ. 2005;330(7488):406‐409. doi:10.1136/bmj.330.7488.406 Buchman SL, Merkler AE. Basilar Artery Occlusion: Diagnosis and Acute Treatment. Curr Treat Options Neurol. 2019;21(10):45. Published 2019 Sep 26. doi:10.1007/s11940-019-0591-0 Meinel TR, Kaesmacher J, Chaloulos-Iakovidis P, et alMechanical thrombectomy for basilar artery occlusion: efficacy, outcomes, and futile recanalization in comparison with the anterior circulationJournal of NeuroInterventional Surgery 2019;11:1174-1180. Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

Contributor: Jared Scott, MD Educational Pearls: Traditional digital block involves dorsal approach on either side of the digit, injecting local anesthetic along each side to numb all four nerves of the digit Newer approach involves a single injection along the palmar surface at MCP joint Recent study further compared a proximal vs distal single palmar (volar) injection with sites at the MCP and PIP joints Injection sites achieved similar anesthesia between groups but PIP injection site had faster time of onset - 2.5 minutes compared to 3.8 minutes References Choi S, Cho YS, Kang B, Kim GW, Han S. The difference of subcutaneous digital nerve block method efficacy according to injection location. Am J Emerg Med. 2020;38(1):95‐98. doi:10.1016/j.ajem.2019.04.031 Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

Contributor: Aaron Lessen, MD Educational Pearls: Supplemental oxygen is not a completely benign intervention. A recent meta-analysis found that O2 saturations above 96% while on supplemental O2 were associated with worse outcomes. Only start a patient on supplemental oxygen if absolutely necessary and aim for a goal of no higher than 96% References Derek K Chu, Lisa H-Y Kim, Paul J Young, Nima Zamiri, Saleh A Almenawer, Roman Jaeschke, Wojciech Szczeklik, Holger J Schünemann, John D Neary, Waleed Alhazzani. Mortality and morbidity in acutely ill adults treated with liberal versus conservative oxygen therapy (IOTA): a systematic review and meta-analysis. The Lancet. Volume 391, Issue 10131. 2018. Pages 1693-1705, Summarized by Will Dewispelaere, MD | Edited by Erik Verzemnieks, MD

Contributor: Aaron Lessen, MD Educational Pearls: Supplemental oxygen is not a completely benign intervention. A recent meta-analysis found that O2 saturations above 96% while on supplemental O2 were associated with worse outcomes. Only start a patient on supplemental oxygen if absolutely necessary and aim for a goal of no higher than 96% References Derek K Chu, Lisa H-Y Kim, Paul J Young, Nima Zamiri, Saleh A Almenawer, Roman Jaeschke, Wojciech Szczeklik, Holger J Schünemann, John D Neary, Waleed Alhazzani. Mortality and morbidity in acutely ill adults treated with liberal versus conservative oxygen therapy (IOTA): a systematic review and meta-analysis. The Lancet. Volume 391, Issue 10131. 2018. Pages 1693-1705, Summarized by Will Dewispelaere, MD | Edited by Erik Verzemnieks, MD

Contributor: Aaron Lessen, MD Educational Pearls:. Focused assessment with Sonography for Trauma (FAST) exam and the extended-FAST (eFAST) are essential components of current trauma care and evaluation There has been an accumulation of research to provide an estimate of effectiveness of identifying certain injuries with ultrasound: For identifying a pneumothorax, the sensitivity ~70% and specificity ~99%. For pericardial effusions, sensitivity 90% and specificity ~ 94%. For hemoperitoneum, sensitivity ~74% and the specificity ~98%. While ultrasound is excellent for identifying many injuries, it may not be adequate alone to rule out serious injuries if the clinical suspicion is high based on these pooled studies References Netherton S, Milenkovic V, Taylor M, Davis PJ. Diagnostic accuracy of eFAST in the trauma patient: a systematic review and meta-analysis. CJEM. 2019;21(6):727‐738. doi:10.1017/cem.2019.381 Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

Contributor: Aaron Lessen, MD Educational Pearls:. Focused assessment with Sonography for Trauma (FAST) exam and the extended-FAST (eFAST) are essential components of current trauma care and evaluation There has been an accumulation of research to provide an estimate of effectiveness of identifying certain injuries with ultrasound: For identifying a pneumothorax, the sensitivity ~70% and specificity ~99%. For pericardial effusions, sensitivity 90% and specificity ~ 94%. For hemoperitoneum, sensitivity ~74% and the specificity ~98%. While ultrasound is excellent for identifying many injuries, it may not be adequate alone to rule out serious injuries if the clinical suspicion is high based on these pooled studies References Netherton S, Milenkovic V, Taylor M, Davis PJ. Diagnostic accuracy of eFAST in the trauma patient: a systematic review and meta-analysis. CJEM. 2019;21(6):727‐738. doi:10.1017/cem.2019.381 Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

Contributor: John Winkler, MD Educational Pearls: Unstable ventricular tachycardia (VT) typically manifests with syncope, shortness of breath, diaphoresis and/or chest pain with hemodynamic instability Electrical cardioversion of unstable ventricular tachycardia is first line treatment Starting with a higher energy level (or just using the maximum) when performing cardioversion may set you up for better success as many providers feel the first shock has the highest likelihood of success References Dresen, W.F. Ferguson, J.D. Ventricular Arrhythmias. Cardiol Clin. 2018 Feb;36(1):129-139. doi: 10.1016/j.ccl.2017.08.007. Epub 2017 Oct 27. Goyal, A. et al. Synchronized Electrical Cardioversion.StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020-. 2020 Feb 13. Summarized by Jackson Roos, MS3 | Edited by Erik Verzemnieks, MD

Contributor: Aaron Lessen, MD Educational Pearls: Mechanical CPR (machine assisted compression devices) remains a hot topic of debate in emergency medicine Machine assisted CPR has been advocated to provide more consistent compressions in cardiac arrest and free up staff for other tasks. However, multiple studies have shown mechanical CPR provides no significant survival benefit yet increased rates of injury to the chest and abdomen from the devices. Unless a clear benefit can be found, mechanical CPR devices should not routinely replace traditional CPR in most situations For prolonged transport as well as resource-limited settings, these devices still may provide the only option for sustained resuscitations References Bonnes, J. et al. Manual Cardiopulmonary Resuscitation Versus CPR Including a Mechanical Chest Compression Device in Out-of-Hospital Cardiac Arrest: A Comprehensive Meta-analysis From Randomized and Observational Studies. Ann Emerg Med. 2016 Mar;67(3):349-360.e3. doi: 10.1016/j.annemergmed.2015.09.023. Epub 2015 Nov 19. Wang, P. Brooks, S. Mechanical Versus Manual Chest Compressions for Cardiac Arrest. Cochrane Database Syst Rev. 2018 Aug 20;8(8):CD007260. doi: 10.1002/14651858.CD007260.pub4. Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD