Emergency Medical Minute

Contributor: Don Stader, MD Educational Pearls: Buprenorphine has been shown to decrease morbidity and mortality in opioid use disorder Buprenorphine used in naloxone-induced withdrawals can displace naloxone at opioid receptors, leading to reduced withdrawal symptoms and lessen the chance of using after discharge Patients in acute withdrawal due to naloxone after an overdose should be given Buprenorphine. Data shows that withholding Buprenorphine leads to increased mortality rates of 5% within the following month, and 10% in the following year. References Herring, Andrew. "Emergency Department Medication-Assisted Treatment of Opioid Addiction." Chcf.org, Aug. 2016, www.chcf.org/wp-content/uploads/2017/12/PDF-EDMATOpioidProtocols.pdf. D.H. Cisewski et al. Approach to buprenorphine use for opioid withdrawal treatment in the emergency setting. American Journal of Emergency Medicine 37 (2019) 143–150 Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

In the US, few people receive vaccination for tuberculosis (TB), a disease that hasn't been a major killer here for many decades. But while we in the US mostly experience TB as a relatively rare but real threat in its multidrug resistant form, particularly in pts with HIV--or in Victorian novels--TB still kills 2 million people a year. There is a vaccine for TB, a live attenuated vaccine called BCG for Bacille Calmette-Guerin. In fact it's the most widely used vaccine on earth, and an estimated 4 billion people have received it since was first administered to a baby whose mother died of TB a few hours after giving birth in the summer of 1921. This connection of this vaccine to COVID caught our attention when a friend suggested a few weeks ago that Russia and other parts of the world where BCG vaccination is routine might be shielded from the worst COVID outbreaks. In the intervening weeks, as Russia grapples with its own COVID epidemic, that possibilty seems less tenable, but it did lead us down an interesting research path. Host: Elizabeth Esty, MD Research By: Elizabeth Esty, MD Sound Editing By: Nate Novotny References: Miller A, Reandelar MJ, Fasciglione K, Roumenova V, Li Y, Otazu GH. Correlation between Universal BCG Vaccination Policy and Reduced Morbidity and Mortality for COVID-19: An Epidemiological Study. Epidemiology; 2020. doi:10.1101/2020.03.24.20042937 Kleinnijenhuis J, Quintin J, Preijers F, et al. Bacille Calmette-Guerin induces NOD2-dependent nonspecific protection from reinfection via epigenetic reprogramming of monocytes. Proceedings of the National Academy of Sciences. 2012;109(43):17537-17542. doi:10.1073/pnas.1202870109 Arts RJW, Moorlag SJCFM, Novakovic B, et al. BCG Vaccination Protects against Experimental Viral Infection in Humans through the Induction of Cytokines Associated with Trained Immunity. Cell Host & Microbe. 2018;23(1):89-100.e5. doi:10.1016/j.chom.2017.12.010 Further Reading: https://www.who.int/news-room/commentaries/detail/bacille-calmette-gu%C3%A9rin-(bcg)-vaccination-and-covid-19 https://clinicaltrials.gov/ct2/show/NCT04328441 https://www.mpg.de/14491738/0219-mpin-116799-modified-tuberculosis-vaccine-as-a-therapy-for-cancer-of-the-bladder

Contributor: Don Stader, MD Educational Pearls: COVID-19 commonly appears as a bilateral patchy infiltrate on chest radiograph, but this is a non-specific finding Sensitivities range from 17-70% for COVID-19 Many other viral pneumonias such as RSV and influenza can have similar findings Point-of-care ultrasound (POCUS) demonstrates B-lines, water-fall sign, or hepatization of the lung, but these are also non-specific Computerized tomography (CT) appears to be one of the more sensitive tests for detecting COVID-19, demonstrating ground-glass opacities - often before or without the patient having symptoms However, routine use of CT for diagnosis COVID-19 is strongly discouraged by many medical societies and the CDC Imaging may not be necessary in most patients presenting with suspected COVID-19 for multiple reasons: Diagnosis is often clinical suspicion, with or without confirmatory PCR testing (if available) Imaging does little to change the management in the majority of patients with COVID-19 Obtaining imaging exposes additional healthcare workers Cleaning protocols for units (especially CT) can be extensive and require significant downtime of the machine, thereby leading to delays in care References Farkas, Josh. "COVID-19." EMCrit Project, 21 Apr. 2020, emcrit.org/ibcc/covid19/#labs. Guan W. et al. Clinical Characteristics of Coronavirus Disease 2019 in China. February 28, 2020, updated on March 6, 2020, at NEJM.org. DOI: 10.1056/NEJMoa2002032 Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

In this timely installment of Mental Health Monthly, mental health expert Lexi Eliades shares useful tips for identifying burnout and mental health decline as well as ways to maintain mental wellness amidst adversity and significant stress. We at Emergency Medical Minute know many of our listeners are on the frontlines of the COVID-19 pandemic. We hope this piece is helpful and that it reaches someone who needs to hear it!

Contributor: Dylan Luyten, MD Educational Pearls Acidosis can be caused by a respiratory, metabolic, or mixed source A respiratory acidosis will have a low serum pH and elevated bicarbonate if it's chronic, but most importantly end tidal CO2 or arterial CO2 will be high. With a metabolic acidosis we expect to see a low serum pH and low serum bicarbonate. Once it's determined a patient is in a metabolic acidosis, we need to determine if it's an elevated anion gap or normal anion gap acidosis. Anion gap is calculated by subtracting the serum anions from the cations, or serum sodium minus the serum chloride and CO2 (Na-(Cl+CO2)). A normal gap is 6-10, gaps over 10 have an elevated anion gap acidosis. The causes of an elevated anion gap acidosis can be remembered with MUDPILES mnemonic (Methanol, Uremia (renal failure), Diabetes/DKA, Paraldehyde, Isoniazid, Lactate, Ethanol/Ethylene glycol, salicylates/aspirin). So when you suspect an elevated gap acidosis you need to evaluate for all causes, so you need to get an venous or arterial blood gas along with lactate, salicylate, and Tylenol levels. References Vanmassenhove J. Lameire N. Approach to the patient presenting with metabolic acidosis. Acta Clin Belg. 2019 Feb;74(1):21-27. doi: 10.1080/17843286.2018.1547245. Epub 2018 Nov 24. Burger MK, Schaller DJ. Physiology, Acidosis, Metabolic. [Updated 2019 Jun 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482146/ Summarized by Jackson Roos, MS3 | Edited by Erik Verzemnieks, MD

Contributor: Don Stader, MD Educational Pearls: Acute respiratory distress syndrome (ARDS) is a catch all term for when lung injury leads to fluid collection in the air spaces of the lungs Ventilatory management in ARDS patients involves lower FiO2 and PEEP than other patients and relies on lung protective ventilation strategies to prevent barotrauma Proning these patients has also been utilized with the goal of matching V/Q, or getting good blood flow to areas of the lung which are well ventilated. References 1. Higher versus Lower Positive End-Expiratory Pressures in Patients with the Acute Respiratory Distress Syndrome. N Engl J Med 2004; 351:327-336. DOI: 10.1056/NEJMoa032193 2. Howell MD, Davis AM. Management of ARDS in Adults. JAMA. 2018;319(7):711–712. doi:10.1001/jama.2018.0307 3. Scholten, E.L. et al. Treatment of ARDS With Prone Positioning. Chest. 2017 Jan;151(1):215-224. doi: 10.1016/j.chest.2016.06.032. Epub 2016 Jul 8. Summarized by Jackson Roos, MS3 | Edited by Erik Verzemnieks, MD

Last week we looked at neurologic presentations of COVID-19; this week we'll look more closely at strokes in young people with COVID. A letter published 2 days ago in the NEJM with lead author Thomas Oxley, the Neuro ICU director at Mt Sinai, presents five case studies of relatively young patients who had strokes at home and presented to Mt Sinai between 23 March and 7 April. In pre-COVID days, Mt Sinai saw on about 3 patients under the age of 50 with strokes per month, so 5 in 2 weeks represents a 7-fold increase. The authors call this one of the clearest and most profound correlations" they've come across. Though strokes in other COVID case reports are also occurring in older pts, other centers are reporting similar increases in young people with few or no risk factors presenting with major strokes. Right now there are at least 3 US centers preparing to publish data on the stroke in young people phenomenon. Host: Elizabeth Esty, MD Research By: Elizabeth Esty and Nate Novotny Sound Editing By: Stephen Bahmani References: Oxley TJ, Mocco J, Majidi S, et al. Large-Vessel Stroke as a Presenting Feature of Covid-19 in the Young. New England Journal of Medicine. 2020;0(0):e60. doi:10.1056/NEJMc2009787 Cha AE. Young and middle-aged people, barely sick with covid-19, are dying of strokes. Washington Post. https://www.washingtonpost.com/health/2020/04/24/strokes-coronavirus-young-patients/. Published April 25, 2020. Klok FA, Kruip MJHA, van der Meer NJM, et al. Incidence of thrombotic complications in critically ill ICU patients with COVID-19. Thromb Res. April 2020. doi:10.1016/j.thromres.2020.04.013

Contributor: Don Stader, MD Educational Pearls: COVID-19 is diagnosed with a nasopharyngeal swab (q-tip). This unfortunately can be painful, but if the swab doesn't go deep into the nasal cavity the sample can be inadequate leading to false negatives (missed infections). The sensitivity of the COVID-19 RT PCR test is low, ranging from 66-80% in various studies. Another study has shown 23% of patients who initially tested negative but had COVID-19 symptoms will test positive when re-tested. So test highly suspicious patients twice. COVID has shown to have an effect on CBC. White blood cell counts are often normal (no leukocytosis), but there is often lymphopenia, or low lymphocytes, and thrombocytopenia. Interestingly, low platelets have appeared to have prognostic value in that lower platelets often indicate worse patient outcomes. Coagulation studies are showing very elevated D-Dimers which has sparked the debate as to whether COVID-19 causes a hypercoagulable state. The increased incidence of MI/heart attacks and strokes in COVID patients supports this argument. While D-Dimers can help point towards a diagnosis of pulmonary embolism, in the setting of highly likely COVID-19 infections, getting a CTA looking for a PE is probably unnecessary unless there's also suspicion for PE. C-reactive protein (CRP) and procalcitonin are two common inflammatory markers. A CRP can help indicate how sick a patient is and procalcitonin can help determine if the infection is bacterial or viral in nature. CRP levels are often elevated in COVID patients, and studies are showing a high CRP is linked to worse patient outcomes. Elevations in procalcitonin can be used to see if there's a concomitant bacterial infection, meaning patients need antibiotics in addition to supportive care for the COVID-19. Flu season is coming to a close, but data has shown a 5-10% co-infection rate of COVID-19 with influenza. As expected patient outcomes have been worse in those with both infections. References 1) Farkas, Josh. "COVID-19." EMCrit Project, 21 Apr. 2020, emcrit.org/ibcc/covid19/#labs. 2) Guan W. et al. Clinical Characteristics of Coronavirus Disease 2019 in China. February 28, 2020, updated on March 6, 2020, at NEJM.org. DOI: 10.1056/NEJMoa2002032 3)Young BE, Ong SWX, Kalimuddin S, et al. Epidemiologic Features and Clinical Course of Patients Infected With SARS-CoV-2 in Singapore. JAMA. 2020;323(15):1488–1494. doi:10.1001/jama.2020.3204 4) Wang M. et al. Clinical diagnosis of 8274 samples with 2019-novel coronavirus in Wuhan. medRxiv 2020.02.12.20022327; doi: https://doi.org/10.1101/2020.02.12.20022327 Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

Contributor: Eric Miller, MD Educational Pearls: A cell count is performed on tubes 1 and 4 to account for changes that may occur from blood entering the first sample from the needle insertion Tube 2 and 3 are usually used for the other studies like protein levels, glucose levels and gram staining Protein levels are often elevated in bacterial meningitis but can be helpful in diagnosis conditions like multiple sclerosis Glucose levels are typically low in bacterial meningitis due to the use of glucose by bacteria Cell counts above 3-5 cells are typically abnormal, but cell counts can vary widely depending on the type of meningitis (viral vs. bacterial) and how long the infection has been present. Cell type and differential can indicate viral vs. bacterial meningitis Neutrophils are more associated with bacterial causes Lymphocytes are more associated with viral etiologies CSF cultures are used to identify the cause of bacterial meningitis but can take days to result. A gram stain can help determine if any bacteria are present as well as cell types present. References Jain, R. Chang, WW. Emergency Department Approach to the Patient with Suspected Central Nervous System Infection. Emerg Med Clin North Am. 2018 Nov;36(4):711-722. doi: 10.1016/j.emc.2018.06.004. Summarized by Jackson Roos, MS3 | Edited by Erik Verzemnieks, MD

Contributor: Don Stader, MD Educational Pearls: When do we give antiplatelet drugs or anti-coagulation drugs? Arterial issues get antiplatelet therapy Venous issues, or slow flow states, get anticoagulation therapy. High flow areas (arteries) are more prone to platelet clotting while the venous system is more prone to allowing blockages caused by coagulation factors. The main side effect with antiplatelet and anticoagulants is bleeding. Typically antiplatelet drugs cause more bleeding issues because platelets are made in the bone marrow, while coagulation factors are made in the liver, so it takes longer for the bone marrow to replete platelets versus the liver which is a fast synthesizer of clotting factors. Reversal of antiplatelet drugs can take a while, so patients on these drugs (ex. Plavix) may need a week of withholding the drug to get surgery, while anti-coagulation drugs (ex. Xarelto) can be stopped a day or two prior to surgery. References 1. Altiok, E. Marx, N. Oral Anticoagulation: Update on Anticoagulation With Vitamin K Antagonists and Non–Vitamin K–Dependent Oral Anticoagulants. Dtsch Arztebl Int. 2018 Nov; 115(46): 776–783. Published online 2018 Nov 16. doi: 10.3238/arztebl.2018.0776 2. Kapil, N. Et al. Antiplatelet and Anticoagulant Therapies for Prevention of Ischemic Stroke. Clin Appl Thromb Hemost. 2017 May;23(4):301-318. doi: 10.1177/1076029616660762. Epub 2016 Jul 26. 3. Ostergaard, L. Fosbol EL. Roe MT. The Role of Antiplatelet Therapy in Primary Prevention. A Review. Curr Pharm Des. 2017;23(9):1294-1306. doi: 10.2174/1381612822666161205115540. Summarized by Jackson Roos, MS3 | Edited by Erik Verzemnieks, MD