Emergency Medical Minute

Author: Aaron Lessen, MD Educational Pearls: Traditional technique of needle thoracostomy for tension penumothorax is along the 2nd intercostal space at the midclavicular line Inserting a large angiocatheter along the 4th or 5th intercostal space at the mid-axillary line may provide a thinner area that is more easily identified, overcoming many of the obstacles of the traditional approach The 10th Edition of ATLS now recommends this location as well A finger thoracostomy, where a scalpel and then the finger are used to penetrate the pleural cavity at the same location, is another method to provide quick decompression of a traumatic tension pneumothorax, allowing a tube thoracostomy to be performed later References Laan DV, Vu TD, Thiels CA, et al. Chest wall thickness and decompression failure: A systematic review and meta-analysis comparing anatomic locations in needle thoracostomy. Injury. 2016;47(4):797–804. doi:10.1016/j.injury.2015.11.045 Inaba K, Branco BC, Eckstein M, Shatz DV, Martin MJ, Green DJ, Noguchi TT, Demetriades D. Optimal positioning for emergent needle thoracostomy: a cadaver-based study. J Trauma. 2011 Nov;71(5):1099-103; discussion 1103. doi: 10.1097/TA.0b013e31822d9618. Summarized and edited by Erik Verzemnieks, MD

EMM is proud to present the pilot episode of our new monthly series, "On the Streets". This will be an informative podcast for all of our listeners, but this one was designed specifically for our EMS listeners. Each month, we will consult medical experts on topics pertinent to prehospital care: Identifying a posterior circulation stroke in the field; Knowing when to do a 12-lead and what to look for; How to use capnography for a variety of datapoints; How to give an effective handoff report. And much much more... On our first episode, we are proud to welcome long-time friend of EMM, now retired Emergency Physician and current Medical Director of the ACC EMS program, Dr. Michael Hunt. This episode focuses exclusively on the Do's and Don'ts of giving handoff report. As we all know, knowledge and timing can make a world of difference when treating acutely ill patients. Like all of our content, we aim to equip you with the resources to forge your medical knowledge while keeping it relevant and time-efficient. Tune into "On the Streets" for real, raw and relevant EMS education. Photo Credit: https://www.flickr.com/photos/sc-axman/2327963351/

Contributor: Don Stader, MD Educational Pearls: Olanzapine (Zyprexa) is an atypical antipsychotic that can be used in a similar fashion to haloperidol for pain and nausea, including that with abdominal pain and headaches Olanzapine can be administered as an oral disolving tablets, intramuscular or intravenous injection Because Zyprexa is an atypical antipsychotic, it has a lower risk for tardive dyskinesia and akathisia Olanzapine may cause transient rises in glucose and should be considered when contemplating use in a diabetic References Olanzapine for the prevention and treatment of cancer-related nausea and vomiting in adults.Sutherland A, Naessens K, Plugge E, Ware L, Head K, Burton MJ, Wee B. Cochrane Database Syst Rev. 2018;9:CD012555. Epub 2018 Sep 21. Silberstein, S.D., Peres, M.F., Hopkins, M.M., Shechter, A.L., Young, W.B. and Rozen, T.D. (2002), Olanzapine in the Treatment of Refractory Migraine and Chronic Daily Headache. Headache: The Journal of Head and Face Pain, 42: 515-518. doi:10.1046/j.1526-4610.2002.02126. Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

Contributor: Rachel Beham, PharmD Educational Pearls: Coricidin HBP Cough & Cold (dextromethorphan and chlorpheniramine) is one of the more commonly abused over-the-counter medications Dextromethorphan, binds to multiple receptors, particularly at high doses Opioid receptors, causing respiratory depression, CNS depression NMDA receptors, causing agitation and hallucinations Serotonin-reuptake inhibition, which may lead to serotonin syndrome, especially when combined with other agents Dextromethorphan also contains bromide, which when chronically abused can lead to bromism (behavioral changes, hallucinations, weight loss, and neurologic changes) Chlorpheniramine is an antihistamine and can cause anticholinergic effects in overdose, such agitation, hyperthermia, and hallucinations Acute treatment of Coricidin abuse is mostly supportive, which may include benzodiazepines, naloxone, dialysis, sodium bicarbonate, and physostigmine depending on the predominate toxidrome and symptoms present References Ritter D, Ouellette L, Sheets JD, Riley B, Judge B, Cook A, Houseman J, Jones JS. "Robo-tripping": Dextromethorphan toxicity and abuse. Am J Emerg Med. 2019 Nov 17. pii: S0735-6757(19)30655-2. doi: 10.1016/j.ajem.2019.10.001. Bryner JK, Wang UK, Hui JW, Bedodo M, MacDougall C, Anderson IB. Dextromethorphan abuse in adolescence: an increasing trend: 1999-2004. Arch Pediatr Adolesc Med. 2006;160(12):1217–1222. doi:10.1001/archpedi.160.12.1217 Monks S, Yen M, Myers J. Bromism: An overlooked and elusive toxidrome from chronic dextromethorphan abuse. Am J Emerg Med. 2019 Nov 15:158491. doi: 10.1016/j.ajem.2019.158491. Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

Contributor: Jared Scott, MD Educational Pearls: A distal 5th metacarpal neck fracture is often referred to as a "boxer's fracture" and a common fracture encountered in the emergency department Splinting with an ulnar gutter splint is the typical management of uncomplicated boxer's fractures A recent study randomized patients to buddy taping or ulnar gutter splint for uncomplicated Boxer's fractures. Similar functional and pain outcomes were found at follow-up, and those in the buddy taping group returned to work more quickly. One limitation was nearly 20% of study patients were lost to follow up Editor's note: remember - this only applies to a true boxer's fracture, which is a distal 5th metacarpal neck fracture, not just any 5th metacarpal shaft fracture References Richard Pellatt, Igor Fomin, Carli Pienaar, Randipsingh Bindra, Michael Thomas, Ezekiel Tan, Cindy Mervin, Ping Zhang, Gerben Keijzers. Is Buddy Taping as Effective as Plaster Immobilization for Adults With an Uncomplicated Neck of Fifth Metacarpal Fracture? A Randomized Controlled Trial, Annals of Emergency Medicine, Volume 74, Issue 1, 2019, Pages 88-97, Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

Contributor: Don Stader, MD Educational Pearls: High-quality compressions are an essential, and probably one of the most important, part of cardiac arrest Actual evidence for drugs in cardiac arrest included in ACLS are limited, including epinephrine, bicarbonate, amiodarone, etc. Early defibrillation for ventricular tachycardia (VT) or ventricular fibrillation (VF) has a plethora of supporting evidence Double-sequential defibrillation (nearly simultaneous defibrillation using 2 machines) may be considered for refractory dysrhythmias like VF tPA during a cardiac arrest can be considered in the setting of massive PE (although the evidence supporting this practice is poor) Ending a cardiac arrest resuscitation is a difficult decision and use of ultrasound may be helpful to assess for meaningful cardiac function/activity References Link MS, Berkow LC, Kudenchuk PJ, Halperin HR, Hess EP, Moitra VK, Neumar RW, O'Neil BJ, Paxton JH, Silvers SM, White RD, Yannopoulos D, Donnino MW . Part 7: Adult Advanced Cardiovascular Life Support: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015 Nov;132(18 Suppl 2):S444-64. Wang Y, Wang M, Ni Y, Liang B, Liang Z. Can Systemic Thrombolysis Improve Prognosis of Cardiac Arrest Patients During Cardiopulmonary Resuscitation? A Systematic Review and Meta-Analysis.J Emerg Med. 2019;57(4):478. Epub 2019 Oct 5. Eric Cortez, William Krebs, James Davis, David P. Keseg, Ashish R. Panchal. Use of double sequential external defibrillation for refractory ventricular fibrillation during out-of-hospital cardiac arrest. Resuscitation. Volume 108. 2016. Pages 82-86, Atkinson PR, Beckett N, French J, Banerjee A, Fraser J, Lewis D. Does Point-of-care Ultrasound Use Impact Resuscitation Length, Rates of Intervention, and Clinical Outcomes During Cardiac Arrest? A Study from the Sonography in Hypotension and Cardiac Arrest in the Emergency Department (SHoC-ED) Investigators. Cureus. 2019;11(4):e4456. Published 2019 Apr 13. doi:10.7759/cureus.4456 Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

Dr. Vivek Tayal of Carolinas Medical Center, a pioneer of using ultrasound in the emergency department, reflects on his role in establishing ultrasound use in emergency medicine and much more! Ultrasound Program Management: https://www.amazon.com/Ultrasound-Program-Management-Point-Care/dp/3319631411 Intro Music: Backbay Lounge Kevin MacLeod (incompetech.com) Licensed under Creative Commons: By Attribution 3.0 License http://creativecommons.org/licenses/by/3.0/

Contributor: Dylan Luyten, MD Educational Pearls: Clear the nasal passages - have the patient, if stable, blow their nose to dislodge any clot that might be in the way Searching for the source of bleeding can be tough. Majority of anterior bleeding is from Kesselbach's plexus Placing a clamp to provide direct pressure is a mainstay of treatment Application of a topical agent, which may include lidocaine epinephrine tetracaine (LET), tranexamic acid (TXA), or oxymetazoline Nasal packing with a nasal balloon or merocel may be necessary if bleeding persists Posterior epistaxis can be potentially devastating - for all practical purposes are epistaxis that does not resolve with anterior packing Interventional radiology can be a helpful consultant for controlling of posterior epistaxis, and may be just as or more helpful than ENT References Supriya M, Shakeel M, Veitch D, Ah-See K. Epistaxis: prospective evaluation of bleeding site and its impact on patient outcome. J Laryngol Otol. 2010;124(7):744-749. Shargorodsky J, Bleier B, Holbrook E, et al. Outcomes analysis in epistaxis management: development of a therapeutic algorithm. Otolaryngol Head Neck Surg. 2013;149(3):390-398. Singer A, Blanda M, Cronin K, et al. Comparison of nasal tampons for the treatment of epistaxis in the emergency department: a randomized controlled trial. Ann Emerg Med. 2005;45(2):134-139. Womack JP, Kropa J Jimenez Stabile M. Epistaxis: Outpatient Management. Am Fam Physician. 2018 Aug 15;98(4):240-245. Liu WH, Chen YH, Hsieh CT, Lin EY, Chung TT, Ju DT. Transarterial embolization in the management of life-threatening hemorrhage after maxillofacial trauma: a case report and review of literature. Am J Emerg Med. 2008 May;26(4):516.e3-5. doi: 10.1016/j.ajem.2007.07.036. Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

Contributor: Aaron Lessen, MD Educational Pearls: Emergency department evaluation of falls, particularly in the elderly, should include an assessment of risk factors Common causes of falls in the elderly include medications. Review medication list for sedating medications amongst others Consult with your hospital physical therapist to discuss fall prevention techniques with the patient One study has shown that a comprehensive interdisciplinary approach to geriatric falls in the ED can reduce return visits and hospital admissions. References Caplan GA, Williams AJ, Daly B, Abraham K. A randomized, controlled trial of comprehensive geriatric assessment and multidisciplinary intervention after discharge of elderly from the emergency department--the DEED II study. J Am Geriatr Soc. 2004;52(9):1417–23. Albert M, Rui P, McCaig LF. Emergency department visits for injury and illness among adults aged 65 and over: United States, 2012-2013. NCHS Data Brief. 2017;(272):1–8. Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

In the first episode of this new series, the complexities of decision making capacity are discussed. References and Further Reading: [1] Appelbaum, P. S. (2007). Assessment of patients' competence to consent to treatment. New England Journal of Medicine, 357(18), 1834-1840. [2] Etchells, E., Darzins, P., Silberfeld, M., Singer, P. A., McKenny, J., Naglie, G., ... & Strang, D. (1999). Assessment of patient capacity to consent to treatment. Journal of general internal medicine, 14(1), 27-34. Joint Centre for Bioethics - Aid to Capacity Evaluation (ACE)