Emergency Medical Minute

Contributor: Jared Scott, MD Educational Pearls In a 4 yr period at 2 hospital systems, unprofessional behavior of surgeons was monitored via a complaint system. Number of complaints was compared with surgical complications. In 13000 patients over this period, the number of surgical complications was found to vary with the number of complaints. Surgeons with with zero complaints had a 10% complication rate, 1-3 complaints had a 14% rate, and those with >4 and an 11.9% rate. There was statistical significance that persisted after adjustment for a variety of patient factors It never hurts to be professional! References Cooper WO, Spain DA, Guillamondegui O, et al. Association of Coworker Reports About Unprofessional Behavior by Surgeons With Surgical Complications in Their Patients. JAMA Surg. 2019;154(9):828–834. doi:https://doi.org/10.1001/jamasurg.2019.1738 Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

Contributor: Dylan Luyten, MD Educational Pearls: Bag-valve masks (BVM) typically have a port to connect O2 to. Unfortunately room air becomes entrained in the mask, reducing the FiO2 delivered to the patient. This can be overcome by using a PEEP (positive end-expiratory pressure) valve on the BMV PEEP valves function by keeping alveoli open in the lungs at the end of expiration. This increases the oxygen diffusing ability of the lungs, keeping patients' oxygen saturations higher. Patients who are critically ill can become quickly hypoxic after RSI meds due to reduced functional residual lung capacity - an issue that can be overcome with a PEEP valve PEEP also will reduce work of breathing in COPD and CHF patients References Bucher JT, Cooper JS. Bag Mask Ventilation (Bag Valve Mask, BVM) [Updated 2019 Jul 30]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441924/ Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

Lisa Raville and Dr. Josh Blum, two pioneers of harm reduction in Denver, discuss the addiction crisis, the current state of harm reduction and how it will evolve in the future. 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: Erik Verzemnieks, MD Educational Pearls: Important to realize complications can occur in the post-opioid overdose patient regardless of cause Narcan administration has been associated with non-cardiogenic pulmonary edema, although the mechanism of this is not quite known Symptoms include progressive shortness of breath and hypoxia. Treatment is with positive-pressure ventilation and diuresis, similar to cardiogenic causes Though rare, it would appear this typically resolves with treatment Reference Jiwa N, Sheth H, Silverman R. Naloxone-Induced Non-Cardiogenic Pulmonary Edema: A Case Report. Drug Saf Case Rep. 2018;5(1):20. Published 2018 May 10. doi:10.1007/s40800-018-0088-x All by Erik Verzemnieks, MD

Contributor: Jared Scott, MD Educational Pearls: Non-accidental trauma (NAT) to children is commonly missed by medical providers Try to remember TEN-4-FACES as a useful aide for concerning patterns that may reflect NAT: Torso, ears, neck and any bruising in child 4 months or longer Frenulum, angle of the mandible, cheek, eyes, sclera References Pierce MC, Magana JN, Kaczor K, Lorenz DJ, Meyers G, Bennett BL, Kanegaye JT. The Prevalence of Bruising Among Infants in Pediatric Emergency Departments. Ann Emerg Med. 2016 Jan;67(1):1-8. PMID: 26233923. Pierce MC, Kaczor K, Aldridge S, O'Flynn J, Lorenz DJ. Bruising characteristics discriminating physical child abuse from accidental trauma. Pediatrics. 2010 Jan;125(1):67-74. PMID: 19969620. Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

Author: Don Stader, MD Educational Pearls: Suboxone, methadone, and naltrexone are commonly used as treatments for opiate use disorder. Naltrexone is a full mu-opiate receptor antagonist, making acute pain control difficult in patients taking it. Options for pain control in patients on naltrexone include nerve blocks, NSAIDS, ketamine, and high doses of opiates. Of the opiates, Dilaudid (hydromorphone) has the highest affinity for mu-opiate receptors, and will be the most effective. References Vickers AP, Jolly A. Naltrexone and problems in pain management. BMJ. 2006;332(7534):132–133. doi:10.1136/bmj.332.7534.132 Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

Author: John Winkler, MD Educational Pearls: The plague (black death) is caused by the Yersinia Pestis bacteria. This bacteria is spread by fleas and carried by rats. It is very contagious and only needs ~ 100 bacteria to cause an infection. The pulmonary form presents with cough, fever, night sweats, hemoptysis and has a near 100% fatality rate if not treated in the first day of symptoms The bubonic form causes buboes, which are necrotic, purulent lymph nodes that can lead to sepsis. Prairie dogs are a common carrier in modern times References https://www.cdc.gov/plague/index.html Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

Author: Don Stader, MD Educational Pearls: Abstinence from substances such as tobacco or alcohol are effective strategies to achieve long term sobriety However, abstinence is not an effective strategy for achieving sobriety with opiate use disorder (OUD) Up to 90% of those who use an abstinence-only strategy for OUD will relapse within a month. Attending a rehabilitation facility increases mortality in those with OUD due to decreased tolerance and higher rates of overdose. Medication-assisted therapy (MAT) with naltrexone, buprenorphine or methadone for OUD is supported by evidence, and is the preferred method for achieving remission References Nielsen S, Larance B, Degenhardt L, Gowing L, Kehler C, Lintzeris N. Opioid agonist treatment for pharmaceutical opioid dependent people. Cochrane Database Syst Rev. 2016 May 9;(5):CD011117. doi: 10.1002/14651858.CD011117.pub2. Review. PubMed PMID: 27157143. Medications for Opioid Use Disorder Save Lives. 2019 Mar 30;. doi: 10.17226/25310. Review. PubMed PMID: 30896911. Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD Music credit: "Smooth Lovin" by Kevin MacLoed (incompetech.com). Licensed under Creative Commons By Attribution 3.0 License. http://creativecommons.org/licenses/by/3.0/

Author: Rachel Beham, PharmD Educational Pearls: There are currently many Ebola vaccines that are being studied, and one (recombinant VZV-Ebola vaccine) is currently being used in Africa. This vaccine has so far shown good efficacy in reducing Ebola infections and mortality from Ebola in those who do become infected. There are antibody-based treatments that are currently under investigation for the treatment of Ebola. They have been well tolerated in phase 1 trials and show some promise of efficacy. References Shcheblyakov D et. al. Development and characterization of two GP-specific monoclonal antibodies, which synergistically protect non-human primates against Ebola lethal infection. Antiviral Res. 2019 Oct 5:104617. doi: 10.1016/j.antiviral.2019.104617. [Epub ahead of print] Fries L et. al. A Randomized, Blinded, Dose-Ranging Trial of an Ebola Virus Glycoprotein (EBOV GP) Nanoparticle Vaccine with Matrix-M™ Adjuvant in Healthy Adults. J Infect Dis. 2019 Oct 11. pii: jiz518. doi: 10.1093/infdis/jiz518. [Epub ahead of print] Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD Music credit: "Smooth Lovin" by Kevin MacLoed (incompetech.com). Licensed under Creative Commons By Attribution 3.0 License. http://creativecommons.org/licenses/by/3.0/

Author: John Winkler, MD Educational Pearls: There is a new outbreak of Ebola in The Congo. This is likely due to civil war and rebel attacks on healthcare workers in the area. Ebola is now spreading from the Congo into neighboring Uganda, but vaccination efforts are staving off the spread across the border Early symptoms of Ebola are similar to the flu Spread occurs through close contact with bodily fluids. Proper PPE is required when treating patients with suspected ebola References https://wwwnc.cdc.gov/travel/notices/alert/ebola-democratic-republic-of-the-congo https://www.cdc.gov/vhf/ebola/symptoms/index.html Malvy D, McElroy AK, de Clerck H, Günther S, van Griensven J. Ebola virus disease. Lancet. 2019 Mar 2;393(10174):936-948. doi: 10.1016/S0140-6736(18)33132-5. Epub 2019 Feb 15. Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD Music credit: "Smooth Lovin" by Kevin MacLoed (incompetech.com). Licensed under Creative Commons By Attribution 3.0 License. http://creativecommons.org/licenses/by/3.0/