Emergency Medical Minute

Author: Jared Scott, MD Educational Pearls: Study from Hennepin County EM studied the efficacy of different drugs for agitation, which included 737 patients Most patients in this study were male and *surprise* drunk Compared doses of common sedatives with primary outcome of sedation at 15 minutes (all intramuscular) haloperidol 5 mg ziprasidone 20 mg olanzapine 10 mg midazolam 5 mg haloperidol 10 mg with the main outcome of agitation at 15 minutes Intramuscular midazolam resulted in the lowest level of agitation at 15 minutes, followed by ziprasidone. There were no differences in adverse effects. References Klein LR, Driver BE, Miner JR, Martel ML, Hessel M, Collins JD, Horton GB, Fagerstrom E, Satpathy R, Cole JB. Intramuscular Midazolam, Olanzapine, Ziprasidone, or Haloperidol for Treating Acute Agitation in the Emergency Department. Ann Emerg Med. 2018 Oct;72(4):374-385. doi: 10.1016/j.annemergmed.2018.04.027. Epub 2018 Jun 7. PubMed PMID: 29885904. Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

Treatment with buprenorphine is easier, less time consuming and far more effective for management of opioid withdrawal and OUD than standard care with clonidine, IVF, haldol and other symptomatic therapies. Induction with buprenorphine is easy, requires no IV or labs, and is usually accomplished in 1-2 hours. It requires a chair, not a hospital bed. To identify patients who are candidates, be sure they're in sufficient opioid withdrawal using clinical impression or the COWS scale, obtain a history of type of opioid use and time of last use and any prior experience with buprenorphine, and confirm patient consent for buprenorphine induction. Precipitated withdrawal is a risk with induction if a patient is not sufficiently in withdrawal. Consensus on the treatment of precipitated withdrawal will require further study. Some protocols recommend stopping buprenorphine if withdrawal symptoms worsen, while others recommend treatment with additional doses of buprenorphine in addition to symptomatic meds. Patients should be discharged with overdose education, naloxone and a plan for close follow-up with a warm handoff to an OTP or OBOT. For adolescents 16 years old or older with OUD, buprenorphine is an option. For pregnant women, buprenorphine is a life-saver for both fetus and mother. ED providers can be part of the solution to the opioid epidemic. Consistent appropriate use of buprenorphine in the ED has the potential to transform ED care of patients with OUD. Click HERE for more information.

There are three MAT drugs available to treat addiction: naltrexone (brand name Vivitrol), methadone (brand names Dolophine or Methadose) & buprenorphine (brand name Suboxone, Subutex, and Sublicade). The only MAT drug appropriate for initiation in the ED is buprenorphine. Buprenorphine is a semi-synthetic opioid which acts as partial agonist at the mu receptor. Buprenorphine does not produce as much euphoria or as much of the respiratory depression seen with other opioids. It has a quick onset and long half-life and is usually administered sublingually. The most commonly used formulation of buprenorphine is mixed with naloxone for one reason and one reason only - to prevent diversion and IV drug use. When taken orally, the buprenorphine effect is predominant; when taken IV, the naloxone effect is predominant Any ED provider can administer buprenorphine in the ED for up to 3 consecutive days in order to bridge a patient to addiction services. X-Waivers allow you to prescribe buprenorphine from the ED, which is a great service you can provide your patients, particularly in rural communities. In 2019 ACEP will be producing an ED physician specific X-Waiver training which will focus exclusively on ED-based care. Click HERE for more information

Medication Assisted Treatment or (Medication for Addiction Treatment) is an important frontier in ED care of patients with Opioid Use Disorder. Naltrexone, methadone and buprenorphine are the medications approved for the treatment of OUD. Addiction is a disease that is widely misunderstood and rarely taught in medical school. It is a dangerous myth that the best treatment of all addictions is simply abstinence. The evolving consensus around OUD is that is best treated with medication. An opioid addiction should be treated with an opioid agonist. MAT is shown to substantially decrease mortality and morbidity for OUD. The treatment gap for OUD is egregious--as high as 75% in Colorado. Emergency department providers can be part of the solution to this problem by understanding and, when indicated, initiating proper treatment for OUD. Click HERE for more information

Addiction is widely misunderstood by the public and by many healthcare providers. It is not taught in most medical schools. Combating the opioid epidemic will require providers to understand Opioid Use Disorder (OUD) and its treatment. Addiction is a chronic, relapsing disease with extraordinarily high morbidity and mortality. It is the transition from controlled to impulsive and compulsive drug intake. Physiologic dependence is just one aspect of addiction. The behavioral and social derangements seen in addiction are the major source of harm for people with substance use disorders. Addiction is not a personal failure of will. The role of genetics and environment are enormous. It is more useful to think of addiction as a kind of "brain failure." Dopamine and different dopaminergic systems are severely affected by drug use, resulting in chronic changes and even death to areas of the brain. We do not stigmatize patients with diabetes or CHF for life choices contributing to their disease, nor do we refuse them care or make their care conditional on their behavior. We treat them. Opioid use disorder is a treatable disease. It is time that ED providers start treating it. Click HERE for more information

Author: Dave Saintsing Educational Pearls: Poor sleep is an independent risk factor for development of health problems such as type 2 diabetes. A 2019 study, randomized participants to 3 groups: 9 hours of sleep, 5 hours of sleep with weekend catch-up sleep, and 5 hours of sleep without catch-up sleep. In the sleep deprived (5 hour) groups, there was significantly more insulin resistance, calorie intake, and weight gain regardless of catch-up sleep. Tramadol is prescribed 25 million times a year in the USA, usually to avoid prescribing traditional opiates such as Percocet or Oxycodone. Tramadol has complex pharmacology in that is is both an SNRI and mu-opiate agonist after metabolism in the liver. The pharmacogenetics of this vary greatly between people. Many people have rapid metabolism that will lead to increased opiate effects. Other medications interfere with metabolism (such as SSRI's). A recent study demonstrated increased risk of hypoglycemia in diabetics taking Tramadol. Use caution when prescribing this drug. Sepsis resuscitation has traditionally been gauged by following lactate levels on the presumption that lactate is an adequate marker of organ perfusion. Unfortunately, lactate levels are often elevated by medications and other health conditions such as kidney or liver disease, making lactate an often ineffective biomarker for perfusion. The Andromeda-Shock trial compared using capillary refill to lactate as guides for resuscitation with the primary endpoint of reducing 28-day mortality. The capillary refill group had a 9% absolute risk reduction in mortality, but this did not reach statistical significance. However, capillary refill can be used as another data point while resuscitating your septic patients. When should you start pressors for patients in septic shock? A 2019 study compared routine resuscitation (30cc/kg fluid bolus) to initiation of norepinephrine with the first 30cc/kg crystalloid. They found that the early pressor group had significantly more "shock control" (MAP>65) at 6 hours, compared to the control group. While there was a trend towards less mortality in the early pressor group, it was not statistically significant. Keep an eye out for more studies in this area! A recent study in JAMA found that 88% of deaths from sepsis were unavoidable, due to severe chronic comorbidities. Remember that patients will still die from septic shock despite your best efforts and knowledge of the newest literature. References Depner CM, Melanson EL, Eckel RH, Snell-Bergeon JK, Perreault L, Bergman BC, Higgins JA, Guerin MK, Stothard ER, Morton SJ, Wright KP Jr. Curr Biol. 2019 Feb 11. pii: S0960-9822(19)30098-3. doi: 10.1016/j.cub.2019.01.069. [Epub ahead of print]. PMID:30827911. Fournier J, Azoulay L, Yin H, Montastruc J, Suissa S. Tramadol Use and the Risk of Hospitalization for Hypoglycemia in Patients With Noncancer Pain. JAMA Intern Med. 2015;175(2):186–193. doi:10.1001/jamainternmed.2014.6512 Hernández G, Ospina-Tascón GA, Damiani LP, et al. Effect of a Resuscitation Strategy Targeting Peripheral Perfusion Status vs Serum Lactate Levels on 28-Day Mortality Among Patients With Septic Shock: The ANDROMEDA-SHOCK Randomized Clinical Trial. JAMA. Published online February 17, 2019321(7):654–664. doi:10.1001/jama.2019.0071 Permpikul C, Tongyoo S, Viarasilpa T, Trainarongsakul T, Chakorn T, Udompanturak S. Early Use of Norepinephrine in Septic Shock Resuscitation (CENSER). A Randomized Trial. Am J Respir Crit Care Med. 2019 May 1;199(9):1097-1105. doi: 10.1164/rccm.201806-1034OC. Rhee C, Jones TM, Hamad Y, et al. Prevalence, Underlying Causes, and Preventability of Sepsis-Associated Mortality in US Acute Care Hospitals. JAMA Netw Open. Published online February 15, 20192(2):e187571. doi:10.1001/jamanetworkopen.2018.7571 Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD From CarePoint PA Academy, 2019

Podcast # 499: Posterior Circulation Strokes Contributor: Neal O'Connor, MD Educational Pearls: Dizziness is a very common complaint in the emergency department, but how can we find patients with a dangerous cause of their symptoms, namely a posterior circulation stroke? Consider a posterior circulation stroke in those with an abrupt onset of headache with neck pain, balance problem, blurred vision, or dysphagia Thorough cranial nerve exam can be important to screen for posterior circulation stroke, as much of the brainstem is supplied by the posterior circulation. The most common posterior circulation stroke is a lateral medullary infarct (Wallenberg Syndrome), which produces dysphagia due to cranial nerve IX and XII involvement Other physical exam findings include truncal ataxia, extremity ataxia, visual field cuts, and Horner syndrome (Ptosis, Miosis, Anhidrosis) The HINTS exam (Head Impulse - Nystagmus - Test of Skew)can be used to differentiate between peripheral and central causes of dizziness Concerning exam findings for central cause may include vertical nystagmus, gaze skew, or inability to track with head impulse References Áine Merwick, David Werring. Posterior circulation ischaemic stroke. BMJ 2014;348:g3175 doi: 10.1136/bmj.g3175 Kattah JC, Talkad AV, Wang DZ, Hsieh YH, Newman-Toker DE. HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging. Stroke. 2009;40(11):3504–3510. doi:10.1161/STROKEAHA.109.551234 Nouh A, Remke J, Ruland S. Ischemic posterior circulation stroke: a review of anatomy, clinical presentations, diagnosis, and current management. Front Neurol. 2014;5:30. Published 2014 Apr 7. doi:10.3389/fneur.2014.00030 From CarePoint PA Academy, 2019

Author: Susan Ryan, DO Educational Pearls: General orthopedic principles: Examine above and below the injury Document neurovascular status X-ray imaging typically requires three different views Fracture description should include name the bone, location of fracture, degree of displacement, and if it is closed or open Osgood-Schlatter (tibia) and Sever's (calcaneus) disease are apophyseal injuries caused by ligaments that are "stronger" than the bones they attach to When looking for scaphoid injuries, get extra (turned) views of the wrist. Remember that the scaphoid has a reverse blood flow and is prone to avascular necrosis Acute carpal tunnel syndrome can occur in forearm fractures. Again, don't forget your neuro exam. Distal radial-ulnar joint (DRUJ) injuries are caused by tears in the ligaments that stabilize the wrist. They cause chronic pain with pronation and supination. Posterior effusions in the elbow in the 90 degree view nearly always indicate a fracture Lisfranc injuries are commonly missed, especially if the mechanism is perceived as low energy. Look for the "fleck sign", which is an avulsion fracture at the base of 2nd metatarsal Syndesmotic injuries of the ankle (a high ankle sprain) can be identified through the squeeze test Knee dislocations are neurovascular emergencies

Author: Dylan Luyten, MD Educational Pearls: While certain aspects of the history, exam, and EKG may increase likelihood of ACS, there is no one element that performs well on its own Elements of the history have been found to have different likelihood ratios, which can increase or decrease the probability of a patient having ACS Likelihood ratios greater than one increase the chance of the patient having the disease. Ratios less than one decrease it Bilateral arm radiation is one of very few historical features that increases the likelihood of ACS ST depressions are one of the few EKG findings with a high LR for ACS Scoring systems such as the HEART score can be useful to risk stratify your patients References Fanaroff AC, Rymer JA, Goldstein SA, Simel DL, Newby LK. Does This Patient With Chest Pain Have Acute Coronary Syndrome?: The Rational Clinical Examination Systematic Review. JAMA. 2015 Nov 10;314(18):1955-65. doi: 10.1001/jama.2015.12735. Review. PubMed PMID: 26547467. Backus BE, Six AJ, Kelder JC, Bosschaert MA, Mast EG, Mosterd A, Veldkamp RF, Wardeh AJ, Tio R, Braam R, Monnink SH, van Tooren R, Mast TP, van den Akker F, Cramer MJ, Poldervaart JM, Hoes AW, Doevendans PA. A prospective validation of the HEART score for chest pain patients at the emergency department. Int J Cardiol. 2013 Oct 3;168(3):2153-8. doi: 10.1016/j.ijcard.2013.01.255. Epub 2013 Mar 7. PubMed PMID: 23465250. From CarePoint PA Academy, 2019

Author: David Holland, MD Educational Pearls: Hallucinogenics have been used for a variety of cultural and religious reasons for thousands of years In the 1960's a Harvard professor began experimenting with psilocybin mushrooms. There was resulting public outcry, eventually leading to all hallucinogens being listed as schedule I drugs Common hallucinogens include: LSD (acid), Mescaline (peyote), DMT (ayahuasca), Psilocybin (mushrooms), MDMA (ecstacy) Effects vary by specific drug but may include auditory/visual hallucinations, increased empathy, loss of fear Physiologic effects often include mydriasis, tachycardia, hyperthermia and hypertension Recent neuroimaging studies have shown increased neural connectivity in people after administration of hallucinogens Each hallucinogen has a specific dose and duration, some can last half a day or more References Heal DJ, Gosden J, Smith SL. Evaluating the abuse potential of psychedelic drugs as part of the safety pharmacology assessment for medical use in humans.Neuropharmacology. 2018 Nov;142:89-115. doi: 10.1016/j.neuropharm.2018.01.049. Epub 2018 Feb 8. Review. PubMed PMID: 29427652. Garcia-Romeu A, Kersgaard B, Addy PH. Clinical applications of hallucinogens: A review. Exp Clin Psychopharmacol. 2016 Aug;24(4):229-68. doi: 10.1037/pha0000084. Review. PubMed PMID: 27454674; PubMed Central PMCID: PMC5001686. Bogenschutz MP, Johnson MW. Classic hallucinogens in the treatment of addictions.Prog Neuropsychopharmacol Biol Psychiatry. 2016 Jan 4;64:250-8. doi: 10.1016/j.pnpbp.2015.03.002. Epub 2015 Mar 14. Review. PubMed PMID: 25784600. From CarePoint PA Academy