Emergency Medical Minute

Author: Rachel Brady, MD Educational Pearls: Elderly patients (>65 years old) have a higher trauma mortality compared to younger patients, even though they have lower mechanisms of injury Elder trauma is often under-triaged due to low-energy mechanisms and lack of physiologic response due to age and medications such as beta-blockers. Do not be reassured by normal vital signs. Image elderly patients with head injury aggressively since they are at high risk of intracranial bleeds Be sure to ask about anticoagulation use. Up to 15% of asymptomatic head injury patients on warfarin will have intracranial bleeds on CT. Be on the lookout for unstable C-spine injuries such as type II odontoid fractures Central cord syndrome is a possibility with any neck extension injury Rib fractures are common, with mortality increasing greatly with more than 2 ribs involved The elderly are more prone to musculoskeletal injuries due to loss of bone density Always discuss goals of care with these patients References Rathlev NK, Medzon R, Lowery D, Pollack C, Bracken M, Barest G, Wolfson AB, Hoffman JR, Mower WR. Intracranial pathology in elders with blunt head trauma. Acad Emerg Med. 2006 Mar;13(3):302-7. doi: 10.1197/j.aem.2005.10.015. PubMed PMID: 16514123. Keller JM, Sciadini MF, Sinclair E, O'Toole RV. Geriatric trauma: demographics, injuries, and mortality. J Orthop Trauma. 2012 Sep;26(9):e161-5. doi: 10.1097/BOT.0b013e3182324460. PubMed PMID: 22377505. Bulger EM, Arneson MA, Mock CN, Jurkovich GJ. Rib fractures in the elderly. J Trauma.2000 Jun;48(6):1040-6; discussion 1046-7. doi: 10.1097/00005373-200006000-00007. PubMed PMID: 10866248. Hashmi A, Ibrahim-Zada I, Rhee P, Aziz H, Fain MJ, Friese RS, Joseph B. Predictors of mortality in geriatric trauma patients: a systematic review and meta-analysis. J Trauma Acute Care Surg. 2014 Mar;76(3):894-901. doi: 10.1097/TA.0b013e3182ab0763. Review. PubMed PMID: 24553567. Brooks SE, Peetz AB. Evidence-Based Care of Geriatric Trauma Patients. Surg Clin North Am. 2017 Oct;97(5):1157-1174. doi: 10.1016/j.suc.2017.06.006. Review. PubMed PMID: 28958363.

Contributor: JP Brewer, MD Educational Pearls: Obtaining collateral is often vital to determine the potential drugs accessible to the patient - this may include After this, use ancillary sources such as EMS, family/friends, and police to determine the patient's last normal, PMH and medications To help separate toxidromes, pupillary exam and skin exam are helpful Important physical exam clues in toxicology include the pupils and the skin Adjunct laboratory evaluation may include liver function tests, acetaminophen level, salicylate levels, urine drug screens, particularly in unknown ingestions Your local toxicologist (if you are fortunate to have one) or the Poison Center can always provide assistance in treatment and workup - consider involving them early References Erickson TB, Thompson TM, Lu JJ. The approach to the patient with an unknown overdose. Emerg Med Clin North Am 2007; 25:249.

Contributor: JP Brewer, MD Educational Pearls: Because of their smaller size, there are a variety of adult-dose pills that are potentially toxic to children. The most common categories of medications that may be toxic include cardiac, diabetic, pain, psychiatric, anti-malarial, and herbals/caustics Oral hypoglycemics such as sulfonylureas can be particularly dangerous in children. Opiates and benzodiazepines have the potential for respiratory arrest Anti-malarial medications are arrhythmogenic to children Camphor, batteries, oil of wintergreen (for the salicylate), and household caustic materials are dangerous non-pharmacologic ingestions to think about in children If you encounter any of the above situations, consult your local poison control center 1-800-222-1222 or your toxicologist if you are lucky enough to have one on call References https://www.acep.org/how-we-serve/sections/toxicology/news/march-2016/one-pill-or-sip-can-kill/ Schillie SF, Shehab N, Thomas KE, Budnitz DS. Medication overdoses leading to emergency department visits among children. Am J Prev Med 2009;37:181-7. Oz B, Levichek Z, Koren G. Medications That Can Be Fatal For a Toddler with One Tablet or Teaspoonful A 2004 Update. Pediatric Drugs, 2004; 6(2): 123-126

Contributor: Don Stader, MD Educational Pearls: Buprenorphine is a partial Mu-agonist and binds with higher affinity than most opioids Pain management with opioids therefore can be difficult in patients taking buprenorphine Ketamine is a good option for pain control in these patients You can also consider using additional buprenorphine Intravenous buprenorphine is dosed differently than oral formulations Consider receptor availability - patients on high doses of buprenorphine (32mg) will have few Mu receptors available, and thus will likely not benefit from opiate pain meds of any kind References Alford DP, Compton P, Samet JH. Acute pain management for patients receiving maintenance methadone or buprenorphine therapy. Ann Intern Med. 2006;144(2):127–134. Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

Educational Pearls: Buprenorphine is a semi-synthetic derivative of the opium poppy FDA approved for the treatment of opiate use disorder and chronic pain Benefit in emergency department use is the ceiling effect - producing less euphoria as well as respiratory depression with higher doses It has an onset of 30-60 minutes, peak effect at 1-4 hours Duration of action depends is dose dependent, typically 6-12 hours, but can be as long as 24-72 hours in doses over 16 mg Use buprenorphine in those in moderate to severe opiate withdrawal Clinical Opioid Withdrawal Scale (COWS) can be used to assess and score severity of withdrawal A reasonable starting dose is 8mg. A second dose can be given after an hour, ranging from 8-24 mg depending on symptoms still present Buprenorphine can induce withdrawals so someone needs to be in true withdrawals for it to provide benefit References https://www.mdcalc.com/cows-score-opiate-withdrawal https://ed-bridge.org Herring AA, Perrone J, Nelson LS. Managing Opioid Withdrawal in the Emergency Department With Buprenorphine. Ann Emerg Med. 2019 May;73(5):481-487. doi: 10.1016/j.annemergmed.2018.11.032. Epub 2019 Jan 5. Review. PubMed PMID: 30616926. Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

Contributor: Don Stader, MD Educational Pearls: Syncope is usually benign but can be caused by serious etiologies which include: PE, certain cardiac arrhythmias, AAA, intracranial bleed/stroke The Canadian Syncope Rule appears to identify those patients with syncope and low risk of serious outcomes The score is based on vital signs, EKG and history Negative scores preclude a very low risk of adverse events A calculated score greater than 1 are considered medium risk Scores greater than 4 are high risk Anyone with a medium risk or higher should have their cause thoroughly investigated - which may involve admission or a shared decision making utilizing this rule if discharged Editor's note: just remember this rule has not been externally validated… yet References https://www.mdcalc.com/canadian-syncope-risk-score Thiruganasambandamoorthy V, Kwong K, Wells GA, et al. Development of the Canadian Syncope Risk Score to predict serious adverse events after emergency department assessment of syncope. CMAJ. 2016;188(12):E289–E298. doi:10.1503/cmaj.151469 Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

Contributor: Jared Scott, MD Educational Pearls: The CDC recommends rabies prophylaxis if there was a direct encounter with a possibly rabid animal except... Bats are treated differently since their bites may be very superficial and not seen/felt. All people with possible close encounters with a bat should receive rabies prophylaxis From 1990-2007 there were 34 rabies cases associated with bats: 6 of these had a reported bat bite 15 there was a reported exposure but no reported bite 11 had no reported bat exposure but DNA testing revealed that the rabies came from a bat References Pieracci EG, Pearson CM, Wallace RM, Blanton JD, Whitehouse ER, Ma X, Stauffer K, Chipman RB, Olson V. Vital Signs: Trends in Human Rabies Deaths and Exposures - United States, 1938-2018. MMWR Morb Mortal Wkly Rep. 2019 Jun 14;68(23):524-528. doi: 10.15585/mmwr.mm6823e1. PubMed PMID: 31194721; PubMed Central PMCID: PMC6613553. https://www.cdc.gov/rabies/specific_groups/doctors/index.html Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

Contributor: Nick Hatch, MD Educational Pearls: Dalbavancin (Dalvance®) is an antibiotic that can be used for skin and soft tissue infections, providing MRSA coverage It cannot be used in other infections or sepsis Dalbavancin may be appealing as a single dose lasts about 2 weeks Expense is currently a large barrier to use Patients with a vancomycin allergy will likely be allergic to Dalbavancin as the two are related References Patel M, Smalley S, Dubrovskaya Y, Siegfried J, Caspers C, Pham V, Press RA, Papadopoulos J. Dalbavancin Use in the Emergency Department Setting. Ann Pharmacother. 2019 Jun 3;:1060028019855159. doi: 10.1177/1060028019855159. [Epub ahead of print] PubMed PMID: 31155916. Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

Contributor: Michael Hunt, MD Educational Pearls: Due to the efficacy of vaccination, epiglottitis is now more common in adults than children Risk factors include smoking and other immunocompromising co-morbidities, such as diabetes Epiglottitis can present with sore throat and fever, with potential rapid progression to respiratory distress and stridor Diagnosis can include x-ray to look for the "thumbprint sign," nasofiberoptics, and/or CT Antibiotics are mainstay of treatment but severe cases may need establishment of a definitive airway, typically done with fiberoptics in the operating room due to the potential to irritate the epiglottitis with traditional laryngoscopy References Li RM, Kiemeney M. Infections of the Neck. Emerg Med Clin North Am. 2019 Feb;37(1):95-107. doi: 10.1016/j.emc.2018.09.003. Review. PubMed PMID: 30454783. Tsai YT, Huang EI, Chang GH, Tsai MS, Hsu CM, Yang YH, Lin MH, Liu CY, Li HY. Risk of acute epiglottitis in patients with preexisting diabetes mellitus: A population-based case-control study. PLoS One. 2018;13(6):e0199036. doi: 10.1371/journal.pone.0199036. eCollection 2018. PubMed PMID: 29889887; PubMed Central PMCID: PMC5995441. Guerra AM, Waseem M. Epiglottitis. [Updated 2018 Nov 15]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430960/ Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

Contributor: Nick Hatch, MD Educational Pearls: True morel mushrooms are commonly foraged The false morel mushroom (Gyromitra esculenta) looks similar to the true morel, but is toxic False morel mushroom toxicity can cause gastrointestinal symptoms as well as liver failure, rhabdomyolysis, and seizures Seizures can be refractory to benzodiazepine therapy and may require use of vitamin B6 and propofol References Horowitz KM, Horowitz BZ. Gyromitra Mushroom Toxicity. [Updated 2019 May 12]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470580/ Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD