Emergency Medical Minute

Contributor: Jared Scott, MD Educational Pearls: Cerebellar strokes make up a disproportionate number of missed or delayed diagnosis for stroke likely due to the subtle nature of the presentation Cerebellar strokes can present with vomiting, dizziness, and ataxia. Unlike anterior circulation stroke, exam findings in a cerebellar stroke are ipsilateral to the lesion On neuro exam, findings may include: Dysmetria: lack of coordination with overshooting/undershooting intended position of limb Dysdiadochokinesia: difficulty with rapid alternating movements Ataxia Nystagmus Consider a cerebellar stroke in patients presenting with vomiting and dizziness without an alternative diagnosis References Edlow JA, Newman-Toker DE, Savitz SI. Diagnosis and initial management of cerebellar infarction. Lancet Neurol. 2008 Oct;7(10):951-64. doi: 10.1016/S1474-4422(08)70216-3. Review. PubMed PMID: 18848314. Datar S, Rabinstein AA. Cerebellar infarction. Neurol Clin. 2014 Nov;32(4):979-91. doi: 10.1016/j.ncl.2014.07.007. Epub 2014 Sep 13. Review. PubMed PMID: 25439292. Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

Contributor: Charleen Gnisci, PharmD Educational Pearls: Causes of increased intracranial pressure may include intracranial hemorrhage, malignancy, and trauma. While definite treatment is to remove the offending cause, there are emergency medicine Non-pharmacologic methods include elevating head of bed and removing noxious stimuli Pharmacologic options include mannitol and hypertonic saline Hypertonic saline is best delivered through a central line but not required Both these agents benefit from adequate renal function Before using mannitol, be sure to inspect the bag to ensure that it has not precipitated. If it has, try warming the bag before administration. References https://pulmccm.org/critical-care-review/hyperosmolar-therapy-for-increased-intracranial-pressure-review-nejm/ Burgess S, Abu-Laban RB, Slavik RS, Vu EN, Zed PJ. A Systematic Review of Randomized Controlled Trials Comparing Hypertonic Sodium Solutions and Mannitol for Traumatic Brain Injury: Implications for Emergency Department Management. Ann Pharmacother. 2016 Apr;50(4):291-300. doi: 10.1177/1060028016628893. Epub 2016 Jan 29. Review. PubMed PMID: 26825644. Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

Contributor: Don Stader, MD Educational Pearls: Antiplatelets include aspirin and clopidogrel, and are generally used for arterial clotting (MI, stroke) Anticoagulants such as coumadin, Xarelto, Eliquis are generally used for venous clotting (DVT/PE) Growing data suggests that dual antiplatelet therapy (aspirin+clopidogrel) is superior to aspirin alone in reducing stroke for diagnosed with TIA References: Kheiri B, Osman M, Abdalla A, Haykal T, Swaid B, Ahmed S, Chahine A, Hassan M, Bachuwa G, Al Qasmi M, Bhatt DL. Clopidogrel and aspirin after ischemic stroke or transient ischemic attack: an updated systematic review and meta-analysis of randomized clinical trials. J Thromb Thrombolysis. 2019 Feb;47(2):233-247. doi: 10.1007/s11239-018-1786-z. PubMed PMID: 30511260. Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

Contributor: Michael Hunt, MD Educational Pearls: Tetracycline antibiotics such as minocycline can cause greyish hyperpigmentation This hyperpigmentation can sometimes be reversible but not always Minocycline has been used for its effects in autoimmune and neurological diseases, where it is often taken chronically, which can lead to increased pigmentation References La Placa M, Infusino SD, Balestri R, Vincenzi C. Minocycline-Induced Blue-Gray Discoloration. Skin Appendage Disord. 2017 Aug;3(3):161-162. doi: 10.1159/000469712. Epub 2017 Apr 22. PubMed PMID: 28879193; PubMed Central PMCID: PMC5582477. Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

Contributor: Peter Bakes, MD Educational Pearls: While there are many different types of medical error, one of the most common errors in emergency medicine is failure to diagnose Systematic error in thinking that negatively affects judgement Medical errors are often driven by cognitive biases, which include anchoring, attribution, and availability Anchoring bias occurs when early information leads to premature closure on a single diagnosis. There is subsequent failure to consider alternative diagnoses, even in the face of conflicting new data and test results. Attribution bias occurs when assumptions about personal and medical characteristics are made about a specific group of people. Availability bias occurs when recent experiences drive providers to over or under consider diagnoses. References Croskerry P. Cognitive forcing strategies in clinical decisionmaking. Ann Emerg Med. 2003 Jan;41(1):110-20. doi: 10.1067/mem.2003.22. PubMed PMID: 12514691. Redelmeier DA. Improving patient care. The cognitive psychology of missed diagnoses. Ann Intern Med. 2005 Jan 18;142(2):115-20. doi: 10.7326/0003-4819-142-2-200501180-00010. PubMed PMID: 15657159. https://www.nuemblog.com/blog/cognitive-bias Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

Author: Sam Killian, MD Educational Pearls: Abuse occurs by breathing in volatile substances such as solvents, glues, paints, butane, and propane Inhalants are generally depressants Estimated that 100-125 people die every year in the US from acute inhalant abuse. Short-term effects include memory impairment, slurred speech, diplopia, seizures, and cardiac arrhythmias Long term effects include renal dysfunction, neuropathy, blindness and cognitive blunting Evaluation includes a detailed lung exam, cardiac monitoring, and assessments of oxygenation and renal function Treatment is generally supportive. References Lipari RN. Understanding Adolescent Inhalant Use. 2013;. Review. PubMed PMID: 28722849. Howard MO, Bowen SE, Garland EL, Perron BE, Vaughn MG. Inhalant use and inhalant use disorders in the United States. Addict Sci Clin Pract.2011 Jul;6(1):18-31. Review. PubMed PMID: 22003419; PubMed Central PMCID: PMC3188822. Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

Author: Nick Hatch, MD Educational Pearls: Pregnancy is a hypercoagulable state, which predisposes women to venous thromboembolism, but also elevates levels of circulating d-dimer A recent study evaluated the YEARS protocol in combination of adjusted d-dimer cutoffs in pregnant women to evaluate for DVT and PE Using this protocol, only 1 DVT was missed. No PE's were missed. This protocol has growing evidence as an option in pregnant women in whom you must rule out a DVT/PE but more validating studies are likely necessary References van der Pol LM, Tromeur C, Bistervels IM, Ni Ainle F, van Bemmel T, Bertoletti L, Couturaud F, van Dooren YPA, Elias A, Faber LM, Hofstee HMA, van der Hulle T, Kruip MJHA, Maignan M, Mairuhu ATA, Middeldorp S, Nijkeuter M, Roy PM, Sanchez O, Schmidt J, Ten Wolde M, Klok FA, Huisman MV. Pregnancy-Adapted YEARS Algorithm for Diagnosis of Suspected Pulmonary Embolism. N Engl J Med. 2019 Mar 21;380(12):1139-1149. doi: 10.1056/NEJMoa1813865. PubMed PMID: 30893534. Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

Author: Chris Holmes, MD Educational Pearls: Hallucinogenic drugs have been in use since ancient times for both medical and recreational purposes Ayahausca is an ancient psychedelic with origins in Bolivia that causes intense vomiting followed by a psychedelic experience This and other hallucinogens are gaining gaining interest for their use in depression with some startling positive initial results References https://www.nationalgeographic.com/culture/2019/05/ancient-hallucinogens-oldest-ayahuasca-found-shaman-pouch/ Carhart-Harris RL et. al. Psilocybin with psychological support for treatment-resistant depression: six-month follow-up. Psychopharmacology (Berl). 2018 Feb;235(2):399-408. doi: 10.1007/s00213-017-4771-x. Epub 2017 Nov 8. PubMed PMID: 29119217; PubMed Central PMCID: PMC5813086. Palhano-Fontes F et. al. Rapid antidepressant effects of the psychedelic ayahuasca in treatment-resistant depression: a randomized placebo-controlled trial. Psychol Med. 2019 Mar;49(4):655-663. doi: 10.1017/S0033291718001356. Epub 2018 Jun 15. PubMed PMID: 29903051; PubMed Central PMCID: PMC6378413. Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

Author: Nick Hatch, MD Educational Pearls: Postpolypectomy electrocoagulation syndrome (PES) is a rare complication of polypectomy and electrocautery during colonoscopy Occurs when cautery causes transmural thickening from a contact burn Patients can present as if they have peritonitis, with guarding, leukocytosis, fever, etc. CT is the imaging of choice mainly to evaluate for bowel perforation as PES may not be seen on imaging Treatment is often with antibiotics and supportive care - in severe cases, hospitalization may be required. References Benson BC, Myers JJ, Laczek JT. Postpolypectomy electrocoagulation syndrome: a mimicker of colonic perforation. Case Rep Emerg Med. 2013;2013:687931. doi: 10.1155/2013/687931. Epub 2013 Jul 15. PubMed PMID: 23956889; PubMed Central PMCID: PMC3728495. Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

Author: Dylan Luyten, MD Educational Pearls: Actual wait times are weakly correlated to patient satisfaction but the difference between perceived/expected wait times and actual wait times is strongly correlated Having others in the room or with the patient while they wait also has a positive effect Under-promising and over-delivering can result in better patient experience Managing up others and services provided also is demonstrated to improve satisfaction Perceived time with health care members (physicians, APPs, nurses, etc) also is supported to improve satisfaction Sitting with patients increases the perception of time References Trout A, Magnusson AR, Hedges JR. Patient satisfaction investigations and the emergency department: what does the literature say?. Acad Emerg Med. 2000 Jun;7(6):695-709. Review. PubMed PMID: 10905652. Sonis JD, Aaronson EL, Lee RY, Philpotts LL, White BA. Emergency Department Patient Experience: A Systematic Review of the Literature. J Patient Exp. 2017;5(2):101–106. doi:10.1177/2374373517731359 Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD