Emergency Medical Minute

Author: Michael Hunt, MD Educational Pearls: A recent study evaluated the relationship between abnormal orthostatic vital signs and serious outcomes within 30 days in patients over 60 presenting to the ED with syncope Of the roughly 2000 patients enrolled, about ⅓ had abnormal orthostatic vital signs There was no statistically significance between orthostatic vital signs and serious outcomes in 30 days Editor's note: study used a composite end-point of multiple serious outcomes References White JL, Hollander JE, Chang AM, Nishijima DK, Lin AL, Su E, Weiss RE, Yagapen AN, Malveau SE, Adler DH, Bastani A, Baugh CW, Caterino JM, Clark CL, Diercks DB, Nicks BA, Shah MN, Stiffler KA, Storrow AB, Wilber ST, Sun BC. Orthostatic vital signs do not predict 30 day serious outcomes in older emergency department patients with syncope: A multicenter observational study. Am J Emerg Med. 2019 Mar 25;. doi: 10.1016/j.ajem.2019.03.036. [Epub ahead of print] PubMed PMID: 30928476. Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

Author: Peter Bakes, MD Educational Pearls: The differential diagnosis for pedal edema includes issues in the heart, kidney, and liver Obesity hypoventilation syndrome (OHS) is an important and common cause of right heart failure. Nighttime hypoventilation leads to pulmonary hypertension, causing right heart strain followed by right heart failure OHS criteria includes obesity, sleep disordered breathing, and alveolar hypoventilation (PaCO2 > 45 mmHg) The causes of OHS are multifactorial, and include mechanical problems with breathing and hormonal changes References Balachandran JS, Masa JF, Mokhlesi B. Obesity Hypoventilation Syndrome Epidemiology and Diagnosis. Sleep Med Clin. 2014;9(3):341–347. doi:10.1016/j.jsmc.2014.05.007 Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

Author: Sam Killian, MD Educational Pearls: A recent study in Pediatrics compared the rates of antibiotic prescriptions for acute respiratory infections (ARIs) between direct to consumer (DTC) telemedicine, urgent care, and primary care providers Among the nearly 530,000 visits studied, the rate of antibiotic prescription was 52%, 42% and 31% for telemedicine, urgent care, and primary care providers, respectively Nearly 4/10 antibiotic prescriptions from telemedicine visits were not indicated based on antibiotics guideline recommendations References Ray KN, Shi Z, Gidengil CA, Poon SJ, Uscher-Pines L, Mehrotra A. Antibiotic Prescribing During Pediatric Direct-to-Consumer Telemedicine Visits. Pediatrics. 2019 May;143(5). doi: 10.1542/peds.2018-2491. Epub 2019 Apr 8. PubMed PMID: 30962253. Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

Author: Gretchen Hinson, MD Educational Pearls: In most healthcare settings, normal saline (NS) has become ubiquitous as an intravenous fluid despite some potential drawbacks Compared to normal saline, a balanced crystalloid (either lactated Ringer's or Plasma-Lyte) was associated with a lower composite endpoint of mortality, renal replacement therapy, and renal injury in SMART (Isotonic Solutions and Major Adverse Renal Events Trial) Balanced crystalloids such as lactate Ringer's may be preferable in more critically ill populations References Yau YW, Kuan WS. Choice of crystalloids in sepsis: a conundrum waiting to be solved. Ann Transl Med. 2016;4(6):121. doi:10.21037/atm.2016.02.09 Semler MW, Self WH, Wanderer JP, et al. Balanced Crystalloids versus Saline in Critically Ill Adults. N Engl J Med. 2018;378(9):829–839. doi:10.1056/NEJMoa1711584 Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

Author: Don Stader, MD Educational Pearls: Cyclic vomiting syndrome (CVS) is different than cannabis hyperemesis syndrome (CHS). It is important to differentiate the two. CHS is thought to be caused by activation of THC receptors in the gut CVS is associated with migraines and therefore responds to similar medications Olanzapine (Zyprexa) is an alternative to haloperidol (Haldol) Amitriptyline, as well as anti-epileptics can be used to prevent CVS Opioids worsen CVS References Lapoint J, Meyer S, Yu CK, Koenig KL, Lev R, Thihalolipavan S, Staats K, Kahn CA.Cannabinoid Hyperemesis Syndrome: Public Health Implications and a Novel Model Treatment Guideline. West J Emerg Med. 2018 Mar;19(2):380-386. doi: 10.5811/westjem.2017.11.36368. Epub 2017 Nov 8. PubMed PMID: 29560069; PubMed Central PMCID: PMC5851514. Boles RG, Lovett-Barr MR, Preston A, Li BU, Adams K. Treatment of cyclic vomiting syndrome with co-enzyme Q10 and amitriptyline, a retrospective study. BMC Neurol. 2010;10:10. Epub 2010 Jan 28. Hikita T, Kodama H, Kaneko S, Amakata K, Ogita K, Mochizuki D, Kaga F, Nakamoto N, Fujii Y, Kikuchi A. Sumatriptan as a treatment for cyclic vomiting syndrome: a clinical trial. Cephalalgia. 2011;31(4):504. Epub 2010 Dec 8. Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

Author: Jared Scott, MD Educational Pearls: Ondansetron (Zofran) is one of the latest drugs that has had concerns raised about side effects, particularly in pregnancy 2018 study probed two birth defect databases to assess increases in 51 major birth defects with increased exposure to ondansetron Only two of the 51 had even a modest increase, which is unclear in causation (cleft palate and renal agenesis) When administering ondansetron (or any drug) to pregnant women, be able to discuss any potential risks for an informed decision by the patient Editor's note: in this study, adjusted odds ratios for risk of birth defects from exposure to ondansetron were: cleft palate 1.6 (95% CI 1.1-2.3) and renal agenesis 1.8 (95% CI 1.1-3.0) References Parker SE, Van Bennekom C, Anderka M, Mitchell AA. Ondansetron for Treatment of Nausea and Vomiting of Pregnancy and the Risk of Specific Birth Defects. Obstet Gynecol. 2018 Aug;132(2):385-394. doi: 10.1097/AOG.0000000000002679. PubMed PMID: 29995744. Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

Author: Dave Rosenberg, MD Educational Pearls: Nothing by mouth (NPO) status routinely used before surgery to reduce the theoretical risk of aspiration However, surgery poses a large physiological stress. Calories and fluid are needed to overcome stresses like these Patients who drank 1/2 strength Gatorade up to 2 hours before surgery did better than those who did not References Alyssa Cheng-Cheng Zhu, Aalok Agarwala, Xiaodong Bao. Perioperative Fluid Management in the Enhanced Recovery after Surgery (ERAS) Pathway. Clinics in Colon and Rectal Surgery 2019; 32(02): 114-120. DOI: 10.1055/s-0038-1676476 Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

Educational Pearls: Tiflitis refers to the presence of enterocolitis in the setting of neutropenia - also known as neutropenic enterocolitis Commonly a result of chemotherapy for hematologic malignancies. The infection is usually polymicrobial/fungal and can lead to septic shock Usually presents with fever, abdominal pain, with associated GI complaints Workup includes CBC for the ANC (usually Treatment typically with broad-spectrum antibiotics with or without anti-fungal agents Mortality can be as high as 50% References Cloutier RL. Neutropenic enterocolitis. Emerg Med Clin North Am. 2009 Aug;27(3):415-22. doi: 10.1016/j.emc.2009.04.002. PubMed PMID: 19646645. Rodrigues FG, Dasilva G, Wexner SD. Neutropenic enterocolitis. World J Gastroenterol.2017 Jan 7;23(1):42-47. doi: 10.3748/wjg.v23.i1.42. Review. PubMed PMID: 28104979; PubMed Central PMCID: PMC5221285. Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

Author: Erik Verzemnieks, MD Educational Pearls: Cauda equina syndrome is caused by the compression of the nerve roots that extend beyond the termination of the spinal cord Trauma, infection, hematoma, disc rupture/herniation can cause this - basically anything that can cause pressure and fill space Symptoms can include saddle anesthesia, lower extremity pain, numbness, incontinence, and constipation Post-void residual that is abnormally high may be an indicator MRI is diagnostic modality of choice Emergent surgical decompression is treatment References Jalloh I, Minhas P. Delays in the treatment of cauda equina syndrome due to its variable clinical features in patients presenting to the emergency department. Emerg Med J. 2007 Jan;24(1):33-4. doi: 10.1136/emj.2006.038182. PubMed PMID: 17183040; PubMed Central PMCID: PMC2658150.

Author: Nicholas Hatch, MD Educational Pearls: Measles has a period of infectivity starts before the appearance of the characteristic rash, up to 4-5 days A devastating consequence of measles is Subacute Sclerosing Panencephalitis (SSPE), which manifests 7-10 years after the initial measles infection SSPE is a central nervous system disease that has no cure and is nearly universally fatal Educating patients on the importance of vaccination should include discussion of these long term consequences References Pallivathucal LB, Noymer A. Subacute sclerosing panencephalitis mortality, United States, 1979-2016: Vaccine-induced declines in SSPE deaths. Vaccine. 2018 Aug 23;36(35):5222-5225. doi: 10.1016/j.vaccine.2018.07.030. Epub 2018 Jul 26. PubMed PMID: 30057285. Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD