Emergency Medical Minute

Author: Don Stader, MD Educational Pearls: Recent study demonstrated patients with non-STEMI treated with heparin had no difference in survival, but had an increased risk of major bleeding Heparin may be an outdated medication in the era of dual anti-platelet therapy and PCI Heparin may fall to the wayside like other former treatments for ACS such as morphine, oxygen and nitroglycerin as far as mortality benefit References: Chen JY, He PC, Liu YH, Wei XB, Jiang L, Guo W, Duan CY, Guo YS, Yu XP, Li J, Li WS, Zhou YL, Lin CY, Luo JF, Yu DQ, Chen ZJ, Chen W, Chen YY, Guo ZQ, Geng QS, Tan N. Association of Parenteral Anticoagulation Therapy With Outcomes in Chinese Patients Undergoing Percutaneous Coronary Intervention for Non-ST-Segment Elevation Acute Coronary Syndrome. JAMA Intern Med. 2019 Feb 1;179(2):186-194. doi: 10.1001/jamainternmed.2018.5953. PubMed PMID: 30592483 Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Author: Katie Sprinkle, MD Educational Pearl: Carbon monoxide (CO) is the leading cause of death from poison world-wide CO forms from the combustion of any carbon based product Patients often present with non specific symptom like headache, vomiting, and malaise Consider this diagnosis with multiple people presenting with similar symptoms from a single location Treatment is with high flow oxygen (i.e. non-rebreather) Hyperbaric therapy is controversial and up for debate - discussion with local consultants may help guide this management/transfer Tobacco smokers typically have elevated levels of carbon monoxide at baseline Editor's Note: smoking hookah for one hour may be the equivalent of smoking nearly 100 cigarettes References: Jacob P, Abu Raddaha AH, Dempsey D, et al. Nicotine, carbon monoxide, and carcinogen exposure after a single use of a water pipe. Cancer Epidemiol Biomarkers Prev. 2011;20(11):2345-53. Ng PC, Long B, Koyfman A. Clinical chameleons: an emergency medicine focused review of carbon monoxide poisoning. Intern Emerg Med. 2018 Mar;13(2):223-229. doi: 10.1007/s11739-018-1798-x. Epub 2018 Feb 12. Review. Erratum in: Intern Emerg Med. 2018 Mar 22;:. PubMed PMID: 29435715. American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Carbon Monoxide Poisoning:., Wolf SJ, Maloney GE, Shih RD, Shy BD, Brown MD. Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Acute Carbon Monoxide Poisoning. Ann Emerg Med. 2017 Jan;69(1):98-107.e6. doi: 10.1016/j.annemergmed.2016.11.003. PubMed PMID: 27993310. Guzman JA. Carbon monoxide poisoning. Crit Care Clin. 2012 Oct;28(4):537-48. doi: 10.1016/j.ccc.2012.07.007. Review. PubMed PMID: 22998990. Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Author: Aaron Lessen, MD Educational Pearls: Several studies have shown administration of tPA can improve outcomes and reduce need for amputation tPA is considered in grade III and IV frostbite tPA cannot be given until after the warming process Administration is systemically, not catheter directed or intra-arterial References: Jones LM, Coffey RA, Natwa MP, Bailey JK. The use of intravenous tPA for the treatment of severe frostbite. Burns. 2017 Aug;43(5):1088-1096. doi: 10.1016/j.burns.2017.01.013. Epub 2017 Jan 31. PubMed PMID: 28159151. Wexler A, Zavala S. The Use of Thrombolytic Therapy in the Treatment of Frostbite Injury. J Burn Care Res. 2017 Sep/Oct;38(5):e877-e881. doi: 10.1097/BCR.0000000000000512. PubMed PMID: 28296671. Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Author: Aaron Lessen, MD Educational Pearl: A double ingestion of a single pill is typically a benign event but several drug classes may cause problems A published review of 10 years of single medication double dose ingestion found 12 out of 876 cases had adverse events. The drugs and events were: Propafenone ingestion leading to ventricular tachycardia Beta blocker ingestion leading to bradycardia and hypotension Calcium channel blocker leading to bradycardia and hypotension Bupropion ingestion leading to seizures Tramadol ingestion leading to ventricular tachycardia Editor's Note: References: Correia MS, Whitehead E, Cantrell FL, Lasoff DR, Minns AB. A 10-year review of single medication double-dose ingestions in the nation's largest poison control system. Clin Toxicol (Phila). 2019 Jan;57(1):31-35. doi: 10.1080/15563650.2018.1493205. Epub 2018 Nov 28. PubMed PMID: 30484705. Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Podcast # 437 : Myasthenia Gravis Author: Gretchen Hinson, MD Educational Pearls: Myasthenia gravis (MG) is an antibody mediated autoimmune disorder against the acetylcholine receptors at the neuromuscular junctions. Bimodal age distribution (20's-30's: women; 60's-70's: men) Presents with fluctuating muscle weakness typically worse at the end of the day with upper extremities affected more than lower and typically involving facial muscles. Myasthenia crisis occurs when muscle fatigue begins to cause respiratory depression MG was historically diagnosed with the Tensilon test but now often by EMG Treatment of MG crisis involves plasma exchange and IVIG. Those in crisis often require intubation and ICU admission References: Gilhus NE. Myasthenia Gravis. N Engl J Med. 2016 Dec 29;375(26):2570-2581. doi: 10.1056/NEJMra1602678. Review. PubMed PMID: 28029925. Roper J, Fleming ME, Long B, Koyfman A. Myasthenia Gravis and Crisis: Evaluation and Management in the Emergency Department. J Emerg Med. 2017 Dec;53(6):843-853. doi: 10.1016/j.jemermed.2017.06.009. Epub 2017 Sep 12. PubMed PMID: 28916122. Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Author: Charleen Gnisci, PharmD Educational Pearls: Between 2011 to 2016, Mylan increased EpiPen prices by 400% ($700 for 2 packs) AUVI-Q was recalled in 2012, which left the market share to the EpiPen until recently Teva announced last year it will be making a generic version of the EpiPen retailing around $300 but expected to decrease References: Kaplan, S. F.D.A. Approves Generic EpiPen That May Be Cheaper. The New York Times, The New York Times, 2018. Retrived from www.nytimes.com/2018/08/16/health/epipen-generic-drug-prices.html. Tirrell, M. FDA approves Teva's generic EpiPen after yearslong delay. 2018. Retrieved from https://www.cnbc.com/2018/08/16/fda-approves-tevas-generic-epipen-after-years-long-delay.html Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Author: Ryan Circh, MD Educational Pearls: Ulnar collateral ligament injury is often called gamekeeper's thumb or skier's thumb Can results from traumatic deviating the thumb radially (abduction) Poor rabbits Have a low threshold for referral to hand surgery for follow up - treatment for minor injuries can be conservative but more severe require surgery to preserve function This injury should be placed in a thumb spica splint Radiographs are often negative unless an avulsion fracture is present Editor's note: to test for UCL injuries, I like this. References: Schroeder NS, Goldfarb CA. Thumb ulnar collateral and radial collateral ligament injuries. Clin Sports Med. 2015 Jan;34(1):117-26. doi: 10.1016/j.csm.2014.09.004. Epub 2014 Oct 11. Review. PubMed PMID: 25455399. Madan SS, Pai DR, Kaur A, Dixit R. Injury to ulnar collateral ligament of thumb. Orthop Surg. 2014 Feb;6(1):1-7. doi: 10.1111/os.12084. Review. PubMed PMID: 24590986. Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Author: Peter Bakes, MD Educational Pearl: Transient ischemic attack (TIA) is defined as neurologic symptoms that resolve in 24 hours with no new changes on head imaging Mimics include complex migraine, carotid dissection, seizure (Todd's paralysis) Typical presentation is with sudden onset of negative symptoms such as numbness, weakness, etc. Mimics tend to have positive symptoms such as photophobia, pain, etc. References: Kernan WN, Ovbiagele B, Black HR, et al. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2014; 45:2160. Simmons B, et al. Transient Ischemic Attack: Part I. Diagnosis and Evaluation. American Family Physician 2012; 86(6):521-526. Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Author: Michael Hunt, MD Educational Pearls: Recent study compared ketamine to morphine in elderly patient Ketamine (IV dose 0.3 mg /kg) provided equivalent pain control to morphine (IV dose 0.1 mg / kg) However, etamine group had much higher rate of side effects, including psychoperceptual A lower does of 0.1 mg / kg given intravenously over 15 minutes might be a better option to start in the elderly population - you can always add more! References Motov S, Mann S, Drapkin J, Butt M, Likourezos A, Yetter E, Brady J, Rothberger N, Gohel A, Flom P, Mai M, Fromm C, Marshall J. Intravenous subdissociative-dose ketamine versus morphine for acute geriatric pain in the Emergency Department: A randomized controlled trial. Am J Emerg Med. 2019 Feb;37(2):220-227. doi: 10.1016/j.ajem.2018.05.030. Epub 2018 May 16. PubMed PMID: 29807629. Summarized and edited by Erik Verzemnieks, MD

Author: Michael Hunt, MD Educational Pearls: As many as 20% of women in assisted living have asymptomatic bacteriuria This can present a diagnostic conundrum when seeing these patients in the emergency department, particularly for altered mental status and deciding whether to treat True diagnosis of UTI in the emergency department is difficult as true diagnoses required culture results and repeated positive samples Procalcitonin is an emerging biomarker that may be helpful in determining the presence of infection References: Cortes-Penfield NW, Trautner BW, Jump RLP. Urinary Tract Infection and Asymptomatic Bacteriuria in Older Adults. Infect Dis Clin North Am. 2017 Dec;31(4):673-688. doi: 10.1016/j.idc.2017.07.002. Review. PubMed PMID: 29079155; PubMed Central PMCID: PMC5802407. Huang DT, Angus DC, Chang CH, Doi Y, Fine MJ, Kellum JA, Peck-Palmer OM, Pike F, Weissfeld LA, Yabes J, Yealy DM; ProACT Investigators.. Design and rationale of the Procalcitonin Antibiotic Consensus Trial (ProACT), a multicenter randomized trial of procalcitonin antibiotic guidance in lower respiratory tract infection. BMC Emerg Med. 2017 Aug 29;17(1):25. doi: 10.1186/s12873-017-0138-1. PubMed PMID: 28851296; PubMed Central PMCID: PMC5576372. Summarized by Erik Verzemnieks, MD