Emergency Medical Minute

Author: Gretchen Hinson, MD Educational Pearls: Diabetic ketoacidosis patients are subject to electrolyte derangements Potassium should be monitored closely: K 3.3 K > 5.3 = delay potassium replacement Adult patients are typically severely volume depleted and can require 50 cc/kg bolus or more Insulin typically given in bolus of 0.1 units/kg followed by drip at 0.1 units/kg/hr References: Fayfman M, Pasquel FJ, Umpierrez GE. Management of Hyperglycemic Crises: Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar State. Med Clin North Am. 2017 May;101(3):587-606. doi: 10.1016/j.mcna.2016.12.011. Review. PubMed PMID: 28372715. Nyenwe EA, Kitabchi AE. The evolution of diabetic ketoacidosis: An update of its etiology, pathogenesis and management.Metabolism. 2016 Apr;65(4):507-21. doi: 10.1016/j.metabol.2015.12.007. Epub 2015 Dec 19. Review. PubMed PMID: 26975543. Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Author: Don Stader, MD Educational Pearls: Recent meta-analysis has demonstrated that there is no significant risk for kidney injury from CT contrast Most kidney injury seen after contrast CTs were due to other underlying illnesses (sepsis, hypovolemia, etc.) Older contrast agents likely did have nephrotoxic effects but this appears to be a thing of the past References: Aycock RD, Westafer LM, Boxen JL, Majlesi N, Schoenfeld EM, Bannuru RR. Acute Kidney Injury After Computed Tomography: A Meta-analysis. Ann Emerg Med. 2018 Jan;71(1):44-53.e4. doi: 10.1016/j.annemergmed.2017.06.041. Epub 2017 Aug 12. Review. PubMed PMID: 28811122. Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Author: Don Stader, MD Educational Pearls: Etripamil is an intranasal calcium channel blocker in development for use in SVT A recent study showed that etripamil has an SVT conversion rate of around 80% Etripamil does not have the same feeling of "impending doom" that can occur with adenosine Editor's note: Etripamil is still in development and these results are from a phase II clinical trial. References: Stambler BS, Dorian P, Sager PT, Wight D, Douville P, Potvin D, Shamszad P, Haberman RJ, Kuk RS, Lakkireddy DR, Teixeira JM, Bilchick KC, Damle RS, Bernstein RC, Lam WW, O'Neill G, Noseworthy PA, Venkatachalam KL, Coutu B, Mondésert B, Plat F. Etripamil Nasal Spray for Rapid Conversion of Supraventricular Tachycardia to Sinus Rhythm. J Am Coll Cardiol. 2018 Jul 31;72(5):489-497. doi: 10.1016/j.jacc.2018.04.082. PubMed PMID: 30049309. Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Author: Don Stader, MD Educational Pearls: Vertebral artery dissection (VAD) contributes to just 2% of strokes overall but ~25% of strokes for patients VAD is associated with minor trauma (chiropractic manipulation, yoga), typically with neck extension and rotation. VAD can cause posterior stroke symptoms (vertigo, diplopia, Horner's Syndrome, Wallenberg Syndrome) Overall a good prognosis with around 50% of patients recovering without lasting neurologic deficits. References: Debette S, Leys D. Cervical-artery dissections: predisposing factors, diagnosis, and outcome. Lancet Neurol. 2009 Jul;8(7):668-78. doi: 10.1016/S1474-4422(09)70084-5. Review. PubMed PMID: 19539238. Gottesman RF, Sharma P, Robinson KA, et al. Clinical characteristics of symptomatic vertebral artery dissection: a systematic review. Neurologist. 2012;18(5):245-54. Schievink WI. Spontaneous dissection of the carotid and vertebral arteries. N Engl J Med. 2001 Mar 22;344(12):898-906. Review. PubMed PMID: 11259724. Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Author: Katie Sprinkle, MD Educational Pearls: Hyponatremia results when patients over hydrate and dilute their sodium with too much free water Symptoms of hyponatremia can mimic symptoms of dehydration (dizziness, lightheadedness, general malaise) With severe hyponatremia patients can progress to seizure, coma, and death Hypernatremia results from dehydration and is more common References: Bennett BL, Hew-Butler T, Hoffman MD, Rogers IR, Rosner MH; Wilderness Medical Society.. Wilderness Medical Society practice guidelines for treatment of exercise-associated hyponatremia: 2014 update. Wilderness Environ Med. 2014 Dec;25(4 Suppl):S30-42. doi: 10.1016/j.wem.2014.08.009. PubMed PMID: 25498260. Braun MM, Barstow CH, Pyzocha NJ. Diagnosis and management of sodium disorders: hyponatremia and hypernatremia. Am Fam Physician. 2015 Mar 1;91(5):299-307. PubMed PMID: 25822386. Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Author: Aaron Lessen, MD Educational Pearls: Defined as QRS over 120 ms and rate over 120 Two major rhythms = Vetricular tachycardia (VT) or SVT with aberrancy Safest approach is to assume it is VT Synchronized Cardioversion is preferred even for stable VT for multiple reasons including safety and efficacy Procainamide is preferred pharmacologic option Amiodarone is less preferred third option Calcium channel blockers (i.e. diltiazem) can worsen certain rhythms and should be avoided References: Long B, Koyfman A. Best Clinical Practice: Emergency Medicine Management of Stable Monomorphic Ventricular Tachycardia. J Emerg Med. 2017 Apr;52(4):484-492. doi: 10.1016/j.jemermed.2016.09.010. Epub 2016 Oct 15. Review. PubMed PMID: 27751700. Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Author: Ryan Circh, MD Educational Pearls: Myofascial pain syndrome (MFPS) is typically unilateral with discrete points of palpable pain Often secondary to repeated use and poor posture. MFPS typically responds very well to trigger point injections. Fibromyalgia is bilateral and diffuse and is thought to have a psychological component Some of the best pharmacological treatments for fibromyalgia are Tramadol and Flexeril References: Tofferi JK, Jackson JL, O'Malley PG. Treatment of fibromyalgia with cyclobenzaprine: A meta-analysis. Arthritis Rheum. 2004 Feb 15;51(1):9-13. PubMed PMID: 14872449. Goldenberg DL, Burckhardt C, Crofford L. Management of fibromyalgia syndrome. JAMA. 2004 Nov 17;292(19):2388-95. Review. PubMed PMID: 15547167. Giamberardino MA, Affaitati G, Fabrizio A, Costantini R. Myofascial pain syndromes and their evaluation. Best Pract Res Clin Rheumatol. 2011 Apr;25(2):185-98. doi: 10.1016/j.berh.2011.01.002. Review. PubMed PMID: 22094195. Borg-Stein J, Iaccarino MA. Myofascial pain syndrome treatments. Phys Med Rehabil Clin N Am. 2014 May;25(2):357-74. doi: 10.1016/j.pmr.2014.01.012. Epub 2014 Mar 17. Review. PubMed PMID: 24787338 Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Author: Dylan Luyten, MD Educational Pearls: Symptoms of acute limb ischemia are the 5 P's: Pulselessness, pain, pallor, paresthesias, and poikilothermia Sudden onset of non-traumatic extremity pain should raise concern for this diagnosis Obtaining an ankle brachial index (ABI) can help confirm the diagnosis Consultation with vascular surgery should be immediately after the clinical diagnosis and before any further delays to obtain further imaging References: Santistevan JR. Acute Limb Ischemia: An Emergency Medicine Approach. Emerg Med Clin North Am. 2017 Nov;35(4):889-909. doi: 10.1016/j.emc.2017.07.006. Epub 2017 Aug 23. Review. PubMed PMID: 28987435. Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Author: Katie Sprinkle, MD Educational Pearls: The fascia iliaca block is useful for hip and proximal femur fractures. Typically involves injecting 40-60 mL of diluted bupivacaine (0.25%) under the fascia iliaca (or other anesthetic) Anesthesia is achieved of the femoral, obturator, and lateral femoral cutaneous nerves. Monitor for signs of bupivacaine toxicity (paresthesias, AMS, seizures, arrhythmias) Intralipid can be an effective treatment for life-threatening toxicity References: Hoegberg LC, Bania TC, Lavergne V, Bailey B, Turgeon AF, Thomas SH, Morris M, Miller-Nesbitt A, Mégarbane B, Magder S, Gosselin S; Lipid Emulsion Workgroup.. Systematic review of the effect of intravenous lipid emulsion therapy for local anesthetic toxicity. Clin Toxicol (Phila). 2016 Mar;54(3):167-93. doi: 10.3109/15563650.2015.1121270. Epub 2016 Feb 6. Review. PubMed PMID: 26853119. https://www.acepnow.com/article/control-hip-fracture-pain-without-opioids-using-ultrasound-guided-fascia-iliaca-compartment-block/?singlepage=1&theme=print-friendly Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Author: Aaron Lessen, MD Educational Pearls: Patients with "minor" strokes with NIHSS 0 to 5 can still end up having poor long-term outcomes Recent study compared use of alteplase vs. aspirin for these patients and saw no difference in regards to favorable neurologic outcome at 90 days Study was ended early due to patient recruitment difficulties Editor's note: though ended early, it is debatable whether even if appropriately powered there would have been an identifiable benefit References: Khatri P, Kleindorfer DO, Devlin T, Sawyer RN Jr, Starr M, Mejilla J, Broderick J, Chatterjee A, Jauch EC, Levine SR, Romano JG, Saver JL, Vagal A, Purdon B, Devenport J, Pavlov A, Yeatts SD; PRISMS Investigators. Effect of Alteplase vs Aspirin on Functional Outcome for Patients With Acute Ischemic Stroke and Minor Nondisabling Neurologic Deficits: The PRISMS Randomized Clinical Trial. JAMA. 2018 Jul 10;320(2):156-166. doi: 10.1001/jama.2018.8496. PubMed PMID: 29998337. Summary by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD