Emergency Medical Minute

Author: Dylan Luyten, MD Educational Pearls: Early recognition that the current situation is a mass casualty incident (MCI) is essential with establishing a sole provider/nurse to oversee Team members labeling themselves by name and role is also helpful Practice and prepare for these unfortunate events Editor's note: This podcast comes at the end of a MCI drill over several days References: http://epmonthly.com/article/not-heroes-wear-capes-one-las-vegas-ed-saved-hundreds-lives-worst-mass-shooting-u-s-history/ Summary by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Author: Aaron Lessen, MD Educational Pearls: Retrospective study looking at type of transportation and mortality outcomes for patients with penetrating trauma Mortality was 2.2 % for those brought in by private vehicle compared to 11.6% by EMS Editor's note: the above is raw mortality - even after risk adjustments the odds ratio of death was statistically significant for penetrating injuries, which held true even over multiple trauma systems. Shout out to Dr Haut as well! References: Wandling MW, Nathens AB, Shapiro MB, Haut ER. Association of Prehospital Mode of Transport With Mortality in Penetrating Trauma: A Trauma System-Level Assessment of Private Vehicle Transportation vs Ground Emergency Medical Services. JAMA Surg. 2018 Feb 1;153(2):107-113. doi: 10.1001/jamasurg.2017.3601. PubMed PMID: 28975247; PubMed Central PMCID: PMC5838586. Summary by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Author: Nick Hatch, MD Educational Pearls: Quick review on typical treatments for acute CHF: Nitrates are a mainstay to reduce preload Furosemide has fallen out of favor in regards to urgency but still essential; it can also be utilized in those with poor renal function Before going into the weeds: Phlebotomy can be used to remove volume and may be helpful in certain clinical scenarios Trapping venous blood by using blood pressure cuffs on three of four extremities was a very early treatment of CHF References: Alzahri MS, Rohra A, Peacock WF. Nitrates as a Treatment of Acute Heart Failure. Card Fail Rev. 2016 May;2(1):51-55. doi: 10.15420/cfr.2016:3:3. PubMed PMID: 28785453; PubMed Central PMCID: PMC5490950. Paterna S, Di Gaudio F, La Rocca V, Balistreri F, Greco M, Torres D, Lupo U, Rizzo G, di Pasquale P, Indelicato S, Cuttitta F, Butler J, Parrinello G. Hypertonic Saline in Conjunction with High-Dose Furosemide Improves Dose-Response Curves in Worsening Refractory Congestive Heart Failure. Adv Ther. 2015 Oct;32(10):971-82. doi: 10.1007/s12325-015-0254-9. Epub 2015 Oct 31. PubMed PMID: 26521190; PubMed Central PMCID: PMC4635178. Huijskes RV, Hoogenberg K, Wiesfeld AC, Pijl ME, van Gelder IC. Phlebotomies as a treatment of serious heart failure due to haemochromatosis: a case report. Neth Heart J. 2009;17(11):438-41. Burch, George E., and Nicholas P. DePasquale. "Congestive Heart Failure—Acute Pulmonary Edema." JAMA 208.10 (1969): 1895-1897. Summary by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Author: Don Stader, MD Educational Pearls: Recent study showed efficacy 5mg IM midazolam > 10mg IM olanzapine > 10mg IM haloperidol for quickly sedating an agitated patient If you have access, ketamine intravenous is the fastest Olanzapine should be used with caution in elderly patients because of its anticholinergic properties Ketamine can transiently worsen psychosis in some mental illness Haloperidol is contraindicated in patients with prolonged QT Olanzapine can be safely given intravenous as another option to your sedating arsenal References: Klein LR, Driver BE, Miner JR, Martel ML, Hessel M, Collins JD, Horton GB, Fagerstrom E, Satpathy R, Cole JB. Intramuscular Midazolam, Olanzapine, Ziprasidone, or Haloperidol for Treating Acute Agitation in the Emergency Department. Ann Emerg Med. 2018 Oct;72(4):374-385. doi: 10.1016/j.annemergmed.2018.04.027. Epub 2018 Jun 7. PubMed PMID: 29885904. Chew ML, Mulsant BH, Pollock BG, Lehman ME, Greenspan A, Kirshner MA, Bies RR, Kapur S, Gharabawi G. A model of anticholinergic activity of atypical antipsychotic medications. Schizophr Res. 2006 Dec;88(1-3):63-72. Epub 2006 Aug 22. PubMed PMID: 16928430. Mankowitz SL, Regenberg P, Kaldan J, Cole JB. Ketamine for Rapid Sedation of Agitated Patients in the Prehospital and Emergency Department Settings: A Systematic Review and Proportional Meta-Analysis. J Emerg Med. 2018 Nov;55(5):670-681. doi: 10.1016/j.jemermed.2018.07.017. Epub 2018 Sep 7. PubMed PMID: 30197153. Summary by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Author: Don Stader, MD Educational Pearls: Three options for a blister in partial thickness burns: do nothing, unroof it, or poke a hole in it Recent study suggest that aspirating the blister may be more effective in regards to wound healing The overlying skin acts as a bio-band-aid and patients recover slightly faster References: Ro HS, Shin JY, Sabbagh MD, Roh SG, Chang SC, Lee NH. Effectiveness of aspiration or deroofing for blister management in patients with burns: A prospective randomized controlled trial. Medicine (Baltimore). 2018 Apr;97(17):e0563. doi: 10.1097/MD.0000000000010563. PubMed PMID: 29703044; PubMed Central PMCID: PMC5944508. Summary by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Author: Don Stader, MD Educational Pearls: Intravenous Tylenol currently is many times more expensive than oral Single ED study comparing the two has methodology flaws and there is a lack of additional evidence to support intravenous over oral formulations solely for pain control Oral Tylenol appears to be at least equally efficacious, though with a slightly slower onset of action References: Furyk J, Levas D, Close B, Laspina K, Fitzpatrick M, Robinson K, Vangaveti VN, Ray R. Intravenous versus oral paracetamol for acute pain in adults in the emergency department setting: a prospective, double-blind, double-dummy, randomised controlled trial. Emerg Med J. 2018 Mar;35(3):179-184. doi: 10.1136/emermed-2017-206787. Epub 2017 Dec 15. PubMed PMID: 29247042. Jibril F, Sharaby S, Mohamed A, Wilby KJ. Intravenous versus Oral Acetaminophen for Pain: Systematic Review of Current Evidence to Support Clinical Decision-Making. Can J Hosp Pharm. 2015 May-Jun;68(3):238-47. Review. PubMed PMID: 26157186; PubMed Central PMCID: PMC4485512. Summary by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Author: Don Stader, MD Educational Pearls: Recent study has revealed that infant walkers are more harmful than helpful Infant walkers can also delay motor function The American Academy of Pediatrics calls for a ban on walkers as they are a preventable cause of injury References: Siegel AC, Burton RV. (1999).Effects of baby walkers on motor and mental development in human infants. Journal of Developmental and Behavioral Pediatrics. 20:355–361. Sims A, et al. (2018). Infant Walker-Related Injuries in United States. Pediatrics 142(4). Summary by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Author: Sam Killian, MD Educational Pearls: Recent news articles are showing an increase in injuries related to riding electric scooters Year-to-year, scooter injuries have increased as high as three to four times More definitive evidence still to come Editor's note: don't follow birdgraveyard on instagram References: https://www.washingtonpost.com/business/economy/scooter-use-is-rising-in-major-cities-so-are-trips-to-the-emergency-room/2018/09/06/53d6a8d4-abd6-11e8-a8d7-0f63ab8b1370_story.html?noredirect=on&utm_term=.a6e46ff35bdc https://kutv.com/news/local/er-doctors-report-161-increase-in-scooter-injuries-in-downtown-salt-lake-city Summary by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Author: Mark Hinton, MD Educational Pearls: Meniscus lock can occur with a tear leading to inability to extend the knee Treatment can include an intra-articular joint block followed by straightening Medial meniscus injuries are more common References: Allum RL, Jones JR. The locked knee. Injury. 1986 Jul;17(4):256-8. PubMed PMID: 3770920. Critchley IJ, Bracey DJ. The acutely locked knee--is a manipulation worth while? Injury. 1985 Jan;16(4):281-3. PubMed PMID: 3967919. Summary by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Educational Pearls: RSI includes induction agent (sedative) and a paralytic Succinylcholine is a depolarizing paralytic of rapid onset and short duration with contraindications in hyperkalemic states and muscular dystrophy Rocuronium and vecuronium are longer acting, non-depolarizing paralytic, more commonly Common induction agents are etomidate and ketamine Ketamine can be particularly beneficial for bronchodilator effects in those with reactive airway disease References: Stollings JL, Diedrich DA, Oyen LJ, Brown DR. Rapid-sequence intubation: a review of the process and considerations when choosing medications. Ann Pharmacother. 2014 Jan;48(1):62-76. doi: 10.1177/1060028013510488. Epub 2013 Nov 4. Review. PubMed PMID: 24259635. Summary by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD