Emergency Medical Minute

Author: Gretchen Hinson, MD Educational Pearls: Diagnosis can be difficult and often delayed Asymmetric breath sounds, choking, stridor may be present, but children also present asymptomatically Peak incidence around one to two years of age Hot dogs, nuts, popcorn – round and smooth objects are most commonly aspirated References: Green SS. Ingested and Aspirated Foreign Bodies. Pediatr Rev. 2015 Oct;36(10):430-6. doi: 10.1542/pir.36-10-430. Review. PubMed PMID: 26430203. Sink JR, Kitsko DJ, Georg MW, Winger DG, Simons JP. Predictors of Foreign Body Aspiration in Children. Otolaryngol Head Neck Surg. 2016 Sep;155(3):501-7. doi: 10.1177/0194599816644410. Epub 2016 Apr 12. PubMed PMID: 27071446. Summary by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Author: Dylan Luyten, MD Educational Pearls: Extracorporeal membrane oxygenation (ECMO) is similar to bypass ECMO is being utilized routinely at some centers and even prehospital in cardiac arrest There are two general types of ECMO: Venovenous (VV-ECMO) is useful when the patient cannot oxygenate but has adequate heart function. Venoarterial (VA-ECMO) is more like typical bypass and can be used in a pulseless patient References: Ouweneel DM, Schotborgh JV, Limpens J, Sjauw KD, Engström AE, Lagrand WK, Cherpanath TGV, Driessen AHG, de Mol BAJM, Henriques JPS. Extracorporeal life support during cardiac arrest and cardiogenic shock: a systematic review and meta-analysis. Intensive Care Med. 2016 Dec;42(12):1922-1934. doi: 10.1007/s00134-016-4536-8. Epub 2016 Sep 19. Review. PubMed PMID: 27647331; PubMed Central PMCID: PMC5106498. Tonna JE, Johnson NJ, Greenwood J, Gaieski DF, Shinar Z, Bellezo JM, Becker L, Shah AP, Youngquist ST, Mallin MP, Fair JF 3rd, Gunnerson KJ, Weng C, McKellar S; Extracorporeal REsuscitation ConsorTium (ERECT) Research Group.. Practice characteristics of Emergency Department extracorporeal cardiopulmonary resuscitation (eCPR) programs in the United States: The current state of the art of Emergency Department extracorporeal membrane oxygenation (ED ECMO). Resuscitation. 2016 Oct;107:38-46. doi: 10.1016/j.resuscitation.2016.07.237. Epub 2016 Aug 11. PubMed PMID: 27523953; PubMed Central PMCID: PMC5475402. Summary by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Author: Michael Hunt, MD Educational Pearls: Alcohol and gallstones are most common causes of pancreatitis Diagnosis is not simply based on lipase alone - must have at least two the the three criteria: Elevated lipase (greater than 3x upper limit of reference range) Typical pain (epigastric pain, radiating to back, etc.) Radiographic findings suggestive of pancreatitis (CT, MRI, US) BISAP criteria can help risk stratify mortality in pancreatitis. You get 1 point for each of the following: BNP > 25 Impaired mental status SIRS criteria, more than 2 AGE > 60 Pleural effusion BISAP score of 0 has Editor's note: The severity of pancreatitis does not correlate with serum lipase levels - notice how it is not used in the BISAP criteria, as an example. Even a mild elevation in serum testing can result in severe pancreatitis. References: Banks PA, Bollen TL, Dervenis C, Gooszen HG, Johnson CD, Sarr MG, Tsiotos GG, Vege SS; Acute Pancreatitis Classification Working Group.. Classification of acute pancreatitis--2012: revision of the Atlanta classification and definitions by international consensus. Gut. 2013 Jan;62(1):102-11. doi: 10.1136/gutjnl-2012-302779. Epub 2012 Oct 25. PubMed PMID: 23100216. Papachristou GI, Muddana V, Yadav D, O'Connell M, Sanders MK, Slivka A, Whitcomb DC. Comparison of BISAP, Ranson's, APACHE-II, and CTSI scores in predicting organ failure, complications, and mortality in acute pancreatitis. Am J Gastroenterol. 2010 Feb;105(2):435-41; quiz 442. doi: 10.1038/ajg.2009.622. Epub 2009 Oct 27. PubMed PMID: 19861954. Wu BU, Johannes RS, Sun X, Tabak Y, Conwell DL, Banks PA. The early prediction of mortality in acute pancreatitis: a large population-based study. Gut. 2008 Dec;57(12):1698-703. doi: 10.1136/gut.2008.152702. Epub 2008 Jun 2. PubMed PMID: 18519429.

Author: Erik Verzemnieks, MD Educational Pearls: Recent study provides at least some evidence to help predict antibiotic failure for cellulitis, which is not necessarily straight forward Intuitive risk factors such as recent cellulitis, chronic ulcers, history of MRSA are associated with antibiotic treatment failure Oddly, tachypnea at triage was associated with the highest odds ratio for treatment failure References: Yadav K, Suh KN, Eagles D, MacIsaac J, Ritchie D, Bernick J, Thiruganasambandamoorthy V, Wells G, Stiell IG. Predictors of Oral Antibiotic Treatment Failure for Nonpurulent Skin and Soft Tissue Infections in the Emergency Department. Acad Emerg Med. 2018 Jun 5. doi: 10.1111/acem.13492. Summarized and edited by Erik Verzemnieks, MD

Author: Aaron Lessen, MD Educational Pearls: Injuries from penetrating pharyngeal trauma are often subtle on examination in children Potentially serious complications including carotid artery injury, mediastinitis from spreading infection, or airway compromise from hematoma formation Imaging choice is typically CTA to assess for vascular injuries These injuries may require antibiotics References: Zonfrillo MR, Roy AD, Walsh SA. Management of pediatric penetrating oropharyngeal trauma. Pediatr Emerg Care. 2008 Mar;24(3):172-5. doi: 10.1097/PEC.0b013e3181669072. PubMed PMID: 18347498. Sasaki T, Toriumi S, Asakage T, Kaga K, Yamaguchi D, Yahagi N. The toothbrush: a rare but potentially life-threatening cause of penetrating oropharyngeal trauma in children. Pediatrics. 2006 Oct;118(4):e1284-6. PubMed PMID: 17015515. Summary by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Author: Rachel Brady, MD Educational Pearls: Hypercalcemia of malignancy: Hypercalcemia of malignancy can present with lethargy, muscle weakness, hyperreflexia, altered mental status, cardiac dysrhythmias, and even cardiac arrest. Treatment is based both on calcium level and symptoms Intravenous rehydration is first line treatment Other options include steroids, bisphosphonates and calcitonin. Tumor Lysis Syndrome Occurs due to the breakdown of tumor cells after chemotherapy/radiation Presents as hyperkalemia, hyperuricemia, hyperphosphatemia, and hypocalcemia Treatment is very similar to severe hypercalcemia - hydration with crystalloids Hyperuricemia can be treated using rasburicase or allopurinol References: Ñamendys-Silva SA, Arredondo-Armenta JM, Plata-Menchaca EP, Guevara-García H, García-Guillén FJ, Rivero-Sigarroa E, Herrera-Gómez A. Tumor lysis syndrome in the emergency department: challenges and solutions. Open Access Emerg Med. 2015 Aug 20;7:39-44. doi: 10.2147/OAEM.S73684. eCollection 2015. Review. PubMed PMID: 27147889; PubMed Central PMCID: PMC4806807. Zagzag J, Hu MI, Fisher SB, Perrier ND. Hypercalcemia and cancer: Differential diagnosis and treatment. CA Cancer J Clin. 2018 Sep;68(5):377-386. doi: 10.3322/caac.21489. Epub 2018 Sep 21. Review. PubMed PMID: 30240520. Summary by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Author: Aaron Lessen, MD Educational Pearls: In patients without indications for aspirin, three recent studies looked at prevention of several end points in the elderly These showed no benefit in preventing cardiovascular events (stroke, MI, hear failure), disability, or death in elderly These studies also demonstrated higher mortality and increased bleeding risk in patients who were taking aspirin without clear indications Editor's note: the increased all cause mortality is intriguing - but attributed to an increase in cancer mortality. Unclear why but will be important to see if this trend is seen in other studies. References: McNeil JJ, Woods RL, Nelson MR, et al., on behalf of the ASPREE Investigator Group. Effect of Aspirin on Disability-free Survival in the Healthy Elderly. N Engl J Med. 2018 Oct 18;379(16):1499-1508. doi: 10.1056/NEJMoa1800722. Epub 2018 Sep 16. PubMed PMID: 30221596. McNeil JJ, Woods RL, Nelson MR, et al., on behalf of the ASPREE Investigator Group. Effect of Aspirin on Cardiovascular Events and Bleeding in the Healthy Elderly. N Engl J Med. 2018 Oct 18;379(16):1509-1518. doi: 10.1056/NEJMoa1805819. Epub 2018 Sep 16. PubMed PMID: 30221597. McNeil JJ, Woods RL, Nelson MR, et al., on behalf of the ASPREE Investigator Group. Effect of Aspirin on All-Cause Mortality in the Healthy Elderly. N Engl J Med. 2018 Oct 18;379(16):1519-1528. doi: 10.1056/NEJMoa1803955. Epub 2018 Sep 16. PubMed PMID: 30221595. Summary by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Author: Katie Sprinkle, MD Educational Pearls: Medication Assisted Treatment (MAT) is the treatment of addiction with medications, commonly used for opioid use disorders A long held belief is MAT simply replaces one addiction for another, which is patently false MAT is one of the most affective methods to treat a patient with opioid addiction Unfortunately, outdated requirements for prescribers along further prevent its widespread use References: Salsitz E, Wiegand T. Pharmacotherapy of Opioid Addiction: "Putting a Real Face on a False Demon." Journal of Medical Toxicology. 2016;12(1):58-63. doi:10.1007/s13181-015-0517-5. Duber HC, Barata IA, Cioè-Peña E, Liang SY, Ketcham E, Macias-Konstantopoulos W, Ryan SA, Stavros M, Whiteside LK. Identification, Management, and Transition of Care for Patients With Opioid Use Disorder in the Emergency Department. Ann Emerg Med. 2018 Oct;72(4):420-431. doi: 10.1016/j.annemergmed.2018.04.007. Epub 2018 Jun 5. Review. PubMed PMID: 29880438. Summary by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Author: Peter Bakes, MD Educational Pearls: Important historical information to elicit is the birth history, feeding habits, stooling habits, associated symptoms, presence of bile, and presence of trauma. Volvulus is a common etiology of intestinal obstruction and is often due to malrotation in utero. Editor's note: get an upper GI series if there is any bilious vomiting in a neonate. Any time of the night. Wake people up. Transfer if necessary to get the study. This can diagnose volvulus and save bowel. References: Ratnayake K, Kim TY. Evidence-based management of neonatal vomiting in the emergency department. Pediatr Emerg Med Pract. 2014 Nov;11(11):1-20; Review. PubMed PMID: 25928976. Burge DM. The management of bilious vomiting in the neonate. Early Hum Dev. 2016 Nov;102:41-45. doi: 10.1016/j.earlhumdev.2016.09.002. Epub 2016 Sep 12. Review. PubMed PMID: 27634337. Summary by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Author: Jared Scott, MD Educational Pearls: Interest started as it was noticed soldiers who had wounds infected with maggots had better outcomes than those without maggots Studies have shown that wound care with maggots is essentially equivalent to traditional therapy with oxygen, antibiotics, and debridement Maggots debride the wound with proteolytic enzymes, sterilize the wound, and stimulate wound healing References: Sherman RA. Maggot therapy takes us back to the future of wound care: new and improved maggot therapy for the 21st century. J Diabetes Sci Technol. 2009 Mar 1;3(2):336-44. Review. PubMed PMID: 20144365; PubMed Central PMCID: PMC2771513. Baer WS. The treatment of chronic osteomyelitis with the maggot (larva of the blow fly) J Bone & Joint Surg. 1931;13:438–475. DOI: 10.1007/s11999-010-1416-3 Summary by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD