Emergency Medical Minute

Author: Sam Killian, MD Educational Pearls: MRI machines can generate enough heat from the radiofrequency to cause thermal burns Patients with EKG stickers, medication patches, clothing impregnated with metallic ions, etc., can all increase risk of burns Even skin-to-skin contact within the patient can cause a misinterpretation from the software and increased energy, leading to burn References: Cross NM, Hoff MN, Kanal KM. Avoiding MRI-Related Accidents: A Practical Approach to Implementing MR Safety. J Am Coll Radiol. 2018 Aug 24. pii: S1546-1440(18)30762-2. doi: 10.1016/j.jacr.2018.06.022. [Epub ahead of print] PubMed PMID: 30149951. Takahashi T, Fujimoto N, Hamada Y, Tezuka N, Tanaka T. MRI-related thermal injury due to skin-to-skin contact. Eur J Dermatol. 2016 Jun 1;26(3):296-8. doi: 10.1684/ejd.2016.2740. PubMed PMID: 26987101. Pietryga JA, Fonder MA, Rogg JM, North DL, Bercovitch LG. Invisible metallic microfiber in clothing presents unrecognized MRI risk for cutaneous burn. AJNR Am J Neuroradiol. 2013 May;34(5):E47-50. doi: 10.3174/ajnr.A2827. Epub 2011 Dec 15. PubMed PMID: 22173750. Dempsey MF, Condon B. Thermal injuries associated with MRI. Clin Radiol. 2001 Jun;56(6):457-65. Review. PubMed PMID: 11428795.

Author: Ryan Circh, MD Educational Pearls: Review of 25 randomized control trials encompassing 16,037 acutely ill hospitalized patients Patients given oxygen with saturations > 94% on room air were found to have associated increased mortality in-hospital, at 30-days, and at long-term follow up It may seem intuitive, but do not give oxygen to patients that do not need it References: Chu DK, et al (2018). Mortality and morbidity in acutely ill adults treated with liberal versus conservative oxygen therapy (IOTA): a systematic review and meta-analysis. Lancet. 391(10131):1693-1705

Author: Sam Killian, MD Educational Pearls: Patients may have certain fears or expectations about the flu based on hearsay and other less reliable sources Taking extra time explaining the risks of the flu may help base these expectations more in reality This includes providing good return precautions and acknowledging that the disease can still be unpredictable

Author: Michael Hunt, MD Educational Pearls: Use the mnemonic NOT RECLUSE to rule out a brown recluse spider bite: Numerous bites (recluse spiders will bite once) Occurence (recluse bites between April- October) Timing (recluse spiders are… get this… reclusive) Red (recluse bites are white/pale) Elevated (recluse bites are flat) Chronic (recluse bites are acute) Large (recluse wounds are small) Ulceration, early (recluse bites ulcerate between 7-14 days) Swollen (recluse bites are flat) Exudative (recluse bites are dry) References: Stoecker WV, Vetter RS, Dyer JA. NOT RECLUSE-A Mnemonic Device to Avoid False Diagnoses of Brown Recluse Spider Bites. JAMA Dermatol. 2017 May 1;153(5):377-378. doi: 10.1001/jamadermatol.2016.5665. PubMed PMID: 28199453.

Author: Nick Tsipis, MD Educational Pearls: Persistent fever or positive blood cultures should raise suspicion for endocarditis Patients with recent dental procedures, recent cardiac surgeries are at risk, or who inject drugs are at higher risk Physical exam findings may include fever with a new murmur, Janeway lesions, Osler nodes, and/or splinter hemorrhages References: Long B, Koyfman A. Infectious endocarditis: An update for emergency clinicians. Am J Emerg Med. 2018 Sep;36(9):1686-1692. doi: 10.1016/j.ajem.2018.06.074. Epub 2018 Jul 2. Review. PubMed PMID: 30001813. Murdoch DR, Corey GR, Hoen B et. al. International Collaboration on Endocarditis-Prospective Cohort Study (ICE-PCS) Investigators. Clinical presentation, etiology, and outcome of infective endocarditis in the 21st century: the International Collaboration on Endocarditis-Prospective Cohort Study. Arch Intern Med. 2009 Mar 9;169(5):463-73. doi: 10.1001/archinternmed.2008.603

Educational Pearls: Blood concentrations over 0.4 mg/dL is associated with respiratory depression and possible death in alcohol naive patients Alcohol overdose accounts to 2,200 deaths per year Don't forget about checking for hypoglycemia in severe alcohol intoxication Consider ketamine for agitation to prevent further respiratory depression Editor's note: check out our podcast on ketamine for alcohol withdrawal here References: Jung YC, Namkoong K. Alcohol: intoxication and poisoning - diagnosis and treatment. Handb Clin Neurol. 2014;125:115-21. doi: 10.1016/B978-0-444-62619-6.00007-0. Centers for Disease Control and Prevention (CDC). "Vital signs: binge drinking prevalence, frequency, and intensity among adults-United States, 2010." MMWR. Morbidity and mortality weekly report 61.1 (2012): 14.

Author: Jared Scott, MD Educational Pearls: Blood at urethral meatus in trauma can be a sign of bladder/urethral injury Blind placement of a Foley catheter can make an undiagnosed urethral injury worse Urethral injury is evaluated using a retrograde urethrogram (RUG) If urethra is confirmed to be intact, Foley catheter can be placed to allow additional tests References: Avery, L. (2012). Imaging of male pelvic trauma. Radiologic Clinics of North America., 50(6), 1201-1217.

Author: Sue Chilton, MD Educational Pearls: An unusual cause of leg pain that can mimic sciatica/claudication Predominantly occurring in high endurance athletes, particularly cyclists and runners More common in men Check supine ABIs 1 minute after activity in the ED: a value References: Mansour A, Murney S, Jordan K, Laperna L. Endofibrosis: an unusual cause of leg pain in an athlete. J Sports Med Phys Fitness. 2016 Jan-Feb;56(1-2):157-61. Epub 2015 Jul 3. PubMed PMID: 26140352. Peach G, Schep G, Palfreeman R, Beard JD, Thompson MM, Hinchliffe RJ. Endofibrosis and kinking of the iliac arteries in athletes: a systematic review. Eur J Vasc Endovasc Surg. 2012;43(2):208–17.

Author: Gretchen Hinson, MD Educational Pearls: Legionnaires disease refers to a severe pneumonia caused by Legionella pneumophilia and occurs typically at the extremes of age Associated gastrointestinal symptoms (nausea/vomiting/diarrhea) may be present Hyponatremia is a common laboratory finding Legionella urinary antigen can be a convenient test to identify the infection Treatment is with fluoroquinolones, macrolides and/or tetracyclines References Pierre DM, Baron J, Yu VL, Stout JE. Diagnostic testing for Legionnaires' disease. Annals of Clinical Microbiology and Antimicrobials. 2017;16:59. doi:10.1186/s12941-017-0229-6. Cunha BA, Cunha CB. Legionnaire's Disease and its Mimics: A Clinical Perspective. Infect Dis Clin North Am. 2017 Mar;31(1):95-109. doi: 10.1016/j.idc.2016.10.008. Review.

Author: Don Stader, MD Educational Pearls: 8014 patients with out-of-hospital cardiac arrest randomized to epinephrine vs placebo 30-day survival was not dramatically better between groups (3.2%in the epinephrine group and 2.4% in the placebo group) Functional neurological outcome was nearly identical at 2.2% and 1.9% of patients Adds to literature that epinephrine provides little important benefit in cardiac arrest - focus on chest compressions and early defibrillation Editor's note: NNT for epinephrine to prevent one death in this study was 115 - compared to bystander CPR (NNT 15) and defibrillation (NNT 5) from prior studies. References Perkins GD et. al. . A Randomized Trial of Epinephrine in Out-of-Hospital Cardiac Arrest. N Engl J Med. 2018 Aug 23;379(8):711-721. doi: 10.1056/NEJMoa1806842. Epub 2018 Jul 18. Kitamura T, Kiyohara K, Sakai T, et al. Public-access defibrillation and out-of-hospital cardiac arrest in Japan. N Engl J Med 2016;375:1649-1659. Hasselqvist-Ax I, Riva G, Herlitz J, et al. Early cardiopulmonary resuscitation in out-of-hospital cardiac arrest. N Engl J Med 2015;372:2307-2315. Hagihara A, Hasegawa M, Abe T, Nagata T, Wakata Y, Miyazaki S. Prehospital epinephrine use and survival among patients with out-of-hospital cardiac arrest. JAMA. 2012 Mar 21;307(11):1161-8. doi: 10.1001/jama.2012.294. PubMed PMID: 22436956. Sanghavi P, Jena AB, Newhouse JP, Zaslavsky AM. Outcomes after out-of-hospital cardiac arrest treated by basic vs advanced life support. JAMA Intern Med. 2015 Feb;175(2):196-204. doi: 10.1001/jamainternmed.2014.5420.