Emergency Medical Minute

Author: Peter Bakes, MD Educational Pearls: Important to find out if patients mean dysequilibrium, lightheadedness, or vertigo when patients say they are "dizzy." Differentiate central vs. peripheral vertigo Central vertigo typically present with bulbar syndromes (difficulty swallowing, facial nerve palsy) and cerebellar symptoms (ataxia). Peripheral vertigo typically present with sudden onset vertigo with nausea and vomiting in the absence of bulbar symptoms. Episodic? BPPV or Meniere's Disease. BPPV has not auditory symptoms and is associated with head position; Meniere's has hearing loss, tinnitus, and ear fullness. Constant? Neuronitis has no auditory symptoms, while labyrinthitis has associated hearing loss/tinnitus and is associated with a recent infection (OM). References Baloh RW. Differentiating between peripheral and central causes of vertigo. Otolaryngol Head Neck Surg 1998; 119:55. Chase M, Goldstein JN, Selim MH, et al. A prospective pilot study of predictors of acute stroke in emergency department patients with dizziness. Mayo Clin Proc 2014; 89:173. Kerber KA, Brown DL, Lisabeth LD, et al. Stroke among patients with dizziness, vertigo, and imbalance in the emergency department: a population-based study. Stroke 2006; 37:2484.

Author: Dylan Luyten, MD. Educational Pearls: Dangerous causes of back pain: AAA, cauda equina syndrome, epidural abscess. Young person with back pain needs to be evaluated for injection drug use (major risk factor). Patient with focal neurologic deficits (FND) require an MRI. Patients without FND can be screened with ESR and CRP. An ESR Treatment is IV antibiotics and surgical debridement. References Davis DP et al. Prospective evaluation of a clinical decision guideline to diagnose spinal epidural abscess in patients who present to the emergency department with spine pain, Journal of Neurosurgery: Spine. 2011. 14:765-770.

Author: Sam Killian, MD. Educational Pearls: Computer interpretation has a very good negative predictive value of a normal EKG (99%). Of 222 interpreted as "normal," 13 were deemed to have some abnormality by a cardiologist in a recent study. Those 13 EKG's were read by 2 ER docs, and only 1 missed interpretation warranted a move from triage to a bed. References Katie E. Hughes KE., Scott M. Lewis SM., Laurence Katz and Jonathan Jones Safety of Computer Interpretation of Normal Triage Electrocardiograms. 2017. Academic Emergency Medicine 24(1):120-124. http://onlinelibrary.wiley.com/doi/10.1111/acem.13067/full.

Author: Erik Verzemnieks, MD Educational Pearls: Otic (ear) specific antibiotic drops can be expensive Opthalmic (eye) versions are basically identical and can be used as an affordable substitute as many are on the $4 drug lists But don't do the reverse (don't use ear drops on the eye) Use caution when administering aminoglycoside if tympanic membrane rupture is present References https://tgtfiles.target.com/pharmacy/WCMP02-032536_RxGenericsList_NM7.pdf http://i.walmart.com/i/if/hmp/fusion/four_dollar_drug_list.pdf https://www.uptodate.com/contents/external-otitis-treatment

Author: Michael Hunt, MD Educational Pearls: Toxicity happens from local anesthetics being given too fast, too much, or in the unintended spot Systemic toxicity manifests first with neurologic symptoms like circumoral numbness, tinnitus, blurred vision, nausea, and even seizures. Severe toxicity can then progress to arrhythmias and cardiac arrest. Maximum doses of lidocaine: 4 mg/kg; and with epinephrine: 7mg/kg. Maximum dose of bupivacaine: 2mg/kg; with epinephrine 3mg/kg Editor note: treat seizures with benzodiazepines and avoid propofol for sedation; severe toxicity can also be treated with a 20% lipid emulsion, though there is debate on its efficacy References Dickerson DM, Apfelbaum JL. Local anesthetic systemic toxicity. Aesthet Surg J. 2014 Sep;34(7):1111-9. doi: 10.1177/1090820X14543102. Neal JM, Mulroy MF, Weinberg GL; American Society of Regional Anesthesia and Pain Medicine.. American Society of Regional Anesthesia and Pain Medicine checklist for managing local anesthetic systemic toxicity: 2012 version. Reg Anesth Pain Med. 2012 Jan-Feb;37(1):16-8. doi: 10.1097/AAP.0b013e31822e0d8a. Vasques F, Behr AU, Weinberg G, Ori C, Di Gregorio G. A Review of Local Anesthetic Systemic Toxicity Cases Since Publication of the American Society of Regional Anesthesia Recommendations: To Whom It May Concern. Reg Anesth Pain Med. 2015 Nov-Dec;40(6):698-705. doi: 10.1097/AAP.0000000000000320.

Author: Don Stader, MD. Educational Pearls: A baby can be born dependent on opioids but not addicted to them. Opioid addiction (Opioid Use Disorder) is a disease of mature brains and is characterized by compulsive drug use despite adverse consequences. Opioid addiction is a disease that affects the reward center of the brain Pregnant patients struggling with addiction do better when started on buprenorphine or methadone. This treatment will cause opioid withdrawal syndrome in newborns, but not the long term morbidity and mortality of illicit opioids. References Gowing L, Farrell MF, Bornemann R, Sullivan LE, Ali R. Oral substitution treatment of injecting opioid users for prevention of HIV infection. Cochrane Database of Systematic Reviews 2011, Issue 8: CD004145. DOI: 10.1002/14651858.CD004145.pub4. Volkow ND, Koob GF, McLellan AT ( 2016). "Neurobiologic Advances from the Brain Disease Model of Addiction." New England Journal of Medicine. 374 (4): 363–371.

Author: Aaron Lessen, MD Educational Pearls: Re-emerging STI. Progresses through distinct phases if untreated: Primary syphilis: frequently overlooked because initial chancre is painless. Secondary syphilis: viral syndrome, rash on trunk, palms, and soles. Latent syphilis: asymptomatic period, lasting 5-20 years. Tertiary syphilis: includes neurosyphilis (dementia, encephalitis, etc.) and cardiovascular syphilis (aortitis, etc). Treatment penicillin G 2.4 million units once for primary or secondary treatment; once weekly for 3 weeks for latent/tertiary. References Mattei, P., Beachkofsky, T., Gilson, R., Wisco, O. Syphilis: A reemerging infection. 2012. American Family Physician., 86(5), 433-440.

Author: Sam Killian, MD Educational Pearls: Hematometra: uterus filled with blood due to obstruction of outflow tract. Most commonly a result congenital abnormalities (imperforate hymen, transverse vaginal septum, etc.) but can be acquired due to cervical stenosis, intrauterine adhesions, neoplasms, and post-surgical scarring. Symptoms include: pain, abnormal bleeding, enlarged uterus Diagnosis: commonly achieved by ultrasound and physical exam. Treatment is surgical (cervical dilatation, hysteroscopy, etc.). References U Nayak A, Swarup A, G S J, N S. Hematometra and acute abdomen. Journal of Emergencies, Trauma and Shock. 2010;3(2):191-192. doi:10.4103/0974-2700.62117. Kotter HC, Weingrow D, Canders CP. Hematometrocolpos in a Pubescent Girl with Abdominal Pain. Clinical Practice and Cases in Emergency Medicine. 2017;1(3):218-220. doi:10.5811/cpcem.2017.3.33369.

Author: Sam Killian, MD Educational Pearls: Japan recently approved baloxavir marboxil (Xofluza), which may potentially "kill" Flu A/B within 24 hours Recent RCT trial showed superiority over oseltamavir (Tamiflu) in cessation of viral shedding (24 vs 72 hours) Compared to placebo, superior in time to symptom resolution (53.7 vs 80.7 hours) Administered as single dose Yet to be considered for FDA approval References Portsmouth S, Kawaguchi K, Arai M, Tsuchiya K, Uehara T. Cap-dependent Endonuclease Inhibitor S-033188 for the Treatment of Influenza: Results from a Phase 3, Randomized, Double-Blind, Placebo- and Active-Controlled Study in Otherwise Healthy Adolescents and Adults with Seasonal Influenza. Open Forum Infectious Diseases. 2017;4(Suppl 1):S734. doi:10.1093/ofid/ofx180.001.

Podcast #352: TXA for Epistaxis Author: Chris Holmes, M.D. Educational Pearls: TXA: tranexamic acid; used in control of bleeding in major trauma, postpartum hemorrhage, etc. In study of 216 patients with epistaxis, TXA placed on a pledget was compared to anterior cotton nasal packing. The TXA group had faster time to bleeding control, quicker time to discharge, better patient satisfaction, and lower rates of re-bleeding. References: Zahed R, Moharamzadeh P, Alizadeharasi S, Ghasemi A, Saeedi M. A new and rapid method for epistaxis treatment using injectable form of tranexamic acid topically: a randomized controlled trial. Am J Emerg Med. 2013 Sep;31(9):1389-92. doi: 10.1016/j.ajem.2013.06.043.