Emergency Medical Minute

Author: Jared Scott, M.D. Educational Pearls: Recent study compared Compazine with Benadryl vs. Dilaudid for acute migraine management in the ED. Compazine + Benadryl demonstrated migraine relief in 60% of patients compared to the 31% of patients who were relieved with Dilaudid. Compazine + Benadryl is a superior migraine treatment than Dilaudid. References: Friedman BW, et. al. (2017). Randomized study of IV prochlorperazine plus diphenhydramine vs IV hydromorphone for migraine. Neurology. 89(20):2075-2082

Author: Don Stader, M.D. Educational Pearls: Pulmonary embolism is one of the leading causes of maternal mortality. There is disagreement among different medical societies about the value of D-dimer as a screening modality. If you use it, consider the rational D-dimer approach whereby you add 250 to your cut-off for every trimester. A useful screening modality is an ultrasound of bilateral lower extremities looking for DVT. Keep in mind, both a V/Q scan and CT scan have a significant amount of radiation. CTA is probably the right diagnostic test (less radiation than CT w&w/o). Always use the shared decision-making model and clinical acumen to choose your tests. References: Leung AN, et. al. (2011). An official American Thoracic Society/Society of Thoracic Radiology clinical practice guideline: evaluation of suspected pulmonary embolism in pregnancy. American Journal of Respiratory and Critical Care Medicine. 184(10):1200-8 Polak JF, Wilkinson DL. (1991). Ultrasonographic diagnosis of symptomatic deep venous thrombosis in pregnancy. American Journal of Obstetrics and Gynecology. 165(3):625-9. Sachs BP, et. al. (1987). Maternal mortality in Massachusetts. Trends and prevention. New England Journal of Medicine. 316(11):667-72.

Author: Aaron Lessen, MD Educational Pearls: Shockable rhythms like V-fib or V-tach have a better prognosis than patients with PEA or asystole. Recent study has shown an initial electrical frequency in PEA between 10-24/min had worse outcomes than PEA with initial rhythm over 60/min. Patients with an initial electrical frequency in PEA over 60/min did just as well as patients with shockable rhythms. Of them, there was a 22% survival rate with 15% having a good neurologic outcome. References: Weiser, C., et al. (2018). Initial electrical frequency predicts survival and neurological outcome in out of hospital cardiac arrest patients with pulseless electrical activity. Resuscitation. 125:34-38

Author: Erik Verzemnieks, M.D. Educational Pearls: ● Common causes of nystagmus: Congenital disorders, CNS diseases (MS, CVA), Intoxication ● Drugs associated (ETOH, Ketamine, PCP, SSRI, MDMA, Lithium, Phenytoin, Barbiturates) ● If a patient has nystagmus and is intoxicated, consider other drugs and etiologies as potential sources References: Alpert JN. (1978). Downbeat nystagmus due to anticonvulsant toxicity. ​Annals of Neurology.​ 4(5):471-3. Rosenberg, ML. (1987) Reversible downbeat nystagmus secondary to excessive alcohol intake. ​Journal of Clinical Neuroophthalmology​. 7(1):23-5. Weiner AL, Vieira L, McKay CA, Bayer MJ. (2000). Ketamine abusers presenting to the emergency department: a case series. ​Journal of Emergency Medicine.​ 18(4):447-51.

Author: John Winkler, M.D. Educational Pearls: ● Lower mechanisms of injury have a lower chance of an associated fracture or major ligament injury ● One major concern is having a fracture fragment in the joint (can lead to chronic arthritic pain) ● Evaluation should involve checking the neurovascular status of the arm and reduce the fracture as soon as possible. Immobilize arm in a sling and consult orthopedics if there is intra-articular involvement. References: https://orthoinfo.aaos.org/en/diseases--conditions/elbow-dislocation/ Mehta, JA; Bain, GI. (2004). Elbow dislocations in adults and children. ​Clinics in Sports Medicine.​ 23(4):609-27.

Author: Michael Hunt, M.D. Educational Pearls: 1% of patients presenting to ED with alcohol intoxication end up going to the ICU Most common critical illnesses were acute hypoxic respiratory failure, sepsis, and intracranial hemorrhage Predictive markers: Vital abnormalities (hypoxia, tachycardic, tachypneic, hypothermic, hyperthermia, hypoglycemia) and patients receiving parenteral sedatives had higher incidence of ICU admission References: Klein, LR; et al. (2018). Unsuspected Critical Illness Among Emergency Department Patients Presenting for Acute Alcohol Intoxication. Annals of Emergency Medicine. 71(3):279-288

Dive into the world of retropharyngeal infections in children, exploring their anatomy and the critical need for timely treatment. Learn about the various signs and symptoms like drooling and neck swelling that indicate potential danger. Examine differential diagnoses that can complicate treatment, and discover effective antibiotic protocols to ensure better outcomes. The discussion also highlights possible complications, emphasizing the importance of swift intervention in pediatric cases.

Author: Gretchen Hinson, M.D. Educational Pearls: PNES vs. epilepsy: postictal state is diagnostic of an epileptic seizure (sonorous respirations and/or confusion, lasting typically 20-30 minutes); Epileptiform seizures show decrease in convulsion frequency, but increase in convulsion amplitude while PNES convulsions demonstrate episodic convulsion amplitudes; and epileptiform seizures usually do not pause. PNES is a form of conversion disorder and can be associated with underlying personality disorder; however there are patients with epilepsy that also can have PNES which complicates the diagnosis and treatment. Patients that are malingering may have flailing movements and might talk during the episodes - both not typical of epileptic seizures or PNES. Treatment for PNES is with psychotropic medications and psychotherapy as opposed to antiepileptic medications References: Avbersek, A; Sisodiya, S. (2010). Does the primary literature provide support for clinical signs used to distinguish psychogenic nonepileptic seizures from epileptic seizures?. Journal of neurology, neurosurgery, and psychiatry. 81(7):719-25. Devinsky, O; Gazzola, D; LaFrance, W. Curt (2011). Differentiating between nonepileptic and epileptic seizures. Nature Reviews. Neurology. 7 (4): 210–220. Lesser, RP. (2003). Treatment and Outcome of Psychogenic Nonepileptic Seizures. Epilepsy Currents. 3(6):198-200. doi:10.1046/j.1535-7597.2003.03601.x. Pillaia, JA; Hautab SR. (2012). Patients with epilepsy and psychogenic non-epileptic seizures: An inpatient video-EEG monitoring study. Seizure. 21(1): 24-27.

Author: Dr. Peter Bakes Educational Pearls: High risk patients: underlying lung disease, immunocompromised, extremes of age (65), underlying cardiac/renal/neurologic disease, and pregnant women Testing: RT-PCR (RNA based test that is both sensitive and specific) Workup: comorbidities dictate whether or not they are screened; CXR indicated in high risk patients with respiratory symptoms Morbidity from flu comes from secondary pneumonia, sepsis, and septic shock Treatment options are Tamiflu and Relenza (Relenza is contraindicated in patients with lung disease) High risk patients see average of 2.5 days shortening of illness and a decrease in illness severity. Low risk patients see average of 1.5 days shortening of illness. References: https://www.cdc.gov/flu/about/disease/high_risk.htm Binnicker MJ, Espy MJ, Irish CL, Vetter EA. Direct Detection of Influenza A and B Viruses in Less Than 20 Minutes Using a Commercially Available Rapid PCR Assay. J Clin Microbiol. 2015 Jul; 53(7): 2353-4. Longo, Dan L. (2012). "187: Influenza". Harrison's principles of internal medicine (18th ed.). New York: McGraw-Hill. ISBN 9780071748896.

Author: Sam Killian, M.D. Educational Pearls: Spinal cord injury without radiographic abnormality (SCIWORA) is a diagnosis defined as traumatic injury to spine with clinical sx of traumatic myelopathy (paraplegia, paresthesias, FND) without radiographic abnormalities. Term was established in 1970's before MRI and accounted for about 15% of injuries at the time (mainly children). Today SCIWORA accounts for about 10% of spinal injuries. Belief is that injury causes subtle movement of the spinal cord from its natural position with resultant contusion or ischemia with subsequent deficits. Treatment involves prolonged immobilization (up to 12 weeks). References: Walecki, J. (2014). Spinal Cord Injury Without Radiographic Abnormality (SCIWORA) – Clinical and Radiological Aspects. Polish Journal of Radiology,79, 461-464. doi:10.12659/pjr.890944