Emergency Medical Minute

Author: Peter Bakes, M.D. Educational Pearls Chronic diarrhea is defined as 3 or more loose, watery stools lasting more than 2-3 weeks. Look for clues in the history, including travel (could suggest infectious etiology), antibiotic use (could suggest C. Diff), and family history. Irritable Bowel Disease (Crohn's/Ulcerative Colitis) is an autoimmune disorder that affects 1.3 million Americans and is a leading cause of chronic diarrhea. Crohn's always involves the terminal ileum, but can present anywhere along the GI tract. It causes transmural inflammation of the bowel wall and can lead to adhesions, perforations, and fistulas. Ulcerative colitis usually involves the rectum and causes mucosal inflammation only. Workup for IBD includes colonoscopy and tissue biopsy. Treatment for IBD includes dietary changes, 5-ASA/Mesalamine, steroids, and infliximab (anti-TNF alpha). References: https://www.aafp.org/afp/2011/1115/p1119.html

Author: Aaron Lessen, M.D. Educational Pearls Treatment "bundles" are a popular approach to the rapid resuscitation of septic patients. A recent study in New York, where sepsis bundles are mandatory, sought to figure out which aspects of the bundle had impacts on mortality. In a study of 40,000 septic patients, the study found that early antibiotics were associated with better outcomes, while early IV fluids were not associated with better outcomes. This study affirms the important role of early antibiotics in sepsis. IV fluids may play an important role in the treatment of sepsis in some patients, but its role is less clear than antibiotics. References: Time to Treatment and Mortality during Mandated Emergency Care for Sepsis Christopher W. Seymour, M.D., Foster Gesten, M.D., Hallie C. Prescott, M.D., Marcus E. Friedrich, M.D., Theodore J. Iwashyna, M.D., Ph.D., Gary S. Phillips, M.A.S., Stanley Lemeshow, Ph.D., Tiffany Osborn, M.D., M.P.H., Kathleen M. Terry, Ph.D., and Mitchell M. Levy, M.D. N Engl J Med 2017; 376:2235-2244 June 8, 2017 DOI: 10.1056/NEJMoa1703058

Author: Don Stader, M.D. Educational Pearls While we usually associate the coronary vasculature with STEMIs, there are other pathologies that can affect the heart's blood supply. Kounis syndrome: an allergic vasospasm of the coronary arteries. This can happen post anaphylaxis or be caused by a stent allergy. It is best treated with aggressive management of the allergic reaction. Kawasaki disease: An autoimmune condition that presents in kids as conjunctivitis, lymphadenopathy, hand/foot swelling, rash, and fever. It can also cause coronary aneurysms, which can rupture and be rapidly fatal. Prinzmetal angina: Caused by coronary vasospasm. Presents with transient chest pain at rest. Treat with CCBs. Cocaine: Causes coronary vasospasm. Cocaine-induced vasospasm is best treated with BZDs. Coronary artery dissection: increased risk in pregnant women and those with connective tissue disorders. References: Memon S, Chhabra L, Masrur S, Parker MW. Allergic acute coronary syndrome (Kounis syndrome). Proceedings (Baylor University Medical Center). 2015;28(3):358-362.

Author: Aaron Lessen, M.D. Educational Pearls While C. difficile infections are generally thought of as nosocomial, there is a subset of patients who acquire the infection in the community. One recent study showed that about 10% of patients presenting to the ED with diarrhea and without vomiting had a C. diff infection. Another study found risk factors for community-acquired C. diff included recent ED/Urgent care visits and antibiotic use. However, 36% of the patients in that study had no identifiable risk factors. References: Gupta A, Khanna S. Community-acquired Clostridium difficile infection: an increasing public health threat. Infection and Drug Resistance. 2014;7:63-72. doi:10.2147/IDR.S46780.

Author: Erik Verzemneicks, M.D. Educational Pearls 1/600 flights has an on-board request for medical assistance. Most common complaints on board include: syncope, respiratory complaints, and GI complaints. Most of the time, these are exacerbations of underlying chronic conditions. Except for situations involving gross negligence, the Aviation Assistance Act protects providers from legal action as long as they are acting within their scope of practice. Flight crew are CPR and AED trained. The onboard medical kit includes: epinephrine, dextrose, nitroglycerin, NSAIDs, injectable antihistamine, antiemetic, steroids, beta-blocker, aspirin, stethoscope, BP cuff, airway tools, thermometer and more. There is ground-based medical control for consult and guidance. References: https://www.acep.org/Clinical---Practice-Management/Emergency-at-30,000-Feet---What-You-Can-Do/#sm.0001eqpidqrpoczltzg1epg0m0aqu

Author: John Winkler, M.D. Educational Pearls Photokeratitis is a UV burn of the sclera and cornea, which can cause blindness. UV light causes eyelid swelling with diffuse scarring of the eye (widespread, punctate uptake of fluorescein dye). While this can eventually heal, it is incredibly painful. Snow reflects light underneath sunglasses, so wrap-around goggles are the best form of prevention. This can happen to welders, sunbathers or any other person with prolonged UV light exposure. References: https://emedicine.medscape.com/article/799025-treatment

Author: Dave Rosenberg, M.D. Educational Pearls EKG changes that can be seen in DKA include ST elevation and peaked T-waves secondary to derangements in K levels. In DKA, serum K is high, but total body K is low, which can cause said EKG abnormalities. Many things cause ST elevation besides MI, so think beyond STEMI. When someone in in DKA, think about the "Three I's" for underlying cause: (not taking) insulin, ischemia, infection. References: Nageswara Rao Chava. ECG in Diabetic Ketoacidosis. Arch Intern Med. 1984;144(12):2379–2380. doi:10.1001/archinte.1984.00350220101022

Author: John Winkler, M.D. Dr. Winkler shares his knowledge of wilderness medicine and provides insight on how to prevent and treat conditions such as hypothermia, frostbite and sun blindness. More importantly, he gives us tips on how to stay safe while doing our favorite wintertime activities!

Podcast #281: Intracranial Hemorrhage Treatment Author: Don Stader, M.D. Educational Pearls Types of traumatic bleeds include subdural, epidural, and subarachnoid. Treatment for a traumatic bleed includes maintenance of systolic BP above 120 and seizure prophylaxis with phenytoin. In atraumatic bleeds, treatment should focus on lowering blood pressure to reduce bleeding. References: https://www.aliem.com/2017/09/intracranial-hemorrhage-management/

Author: Aaron Lessen, M.D. Educational Pearls Patients with an ischemic stroke from occlusion of the left middle cerebral artery often present with aphasia in addition to other neurological deficits. A recent study looked at patients presenting with suspected stroke. Of the 700 patients recruited, 3% had isolated aphasia on exam. On follow-up, none of the 3% had evidence of stroke on imaging. Underlying causes of the isolated aphasia in these patients included syncope, infections, seizures were the underlying cause. References: Gabriel Casella, Rafael H. Llinas, Elisabeth B. Marsh, Isolated aphasia in the emergency department: The likelihood of ischemia is low, Clinical Neurology and Neurosurgery, Volume 163, 2017, Pages 24-26, ISSN 0303-8467, https://doi.org/10.1016/j.clineuro.2017.10.013.