Emergency Medical Minute

Author: Michael Hunt, M.D. Educational Pearls Tattoo ink is applied below the skin, and because of this, they can lead to keloids, granulomas, tetanus, hepatitis B and C, and skin infections. Tattoo pigment has been found to contain substances like lead, cadmium, chromium, and arsenic; however, there are no long-term studies of the health effects of tattoos. In one study 14% of inks had ingredients that were banned in cosmetics. Nanoparticles of tattoo pigment can be found in the lymph nodes, and laser removal can precipitate their spread. Those with tattoos could experience complications with MRI because of the metal content of the ink. References: Khunger N, Molpariya A, Khunger A. Complications of Tattoos and Tattoo Removal: Stop and Think Before you ink. Journal of Cutaneous and Aesthetic Surgery. 2015;8(1):30-36. doi:10.4103/0974-2077.155072.

Author: Dave Rosenberg, M.D. Educational Pearls Poiseuille's Law addresses the flow of a fluid through a tube. Many common ED presentations involve alterations in flow: asthma, MI, ischemic stroke, etc. According to the law, flow increases with the 4th power of the radius. That is to say, doubling the radius of the tube will increase the flow by 16x. Therefore, in situations that require re-opening of an anatomic tube (artery, airway), small changes in the size of the opening will result in dramatic effects. References: https://www.openanesthesia.org/poiseuilles_law_iv_fluids/

Author: Dylan Luyten, M.D. Educational Pearls Lactate is a byproduct of anaerobic metabolism, a sign of dying tissue. Dangerous causes of high lactates will not normalize with repeat labs. Crush injuries, seizures, bowel necrosis, end-stage liver disease, and metformin toxicity are common causes of highly elevated lactate. References: https://lifeinthefastlane.com/ccc/lactic-acidosis/

Author: John Winkler, M.D. Educational Pearls Some risk factors for MI in the young are history of CAD, stimulant drug use, coronary spasm and diabetes. In those with diffuse ST elevations on EKG, think pericarditis. Troponin will also be elevated. References: Egred M, Viswanathan G, Davis GK Myocardial infarction in young adults Postgraduate Medical Journal 2005;81:741-745.

Author: Rachel Beham, PharmD, Advanced Clinical Pharmacist - Emergency Medicine Educational Pearls CDC recommends using the inactivated, injectable flu vaccine in those 6 months and older. The live attenuated vaccine is not used because of low efficacy. Pregnant women should be vaccinated, and can receive the vaccine at any stage of their pregnancy. The vaccine is contraindicated ONLY in those with a history of a severe anaphylactic reaction to the injection in the past. Antivirals (oseltamivir, zanamivir) are useful for Flu A and B. Their dosing needs to be adjusted for renal function, and it is contraindicated in those with ESRD who are not receiving dialysis. It should be used for prophylaxis in those with exposure and/or for the very young, very old, morbidly obese, nursing home residents, and those who are immunocompromised. They may be effective as long as 72 hours after symptom onset. References: https://www.cdc.gov/flu/professionals/index.htm

Author: Aaron Lessen, M.D. Educational Pearls For patients with in-hospital cardiac arrest, intubation in the 1st 15 minutes of resuscitation was associated with worse outcomes (mortality, neurologic outcome). This is likely due to cessation of high-quality CPR and defibrillation during the intubation sequence. In those with an in-hospital, shockable, cardiac arrest, administration of epinephrine before the 2nd defibrillatory shock was associated with worse outcome. This was likely due to the cessation of high-quality CPR. For in-hospital cardiac arrest, resuscitation should focus on high-quality CPR. References: Andersen LW, Granfeldt A, Callaway CW, Bradley SM, Soar J, Nolan JP, Kurth T, Donnino MW, for the American Heart Association's Get With The Guidelines–Resuscitation Investigators. Association Between Tracheal Intubation During Adult In-Hospital Cardiac Arrest and Survival. JAMA. 2017;317(5):494–506. doi:10.1001/jama.2016.20165

Educational Pearls After the first hour, every 1 hour delay in antibiotics in a patient with septic shock patient is associated with a 4% increase in mortality. In patients with high suspicion for septic shock (fever and hypotension), antibiotics should be initiated ASAP. Rocephin (ceftriaxone) should be used for those with community-acquired sepsis, zosyn for nosocomial or IV-associated sepsis. References: https://lifeinthefastlane.com/ccc/antibiotic-timing/

Author: Julian Orenstein, M.D. Educational Pearls Colorado has a high population of unvaccinated children, and is at increased risk for pertussis outbreaks. The causative organism is Bordetella pertussis. It causes causes respiratory epithelial necrosis leading to congestion of the bronchioles, leading to cough. The cough is unique - it is usually a series of expiratory coughs followed by one deep inspiration The clinical presentation is divided into 3 phases: Catarrhal: cough and congestion with low-grade fever and coryza. Whooping: characteristic cough. Resolution: recovery with persistent cough. Infants may not get this presentation, but may get apnea and nonspecific cough. Tongue depressor can be used to elicit cough for diagnosis. References: Tozzi AE, Pastore Celentano L, Ciofi degli Atti ML, Salmaso S. Diagnosis and management of pertussis. CMAJ : Canadian Medical Association Journal. 2005;172(4):509-515. doi:10.1503/cmaj.1040766.

Authors: Katie Sprinkel, MD Emergency Medicine Physician SANE Medical Director, Medical Center of Aurora Amy Ferrin, Senior Deputy District Attorney County Court Supervisor Office of the District Attorney, 18th Judicial District Amy Ferrin and Dr. Katie Sprinkel speak about the medical and legal aspects of domestic violence.

Author: Aaron Lessen, M.D. Educational Pearls Icatibant was introduced to treat ACE-inhibitor induced angioendema. This type of angioedema is refractory to epinephrine and antihistamines, and is likely mediated by elevated bradykinin.(which is inactivated by ATII and ACE). Icatibant initially was shown to reduce facial swelling and airway obstruction in the setting of ACE-I angioedema, but later, better-powered studies showed that it had no benefit compared to standard treatment. References: Sinert R et al. Randomized Trial of Icatibant for Angiotensin-Converting Enzyme Inhibitor-Induced Upper Airway Angioedema. J Allergy Clin Immunol Pract 2017. PMID: 28552382