Emergency Medical Minute

Author: Rachel Beham, PharmD, Advanced Clinical Pharmacist – Emergency Medicine Educational Pearls Cyanide poisoning is suspected in patients who present with lactic acidosis after being trapped around burning household objects. It affects our ability to metabolize and can quickly lead to CV collapse and death. Because cyanide blood levels are not quickly available, the diagnosis is made by history and lactic acidosis on ABG. The cyanokit is the key treatment. It contains hydroxocobalamin, which binds to cyanide so it can be excreted. One side effect to be aware of is that the cyanokit will turn everything red, including mucous membranes, saliva, urine, and skin. This will interfere with some lab values, so make sure to get labs before administration. References: Mégarbane B, et al. Antidotal treatment of cyanide poisoning. J Chin Med Assoc. 2003

Author: Rachael Duncan, PharmD BCPS BCCCP Educational Pearls Desmopressin is an ADH mimetic and helps retain water, release von Willibrand Factor (in high doses), and treat diabetes insipidus (in low doses). It can also be used in renal colic, because it may reduce muscle spasm in the ureters. The dosing for renal colic is very small (40 micrograms). References: http://reference.medscape.com/drug/ddavp-stimate-noctiva-desmopressin-342819

Author: Jared Scott, M.D. Educational Pearls Overall, medical providers are bad at detecting pulses. However, only 2% of patients do not have a detectable DP pulse. In one study, for patients with limb claudication, there was only about 50% agreement on the presence of a DP pulse. References: Brearley et al. Peripheral pulse palpation: an unreliable physical sign. Annals of the Royal College of Surgeons of England. 1992

Author: Aaron Lessen, M.D. Educational Pearls Traditionally the family is removed from the room during procedures and codes, but recent research shows that family presence may be beneficial. 50% patients want family present during a code. Family-related outcomes were improved with presence. There was no change in medical outcomes, and no increased incidence of medicolegal issues. References: Jabre et al. Family Presence during Cardiopulmonary Resuscitation. NEJM. 2013.

Author: Michael Hunt, M.D. Educational Pearls In the recent YEARS study, investigators checked every patient with suspicion for PE with a D-dimer, using a modified Wells score for risk stratification. The goal of the study was to show that CT scan usage could safely reduced using this screening method. The Wells Criteria measures they used to stratify risk were: PE mostly likely dx, hemoptysis, and evidence of DVT. If the d-dimer was 1, but the patient had none of the Wells criteria, the patient did not get a CT. If the patient had any of the criteria, but the d-dimer was only 0.5, the patient did not get a CT scan. The investigators reduced CT usage by 14% using the new criteria, with no significant increase in morbidity and mortality. References: van der Hulle et al. Simplified diagnostic management of suspected pulmonary embolism (the YEARS study): a prospective, multicentre, cohort study. The Lancet. 2017

Author: Jared Scott, M.D. Educational Pearls The foramen ovale (FO) connects the left and right atria to allow oxygenated blood to bypass the developing lungs, it usually closes at birth but for some it remains patent (PFO). A PFO allows clots to cross from the venous to arterial circulation, increasing the likelihood of stroke. PFO is present in 25% of general population, present in 50% of those with stroke of unknown cause, and very common those with stroke under 50 years old. Treat with anticoagulation or surgical correction. References: http://www.heart.org/HEARTORG/Conditions/More/CardiovascularConditionsofChildhood/Patent-Foramen-Ovale-PFO_UCM_469590_Article.jsp#.WarsZZN95E4

Author: Don Stader, M.D. Educational Pearls Ear pain is a common complaint in adults and kids. A red, hot, painful ear with involvement of the pinna could indicate perichondritis - an infection of the cartilage that is usually caused by pseudomonas. A painful, swollen ear with involvement of the mastoid process could be mastoiditis, which needs to be treated with IV antibiotics to avoid cerebellar abscess. Ear pain with significant drainage and a cranial nerve deficit points to malignant otitis externa, which needs to be treated with IV antibiotics. References: John W. Ely, Marlan R. Hansen, Elizabeth C. Clark. Diagnosis Of Ear Pain. 2008. American Family Physician.

Author: Nick Hatch, M.D. Educational Pearls A recent observational cohort study found that the biggest predictor for sepsis survival was fever. Those with higher fevers had better outcomes. Some possible explanations for this finding are that high fevers indicate good immune response or that high fever cued providers to treat sepsis more aggressively. References: Paul J Young, Rinaldo Bellomo. Fever in Sepsis: is it cool to be hot?. 2014. Critical Care

Author: Dylan Luyten, M.D. Educational Pearls Hypoglycemia is very common in type 2 diabetics, and is often caused by insulin overdose or missed meals. Knowing the peak time of action for common diabetes medications can help inform treatment and disposition. Regular insulin's action peaks around 60 minutes. By the time most of these patients present to the ED, the drug has had most of its effect. Lantis' action does not peak, and will continue to exert its effect for 12 or more hours. Levamir has a peak around 6-8 hours. Metformin sensitizes tissues to insulin, so it cannot cause hypoglycemia alone. Glipizides have half-lives over 12 hours and work by increasing insulin release by the pancreas. Hypoglycemia in a patient taking a glipizide usually indicates there is another medical issue interfering with clearance References: http://emedicine.medscape.com/article/122122-workup

Author: Nick Hatch, M.D. Educational Pearls The force required to break a clavicle is significant, so clavicle fracture may be associated with other injury (pneumothorax, vascular injury). Most fractures occur in the middle 1/3 of the clavicle. Traditionally, clavicle fractures have been managed without surgery. However, recent studies have shown that surgery may be beneficial in a larger population than previously thought. References: http://emedicine.medscape.com/article/398799-overview