Emergency Medical Minute

Author: Don Stader, M.D. Educational Pearls Cluster headaches are usually intense, unilateral, and involve the periorbital area. CN V (Trigeminal) provides sensory and autonomic innervation the face and eyes, which play roles in headache pathology. Cluster headaches can be treated with high flow oxygen, but a new treatment involves blocking the sphenopalatine ganglion (SPG) with lidocaine. Because sensory and autonomic branches of the trigeminal traverse the SPG, lidocaine will effectively treat a cluster headache. To block the ganglion, intranasal lidocaine may be used, or a Q-tip soaked in 4% lidocaine can be applied to the most posterior aspect of the pharynx for 10-15 minutes. References: https://www.aliem.com/2017/03/trick-sphenopalatine-ganglion-block-primary-headaches/

Author: Suzanne Chilton, M.D. Educational Pearls Pott's puffy tumor is a subperiosteal abscess of the frontal bone that arises from hematologic spread or direct infection via the frontal sinuses. The primary symptom is facial swelling. It is much more common in children and adolescents. Treatment involves removal of the frontal bone, reconstructive surgery, and 6-8 weeks of IV antibiotics. References: Grewal HS, Dangaych NS, Esposito A. A tumor that is not a tumor but it sure can kill! The American Journal of Case Reports. 2012;13:133-136. doi:10.12659/AJCR.883236.

Author: Dave Rosenberg, M.D. Educational Pearls MI and GERD can present similarly. For example, 47% with angina report increased belching with an anginal attack, and 20% of people with an MI describe symptoms of indigestion that are relieved by antacids. Overall, GERD is more common in those with CAD, so don't be "reassured" by GERD symptoms in the setting of chest pain. References: http://www.mdedge.com/ecardiologynews/article/82215/cad-atherosclerosis/gerd-may-boost-risk-mi

Podcast #240: Honey and Burns Author: Nick Hatch, M.D. Educational Pearls Honey can be used to treat burns because it has antibacterial properties. In one study, honey outperformed silver sulfadiazine for burn treatment, but more research is needed in this area. In practice, honey is likely more useful outside the ER than inside the ER. References: Gupta SS, Singh O, Bhagel PS, Moses S, Shukla S, Mathur RK. Honey Dressing Versus Silver Sulfadiazene Dressing for Wound Healing in Burn Patients: A Retrospective Study. Journal of Cutaneous and Aesthetic Surgery. 2011;4(3):183-187. doi:10.4103/0974-2077.91249.

Author: Rachel Beham, PharmD, Advanced Clinical Pharmacist - Emergency Medicine Educational Pearls Tetanus Ig is indicated in those who have no or unknown tetanus vaccination history who present with contaminated cuts that or dirty puncture wounds The tetanus vaccine is a 5 shot series (DTAP) for children, TDAP is used for adults There is no harm is receiving the TDAP more than once if vaccination history is unknown References: https://www.cdc.gov/features/tetanus/index.html

Author: Aaron Lessen M.D. Educational Pearls Ultrasound is helpful in the setting of cardiac arrest for finding a cause like cardiac tamponade or PE, but also for predicting outcomes for non-shockable rhythms. One study showed that in those that presented with asystole or PEA and cardiac activity on US had a 4% survival rate, while those without cardiac activity had almost no chance. References: Philip Salen, Larry Melniker, Carolyn Chooljian, John S. Rose, Janet Alteveer, James Reed, Michael Heller, Does the presence or absence of sonographically identified cardiac activity predict resuscitation outcomes of cardiac arrest patients?, The American Journal of Emergency Medicine, Volume 23, Issue 4, 2005, Pages 459-462, ISSN 0735-6757, http://dx.doi.org/10.1016/j.ajem.2004.11.007.

Author: Susan Brion, M.D. Dr. Brion enlightens us on the ever-evolving standard of sepsis management.

Author: Sam Killian, M.D. Educational Pearls Phimosis refers to the inability to retract the distal foreskin over the glans penis in uncircumcised males. Paraphimosis is the entrapment of the foreskin proximal to the glans penis in these patients. Phimosis is rarely a medical emergency, but requires follow up with urology. Paraphimosis, on the other hand, can cause venous and lymphatic insufficiency, leading to infarction, necrosis and autoamputation. Therefore, paraphimosis requires emergent treatment with manual reduction of the foreskin or surgery. References: Aaron Vunda, M.D., Laurence E. Lacroix, M.D., Franck Schneider, Sergio Manzano, M.D., and Alain Gervaix, M.D. Reduction of Paraphimosis in Boys. N Engl J Med 2013; 368:e16

Author: Nick Hatch, M.D. Educational Pearls When peripheral or central IV access is difficult, sometimes providers will try to use a peripheral IV setup at an IJ site using US guidance. Case studies have shown that this method is often successful, with the most common complication being the loss of access. References: Ash AJ, Raio C. Seldinger Technique for Placement of "Peripheral" Internal Jugular Line: Novel Approach for Emergent Vascular Access. Western Journal of Emergency Medicine. 2016;17(1):81-83. doi:10.5811/westjem.2015.11.28726.

Author: Pete Bakes, M.D. Educational Pearls One of the roles of the ER provider is to discharge patients only after life-threatening conditions have been ruled out. However, some patients that are discharged from the ED die within days of their discharge. One recent study sought to investigate the factors and diagnoses associated with death within 7 days of discharge. This study was a retrospective study in 10 million medicare recipients that presented to the ER over 10 years. They excluded palliative, hospice and SNF patients. 0.12% of these patients died within 7 days of ER discharge. Signs and symptoms such as altered mental status, general malaise and fatigue, and nonspecific dyspnea had relative risks of 3-5 for death following discharge. Think carefully before discharge in patients with the signs/symptoms above. References: Obermeyer Ziad, Cohn Brent, Wilson Michael, JenaAnupam B, Cutler David M. Early death after discharge from emergency departments: analysis of national US insurance claims data BMJ 2017;356 :j239