Emergency Medical Minute

Author: Nick Hatch, M.D. Educational Pearls Acyclovir toxicity can uncommonly cause altered mental status, low blood glucose, hallucinations and myoclonic jerks. Toxicity often occurs in the setting of renal insufficiency, as it is cleared by the kidneys. Acyclovir is often used to treat shingles, which can also cause similar symptoms as acyclovir toxicity due to encephalitis - rule this out in the setting of a concomitant shingles infection. References: http://www.rxlist.com/zovirax-drug.htm

Author: Michael Hunt, M.D. Educational Pearls Wells Criteria was initially designed to screen patients for further workup for PE. Aspects of the Wells Criteria include: signs and symptoms of DVT (3 points), PE most likely dia (3 points), HR > 100 (1.5 points), immobility for > 3 days or surgery in last 4 weeks (1.5 points), documented history of PE (1.5), hemoptysis (1), treatment for cancer in last 6 mo (1). ACEP uses a score of less than or equal to 4 to define "low risk." Greater than 4 is "high risk". Use Wells to guide clinical decisions about PE workup. References: http://www.ebmedicine.net/media_library/files/1212%20Pulmonary%20Embolism

Podcast #221: Walking Corpse Syndrome Author: Erik Verzemnieks, M.D. Educational Pearls Walking Corpse Syndrome (aka Cotard Delusion) is a very rare psychiatric disorder that leads to the belief that one is a "walking corpse". Often co-presents with depression, schizophrenia, and starvation. Responds to ECT. References: https://en.wikipedia.org/wiki/Cotard_delusion

Author: Aaron Lessen, M.D. Educational Pearls Atrial fibrillation is common. One of the best treatments for a fib is cardioversion back into sinus rhythm. Cardioversion may increase stroke risk if A-Fib duration is greater than 48 hours, but some new data suggests that this risk may happen as soon as 12 hours. However, newer studies show that cardioversion is generally safe as a treatment for A-Fib. References: Aatish Garg, Monica Khunger, Sinziana Seicean, Mina K. Chung, Patrick J.Tchou Incidence of Thromboembolic Complications Within 30 Days of Electrical Cardioversion Performed Within 48 Hours of Atrial Fibrillation Onset. JACC: Clinical Electrophysiology Aug 2016, 2 (4) 487-494; DOI: 10.1016/j.jacep.2016.01.018

Author: Chris Holmes, M.D. Educational Pearls "Sepo' is a term from Homer (author of The Iliad and The Odyssey), and means "I rot". Hippocrates in 400 BC identified sepsis as a "dangerous decay within the body". Galen in 200 AD believed pus was "laudable". The Greeks and Romans used the term "myasma" to describe the smell of swamp and rotting flesh. Dr. Emmanuel Rivers in Detroit did one of the the first big studies about sepsis and was an advocate for goal-directed therapy. Now, Vitamin C cocktails are in use, but new sepsis treatments should be investigated carefully before implementation. References: Funk, Duane J. et al. Sepsis and Septic Shock: A History. Critical Care Clinics , Volume 25 , Issue 1 , 83 - 101

Author: Aaron Lessen, M.D. Educational Pearls Asking parents and Broselow Tape are common options for estimating pediatric weight. Equipment sizes should not be adjusted for under/overweight kids based on Broselow Tape estimates. The finger counting method (see reference) is just as accurate as Broselow Tape method, according to one study. References: http://handtevy.com/images/Casestudies/Americanjournalofemergencymedicine.pdf

Author: John Winkler, M.D. Educational Pearls: Designer, or "synthetic" drugs include bath salts, synthetic THC, and many others. Many of these drugs are originally manufactured in China and are shipped globally. Treatment usually involves airway control and sedation - ketamine may be useful. Traditional tox screens do not test for these drugs. References: https://www.drugabuse.gov/related-topics/trends-statistics/national-drug-early-warning-system-ndews

Author: Aaron Lessen, M.D. Educational Pearls: Anecdotal evidence suggests that roller coasters may help with kidney stones. A recent study used a model of a kidney and ureter with different sized stones and put it on Thunder Mountain roller coaster in Disney World. There was "dramatic passage" of the kidney stones at the rear of the roller coaster. References: Marc A. Mitchell, DO; David D. Wartinger, DO, JD. Validation of a Functional Pyelocalyceal Renal Model for the Evaluation of Renal Calculi Passage While Riding a Roller Coaster. The Journal of the American Osteopathic Association, October 2016, Vol. 116, 647-652. doi:10.7556/jaoa.2016.128. http://jaoa.org/article.aspx?articleid=2557373

PRACTICE RECOMMENDATIONS 1. Patients who abuse opioids should be managed without judgement; addiction is a medical condition and not a moral failing. Caregivers should endeavor to meet patients "where they are," infusing empathy and understanding into the patient/medical provider relationship. 2. Every emergency clinician should be well-versed in the safe injection of heroin and other intravenous (IV) drugs, and understand the practical steps for minimizing the dangers of overdose, infection, and other complications. When treating patients with complications of IV drug use, injection habits should be discussed and instruction should be given about safe practices. 3. Emergency department patients who inject drugs should be referred to local syringe access programs, where they can obtain sterile injection materials and support services such as counseling, HIV/hepatitis testing, and referrals. 4. Emergency departments should provide naloxone to high-risk patients at discharge. If the drug is unavailable at the time of release, patients should receive a prescription and be informed about the over-the-counter availability of the drug in most Colorado pharmacies. 5. Emergency clinicians should be familiar with Colorado's regulations pertaining to naloxone. State laws eliminate liability risk for prescribing the drug, encourage good samaritan reporting of overdose, and make naloxone legal and readily available over the counter in most pharmacies. 6. Emergency department patients who receive prescriptions for opioids should be educated on their risks, safe storage methods, and the proper disposal of leftover medications. POLICY RECOMMENDATIONS 1. Harm reduction agencies and community programs that provide resources for people who inject drugs (PWID) should be made readily available. 2. When local programs are unavailable for PWID, emergency departments should establish their own programs to provide services such as safe syringe exchanges.

PRACTICE RECOMMENDATIONS 1. All emergency departments should implement ALTO programs and provide opioid-free pain treatment pathways for the following conditions: a. Acute on chronic opioid-tolerant radicular lower back pain b. Opioid-naive musculoskeletal pain c. Migraine or recurrent primary headache d. Extremity fracture or joint dislocation e. Gastroparesis-associated or chronic functional abdominal pain f. Renal colic 2. Emergency departments should integrate ALTO into their computerized physician order entry systems to facilitate a seamless adoption by clinicians. 3. Low-dose, subdissociative ketamine (0.1-0.3 mg/kg) is an effective analgesic that can be opioid-sparing for many acute pain syndromes. Institutional guidelines and policies should be in place to enable clinicians and nurses who administer this agent for pain. 4. For musculoskeletal pain, consider a multimodal treatment approach using acetaminophen, NSAIDs, steroids, topical medications, trigger-point injections, and (for severe pain) ketamine. 5. For headache and migraine, consider a multimodal treatment approach that includes the administration of antiemetic agents, NSAIDs, steroids, valproic acid, magnesium, and triptans. Strongly consider cervical trigger-point injection. 6. For pain with a neuropathic component, consider gabapentin. 7. For pain with a tension component, consider a muscle relaxant. 8. For pain caused by renal colic, consider an NSAID, lidocaine infusion, and desmopressin nasal spray. 9. For chronic abdominal pain, consider low doses of haloperidol, diphenhydramine, and lidocaine infusion. 10. For extremity fracture or joint dislocation, consider the immediate use of nitrous oxide and low-dose ketamine while setting up for ultrasound-guided regional anesthesia. 11. For arthritic or tendinitis pain, consider an intra-articular steroid/anesthetic injection. POLICY RECOMMENDATIONS 1. Hospitals should update institutional guidelines and put policies in place that enable clinicians to order and nurses to administer dose-dependent ketamine and IV lidocaine in non-ICU areas. 2. Emergency departments are encouraged to assemble an interdisciplinary pain management team that includes clinicians, nurses, pharmacists, physical therapists, social workers, and case managers. 3. Reimbursement should be available for any service directly correlated to pain management, the reduction of opioid use, and treatment of drug-addicted patients.