Emergency Medical Minute

For this episode of Mental Health Monthly, EMM is honored to collaborate with the hosts of Millennial Mental Health Channel podcast to explain Borderline Personality Disorder and tips to manage patients with this diagnosis in the Emergency Department. Dr. Justin Romano is a third year psychiatry resident in Omaha, Nebraska and Eddie Carrillo is a licensed mental health therapist currently working at partial hospitalization and IOP eating disorder program in Portland, Oregon. Their podcast Millennial Mental Health Channel seeks to explore the world of mental health from their two professional perspectives. You can listen to their podcast on all major streaming platforms including Apple Podcasts, Spotify and Google Podcasts. Follow them on Twitter and Instagram @millennialmhc Contributors: Dr. Justin Romano and Eddie Carrillo, M.A., LPC Educational Pearls: 4% of the general population has Bipolar Personality Disorder (BPD) and 9% of all emergency room visits involve patients with BPD. BPD is defined as a pervasive pattern of instability of interpersonal relationships, self-image, affect and marked impulsivity beginning by early adulthood and present in a variety of contexts. There are 9 symptoms of BPD. In order to meet criteria for diagnosis you need 5 of the 9. Symptoms include: Frantic efforts to avoid real or imagined abandonment Pattern of unstable and intense interpersonal relationships, characterized by alternating between extremes of idealization and devaluation Identity disturbance: markedly and persistently unstable self-image or sense of self Impulsivity in at least two areas that are potentially self-damaging Recurrent suicidal behaviors, gestures, threats or self-mutilating behavior Affect instability due to marked reactivity of mood Chronic feelings of emptiness Inappropriate intense anger or difficulty controlling anger Transient stress related paranoid ideation or severe dissociative symptoms Pathophysiology behind BPD: Overactivation of the amygdala within the limbic system which controls fear, anxiety and anger. Often patients with BPD have dealt with an increased amount of trauma in their lives. They have one of the highest suicide rates at 10%. Behaviors in individuals with BPD are often due to an invalidating environment in an attempt to reconnect with people they love. Tips to managing patients in the emergency room with BPD. Stay calm, consistent and caring and validate their feelings with: Body language: sit at eye level, make good eye contact, nod your head when they talk, and use repeat back clarification questions. Facial expressions: be cognizant of your facial expressions. Patients with BPD are more likely to interpret a neutral face as angry. Set boundaries and stick to your word. Patients with BPD can be described as manipulative, but often they are unaware they are doing this. Give validating statements. This will ensure the patient you are listening and working with them to solve their problems. Summarized by Emily Mack, OMSIII

Contributor: Aaron Lessen, MD Educational Pearls: Contrary to many assumptions, meter-dose inhalers (MDIs) are as effective as nebulizers in pediatric and adult patients Nebulizers are associated with higher rates of tremor, tachycardia; they cost more and are associated with longer ED stays Though it may take some convincing, in a patient that is physically able, using an MDI with spacer appears to be the better option - and that was even before COVID. References Snider MA, Wan JY, Jacobs J, Kink R, Gilmore B, Arnold SR. A Randomized Trial Comparing Metered Dose Inhalers and Breath Actuated Nebulizers. J Emerg Med. 2018 Jul;55(1):7-14. doi: 10.1016/j.jemermed.2018.03.002. Epub 2018 Apr 30. PMID: 29716819. Brocklebank D, Ram F, Wright J, Barry P, Cates C, Davies L, Douglas G, Muers M, Smith D, White J. Comparison of the effectiveness of inhaler devices in asthma and chronic obstructive airways disease: a systematic review of the literature. Health Technol Assess. 2001;5(26):1-149. doi: 10.3310/hta5260. PMID: 11701099. Dhuper S, Chandra A, Ahmed A, Bista S, Moghekar A, Verma R, Chong C, Shim C, Cohen H, Choksi S. Efficacy and cost comparisons of bronchodilatator administration between metered dose inhalers with disposable spacers and nebulizers for acute asthma treatment. J Emerg Med. 2011 Mar;40(3):247-55. doi: 10.1016/j.jemermed.2008.06.029. Epub 2008 Dec 11. PMID: 19081697. Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.com/cme-courses/ and create an account.

Contributor: Ryan Circh, MD Educational Pearls: Diabetic ketoacidosis (DKA) can be the initial presenting condition of undiagnosed diabetes type I in pediatric patients Unlike adults, children typically need less fluid (i.e. 10 mL/kg bolus for those in shock followed by maintenance) Cerebral edema is a concern from rapid administration of fluids An insulin drip at 0.1 units/Kg/hr should be started but a bolus isn't required Editor's note: While conceptually similar, treatment for pediatric DKA is overall less aggressive (no bolus of insulin, less fluids, slower corrections, etc.). Recent literature also continues to argue against cerebral edema being related to fluid management References Hsia D, Tarai S, Alimi A, Coss-Bu J, Haymond M. Fluid management in pediatric patients with DKA and rates of suspected clinical cerebral edema. Pediatr Diabetes. 2015;16(5):338-344. Wolfsdorf J, Glaser N, Sperling M, American D. Diabetic ketoacidosis in infants, children, and adolescents: A consensus statement from the American Diabetes Association. Diabetes Care. 2006;29(5):1150-1159. Olivieri L, Chasm R. Diabetic ketoacidosis in the pediatric emergency department. Emerg Med Clin North Am. 2013 Aug;31(3):755-73. doi: 10.1016/j.emc.2013.05.004. Epub 2013 Jul 6. PMID: 23915602. Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.com/cme-courses/ and create an account.

Contributor: Nick Tsipis, MD Educational Pearls: Perichondritis involves infection of not only the connective tissue of the ear but typically the cartilage as well Symptoms include erythema, ear pain, and fevers The most common bacterial cause is Pseudomonas. Perichondritis often occurs after a wound or piercing, but trauma is not necessary for the infection to occur Anti-pseudomonal coverage is essential with typically oral agents for milder disease and IV antibiotics for severe infections Can have devastating outcomes if not treated aggressively and/or treated early due to poor blood supply to the cartilage of the ear References Prasad HK, Sreedharan S, Prasad HS, Meyyappan MH, Harsha KS. Perichondritis of the auricle and its management. J Laryngol Otol. 2007 Jun;121(6):530-4. doi: 10.1017/S0022215107005877. Epub 2007 Feb 26. PMID: 17319983. Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.com/cme-courses/ and create an account.

Contributor: Sam Killian, MD Educational Pearls: Spontaneous bacterial peritonitis (SBP) is an infection of peritoneal fluid that typically occurs in cirrhotic patients Symptoms may include abdominal pain, fever, and/or altered mental status Paracentesis is diagnostic test of choice. Diagnostic criteria includes > 250 polymorphonuclear cells (PMNs) or a positive gram stain/culture Treatment is typically a 3rd generation cephalosporin ·30-40% of SBP patients will go into renal failure and SBP associated with sepsis has an ~80% mortality References Dever JB, Sheikh MY. Review article: spontaneous bacterial peritonitis--bacteriology, diagnosis, treatment, risk factors and prevention. Aliment Pharmacol Ther. 2015 Jun;41(11):1116-31. doi: 10.1111/apt.13172. Epub 2015 Mar 26. PMID: 25819304. MacIntosh T. Emergency Management of Spontaneous Bacterial Peritonitis - A Clinical Review. Cureus. 2018 Mar 1;10(3):e2253. doi: 10.7759/cureus.2253. PMID: 29721399; PMCID: PMC5929973. Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.com/cme-courses/ and create an account.

Contributor: Rachael Waterson, PharmD Educational Pearls: Drug shortages have been an ongoing issue since the 2000's. Improvement was being made; however, several factors have exacerbated the drug supply more recently. According to the US Food and Drug Administration (FDA) Report there are 163 drugs currently on the drug shortage list. Of the 40 drugs critical to treating COVID-19, 18 are on this list. In comparison, according to the American Society of Health-Systems Pharmacists (ASHP), the current drug shortages have limited 29 of the 40 drugs deemed critical to treating COVID-19 patients. COVID-19 has had an impact on the supply and demand for pharmaceuticals and has exposed the vulnerability of the US drug supply chain. The demand for drugs that are specific to treating COVID-19 patients have increased, while supply has been impacted due to closed factories, shipping delays, trade limitations, and export bans. Supply has been further limited due to COVID-19 heavily affecting 2 of the 3 main drug manufacturer areas of the world, India and Italy. In order to combat drug shortages, the US federal government developed a contract with a company to make generics in short supply during the pandemic. There is also current discussion about creating an "America First" program to increase domestic production of active pharmaceutical ingredients. How pharmacists combat drug shortages: Re-assess the definition of need; need vs convenience of a medication. Look to see if there is another product, manufacturer, vial size, or drug concentration of that exact medication that can be substituted. Substitution of a similar drug if possible. Placing restrictions as to which patients can receive medications, who can prescribe medications and medication use dependent on location in the hospital. References: American Society of Health-System Pharmacists. (2020). Drug Shortages. ASHP. https://www.ashp.org/Drug-Shortages?loginreturnUrl=SSOCheckOnly. FDA Drug Shortages. accessdata.fda.gov. (2020, October). https://www.accessdata.fda.gov/scripts/drugshortages/. Summarized by Emily S Mack, MSBS, OMS III | Rachael Waterson, PharmD

Dr. Tsipis sits down with colleague Dr. Ricky Dhaliwal for some insightful conversation regarding the differences between academic and community settings as well as the various roles of advocacy in medicine. Time Stamps 00:23 Banter and introductions 2:41 upbringing in 1st generation immigrant Indian household 14:30 losing culture as 2nd gen immigrant 7:32 Balancing family and work with a two doc family 8:32 President of EMRA 10:42 Working in academia vs community 13:29 New job advice 15:55 Nick talks about being the product of your environment and needing to be challenged 20:42 Advocacy in medicine 25:49 Legislative advocacy 27:27 Advocacy for medicine in COVID 29:44 Who are the most influential figures in your career? 33:23 What is your teaching style 38:05 What does the future hold for you?

Contributor: Dave Rosenberg, MD Educational Pearls: The potential of vaccinations was first observed in the late 1600s when Jenner observed people who had cowpox never contracted smallpox, so he inoculated people with cowpox to see if it prevented smallpox, and… Years later, Louis Pasteur inoculated chickens with cholera after his assistant accidently created the first live attenuated vaccine by creating a weakened bacteria when he left the bacteria out while he went on vacation Pasteur observed that exposing chickens to full strength cholera after the exposure with the weakened bacteria led to minimal or no ill effects References Stewart AJ, Devlin PM. The history of the smallpox vaccine. J Infect. 2006 May;52(5):329-34. doi: 10.1016/j.jinf.2005.07.021. Epub 2005 Sep 19. PMID: 16176833. Hajj Hussein I, Chams N, Chams S, El Sayegh S, Badran R, Raad M, Gerges-Geagea A, Leone A, Jurjus A. Vaccines Through Centuries: Major Cornerstones of Global Health. Front Public Health. 2015 Nov 26;3:269. doi: 10.3389/fpubh.2015.00269. PMID: 26636066; PMCID: PMC4659912. Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.com/cme-courses/ and create an account.

Contributor: Chris Holmes, MD Educational Pearls: During a typical flu season positive rates of flu tests run around ~20% Surveillance data from Australia, South Africa, and Chile showed remarkably low rates of flu during their typical high season - only 51 total cases were reported This overlapped with COVID, meaning extensive social distancing and other measures likely have benefit with flu Editor's note: at 35 cases, we are over half way there! References https://www.cdc.gov/mmwr/volumes/69/wr/mm6937a6.htm https://www.cdc.gov/flu/weekly/index.htm Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.com/cme-courses/ and create an account.

Contributor: John Winkler, MD Educational Pearls: Swimmers itch is due to a flatworm parasitic infection that causes an itchy rash after the worm burrows into the skin The flatworm is passed between bird and snail hosts The itch is due to the death of the parasite under the skin which leads to an extremely itchy reaction. The rash can be difficult to identify, often erythematous and macular but can develop papules and vesicles eventually scaling The treatment is diphenhydramine for milder cases and steroids for more severe cases. References Kolářová L, Horák P, Skírnisson K, Marečková H, Doenhoff M. Cercarial dermatitis, a neglected allergic disease. Clin Rev Allergy Immunol. 2013 Aug;45(1):63-74. doi: 10.1007/s12016-012-8334-y. PMID: 22915284 Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.com/cme-courses/ and create an account.

Contributor: Nick Hatch, MD Educational Pearls: Kratom is derived from the evergreen tree sharing the same name, found in Southeast Asia Kratom is legal is most regions Adverse effects of this substance are increasing in prevalence as its use becomes more widespread At lower doses kratom has a stimulatory effect Higher doses of kratom can cause opioid-like and psychotropic effects Documented instances of more severe acute liver toxicity do exists References LiverTox: Clinical and Research Information on Drug-Induced Liver Injury [Internet]. Bethesda (MD): National Institute of Diabetes and Digestive and Kidney Diseases; 2012–. Kratom. 2020 Apr 3. PMID: 31643556. https://www.fda.gov/news-events/public-health-focus/fda-and-kratom Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.com/cme-courses/ and create an account.

Contributor: Jared Scott, MD Educational Pearls: Lactate is a byproduct of anaerobic metabolism or tissue hypoperfusion Though typically associated with severe sepsis, hyperlactatemia can be caused by vigorous exercise, seizures, liver failure, asthma exacerbations, albuterol, metformin, antiretroviral drugs, and propofol Liver failure can lead to an inability to clear lactate, or convert it back to glucose byproducts, instead of an overproduction of lactate Always remember the other causes of elevated lactic acid besides sepsis but also remember sepsis! References: Kraut JA, Madias NE. Lactic acidosis. N Engl J Med. 2014 Dec 11;371(24):2309-19. doi: 10.1056/NEJMra1309483. PMID: 25494270. Wardi G, Brice J, Correia M, Liu D, Self M, Tainter C. Demystifying Lactate in the Emergency Department. Ann Emerg Med. 2020 Feb;75(2):287-298. doi: 10.1016/j.annemergmed.2019.06.027. Epub 2019 Aug 29. Erratum in: Ann Emerg Med. 2020 Apr;75(4):557. PMID: 31474479. Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.com/cme-courses/ and create an account.

Contributor: Don Stader, MD Educational Pearls: Pain is ubiquitous in the emergency department but it is not the enemy - suffering is Nociception is the ability to feel noxious stimuli which usually causes a reaction, like pulling a limb away when you feel something painful. Nociception is really a brainstem reflex. Pain is nociception plus cognition, meaning we process the noxious stimuli in our frontal cortex but it is not necessarily suffering. Pain can be associated with euphoria, such as with distance running Suffering, unlike pain, is associated with emotional distress Nociception is a brainstem reflex, pain involves the brainstem and the frontal cortex, while suffering involves the brainstem, frontal cortex, and the limbic system attaching an emotional response Providers should educate patients' expectations on pain as a part of the physiologic process and emphasize the focus on alleviating suffering References Sneddon LU. Comparative Physiology of Nociception and Pain. Physiology (Bethesda). 2018 Jan 1;33(1):63-73. doi: 10.1152/physiol.00022.2017. PMID: 2921289 Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

Emergency Medical Minute collaborated with CarePoint Health in early March for a night of education on Pediatric Emergencies geared towards mid-level providers at a local Denver brewery for our latest Brewcast. Pediatric patients require special considerations compared to adults when receiving medical care, and that remains true when dealing with respiratory illnesses across different age ranges. Dr. Parisa Jamshidi, Pediatric Emergency Physician, reviews common respiratory illnesses including bronchiolitis, croup and bacterial tracheitis in pediatric patients covering their presentation on exam and via diagnostics, treatment plans and special considerations. Her lecture is complete with a case review of a patient presenting with croup and its management, differentiation of airway sounds and high flow oxygen delivery recommendations. Listen to brush up on on your knowledge of pediatric respiratory emergencies. The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.com/cme-courses/ and create an account. Photo by National Cancer Institute on Unsplash

Contributor: Aaron Lessen, MD Educational Pearls: The use of oxygen is controversial when treating patients with certain conditions, like MI's, stokes, or ARDS because adverse outcomes have been demonstrated with using high oxygen concentrations. The Oxygen ICU trial looked at using higher and lower oxygen levels in treating intubated ARDS patients and found that mortality was improved when less oxygen was given allowing oxygen saturations to sit around 95% versus using high oxygen levels to obtain 100% blood oxygen saturation. The LOCO trial tested using even lower oxygen concentrations allowing patients to have oxygen saturations around 88% compared to more oxygen with saturation goals of 96%. They found a 15% increase in mortality in the lower saturation group and had some incidences of mesenteric ischemia leading to a premature termination of the trial due to the detrimental outcomes. This means a blood oxygen saturation rate of around 94% is probably a safe bet for patients to reduce episodes of hypoxia but limit over oxygenation injuries, especially in patients requiring longer term oxygen therapy. References 1) Girardis M, Busani S, Damiani E, Donati A, Rinaldi L, Marudi A, Morelli A, Antonelli M, Singer M. Effect of Conservative vs Conventional Oxygen Therapy on Mortality Among Patients in an Intensive Care Unit: The Oxygen-ICU Randomized Clinical Trial. JAMA. 2016 Oct 18;316(15):1583-1589. doi: 10.1001/jama.2016.11993. PMID: 27706466. 2) Barrot L, Asfar P, Mauny F, Winiszewski H, Montini F, Badie J, Quenot JP, Pili-Floury S, Bouhemad B, Louis G, Souweine B, Collange O, Pottecher J, Levy B, Puyraveau M, Vettoretti L, Constantin JM, Capellier G; LOCO2 Investigators and REVA Research Network. Liberal or Conservative Oxygen Therapy for Acute Respiratory Distress Syndrome. N Engl J Med. 2020 Mar 12;382(11):999-1008. doi: 10.1056/NEJMoa1916431. PMID: 32160661. Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.com/cme-courses/ and create an account.

Contributor: Peter Bakes, MD Educational Pearls: Classically presents with the 6Ps: Pain, pallor, paresthesia, pulseless, poikilothermia (cold), and paralysis Acute limb ischemia occurs by embolic or thrombotic causes Thrombotic causes are now more common due to aging populations and advancements in vascular surgery like stents which can be a nidus for thrombosis. Sudden onset of pain without prior symptoms is more typical of embolic causes Preceding symptoms leading to acute ischemia are more often from thrombosis Diagnosis can be clinical based on absent pulses, ultrasound or CT angiogram Definitive treatment includes thrombectomy, stenting, or bypass surgery to restore the blood flow to the distal limb References McNally MM, Univers J. Acute Limb Ischemia. Surg Clin North Am. 2018 Oct;98(5):1081-1096. doi: 10.1016/j.suc.2018.05.002. PMID: 30243449. Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

Capnography is the measurement of the partial pressure of exhaled CO2 and is an indirect measurement of your cellular respiration. It is displayed visually as a block-like waveform during the exhalation phase of respiration and monitors ventilation in real-time. Capnography is the gold standard for monitoring sedated and intubated patients in the hospital and the field and can be used in many other situations to discern more information about your patient. Our host Jordan Ourada is joined by Dr. Eric Hill who is a board certified Emergency Physician, EMS Director for 9 agencies around Colorado, a retired military physician with the Army, former paramedic firefighter and combat veteran to discuss advanced applications of capnography to monitor a range of different patients in the pre-hospital setting. Tune in to learn how to apply capnography to monitor your patients and detect serious conditions like sepsis and DKA and initiate time-sensitive interventions that reduce mortality in patients. Quick Educational Pearls: Normal range is between 35 - 45 mmHg Low capnography indicates they are blowing off CO2 High capnography indicates they are retaining CO2 Normal waveform morphology is box-like with gradual expiratory plateau after expiratory upstroke Monitor your patient's status and interpret the capnography numbers, rate and waveforms accordingly Time Stamps 1:32 Capnography definition 6:36 Normal range 7:40 Reading capnography waveforms 12:36 Capnography monitoring in sedated/intubated patients 13:36 Intubation monitoring 18:03 VQ match vs mismatch 21:42 Asthmatic patients 24:30 Capnography cannula 26:24 Cardiac arrest uses 31:28 Acid-base physiology 37:28 Diabetic patients 40:15 COPD patients 41:42 CHF patients 45:18 Head injury patients 52:07 Sepsis detection and subsequent prehospital management 1:08:15 Closing thoughts on using capnography in the field REFERENCES Brandt, P. "Current Capnography Field Uses." JEMS. 2010, Nov. DiCorpo,P.,etal."CapnographyProvidesBiggerPhysiological Picture to Maximize Patient Care." JEMS. 2015, Nov. Eckstein,M.,etal."End-tidalCO2asapredictorofsurvivalinout-of- hospital cardiac arrest." Prehosp Disaster Med. 2011 Jun;26(3):148-50 Kodali,B."Physicsofcapnography."2014 Poste,J.,etal."Airmedicaltransportofseverelyhead-injured patients undergoing paramedic rapid sequence intubation." Air Med J. 2004 Jul-Aug;23(4):36-40 Davis, D., et al. "Predictors of Intubation Success and Therapeutic Value of Paramedic Airway Management in a Large, Urban EMS System." Prehospital Emergency Care. 2006: Vol. 10, Iss. 3. Grmec, S. "Comparison of three different methods to confirm endotracheal tube placement in emergency intubation." Intensive Care Medicine. 2002; 28: 701-4. Silvestri, et al. "The Effectiveness of out of hospital use of continuous end-tidal carbon dioxide monitoring on the rate of unrecognized misplaced intubation within a regional emergency medical services system." Ann Emerg Med. 2005; 45: 497- 503. Hartman, et al. "Systematic Review and Meta- Analysis of End-Tidal Carbon Dioxide Values Associated With Return of Spontaneous Circulation During Cardiopulmonary Resuscitation." Journal Intensive Care Med. 2015, Oct;30 (7) 426-35. Levine, et al. "End-tidal carbon dioxide and outcome of out-of-hospital cardiac arrest." N England J Med. 1997, Jul 31; 337(5): 301-6. AHA 2015 Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Hunter CL, et al. "A prehospital screening tool utilizing end-tidal carbon dioxide predicts sepsis and severe sepsis." American Journal of Emergency Medicine. 2016 May; 34(5):813-819. Bou Chebi, R, et al. "Diagnostic value of end tidal capnography in patients with hyperglycemia in the emergency department." BMC Emerg Med. 2016 Jan 29; 16:7 Soleimanpour, H, et al. "Predictive value of capnography for suspected diabetic ketoacidosis in the emergency department." West J Emerg Med. 2013;14(6): 590-4. The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.com/cme-courses/ and create an account.

Contributor: Erik Verzemnieks, MD Educational Pearls: Baclofen is used to treat muscle spasms or spasticity. Baclofen comes in two forms: oral and intrathecal Withdrawal is much more common with those receiving intrathecal administration from a Baclofen pump, which is typically spinal cord patients Withdrawal symptoms usually start within 1-3 days after stopping baclofen Symptoms include altered mental status, muscle rigidity, and fevers, which can mimic other severe illnesses It is nearly impossible to reverse withdrawal symptoms with oral baclofen if a patient is receiving it intrathecally, so solving the pump problem is key References Ross JC, Cook AM, Stewart GL, Fahy BG. Acute intrathecal baclofen withdrawal: a brief review of treatment options. Neurocrit Care. 2011 Feb;14(1):103-8. doi: 10.1007/s12028-010-9422-6. PMID: 20717751. Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.com/cme-courses/ and create an account.

Contributor: Don Stader, MD Educational Pearls: Fractures and dislocations that require reduction do not necessarily require sedation Nerve blocks are an effective alternative that can provide analgesia to reduce fractures and dislocations and provide sustained pain relief after the reduction is completed Hematoma blocks are effective for distal radius and various ankle fractures Shoulder dislocations can be reduced by performing a scapular nerve block References Tezel O, Kaldirim U, Bilgic S, Deniz S, Eyi YE, Ozyurek S, Durusu M, Tezel N. A comparison of suprascapular nerve block and procedural sedation analgesia in shoulder dislocation reduction. Am J Emerg Med. 2014 Jun;32(6):549-52. doi: 10.1016/j.ajem.2014.02.014. Epub 2014 Feb 17. PMID: 24721024. Tseng PT, Leu TH, Chen YW, Chen YP. Hematoma block or procedural sedation and analgesia, which is the most effective method of anesthesia in reduction of displaced distal radius fracture? J Orthop Surg Res. 2018 Mar 27;13(1):62. doi: 10.1186/s13018-018-0772-7. PMID: 29580286; PMCID: PMC5869786. Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.com/cme-courses/ and create an account.

Contributor: Donald Stader, MD Educational Pearls: Not uncommon for patients presenting after opiate overdose and narcan administration to be observed for 4-6 hours This has been based more on tradition than evidence Observation periods for overdose may vary based on the opiate(s) used Fentanyl and heroin have half lives of about 2 hours, while oxycodone and methadone have significantly longer half lives. HOUR trial attempted to externally validate a scoring tool for stratification of low risk patients appropriate for discharge after 1 hour References Clemency BM, Eggleston W, Shaw EW, Cheung M, Pokoj NS, Manka MA, Giordano DJ, Serafin L, Yu H, Lindstrom HA, Hostler D. Hospital Observation Upon Reversal (HOUR) With Naloxone: A Prospective Clinical Prediction Rule Validation Study. Acad Emerg Med. 2019 Jan;26(1):7-15. doi: 10.1111/acem.13567. Epub 2018 Dec 28. PMID: 30592101. Summarized by Will Dewispelaere, MD | Edited by Erik Verzemnieks, MD

Contributor: Sam Killian, MD Educational Pearls: Droperidol (Inapsine) is an antipsychotic drug with efficacy for nausea, vomiting, headaches, and treating agitation In the early 2000's, Droperidol received a black box warning for QT prolongation This caused a precipitous drop of in administration and ultimately led to a stop in production More careful analysis since has called into question the true incidence of QT prolongation in typical dosing Retrospective review published this year looked at 15,374 non-critical and 1,172 critical patients who received droperidol with only a single episode of Torsades des pointes (which was attributed to multiple other risk factors) Of the 2,431 non-critical patients, and 396 critical patients, who received an ECG before and after administration, there were no changes to the mean QTc Droperidol is being manufactured again and the prior black box warning being called into question, so it will likely begin to become more widely available for use References Cole JB, Lee SC, Martel ML, Smith SW, Biros MH, Miner JR. The Incidence of QT Prolongation and Torsades des Pointes in Patients Receiving Droperidol in an Urban Emergency Department. West J Emerg Med. 2020 Jul 2;21(4):728-736. doi: 10.5811/westjem.2020.4.47036. PMID: 32726229; PMCID: PMC7390553. Perkins J, Ho JD, Vilke GM, DeMers G. American Academy of Emergency Medicine Position Statement: Safety of Droperidol Use in the Emergency Department. J Emerg Med. 2015 Jul;49(1):91-7. doi: 10.1016/j.jemermed.2014.12.024. Epub 2015 Mar 30. PMID: 25837231. Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

Emergency Medical Minute collaborated with CarePoint Health in early March for a night of education on Pediatric Emergencies geared towards mid-level providers at a local Denver brewery for our latest Brewcast. Pediatric patients require special considerations compared to adults when receiving medical care, and that remains true when dealing with fevers across different age ranges. With flu season around the corner, now is a good time to brush up on your knowledge surrounding pediatric fevers. Dr. Leslie Tourangeau, Pediatric Emergency Medicine Physician, breaks down what qualifies as a fever and how they should be managed for different development ranges of pediatric patients. It's important to consider the timeline of the patient's fever and the patient's vaccination history to inform your differential diagnoses and guide your workup. Tune in for a full run-down on how to proceed with pediatric fever patients you may encounter in the Emergency Department, complete with workup, consultation and disposition recommendations. References: Up To Date

Contributor: Aaron Lessen, MD Educational Pearls: True allergies to penicillin compared to reported allergies from patients ranges around 10% Recent study took patients undergoing sensitivity tests and developed the PEN(icillin)-FAST score to address reported penicillin allergies PEN-FAST has four components for a total score of 0-4: o F = five years or less since prior reaction. o A = Angioedema/Anaphylaxis. o S = Severe cutaneous reaction (rash). o T = Treatment, did they require treatment for a reaction? Patients with a score of 0 had Even a score of 1-2 points had around 5% incidence of a true allergy References Trubiano JA, Vogrin S, Chua KYL, Bourke J, Yun J, Douglas A, Stone CA, Yu R, Groenendijk L, Holmes NE, Phillips EJ. Development and Validation of a Penicillin Allergy Clinical Decision Rule. JAMA Intern Med. 2020 May 1;180(5):745-752. doi: 10.1001/jamainternmed.2020.0403. PMID: 32176248; PMCID: PMC7076536. Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

Contributor: Don Stader, MD Educational Pearls: Local anesthetics injected directly into wounds can cause distortion - especially important in facial lacerations Several blocks can be helpful to help numb branches of the trigeminal nerve (CN V) which innervates the face: Supraorbital nerve block: blocks distribution of V1 (most of the forehead) through injection above the eyebrow External nasal nerve block: blocks superficial innervation of nose through injection along the nasal dorsum Infraorbital nerve block: blocks innervation to lip and cheek by injection below the eye Mental nerve block: blocks innervation to chin and lower lip by injection at the mandible Zygomatic nerve block: blocks innervation to temporal scalp and lateral aspect of forehead by injection at the temple Greater auricular nerve block: blocks innervation to on and around the lower ear by injection across the sternocleidomastoid References http://highlandultrasound.com/facial-blocks https://www.nysora.com/techniques/head-and-neck-blocks/nerve-blocks-face/ Moskovitz JB, Sabatino F. Regional nerve blocks of the face. Emerg Med Clin North Am. 2013 May;31(2):517-27. doi: 10.1016/j.emc.2013.01.003. Epub 2013 Feb 18. PMID: 23601486. Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

General Counsel attorney, Debi Smith, joins Dr. Nick Tsipis to discuss the ins and outs of healthcare law. Many people forget that a subpoena only compels attendance to a court date, it does not compel one to provide any information on a case without a specific HIPAA compliant authorization for use and disclosure of protected health information. Tune in for more details, perspective on the intricacies of the legal world as it pertains to medicine and for tips on how to navigate different general situations from contracts to litigation. Time Stamps 0:47 Legal Disclaimer 3:14 Evolution of healthcare law 5:00 Contracts 9:36 Independent medical decision making without influence from a corporation 11:00 Importance of protecting your ideas 12:30 How to navigate litigation 15:09 Choosing to be an expert witness 15:56 Malpractice 17:22 common mistakes with subpoenas 18:56 COVID 22:01 Advice to getting involved in healthcare law

Contributor: Aaron Lessen, MD Educational Pearls: Early antibiotics have been shown to improve outcomes in septic patients time after time Emerging evidence challenges the concept of one-size-fits-all large fluid boluses for septic shock patients and fluid may worsen patients who have underlying sepsis-induced pulmonary capillary leak Starting peripheral vasopressors early, and relaxing if fluid resuscitation is successful, is appearing to be a more appropriate strategy than fluids first, then vasopressors References CLASSIC Trial Group; Scandinavian Critical Care Trials Group. Restricting volumes of resuscitation fluid in adults with septic shock after initial management: the CLASSIC randomised, parallel-group, multicentre feasibility trial. Intensive Care Med. 2016 Nov;42(11):1695-1705. doi: 10.1007/s00134-016-4500-7. Epub 2016 Sep 30. PMID: 27686349. Permpikul C, Tongyoo S, Viarasilpa T, Trainarongsakul T, Chakorn T, Udompanturak S. Early Use of Norepinephrine in Septic Shock Resuscitation (CENSER). A Randomized Trial. Am J Respir Crit Care Med. 2019 May 1;199(9):1097-1105. doi: 10.1164/rccm.201806-1034OC. PMID: 30704260. Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

Contributor: Sam Killian, MD Educational Pearls: One study found that patients presented with headaches more frequently when there was high temperatures and low humidity, while higher humidity is correlated to lower incidence of headache. Moon phases had no effect on headache frequency. A Canadian study looking at over 100,000 ED visits for headaches found increased incidence of headaches when there were higher levels of air pollution/particulates, like smoke. References Yilmaz M, Gurger M, Atescelik M, Yildiz M, Gurbuz S. Meteorologic parameters and migraine headache: ED study. Am J Emerg Med. 2015;33(3):409-413. doi:10.1016/j.ajem.2014.12.056 Szyszkowicz M, Stieb DM, Rowe BH. Air pollution and daily ED visits for migraine and headache in Edmonton, Canada. Am J Emerg Med. 2009;27(4):391-396. doi:10.1016/j.ajem.2008.03.013 Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

Emergency Medical Minute collaborated with CarePoint Health in early March for a night of education on Pediatric Emergencies at a local Denver brewery for our latest Brewcast. Pediatric patients require special considerations compared to adults when receiving medical care, and that remains true for traumatic injuries dealt with in the ED and pre-hospital settings. Dr. Christine Darr, Pediatric Emergency Medicine Physician, discusses a range of traumatic injuries in pediatric patients and how to appropriately perform a physical exam, order radiographic diagnostics to further assess and identify injuries and key steps for management. She reviews growth plate injuries as well as considerations at different developmental stages that can mask the presence of more serious injuries like blunt internal organ trauma without rib fractures and SCIWORA (spinal cord injury without radiographic abnormality). Common injuries associated with abuse at different ages are also addressed to help you identify concerning signs of maltreatment of pediatric patients. Listen for a deep dive into the intricacies of pediatric trauma!

Contributor: Aaron Lessen, MD Educational Pearls: Traditional teaching has shied away from using vasopressors through peripheral IVs Tissue necrosis from extravasation is cited as a risk of use of vasopressors through a peripheral site However, risk of extravasation is low (2-4%) and even more rarely results in significant complications Using an IV that is more proximal and larger bore with monitoring can further minimize these risks Starting with peripheral vasopressors in a critically ill patient appears to be without significant increased cutaneous complications compared to using a central line alone References Loubani OM, Green RS. A systematic review of extravasation and local tissue injury from administration of vasopressors through peripheral intravenous catheters and central venous catheters. J Crit Care. 2015;30(3):653.e9-653.e6.53E17. doi:10.1016/j.jcrc.2015.01.014 Cardenas-Garcia J, Schaub KF, Belchikov YG, Narasimhan M, Koenig SJ, Mayo PH. Safety of peripheral intravenous administration of vasoactive medication. J Hosp Med. 2015;10(9):581-585. doi:10.1002/jhm.2394 Lewis T, Merchan C, Altshuler D, Papadopoulos J. Safety of the Peripheral Administration of Vasopressor Agents. J Intensive Care Med. 2019;34(1):26-33. doi:10.1177/0885066616686035 Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

Contributor: Don Stader, MD Educational Pearls: On average, smoking reduces life expectancy by 13.2 years for men and for 14.5 years for women Nicotine is highly addictive and has both stimulant and calming effects Having a newborn can be a strong motivator to quit so take advantage and educate new (or expecting) parents to the risks of smoking and benefits of quitting Smoking has been associated with sudden infant death Biggest predictor of children smoking is seeing their parents smoking Side effects of smoking that can be discussed with patients are cataracts/blindness, cancers (lung and throat), coronary artery disease, early menopause, osteoporosis/fractures, and impotency References Haug S, Schaub MP, Schmid H. Predictors of adolescent smoking cessation and smoking reduction. Patient Educ Couns. 2014;95(3):378-383. doi:10.1016/j.pec.2014.03.004 Mays D, Gilman SE, Rende R, Luta G, Tercyak KP, Niaura RS. Parental smoking exposure and adolescent smoking trajectories. Pediatrics. 2014;133(6):983-991. doi:10.1542/peds.2013-3003 Anderson TM, Lavista Ferres JM, Ren SY, et al. Maternal Smoking Before and During Pregnancy and the Risk of Sudden Unexpected Infant Death. Pediatrics. 2019;143(4):e20183325. doi:10.1542/peds.2018-3325 Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

Dr. Glenda Quan, esteemed Trauma Surgeon at Swedish Medical Center, discusses cases related to limb injury and reviews their management. Topics include proper tourniquet application as well as alternatives to commercially available devices how to manage pain or a difficult patient with significant limb injury. We also explore the use of new "hybrid ORs" where multiple surgical teams can care for various injuries simultaneously and briefly chat about the use of blood products in the prehospital setting. Thought we were done? Nope. We finish with pearls on temperature management as part of trauma resuscitation and find the answer to when you consider reduction of a joint or mid-shaft fracture?

Contributor: Ricky Dhaliwal, MD, JD Educational Pearls: Topical anesthetization can allow for an awake intubation, which substantially decreases chance of loss of airway or respiratory drive because sedatives/paralytics are not necessary Lidocaine treatments like URO-JET (2% lidocaine jelly) can be applied through the nare followed by LMX cream (4% lidocaine) which should be applied to the back of the tongue to anesthetize the tongue and larynx. Good topicalization can be confirmed by testing for lack of a gag reflex References Simmons ST, Schleich AR. Airway regional anesthesia for awake fiberoptic intubation. Reg Anesth Pain Med. 2002;27(2):180-192. doi:10.1053/rapm.2002.30659 Ducharme J, Matheson K. What is the best topical anesthetic for nasogastric insertion? A comparison of lidocaine gel, lidocaine spray, and atomized cocaine. J Emerg Nurs. 2003;29(5):427-430. doi:10.1016/s0099-1767(03)00295-2 Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

Contributor: Ricky Dhaliwal, MD, JD Educational Pearls: Tranexamic acid (TXA) as shown to have mortality benefit to patients with traumatic GI hemorrhage but should it be used to achieve hemostasis in atraumatic GI bleeding? HALT-IT study looked at TXA for the treatment of upper and lower GI hemorrhage and found no 5 day mortality benefit Patients given TXA also had higher occurrences of DVT and PE References Roberts I, Coats T, Edwards P, et al. HALT-IT--tranexamic acid for the treatment of gastrointestinal bleeding: study protocol for a randomised controlled trial. Trials. 2014;15:450. Published 2014 Nov 19. doi:10.1186/1745-6215-15-450 Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

Contributor: Ramnik Dhaliwal, MD, JD Educational Pearls: Nitrates Nitroprusside: becomes effective in under a minute, and becomes ineffective 10 minutes after stopping it. Nitroprusside can metabolize into cyanide leading to toxicity, however this is rare. Nitroglycerin: predominately causes vasodilation but some arterial dilation as well; preferred agent in patients with volume overload/CHF Adrenergic Blocking Agents Labetalol: alpha/beta-blocking agent with a rapid onset of 5 minutes or less given as bolus or intravenous drip Esmolol: cardioselective beta blocker with rapid onset and short duration of action making it easily titratable Hydralazine: direct arterial dilator; patient dependent response that can be unpredictable. Use with caution in patients with CAD or an aortic dissection because there will be a reflexive increase in heart rate to combat the arteriolar dilation. Calcium Channel Blockers Nicardipine: Given as an IV infusion starting at 5g/hr up to 15g/hr. This drug has a slower onset of action making it difficult to titrate and it has a longer serum elimination half-life (3-6 hours) Clevidipine: rapid onset and short duration of action; Reduces BP without affecting cardiac filling pressures but can cause reflex tachycardia References )Wani-Parekh P, Blanco-Garcia C, Mendez M, Mukherjee D. Guide of Hypertensive Crisis Pharmacotherapy. Cardiovasc Hematol Disord Drug Targets. 2017;17(1):52-57. doi:10.2174/1871529X16666161220142020 Suneja M, Sanders ML. Hypertensive Emergency. Med Clin North Am. 2017;101(3):465-478. doi:10.1016/j.mcna.2016.12.007 Maloberti A, Cassano G, Capsoni N, et al. Therapeutic Approach to Hypertension Urgencies and Emergencies in the Emergency Room. High Blood Press Cardiovasc Prev. 2018;25(2):177-189. doi:10.1007/s40292-018-0261-4 Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

Emergency Medical Minute collaborated with CarePoint Health in early March for a night of education on Pediatric Emergencies at a local Denver brewery for our latest Brewcast. Pediatric patients require special considerations compared to adults when receiving medical care, and that remains true in the ED and pre-hospital settings. As such, it's important to be careful with the documentation of these patients to maintain accuracy and avoid inclusion of common normal findings that may populate in "normal patient" macros that are inappropriate for pediatric patients. Dr. Karen Woolf, Pediatric Emergency Medicine Physician, shares some key areas to be wary of in your documentation for pediatric patients. Some examples include the description of vital signs and whether they fall within normal ranges, general appearance descriptors as well as developmental stage specific findings i.e AAOx3, normal gait and fontanelle description etc. Listen for a rundown of the key pointers for keeping pediatric documentation accurate and informative.

The penicillin and cephalosporin drug classes include many first line drug options for infectious disease although high rates of self-reported allergies may cause physicians to seek alternative options. In part two of our dive into antibiotics use for infectious disease, listen as Dr. Rachael Duncan, Emergency Medicine Clinical Pharmacist, addresses the need to investigate the validity of these reported allergies and their severity to avoid us elf riskier alternatives, like fluoroquinolones. Cross-reactivity between cephalosporins is most often dictated by side chain of cephalosporins rather than the beta-lactam ring. Refer to the chart included for cross-reactivity tips. References: Li M, Krishna MT, Razaq S, Pillay D. A real-time prospective evaluation of clinical pharmaco-economic impact of diagnostic label of 'penicillin allergy' in a UK teaching hospital. J Clin Pathol 2014; 67(12): 1088-92. Romano A, Gueant-Rodriguez RM, Viola M, Pettinato R, Gueant JL. Cross-reactivity and tolerability of cephalosporins in patients with immediate hypersensitivity to penicillins. Ann Intern Med 2004; 141(1): 16-22. Macy E, Contreras R. Health care use and serious infection prevalence associated with penicillin "allergy" in hospitalized patients: A cohort study. J Allergy Clin Immunol 2014; 133(3): 790-6

Trauma and loss are common issues faced by emergency personnel and first responders. These challenges have since been heightened by the COVID-19 pandemic. On this installment of Mental Health Monthly, Anat 'Nati' Geva, PsyD, LP joins us to discuss the stages of grief in response to loss and trauma and how they pertain to first responders and frontline workers in particular. Each of the five stages of grief: denial, anger, bargaining, despair and acceptance are addressed and explained so you can expand your understanding of the natural process of grieving, identify signs and symptoms and take steps towards moving forward. If you or a love one is struggling through the grieving process and need more support, we encourage you to utilize the resources below: My Strengths - https://mystrength.com/ passcode: TMCAProfessional Responder Strong - https://you.responderstrong.org/ Jason's Foundation - https://jasonfoundation.com/ Rocky Mountain Crisis Partners (also known as "the crisis line") – 1-844-493-8255 (TALK) https://rmcrisispartners.org/ HCAT – 1-844-556-2012 Anat 'Nati' Geva, PsyD, LP [email protected] If you are interested in taking part in a personalized experiential application of the content, there will be a Webex webinar session tomorrow, August 27th from 10 - 11 am MST. The focus group follow-up is a complimentary experiential component for individuals who want to deepen their understanding of the material from this podcast. It will benefit those who want to take the opportunity to make the content personal to their situation. In this session, participants will discuss the prominent experiences for participants, have more extended time for Q&A, and then explore (a facet of) the primary model used. Time allowing, participants will be invited to join and share insights for the benefit of all participants. Details for joining: Join via Webex Join from a video system or application Dial [email protected] Tap to join from a mobile device (attendees only) +1-415-655-0003,,1453267047## United States TOLL Join by phone +1-415-655-0003 United States TOLL Global call-in numbers Access code: 145 326 7047 Meeting password: Meeting password: mVx3rt6Kwb

Contributor: Aaron Lessen, MD Educational Pearls: Carbonated beverages have shown efficacy in helping patients spontaneously pass esophageal food impactions Glucagon, while historically used for treatment, has been shown to have significant side effects without any clinical benefit Definitive treatment is with endoscopy performed typically by a gastroenterologist References Long B, Koyfman A, Gottlieb M. Esophageal Foreign Bodies and Obstruction in the Emergency Department Setting: An Evidence-Based Review. J Emerg Med. 2019;56(5):499-511. doi:10.1016/j.jemermed.2019.01.025 Peksa GD, DeMott JM, Slocum GW, Burkins J, Gottlieb M. Glucagon for Relief of Acute Esophageal Foreign Bodies and Food Impactions: A Systematic Review and Meta-Analysis. Pharmacotherapy. 2019;39(4):463-472. doi:10.1002/phar.2236 Akram J, Amin FM, Toft JG, Rømeling F. Håndtering af fremmedlegeme i øsofagus med synkestop [Treatment of foreign body impactions in oesophagus]. Ugeskr Laeger. 2013;175(10):640-643. Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

Contributor: Peter Bakes, MD Educational Pearls: Dental fractures are described by the Ellis classifications, which are based on the involvement of layers of the teeth: Ellis I: involvement of the enamel Ellis II: involvement of the enamel and dentin Ellis III: involvement of the enamel, dentin, and pulp While Ellis I injuries can be sent for dental follow up without intervention, Ellis II/III injuries require covering of the exposed dental layers, particularly because bacteria can more easily enter into the pulp Calcium hydroxide (Dycal) is used to cover teeth until patients can get to a dentist. Dental avulsions, or displacement of the tooth from the socket, are time sensitive. Every minute the tooth is not put back in place carries an increased risk of permanent loss. After the tooth is replanted, it requires fixation or bracing Dental subluxations can also be secured or braced with dental follow up References Marte, D, and B Robinson. Dental Trauma. Core EM, 7 Oct. 2019, coreem.net/core/dental-trauma/#ellis-classification-system-for-dental-fractures. Rosenberg H, Rosenberg H, Hickey M. Emergency management of a traumatic tooth avulsion. Ann Emerg Med. 2011;57(4):375-377. Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

Welcome to EMM's first Pharmacy Friday where we dive deeper on a certain pharmacological topic as it pertains to emergency medicine. Dr. Rachael Duncan, emergency medicine clinical Pharmacist, joins us today to talk about antibiotics use for infectious disease, specifically fluoroquinolones. Special thanks to Dr. Nichole Neville, infectious disease pharmacist, for much of the information presented in this podcast. Educational Pearls: Levofloxacin and other fluoroquinolones used to be relied upon heavily due to key upsides including ease of use and wide spectrum coverage of common bacteria. Overuse over the past decade has resulted in the discovery of 3 concerns that have led to their use being advised against in most patients These concerns are patient adverse reactions, safety concerns and drug resistance. Patient adverse reactions include potential QTc prolongation, neurologic symptoms including worsening of myasthenia gravis or peripheral neuropathy and severe hypoglycemia. Due to these adverse effects, a new term was coined: fluoroquinolone-associated disability. In an FDA report, they looked at the percentage of disability reports among all serious outcome reports of selected antibiotics and found that the top 5 antibiotics that led to disability reports were fluoroquinolones. Safety concerns have led to several black box warnings as well. Drug resistance due to overuse has also severely decreased the susceptibility rates of fluoroquinolones at many institutions. Check out your facility's antibiograms to get an idea of what susceptibility rates are for different drugs. Common infections that are inappropriately given fluoroquinolones when other options would be better suited are PNA, UTI and intra-abdominal infections. Tune in next week for more on cross-reactivity of cephalosporins and penicillins References: Fda.gov. 2017. Fluoroquinolone Safety Labeling Changes. [online] Available at: https://www.fda.gov/media/104060/download> [Accessed 21 August 2020]. Idsociety.org. 2018. Practice Guidelines. [online] Available at: https://www.idsociety.org/practice-guideline/practice-guidelines/#/date_na_dt/DESC/0/+/> [Accessed 18 August 2020]. U.S. Food and Drug Administration. 2018. FDA Updates Warnings For Oral And Injectable Fluoroquinolone. [online] Available at: https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-fda-updates-warnings-oral-and-injectable-fluoroquinolone-antibiotics> [Accessed 18 August 2020].

EMM would like to extend a large thank you to the Pain Management and Addiction Medicine section of the American College of Emergency Physicians for allowing us to post their webinar panel discussion facilitated by EMM's own Don Stader, MD, FACEP on Buprenorphine use after Naloxone. This episode discusses the nuances of emergency physicians inducing patients on Buprenorphine following an opioid overdose and covers key considerations including dosing, precipitated withdrawal and contraindications to Buprenorphine administration. Panelists include: Rachel Haroz, MD - EM physician boarded in Medical Toxicology and Addiction working in Camden, NJ Andrew Herring, MD - EM physician boarded in Pain and Addiction working in Oakland, CA and leads California's Bridge program that helps hospitals start Buprenorphine programs Eric Ketcham, MD, FACEP - EM physician who is a cofounder and chair of ACEP's Pain Management and Addiction Medicine section working in New Mexico

Contributor: Ricky Dhaliwal, MD, JD Educational Pearls: Ventricular Fibrillation (VF) is a potentially fatal cardiac arrhythmia; Refractory VF even more so Epinephrine stimulates alpha and beta receptors which increase sympathetic tone, thereby increasing cardiac oxygen demand and myocardial calcium levels which can cause new arrhythmias, particularly a problem during resuscitation Esmolol (or any beta blocker) can be used in VF refractory to defibrillation, epinephrine and amiodarone in a last-ditch effort. Esmolol in the setting of epinephrine can help prevent some of these known effects from repeated beta stimulation Dosing esmolol for refractory VF: 500mcg/kg bolus, followed by drip (max typically 1000 mcg/kg/min) Esmolol is associated with improved mortality in ACLS care in refractory VF References Long DA, Long B, April MD. Does β-Blockade for Treatment of Refractory Ventricular Fibrillation or Pulseless Ventricular Tachycardia Improve Outcomes?. Ann Emerg Med. 2020;76(1):42-45. doi:10.1016/j.annemergmed.2020.01.025 Lee YH, Lee KJ, Min YH, et al. Refractory ventricular fibrillation treated with esmolol. Resuscitation. 2016;107:150-155. doi:10.1016/j.resuscitation.2016.07.243 Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

Contributor: Jared Scott, MD Educational Pearls: Burnout happens. This study reminds us to take a few minutes on shift to take care of yourself. A new study looked at burnout in ER nurses, residents, and attending physicians where they were asked to take a 5-minute break on shift to color or play with a therapy dog. Researchers measured stress levels and checked salivary cortisol levels after the breaks to see if the therapies were working against a control group who did not have the breaks. Those who colored reported increased stress levels at the end of their shifts, while those who played with dogs reported decreased stress. Cortisol levels dropped in both coloring and pet therapy groups. Interestingly, patients couldn't see any difference in their providers' stress level. Those who conducted the study believe maybe coloring increased stress only because those who colored were denied the chance to play with a dog. Go figure. References 1) Kline JA, VanRyzin K, Davis JC, et al. Randomized Trial of Therapy Dogs Versus Deliberative Coloring (Art Therapy) to Reduce Stress in Emergency Medicine Providers . Acad Emerg Med. 2020; doi:10.1111/acem.13939

Burns are low-volume, high-acuity injuries that require special attention and care from the pre-hospital team to the Emergency Department and finally to a dedicated burn unit and ICU. As a first responder in the pre-hospital setting, there are a couple things that need to remain at the forefront of your mind when dealing with burn patients. On this episode of On the Streets, host Jordan Ourada sits down with Board Certified Plastic Surgeon and Hand Surgeon Dr. Benson Pulikkottil, who is the Medical Director for Swedish Medical Center's Burn Unit and Sean McConnell RN, former flight nurse and current charge nurse at Swedish's burn clinic to review the most important pearls to pre-hospital practice when it comes to burns. They discuss the in-depth importance of the details surrounding the mechanism of injury, field treatments and surface area estimation among many other nuances related to burn care. Tune in to hear from the experts about how to provide the best possible care for your burn patients when they present themselves.

Contributor: Don Stader, MD Educational Pearls: Toxic shock syndrome (TSS) is a rare cause of shock typically caused by Staph aureus or Strep pyogenes, that produces a toxin that leads to rapid onset hypotension with a diffuse erythematous rash. Signs of TSS may include rapid onset of altered mental status, dizziness, nausea, abdominal discomfort, hypotension, and rash TSS is associated with foreign bodies, such as tampons or nasal packing - make sure to remove any offending object Clindamycin is the drug of choice because it stops protein synthesis which helps treat toxic shock because toxic shock is caused by a protein (TSST-1) made by the bacteria. TSS is associated iwth high morbidity and mortality despite treatments Despite the association with TSS, there is little supporting evidence for prophylactic antibiotics when placing nasal packing References Gottlieb M, Long B, Koyfman A. The Evaluation and Management of Toxic Shock Syndrome in the Emergency Department: A Review of the Literature. J Emerg Med. 2018;54(6):807-814. doi:10.1016/j.jemermed.2017.12.048 Lange JL, Peeden EH, Stringer SP. Are prophylactic systemic antibiotics necessary with nasal packing? A systematic review. Am J Rhinol Allergy. 2017;31(4):240-247. doi:10.2500/ajra.2017.31.4454 Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

Contributor: Don Stader, MD Educational Pearls: Gout is an arthritis caused by the deposition of urate crystals into the joint space Colchicine works by disrupting microtubules and prevents white blood cells from getting into the joint space which stops the inflammatory response Colchicine has a high rate of adverse events, in particular explosive diarrhea The drug also has a very narrow therapeutic index and overdose is nearly universally fatal, with no antidote or effective treatment option available Alternative agents such as steroids, which reduce the inflammatory response to urate crystals, along with NSAIDs may be better options for treatment References Angelidis C, Kotsialou Z, Kossyvakis C, et al. Colchicine Pharmacokinetics and Mechanism of Action. Curr Pharm Des. 2018;24(6):659-663. doi:10.2174/1381612824666180123110042 Finkelstein Y, Aks SE, Hutson JR, et al. Colchicine poisoning: the dark side of an ancient drug. Clin Toxicol (Phila). 2010;48(5):407-414. doi:10.3109/15563650.2010.495348 Dalbeth N, Merriman TR, Stamp LK. Gout. Lancet. 2016;388(10055):2039-2052. doi:10.1016/S0140-6736(16)00346-9 Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

Contributor: Jared Scott, MD Educational Pearls: Suicide is currently the 10th leading cause of death in the US Low quality studies have reported ketamine as a potential promising agent in treating depression and preventing suicidal ideations or thoughts Randomized study was performed looking at giving ketamine to depressed patients in the ED to see if they could establish a proof of concept, meaning: would looking at ketamine for treatment of acute depression or suicidality be viable? 18 suicidal patients who required hospitalization for their depression and suicidality were entered in the study. 88% of the group treated with ketamine felt like their symptoms improved for up to 3 days, while only 33% of the placebo group reported an improvement References Domany Y, Shelton RC, McCullumsmith CB. Ketamine for acute suicidal ideation. An emergency department intervention: A randomized, double-blind, placebo-controlled, proof-of-concept trial. Depression & Anxiety (1091-4269). 2020;37(3):224-233. doi:10.1002/da.22975. Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

Contributor: Aaron Lessen, MD Educational Pearls: Hand raising test: a simple but effective tool to diagnose carpal tunnel Patients hold their hands over their head and if symptoms of carpal tunnel develop within 2 minutes, it is considered positive, meaning they likely have carpel tunnel Symptom included numbness and dull pain in the distribution of the median nerve Treatment for carpal tunnel in the ED can include splinting in a neutral position and oral steroids with possible follow up for steroid injections or surgery References Padua L, Coraci D, Erra C, et al. Carpal tunnel syndrome: clinical features, diagnosis, and management. Lancet Neurol. 2016;15(12):1273-1284. doi:10.1016/S1474-4422(16)30231-9 Ma H, Kim I. The diagnostic assessment of hand elevation test in carpal tunnel syndrome. J Korean Neurosurg Soc. 2012;52(5):472-475. doi:10.3340/jkns.2012.52.5.472 Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

Meet Adis Keric, Board Certified Pharmacotherapy Specialist and a Board Certified Critical Care pharmacist who works in the Emergency Department and ICU of level 1 trauma center Regions Hospital in Saint Paul, MN. Adis is the founder and host of a new FOAMed podcast, ER-Rx. He started the podcast to inform clinicians in the ED and ICU about up-to-date, appropriate and optimal use of medications in different clinical scenarios. Dr. Nick Tsipis sits down with Adis to discuss some pearls in Emergency Medicine Pharmacy. Time Stamps: 0:10 Intros 4:35 Antibiotics 8:30 Post-Intubation Sedation 12:00 Anti-coagulation reversal* 16:00 ER-Rx Plug *Correction to figures quoted on anticoagulation reversal pricing. High-dose Andexxa regimen maxes out around $60,000 and Kcentra maxes out at $6,000. So there is still a massive price difference, but not as high as quoted in the audio. Check out ER-Rx on iTunes, Google Podcasts, Spotify, YouTube and other major podcast hosting platforms! Instagram: @errxpodcast Website: http://errxpodcast.com/

Contributor: Michael Hunt, MD Educational Pearls: Contrast agents are commonly used for X-rays and CT's to better characterize disease, but contrast doesn't work with MRI. That's where the element Gadolinium comes into play. Gadolinium, element 64, is ferromagnetic (attracted to iron) below 68 degrees and above that temperature it's paramagnetic which makes it useful in MRI (Magnetic Resonance Imaging). Gadolinium is toxic alone, but when paired with chelators it can be used in humans and allows for better characterization of tumors or abnormal tissue on MRI. It helps identify this abnormal tissue because when MRI causes polarization of our body's cells, the gadolinium, which has the maximum number of unpaired electrons in its orbital shells, alters the rate of decay in abnormal tissue highlighting abnormalities on imaging. Gadolinium can also be used in the treatment of cancers because it collects in the cells of abnormal tissue, allowing for more targeted therapies. In people exposed to gadolinium, the anaphylaxis rate is low, below 1/1000, and in rare cases there are reports of kidney injury and nephrogenic systemic fibrosis which is why it's not recommended in renal failure patients. References 1)Ibrahim MA, Hazhirkarzar B, Dublin AB. Magnetic Resonance Imaging (MRI) Gadolinium. [Updated 2020 Mar 9]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482487/ 2)Pasquini L, Napolitano A, Visconti E, et al. Gadolinium-Based Contrast Agent-Related Toxicities [published correction appears in CNS Drugs. 2018 May 15;:]. CNS Drugs. 2018;32(3):229-240. doi:10.1007/s40263-018-0500-1 Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD