Emergency Medical Minute

Contributor: Nick Tsipis, MD Educational Pearls: Significant cyanide exposure most commonly occurs from fire/smoke exposure particularly when plastics are involved Cyanide binds to cytochrome oxidase leading to the use of anaerobic metabolism which causes a profound lactic acidosis Classic toxicity includes a rapid loss of consciousness, hypotension, bradycardia, respiratory depression, and seizures Mild exposures can lead to nausea/vomiting, headaches, and other nonspecific symptoms. Sometimes patients will complain of an almond taste. Cyanide toxicity will manifest on labs by a profound anion gap acidosis with elevated lactate (but don't wait for them to ponder the diagnosis) Antidote is hydroxocobalamin and sodium thiosulfate Severe cyanide exposure will likely need ICU level care until the blood gas levels return to their baselines and the lactic acidosis resolves References Nickson Chris C, Australian Centre for Health Innovation at Alfred Health. Cyanide Poisoning • LITFL • CCC Toxicology. Life in the Fast Lane • LITFL • Medical Blog. https://litfl.com/cyanide-poisoning-ccc/. Published April 2, 2019. Accessed June 11, 2020. Parker-Cote JL, Rizer J, Vakkalanka JP, Rege SV, Holstege CP. Challenges in the diagnosis of acute cyanide poisoning. Clin Toxicol (Phila). 2018;56(7):609‐617. doi:10.1080/15563650.2018.1435886 MacLennan L, Moiemen N. Management of cyanide toxicity in patients with burns. Burns. 2015;41(1):18‐24. doi:10.1016/j.burns.2014.06.001 Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

Contributor: Nick Tsipis, MD Educational Pearls: Arsenic is a heavy metal that binds to multiple cellular enzymes and inhibits aerobic metabolism It is primarily absorbed through the skin, respiratory and GI tract. The classic symptoms of heavy metal exposure are GI irritation (watery diarrhea, vomiting and abdominal pain) with multisystem organ failure. Neuropathy can present insidiously Initial work up includes EKG, and basic lab work (expect a delayed rise in liver function tests). Acute arsenic ingestions can sometimes show up on imaging as it is radioapaque Diagnosis is usually made with the history and evidence of multisystem organ failure. Treatment should be coordinated with your local Poison Control or toxicologist and involves predominantly supportive care along with chelating agents succimer (oral) or dimercaprol (intramuscular) References Long N. Arsenic toxicity • LITFL • Toxicology Library Toxicant. Life in the Fast Lane • LITFL • Medical Blog. https://litfl.com/arsenic-toxicity/. Published August 25, 2019. Kuivenhoven M, Mason K. Arsenic (Arsine) Toxicity. [Updated 2019 Apr 29]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK541125/

In addition to producing our own content, we believe in using our platform to amplify other voices and perspectives in medicine. With that in mind, check out 'The Black Doctor Podcast' from Dr. Steven Bradley which features interviews with leading minority professionals of the current generation as well as stories of how they overcame adversity and attained their goals. "Listen and be inspired." Podcasts available on Apple Podcasts, Spotify and all other major streaming platforms Twitter: @StevenBradleyMD Instagram: @theblackdoctorspodcast

Contributor: Aaron Lessen, MD Educational Pearls: Locked in syndrome results typically from an infarct of the basilar artery leading to infarction of the brainstem but typically preservation of the higher structures The result is complete paralysis with preserved cognitive function, hence the name Because of their location within the brainstem, ocular movements are sometimes preserved, allowing a patient who recovers from the initial injury to communicate Patients typically do not regain any motor function and have a poor prognosis of recovery Thrombectomy of the basilar artery is sometimes considered even late after the initial presentation given the devastating prognosis References Smith E, Delargy M. Locked-in syndrome. BMJ. 2005;330(7488):406‐409. doi:10.1136/bmj.330.7488.406 Buchman SL, Merkler AE. Basilar Artery Occlusion: Diagnosis and Acute Treatment. Curr Treat Options Neurol. 2019;21(10):45. Published 2019 Sep 26. doi:10.1007/s11940-019-0591-0 Meinel TR, Kaesmacher J, Chaloulos-Iakovidis P, et alMechanical thrombectomy for basilar artery occlusion: efficacy, outcomes, and futile recanalization in comparison with the anterior circulationJournal of NeuroInterventional Surgery 2019;11:1174-1180. Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

Contributor: Jared Scott, MD Educational Pearls: Traditional digital block involves dorsal approach on either side of the digit, injecting local anesthetic along each side to numb all four nerves of the digit Newer approach involves a single injection along the palmar surface at MCP joint Recent study further compared a proximal vs distal single palmar (volar) injection with sites at the MCP and PIP joints Injection sites achieved similar anesthesia between groups but PIP injection site had faster time of onset - 2.5 minutes compared to 3.8 minutes References Choi S, Cho YS, Kang B, Kim GW, Han S. The difference of subcutaneous digital nerve block method efficacy according to injection location. Am J Emerg Med. 2020;38(1):95‐98. doi:10.1016/j.ajem.2019.04.031 Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

Contributor: Aaron Lessen, MD Educational Pearls: Supplemental oxygen is not a completely benign intervention. A recent meta-analysis found that O2 saturations above 96% while on supplemental O2 were associated with worse outcomes. Only start a patient on supplemental oxygen if absolutely necessary and aim for a goal of no higher than 96% References Derek K Chu, Lisa H-Y Kim, Paul J Young, Nima Zamiri, Saleh A Almenawer, Roman Jaeschke, Wojciech Szczeklik, Holger J Schünemann, John D Neary, Waleed Alhazzani. Mortality and morbidity in acutely ill adults treated with liberal versus conservative oxygen therapy (IOTA): a systematic review and meta-analysis. The Lancet. Volume 391, Issue 10131. 2018. Pages 1693-1705, Summarized by Will Dewispelaere, MD | Edited by Erik Verzemnieks, MD

Contributor: Aaron Lessen, MD Educational Pearls: Supplemental oxygen is not a completely benign intervention. A recent meta-analysis found that O2 saturations above 96% while on supplemental O2 were associated with worse outcomes. Only start a patient on supplemental oxygen if absolutely necessary and aim for a goal of no higher than 96% References Derek K Chu, Lisa H-Y Kim, Paul J Young, Nima Zamiri, Saleh A Almenawer, Roman Jaeschke, Wojciech Szczeklik, Holger J Schünemann, John D Neary, Waleed Alhazzani. Mortality and morbidity in acutely ill adults treated with liberal versus conservative oxygen therapy (IOTA): a systematic review and meta-analysis. The Lancet. Volume 391, Issue 10131. 2018. Pages 1693-1705, Summarized by Will Dewispelaere, MD | Edited by Erik Verzemnieks, MD

Contributor: Aaron Lessen, MD Educational Pearls:. Focused assessment with Sonography for Trauma (FAST) exam and the extended-FAST (eFAST) are essential components of current trauma care and evaluation There has been an accumulation of research to provide an estimate of effectiveness of identifying certain injuries with ultrasound: For identifying a pneumothorax, the sensitivity ~70% and specificity ~99%. For pericardial effusions, sensitivity 90% and specificity ~ 94%. For hemoperitoneum, sensitivity ~74% and the specificity ~98%. While ultrasound is excellent for identifying many injuries, it may not be adequate alone to rule out serious injuries if the clinical suspicion is high based on these pooled studies References Netherton S, Milenkovic V, Taylor M, Davis PJ. Diagnostic accuracy of eFAST in the trauma patient: a systematic review and meta-analysis. CJEM. 2019;21(6):727‐738. doi:10.1017/cem.2019.381 Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

Contributor: Aaron Lessen, MD Educational Pearls:. Focused assessment with Sonography for Trauma (FAST) exam and the extended-FAST (eFAST) are essential components of current trauma care and evaluation There has been an accumulation of research to provide an estimate of effectiveness of identifying certain injuries with ultrasound: For identifying a pneumothorax, the sensitivity ~70% and specificity ~99%. For pericardial effusions, sensitivity 90% and specificity ~ 94%. For hemoperitoneum, sensitivity ~74% and the specificity ~98%. While ultrasound is excellent for identifying many injuries, it may not be adequate alone to rule out serious injuries if the clinical suspicion is high based on these pooled studies References Netherton S, Milenkovic V, Taylor M, Davis PJ. Diagnostic accuracy of eFAST in the trauma patient: a systematic review and meta-analysis. CJEM. 2019;21(6):727‐738. doi:10.1017/cem.2019.381 Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

Contributor: John Winkler, MD Educational Pearls: Unstable ventricular tachycardia (VT) typically manifests with syncope, shortness of breath, diaphoresis and/or chest pain with hemodynamic instability Electrical cardioversion of unstable ventricular tachycardia is first line treatment Starting with a higher energy level (or just using the maximum) when performing cardioversion may set you up for better success as many providers feel the first shock has the highest likelihood of success References Dresen, W.F. Ferguson, J.D. Ventricular Arrhythmias. Cardiol Clin. 2018 Feb;36(1):129-139. doi: 10.1016/j.ccl.2017.08.007. Epub 2017 Oct 27. Goyal, A. et al. Synchronized Electrical Cardioversion.StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020-. 2020 Feb 13. Summarized by Jackson Roos, MS3 | Edited by Erik Verzemnieks, MD

Contributor: Aaron Lessen, MD Educational Pearls: Mechanical CPR (machine assisted compression devices) remains a hot topic of debate in emergency medicine Machine assisted CPR has been advocated to provide more consistent compressions in cardiac arrest and free up staff for other tasks. However, multiple studies have shown mechanical CPR provides no significant survival benefit yet increased rates of injury to the chest and abdomen from the devices. Unless a clear benefit can be found, mechanical CPR devices should not routinely replace traditional CPR in most situations For prolonged transport as well as resource-limited settings, these devices still may provide the only option for sustained resuscitations References Bonnes, J. et al. Manual Cardiopulmonary Resuscitation Versus CPR Including a Mechanical Chest Compression Device in Out-of-Hospital Cardiac Arrest: A Comprehensive Meta-analysis From Randomized and Observational Studies. Ann Emerg Med. 2016 Mar;67(3):349-360.e3. doi: 10.1016/j.annemergmed.2015.09.023. Epub 2015 Nov 19. Wang, P. Brooks, S. Mechanical Versus Manual Chest Compressions for Cardiac Arrest. Cochrane Database Syst Rev. 2018 Aug 20;8(8):CD007260. doi: 10.1002/14651858.CD007260.pub4. Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

"Go unafraid! And also know that you got to reach out to the right people and hold on to those people no matter what they look like, no matter what background they come from...Find people who are positive in your life who can help you. If I'm one of those people, reach out to me." Russell J. Ledet hails from Lake Charles, Louisiana. After serving in the U.S. Navy, he attended Southern University and A&M College for his undergraduate degrees in biology and chemistry. Afterwards, he went on to complete his Ph.D. in molecular oncology at New York University. He is currently a second-year MD-MBA student at Tulane University School of Medicine and A.B. Freeman School of Business. He is the co-founder and president of 'The 15 White Coats', a non profit organization focused on helping people of color get into medical school and improving the cultural literacy of our learning spaces. The 15 White Coats website: https://www.the15whitecoats.org/ Get in touch with Russell: E-Mail: [email protected] Twitter: @theguywithyes Instagram: @maleahandmahlinasbaba

Russell J. Ledet hails from Lake Charles, Louisiana. After serving in the U.S. Navy, he attended Southern University and A&M College for his undergraduate degrees in biology and chemistry. Afterwards, he went on to complete his Ph.D. in molecular oncology at New York University. He is currently a second-year MD-MBA student at Tulane University School of Medicine and A.B. Freeman School of Business. He is the co-founder and president of 'The 15 White Coats', a non profit organization focused on helping people of color get into medical school and improving the cultural literacy of our learning spaces. In this very special episode of UnfilterED, Russell speaks candidly about his childhood, the challenges that made him the man he is today and his plans for the future, including The 15 White Coats' goal to put an individual of color through medical school debt-free. Time Stamps: 1:53 - Russell's Introduction 6:50 How have you learned from your experiences and where you came from? 9:30 - Entrepreneurship at a young age 14:15 - Russell's Faith 16:20 - Joining the Navy 20:30 - Role Models 32:40 - Visiting the Whitney Plantation and the origin of The 15 White Coats 44:40 - The future of The 15 White Coats 53:00 - What is your take home message for a young person of color listening to this interview? The 15 White Coats website: https://www.the15whitecoats.org/ Get in touch with Russell: E-Mail: [email protected] Twitter: @theguywithyes Instagram: @maleahandmahlinasbaba Intro Music: Backbay Lounge Kevin MacLeod (incompetech.com) Licensed under Creative Commons: By Attribution 3.0 License http://creativecommons.org/licenses/by/3.0/

Contributor: Jared Scott, MD Educational Pearls: Cholera has been responsible for 6 previous global pandemics and currently the world is in the seventh pandemic of cholera, ongoing since 1961. Cholera originated in the Ganges Delta of India and spread worldwide but largely is unseen in the US and other developed countries due to water sanitation Cholera is a bacterial illness that is water borne and causes severe diarrhea Estimates say that there are 1.3-4 million cases annually and up to 143,000 people die each year from Cholera. Treatment is largely supportive and can be done with oral rehydration therapy consisting of water, salt, and sugar. There are three oral vaccinations for Cholera but unfortunately are not widely available Cholera has been responsible for ushering in public health initiatives. Most famously when John Snow was able to isolate a single water source causing Cholera infections in London and by shutting it off eradicated the bacteria References "Cholera." World Health Organization, World Health Organization, 17 Jan. 2019, https://www.who.int/news-room/fact-sheets/detail/cholera Clemens JD, Nair GB, Ahmed T, Qadri F, Holmgren J. Cholera. Lancet. 2017;390(10101):1539‐1549. doi:10.1016/S0140-6736(17)30559-7 Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

Contributor: Nick Hatch, MD Educational Pearls: A cesarean scar ectopic pregnancy occurs when the pregnancy implants along the scar tissue deep in the myometrium from a prior cesarean surgery, felt to be precipitated by a small fissure or fistula residual in the scar Diagnosis can be challenging and ultrasound may not clearly show this type of ectopic pregnancy MRI has been successfully used for diagnosis as well Various treatment options exist including medical and surgical management but if left untreated, cesarean ectopic pregnancies are life threatening References Gonzalez N, Tulandi T. Cesarean Scar Pregnancy: A Systematic Review. J Minim Invasive Gynecol. 2017;24(5):731‐738. doi:10.1016/j.jmig.2017.02.020 Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

Host: Elizabeth Esty, MD. At this point, with so many of the studies we've digested exploring correlations, associations, observational studies and anecdotal reports and speculation, we could subtitle the show: what we don't know about COVID. And so, today, we'll look at what we don't know about Vitamin D and COVID. There have been a number of studies and a fair amount of media coverage in recent weeks that look at a possible link between low Vitamin D levels and severity of COVID. Vitamin D plays a role in both adaptive and innate immunity, which we discussed at some length in our episode on the BCG vaccine and COVID. Macrophages starved for Vitamin D can't produce peroxide to kill microbes, and some of the toll-like receptors crucial to innate immunity that recognize pathogen molecules don't work right without Vitamin D. Finally, Vitamin D modulates the immune response, preventing release of too many cytokines. The potential for Vitamin D to play a role in preventing severe COVID-19 seems plausible, but what does the science say? Research By: Elizabeth Esty and Nathan Novotny. Sound Editing By: Nathan Novotny. References: [1] Institute of Medicine (US) Committee to Review Dietary Reference Intakes for Vitamin D and Calcium; Ross AC, Taylor CL, Yaktine AL, et al., editors. Dietary Reference Intakes for Calcium and Vitamin D. Washington (DC): National Academies Press (US); 2011. 3, Overview of Vitamin D. Available from: https://www.ncbi.nlm.nih.gov/books/NBK56061/ [2] Helming L, Böse J, Ehrchen J, et al. 1α,25-dihydroxyvitamin D3 is a potent suppressor of interferon γ–mediated macrophage activation. Blood. 2005;106(13):4351-4358. doi:10.1182/blood-2005-03-1029 [3] Parva NR, Tadepalli S, Singh P, et al. Prevalence of Vitamin D Deficiency and Associated Risk Factors in the US Population (2011-2012). Cureus. 10(6). doi:10.7759/cureus.2741 [4] Sizar O, Khare S, Goyal A, Bansal P, Givler A. Vitamin D Deficiency. In: StatPearls. StatPearls Publishing; 2020. Accessed May 21, 2020. http://www.ncbi.nlm.nih.gov/books/NBK532266/ [5] Ilie PC, Stefanescu S, Smith L. The role of vitamin D in the prevention of coronavirus disease 2019 infection and mortality. Aging Clin Exp Res. Published online May 6, 2020. doi:10.1007/s40520-020-01570-8 [6] Vitamin D and Inflammation – Potential Implications for Severity of Covid-19 – Irish Medical Journal. Accessed May 21, 2020. http://imj.ie/vitamin-d-and-inflammation-potential-implications-for-severity-of-covid-19/ [7] Raharusun P, Priambada S, Budiarti C, Agung E, Budi C. Patterns of COVID-19 Mortality and Vitamin D: An Indonesian Study. Social Science Research Network; 2020. doi:10.2139/ssrn.3585561 [8] The Center for Evidence Based Medicine. Vitamin D: A rapid review of the evidence for treatment or prevention in COVID-19. CEBM. Accessed May 21, 2020. https://www.cebm.net/covid-19/vitamin-d-a-rapid-review-of-the-evidence-for-treatment-or-prevention-in-covid-19/ [9] Hastie CE, Mackay DF, Ho F, et al. Vitamin D concentrations and COVID-19 infection in UK Biobank. Diabetes & Metabolic Syndrome: Clinical Research & Reviews. 2020;14(4):561-565. doi:10.1016/j.dsx.2020.04.050

Jordan sits down to discuss trauma with Dr. Kaysie Banton, the Trauma Services Medical Director at Level 1 Trauma Center Swedish Medical Center in Englewood, Colorado. In this laid back interview, Dr. Banton discusses how the COVID-19 has affected trauma volumes at Swedish. While trauma as an aggregate hasn't decreased, the types of trauma for the time of year have shifted as well as the acuity of injuries that present. This episode focuses on how public opinion surrounding the pandemic has shifted the way patients seek care, how delays to seeking care changes her role as a trauma surgeon and what is being done at hospitals to emphasize the safety of patients amidst COVID. Jordan and Dr. Banton talk about how EMS can shift their interview and examinations with this type of behavior in mind. As people delay their care for fear of contracting COVID-19, traumatic injuries that might only require a day or two in the hospital are worsening while untreated and progress to stages that are unnecessary. Dr. Banton leaves medical practitioners with a call to action to educate the public about the benefits of seeking medical care as one normally would outside the pandemic to avoid the worsening of an injury.

Contributor: Nick Tsipis, MD Educational Pearls: Recent randomized controlled trial compared early intervention (PCI/CABG) to medical management for those diagnosed with moderate to severe cardiac ischemia on stress testing Primary outcome was a composite of death from cardiovascular causes, myocardial infarction, or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest Secondary outcome was death from cardiovascular causes or myocardial infarction. The study reported that patients who had more aggressive invasive procedures early on in treatment had a 2% increase in poor outcomes in the immediate period after intervention (6 months) but long term had a 2% decrease in poor outcomes. Overall the mortality was essentially identical between the two groups References 1) Maron, D.J., et al. Initial Invasive or Conservative Strategy for Stable Coronary Disease. N Engl J Med. 2020 Apr 9;382(15):1395-1407. doi: 10.1056/NEJMoa1915922. Epub 2020 Mar 30.

Contributor: Nick Hatch, MD Educational Pearls: An AC (acromioclavicular joint) separation in the shoulder is a common traumatic injury XRs can help rule out other injuries as well as help with grading the injury There are six different grades for AC separations: Grade I: is stretching of the AC ligament without disruption or displacement of the clavicle and recovers with time. Grade II: is partial tearing of the AC ligament with some displacement but will also heal with time. Grade III: is a full separation with ligament rupture and may require surgery but is not always indicated. Surgery is more common in active patients. Grades IV, V, and VI are severe separations and all require surgery. Other ligament damage or tears, like a slap injury, can mimic an AC separation and often require surgery but should remain on the differential diagnosis when working up shoulder trauma. Setting expectations is key. Patients with a grade 1 or 2 separation should expect 6+ weeks of limited range of motion and up to 12 weeks until return to full function. Cosmetically there may be a persistent bump on the shoulder. References van Bergen CJA, van Bemmel AF, Alta TDW, van Noort A. New insights in the treatment of acromioclavicular separation. World J Orthop. 2017;8(12):861‐873. Published 2017 Dec 18. doi:10.5312/wjo.v8.i12.861 Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

Host: Elizabeth Esty, MD. Smoking is known to increase both susceptibility and severity of all manner of colds and pneumonias, so you'd think the world's 1.1 billion smokers would be at risk in this pandemic of what at first seemed to be a just a respiratory virus. What's more, tobacco smoking increases risk for COPD, diabetes and coronary disease, so it may increase risk for more severe COVID indirectly. So it's remarkable that preliminary evidence suggests that smokers may be less likely to be harmed by COVID than non-smokers. A story that's gotten a fair amount of attention in the media concerns reports from France that smoking may be protective against COVID. We took a closer look and found that similar reports are coming in from across the globe, including the US. We decided to take some time to look at papers and attempt to explain this relationship. Research By: Elizabeth Esty, MD. Sound Editing By: Nathan Novotny. References: [1] Miyara M, Tubach F, Pourcher V, et al. Low incidence of daily active tobacco smoking in patients with symptomatic COVID-19. Qeios. April 2020. doi:10.32388/WPP19W.3 [2] Guan W, Ni Z, Hu Y, et al. Clinical Characteristics of Coronavirus Disease 2019 in China. New England Journal of Medicine. 2020;382(18):1708-1720. doi:10.1056/NEJMoa2002032 [3] Chow N, Fleming-Dutra K, Gierke R, et al. Preliminary Estimates of the Prevalence of Selected Underlying Health Conditions Among Patients with Coronavirus Disease 2019 — United States, February 12–March 28, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(13):382-386. doi:10.15585/mmwr.mm6913e2 [4] Richardson S, Hirsch JS, Narasimhan M, et al. Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area. JAMA. April 2020. doi:10.1001/jama.2020.6775 [5] Berlin I, Thomas D, Le Faou A-L, Cornuz J. COVID-19 and Smoking. Nicotine Tob Res. doi:10.1093/ntr/ntaa059 [6] Farsalinos K, Niaura R, Houezec JL, et al. Editorial: Nicotine and SARS-CoV-2: COVID-19 may be a disease of the nicotinic cholinergic system. Toxicology Reports. doi:10.1016/j.toxrep.2020.04.012 Photo Sourced From: https://www.henryford.com/blog/2020/04/smoking-and-vaping-increase-covid-risks

Contributor: Nick Tsipis, MD Educational Pearls: Case series reported 5 cases of generally young and healthy patients with COVID-19 who presented to the ER with acute stroke Now several case series showing cardiovascular involvement or complications related to COVID-19 While these case series may shed light on the nature of COVID-19 complications, it's worth remembering that so far these cases represent a few unique instances and we need more studies and data to pronounce COVID-19 infected patients at higher risk of thromboembolic events like strokes and heart attacks References Oxley, T. et al. Large-Vessel Stroke as a Presenting Feature of Covid-19 in the Young. April 28, 2020. DOI: 10.1056/NEJMc2009787 Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

Contributor: Don Stader, MD Educational Pearls: Buprenorphine has been shown to decrease morbidity and mortality in opioid use disorder Buprenorphine used in naloxone-induced withdrawals can displace naloxone at opioid receptors, leading to reduced withdrawal symptoms and lessen the chance of using after discharge Patients in acute withdrawal due to naloxone after an overdose should be given Buprenorphine. Data shows that withholding Buprenorphine leads to increased mortality rates of 5% within the following month, and 10% in the following year. References Herring, Andrew. "Emergency Department Medication-Assisted Treatment of Opioid Addiction." Chcf.org, Aug. 2016, www.chcf.org/wp-content/uploads/2017/12/PDF-EDMATOpioidProtocols.pdf. D.H. Cisewski et al. Approach to buprenorphine use for opioid withdrawal treatment in the emergency setting. American Journal of Emergency Medicine 37 (2019) 143–150 Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

In the US, few people receive vaccination for tuberculosis (TB), a disease that hasn't been a major killer here for many decades. But while we in the US mostly experience TB as a relatively rare but real threat in its multidrug resistant form, particularly in pts with HIV--or in Victorian novels--TB still kills 2 million people a year. There is a vaccine for TB, a live attenuated vaccine called BCG for Bacille Calmette-Guerin. In fact it's the most widely used vaccine on earth, and an estimated 4 billion people have received it since was first administered to a baby whose mother died of TB a few hours after giving birth in the summer of 1921. This connection of this vaccine to COVID caught our attention when a friend suggested a few weeks ago that Russia and other parts of the world where BCG vaccination is routine might be shielded from the worst COVID outbreaks. In the intervening weeks, as Russia grapples with its own COVID epidemic, that possibilty seems less tenable, but it did lead us down an interesting research path. Host: Elizabeth Esty, MD Research By: Elizabeth Esty, MD Sound Editing By: Nate Novotny References: Miller A, Reandelar MJ, Fasciglione K, Roumenova V, Li Y, Otazu GH. Correlation between Universal BCG Vaccination Policy and Reduced Morbidity and Mortality for COVID-19: An Epidemiological Study. Epidemiology; 2020. doi:10.1101/2020.03.24.20042937 Kleinnijenhuis J, Quintin J, Preijers F, et al. Bacille Calmette-Guerin induces NOD2-dependent nonspecific protection from reinfection via epigenetic reprogramming of monocytes. Proceedings of the National Academy of Sciences. 2012;109(43):17537-17542. doi:10.1073/pnas.1202870109 Arts RJW, Moorlag SJCFM, Novakovic B, et al. BCG Vaccination Protects against Experimental Viral Infection in Humans through the Induction of Cytokines Associated with Trained Immunity. Cell Host & Microbe. 2018;23(1):89-100.e5. doi:10.1016/j.chom.2017.12.010 Further Reading: https://www.who.int/news-room/commentaries/detail/bacille-calmette-gu%C3%A9rin-(bcg)-vaccination-and-covid-19 https://clinicaltrials.gov/ct2/show/NCT04328441 https://www.mpg.de/14491738/0219-mpin-116799-modified-tuberculosis-vaccine-as-a-therapy-for-cancer-of-the-bladder

Contributor: Don Stader, MD Educational Pearls: COVID-19 commonly appears as a bilateral patchy infiltrate on chest radiograph, but this is a non-specific finding Sensitivities range from 17-70% for COVID-19 Many other viral pneumonias such as RSV and influenza can have similar findings Point-of-care ultrasound (POCUS) demonstrates B-lines, water-fall sign, or hepatization of the lung, but these are also non-specific Computerized tomography (CT) appears to be one of the more sensitive tests for detecting COVID-19, demonstrating ground-glass opacities - often before or without the patient having symptoms However, routine use of CT for diagnosis COVID-19 is strongly discouraged by many medical societies and the CDC Imaging may not be necessary in most patients presenting with suspected COVID-19 for multiple reasons: Diagnosis is often clinical suspicion, with or without confirmatory PCR testing (if available) Imaging does little to change the management in the majority of patients with COVID-19 Obtaining imaging exposes additional healthcare workers Cleaning protocols for units (especially CT) can be extensive and require significant downtime of the machine, thereby leading to delays in care References Farkas, Josh. "COVID-19." EMCrit Project, 21 Apr. 2020, emcrit.org/ibcc/covid19/#labs. Guan W. et al. Clinical Characteristics of Coronavirus Disease 2019 in China. February 28, 2020, updated on March 6, 2020, at NEJM.org. DOI: 10.1056/NEJMoa2002032 Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

In this timely installment of Mental Health Monthly, mental health expert Lexi Eliades shares useful tips for identifying burnout and mental health decline as well as ways to maintain mental wellness amidst adversity and significant stress. We at Emergency Medical Minute know many of our listeners are on the frontlines of the COVID-19 pandemic. We hope this piece is helpful and that it reaches someone who needs to hear it!

Contributor: Dylan Luyten, MD Educational Pearls Acidosis can be caused by a respiratory, metabolic, or mixed source A respiratory acidosis will have a low serum pH and elevated bicarbonate if it's chronic, but most importantly end tidal CO2 or arterial CO2 will be high. With a metabolic acidosis we expect to see a low serum pH and low serum bicarbonate. Once it's determined a patient is in a metabolic acidosis, we need to determine if it's an elevated anion gap or normal anion gap acidosis. Anion gap is calculated by subtracting the serum anions from the cations, or serum sodium minus the serum chloride and CO2 (Na-(Cl+CO2)). A normal gap is 6-10, gaps over 10 have an elevated anion gap acidosis. The causes of an elevated anion gap acidosis can be remembered with MUDPILES mnemonic (Methanol, Uremia (renal failure), Diabetes/DKA, Paraldehyde, Isoniazid, Lactate, Ethanol/Ethylene glycol, salicylates/aspirin). So when you suspect an elevated gap acidosis you need to evaluate for all causes, so you need to get an venous or arterial blood gas along with lactate, salicylate, and Tylenol levels. References Vanmassenhove J. Lameire N. Approach to the patient presenting with metabolic acidosis. Acta Clin Belg. 2019 Feb;74(1):21-27. doi: 10.1080/17843286.2018.1547245. Epub 2018 Nov 24. Burger MK, Schaller DJ. Physiology, Acidosis, Metabolic. [Updated 2019 Jun 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482146/ Summarized by Jackson Roos, MS3 | Edited by Erik Verzemnieks, MD

Contributor: Don Stader, MD Educational Pearls: Acute respiratory distress syndrome (ARDS) is a catch all term for when lung injury leads to fluid collection in the air spaces of the lungs Ventilatory management in ARDS patients involves lower FiO2 and PEEP than other patients and relies on lung protective ventilation strategies to prevent barotrauma Proning these patients has also been utilized with the goal of matching V/Q, or getting good blood flow to areas of the lung which are well ventilated. References 1. Higher versus Lower Positive End-Expiratory Pressures in Patients with the Acute Respiratory Distress Syndrome. N Engl J Med 2004; 351:327-336. DOI: 10.1056/NEJMoa032193 2. Howell MD, Davis AM. Management of ARDS in Adults. JAMA. 2018;319(7):711–712. doi:10.1001/jama.2018.0307 3. Scholten, E.L. et al. Treatment of ARDS With Prone Positioning. Chest. 2017 Jan;151(1):215-224. doi: 10.1016/j.chest.2016.06.032. Epub 2016 Jul 8. Summarized by Jackson Roos, MS3 | Edited by Erik Verzemnieks, MD

Last week we looked at neurologic presentations of COVID-19; this week we'll look more closely at strokes in young people with COVID. A letter published 2 days ago in the NEJM with lead author Thomas Oxley, the Neuro ICU director at Mt Sinai, presents five case studies of relatively young patients who had strokes at home and presented to Mt Sinai between 23 March and 7 April. In pre-COVID days, Mt Sinai saw on about 3 patients under the age of 50 with strokes per month, so 5 in 2 weeks represents a 7-fold increase. The authors call this one of the clearest and most profound correlations" they've come across. Though strokes in other COVID case reports are also occurring in older pts, other centers are reporting similar increases in young people with few or no risk factors presenting with major strokes. Right now there are at least 3 US centers preparing to publish data on the stroke in young people phenomenon. Host: Elizabeth Esty, MD Research By: Elizabeth Esty and Nate Novotny Sound Editing By: Stephen Bahmani References: Oxley TJ, Mocco J, Majidi S, et al. Large-Vessel Stroke as a Presenting Feature of Covid-19 in the Young. New England Journal of Medicine. 2020;0(0):e60. doi:10.1056/NEJMc2009787 Cha AE. Young and middle-aged people, barely sick with covid-19, are dying of strokes. Washington Post. https://www.washingtonpost.com/health/2020/04/24/strokes-coronavirus-young-patients/. Published April 25, 2020. Klok FA, Kruip MJHA, van der Meer NJM, et al. Incidence of thrombotic complications in critically ill ICU patients with COVID-19. Thromb Res. April 2020. doi:10.1016/j.thromres.2020.04.013

Contributor: Don Stader, MD Educational Pearls: COVID-19 is diagnosed with a nasopharyngeal swab (q-tip). This unfortunately can be painful, but if the swab doesn't go deep into the nasal cavity the sample can be inadequate leading to false negatives (missed infections). The sensitivity of the COVID-19 RT PCR test is low, ranging from 66-80% in various studies. Another study has shown 23% of patients who initially tested negative but had COVID-19 symptoms will test positive when re-tested. So test highly suspicious patients twice. COVID has shown to have an effect on CBC. White blood cell counts are often normal (no leukocytosis), but there is often lymphopenia, or low lymphocytes, and thrombocytopenia. Interestingly, low platelets have appeared to have prognostic value in that lower platelets often indicate worse patient outcomes. Coagulation studies are showing very elevated D-Dimers which has sparked the debate as to whether COVID-19 causes a hypercoagulable state. The increased incidence of MI/heart attacks and strokes in COVID patients supports this argument. While D-Dimers can help point towards a diagnosis of pulmonary embolism, in the setting of highly likely COVID-19 infections, getting a CTA looking for a PE is probably unnecessary unless there's also suspicion for PE. C-reactive protein (CRP) and procalcitonin are two common inflammatory markers. A CRP can help indicate how sick a patient is and procalcitonin can help determine if the infection is bacterial or viral in nature. CRP levels are often elevated in COVID patients, and studies are showing a high CRP is linked to worse patient outcomes. Elevations in procalcitonin can be used to see if there's a concomitant bacterial infection, meaning patients need antibiotics in addition to supportive care for the COVID-19. Flu season is coming to a close, but data has shown a 5-10% co-infection rate of COVID-19 with influenza. As expected patient outcomes have been worse in those with both infections. References 1) Farkas, Josh. "COVID-19." EMCrit Project, 21 Apr. 2020, emcrit.org/ibcc/covid19/#labs. 2) Guan W. et al. Clinical Characteristics of Coronavirus Disease 2019 in China. February 28, 2020, updated on March 6, 2020, at NEJM.org. DOI: 10.1056/NEJMoa2002032 3)Young BE, Ong SWX, Kalimuddin S, et al. Epidemiologic Features and Clinical Course of Patients Infected With SARS-CoV-2 in Singapore. JAMA. 2020;323(15):1488–1494. doi:10.1001/jama.2020.3204 4) Wang M. et al. Clinical diagnosis of 8274 samples with 2019-novel coronavirus in Wuhan. medRxiv 2020.02.12.20022327; doi: https://doi.org/10.1101/2020.02.12.20022327 Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

Contributor: Eric Miller, MD Educational Pearls: A cell count is performed on tubes 1 and 4 to account for changes that may occur from blood entering the first sample from the needle insertion Tube 2 and 3 are usually used for the other studies like protein levels, glucose levels and gram staining Protein levels are often elevated in bacterial meningitis but can be helpful in diagnosis conditions like multiple sclerosis Glucose levels are typically low in bacterial meningitis due to the use of glucose by bacteria Cell counts above 3-5 cells are typically abnormal, but cell counts can vary widely depending on the type of meningitis (viral vs. bacterial) and how long the infection has been present. Cell type and differential can indicate viral vs. bacterial meningitis Neutrophils are more associated with bacterial causes Lymphocytes are more associated with viral etiologies CSF cultures are used to identify the cause of bacterial meningitis but can take days to result. A gram stain can help determine if any bacteria are present as well as cell types present. References Jain, R. Chang, WW. Emergency Department Approach to the Patient with Suspected Central Nervous System Infection. Emerg Med Clin North Am. 2018 Nov;36(4):711-722. doi: 10.1016/j.emc.2018.06.004. Summarized by Jackson Roos, MS3 | Edited by Erik Verzemnieks, MD

Contributor: Don Stader, MD Educational Pearls: When do we give antiplatelet drugs or anti-coagulation drugs? Arterial issues get antiplatelet therapy Venous issues, or slow flow states, get anticoagulation therapy. High flow areas (arteries) are more prone to platelet clotting while the venous system is more prone to allowing blockages caused by coagulation factors. The main side effect with antiplatelet and anticoagulants is bleeding. Typically antiplatelet drugs cause more bleeding issues because platelets are made in the bone marrow, while coagulation factors are made in the liver, so it takes longer for the bone marrow to replete platelets versus the liver which is a fast synthesizer of clotting factors. Reversal of antiplatelet drugs can take a while, so patients on these drugs (ex. Plavix) may need a week of withholding the drug to get surgery, while anti-coagulation drugs (ex. Xarelto) can be stopped a day or two prior to surgery. References 1. Altiok, E. Marx, N. Oral Anticoagulation: Update on Anticoagulation With Vitamin K Antagonists and Non–Vitamin K–Dependent Oral Anticoagulants. Dtsch Arztebl Int. 2018 Nov; 115(46): 776–783. Published online 2018 Nov 16. doi: 10.3238/arztebl.2018.0776 2. Kapil, N. Et al. Antiplatelet and Anticoagulant Therapies for Prevention of Ischemic Stroke. Clin Appl Thromb Hemost. 2017 May;23(4):301-318. doi: 10.1177/1076029616660762. Epub 2016 Jul 26. 3. Ostergaard, L. Fosbol EL. Roe MT. The Role of Antiplatelet Therapy in Primary Prevention. A Review. Curr Pharm Des. 2017;23(9):1294-1306. doi: 10.2174/1381612822666161205115540. Summarized by Jackson Roos, MS3 | Edited by Erik Verzemnieks, MD

Accumulating clinical evidence suggests that many patients with COVID have neurological symptoms and that some may even present with neurologic manifestations of the disease. Most COVID patients have a cough, respiratory distress, and while clinicians often speak about how similar the presentations of patients with respiratory COVID are, it's worth looking at the possibility that COVID has atypical presentations, too.There's very good evidence that coronaviruses can infect all sorts of human cells--not just those in the respiratory tract. A few weeks ago we discussed ACE inhibitors and NSAIDs and SARS COV2 and you may remember that the virus attaches to the ACE2 receptor--a receptor which is found on a wide range of human cells. What are the chances the virus can infect a patients brain cells, cranial nerves, peripheral nerves? Host: Elizabeth Esty, MD Research By: Tanisha Crosby-Attipoe & Mason Tuttle Sound Editing By: Stephen Bahmani Time Stamps: 0:23 - Numbers 1:25 - Possible Neurological Manifestations of COVID 4:15 - What are the chances the virus can infect a patients brain cells, cranial nerves, peripheral nerves? 4:55 - The neuroinvasive potential of SARS‐CoV2 may play a role in the respiratory failure of COVID‐19 patients 8:24 - early neurological research from NEJM in February 9:10 - some early research indicated possible neurological manifestations 10:05 - COVID and serious CV incidents 10:40 - Italian Neurologists urge other nations to be alert for neuro presentations of COVID 11:11 - Case report in Radiology, COVID patient with encephalopathy 12:06 - Possible link with Guillain-Barré References: Li Y-C, Bai W-Z, Hashikawa T. The neuroinvasive potential of SARS-CoV2 may play a role in the respiratory failure of COVID-19 patients. Journal of Medical Virology. 2020;92(6):552-555. doi:10.1002/jmv.25728 Poyiadji N, Shahin G, Noujaim D, Stone M, Patel S, Griffith B. COVID-19–associated Acute Hemorrhagic Necrotizing Encephalopathy: CT and MRI Features. Radiology. March 2020:201187. doi:10.1148/radiol.2020201187 Mao L, Jin H, Wang M, et al. Neurologic Manifestations of Hospitalized Patients With Coronavirus Disease 2019 in Wuhan, China. JAMA Neurol. April 2020. doi:10.1001/jamaneurol.2020.1127 Li Y, Wang M, Zhou Y, et al. Acute Cerebrovascular Disease Following COVID-19: A Single Center, Retrospective, Observational Study. Rochester, NY: Social Science Research Network; 2020. doi:10.2139/ssrn.3550025 Zhao H, Shen D, Zhou H, Liu J, Chen S. Guillain-Barré syndrome associated with SARS-CoV-2 infection: causality or coincidence? The Lancet Neurology. 2020;19(5):383-384. doi:10.1016/S1474-4422(20)30109-5 Further reading and listening: https://www.medscape.com/viewarticle/928069 http://emguidewire.libsyn.com/rss

In this organic conversation, Nick and Dr. Helman establish a warm rapport early on as they discuss musical beginnings, life-changing mentors and the origins of Emergency Medicine Cases. Their banter includes Dr. Helman's views on FOAMed and multimodal learning and treatment hacks learned on the frontlines of COVID-19. Intro Music: Backbay Lounge Kevin MacLeod (incompetech.com) Licensed under Creative Commons: By Attribution 3.0 License http://creativecommons.org/licenses/by/3.0/

In this episode of the COVID-19 Digest, we revisit the airborne vs droplet transmission debate and analyze a highly publicized study on Remdesivir from the New England Journal of Medicine. Host: Elizabeth Esty, MD & Dylan Luyten, MD Research By: Tanisha Crosby-Attipoe & Nathan Novotny Sound Editing By: Stephen Bahmani Time Stamps: 0:00 - Numbers 0:58 - "Transmission Potential of SARS-CoV-2 in Viral Shedding Observed at the University of Nebraska Medical Center" 6:53 - "Compassionate Use of Remdesivir for Patients with Severe Covid-19" References: [1] Santarpia, J. L., Rivera, D. N., Herrera, V., Morwitzer, M. J., Creager, H., Santarpia, G. W., Lowe, J. J. (2020). Transmission Potential of SARS-CoV-2 in Viral Shedding Observed at the University of Nebraska Medical Center doi:10.1101/2020.03.23.20039446 [2]Grein J, Ohmagari N, Shin D, et al. Compassionate Use of Remdesivir for Patients with Severe Covid-19. New England Journal of Medicine. 2020;0(0):.doi:10.1056/NEJMoa2007016

In part 2 of our interview with Dr. Adam Graham, Jordan takes a deep dive into posterior circulation strokes and how to identify them in the field.

Contributor: Dave Rosenberg, MD Educational Pearls: White noise is all the surrounding sound frequencies mixed together that your brain tunes down so you don't get distracted while you're sleeping Pink noise, or deep soothing noises, is the accentuated bass sounds like falling rain or waves crashing your brain keys into while sleeping. Brain electrical waves during stage 4 sleep (the deepest of sleeps), cause sudden increases and decreases in cerebral blood flow allowing for CSF washing of the brain, which helps eliminate beta amyloid - the misfolded protein linked to Alzheimers Pink noise during sleep has been shown to increase stage 4, creating more CSF washout of beta amyloid. References 1. Spinedi, E. Cardinali, DP. Neuroendocrine Metabolic Dysfunction and Sleep Disturbances in Neurodegenerative Disorders: Focus on Alzhimer's Disease and Melatonin. Neuroendocrinology. 2019;108(4):354-364. doi: 10.1159/000494889. Epub 2018 Oct 28. 2. Zee, P. Papalambros NA. et al. Acoustic Enhancement of Sleep Slow Oscillations and Concomitant Memory Improvement in Older Adults. Front Hum Neurosci. 2017 Mar 8;11:109. doi: 10.3389/fnhum.2017.00109. eCollection 2017. Summarized by Jackson Roos, MS3 | Edited by Erik Verzemnieks, MD

The circumstances that led to the national shortage in PPE for healthcare workers, the inspiring work of New Orleans med students to equip medical providers with PPE and the science behind personal use of cloth masks are all topics covered in this special edition of the Emergency Medical Minute. Host: Elizabeth Esty, MD Research By: Julia Luyten Sound Editing By: Stephen Bahmani Time Stamps: 0:00 - The scope of the mask shortage 1:04 - What led to the shortage 5:01 - Interview with Taylor Hopper, med student from Tulane University School of Medicine (TUSOM), who's part of TUSOM COVID Response Group - an organization frantically working to adequately supply hospitals with PPE in New Orleans. 16:23 - The science behind personal use of cloth masks References and Further Reading: https://www.fda.gov/medical-devices/personal-protective-equipment-infection-control/faqs-shortages-surgical-masks-and-gowns https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2190272/?smid=nytcore-ios-share https://www.sciencedirect.com/science/article/pii/S0140673620305201?via%3Dihub https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7118603/ https://www.msn.com/en-us/news/us/how-the-worlds-richest-country-ran-out-of-a-75-cent-face-mask/ar-BB11GgLi?li=BBnbcA1 https://www.vox.com/the-goods/2020/3/20/21188369/face-masks-short-supply-coronavirus-donations https://www.nytimes.com/2020/03/26/opinion/coronavirus-doctors-hoarding.html https://columbiasurgery.org/donate-ppe https://www.vox.com/policy-and-politics/2020/3/27/21194402/coronavirus-masks-n95-respirators-personal-protective-equipment-ppe https://www.nytimes.com/article/face-masks-coronavirus.html?smid=nytcore-ios-share Photo Credit: https://flickr.com/photos/91499534@N00/49432443047

Contributor: Dylan Luyten, MD Educational pearls: Clinical management of COVID-19 is rapidly evolving, relying on case reports and clinical experience In just a month, the consensus around management of COVID patients with severe hypoxia has shifted from an early intubation strategy to other, non-invasive means Intubating early can quickly consume ventilator resources, require increased intensive care monitoring, and likely leads to longer hospital stays and once COVID patients are intubated, extubation can take days to weeks. In Italy, ventilator supplies were depleted leading to the use of helmet CPAP machines, which appeared to be effective in management of respiratory distress in COVID, though not available for use in the US Non-invasive ventilation such as CPAP/BiPAP is thought to increase risk to staff for infection via aerosolization, and has often been avoided in COVID patients High flow nasal cannulas appear to pose less of a risk of aerosolization of viral particles (especially when a surgical mask is placed over the patient's nose, mouth and apparatus) Anecdotal evidence from NYC has shown success allowing conscious patients to maintain hypoxia on HFN, where they will self prone to help with lung recruitment, and seemingly do well despite persistent saturations in the 80s or less Hospitals around the country are moving away from the intubate early methodology in favor of high flow oxygen therapy as long as they are not having issues with work of breathing or other complications The pathophysiology of respiratory distress and hypoxia in COVID patients is evolving as well, and some presentations appear similar to disease processes such as high altitude pulmonary edema (HAPE) rather than acute respiratory distress syndrome (ARDS), in that patients are quite well appearing despite phenomenally low oximetry readings. These select patients appear to be excellent candidates for non-invasive means rather than an early intubation strategy Editor's note: do not take lightly that intubation is one of the highest risk aerosolization generating procedures, along with many peri-intubation procedures like suctioning, BVM, etc. References [1]. Sorbello, M. et al. The Italian coronavirus disease 2019 outbreak: recommendations from clinical practice. Anaesthesia. 2020 Mar 27. [2]. Giwa, AL. Desai A. Duca A. Novel 2019 coronavirus SARS-CoV-2 (COVID-19): An updated overview for emergency clinicians. Emerg Med Pract. 2020 May 1;22(5):1-28. [3]. Ather B, Edemekong PF. Airborne Precautions. [Updated 2020 Feb 17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan. Summarized by Jackson Roos, MS3 | Edited by Erik Verzemnieks, MD Photo Credit: New England Journal of Medicine https://www.nejm.org/doi/full/10.1056/NEJMc2007589?query=RP

In our coverage of COVID-19 this week, we've investigated the shakey evidence for NSAID use making COVID worse, heard first-hand accounts from ED clinicians with COVID, and looked at the status of testing in the United States. Before capping our week of coverage off, we wanted to analyze some of the most recent literature on clinical interventions for COVID, particularly the recently FDA approved hydroxychloroquine. Host: Elizabeth Esty, MD Research By: Elizabeth Esty and Nathan Novotny Sound Editing By: Stephen Bahmani References Wang M, Cao R, Zhang L, et al. Remdesivir and chloroquine effectively inhibit the recently emerged novel coronavirus (2019-nCoV) in vitro. Cell Research. 2020;30(3):269-271. doi:10.1038/s41422-020-0282-0 Gautret P, Lagier J-C, Parola P, et al. Hydroxychloroquine and azithromycin as a treatment of COVID-19: results of an open-label non-randomized clinical trial. Int J Antimicrob Agents. March 2020:105949. doi:10.1016/j.ijantimicag.2020.105949 Molina JM, Delaugerre C, Goff JL, et al. No Evidence of Rapid Antiviral Clearance or Clinical Benefit with the Combination of Hydroxychloroquine and Azithromycin in Patients with Severe COVID-19 Infection. Médecine et Maladies Infectieuses. March 2020. doi:10.1016/j.medmal.2020.03.006 Chen Z, Hu J, Zhang Z, et al. Efficacy of hydroxychloroquine in patients with COVID-19: results of a randomized clinical trial. medRxiv. March 2020:2020.03.22.20040758. doi:10.1101/2020.03.22.20040758

A dive into how the United States responded to an emerging pandemic and the pitfalls along the way that led to stalled testing capacity across the country before community transmission was confirmed. Hear what led us to our current situation, what continues to be an issue and new technologies on the horizon as well as how the rest of the world has responded. Host: Elizabeth Esty, MD Research By: Mason Tuttle Sound Editing By: Stephen Bahmani References: Shear M, Goodnough A, Kaplan S, Fink S, Thomas K, Weiland N. The Lost Month: How a Failure to Test Blinded the U.S. to Covid-19. The New York Times. https://www.nytimes.com/2020/03/28/us/testing-coronavirus-pandemic.html?smid=nytcore-ios-share. Published March 28, 2020. Topol E. US Betrays Healthcare Workers in Coronavirus Disaster. MedScape. https://www.medscape.com/viewarticle/927811. Published March 30, 2020. Abbott. DETECT COVID-19 IN AS LITTLE AS 5 MINUTES. https://www.abbott.com/corpnewsroom/product-and-innovation/detect-covid-19-in-as-little-as-5-minutes.html. Published March 27, 2020. Abdelmalek M, David E, Margolin J. Why coronavirus antibody testing in one Colorado town could provide a way forward. ABC News. https://abcnews.go.com/Health/antibody-testing-colorado-town-provide-forward/story?id=69856623. Published March 28, 2020. Kuznia R, Devine C, Griffin D. Severe shortages of swabs and other supplies hamper coronavirus testing. CNN. https://www.cnn.com/2020/03/18/us/coronovirus-testing-supply-shortages-invs/index.html. Published March 18, 2020. Judd D, Zaslav A, Diaz D. America is ramping up Covid-19 testing, but a shortage of basic supplies is limiting capabilities. CNN. https://www.cnn.com/2020/03/28/politics/coronavirus-swabs-supplies-shortage-states/index.html. Published March 28, 2020. Haug G. "A game changer": FDA authorizes Abbott Labs' portable, 5-minute coronavirus test the size of a toaster. USA Today. https://www.usatoday.com/story/news/health/2020/03/28/coronavirus-fda-authorizes-abbott-labs-fast-portable-covid-test/2932766001/. Published March 28, 2020. Hasell J, Roser M, Ortiz-Ospina E. Data on COVID-19 testing. Our World In Data. https://ourworldindata.org/covid-testing. Published March 28, 2020. Hale T. Iceland's Prolific COVID-19 Testing Is Telling Us A Lot About The Outbreak. IFLScience! https://www.iflscience.com/health-and-medicine/icelands-prolific-covid19-testing-is-telling-us-a-lot-about-the-outbreak/. Published March 27, 2020.

Long time friends of EMM, Aaron and Bree, share their experiences on the frontlines in the ED, coping with COVID, managing anxiety and quarantining with their family.

In the past two weeks, warnings, questions, and misinformation concerning COVID-19 and NSAID use have been spreading...no pun intended..virally. The pace of this evolving pandemic and the equally quick pace of the news and social media news cycle have meant that information and misinformation travel equally fast. Today we bring to you the story of how a letter in The Lancet led to a world of confusion. Host: Elizabeth Esty, MD Research By: Elizabeth Esty & Nathan Novotny Sound Editing By: Stephen Bahmani Time Stamps: 0:00 - COVID-19 Statistics 2:55 - The Lancet Letter: What Started the Rumor 4:10 - ACE Inhibitors & ARB's 5:00 - What The Lancet Letter Got Wrong 6:25 - Treatment of HTN and DM in China vs. the U.S. 9:13 - Do ACE Inhibitors Actually Increase ACE-2 Expression? 11:00 - The French Ministry of Health and Their Warning About NSAIDs 14:09 - Misinformation in the Age of COVID-19 15:09 - Potential Harms of Tylenol Use 16:11 - The Need for High-Quality Science to Overcome COVID-19 References: Fang L, Karakiulakis G, Roth M. Are patients with hypertension and diabetes mellitus at increased risk for COVID-19 infection? The Lancet Respiratory Medicine. March 2020:S2213260020301168. doi:10.1016/S2213-2600(20)30116-8 Kane S. Ibuprofen - Drug Usage Statistics, ClinCalc DrugStats Database. ClinCalc DrugStats Database. https://clincalc.com/DrugStats/Drugs/Ibuprofen. Published December 23, 2019. Accessed March 30, 2020. Hoffmann M, Kleine-Weber H, Schroeder S, et al. SARS-CoV-2 Cell Entry Depends on ACE2 and TMPRSS2 and Is Blocked by a Clinically Proven Protease Inhibitor. Cell. March 2020. doi:10.1016/j.cell.2020.02.052 Lu J, Lu Y, Wang X, et al. Prevalence, awareness, treatment, and control of hypertension in China: data from 1·7 million adults in a population-based screening study (China PEACE Million Persons Project). The Lancet. 2017;390(10112):2549-2558. doi:10.1016/S0140-6736(17)32478-9 Wang Zengwu, Chen Zuo, Zhang Linfeng, et al. Status of Hypertension in China. Circulation. 2018;137(22):2344-2356. doi:10.1161/CIRCULATIONAHA.117.032380 Hu C, Jia W. Diabetes in China: Epidemiology and Genetic Risk Factors and Their Clinical Utility in Personalized Medication. Diabetes. 2018;67(1):3-11. doi:10.2337/dbi17-0013 Yuan H, Li X, Wan G, et al. Type 2 diabetes epidemic in East Asia: a 35-year systematic trend analysis. Oncotarget. 2018;9(6). doi:10.18632/oncotarget.22961 Woo KS, Nicholls MG. High prevalence of persistent cough with angiotensin converting enzyme inhibitors in Chinese. Br J Clin Pharmacol. 1995;40(2):141-144. Chen X, Hu W, Ling J, et al. Hypertension and Diabetes Delay the Viral Clearance in COVID-19 Patients. medRxiv. March 2020:2020.03.22.20040774. doi:10.1101/2020.03.22.20040774 Perico L, Benigni A, Remuzzi G. Should COVID-19 Concern Nephrologists? Why and to What Extent? The Emerging Impasse of Angiotensin Blockade. NEF. March 2020:1-9. doi:10.1159/000507305 Qiao Y, Shin J-I, Chen TK, et al. Association Between Renin-Angiotensin System Blockade Discontinuation and All-Cause Mortality Among Persons With Low Estimated Glomerular Filtration Rate. JAMA Intern Med. March 2020. doi:10.1001/jamainternmed.2020.0193 The Local. UPDATE - Coronavirus: French health minister and WHO issue warning over taking anti-inflammatories. https://www.thelocal.fr/20200314/coronavirus-french-health-minister-issues-warning-over-anti-flammatories. Published March 14, 2020. Accessed March 30, 2020. ScienceAlert. Updated: WHO Now Doesn't Recommend Avoiding Ibuprofen For COVID-19 Symptoms. https://www.sciencealert.com/who-recommends-to-avoid-taking-ibuprofen-for-covid-19-symptoms. Accessed March 30, 2020. European Medicines Agency. Coronavirus disease (COVID-19). https://www.ema.europa.eu/en/human-regulatory/overview/public-health-threats/coronavirus-disease-covid-19#advice-on-using-non-steroidal-anti-inflammatory-medicines-such-as-ibuprofen--section. Published March 18, 2020. U.S. Food and Drug Administration. FDA advises patients on use of non-steroidal anti-inflammatory drugs (NSAIDs) for COVID-19. https://www.fda.gov/drugs/drug-safety-and-availability/fda-advises-patients-use-non-steroidal-anti-inflammatory-drugs-nsaids-covid-19. Published March 19, 2020. BBC Reality Check team and BBC Monitoring. Coronavirus and ibuprofen: Separating fact from fiction. BBC News. https://www.bbc.com/news/51929628. Published March 17, 2020. Mosbergen D. Tylenol Overdose Risk Is Staggering; Acetaminophen Safeguards Remain Insufficient: Report. HuffPost. https://www.huffpost.com/entry/tylenol-overdose_n_3976991. Published September 24, 2013.

Contributor: Dylan Luyten, MD Educational Pearls: After you diagnose a pulmonary embolism (PE) via CT or VQ scan, we need to categorize the PE as massive, sub-massive, or just PE to dictate treatment. Massive PE: shock with hypotension due to an embolism, and the treatment of choice is thrombolysis with IV tPA with anticoagulation after lysis. Catheter thrombolysis is not used in the hemodynamically unstable patient but can be done after they are stable. Sub-massive: signs of right heart strain/failure but hemodynamically stable. This can be EKG changes, positive biomarkers, or imaging findings. These patients can be treated with IV heparin as there may benefit from catheter directed thrombolysis which has been shown to lead to better functional outcomes. Everything else can be stratified to determine whether inpatient even outpatient treatment is necessary Pulmonary Embolism Severity Index (PESI) or Hestia criteria and can help determine if the patient is better suited for in or outpatient management. Non massive or sub-massive PEs are treated with heparin/Lovenox bridged to Warfarin, a factor Xa inhibitor (ex. Xarelto), or direct oral anticoagulants (DOAC). Editor's note: intravenous heparin is preferable to other anticoagulants when considering interventional radiology as it can be shut off and/or reversed if necessary prior to procedure References 1. Sista, A. et al. Stratification, Imaging, and Management of Acute Massive and Submassive Pulmonary Embolism. 2017 Jul;284(1):5-24 2. Aujesky D, Obrosky DS, Stone RA, Auble TE, Perrier A, Cornuz J, Roy PM, Fine MJ. Derivation and validation of a prognostic model for pulmonary embolism. Am J Respir Crit Care Med. 2005 Oct 15;172(8):1041-6 3. Jimenez, D. et al. Risk stratification of patients with acute symptomatic pulmonary embolism. Intern Emerg Med. 2016 Feb;11(1):11-8. Summarized by Jackson Roos, MS3 | Edited by Erik Verzemnieks, MD

Host: Elizabeth Esty, MD Research By: Elizabeth Esty and Nathan Novotny References: Osumi M. Questions raised over COVID-19 reinfection after Japanese woman develops illness again. The Japan Times. https://www.japantimes.co.jp/news/2020/02/28/national/coronavirus-reinfection/#.Xn4coZNKhQI. Published February 28, 2020. Bao L, Deng W, Gao H, et al. Reinfection could not occur in SARS-CoV-2 infected rhesus macaques. bioRxiv. March 2020:2020.03.13.990226. doi:10.1101/2020.03.13.990226 Steinbuch Y. Doctor asks recovered coronavirus patients to be tested for antibodies. New York Post. https://nypost.com/2020/03/26/doctor-asks-recovered-coronavirus-patients-to-be-tested-for-antibodies/. Published March 26, 2020. Casadevall A. How a Boy's Blood Stopped an Outbreak. The Wall Street Journal. https://www.wsj.com/articles/how-a-boys-blood-stopped-an-outbreak-11582847330. Published February 27, 2020. U.S. Food and Drug Administration. Investigational COVID-19 Convalescent Plasma - Emergency INDs.https://www.fda.gov/vaccines-blood-biologics/investigational-new-drug-ind-or-device-exemption-ide-process-cber/investigational-covid-19-convalescent-plasma-emergency-inds. Published March 24, 2020. Carmichael T. Takeda Pharmaceutical Announces a Plasma-Derived Coronavirus Therapy. Nasdaq. https://www.nasdaq.com/articles/takeda-pharmaceutical-announces-a-plasma-derived-coronavirus-therapy-2020-03-04. Published March 4, 2020. Maxmen A. How blood from coronavirus survivors might save lives. Nature. March 2020. https://www.nature.com/articles/d41586-020-00895-8. Amanat F, Nguyen T, Chromikova V, et al. A serological assay to detect SARS-CoV-2 seroconversion in humans. medRxiv. March 2020:2020.03.17.20037713. doi:10.1101/2020.03.17.20037713 Steinbuch Y. Mount Sinai researchers develop test for coronavirus antibodies. New York Post. https://nypost.com/2020/03/24/mount-sinai-researchers-develop-test-for-coronavirus-antibodies/. Published March 24, 2020.

Recorded 3/26/20

The circumstances surrounding the COVID-19 virus are quickly evolving and that means that EMM will have to as well. For the foreseeable future, EMM will be releasing COVID-19 updates. In this series, we will report the most recent statistics, summarize the newest literature and answer YOUR burning questions. Submit your questions through comments on this post or through private messages on any of our social media platforms. Host: Elizabeth Esty, MD Research By: Elizabeth Esty, Jackson Roos, Nathan Novotny & Mason Tuttle Time Stamps: 0:00 - COVID-19 by the numbers 2:50 - Hydroxychloroquine and Azithromycin 6:05 - Ongoing Anti-Viral Therapy Research 7:47 - Anosmia 9:31 - Viability of COVID-19 Aerosolized vs. on Surfaces 10:49 - Listener Questions References: [1] The Center for Systems Science and Engineering (CSSE) at Johns Hopkins University Interactive Map [2] Gautret et al. (2020) Hydroxychloroquine and azithromycin as a treatment of COVID‐19: results of an open‐label nonrandomized clinical trial. International Journal of Antimicrobial Agents – In Press 17 March 2020 –DOI : 10.1016/j.ijantimicag.2020.105949 [3] Belhadi D, Peiffer-Smadja N, Yazdanpanah Y, Mentré F, Laouénan C. A brief review of antiviral drugs evaluated in registered clinical trials for COVID-19. medRxiv. March 2020:2020.03.18.20038190.doi:10.1101/2020.03.18.20038190 [4] Hopkins C, Kumar N, ENT UK at The Royal College of Surgeons of England. Loss of sense of smell as marker of COVID-19 infection. https://www.entuk.org/sites/default/files/files/Loss%20of%20sense%20of%20smell%20as%20marker%20of%20COVID.pdf.

Contributor: Don Stader, MD Educational Pearls: PPIs (Proton pump inhibitors) reduce stomach acid levels and are commonly prescribed in patients with GERD or peptic ulcer disease Stopping a PPI after sustained use for a month or longer can lead to withdrawal - causing a rebound indigestion or reflux due to a surge in acid production Long term PPI use has noteworthy side effects including increased incidence of bacterial GI infections and pneumonia Be cautious in prescribing a PPI for over 2 weeks. If continued indigestion control is needed, transition to a H2 blocker or OTC antacids if prolonged treatment is needed. References 1)Haastrup PF, Thompson W, Søndergaard J, Jarbøl DE (2018) Side effects of long-term proton pump inhibitor use: a review. Basic Clin Pharmacol Toxicol 123(2):114–121. https://doi.org/10.1111/bcpt.13023 Review 2) Helgadottir, H.; Bjornsson, E.S. Problems Associated with Deprescribing of Proton Pump Inhibitors. Int. J. Mol. Sci. 2019, 20, 5469. Summarized by Jackson Roos, MS3 | Edited by Erik Verzemnieks, MD

In this special edition of our On the Streets podcast, we discuss COVID-19 as well as what first responders and emergency providers need to know to keep themselves and their patients safe during this pandemic.

Contributor: Sam Killian, MD Educational Pearls: Agitation can be due to a number of causes, but regardless of the cause, sedation often plays a key role in patient and provider safety. But what is the best sedative agent? A study looked at control of agitation with intramuscular medication. Specifically, 5 different IM sedative agents were compared to see which one best provides "adequate" sedation in 15 minutes or less. Haldol 5mg, Haldol 10mg, Versed 5mg, Zyprexa 10mg, and Geodon 20mg were all compared, and by far Versed provided the best sedative results. All medications had approximately the same amount of adverse effects. There are so many sedative options, but time and time again large dose benzodiazepines have demonstrated great effectiveness in treating acute agitation References 1) Klein, Lauren R. et al. Intramuscular Midazolam, Olanzapine, Ziprasidone, or Haloperidol for Treating Acute Agitation in the Emergency Department. Annals of Emergency Medicine. 2018. 72(4), 374 - 385 Summarized by Jackson Roos, MS3 | Edited by Erik Verzemnieks, MD

Contributor: Sam Killian, MD Educational Pearls: Classic dogma teaching that epinephrine should not be used in the fingers, nose, penis, and toes when performing local anesthesia due to concerns for ischemia is wrong This has been well documented in multiple literature reviews A prospective, randomized double-blind study compared lidocaine vs lidocaine with epinephrine for finger injuries and the use of epinephrine was associated with less bleeding and better anesthesia Editor's note: in the lidocaine without epinephrine group, 5 (not 7) needed additional dosing of local anesthesia. The groups were also split 29 for lidocaine alone and 31 for lidocaine with epinephrine but we're in a pandemic so who is noticing anyways References 1. Wilhelmi, B.J., et al. Do not use epinephrine in digital blocks: myth or truth? Plast Reconstr Surg. 2001 Feb;107(2):393-7. 2. Ilicki, J. Safety of Epinephrine in Digital Nerve Blocks: A Literature Review. J Emerg Med. 2015 Nov;49(5):799-809. doi: 10.1016/j.jemermed.2015.05.038. Epub 2015 Aug 4. 3. Walsh, K., Baker, B.G., Iyer, S. Adrenaline Auto-injector injuries to digits; a systematic review and recommendations for emergency management. 2020 Feb 8. pii: S1479-666X(20)30016-0. doi: 10.1016/j.surge.2020.01.005. Summarized by Jackson Roos, MS3 | Edited by Erik Verzemnieks, MD