Emergency Medical Minute

Contributor: Don Stader, MD Educational Pearls: Syncope is usually benign but can be caused by serious etiologies which include: PE, certain cardiac arrhythmias, AAA, intracranial bleed/stroke The Canadian Syncope Rule appears to identify those patients with syncope and low risk of serious outcomes The score is based on vital signs, EKG and history Negative scores preclude a very low risk of adverse events A calculated score greater than 1 are considered medium risk Scores greater than 4 are high risk Anyone with a medium risk or higher should have their cause thoroughly investigated - which may involve admission or a shared decision making utilizing this rule if discharged Editor's note: just remember this rule has not been externally validated… yet References https://www.mdcalc.com/canadian-syncope-risk-score Thiruganasambandamoorthy V, Kwong K, Wells GA, et al. Development of the Canadian Syncope Risk Score to predict serious adverse events after emergency department assessment of syncope. CMAJ. 2016;188(12):E289–E298. doi:10.1503/cmaj.151469 Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

Contributor: Jared Scott, MD Educational Pearls: The CDC recommends rabies prophylaxis if there was a direct encounter with a possibly rabid animal except... Bats are treated differently since their bites may be very superficial and not seen/felt. All people with possible close encounters with a bat should receive rabies prophylaxis From 1990-2007 there were 34 rabies cases associated with bats: 6 of these had a reported bat bite 15 there was a reported exposure but no reported bite 11 had no reported bat exposure but DNA testing revealed that the rabies came from a bat References Pieracci EG, Pearson CM, Wallace RM, Blanton JD, Whitehouse ER, Ma X, Stauffer K, Chipman RB, Olson V. Vital Signs: Trends in Human Rabies Deaths and Exposures - United States, 1938-2018. MMWR Morb Mortal Wkly Rep. 2019 Jun 14;68(23):524-528. doi: 10.15585/mmwr.mm6823e1. PubMed PMID: 31194721; PubMed Central PMCID: PMC6613553. https://www.cdc.gov/rabies/specific_groups/doctors/index.html Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

Contributor: Nick Hatch, MD Educational Pearls: Dalbavancin (Dalvance®) is an antibiotic that can be used for skin and soft tissue infections, providing MRSA coverage It cannot be used in other infections or sepsis Dalbavancin may be appealing as a single dose lasts about 2 weeks Expense is currently a large barrier to use Patients with a vancomycin allergy will likely be allergic to Dalbavancin as the two are related References Patel M, Smalley S, Dubrovskaya Y, Siegfried J, Caspers C, Pham V, Press RA, Papadopoulos J. Dalbavancin Use in the Emergency Department Setting. Ann Pharmacother. 2019 Jun 3;:1060028019855159. doi: 10.1177/1060028019855159. [Epub ahead of print] PubMed PMID: 31155916. Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

Contributor: Michael Hunt, MD Educational Pearls: Due to the efficacy of vaccination, epiglottitis is now more common in adults than children Risk factors include smoking and other immunocompromising co-morbidities, such as diabetes Epiglottitis can present with sore throat and fever, with potential rapid progression to respiratory distress and stridor Diagnosis can include x-ray to look for the "thumbprint sign," nasofiberoptics, and/or CT Antibiotics are mainstay of treatment but severe cases may need establishment of a definitive airway, typically done with fiberoptics in the operating room due to the potential to irritate the epiglottitis with traditional laryngoscopy References Li RM, Kiemeney M. Infections of the Neck. Emerg Med Clin North Am. 2019 Feb;37(1):95-107. doi: 10.1016/j.emc.2018.09.003. Review. PubMed PMID: 30454783. Tsai YT, Huang EI, Chang GH, Tsai MS, Hsu CM, Yang YH, Lin MH, Liu CY, Li HY. Risk of acute epiglottitis in patients with preexisting diabetes mellitus: A population-based case-control study. PLoS One. 2018;13(6):e0199036. doi: 10.1371/journal.pone.0199036. eCollection 2018. PubMed PMID: 29889887; PubMed Central PMCID: PMC5995441. Guerra AM, Waseem M. Epiglottitis. [Updated 2018 Nov 15]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430960/ Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

Contributor: Nick Hatch, MD Educational Pearls: True morel mushrooms are commonly foraged The false morel mushroom (Gyromitra esculenta) looks similar to the true morel, but is toxic False morel mushroom toxicity can cause gastrointestinal symptoms as well as liver failure, rhabdomyolysis, and seizures Seizures can be refractory to benzodiazepine therapy and may require use of vitamin B6 and propofol References Horowitz KM, Horowitz BZ. Gyromitra Mushroom Toxicity. [Updated 2019 May 12]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470580/ Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

Contributor: Jared Scott, MD Educational Pearls: Cerebellar strokes make up a disproportionate number of missed or delayed diagnosis for stroke likely due to the subtle nature of the presentation Cerebellar strokes can present with vomiting, dizziness, and ataxia. Unlike anterior circulation stroke, exam findings in a cerebellar stroke are ipsilateral to the lesion On neuro exam, findings may include: Dysmetria: lack of coordination with overshooting/undershooting intended position of limb Dysdiadochokinesia: difficulty with rapid alternating movements Ataxia Nystagmus Consider a cerebellar stroke in patients presenting with vomiting and dizziness without an alternative diagnosis References Edlow JA, Newman-Toker DE, Savitz SI. Diagnosis and initial management of cerebellar infarction. Lancet Neurol. 2008 Oct;7(10):951-64. doi: 10.1016/S1474-4422(08)70216-3. Review. PubMed PMID: 18848314. Datar S, Rabinstein AA. Cerebellar infarction. Neurol Clin. 2014 Nov;32(4):979-91. doi: 10.1016/j.ncl.2014.07.007. Epub 2014 Sep 13. Review. PubMed PMID: 25439292. Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

Contributor: Charleen Gnisci, PharmD Educational Pearls: Causes of increased intracranial pressure may include intracranial hemorrhage, malignancy, and trauma. While definite treatment is to remove the offending cause, there are emergency medicine Non-pharmacologic methods include elevating head of bed and removing noxious stimuli Pharmacologic options include mannitol and hypertonic saline Hypertonic saline is best delivered through a central line but not required Both these agents benefit from adequate renal function Before using mannitol, be sure to inspect the bag to ensure that it has not precipitated. If it has, try warming the bag before administration. References https://pulmccm.org/critical-care-review/hyperosmolar-therapy-for-increased-intracranial-pressure-review-nejm/ Burgess S, Abu-Laban RB, Slavik RS, Vu EN, Zed PJ. A Systematic Review of Randomized Controlled Trials Comparing Hypertonic Sodium Solutions and Mannitol for Traumatic Brain Injury: Implications for Emergency Department Management. Ann Pharmacother. 2016 Apr;50(4):291-300. doi: 10.1177/1060028016628893. Epub 2016 Jan 29. Review. PubMed PMID: 26825644. Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

Contributor: Don Stader, MD Educational Pearls: Antiplatelets include aspirin and clopidogrel, and are generally used for arterial clotting (MI, stroke) Anticoagulants such as coumadin, Xarelto, Eliquis are generally used for venous clotting (DVT/PE) Growing data suggests that dual antiplatelet therapy (aspirin+clopidogrel) is superior to aspirin alone in reducing stroke for diagnosed with TIA References: Kheiri B, Osman M, Abdalla A, Haykal T, Swaid B, Ahmed S, Chahine A, Hassan M, Bachuwa G, Al Qasmi M, Bhatt DL. Clopidogrel and aspirin after ischemic stroke or transient ischemic attack: an updated systematic review and meta-analysis of randomized clinical trials. J Thromb Thrombolysis. 2019 Feb;47(2):233-247. doi: 10.1007/s11239-018-1786-z. PubMed PMID: 30511260. Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

Contributor: Michael Hunt, MD Educational Pearls: Tetracycline antibiotics such as minocycline can cause greyish hyperpigmentation This hyperpigmentation can sometimes be reversible but not always Minocycline has been used for its effects in autoimmune and neurological diseases, where it is often taken chronically, which can lead to increased pigmentation References La Placa M, Infusino SD, Balestri R, Vincenzi C. Minocycline-Induced Blue-Gray Discoloration. Skin Appendage Disord. 2017 Aug;3(3):161-162. doi: 10.1159/000469712. Epub 2017 Apr 22. PubMed PMID: 28879193; PubMed Central PMCID: PMC5582477. Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

Contributor: Peter Bakes, MD Educational Pearls: While there are many different types of medical error, one of the most common errors in emergency medicine is failure to diagnose Systematic error in thinking that negatively affects judgement Medical errors are often driven by cognitive biases, which include anchoring, attribution, and availability Anchoring bias occurs when early information leads to premature closure on a single diagnosis. There is subsequent failure to consider alternative diagnoses, even in the face of conflicting new data and test results. Attribution bias occurs when assumptions about personal and medical characteristics are made about a specific group of people. Availability bias occurs when recent experiences drive providers to over or under consider diagnoses. References Croskerry P. Cognitive forcing strategies in clinical decisionmaking. Ann Emerg Med. 2003 Jan;41(1):110-20. doi: 10.1067/mem.2003.22. PubMed PMID: 12514691. Redelmeier DA. Improving patient care. The cognitive psychology of missed diagnoses. Ann Intern Med. 2005 Jan 18;142(2):115-20. doi: 10.7326/0003-4819-142-2-200501180-00010. PubMed PMID: 15657159. https://www.nuemblog.com/blog/cognitive-bias Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

Author: Sam Killian, MD Educational Pearls: Abuse occurs by breathing in volatile substances such as solvents, glues, paints, butane, and propane Inhalants are generally depressants Estimated that 100-125 people die every year in the US from acute inhalant abuse. Short-term effects include memory impairment, slurred speech, diplopia, seizures, and cardiac arrhythmias Long term effects include renal dysfunction, neuropathy, blindness and cognitive blunting Evaluation includes a detailed lung exam, cardiac monitoring, and assessments of oxygenation and renal function Treatment is generally supportive. References Lipari RN. Understanding Adolescent Inhalant Use. 2013;. Review. PubMed PMID: 28722849. Howard MO, Bowen SE, Garland EL, Perron BE, Vaughn MG. Inhalant use and inhalant use disorders in the United States. Addict Sci Clin Pract.2011 Jul;6(1):18-31. Review. PubMed PMID: 22003419; PubMed Central PMCID: PMC3188822. Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

Author: Nick Hatch, MD Educational Pearls: Pregnancy is a hypercoagulable state, which predisposes women to venous thromboembolism, but also elevates levels of circulating d-dimer A recent study evaluated the YEARS protocol in combination of adjusted d-dimer cutoffs in pregnant women to evaluate for DVT and PE Using this protocol, only 1 DVT was missed. No PE's were missed. This protocol has growing evidence as an option in pregnant women in whom you must rule out a DVT/PE but more validating studies are likely necessary References van der Pol LM, Tromeur C, Bistervels IM, Ni Ainle F, van Bemmel T, Bertoletti L, Couturaud F, van Dooren YPA, Elias A, Faber LM, Hofstee HMA, van der Hulle T, Kruip MJHA, Maignan M, Mairuhu ATA, Middeldorp S, Nijkeuter M, Roy PM, Sanchez O, Schmidt J, Ten Wolde M, Klok FA, Huisman MV. Pregnancy-Adapted YEARS Algorithm for Diagnosis of Suspected Pulmonary Embolism. N Engl J Med. 2019 Mar 21;380(12):1139-1149. doi: 10.1056/NEJMoa1813865. PubMed PMID: 30893534. Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

Author: Chris Holmes, MD Educational Pearls: Hallucinogenic drugs have been in use since ancient times for both medical and recreational purposes Ayahausca is an ancient psychedelic with origins in Bolivia that causes intense vomiting followed by a psychedelic experience This and other hallucinogens are gaining gaining interest for their use in depression with some startling positive initial results References https://www.nationalgeographic.com/culture/2019/05/ancient-hallucinogens-oldest-ayahuasca-found-shaman-pouch/ Carhart-Harris RL et. al. Psilocybin with psychological support for treatment-resistant depression: six-month follow-up. Psychopharmacology (Berl). 2018 Feb;235(2):399-408. doi: 10.1007/s00213-017-4771-x. Epub 2017 Nov 8. PubMed PMID: 29119217; PubMed Central PMCID: PMC5813086. Palhano-Fontes F et. al. Rapid antidepressant effects of the psychedelic ayahuasca in treatment-resistant depression: a randomized placebo-controlled trial. Psychol Med. 2019 Mar;49(4):655-663. doi: 10.1017/S0033291718001356. Epub 2018 Jun 15. PubMed PMID: 29903051; PubMed Central PMCID: PMC6378413. Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

Author: Nick Hatch, MD Educational Pearls: Postpolypectomy electrocoagulation syndrome (PES) is a rare complication of polypectomy and electrocautery during colonoscopy Occurs when cautery causes transmural thickening from a contact burn Patients can present as if they have peritonitis, with guarding, leukocytosis, fever, etc. CT is the imaging of choice mainly to evaluate for bowel perforation as PES may not be seen on imaging Treatment is often with antibiotics and supportive care - in severe cases, hospitalization may be required. References Benson BC, Myers JJ, Laczek JT. Postpolypectomy electrocoagulation syndrome: a mimicker of colonic perforation. Case Rep Emerg Med. 2013;2013:687931. doi: 10.1155/2013/687931. Epub 2013 Jul 15. PubMed PMID: 23956889; PubMed Central PMCID: PMC3728495. Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

Author: Dylan Luyten, MD Educational Pearls: Actual wait times are weakly correlated to patient satisfaction but the difference between perceived/expected wait times and actual wait times is strongly correlated Having others in the room or with the patient while they wait also has a positive effect Under-promising and over-delivering can result in better patient experience Managing up others and services provided also is demonstrated to improve satisfaction Perceived time with health care members (physicians, APPs, nurses, etc) also is supported to improve satisfaction Sitting with patients increases the perception of time References Trout A, Magnusson AR, Hedges JR. Patient satisfaction investigations and the emergency department: what does the literature say?. Acad Emerg Med. 2000 Jun;7(6):695-709. Review. PubMed PMID: 10905652. Sonis JD, Aaronson EL, Lee RY, Philpotts LL, White BA. Emergency Department Patient Experience: A Systematic Review of the Literature. J Patient Exp. 2017;5(2):101–106. doi:10.1177/2374373517731359 Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

Author: Michael Hunt, MD Educational Pearls: A recent study evaluated the relationship between abnormal orthostatic vital signs and serious outcomes within 30 days in patients over 60 presenting to the ED with syncope Of the roughly 2000 patients enrolled, about ⅓ had abnormal orthostatic vital signs There was no statistically significance between orthostatic vital signs and serious outcomes in 30 days Editor's note: study used a composite end-point of multiple serious outcomes References White JL, Hollander JE, Chang AM, Nishijima DK, Lin AL, Su E, Weiss RE, Yagapen AN, Malveau SE, Adler DH, Bastani A, Baugh CW, Caterino JM, Clark CL, Diercks DB, Nicks BA, Shah MN, Stiffler KA, Storrow AB, Wilber ST, Sun BC. Orthostatic vital signs do not predict 30 day serious outcomes in older emergency department patients with syncope: A multicenter observational study. Am J Emerg Med. 2019 Mar 25;. doi: 10.1016/j.ajem.2019.03.036. [Epub ahead of print] PubMed PMID: 30928476. Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

Author: Peter Bakes, MD Educational Pearls: The differential diagnosis for pedal edema includes issues in the heart, kidney, and liver Obesity hypoventilation syndrome (OHS) is an important and common cause of right heart failure. Nighttime hypoventilation leads to pulmonary hypertension, causing right heart strain followed by right heart failure OHS criteria includes obesity, sleep disordered breathing, and alveolar hypoventilation (PaCO2 > 45 mmHg) The causes of OHS are multifactorial, and include mechanical problems with breathing and hormonal changes References Balachandran JS, Masa JF, Mokhlesi B. Obesity Hypoventilation Syndrome Epidemiology and Diagnosis. Sleep Med Clin. 2014;9(3):341–347. doi:10.1016/j.jsmc.2014.05.007 Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

Author: Sam Killian, MD Educational Pearls: A recent study in Pediatrics compared the rates of antibiotic prescriptions for acute respiratory infections (ARIs) between direct to consumer (DTC) telemedicine, urgent care, and primary care providers Among the nearly 530,000 visits studied, the rate of antibiotic prescription was 52%, 42% and 31% for telemedicine, urgent care, and primary care providers, respectively Nearly 4/10 antibiotic prescriptions from telemedicine visits were not indicated based on antibiotics guideline recommendations References Ray KN, Shi Z, Gidengil CA, Poon SJ, Uscher-Pines L, Mehrotra A. Antibiotic Prescribing During Pediatric Direct-to-Consumer Telemedicine Visits. Pediatrics. 2019 May;143(5). doi: 10.1542/peds.2018-2491. Epub 2019 Apr 8. PubMed PMID: 30962253. Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

Author: Gretchen Hinson, MD Educational Pearls: In most healthcare settings, normal saline (NS) has become ubiquitous as an intravenous fluid despite some potential drawbacks Compared to normal saline, a balanced crystalloid (either lactated Ringer's or Plasma-Lyte) was associated with a lower composite endpoint of mortality, renal replacement therapy, and renal injury in SMART (Isotonic Solutions and Major Adverse Renal Events Trial) Balanced crystalloids such as lactate Ringer's may be preferable in more critically ill populations References Yau YW, Kuan WS. Choice of crystalloids in sepsis: a conundrum waiting to be solved. Ann Transl Med. 2016;4(6):121. doi:10.21037/atm.2016.02.09 Semler MW, Self WH, Wanderer JP, et al. Balanced Crystalloids versus Saline in Critically Ill Adults. N Engl J Med. 2018;378(9):829–839. doi:10.1056/NEJMoa1711584 Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

Author: Don Stader, MD Educational Pearls: Cyclic vomiting syndrome (CVS) is different than cannabis hyperemesis syndrome (CHS). It is important to differentiate the two. CHS is thought to be caused by activation of THC receptors in the gut CVS is associated with migraines and therefore responds to similar medications Olanzapine (Zyprexa) is an alternative to haloperidol (Haldol) Amitriptyline, as well as anti-epileptics can be used to prevent CVS Opioids worsen CVS References Lapoint J, Meyer S, Yu CK, Koenig KL, Lev R, Thihalolipavan S, Staats K, Kahn CA.Cannabinoid Hyperemesis Syndrome: Public Health Implications and a Novel Model Treatment Guideline. West J Emerg Med. 2018 Mar;19(2):380-386. doi: 10.5811/westjem.2017.11.36368. Epub 2017 Nov 8. PubMed PMID: 29560069; PubMed Central PMCID: PMC5851514. Boles RG, Lovett-Barr MR, Preston A, Li BU, Adams K. Treatment of cyclic vomiting syndrome with co-enzyme Q10 and amitriptyline, a retrospective study. BMC Neurol. 2010;10:10. Epub 2010 Jan 28. Hikita T, Kodama H, Kaneko S, Amakata K, Ogita K, Mochizuki D, Kaga F, Nakamoto N, Fujii Y, Kikuchi A. Sumatriptan as a treatment for cyclic vomiting syndrome: a clinical trial. Cephalalgia. 2011;31(4):504. Epub 2010 Dec 8. Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

Author: Jared Scott, MD Educational Pearls: Ondansetron (Zofran) is one of the latest drugs that has had concerns raised about side effects, particularly in pregnancy 2018 study probed two birth defect databases to assess increases in 51 major birth defects with increased exposure to ondansetron Only two of the 51 had even a modest increase, which is unclear in causation (cleft palate and renal agenesis) When administering ondansetron (or any drug) to pregnant women, be able to discuss any potential risks for an informed decision by the patient Editor's note: in this study, adjusted odds ratios for risk of birth defects from exposure to ondansetron were: cleft palate 1.6 (95% CI 1.1-2.3) and renal agenesis 1.8 (95% CI 1.1-3.0) References Parker SE, Van Bennekom C, Anderka M, Mitchell AA. Ondansetron for Treatment of Nausea and Vomiting of Pregnancy and the Risk of Specific Birth Defects. Obstet Gynecol. 2018 Aug;132(2):385-394. doi: 10.1097/AOG.0000000000002679. PubMed PMID: 29995744. Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

Author: Dave Rosenberg, MD Educational Pearls: Nothing by mouth (NPO) status routinely used before surgery to reduce the theoretical risk of aspiration However, surgery poses a large physiological stress. Calories and fluid are needed to overcome stresses like these Patients who drank 1/2 strength Gatorade up to 2 hours before surgery did better than those who did not References Alyssa Cheng-Cheng Zhu, Aalok Agarwala, Xiaodong Bao. Perioperative Fluid Management in the Enhanced Recovery after Surgery (ERAS) Pathway. Clinics in Colon and Rectal Surgery 2019; 32(02): 114-120. DOI: 10.1055/s-0038-1676476 Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

Educational Pearls: Tiflitis refers to the presence of enterocolitis in the setting of neutropenia - also known as neutropenic enterocolitis Commonly a result of chemotherapy for hematologic malignancies. The infection is usually polymicrobial/fungal and can lead to septic shock Usually presents with fever, abdominal pain, with associated GI complaints Workup includes CBC for the ANC (usually Treatment typically with broad-spectrum antibiotics with or without anti-fungal agents Mortality can be as high as 50% References Cloutier RL. Neutropenic enterocolitis. Emerg Med Clin North Am. 2009 Aug;27(3):415-22. doi: 10.1016/j.emc.2009.04.002. PubMed PMID: 19646645. Rodrigues FG, Dasilva G, Wexner SD. Neutropenic enterocolitis. World J Gastroenterol.2017 Jan 7;23(1):42-47. doi: 10.3748/wjg.v23.i1.42. Review. PubMed PMID: 28104979; PubMed Central PMCID: PMC5221285. Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

Author: Erik Verzemnieks, MD Educational Pearls: Cauda equina syndrome is caused by the compression of the nerve roots that extend beyond the termination of the spinal cord Trauma, infection, hematoma, disc rupture/herniation can cause this - basically anything that can cause pressure and fill space Symptoms can include saddle anesthesia, lower extremity pain, numbness, incontinence, and constipation Post-void residual that is abnormally high may be an indicator MRI is diagnostic modality of choice Emergent surgical decompression is treatment References Jalloh I, Minhas P. Delays in the treatment of cauda equina syndrome due to its variable clinical features in patients presenting to the emergency department. Emerg Med J. 2007 Jan;24(1):33-4. doi: 10.1136/emj.2006.038182. PubMed PMID: 17183040; PubMed Central PMCID: PMC2658150.

Author: Nicholas Hatch, MD Educational Pearls: Measles has a period of infectivity starts before the appearance of the characteristic rash, up to 4-5 days A devastating consequence of measles is Subacute Sclerosing Panencephalitis (SSPE), which manifests 7-10 years after the initial measles infection SSPE is a central nervous system disease that has no cure and is nearly universally fatal Educating patients on the importance of vaccination should include discussion of these long term consequences References Pallivathucal LB, Noymer A. Subacute sclerosing panencephalitis mortality, United States, 1979-2016: Vaccine-induced declines in SSPE deaths. Vaccine. 2018 Aug 23;36(35):5222-5225. doi: 10.1016/j.vaccine.2018.07.030. Epub 2018 Jul 26. PubMed PMID: 30057285. Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

Author: Ryan Circh, MD Educational Pearls: The 2019 ANDROMEDA-SHOCK trial compared using serum lactates to capillary refill assessment in septic shock patients to guide resuscitation Capillary refill time was standardized (this is not straightforward): A glass microscope slide was pressed on the ventral side of the right index finger Pressure was increased until the skin was blanched This pressure was sustained for another 10 seconds After pressure was removed, the time to return to normal skin color was timed Greater than three seconds was considered abnormal. No difference between the two groups for mortality at 28-days Editor's note: lactates have become so ingrained in our practice it will be tough to change habits but this is an excellent quiver for those of us that hate the over reliance on this lab value alone, despite some of the limitations of the study. References Hernández G, Ospina-Tascón GA, Damiani LP, et al. Effect of a Resuscitation Strategy Targeting Peripheral Perfusion Status vs Serum Lactate Levels on 28-Day Mortality Among Patients With Septic Shock: The ANDROMEDA-SHOCK Randomized Clinical Trial. JAMA. 2019;321(7):654–664. doi:10.1001/jama.2019.0071 Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

Author: Aaron Lessen, MD Educational Pearls: A problem of take-home-naloxone is the administration of it by an able-bodied bystander Australian study looked at consecutive opioid overdose deaths in a single year to identify characteristics of overdose and potential for bystander administered naloxone Of the 235 fatal heroin overdoses reviewed, 83% were alone with only 17% (38 cases) having another person present Half of those in the presence of others had a bystander that was not impaired Take-home-naloxone needs a competent person to administer it. Make sure to review this along with other harm reduction strategies when prescribing/dispensing it to patients References Stam NC, Gerostamoulos D, Smith K, Pilgrim JL, Drummer OH. Challenges with take-home naloxone in reducing heroin mortality: a review of fatal heroin overdose cases in Victoria, Australia. Clin Toxicol (Phila). 2019 May;57(5):325-330. doi: 10.1080/15563650.2018.1529319. Epub 2018 Nov 17. PubMed PMID: 30451007. Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

Author: Erik Verzemnieks, MD Educational Pearls: Buproprion is used as an antidepressant and for smoking cessation Severe buproprion overdoses can cause seizures and lead to cardiac dysrhythmias Benzodiazepines are treatment of choice for seizures Bicarbonate and Interlipid are also possible treatment options with less evidence References Stall N, Godwin J, Juurlink D. Bupropion abuse and overdose. CMAJ. 2014 Sep 16;186(13):1015. doi: 10.1503/cmaj.131534. Epub 2014 Apr 28. PubMed PMID: 24778361; PubMed Central PMCID: PMC4162783. Balit CR, Lynch CN, Isbister GK. Bupropion poisoning: a case series. Med J Aust. 2003 Jan 20;178(2):61-3. PubMed PMID: 12526723. Bruccoleri RE, Burns MM. A Literature Review of the Use of Sodium Bicarbonate for the Treatment of QRS Widening. J Med Toxicol. 2016 Mar;12(1):121-9. doi: 10.1007/s13181-015-0483-y. Review. PubMed PMID: 26159649; PubMed Central PMCID: PMC4781799.

Author: Don Stader, MD Educational Pearls: 10% of patients seen in the emergency department for opioid overdose patients will die within a year Half of these overdoses will occur in the next month This mortality rate is higher than patients with STEMI, of which 7% will die within one year Take-home naloxone, as well as medication assisted treatment like buprenorphine can save lives References Olfson M, Crystal S, Wall M, Wang S, Liu SM, Blanco C. Causes of Death After Nonfatal Opioid Overdose. JAMA Psychiatry. 2018 Aug 1;75(8):820-827. doi: 10.1001/jamapsychiatry.2018.1471. PubMed PMID: 29926090; PubMed Central PMCID: PMC6143082. Olfson M, Wall M, Wang S, Crystal S, Blanco C. Risks of fatal opioid overdose during the first year following nonfatal overdose.Drug Alcohol Depend. 2018 Sep 1;190:112-119. doi: 10.1016/j.drugalcdep.2018.06.004. Epub 2018 Jul 4. PubMed PMID: 30005310. Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

Author: Gretchen Hinson, MD Educational Pearls: Breath stacking occurs when a patient is unable to expire fully before another inspiration In intubated/ventilated patients, this is because adequate time has not passed before exhalation Asthmatics are susceptible due to the prolonged expiratory phase Complications can include reduction in cardiac preload and cardiovascular collapse Pursed-lip breathing can help in the spontaneously breathing patient Intubation may be required when patients present with status asthmaticus and breath stacking References Phipps P, Garrard CS. The pulmonary physician in critical care . 12: Acute severe asthma in the intensive care unit. Thorax. 2003 Jan;58(1):81-8. Review. PubMed PMID: 12511728; PubMed Central PMCID: PMC1746457. Pohlman MC, McCallister KE, Schweickert WD, Pohlman AS, Nigos CP, Krishnan JA, Charbeneau JT, Gehlbach BK, Kress JP, Hall JB. Excessive tidal volume from breath stacking during lung-protective ventilation for acute lung injury. Crit Care Med. 2008 Nov;36(11):3019-23. doi: 10.1097/CCM.0b013e31818b308b. PubMed PMID: 18824913. Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

Author: Michael Hunt, MD Educational Pearls: Most causes of syncope are benign Pulmonary embolism can result in syncope and is life threatening A recent study of Canadian and US ED patients with syncope showed that 0.4% of patients had a PE at 30 day follow-up PE should always be considered in cases of syncope but overall is a rare cause Editor's note: this study puts to rest a previous study from 2016 that reported a rate of PE in syncope as high as 1 in 6 in patients admitted to syncope - which was met with much skepticism based on clinical practice. References Roncon L, Zuin M, Casazza F, Becattini C, Bilato C, Zonzin P. Impact of syncope and pre-syncope on short-term mortality in patients with acute pulmonary embolism. Eur J Intern Med. 2018 Aug;54:27-33. doi: 10.1016/j.ejim.2018.04.004. Epub 2018 Apr 11. PubMed PMID: 29655808. Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

Author: Julian Orenstein, MD Educational Pearls: Severe clonidine ingestion can present as a fluctuating mental status between typically accompanied by changes in vital signs (hypotension/bradycardia) Respiratory depression requiring intubation is not uncommon References Isbister GK, Heppell SP, Page CB, Ryan NM. Adult clonidine overdose: prolonged bradycardia and central nervous system depression, but not severe toxicity. Clin Toxicol (Phila). 2017 Mar;55(3):187-192. doi: 10.1080/15563650.2016.1277234. Epub 2017 Jan 20. PubMed PMID: 28107093. Spiller HA, Klein-Schwartz W, Colvin JM, Villalobos D, Johnson PB, Anderson DL. Toxic clonidine ingestion in children. J Pediatr. 2005 Feb;146(2):263-6. PubMed PMID: 15689921. Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

Author: Nick Hatch, MD Educational Pearls: A recent study investigated the effect of scheduled IV acetaminophen on the incidence of delirium in post-CABG patients in the ICU The use of scheduled IV acetaminophen reduced the rate of delirium in these patients compared to placebo This may be due to the analgesic effect of acetaminophen and/or less requirement on other deliriogenic medications (opiates) References Subramaniam B, Shankar P, Shaefi S, Mueller A, O'Gara B, Banner-Goodspeed V, Gallagher J, Gasangwa D, Patxot M, Packiasabapathy S, Mathur P, Eikermann M, Talmor D, Marcantonio ER. Effect of Intravenous Acetaminophen vs Placebo Combined With Propofol or Dexmedetomidine on Postoperative Delirium Among Older Patients Following Cardiac Surgery: The DEXACET Randomized Clinical Trial. JAMA. 2019 Feb 19;321(7):686-696. doi: 10.1001/jama.2019.0234. PubMed PMID: 30778597. Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

Author: Jared Scott, MD Educational Pearls: Modified Rankin Score: measure of disability often used to qualify outcomes following stroke = no disability, 6=dead, 0-1 indicate good outcome) 0-6 Scale 0-1 indicative of good outcome ASPECT score: uses CT to quantify the extent of changes in the brain due to ischemia 0-10 Scale 10 areas are assessed on non-contrast CT to assess for early stroke changes -1 for each area with these findings 8-10 is indicative of better outcomes References Aviv RI, Mandelcorn J, Chakraborty S, Gladstone D, Malham S, Tomlinson G, Fox AJ, Symons S. Alberta Stroke Program Early CT Scoring of CT perfusion in early stroke visualization and assessment. AJNR Am J Neuroradiol. 2007 Nov-Dec;28(10):1975-80. Epub 2007 Oct 5. PubMed PMID: 17921237. https://manual.jointcommission.org/releases/TJC2018A/DataElem0569.html Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

Author: Jared Scott, MD Educational Pearls: Beta-blockers can mask the effects of hypoglycemia Prolonged/refractory hypoglycemia should raise a suspicion for sulfonylurea (or other oral hypoglycemic) overdose Interventions to reverse hypoglycemia include feeding the patient, IV dextrose, glucagon Octreotide can be used as an antidote with sulfonylurea ingestion Editor's note: Here is an interesting case report on using steroids for severe hypogylcemia caused by insulin overdose. Perhaps another treatment modality to keep in your back pocket? References Alsahli M, Gerich JE. Hypoglycemia. Endocrinol Metab Clin North Am. 2013 Dec;42(4):657-76. doi: 10.1016/j.ecl.2013.07.002. Review. PubMed PMID: 24286945. Moore C, Woollard M. Dextrose 10% or 50% in the treatment of hypoglycaemia out of hospital? A randomised controlled trial.Emerg Med J. 2005 Jul;22(7):512-5. PubMed PMID: 15983093; PubMed Central PMCID: PMC1726850. Fasano CJ, O'Malley G, Dominici P, Aguilera E, Latta DR. Comparison of octreotide and standard therapy versus standard therapy alone for the treatment of sulfonylurea-induced hypoglycemia. Ann Emerg Med. 2008 Apr;51(4):400-6. Epub 2007 Aug 30. PubMed PMID: 17764782. Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

Author: Michael Hunt, MD Educational Pearls: Like all tests, urine toxicology (utox) screens can have false positives Prescription medications such as demerol, antipsychotics, ketamine, and tramadol can all produce a false positive utox for PCP Over-the-counter medication such as dextromethorphan also mimic PCP on utox References Doyon S. (January 2014). False Positive Urine Screens for Phencyclidine. ToxTidbits. Retrieved from https://www.mdpoison.com/media/SOP/mdpoisoncom/ToxTidbits/2014/January%202014%20ToxTidbits.pdf Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

Educational Pearls: Acetaminophen overdose can also present in patients taking too much over the course of days to weeks - not just intentional ingestions If acute overdose is suspected, refer to the Rumak-Matthew nomogram to guide treatment based on time of ingestion and the time of level In chronic overdose, Tylenol levels will not guide treatment NAPQI is the toxic metabolite of acetaminophen N-acetylcysteine (NAC) can be effective treatment in both acute and chronic overdoses 7.5 g is the daily toxic dose of Tylenol in adults, 150mg/kg in children References: Smilkstein MJ. Acetaminophen. In: Goldfrank's Toxicologic Emergencies, Goldfrank LR, Flomenbaum NE, Lewin NA, et al (Eds), Appleton & Lange, Stamford 1998. P.541. Chiew AL, Gluud C, Brok J, Buckley NA. Interventions for paracetamol (acetaminophen) overdose. Cochrane Database Syst Rev. 2018 Feb 23;2:CD003328. doi: 10.1002/14651858.CD003328.pub3. Review. PubMed PMID: 29473717. Lancaster EM, Hiatt JR, Zarrinpar A. Acetaminophen hepatotoxicity: an updated review. Arch Toxicol. 2015 Feb;89(2):193-9. doi: 10.1007/s00204-014-1432-2. Epub 2014 Dec 24. Review. PubMed PMID: 25537186. Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

Author: Sam Killian, MD Educational Pearls: Headache is a common complaint in the ED. It's plausible that headaches could be correlated with environmental factors A 2015 study ED visits for headache found that temperature was associated with an increase visits, while higher humidity led to fewer A retrospective study looking over a 10-year period for headache found that there was an increase headache presentations during days with high air pollution References: Yilmaz M, Gurger M, Atescelik M, Yildiz M, Gurbuz S. Meteorologic parameters and migraine headache: ED study. Am J Emerg Med. 2015 Mar;33(3):409-13. doi: 10.1016/j.ajem.2014.12.056. Epub 2014 Dec 31. PubMed PMID: 25601162. Szyszkowicz M, Stieb DM, Rowe BH. Air pollution and daily ED visits for migraine and headache in Edmonton, Canada. Am J Emerg Med. 2009 May;27(4):391-6. doi: 10.1016/j.ajem.2008.03.013. PubMed PMID: 19555607. Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

Author: Sam Killian, MD Educational Pearls: Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy (CADASIL) occurs in 1:100000 individuals The disease is caused by a defect in the NOTCH3 gene on chromosome 19 It is an important cause of stroke in young patients Features include ischemia, cognitive deficits, migraines, psychiatric disease, coma, and seizure, all of which is worse with pregnancy Migraine with aura is often the first presenting symptom with onset by age 30 Strokes typically can occur by age 50 Diagnosis is with MRI for characteristic lesions Unfortunately there is no cure, and treatment is focused on stroke prevention with aspirin and statins References: Chabriat H, Joutel A, Dichgans M, Tournier-Lasserve E, Bousser MG. Cadasil. Lancet Neurol. 2009 Jul;8(7):643-53. doi: 10.1016/S1474-4422(09)70127-9. Review. PubMed PMID: 19539236. Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

Author: Don Stader, MD Educational Pearls: Non-steroidal anti-inflammatory drugs (NSAIDs) are effective pain relievers but come with important side effects NSAIDs inhibit COX-1 and/or COX-2, which decreases the production of prostaglandins, which reduce pain and inflammation Side effects of NSAIDS include increased rates myocardial infarction, stroke, and gastrointestinal bleeding, CVA Effective pain reliever doses of many NSAIDs are lower than typically prescribed (i.e. ibuprofen 400 mg is as effective as 800 mg but with less risk of side effects) Topical NSAIDs can be an alternative to reduce systemic effects Selective Cox-2 inhibitors have less GI side effects Editor note: What is ALTO? It's alternative to opioids and consists of multi-modal pain control to reduce exposure to opioids. Check out more here and here. References: Derry S, Wiffen PJ, Kalso EA, Bell RF, Aldington D, Phillips T, Gaskell H, Moore RA. Topical analgesics for acute and chronic pain in adults - an overview of Cochrane Reviews. Cochrane Database Syst Rev. 2017 May 12;5:CD008609. doi: 10.1002/14651858.CD008609.pub2. Review. PubMed PMID: 28497473. Coxib and traditional NSAID Trialists' (CNT) Collaboration., Bhala N, Emberson J, Merhi A, Abramson S, Arber N, Baron JA, Bombardier C, Cannon C, Farkouh ME, FitzGerald GA, Goss P, Halls H, Hawk E, Hawkey C, Hennekens C, Hochberg M, Holland LE, Kearney PM, Laine L, Lanas A, Lance P, Laupacis A, Oates J, Patrono C, Schnitzer TJ, Solomon S, Tugwell P, Wilson K, Wittes J, Baigent C. Vascular and upper gastrointestinal effects of non-steroidal anti-inflammatory drugs: meta-analyses of individual participant data from randomised trials. Lancet. 2013 Aug 31;382(9894):769-79. doi: 10.1016/S0140-6736(13)60900-9. Epub 2013 May 30. PubMed PMID: 23726390; PubMed Central PMCID: PMC3778977. Kaufman DW, Kelly JP, Battista DR, Malone MK, Weinstein RB, Shiffman S. Exceeding the daily dosing limit of nonsteroidal anti-inflammatory drugs among ibuprofen users. Pharmacoepidemiol Drug Saf. 2018 Mar;27(3):322-331. doi: 10.1002/pds.4391. Epub 2018 Jan 26. PubMed PMID: 29372579. Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

Author: Sam Killian, MD Educational Pearls: Viral gastroenteritis alters the gut microbiome and it is theorized that probiotics may help reduce the duration and severity of the disease. Double-blind randomized controlled trial involving almost 900 children with viral gastroenteritis compared 5 days of probiotics to a control group. There was no difference in the rates of severe gastroenteritis between the two groups Probiotics are likely unhelpful for kid with viral gastroenteritis References: Freedman SB, Williamson-Urquhart S, Farion KJ, Gouin S, Willan AR, Poonai N, Hurley K, Sherman PM, Finkelstein Y, Lee BE, Pang XL, Chui L, Schnadower D, Xie J, Gorelick M, Schuh S; PERC PROGUT Trial Group.. Multicenter Trial of a Combination Probiotic for Children with Gastroenteritis. N Engl J Med. 2018 Nov 22;379(21):2015-2026. doi: 10.1056/NEJMoa1802597. PubMed PMID: 30462939. Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

Author: Dylan Luyten, MD Educational Pearls: A "banana bag" is a bag of IV fluid that contains various vitamins and minerals including folate and thiamine IV fluids do not alter intoxicated patients recovery in the emergency department Folate deficiency is rare in the intoxicated patient Some intoxicated patients may be thiamine deficient, and those that would benefit the most need significantly more daily thiamine supplementation than provided in a banana bag References: Perez SR, Keijzers G, Steele M, Byrnes J, Scuffham PA. Intravenous 0.9% sodium chloride therapy does not reduce length of stay of alcohol-intoxicated patients in the emergency department: a randomised controlled trial. Emerg Med Australas. 2013 Dec;25(6):527-34. doi: 10.1111/1742-6723.12151. Epub 2013 Nov 8. PubMed PMID: 24308613; PubMed Central PMCID: PMC4253317. Li SF, Jacob J, Feng J, Kulkarni M. Vitamin deficiencies in acutely intoxicated patients in the ED. Am J Emerg Med. 2008 Sep;26(7):792-5. doi: 10.1016/j.ajem.2007.10.003. PubMed PMID: 18774045. ay E, Bentham PW, Callaghan R, Kuruvilla T, George S. Thiamine for prevention and treatment of Wernicke-Korsakoff Syndrome in people who abuse alcohol. Cochrane Database Syst Rev. 2013 Jul 1;(7):CD004033. doi: 10.1002/14651858.CD004033.pub3. Review. PubMed PMID: 23818100. Summarized by Will Dewsipelaere, MS3 | Edited by Erik Verzemnieks, MD

Author: Ryan Circh, MD Educational Pearls: Chronic salicylate (ASA) toxicity can present in elderly patients as altered mental status Consider chronic toxicity in patients with an unexplained anion gap acidosis Treatment for chronic ingestion typically includes IV fluids and urine alkalinization References: O'Malley GF. Emergency department management of the salicylate-poisoned patient. Emerg Med Clin North Am. 2007 May;25(2):333-46; abstract viii. Review. PubMed PMID: 17482023. Durnas C, Cusack BJ. Salicylate intoxication in the elderly. Recognition and recommendations on how to prevent it. Drugs Aging. 1992 Jan-Feb;2(1):20-34. Review. PubMed PMID: 1554971. Summarized by Will Dewsipelaere, MS3 | Edited by Erik Verzemnieks, MD

Author: Dylan Luyten, MD Educational Pearls: Recent randomized controlled trial compared intravenous to oral acetaminophen in emergency department patients There was no difference in pain relief between the groups While the actual acquisition cost of these drugs are not significant, the cost multipliers that are passed onto patients lead to real dollars With the significant cost of IV acetaminophen, it may not be the best choice given the lack of superiority to other formulations References: Furyk J, Levas D, Close B, Laspina K, Fitzpatrick M, Robinson K, Vangaveti VN, Ray R. Intravenous versus oral paracetamol for acute pain in adults in the emergency department setting: a prospective, double-blind, double-dummy, randomised controlled trial.Emerg Med J. 2018 Mar;35(3):179-184. doi: 10.1136/emermed-2017-206787. Epub 2017 Dec 15. PubMed PMID: 29247042. Summarized by Will Dewsipelaere, MS3 | Edited by Erik Verzemnieks, MD

Author: Dylan Luyten, MD Educational Pearls: 1:500 patients will experience a retinal detachment Consider stroke on your differential (central retinal arterial occlusion) Flashes and floaters are a common complaint with retinal detachments Though patients may report fields of vision loss, visual acuity is often spared Ocular ultrasound is an effective way to diagnosis retinal detachment in the ED These require urgent ophthalmologic consultation for surgical repair References: https://www.aliem.com/2014/03/ocular-ultrasound-retinal-detachment-posterior-vitreous-detachment/ Gottlieb M, Holladay D, Peksa GD. Point-of-Care Ocular Ultrasound for the Diagnosis of Retinal Detachment: A Systematic Review and Meta-Analysis. Acad Emerg Med. 2019 Jan 13. doi: 10.1111/acem.13682. [Epub ahead of print] PubMed PMID: 30636351. Summarized by Will Dewsipelaere, MS3 | Edited by Erik Verzemnieks, MD