Emergency Medical Minute

Author: Rachel Brady, MD Educational Pearls: Medication errors are estimated to be the 3rd leading cause of death A 2016 study estimated 250,000 errors occur per year, with 7000-9000 leading to death About 50% are in the ordering/prescribing phase; 25-30% during administration phase. Overworked and distracted providers are the most common underlying reasons for medication error A 2017 study found 40% of ED nurses witnessed a medication error in the last year Editor's Note: This is a reasonable counterpoint References Farag A, Blegen M, Gedney-Lose A, Lose D, Perkhounkova Y. Voluntary Medication Error Reporting by ED Nurses: Examining the Association With Work Environment and Social Capital. J Emerg Nurs. 2017 May;43(3):246-254. doi: 10.1016/j.jen.2016.10.015. Epub 2017 Mar 28. PubMed PMID: 28359712. Makary MA, Daniel M. Medical error-the third leading cause of death in the US. BMJ. 2016 May 3;353:i2139. doi: 10.1136/bmj.i2139. PubMed PMID: 27143499. Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Author: Aaron Lessen, MD Educational Pearls: Choose the longest needle for the humeral IO Internally rotate and adduct the patients hand (resting on umbilicus) for best access to the site Aim 1 cm superior to the greater tuberosity of the humerus with the needle angled 45 degrees inferiorly Maintaining the line is critical - keep arm internally rotated with sling, tape or whatever works References Kovar J, Gillum L. Alternate route: the humerus bone - a viable option for IO access. JEMS. 2010 Aug;35(8):52-9. doi: 10.1016/S0197-2510(10)70207-2. PubMed PMID: 20708143. http://epmonthly.com/article/get-humeral-io-access/ Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Author: Chris Holmes, MD Educational Pearls: In WWI, the 2nd leading cause of soldier disability were STDs. An early treatment of syphilis included topical and inhaled mercury Bloodletting, vitriol, arsenic, and bismuth were other treatments for syphilis. Infecting patients with Malaria and treating the Malaria was also tried Thankfully penicillin was discovered for our syphilis woes References Frith J. . Syphilis – Its early history and Treatment until Penicillin and the Debate on its Origins. Journal of Military and Veterans Health. 2012. 20(4): 49-58 https://jmvh.org/article/syphilis-its-early-history-and-treatment-until-penicillin-and-the-debate-on-its-origins/ Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Author: Gretchen Hinson, MD Educational Pearls: Clinical manifestations of severe hypothyroidism may include: Pale, cool, diaphoretic skin Myxedema is the non-pitting edema seen in hypothyroidism Hypothermia, heart failure, hypotension and shock Shortness of breath Cholestasis, constipation Encephalopathy and coma Mortality is 30-50% Specific treatment includes thyroid hormone (T3, T4, or both) and glucocorticoids (for potential adrenal insufficiency) References: Kwaku MP, Burman KD. Myxedema coma. J Intensive Care Med. 2007 Jul-Aug;22(4):224-31. Review. PubMed PMID: 17712058. Ono Y, Ono S, Yasunaga H, Matsui H, Fushimi K, Tanaka Y. Clinical characteristics and outcomes of myxedema coma: Analysis of a national inpatient database in Japan. J Epidemiol. 2017 Mar;27(3):117-122. doi: 10.1016/j.je.2016.04.002. Epub 2017 Jan 5. PubMed PMID: 28142035; PubMed Central PMCID: PMC5350620. Lee CH, Wira CR. Severe angioedema in myxedema coma: a difficult airway in a rare endocrine emergency. Am J Emerg Med. 2009 Oct;27(8):1021.e1-2. doi: 10.1016/j.ajem.2008.12.027. PubMed PMID: 19857436. Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Author: Eric Miller, MD Educational Pearls: Recent CDC statement warms against consumption of cookie dough Two common ingredients can pose risk: eggs and flour Flour in dough is a raw agricultural product not treated to kill E. coli A 2016 E. coli outbreak was linked to flour References: https://www.cdc.gov/features/no-raw-dough/index.html https://www.cdc.gov/ecoli/2016/o121-06-16/index.html Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Author: Katrina Iverson, MD Educational Pearls: The winter holiday months present a unique picture of patient presentations to the emergency department Some of the unique presentations include: Children falling off Santa's lap Sledding injuries Falling off ladders Lacerations, ingestion, and insertion of broken ornaments (pediatrics) Parents tend to hurt themselves on their children's toys References: Lauche R, et al. (2018). 'Santa baby, hurry [extra carefully] down the chimney tonight' – Prevalence of Christmas related injuries 2007–2016 in the United States: Observational study. Advances in Integrative Medicine. https://doi.org/10.1016/j.aimed.2018.11.004 https://areyouawellbeing.texashealth.org/common-winter-injuries/ Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Author: Aaron Lessen, MD Educational Pearls: Recent meta-analysis reviewed efficacy oseltamivir (Tamiflu) in pediatric populations treated for influenza, showing an 18 hour reduction in duration of illness for those with laboratory confirmed influenza Those with suspected influenza unsurprisingly had less effect Subgroup analysis showed most benefit in those treated within the first 24 hours of symptom onset Patients with confirmed influenza treated with oseltamivir had a 34% reduction in risk of otitis media Editor's note: Vomiting was higher in the treatment groups; There were no significantly different outcomes in regards to other endpoints, such as lower respiratory tract infections and hospitalizations References: Malosh RE, Martin ET, Heikkinen T, Brooks WA, Whitley RJ, Monto AS. Efficacy and Safety of Oseltamivir in Children: Systematic Review and Individual Patient Data Meta-analysis of Randomized Controlled Trials. Clin Infect Dis. 2018 May 2;66(10):1492-1500. doi: 10.1093/cid/cix1040. PubMed PMID: 29186364. Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Author: Mike Hunt, MD Educational Pearls: Measles is highly contagious and successfully infects 90% of those at risk exposed to the virus. 10 day prodrome where patients are asymptomatic. 3 day period of characteristic cough, coryza, conjunctivitis, fever and Koplick spots with a maculopapular rash that moves from head through trunk Infection risk extends three to four days after the onset of rash but also three to four days prior to onset. Have fun with that. A potential exposure, say in an emergency department waiting room, needs review of any exposed patient's immunization history to contain spread References: Moss WJ. Measles. Lancet. 2017 Dec 2;390(10111):2490-2502. doi: 10.1016/S0140-6736(17)31463-0. Epub 2017 Jun 30. Review. PubMed PMID: 28673424. Bester JC. Measles and Measles Vaccination: A Review. JAMA Pediatr. 2016 Dec 1;170(12):1209-1215. doi: 10.1001/jamapediatrics.2016.1787. Review. PubMed PMID: 27695849. Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Author: Mike Hunt, MD Educational Pearls: Blunt cardiac injuries most commonly occur in motor vehicle collisions, auto-pedestrian collisions, and from sports injuries The more anterior right ventricle is the most commonly injured structure Look for new EKG changes such as bundle branch blocks, ST changes, or other arrhythmias New EKG abnormalities should prompt consideration of further workup and admission for telemetry Patients may have an elevated troponin - but it is unclear when exactly this should be drawn after the injury References: Bellister SA, Dennis BM, Guillamondegui OD. Blunt and Penetrating Cardiac Trauma. Surg Clin North Am. 2017 Oct;97(5):1065-1076. doi: 10.1016/j.suc.2017.06.012. Review. PubMed PMID: 28958358. Marcolini EG, Keegan J. Blunt Cardiac Injury. Emerg Med Clin North Am. 2015 Aug;33(3):519-27. doi: 10.1016/j.emc.2015.04.003. Epub 2015 Jun 10. Review. PubMed PMID: 26226863. Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Author: Jared Scott, MD Educational Pearls: From 1996 to 2012, the total quantity of opioids prescribed increased 647% for non-cancer pain Office based prescriptions accounted for 84% of the total opioid prescriptions, up from 64% The total share of opioids prescribed from the emergency department declined from 10% to 3.9% but Total opioids prescribed from the ED still increased 219% over this same time frame References: Axeen S, Seabury SA, Menchine M. Emergency Department Contribution to the Prescription Opioid Epidemic. Ann Emerg Med. 2018 Jun;71(6):659-667.e3. doi: 10.1016/j.annemergmed.2017.12.007. Epub 2018 Jan 16. PubMed PMID: 29373155 Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Author: Gretchen Hinson, MD Educational Pearls: Diabetic ketoacidosis patients are subject to electrolyte derangements Potassium should be monitored closely: K 3.3 K > 5.3 = delay potassium replacement Adult patients are typically severely volume depleted and can require 50 cc/kg bolus or more Insulin typically given in bolus of 0.1 units/kg followed by drip at 0.1 units/kg/hr References: Fayfman M, Pasquel FJ, Umpierrez GE. Management of Hyperglycemic Crises: Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar State. Med Clin North Am. 2017 May;101(3):587-606. doi: 10.1016/j.mcna.2016.12.011. Review. PubMed PMID: 28372715. Nyenwe EA, Kitabchi AE. The evolution of diabetic ketoacidosis: An update of its etiology, pathogenesis and management.Metabolism. 2016 Apr;65(4):507-21. doi: 10.1016/j.metabol.2015.12.007. Epub 2015 Dec 19. Review. PubMed PMID: 26975543. Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Author: Don Stader, MD Educational Pearls: Recent meta-analysis has demonstrated that there is no significant risk for kidney injury from CT contrast Most kidney injury seen after contrast CTs were due to other underlying illnesses (sepsis, hypovolemia, etc.) Older contrast agents likely did have nephrotoxic effects but this appears to be a thing of the past References: Aycock RD, Westafer LM, Boxen JL, Majlesi N, Schoenfeld EM, Bannuru RR. Acute Kidney Injury After Computed Tomography: A Meta-analysis. Ann Emerg Med. 2018 Jan;71(1):44-53.e4. doi: 10.1016/j.annemergmed.2017.06.041. Epub 2017 Aug 12. Review. PubMed PMID: 28811122. Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Author: Don Stader, MD Educational Pearls: Etripamil is an intranasal calcium channel blocker in development for use in SVT A recent study showed that etripamil has an SVT conversion rate of around 80% Etripamil does not have the same feeling of "impending doom" that can occur with adenosine Editor's note: Etripamil is still in development and these results are from a phase II clinical trial. References: Stambler BS, Dorian P, Sager PT, Wight D, Douville P, Potvin D, Shamszad P, Haberman RJ, Kuk RS, Lakkireddy DR, Teixeira JM, Bilchick KC, Damle RS, Bernstein RC, Lam WW, O'Neill G, Noseworthy PA, Venkatachalam KL, Coutu B, Mondésert B, Plat F. Etripamil Nasal Spray for Rapid Conversion of Supraventricular Tachycardia to Sinus Rhythm. J Am Coll Cardiol. 2018 Jul 31;72(5):489-497. doi: 10.1016/j.jacc.2018.04.082. PubMed PMID: 30049309. Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Author: Don Stader, MD Educational Pearls: Vertebral artery dissection (VAD) contributes to just 2% of strokes overall but ~25% of strokes for patients VAD is associated with minor trauma (chiropractic manipulation, yoga), typically with neck extension and rotation. VAD can cause posterior stroke symptoms (vertigo, diplopia, Horner's Syndrome, Wallenberg Syndrome) Overall a good prognosis with around 50% of patients recovering without lasting neurologic deficits. References: Debette S, Leys D. Cervical-artery dissections: predisposing factors, diagnosis, and outcome. Lancet Neurol. 2009 Jul;8(7):668-78. doi: 10.1016/S1474-4422(09)70084-5. Review. PubMed PMID: 19539238. Gottesman RF, Sharma P, Robinson KA, et al. Clinical characteristics of symptomatic vertebral artery dissection: a systematic review. Neurologist. 2012;18(5):245-54. Schievink WI. Spontaneous dissection of the carotid and vertebral arteries. N Engl J Med. 2001 Mar 22;344(12):898-906. Review. PubMed PMID: 11259724. Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Author: Katie Sprinkle, MD Educational Pearls: Hyponatremia results when patients over hydrate and dilute their sodium with too much free water Symptoms of hyponatremia can mimic symptoms of dehydration (dizziness, lightheadedness, general malaise) With severe hyponatremia patients can progress to seizure, coma, and death Hypernatremia results from dehydration and is more common References: Bennett BL, Hew-Butler T, Hoffman MD, Rogers IR, Rosner MH; Wilderness Medical Society.. Wilderness Medical Society practice guidelines for treatment of exercise-associated hyponatremia: 2014 update. Wilderness Environ Med. 2014 Dec;25(4 Suppl):S30-42. doi: 10.1016/j.wem.2014.08.009. PubMed PMID: 25498260. Braun MM, Barstow CH, Pyzocha NJ. Diagnosis and management of sodium disorders: hyponatremia and hypernatremia. Am Fam Physician. 2015 Mar 1;91(5):299-307. PubMed PMID: 25822386. Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Author: Aaron Lessen, MD Educational Pearls: Defined as QRS over 120 ms and rate over 120 Two major rhythms = Vetricular tachycardia (VT) or SVT with aberrancy Safest approach is to assume it is VT Synchronized Cardioversion is preferred even for stable VT for multiple reasons including safety and efficacy Procainamide is preferred pharmacologic option Amiodarone is less preferred third option Calcium channel blockers (i.e. diltiazem) can worsen certain rhythms and should be avoided References: Long B, Koyfman A. Best Clinical Practice: Emergency Medicine Management of Stable Monomorphic Ventricular Tachycardia. J Emerg Med. 2017 Apr;52(4):484-492. doi: 10.1016/j.jemermed.2016.09.010. Epub 2016 Oct 15. Review. PubMed PMID: 27751700. Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Author: Ryan Circh, MD Educational Pearls: Myofascial pain syndrome (MFPS) is typically unilateral with discrete points of palpable pain Often secondary to repeated use and poor posture. MFPS typically responds very well to trigger point injections. Fibromyalgia is bilateral and diffuse and is thought to have a psychological component Some of the best pharmacological treatments for fibromyalgia are Tramadol and Flexeril References: Tofferi JK, Jackson JL, O'Malley PG. Treatment of fibromyalgia with cyclobenzaprine: A meta-analysis. Arthritis Rheum. 2004 Feb 15;51(1):9-13. PubMed PMID: 14872449. Goldenberg DL, Burckhardt C, Crofford L. Management of fibromyalgia syndrome. JAMA. 2004 Nov 17;292(19):2388-95. Review. PubMed PMID: 15547167. Giamberardino MA, Affaitati G, Fabrizio A, Costantini R. Myofascial pain syndromes and their evaluation. Best Pract Res Clin Rheumatol. 2011 Apr;25(2):185-98. doi: 10.1016/j.berh.2011.01.002. Review. PubMed PMID: 22094195. Borg-Stein J, Iaccarino MA. Myofascial pain syndrome treatments. Phys Med Rehabil Clin N Am. 2014 May;25(2):357-74. doi: 10.1016/j.pmr.2014.01.012. Epub 2014 Mar 17. Review. PubMed PMID: 24787338 Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Author: Dylan Luyten, MD Educational Pearls: Symptoms of acute limb ischemia are the 5 P's: Pulselessness, pain, pallor, paresthesias, and poikilothermia Sudden onset of non-traumatic extremity pain should raise concern for this diagnosis Obtaining an ankle brachial index (ABI) can help confirm the diagnosis Consultation with vascular surgery should be immediately after the clinical diagnosis and before any further delays to obtain further imaging References: Santistevan JR. Acute Limb Ischemia: An Emergency Medicine Approach. Emerg Med Clin North Am. 2017 Nov;35(4):889-909. doi: 10.1016/j.emc.2017.07.006. Epub 2017 Aug 23. Review. PubMed PMID: 28987435. Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Author: Katie Sprinkle, MD Educational Pearls: The fascia iliaca block is useful for hip and proximal femur fractures. Typically involves injecting 40-60 mL of diluted bupivacaine (0.25%) under the fascia iliaca (or other anesthetic) Anesthesia is achieved of the femoral, obturator, and lateral femoral cutaneous nerves. Monitor for signs of bupivacaine toxicity (paresthesias, AMS, seizures, arrhythmias) Intralipid can be an effective treatment for life-threatening toxicity References: Hoegberg LC, Bania TC, Lavergne V, Bailey B, Turgeon AF, Thomas SH, Morris M, Miller-Nesbitt A, Mégarbane B, Magder S, Gosselin S; Lipid Emulsion Workgroup.. Systematic review of the effect of intravenous lipid emulsion therapy for local anesthetic toxicity. Clin Toxicol (Phila). 2016 Mar;54(3):167-93. doi: 10.3109/15563650.2015.1121270. Epub 2016 Feb 6. Review. PubMed PMID: 26853119. https://www.acepnow.com/article/control-hip-fracture-pain-without-opioids-using-ultrasound-guided-fascia-iliaca-compartment-block/?singlepage=1&theme=print-friendly Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Author: Aaron Lessen, MD Educational Pearls: Patients with "minor" strokes with NIHSS 0 to 5 can still end up having poor long-term outcomes Recent study compared use of alteplase vs. aspirin for these patients and saw no difference in regards to favorable neurologic outcome at 90 days Study was ended early due to patient recruitment difficulties Editor's note: though ended early, it is debatable whether even if appropriately powered there would have been an identifiable benefit References: Khatri P, Kleindorfer DO, Devlin T, Sawyer RN Jr, Starr M, Mejilla J, Broderick J, Chatterjee A, Jauch EC, Levine SR, Romano JG, Saver JL, Vagal A, Purdon B, Devenport J, Pavlov A, Yeatts SD; PRISMS Investigators. Effect of Alteplase vs Aspirin on Functional Outcome for Patients With Acute Ischemic Stroke and Minor Nondisabling Neurologic Deficits: The PRISMS Randomized Clinical Trial. JAMA. 2018 Jul 10;320(2):156-166. doi: 10.1001/jama.2018.8496. PubMed PMID: 29998337. Summary by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Author: Dylan Luyten, MD Educational Pearls: Early recognition that the current situation is a mass casualty incident (MCI) is essential with establishing a sole provider/nurse to oversee Team members labeling themselves by name and role is also helpful Practice and prepare for these unfortunate events Editor's note: This podcast comes at the end of a MCI drill over several days References: http://epmonthly.com/article/not-heroes-wear-capes-one-las-vegas-ed-saved-hundreds-lives-worst-mass-shooting-u-s-history/ Summary by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Author: Aaron Lessen, MD Educational Pearls: Retrospective study looking at type of transportation and mortality outcomes for patients with penetrating trauma Mortality was 2.2 % for those brought in by private vehicle compared to 11.6% by EMS Editor's note: the above is raw mortality - even after risk adjustments the odds ratio of death was statistically significant for penetrating injuries, which held true even over multiple trauma systems. Shout out to Dr Haut as well! References: Wandling MW, Nathens AB, Shapiro MB, Haut ER. Association of Prehospital Mode of Transport With Mortality in Penetrating Trauma: A Trauma System-Level Assessment of Private Vehicle Transportation vs Ground Emergency Medical Services. JAMA Surg. 2018 Feb 1;153(2):107-113. doi: 10.1001/jamasurg.2017.3601. PubMed PMID: 28975247; PubMed Central PMCID: PMC5838586. Summary by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Author: Nick Hatch, MD Educational Pearls: Quick review on typical treatments for acute CHF: Nitrates are a mainstay to reduce preload Furosemide has fallen out of favor in regards to urgency but still essential; it can also be utilized in those with poor renal function Before going into the weeds: Phlebotomy can be used to remove volume and may be helpful in certain clinical scenarios Trapping venous blood by using blood pressure cuffs on three of four extremities was a very early treatment of CHF References: Alzahri MS, Rohra A, Peacock WF. Nitrates as a Treatment of Acute Heart Failure. Card Fail Rev. 2016 May;2(1):51-55. doi: 10.15420/cfr.2016:3:3. PubMed PMID: 28785453; PubMed Central PMCID: PMC5490950. Paterna S, Di Gaudio F, La Rocca V, Balistreri F, Greco M, Torres D, Lupo U, Rizzo G, di Pasquale P, Indelicato S, Cuttitta F, Butler J, Parrinello G. Hypertonic Saline in Conjunction with High-Dose Furosemide Improves Dose-Response Curves in Worsening Refractory Congestive Heart Failure. Adv Ther. 2015 Oct;32(10):971-82. doi: 10.1007/s12325-015-0254-9. Epub 2015 Oct 31. PubMed PMID: 26521190; PubMed Central PMCID: PMC4635178. Huijskes RV, Hoogenberg K, Wiesfeld AC, Pijl ME, van Gelder IC. Phlebotomies as a treatment of serious heart failure due to haemochromatosis: a case report. Neth Heart J. 2009;17(11):438-41. Burch, George E., and Nicholas P. DePasquale. "Congestive Heart Failure—Acute Pulmonary Edema." JAMA 208.10 (1969): 1895-1897. Summary by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Author: Don Stader, MD Educational Pearls: Recent study showed efficacy 5mg IM midazolam > 10mg IM olanzapine > 10mg IM haloperidol for quickly sedating an agitated patient If you have access, ketamine intravenous is the fastest Olanzapine should be used with caution in elderly patients because of its anticholinergic properties Ketamine can transiently worsen psychosis in some mental illness Haloperidol is contraindicated in patients with prolonged QT Olanzapine can be safely given intravenous as another option to your sedating arsenal References: Klein LR, Driver BE, Miner JR, Martel ML, Hessel M, Collins JD, Horton GB, Fagerstrom E, Satpathy R, Cole JB. Intramuscular Midazolam, Olanzapine, Ziprasidone, or Haloperidol for Treating Acute Agitation in the Emergency Department. Ann Emerg Med. 2018 Oct;72(4):374-385. doi: 10.1016/j.annemergmed.2018.04.027. Epub 2018 Jun 7. PubMed PMID: 29885904. Chew ML, Mulsant BH, Pollock BG, Lehman ME, Greenspan A, Kirshner MA, Bies RR, Kapur S, Gharabawi G. A model of anticholinergic activity of atypical antipsychotic medications. Schizophr Res. 2006 Dec;88(1-3):63-72. Epub 2006 Aug 22. PubMed PMID: 16928430. Mankowitz SL, Regenberg P, Kaldan J, Cole JB. Ketamine for Rapid Sedation of Agitated Patients in the Prehospital and Emergency Department Settings: A Systematic Review and Proportional Meta-Analysis. J Emerg Med. 2018 Nov;55(5):670-681. doi: 10.1016/j.jemermed.2018.07.017. Epub 2018 Sep 7. PubMed PMID: 30197153. Summary by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Author: Don Stader, MD Educational Pearls: Three options for a blister in partial thickness burns: do nothing, unroof it, or poke a hole in it Recent study suggest that aspirating the blister may be more effective in regards to wound healing The overlying skin acts as a bio-band-aid and patients recover slightly faster References: Ro HS, Shin JY, Sabbagh MD, Roh SG, Chang SC, Lee NH. Effectiveness of aspiration or deroofing for blister management in patients with burns: A prospective randomized controlled trial. Medicine (Baltimore). 2018 Apr;97(17):e0563. doi: 10.1097/MD.0000000000010563. PubMed PMID: 29703044; PubMed Central PMCID: PMC5944508. Summary by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Author: Don Stader, MD Educational Pearls: Intravenous Tylenol currently is many times more expensive than oral Single ED study comparing the two has methodology flaws and there is a lack of additional evidence to support intravenous over oral formulations solely for pain control Oral Tylenol appears to be at least equally efficacious, though with a slightly slower onset of action 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. Jibril F, Sharaby S, Mohamed A, Wilby KJ. Intravenous versus Oral Acetaminophen for Pain: Systematic Review of Current Evidence to Support Clinical Decision-Making. Can J Hosp Pharm. 2015 May-Jun;68(3):238-47. Review. PubMed PMID: 26157186; PubMed Central PMCID: PMC4485512. Summary by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Author: Don Stader, MD Educational Pearls: Recent study has revealed that infant walkers are more harmful than helpful Infant walkers can also delay motor function The American Academy of Pediatrics calls for a ban on walkers as they are a preventable cause of injury References: Siegel AC, Burton RV. (1999).Effects of baby walkers on motor and mental development in human infants. Journal of Developmental and Behavioral Pediatrics. 20:355–361. Sims A, et al. (2018). Infant Walker-Related Injuries in United States. Pediatrics 142(4). Summary by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Author: Sam Killian, MD Educational Pearls: Recent news articles are showing an increase in injuries related to riding electric scooters Year-to-year, scooter injuries have increased as high as three to four times More definitive evidence still to come Editor's note: don't follow birdgraveyard on instagram References: https://www.washingtonpost.com/business/economy/scooter-use-is-rising-in-major-cities-so-are-trips-to-the-emergency-room/2018/09/06/53d6a8d4-abd6-11e8-a8d7-0f63ab8b1370_story.html?noredirect=on&utm_term=.a6e46ff35bdc https://kutv.com/news/local/er-doctors-report-161-increase-in-scooter-injuries-in-downtown-salt-lake-city Summary by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Author: Mark Hinton, MD Educational Pearls: Meniscus lock can occur with a tear leading to inability to extend the knee Treatment can include an intra-articular joint block followed by straightening Medial meniscus injuries are more common References: Allum RL, Jones JR. The locked knee. Injury. 1986 Jul;17(4):256-8. PubMed PMID: 3770920. Critchley IJ, Bracey DJ. The acutely locked knee--is a manipulation worth while? Injury. 1985 Jan;16(4):281-3. PubMed PMID: 3967919. Summary by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Educational Pearls: RSI includes induction agent (sedative) and a paralytic Succinylcholine is a depolarizing paralytic of rapid onset and short duration with contraindications in hyperkalemic states and muscular dystrophy Rocuronium and vecuronium are longer acting, non-depolarizing paralytic, more commonly Common induction agents are etomidate and ketamine Ketamine can be particularly beneficial for bronchodilator effects in those with reactive airway disease References: Stollings JL, Diedrich DA, Oyen LJ, Brown DR. Rapid-sequence intubation: a review of the process and considerations when choosing medications. Ann Pharmacother. 2014 Jan;48(1):62-76. doi: 10.1177/1060028013510488. Epub 2013 Nov 4. Review. PubMed PMID: 24259635. Summary by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Author: Gretchen Hinson, MD Educational Pearls: Diagnosis can be difficult and often delayed Asymmetric breath sounds, choking, stridor may be present, but children also present asymptomatically Peak incidence around one to two years of age Hot dogs, nuts, popcorn – round and smooth objects are most commonly aspirated References: Green SS. Ingested and Aspirated Foreign Bodies. Pediatr Rev. 2015 Oct;36(10):430-6. doi: 10.1542/pir.36-10-430. Review. PubMed PMID: 26430203. Sink JR, Kitsko DJ, Georg MW, Winger DG, Simons JP. Predictors of Foreign Body Aspiration in Children. Otolaryngol Head Neck Surg. 2016 Sep;155(3):501-7. doi: 10.1177/0194599816644410. Epub 2016 Apr 12. PubMed PMID: 27071446. Summary by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Author: Dylan Luyten, MD Educational Pearls: Extracorporeal membrane oxygenation (ECMO) is similar to bypass ECMO is being utilized routinely at some centers and even prehospital in cardiac arrest There are two general types of ECMO: Venovenous (VV-ECMO) is useful when the patient cannot oxygenate but has adequate heart function. Venoarterial (VA-ECMO) is more like typical bypass and can be used in a pulseless patient References: Ouweneel DM, Schotborgh JV, Limpens J, Sjauw KD, Engström AE, Lagrand WK, Cherpanath TGV, Driessen AHG, de Mol BAJM, Henriques JPS. Extracorporeal life support during cardiac arrest and cardiogenic shock: a systematic review and meta-analysis. Intensive Care Med. 2016 Dec;42(12):1922-1934. doi: 10.1007/s00134-016-4536-8. Epub 2016 Sep 19. Review. PubMed PMID: 27647331; PubMed Central PMCID: PMC5106498. Tonna JE, Johnson NJ, Greenwood J, Gaieski DF, Shinar Z, Bellezo JM, Becker L, Shah AP, Youngquist ST, Mallin MP, Fair JF 3rd, Gunnerson KJ, Weng C, McKellar S; Extracorporeal REsuscitation ConsorTium (ERECT) Research Group.. Practice characteristics of Emergency Department extracorporeal cardiopulmonary resuscitation (eCPR) programs in the United States: The current state of the art of Emergency Department extracorporeal membrane oxygenation (ED ECMO). Resuscitation. 2016 Oct;107:38-46. doi: 10.1016/j.resuscitation.2016.07.237. Epub 2016 Aug 11. PubMed PMID: 27523953; PubMed Central PMCID: PMC5475402. Summary by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Author: Michael Hunt, MD Educational Pearls: Alcohol and gallstones are most common causes of pancreatitis Diagnosis is not simply based on lipase alone - must have at least two the the three criteria: Elevated lipase (greater than 3x upper limit of reference range) Typical pain (epigastric pain, radiating to back, etc.) Radiographic findings suggestive of pancreatitis (CT, MRI, US) BISAP criteria can help risk stratify mortality in pancreatitis. You get 1 point for each of the following: BNP > 25 Impaired mental status SIRS criteria, more than 2 AGE > 60 Pleural effusion BISAP score of 0 has Editor's note: The severity of pancreatitis does not correlate with serum lipase levels - notice how it is not used in the BISAP criteria, as an example. Even a mild elevation in serum testing can result in severe pancreatitis. References: Banks PA, Bollen TL, Dervenis C, Gooszen HG, Johnson CD, Sarr MG, Tsiotos GG, Vege SS; Acute Pancreatitis Classification Working Group.. Classification of acute pancreatitis--2012: revision of the Atlanta classification and definitions by international consensus. Gut. 2013 Jan;62(1):102-11. doi: 10.1136/gutjnl-2012-302779. Epub 2012 Oct 25. PubMed PMID: 23100216. Papachristou GI, Muddana V, Yadav D, O'Connell M, Sanders MK, Slivka A, Whitcomb DC. Comparison of BISAP, Ranson's, APACHE-II, and CTSI scores in predicting organ failure, complications, and mortality in acute pancreatitis. Am J Gastroenterol. 2010 Feb;105(2):435-41; quiz 442. doi: 10.1038/ajg.2009.622. Epub 2009 Oct 27. PubMed PMID: 19861954. Wu BU, Johannes RS, Sun X, Tabak Y, Conwell DL, Banks PA. The early prediction of mortality in acute pancreatitis: a large population-based study. Gut. 2008 Dec;57(12):1698-703. doi: 10.1136/gut.2008.152702. Epub 2008 Jun 2. PubMed PMID: 18519429.

Author: Erik Verzemnieks, MD Educational Pearls: Recent study provides at least some evidence to help predict antibiotic failure for cellulitis, which is not necessarily straight forward Intuitive risk factors such as recent cellulitis, chronic ulcers, history of MRSA are associated with antibiotic treatment failure Oddly, tachypnea at triage was associated with the highest odds ratio for treatment failure References: Yadav K, Suh KN, Eagles D, MacIsaac J, Ritchie D, Bernick J, Thiruganasambandamoorthy V, Wells G, Stiell IG. Predictors of Oral Antibiotic Treatment Failure for Nonpurulent Skin and Soft Tissue Infections in the Emergency Department. Acad Emerg Med. 2018 Jun 5. doi: 10.1111/acem.13492. Summarized and edited by Erik Verzemnieks, MD

Author: Aaron Lessen, MD Educational Pearls: Injuries from penetrating pharyngeal trauma are often subtle on examination in children Potentially serious complications including carotid artery injury, mediastinitis from spreading infection, or airway compromise from hematoma formation Imaging choice is typically CTA to assess for vascular injuries These injuries may require antibiotics References: Zonfrillo MR, Roy AD, Walsh SA. Management of pediatric penetrating oropharyngeal trauma. Pediatr Emerg Care. 2008 Mar;24(3):172-5. doi: 10.1097/PEC.0b013e3181669072. PubMed PMID: 18347498. Sasaki T, Toriumi S, Asakage T, Kaga K, Yamaguchi D, Yahagi N. The toothbrush: a rare but potentially life-threatening cause of penetrating oropharyngeal trauma in children. Pediatrics. 2006 Oct;118(4):e1284-6. PubMed PMID: 17015515. Summary by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Author: Rachel Brady, MD Educational Pearls: Hypercalcemia of malignancy: Hypercalcemia of malignancy can present with lethargy, muscle weakness, hyperreflexia, altered mental status, cardiac dysrhythmias, and even cardiac arrest. Treatment is based both on calcium level and symptoms Intravenous rehydration is first line treatment Other options include steroids, bisphosphonates and calcitonin. Tumor Lysis Syndrome Occurs due to the breakdown of tumor cells after chemotherapy/radiation Presents as hyperkalemia, hyperuricemia, hyperphosphatemia, and hypocalcemia Treatment is very similar to severe hypercalcemia - hydration with crystalloids Hyperuricemia can be treated using rasburicase or allopurinol References: Ñamendys-Silva SA, Arredondo-Armenta JM, Plata-Menchaca EP, Guevara-García H, García-Guillén FJ, Rivero-Sigarroa E, Herrera-Gómez A. Tumor lysis syndrome in the emergency department: challenges and solutions. Open Access Emerg Med. 2015 Aug 20;7:39-44. doi: 10.2147/OAEM.S73684. eCollection 2015. Review. PubMed PMID: 27147889; PubMed Central PMCID: PMC4806807. Zagzag J, Hu MI, Fisher SB, Perrier ND. Hypercalcemia and cancer: Differential diagnosis and treatment. CA Cancer J Clin. 2018 Sep;68(5):377-386. doi: 10.3322/caac.21489. Epub 2018 Sep 21. Review. PubMed PMID: 30240520. Summary by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Author: Aaron Lessen, MD Educational Pearls: In patients without indications for aspirin, three recent studies looked at prevention of several end points in the elderly These showed no benefit in preventing cardiovascular events (stroke, MI, hear failure), disability, or death in elderly These studies also demonstrated higher mortality and increased bleeding risk in patients who were taking aspirin without clear indications Editor's note: the increased all cause mortality is intriguing - but attributed to an increase in cancer mortality. Unclear why but will be important to see if this trend is seen in other studies. References: McNeil JJ, Woods RL, Nelson MR, et al., on behalf of the ASPREE Investigator Group. Effect of Aspirin on Disability-free Survival in the Healthy Elderly. N Engl J Med. 2018 Oct 18;379(16):1499-1508. doi: 10.1056/NEJMoa1800722. Epub 2018 Sep 16. PubMed PMID: 30221596. McNeil JJ, Woods RL, Nelson MR, et al., on behalf of the ASPREE Investigator Group. Effect of Aspirin on Cardiovascular Events and Bleeding in the Healthy Elderly. N Engl J Med. 2018 Oct 18;379(16):1509-1518. doi: 10.1056/NEJMoa1805819. Epub 2018 Sep 16. PubMed PMID: 30221597. McNeil JJ, Woods RL, Nelson MR, et al., on behalf of the ASPREE Investigator Group. Effect of Aspirin on All-Cause Mortality in the Healthy Elderly. N Engl J Med. 2018 Oct 18;379(16):1519-1528. doi: 10.1056/NEJMoa1803955. Epub 2018 Sep 16. PubMed PMID: 30221595. Summary by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Author: Katie Sprinkle, MD Educational Pearls: Medication Assisted Treatment (MAT) is the treatment of addiction with medications, commonly used for opioid use disorders A long held belief is MAT simply replaces one addiction for another, which is patently false MAT is one of the most affective methods to treat a patient with opioid addiction Unfortunately, outdated requirements for prescribers along further prevent its widespread use References: Salsitz E, Wiegand T. Pharmacotherapy of Opioid Addiction: "Putting a Real Face on a False Demon." Journal of Medical Toxicology. 2016;12(1):58-63. doi:10.1007/s13181-015-0517-5. Duber HC, Barata IA, Cioè-Peña E, Liang SY, Ketcham E, Macias-Konstantopoulos W, Ryan SA, Stavros M, Whiteside LK. Identification, Management, and Transition of Care for Patients With Opioid Use Disorder in the Emergency Department. Ann Emerg Med. 2018 Oct;72(4):420-431. doi: 10.1016/j.annemergmed.2018.04.007. Epub 2018 Jun 5. Review. PubMed PMID: 29880438. Summary by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Author: Peter Bakes, MD Educational Pearls: Important historical information to elicit is the birth history, feeding habits, stooling habits, associated symptoms, presence of bile, and presence of trauma. Volvulus is a common etiology of intestinal obstruction and is often due to malrotation in utero. Editor's note: get an upper GI series if there is any bilious vomiting in a neonate. Any time of the night. Wake people up. Transfer if necessary to get the study. This can diagnose volvulus and save bowel. References: Ratnayake K, Kim TY. Evidence-based management of neonatal vomiting in the emergency department. Pediatr Emerg Med Pract. 2014 Nov;11(11):1-20; Review. PubMed PMID: 25928976. Burge DM. The management of bilious vomiting in the neonate. Early Hum Dev. 2016 Nov;102:41-45. doi: 10.1016/j.earlhumdev.2016.09.002. Epub 2016 Sep 12. Review. PubMed PMID: 27634337. Summary by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Author: Jared Scott, MD Educational Pearls: Interest started as it was noticed soldiers who had wounds infected with maggots had better outcomes than those without maggots Studies have shown that wound care with maggots is essentially equivalent to traditional therapy with oxygen, antibiotics, and debridement Maggots debride the wound with proteolytic enzymes, sterilize the wound, and stimulate wound healing References: Sherman RA. Maggot therapy takes us back to the future of wound care: new and improved maggot therapy for the 21st century. J Diabetes Sci Technol. 2009 Mar 1;3(2):336-44. Review. PubMed PMID: 20144365; PubMed Central PMCID: PMC2771513. Baer WS. The treatment of chronic osteomyelitis with the maggot (larva of the blow fly) J Bone & Joint Surg. 1931;13:438–475. DOI: 10.1007/s11999-010-1416-3 Summary by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Author: Peter Bakes, MD Educational Pearls: Necrotizing fasciitis is an infection of the deep soft tissues with destruction of the muscle fascia and overlying fat Think of it if pain is out of proportion to your exam Polymicrobial and Clostridium species typically cause condition in susceptible individuals (immunocompromised, diabetics, obese, penetrating injury) Group A strep typically is less specific and can cause necrotizing infections in otherwise healthy individuals Treatment is typically rapid surgical debridement in addition to broad spectrum antibiotics in addition to clindamycin References: Breyre A, Frazee BW. Skin and Soft Tissue Infections in the Emergency Department. Emerg Med Clin North Am. 2018 Nov;36(4):723-750. doi: 10.1016/j.emc.2018.06.005. Review. PubMed PMID: 30297001. Stevens DL, Bryant AE. Necrotizing Soft-Tissue Infections. N Engl J Med. 2017 Dec 7;377(23):2253-2265. doi: 10.1056/NEJMra1600673. Review. PubMed PMID: 29211672. Summary by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Author: Gretchen Hinson, MD Educational Pearls: Reasonable approach of haloperidol 10 mg IM (or 5 mg IV) for pain relief in opioid-dependent patients; can repeat once Chronic opioid use results in hyperalgesia and a narrow therapeutic window in the long-term so alternatives are essential Consider the risk of QTc prolongation with haloperidol, particularly if the patient is on other drugs that may do so Editor's note: Interested in more alternatives to opioids? Check out the Colorado ACEP Opioid Prescribing & Treatment Guidelines and the impact these have had in Colorado References: http://ercast.libsyn.com/haloperidol-for-analgesia Ramirez R, Stalcup P, Croft B, Darracq MA. Haloperidol undermining gastroparesis symptoms (HUGS) in the emergency department. Am J Emerg Med. 2017 Aug;35(8):1118-1120. doi: 10.1016/j.ajem.2017.03.015. Epub 2017 Mar 12. PubMed PMID: 28320545. Seidel S, Aigner M, Ossege M, Pernicka E, Wildner B, Sycha T. Antipsychotics for acute and chronic pain in adults. Cochrane Database Syst Rev. 2013 Aug 29;(8):CD004844. doi: 10.1002/14651858.CD004844.pub3. Review. PubMed PMID: 23990266.

Educational Pearls: BRUE (Brief Resolved Unexplained Event) replaces what was previously called ALTE BRUE describes an event in a child less than one year of age with one or more of the following: cyanosis or pallor absent, decreased, or irregular breathing decreased or increased tone altered responsiveness These must be sudden, brief, and now resolved and without an alternative explanation after a history and physical exam Low risk patients can be safely discharged with reassurance Low risk criteria must all be present: Age over 60 days old >32 weeks gestational age at birth and adjusted gestational age > 45 weeks) No CPR was performed (by a trained medical professional) First event Duration less than 1 minute of event Patients who satisfy above criteria can be considered low risk and may be discharged after minimal/no workup References: Tieder JS, Bonkowsky JL, Etzel RA, et al. Clinical Practice Guideline: Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants: Executive Summary. Pediatrics. 2016:137(5):e20160591. Pediatrics. 2016 Aug;138(2). pii: e20161488. doi: 10.1542/peds.2016-1488. PubMed PMID: 27474017. Summary by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Author: Aaron Lessen, MD Educational Pearls: 5-year follow up study on antibiotic treatment for uncomplicated appendicitis showed 39.1% recurrence rate requiring appendectomy by 5 years Nearly 60% chance then of preventing an appendectomy by using antibiotics only for uncomplicated appendicitis Editor's note: not surprisingly, complications were much higher in the group receiving surgery, which reiterates why an antibiotic-only approach is attractive for the right patient population References: Salminen P, Tuominen R, Paajanen H, Rautio T, Nordström P, Aarnio M, Rantanen T, Hurme S, Mecklin JP, Sand J, Virtanen J, Jartti A, Grönroos JM. Five-Year Follow-up of Antibiotic Therapy for Uncomplicated Acute Appendicitis in the APPAC Randomized Clinical Trial. JAMA. 2018 Sep 25;320(12):1259-1265. doi: 10.1001/jama.2018.13201. PubMed PMID: 30264120. Summary by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Author: Don Stader, MD Educational Pearls: Fluoroquinolones can cause connective tissue disruption leading not only to tendon rupture but also aortic dissection Retrospective study from Taiwan showed over a 2x higher rate of dissection when exposed to fluoroquinolones (1.6% vs 0.6%) Remember to think about aortic dissection when you have a patient with chest pain that travels and/or involves neurologic symptoms Try to use fluoroquinolones when no other appropriate antibiotic exists as they have significant other side effects as well Editor's note: In July 2018, the FDA required strengthening of warning labels on fluoroquinolones about the risks of mental health effects and hypoglycemia References: Lee CC, Lee MG, Hsieh R, Porta L, Lee WC, Lee SH, Chang SS. Oral Fluoroquinolone and the Risk of Aortic Dissection. J Am Coll Cardiol. 2018 Sep 18;72(12):1369-1378. doi: 10.1016/j.jacc.2018.06.067. PubMed PMID: 30213330. Khaliq Y, Zhanel GG. Fluoroquinolone-associated tendinopathy: a critical review of the literature. Clin Infect Dis. 2003 Jun 1;36(11):1404-10. Epub 2003 May 20. Review. PubMed PMID: 12766835. https://www.fda.gov/downloads/Drugs/DrugSafety/UCM612834.pdf Summary by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Author: Kasey Champion, MD Educational Pearls: Transgender populations are frequent victims of discrimination in healthcare Ask transgender patients what their preferred pronoun is It is sometimes important to ask about transition status (i.e. on hormones, surgery) References: Chisolm-Straker M, Willging C, Daul AD, McNamara S, Sante SC, Shattuck DG 2nd, Crandall CS. Transgender and Gender-Nonconforming Patients in the Emergency Department: What Physicians Know, Think, and Do. Ann Emerg Med. 2018 Feb;71(2):183-188.e1. doi: 10.1016/j.annemergmed.2017.09.042. Epub 2017 Nov 3. PubMed PMID: 29103796.

Author: John Winkler, MD Educational Pearls: Probiotics are bacteria that are ingested to promote gut health but recent research casts doubt on their effectiveness. Recent study suggests that most probiotics that are ingested are killed by stomach acid. Those that remain are not very healthy and are outcompeted by the normal gut flora. Probiotics should not be given as a one-size-fits-all treatment. References: Zmora N, Zilberman-Schapira G, Suez J, Mor U, Dori-Bachash M, Bashiardes S, Kotler E, Zur M, Regev-Lehavi D, Brik RB, Federici S, Cohen Y, Linevsky R, Rothschild D, Moor AE, Ben-Moshe S, Harmelin A, Itzkovitz S, Maharshak N, Shibolet O, Shapiro H, Pevsner-Fischer M, Sharon I, Halpern Z, Segal E, Elinav E. Personalized Gut Mucosal Colonization Resistance to Empiric Probiotics Is Associated with Unique Host and Microbiome Features. Cell. 2018 Sep 6;174(6):1388-1405.e21. doi: 10.1016/j.cell.2018.08.041. PubMed PMID: 30193112.

Author: Don Stader, MD Educational Pearls: Recent study suggests we may not need to drain uncomplicated peritonsillar abscesses Patients who received medical therapy alone had no difference in complications and failure compared to those who received surgical drainage plus medical therapy Medical therapy in study was ceftriaxone, clindamycin, and dexamethasone Medical therapy was also associated with fewer opioid prescriptions, sore days, and days off from work. References: Battaglia A, Burchette R, Hussman J, Silver MA, Martin P, Bernstein P. Comparison of Medical Therapy Alone to Medical Therapy with Surgical Treatment of Peritonsillar Abscess. Otolaryngol Head Neck Surg. 2018 Feb;158(2):280-286. doi: 10.1177/0194599817739277. Epub 2017 Nov 7. PubMed PMID: 29110574.

Author: Sam Killian, MD Educational Pearls: Two high quality randomized control trials published in 2018 demonstrated no difference in mortality or neurologic outcomes when using a supraglottic airway compared to endotracheal intubation in out of hospital cardiac arrest These two trials enrolled over a combined 12000 patients Supraglottic airways have a higher success rate than intubations References: Benger JR, Kirby K, Black S, Brett SJ, Clout M, Lazaroo MJ, Nolan JP, Reeves BC, Robinson M, Scott LJ, Smartt H, South A, Stokes EA, Taylor J, Thomas M, Voss S, Wordsworth S, Rogers CA. Effect of a Strategy of a Supraglottic Airway Device vs Tracheal Intubation During Out-of-Hospital Cardiac Arrest on Functional Outcome: The AIRWAYS-2 Randomized Clinical Trial. JAMA. 2018 Aug 28;320(8):779-791. doi: 10.1001/jama.2018.11597. PubMed PMID: 30167701 Wang HE, Schmicker RH, Daya MR, Stephens SW, Idris AH, Carlson JN, Colella MR, Herren H, Hansen M, Richmond NJ, Puyana JCJ, Aufderheide TP, Gray RE, Gray PC, Verkest M, Owens PC, Brienza AM, Sternig KJ, May SJ, Sopko GR, Weisfeldt ML, Nichol G. Effect of a Strategy of Initial Laryngeal Tube Insertion vs Endotracheal Intubation on 72-Hour Survival in Adults With Out-of-Hospital Cardiac Arrest: A Randomized Clinical Trial. JAMA. 2018 Aug 28;320(8):769-778. doi: 10.1001/jama.2018.7044. PubMed PMID: 30167699.

Author: Ryan Circh, MD Educational Pearls: A "shoulder separation" is when the clavicle separates from the scapula - also referred to as an acromio-clavicular (AC) separation Diagnosis is clinical: pain over AC joint, pain with adduction, and difficulty raising harm past horizontal Early range of motion can be critical for recovery References: Lemos MJ. The evaluation and treatment of the injured acromioclavicular joint in athletes. Am J Sports Med. 1998 Jan-Feb;26(1):137-44. Review. PubMed PMID: 9474415. Monica J, Vredenburgh Z, Korsh J, Gatt C. Acute Shoulder Injuries in Adults. Am Fam Physician. 2016 Jul 15;94(2):119-27. Review. PubMed PMID: 27419328.