Emergency Medical Minute

Author: Michael Hunt, MD Educational Pearls: Bedside transtracheal ultrasound to confirm proper endotracheal intubation is simple and effective Review of 17 studies showed transtracheal ultrasound was was 98.7% sensitive and 97.1% specific Curvilinear probe may be preferable as it provides a larger field of view Editor's Note: rather than explain what you're looking for… just go here References: Gottlieb M, Holladay D, Peksa GD. Ultrasonography for the Confirmation of Endotracheal Tube Intubation: A Systematic Review and Meta-Analysis. Ann Emerg Med. 2018 Dec;72(6):627-636. doi: 10.1016/j.annemergmed.2018.06.024. Epub 2018 Aug 14. PubMed PMID: 30119943. Summarized and edited by Erik Verzemnieks, MD

Author: Aaron Lessen, MD Educational Pearls: Dyspnea can occur in up to 50% of intubated patients Dyspnea is associated with prolonged mechanical intubation Often goes undiagnosed as these patients have difficulty communicating Expert opinion on reducing sensation of dyspnea Reduce stimulation of respiratory drive like fever and acidosis Give bronchodilators for patients with wheezing Optimize the ventilator settings Use medications for comfort (i.e. opioids, benzodiazepines) References: Decavèle M, Similowski T, Demoule A. Detection and management of dyspnea in mechanically ventilated patients. Curr Opin Crit Care. 2019 Feb;25(1):86-94. doi: 10.1097/MCC.0000000000000574. PubMed PMID: 30531366. Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Author: Sue Chilton, MD Educational Pearls: Measles is highly contagious Typically patients just look sick Remember 4 & 4, 14, and 4-C's: Contagious 4 days before and after onset of rash 14 days for rash to appear Cough, coryza, conjunctivitis (non-purulent), and Koplik's spots Under 2 and over 20 are highest risk groups 1 in 1000 will die Subacute sclerosing panencephalitis is one of the most feared, degenerative, 100% fatal complications that can occur up to two decades after initial infection Editor's Note: Don't be pro-plague - if you can, vaccinate your children. References: https://www.denverpost.com/2019/01/16/denver-measles-exposure/ 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 and edited by Erik Verzemnieks, MD

Author: Jared Scott, MD Educational Pearls: CXR is 40-90% sensitive for detecting pneumonia when compared to CT Patients with a high degree of suspicion for pneumonia may still warrant treatment despite a negative CXR References: Self WH, Courtney DM, McNaughton CD, Wunderink RG, Kline JA. High discordance of chest x-ray and computed tomography for detection of pulmonary opacities in ED patients: implications for diagnosing pneumonia. Am J Emerg Med. 2013 Feb;31(2):401-5. doi: 10.1016/j.ajem.2012.08.041. Epub 2012 Oct 18. PubMed PMID: 23083885; PubMed Central PMCID: PMC3556231. Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Author: Don Stader, MD Educational Pearls: Recent study demonstrated patients with non-STEMI treated with heparin had no difference in survival, but had an increased risk of major bleeding Heparin may be an outdated medication in the era of dual anti-platelet therapy and PCI Heparin may fall to the wayside like other former treatments for ACS such as morphine, oxygen and nitroglycerin as far as mortality benefit References: Chen JY, He PC, Liu YH, Wei XB, Jiang L, Guo W, Duan CY, Guo YS, Yu XP, Li J, Li WS, Zhou YL, Lin CY, Luo JF, Yu DQ, Chen ZJ, Chen W, Chen YY, Guo ZQ, Geng QS, Tan N. Association of Parenteral Anticoagulation Therapy With Outcomes in Chinese Patients Undergoing Percutaneous Coronary Intervention for Non-ST-Segment Elevation Acute Coronary Syndrome. JAMA Intern Med. 2019 Feb 1;179(2):186-194. doi: 10.1001/jamainternmed.2018.5953. PubMed PMID: 30592483 Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Author: Katie Sprinkle, MD Educational Pearl: Carbon monoxide (CO) is the leading cause of death from poison world-wide CO forms from the combustion of any carbon based product Patients often present with non specific symptom like headache, vomiting, and malaise Consider this diagnosis with multiple people presenting with similar symptoms from a single location Treatment is with high flow oxygen (i.e. non-rebreather) Hyperbaric therapy is controversial and up for debate - discussion with local consultants may help guide this management/transfer Tobacco smokers typically have elevated levels of carbon monoxide at baseline Editor's Note: smoking hookah for one hour may be the equivalent of smoking nearly 100 cigarettes References: Jacob P, Abu Raddaha AH, Dempsey D, et al. Nicotine, carbon monoxide, and carcinogen exposure after a single use of a water pipe. Cancer Epidemiol Biomarkers Prev. 2011;20(11):2345-53. Ng PC, Long B, Koyfman A. Clinical chameleons: an emergency medicine focused review of carbon monoxide poisoning. Intern Emerg Med. 2018 Mar;13(2):223-229. doi: 10.1007/s11739-018-1798-x. Epub 2018 Feb 12. Review. Erratum in: Intern Emerg Med. 2018 Mar 22;:. PubMed PMID: 29435715. American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Carbon Monoxide Poisoning:., Wolf SJ, Maloney GE, Shih RD, Shy BD, Brown MD. Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Acute Carbon Monoxide Poisoning. Ann Emerg Med. 2017 Jan;69(1):98-107.e6. doi: 10.1016/j.annemergmed.2016.11.003. PubMed PMID: 27993310. Guzman JA. Carbon monoxide poisoning. Crit Care Clin. 2012 Oct;28(4):537-48. doi: 10.1016/j.ccc.2012.07.007. Review. PubMed PMID: 22998990. Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Author: Aaron Lessen, MD Educational Pearls: Several studies have shown administration of tPA can improve outcomes and reduce need for amputation tPA is considered in grade III and IV frostbite tPA cannot be given until after the warming process Administration is systemically, not catheter directed or intra-arterial References: Jones LM, Coffey RA, Natwa MP, Bailey JK. The use of intravenous tPA for the treatment of severe frostbite. Burns. 2017 Aug;43(5):1088-1096. doi: 10.1016/j.burns.2017.01.013. Epub 2017 Jan 31. PubMed PMID: 28159151. Wexler A, Zavala S. The Use of Thrombolytic Therapy in the Treatment of Frostbite Injury. J Burn Care Res. 2017 Sep/Oct;38(5):e877-e881. doi: 10.1097/BCR.0000000000000512. PubMed PMID: 28296671. Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Author: Aaron Lessen, MD Educational Pearl: A double ingestion of a single pill is typically a benign event but several drug classes may cause problems A published review of 10 years of single medication double dose ingestion found 12 out of 876 cases had adverse events. The drugs and events were: Propafenone ingestion leading to ventricular tachycardia Beta blocker ingestion leading to bradycardia and hypotension Calcium channel blocker leading to bradycardia and hypotension Bupropion ingestion leading to seizures Tramadol ingestion leading to ventricular tachycardia Editor's Note: References: Correia MS, Whitehead E, Cantrell FL, Lasoff DR, Minns AB. A 10-year review of single medication double-dose ingestions in the nation's largest poison control system. Clin Toxicol (Phila). 2019 Jan;57(1):31-35. doi: 10.1080/15563650.2018.1493205. Epub 2018 Nov 28. PubMed PMID: 30484705. Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Podcast # 437 : Myasthenia Gravis Author: Gretchen Hinson, MD Educational Pearls: Myasthenia gravis (MG) is an antibody mediated autoimmune disorder against the acetylcholine receptors at the neuromuscular junctions. Bimodal age distribution (20's-30's: women; 60's-70's: men) Presents with fluctuating muscle weakness typically worse at the end of the day with upper extremities affected more than lower and typically involving facial muscles. Myasthenia crisis occurs when muscle fatigue begins to cause respiratory depression MG was historically diagnosed with the Tensilon test but now often by EMG Treatment of MG crisis involves plasma exchange and IVIG. Those in crisis often require intubation and ICU admission References: Gilhus NE. Myasthenia Gravis. N Engl J Med. 2016 Dec 29;375(26):2570-2581. doi: 10.1056/NEJMra1602678. Review. PubMed PMID: 28029925. Roper J, Fleming ME, Long B, Koyfman A. Myasthenia Gravis and Crisis: Evaluation and Management in the Emergency Department. J Emerg Med. 2017 Dec;53(6):843-853. doi: 10.1016/j.jemermed.2017.06.009. Epub 2017 Sep 12. PubMed PMID: 28916122. Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Author: Charleen Gnisci, PharmD Educational Pearls: Between 2011 to 2016, Mylan increased EpiPen prices by 400% ($700 for 2 packs) AUVI-Q was recalled in 2012, which left the market share to the EpiPen until recently Teva announced last year it will be making a generic version of the EpiPen retailing around $300 but expected to decrease References: Kaplan, S. F.D.A. Approves Generic EpiPen That May Be Cheaper. The New York Times, The New York Times, 2018. Retrived from www.nytimes.com/2018/08/16/health/epipen-generic-drug-prices.html. Tirrell, M. FDA approves Teva's generic EpiPen after yearslong delay. 2018. Retrieved from https://www.cnbc.com/2018/08/16/fda-approves-tevas-generic-epipen-after-years-long-delay.html Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Author: Ryan Circh, MD Educational Pearls: Ulnar collateral ligament injury is often called gamekeeper's thumb or skier's thumb Can results from traumatic deviating the thumb radially (abduction) Poor rabbits Have a low threshold for referral to hand surgery for follow up - treatment for minor injuries can be conservative but more severe require surgery to preserve function This injury should be placed in a thumb spica splint Radiographs are often negative unless an avulsion fracture is present Editor's note: to test for UCL injuries, I like this. References: Schroeder NS, Goldfarb CA. Thumb ulnar collateral and radial collateral ligament injuries. Clin Sports Med. 2015 Jan;34(1):117-26. doi: 10.1016/j.csm.2014.09.004. Epub 2014 Oct 11. Review. PubMed PMID: 25455399. Madan SS, Pai DR, Kaur A, Dixit R. Injury to ulnar collateral ligament of thumb. Orthop Surg. 2014 Feb;6(1):1-7. doi: 10.1111/os.12084. Review. PubMed PMID: 24590986. Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Author: Peter Bakes, MD Educational Pearl: Transient ischemic attack (TIA) is defined as neurologic symptoms that resolve in 24 hours with no new changes on head imaging Mimics include complex migraine, carotid dissection, seizure (Todd's paralysis) Typical presentation is with sudden onset of negative symptoms such as numbness, weakness, etc. Mimics tend to have positive symptoms such as photophobia, pain, etc. References: Kernan WN, Ovbiagele B, Black HR, et al. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2014; 45:2160. Simmons B, et al. Transient Ischemic Attack: Part I. Diagnosis and Evaluation. American Family Physician 2012; 86(6):521-526. Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Author: Michael Hunt, MD Educational Pearls: Recent study compared ketamine to morphine in elderly patient Ketamine (IV dose 0.3 mg /kg) provided equivalent pain control to morphine (IV dose 0.1 mg / kg) However, etamine group had much higher rate of side effects, including psychoperceptual A lower does of 0.1 mg / kg given intravenously over 15 minutes might be a better option to start in the elderly population - you can always add more! References Motov S, Mann S, Drapkin J, Butt M, Likourezos A, Yetter E, Brady J, Rothberger N, Gohel A, Flom P, Mai M, Fromm C, Marshall J. Intravenous subdissociative-dose ketamine versus morphine for acute geriatric pain in the Emergency Department: A randomized controlled trial. Am J Emerg Med. 2019 Feb;37(2):220-227. doi: 10.1016/j.ajem.2018.05.030. Epub 2018 May 16. PubMed PMID: 29807629. Summarized and edited by Erik Verzemnieks, MD

Author: Michael Hunt, MD Educational Pearls: As many as 20% of women in assisted living have asymptomatic bacteriuria This can present a diagnostic conundrum when seeing these patients in the emergency department, particularly for altered mental status and deciding whether to treat True diagnosis of UTI in the emergency department is difficult as true diagnoses required culture results and repeated positive samples Procalcitonin is an emerging biomarker that may be helpful in determining the presence of infection References: Cortes-Penfield NW, Trautner BW, Jump RLP. Urinary Tract Infection and Asymptomatic Bacteriuria in Older Adults. Infect Dis Clin North Am. 2017 Dec;31(4):673-688. doi: 10.1016/j.idc.2017.07.002. Review. PubMed PMID: 29079155; PubMed Central PMCID: PMC5802407. Huang DT, Angus DC, Chang CH, Doi Y, Fine MJ, Kellum JA, Peck-Palmer OM, Pike F, Weissfeld LA, Yabes J, Yealy DM; ProACT Investigators.. Design and rationale of the Procalcitonin Antibiotic Consensus Trial (ProACT), a multicenter randomized trial of procalcitonin antibiotic guidance in lower respiratory tract infection. BMC Emerg Med. 2017 Aug 29;17(1):25. doi: 10.1186/s12873-017-0138-1. PubMed PMID: 28851296; PubMed Central PMCID: PMC5576372. Summarized by Erik Verzemnieks, MD

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