Emergency Medical Minute

Author: Nick Hatch, MD Educational Pearls: The sodium-glucose cotransporter in the gut is essential for rehydration. Oral rehydration therapies require an equimolar concentration of glucose and sodium to be effective. ORT has saved millions of lives globally. Consider using ORT in patients with dehydration. Especially useful in resource limited settings. References: Victora CG, Bryce J, Fontaine O, Monasch R. Reducing deaths from diarrhoea through oral rehydration therapy. Bull World Health Organ. 2000; 78:1246. Santillanes G, Rose E. Evaluation and Management of Dehydration in Children. Emerg Med Clin North Am. 2018. 36(2):259-273. doi: 10.1016/j.emc.2017.12.004.

Author: Nick Hatch, MD Educational Pearls: Behcet Disease is an autoimmune disease that can affect any organ system. Typical symptoms include recurrent oral and genital ulcers, but more concerning features include skin rashes, ocular problems, and strokes. Patients with Behcet disease with hypotension should have low threshold for giving steroids. References: Arlt W, Allolio B. Adrenal insufficiency. Lancet, 2003; 361:1881. Sakane T, Takeno M, Suzuki N, Inaba G. Behçet's disease. New England Journal of Medicine. 1999; 341:1284.

Author: Dylan Luyten , MD Educational Pearls: Rare autosomal dominant condition that is often misdiagnosed as a psychiatric illness. Presents as profound muscle weakness with frank paralysis that is often precipitated by vigorous exercise, high carb diet, high sodium load, or by high temperatures. Supplemental potassium can rapidly reverse symptoms. Important to rule out thyrotoxicosis (get a TSH!). Prevention is key: adhering to a low carb and low sodium diet with supplemental potassium can help prevent episodes. References: Vicart S, Sternberg D, Arzel-Hézode M, et al. Hypokalemic Periodic Paralysis. 2002 Apr 30 [Updated 2014 Jul 31]. In: Adam MP, Ardinger HH, Pagon RA, et al., editors. GeneReviews® [Internet]. Seattle (WA): University of Washington, Seattle; 1993-2018. Available from: https://www.ncbi.nlm.nih.gov/books/NBK1338/?report=classic Statland JM, Fontaine B, Hanna MG, et al. Review of the Diagnosis and Treatment of Periodic Paralysis. Muscle & Nerve. 2018;57(4):522-530. doi:10.1002/mus.26009.

Author: Sam Killian, MD Educational Pearls: Insufficient sleep and disrupted circadian rhythms are a major health problem today Millions of dollars, thousands of deaths, and millions of injuries are related to sleep deprivation every year 56 billion dollars - 24,000 deaths - 2.5 million disabiling injuries related to a sleep-type deprivation Exxon valdez, challanger, chyrnobel linked to sleep deprivation- at least partially Data has shown that in the Spring (when people lose an hour of sleep) there were 8% more traffic accidents on the Monday immediately after daylight savings. Conversely, in the Fall (when people gain an hour of sleep), there were 8% fewer traffic accidents on the Monday immediately after daylight savings. Studies have also shown an increased risk of myocardial infarction in Spring immediately after daylight savings, and a decreased risk of myocardial infarction in the Fall immediately after daylight savings. References: Corren S. Traffic Accidents and Daylight Saving Time. New England Journal of Medicine. 1996;335(5):355-357. doi:10.1056/nejm199608013350517 Janszky I, Ljung R. Shifts to and from Daylight Saving Time and Incidence of Myocardial Infarction. New England Journal of Medicine. 2008;359(18):1966-1968. doi:10.1056/nejmc0807104.

Author: Don Stader, MD Educational Pearls: The use of fecal occult blood tests is falling out of favor in emergency departments These tests have strong evidence suggesting their efficacy in colon cancer screening but clinical significance in ED is limited They have relatively high false positive and false negative rates Small/microscopic bleeding are often not clinically significant in the ED but can lead to increased costs from over-testing and other harms from fecal occult blood testing References: Gupta A, Tang Z, Agrawal D. Eliminating In-Hospital Fecal Occult Blood Testing: Our Experience with Disinvestment. American Journal of Medicine. (2018). 10.1016/j.amjmed.2018.03.002

Author: Michael Hunt, MD Educational Pearls: Valley fever is a fungal infection known as Coccidiomycosis that can present with vague symptoms like cough, fever, myalgias. A thorough history is critical to the diagnosis. Disease is localized to the Southwestern US (California, New Mexico, Arizona, Nevada, Utah) and parts of Central/South America. Disease is caused by inhaling fungal spores which damage the lung. Rarely, the disease can disseminate and cause infections that require systemic anti fungal therapy. References: Centers for Disease Control and Prevention (CDC). Increase in reported coccidioidomycosis--United States, 1998-2011. MMWR Morb Mortal Wkly Rep 2013; 62:217. Saubolle MA, McKellar PP, Sussland D. (2007). Epidemiologic, clinical, and diagnostic aspects of coccidioidomycosis. Journal of Clinical Microbiology. 45:26. Taylor AB, Briney AK. (1949). Observations on primary coccidioidomycosis. Annals of Internal Medicine. 30:1224.

Author: Sam Killian, MD Educational Pearls: Being exposed to E-cigarette vapor may increase risk of pneumonia. Recent study has shown e-cigarette vapor increases quantities of Platelet-activating-receptor factor in epithelial cells, which may aid pneumococcal bacteria in entering pneumocytes. References: Miyashita L, et al. (2018). E-cigarette vapour enhances pneumococcal adherence to airway epithelial cells. The European Respiratory Journal. 7;51(2).

Author: Rachel Beham, PharmD Educational Pearls: Some synthetic cannabinoids have been contaminated with Brodifacoum. Brodifacoum is a Vitamin K antagonist and can present with a severe coagulopathy. Brodifacoum is commonly known as "superwarfarin" and has a very long half life of 120+ days. Check PT/INR in patients with a bleeding diathesis in setting of synthetic cannabinoid use. Treatment is activated charcoal and large doses of Vitamin K (10mg Q6H for months). References: Lipton R.A.; Klass E.M. (1984). "Human ingestion of a 'superwarfarin' rodenticide resulting in a prolonged anticoagulant effect". JAMA. 252: 3004–3005. La Rosa F; Clarke S; Lefkowitz J. B. (1997). "Brodifacoum intoxication with marijuana smoking". Archives of Pathology & Laboratory Medicine. 121: 67–69

Author: Jared Scott, M.D. Educational Pearls: Cardiac myocytes and vascular smooth muscle are dependent on an intracellular calcium influx for contraction. Pancreatic beta cells rely on calcium to release insulin. Calcium channel blockers will decrease cardiac contractility and heart rate, but will also cause vascular smooth muscle relaxation with a subsequent decrease in systemic vascular resistance. Resultant cardiac depression and hypotension. Pancreatic beta cells also use calcium to release insulin, so calcium channel blockade can cause hyperglycemia. Treatment for calcium channel toxicity include: fluid resuscitation, calcium gluconate, vasopressors, and high dose insulin. Dosing for insulin therapy is usually 1-5 Units/kg/hr. Make sure to add dextrose! References: Boyer EW, Shannon M. (2001).Treatment of calcium-channel-blocker intoxication with insulin infusion. New England Journal of Medicine. 344:1721. Proano L, Chiang WK, Wang RY. (1995).Calcium channel blocker overdose. American Journal of Emergency Medicine. 13:444. St-Onge M, Dubé PA, Gosselin S, et al. (2014). Treatment for calcium channel blocker poisoning: a systematic review. Clinical Toxicology. 52:926.

Author: Nick Hatch, M.D. Educational Pearls: Methemoglobinemia is when the iron in hemoglobin is in the Fe3+ (ferric) state rather than the normal Fe2+ (ferrous) state. Methemoglobin cannot release oxygen at the tissues. Symptoms include cyanosis, headache, tachycardia, dyspnea, and lethargy. Suspect in setting of hypoxia that does not improve with oxygenation, and clinical cyanosis with a normal PaO2 on ABG. Treatment is methylene blue which reduces the iron back to the ferrous state. Causes can be Dapsone, Lidocaine, Benzocaine. References: Agarwal N, Nagel RL, Prchal JT. Dyshemoglobinemias. In: Disorders of Hemoglobin: Genetics, Pathophysiology, and Clinical Management, 2nd ed, Steinberg M (Ed), 2009. P.607 Cortazzo JA, Lichtman AD. (2014). Methemoglobinemia: a review and recommendations for management. Journal of Cardiothoracic and Vascular Anesthesia. 28:1043. Darling R, Roughton F. (1942). The effect of methemoglobin on the equilibrium between oxygen and hemoglobin. American Journal of Physiology. 137:56.

Author: Jared Scott, M.D. Educational Pearls: Recent study compared Compazine with Benadryl vs. Dilaudid for acute migraine management in the ED. Compazine + Benadryl demonstrated migraine relief in 60% of patients compared to the 31% of patients who were relieved with Dilaudid. Compazine + Benadryl is a superior migraine treatment than Dilaudid. References: Friedman BW, et. al. (2017). Randomized study of IV prochlorperazine plus diphenhydramine vs IV hydromorphone for migraine. Neurology. 89(20):2075-2082

Author: Don Stader, M.D. Educational Pearls: Pulmonary embolism is one of the leading causes of maternal mortality. There is disagreement among different medical societies about the value of D-dimer as a screening modality. If you use it, consider the rational D-dimer approach whereby you add 250 to your cut-off for every trimester. A useful screening modality is an ultrasound of bilateral lower extremities looking for DVT. Keep in mind, both a V/Q scan and CT scan have a significant amount of radiation. CTA is probably the right diagnostic test (less radiation than CT w&w/o). Always use the shared decision-making model and clinical acumen to choose your tests. References: Leung AN, et. al. (2011). An official American Thoracic Society/Society of Thoracic Radiology clinical practice guideline: evaluation of suspected pulmonary embolism in pregnancy. American Journal of Respiratory and Critical Care Medicine. 184(10):1200-8 Polak JF, Wilkinson DL. (1991). Ultrasonographic diagnosis of symptomatic deep venous thrombosis in pregnancy. American Journal of Obstetrics and Gynecology. 165(3):625-9. Sachs BP, et. al. (1987). Maternal mortality in Massachusetts. Trends and prevention. New England Journal of Medicine. 316(11):667-72.

Author: Aaron Lessen, MD Educational Pearls: Shockable rhythms like V-fib or V-tach have a better prognosis than patients with PEA or asystole. Recent study has shown an initial electrical frequency in PEA between 10-24/min had worse outcomes than PEA with initial rhythm over 60/min. Patients with an initial electrical frequency in PEA over 60/min did just as well as patients with shockable rhythms. Of them, there was a 22% survival rate with 15% having a good neurologic outcome. References: Weiser, C., et al. (2018). Initial electrical frequency predicts survival and neurological outcome in out of hospital cardiac arrest patients with pulseless electrical activity. Resuscitation. 125:34-38

Author: Erik Verzemnieks, M.D. Educational Pearls: ● Common causes of nystagmus: Congenital disorders, CNS diseases (MS, CVA), Intoxication ● Drugs associated (ETOH, Ketamine, PCP, SSRI, MDMA, Lithium, Phenytoin, Barbiturates) ● If a patient has nystagmus and is intoxicated, consider other drugs and etiologies as potential sources References: Alpert JN. (1978). Downbeat nystagmus due to anticonvulsant toxicity. ​Annals of Neurology.​ 4(5):471-3. Rosenberg, ML. (1987) Reversible downbeat nystagmus secondary to excessive alcohol intake. ​Journal of Clinical Neuroophthalmology​. 7(1):23-5. Weiner AL, Vieira L, McKay CA, Bayer MJ. (2000). Ketamine abusers presenting to the emergency department: a case series. ​Journal of Emergency Medicine.​ 18(4):447-51.

Author: John Winkler, M.D. Educational Pearls: ● Lower mechanisms of injury have a lower chance of an associated fracture or major ligament injury ● One major concern is having a fracture fragment in the joint (can lead to chronic arthritic pain) ● Evaluation should involve checking the neurovascular status of the arm and reduce the fracture as soon as possible. Immobilize arm in a sling and consult orthopedics if there is intra-articular involvement. References: https://orthoinfo.aaos.org/en/diseases--conditions/elbow-dislocation/ Mehta, JA; Bain, GI. (2004). Elbow dislocations in adults and children. ​Clinics in Sports Medicine.​ 23(4):609-27.

Author: Michael Hunt, M.D. Educational Pearls: 1% of patients presenting to ED with alcohol intoxication end up going to the ICU Most common critical illnesses were acute hypoxic respiratory failure, sepsis, and intracranial hemorrhage Predictive markers: Vital abnormalities (hypoxia, tachycardic, tachypneic, hypothermic, hyperthermia, hypoglycemia) and patients receiving parenteral sedatives had higher incidence of ICU admission References: Klein, LR; et al. (2018). Unsuspected Critical Illness Among Emergency Department Patients Presenting for Acute Alcohol Intoxication. Annals of Emergency Medicine. 71(3):279-288

Author: Dr. Karen Woolf, MD Educational Pearls: Anatomy : base of skull to posterior mediastinum, anteriorly bounded by middle layer of deep cervical fascia and posteriorly by the deep layer, communicates to lateral pharyngeal space bounded by carotid sheath. Lymph node chains draining nasopharynx, sinuses, middle ear, etc. run through it. Epidemiology & Microbiology: most common kids 2-4, (neonates too). Polymicrobial (GAS, MSSA, MRSA, respiratory anaerobes). Signs and symptoms can include pharyngitis, dysphagia, odynophagia, drooling, torticollis, muffled voice, respiratory distress, stridor, neck swelling, and trismus. Exam may show drooling, posterior pharyngeal swelling, anterior cervical LAD, or a neck mass. Imaging: Get CT neck w/IV contrast! DDx: epiglottis, croup, bacterial tracheitis, peritonsillar abscess, trauma, foreign body, angioedema, cystic hygroma, meningitis, osteomyelitis, tetanus toxin. Tx: Unasyn, if not responding add Vancomycin or Linezolid; surgical drainage if airway is compromised. Complications: airway obstruction, sepsis, aspiration pneumonia, IJ thrombosis, carotid artery rupture, mediastinitis. References: Craig FW, Schunk JE. Retropharyngeal abscess in children: clinical presentation, utility of imaging, and current management. Pediatrics 2003; 111:1394. Fleisher GR. Infectious disease emergencies. In: Textbook of Pediatric Emergency Medicine, 5th ed, Fleisher GR, Ludwig S, Henretig FM (Eds), Lippincott Williams & Wilkins, Philadelphia 2006. p.783. Goldstein NA, Hammersclag MR. Peritonsillar, retropharyngeal, and parapharyngeal abscesses. In: Textbook of Pediatric Infectious Diseases, 6th ed, Feigin RD, Cherry JD, Demmler-Harrison GJ, Kaplan SL (Eds), Saunders, Philadelphia 2009. P.177

Author: Gretchen Hinson, M.D. Educational Pearls: PNES vs. epilepsy: postictal state is diagnostic of an epileptic seizure (sonorous respirations and/or confusion, lasting typically 20-30 minutes); Epileptiform seizures show decrease in convulsion frequency, but increase in convulsion amplitude while PNES convulsions demonstrate episodic convulsion amplitudes; and epileptiform seizures usually do not pause. PNES is a form of conversion disorder and can be associated with underlying personality disorder; however there are patients with epilepsy that also can have PNES which complicates the diagnosis and treatment. Patients that are malingering may have flailing movements and might talk during the episodes - both not typical of epileptic seizures or PNES. Treatment for PNES is with psychotropic medications and psychotherapy as opposed to antiepileptic medications References: Avbersek, A; Sisodiya, S. (2010). Does the primary literature provide support for clinical signs used to distinguish psychogenic nonepileptic seizures from epileptic seizures?. Journal of neurology, neurosurgery, and psychiatry. 81(7):719-25. Devinsky, O; Gazzola, D; LaFrance, W. Curt (2011). Differentiating between nonepileptic and epileptic seizures. Nature Reviews. Neurology. 7 (4): 210–220. Lesser, RP. (2003). Treatment and Outcome of Psychogenic Nonepileptic Seizures. Epilepsy Currents. 3(6):198-200. doi:10.1046/j.1535-7597.2003.03601.x. Pillaia, JA; Hautab SR. (2012). Patients with epilepsy and psychogenic non-epileptic seizures: An inpatient video-EEG monitoring study. Seizure. 21(1): 24-27.

Author: Dr. Peter Bakes Educational Pearls: High risk patients: underlying lung disease, immunocompromised, extremes of age (65), underlying cardiac/renal/neurologic disease, and pregnant women Testing: RT-PCR (RNA based test that is both sensitive and specific) Workup: comorbidities dictate whether or not they are screened; CXR indicated in high risk patients with respiratory symptoms Morbidity from flu comes from secondary pneumonia, sepsis, and septic shock Treatment options are Tamiflu and Relenza (Relenza is contraindicated in patients with lung disease) High risk patients see average of 2.5 days shortening of illness and a decrease in illness severity. Low risk patients see average of 1.5 days shortening of illness. References: https://www.cdc.gov/flu/about/disease/high_risk.htm Binnicker MJ, Espy MJ, Irish CL, Vetter EA. Direct Detection of Influenza A and B Viruses in Less Than 20 Minutes Using a Commercially Available Rapid PCR Assay. J Clin Microbiol. 2015 Jul; 53(7): 2353-4. Longo, Dan L. (2012). "187: Influenza". Harrison's principles of internal medicine (18th ed.). New York: McGraw-Hill. ISBN 9780071748896.

Author: Sam Killian, M.D. Educational Pearls: Spinal cord injury without radiographic abnormality (SCIWORA) is a diagnosis defined as traumatic injury to spine with clinical sx of traumatic myelopathy (paraplegia, paresthesias, FND) without radiographic abnormalities. Term was established in 1970's before MRI and accounted for about 15% of injuries at the time (mainly children). Today SCIWORA accounts for about 10% of spinal injuries. Belief is that injury causes subtle movement of the spinal cord from its natural position with resultant contusion or ischemia with subsequent deficits. Treatment involves prolonged immobilization (up to 12 weeks). References: Walecki, J. (2014). Spinal Cord Injury Without Radiographic Abnormality (SCIWORA) – Clinical and Radiological Aspects. Polish Journal of Radiology,79, 461-464. doi:10.12659/pjr.890944

Author: Aaron Lessen, M.D. Educational Pearls: Recurrence rate for first time unprovoked seizures - 5% after 48 hours, 14% at 2 weeks , 30% after 4 months. Higher risk for recurrence: age under 3; patients with multiple seizures at initial presentation, focal neurologic findings on initial presentation. Useful for counseling patients and recommending follow up. References: Shinnar S, Berg AT, Moshé SL, et al. Risk of seizure recurrence following a first unprovoked seizure in childhood: a prospective study. Pediatrics 1990; 85:1076.

Author: Gretchen Hinson, M.D. Educational Pearls: Controversial topic. Pathophysiology - acidosis leads to an extracellular potassium shift. Patients in DKA will be intracellularly potassium deplete, but will have a falsely normal/elevated serum potassium. 3 risk of giving bicarb in DKA - alkalosis will drive potassium intracellularly but can overshoot (hypokalemia) and increase risk of arrhythmias; bicarb slows clearance of ketones and will transiently increase their precursors; bicarb can cause elevated CSF acidosis. 3 instances when appropriate to give bicarb in DKA: DKA in arrest; hyperkalemic in DKA with arrhythmia; fluid and vasopressor refractory hypotension. References: Bratton, S. L., & Krane, E. J. (1992). Diabetic Ketoacidosis: Pathophysiology, Management and Complications. Journal of Intensive Care Medicine, 7(4), 199-211. doi:10.1177/088506669200700407 Chua, H., Schneider, A., & Bellomo, R. (2011). Bicarbonate in diabetic ketoacidosis - a systematic review. Annals of Intensive Care, 1(1), 23. doi:10.1186/2110-5820-1-23

Author: Alicia Oberle, MD Educational Pearls: Recent study has shown risk factors for return included patients at high risk for resistance (nursing home, obstructive uropathy), patient where diagnogsis of pyelonephritis was missed, but the biggest risk factor was the existence of bug-drug mismatches. Cephalexin (Keflex) was associated with highest rate of return, while nitrofurantoin (Macrobid) was associated with lowest return rate. Recommendation is to continue to detect between pyelonephritis and cystitis, broaden coverage for patients with complications, and utilize your facilities antibiogram. References: Jorgensen S, et al. ( 2018). Risk factors for early return visits to the emergency department in patients with urinary tract infection. American Journal of Emergency Medicine. 36(1):12-17

Author: Aaron Lessen, M.D. Educational Pearls: There is currently debate within the medical community about what constitutes cardiac activity on ultrasound in the setting of cardiac arrest. A recent study has shown there providers looking at the same clips from an echo will disagree about what constitutes cardiac activity. Some of the confusion stems from movement that is not cardiac in etiology. For example, some alvular movement can be due to IV fluids and some cardiac motion can be due to the patient being bagged. Cardiac activity is defined as "Any intrinsic motion of the myocardium." However, even if this is present, it is important to ask if it clinically significant cardiac activity. Despite disagreement, ultrasound can be useful for clinical decision making. References: Gaspari R et al. (2016) Emergency Department Point-Of-Care Ultrasound in Out-Of-Hospital and in-ED Cardiac Arrest. Resuscitation; 109: 33 – 39. Hu K et al. (2017) Variability in Interpretation of Cardiac Standstill Among Physician Sonographers. Ann Emerg Med.

Author: Peter Bakes, M.D. Educational Pearls: Rare disease with 1-2 patients out of 100,000. About 60% of patients report a preceding diarrheal illness and classically presents with an ascending motor weakness. Pathophysiology is likely due to molecular mimicry where the immune system creates antibodies against a pathogen (C. jejuni ) which appears similar to the myelin of peripheral nerves resulting in autoimmune demyelination. Diagnosis is made by clinical presentation +/- a spinal tap with a characteristic high protein count but without cells. Treatment is IVIG or plasmapharesis. It is important to monitor respiratory function because about 15% of patients progress to respiratory failure. References: Sejvar, James J.; Baughman, Andrew L.; Wise, Matthew; Morgan, Oliver W. (2011). "Population incidence of Guillain–Barré syndrome: a systematic review and meta-analysis" van den Berg, Bianca; Walgaard, Christa; Drenthen, Judith; Fokke, Christiaan; Jacobs, Bart C.; van Doorn, Pieter A. (15 July 2014). "Guillain–Barré syndrome: pathogenesis, diagnosis, treatment and prognosis". Nature Reviews Neurology. 10 (8): 469–482. Yuki, Nobuhiro; Hartung, Hans-Peter (14 June 2012). "Guillain–Barré Syndrome". New England Journal of Medicine. 366 (24): 2294–2304.

Author: Nick Hatch, M.D. Educational Pearls Tramadol acts at multiple receptors and is a partial agonist at the mu opioid receptor, but also blocks reuptake of serotonin and norepinephrine throughout the body among others. One major side effect to be aware of is that it lowers the seizure threshold. Useful in setting of pain control in patients with contraindications to NSAIDs who are poor opioid candidates. Use with caution as it potential for abuse. References Hennies HH, Friderichs E, Schneider J (July 1988). "Receptor binding, analgesic and antitussive potency of tramadol and other selected opioids". Arzneimittel-Forschung. 38 (7): 877–80. "Tramadol Hydrochloride". The American Society of Health-System Pharmacists. Retrieved Dec 1, 2014. "Withdrawal syndrome and dependence: tramadol too". Prescrire Int. 12 (65): 99–100. 2003

Author: Aaron Lessen, M.D. Educational Pearls A "stuffer" is a term for someone who hastily and conceals a bag of drugs orally/rectally/vaginally in an unplanned situation. A "packer" is someone who is planning to smuggle drugs, and does so in a similar manner. "Stuffers"are more likely to have the drug container open up in their system, while packers tend to have more reliable containment, but typically have larger quantities on-board. Be on look out for symptoms associated with the drug's exposure (drug dependent) as well as mechanical symptoms (perforation; obstruction). If suspicious, order CT as X-rays underestimate severity. Management: treat symptoms of intoxication appropriately, observe if packets are intact, consider surgery/endoscopy if necessary. References Dueñas-Laita A, Nogué S, Burillo-Putze G (2004). "Body packing". New England Journal of Medicine. 350 (12): 1260–1 Hergan K, Kofler K, Oser W (2004). "Drug smuggling by body packing: what radiologists should know about it". Eur Radiology. 14 (4): 736–42. Traub SJ, Hoffman RS, Nelson LS (2003). "Body packing—the internal concealment of illicit drugs". New England Journal of Medicine. 349 (26): 2519–26.

Author: Dylan Luyten, MD Educational Pearls Johannes Hoffer coined term Nostalgia in 1688 in his medical dissertation. Nostalgia was a formal medical diagnosis, and one that dates back to 17th century when soldiers had longing for home and melancholy with a constellation of symptoms including lethargy, sadness, disturbed sleep, heart palpitations, GI complaints, and/or skin findings for which the only cure was to return home. In the civil war, over 5000 soldiers were given medical leave for nostalgia. Always remember to view your patient in the appropriate context (psychosocial, cultural, historical, etc.) References Beck, J. (2013, August 14). When Nostalgia Was a Disease. Retrieved March 08, 2018, from https://www.theatlantic.com/health/archive/2013/08/when-nostalgia-was-a-disease/278648/

Author: Dylan Luyten, M.D. Educational Pearls The Lazarus phenomenon is the delayed return of spontaneous circulation after cessation of CPR. A prospective study in Finland found 5 out of 840 patients where CPR was attempted in the setting of cardiac arrest experienced the Lazarus effect (about 0.6%). 3 of these patients died on scene, and the other 2 died in the hospital at 1.5 and 26 hours respectively. Ultimately, the Lazarus effect is rare, but it does occur and providers and family members should be aware that signs such as gasping or twitching may be seen after cardiac arrest, but the prognosis is still dismal. References Kuisma, M, et al. (September 2017) "Delayed return of spontaneous circulation (the Lazarus phenomenon) after cessation of out-of-hospital cardiopulmonary resuscitation". Resuscitation. 118: 107-111

Author: Jared Scott, M.D. Educational Pearls Flu is widespread throughout the US (through Jan 20th 2018). All age groups have seen surge in hospitalizations, but 65 + age group has seen the largest surge in hospitalizations due to flu. New recommendations for treating with Tamiflu! Treat the following high-risk groups at any stage of illness: Children under age 2, Adults 65 and older, patients with comorbidities such as chronic lung disease, heart disease, blood disorders, kidney disorders, liver disorders, neurological disorders, immunosuppressed, pregnant women, American Indians, extreme obesity, women under 19 on long-term aspirin, and nursing home residents. References: https://www.cdc.gov/flu/about/disease/high_risk.htm https://www.cdc.gov/flu/weekly/summary.htm

Author: Don Stader, M.D. Educational Pearls Common pathologies include cholecystitis, choledocholithiasis, and in concerningly ascending cholangitis. Cholecystitis is obstruction at the cystic duct leading to inflammation of gallbladder wall, while choledocholithiasis is a distal obstruction of the biliary tree, and ascending cholangitis is an ascending infection of the biliary tree secondary to obstruction. Risk factors for Cholecystitis are the 5 F's (Fat, Forty, Female, Fertile, Family Hx). Classic symptoms seen in ascending cholangitis are Charcot's Triad of fever, RUQ pain, and jaundice, or Reynold's pentad which is more severe and has the addition ofaltered mental status and hypotension. Porcelain gallbladder is a radiographic finding showing calcification of the gallbladder that is associated with cancer of the gallbladder. References: Kimura Y, Takada T, Kawarada Y, et al. (2007). "Definitions, pathophysiology, and epidemiology of acute cholangitis and cholecystitis: Tokyo Guidelines". J Hepatobiliary Pancreat Surg. Strasberg, SM (26 June 2008). "Clinical practice. Acute calculous cholecystitis". The New England Journal of Medicine. 358 (26): 2804–11.

Since the tragic overdose of his son, Admiral Winnefeld has developed an intriguing strategy on how to combat the Opioid Epidemic.

Sam Quinones, American journalist and author of the critically acclaimed book, Dreamland: The True Tale of America's Opiate Epidemic, shares the story of how he discovered the truth about the Opiate Epidemic.

Lisa Raville, executive director of The Harm Reduction Action Center in Denver, shares tales from her perspective as a Harm Reductionist.

Emergency Medical Minute's very own Donald Stader, MD explains Medicine's contribution to the catastrophe that is the Opioid Epidemic.

Dr. Robert Valuck, director of the Colorado Consortium, presents 10 fallacies that have fueled the Opioid Epidemic.

The Honorable Alby Zweig shares his impactful first-hand experience with addiction, recovery and triumph.

Admiral James Winnefeld and Mary Winnefeld speak publicly for the first time about the tragic overdose of their son, Jonathon, and how 'No Family is S.A.F.E...yet'.

Author: Peter Bakes, M.D. Educational Pearls Probiotics are living bacteria that are taken as an oral supplement. Most of the data to support their use is in the prevention of antibiotic-related diarrhea and the reduction of the symptoms of ulcerative colitis (UC). Some studies have some a reduction of the incidence of antibiotic-related diarrhea in children of up to 12% with the use of probiotics. There may be a reduction of up to 60% in the incidence of antibiotic-related C. diff infection in adults with probiotic use Studies have shown a 10% or more reduction in the duration and severity of the symptoms of UC with probiotic use. Proposed mechanisms of probiotics include a decrease in gut permeability and a decrease in pathogenic gut bacteria due to resource competition. References: http://www.cochrane.org/CD006095/IBD_use-probiotics-prevent-clostridium-difficile-diarrhea-associated-antibiotic-use

Author: Chris Holmes, M.D. Educational Pearls It's estimated that about 25 million people died during the Black Plaque. Researchers have confirmed this number by assessing how much old, broken pottery was buried in front of homes and churches from that time period. Traditional thinking has been that the Black Plague was spread primarily by flea bites. However, using mathematical modeling, researchers have theorized that person-to-person spread was more common. References: https://www.washingtonpost.com/news/speaking-of-science/wp/2016/05/24/broken-pottery-reveals-the-sheer-devastation-caused-by-the-black-death/

Author: Sam Killian, M.D. Educational Pearls The availability of antiepileptic treatment has changed in the last 30 years. A recent study in JAMA followed 18,000 pts with epilepsy for 30 years to assess the effectiveness of looked at seizure control. The study found that although there have been new drugs introduced over the last 30 years, there has not been much of an improvement in seizure control. Side effect profiles and medicine compliance may have improved in this time period, but the main goal of reducing seizure frequency has not been reached. References: Chen Z, Brodie MJ, Liew D, Kwan P. Treatment Outcomes in Patients with Newly Diagnosed Epilepsy Treated With Established and New Antiepileptic DrugsA 30-Year Longitudinal Cohort Study. JAMA Neurol. Published online December 26, 2017. doi:10.1001/jamaneurol.2017.3949

Educational Pearls Truvada (Emtricitabine/tenofovir) is a combination nucleotide reverse transcriptase inhibitor that can be used as pre-exposure prophylaxis (PrEP) for HIV. It has been shown to dramatically reduce the risk of contracting HIV. It is used in high-risk patients, like the MSM community or those who are in a relationship with someone with HIV. Side effects include nausea, vomiting, headache, and liver damage. HIV testing should be performed every 3 months while taking it, since it is not meant to fight an actual infection. Since 2012, there have only been 3 confirmed cases of transmission while using Truvada. It costs between 50-60$ dollars per pill, but it is covered by most insurances, including Medicaid. Generic version has recently been FDA approved. References: https://www.cdc.gov/hiv/pdf/prep_gl_patient_factsheet_truvada_english.pdf

Author: Rachael Duncan, PharmD Educational Pearls A NEJM study report in July 2016 discussed a situation in New York during which 30 people became "zombie-like" after ingesting synthetic cannabinoids (aka "Spice). The ER managed to coordinate with the CDC to evaluate blood samples from 18 patients who were transported to the hospital. Of those who went to the ER, the mean age was 36.8, many of them were homeless, all of them were male. Mass spectrometry was used to confirm the presence of synthetic cannabinoid in their blood. Compared to normal THC, synthetic cannabinoids have a much lower EC50 and LD50. Spice intoxication presents in a variety of ways -patients may be hyperthermic, combative, delirious and/or seizing. Treatment is supportive, including fluids, cooling, electrolyte management, and sedatives. References: Adams, A. J., Banister, S. D., Irizarry, L., Trecki, J., Schwartz, M., & Gerona, R. (2017). "Zombie" Outbreak Caused by the Synthetic Cannabinoid AMB-FUBINACA in New York. New England Journal of Medicine, 376(3), 235-242. doi:10.1056/nejmoa1610300

Author: Sam Killian, M.D. Educational Pearls Traditionally, UTI diagnosis has been dependent on urine culture, urinalysis and clinical symptoms. But a recent study casts some doubt on the utility of urine cultures. A study in the Journal of Clinical Microbiology did urine cultures and E. coli PCR in 220 women with UTI symptoms and 86 women without UTI symptoms. In the symptomatic women, 67% had positive E. Coli PCR and 98% had a pathogenic bacteria in their urine culture. In the asymptomatic women, 10% had positive E. coli PCR and/or urine culture. Therefore, this study suggests that urine culture may be of limited utility, since symptoms alone seemed to predict bacteriuria. References: Burd EM, Kehl KS. A Critical Appraisal of the Role of the Clinical Microbiology Laboratory in the Diagnosis of Urinary Tract Infections. Journal of Clinical Microbiology. 2011;49(9 Supplement). doi:10.1128/jcm.00788-11.

Author: Michael Hunt, M.D. Educational Pearls Rhabdomyolysis is caused by the destruction of skeletal muscle that leads to the release of myoglobin, which causes renal failure. It presents with pain and weakness in the affected muscle, as well as dark urine. Diagnosis is made with creatinine kinase levels It can happen to extreme athletes after competition, but the most common presentation is in people who fall and are immobilized for long periods of time. Other causes include burns, crush injuries, viral infections (influenza), bacterial infections (Legionella), and medications (statins in adults, propofol in kids) Treatment is aggressive fluids References: Huerta-Alardín AL, Varon J, Marik PE. Bench-to-bedside review: Rhabdomyolysis – an overview for clinicians. Critical Care. 2005;9(2):158-169. doi:10.1186/cc2978.

Author: Sam Killian, M.D. Educational Pearls Transient global amnesia is a paroxysmal, transient memory issue. Remote and immediate memory is preserved, but new memories cannot be made. Patients will have a normal neurological exam and usually no other complaints. The episode will last less than 24 hours, but they usually resolve after 1-2 hours. This is relatively common. It happens in 5/100000 people, mostly men over 50. Recurrence is rare. There is no known cause, but it is associated with migraines and classically occurs after heavy physical exertion or emotional stress. Workup includes a full neuro exam, imaging for ongoing symptoms, and labs to rule out other causes. Patients can be sent home with reassurance after symptoms resolve. Instruct them to follow up with neurology. Patients with continuing symptoms should be admitted. References: Owen D, Paranandi B, Sivakumar R, Seevaratnam M. Classical diseases revisited: transient global amnesia. Postgraduate Medical Journal. 2007;83(978):236-239. doi:10.1136/pgmj.2006.052472.

Author: John Winkler, M.D. Educational Pearls Normally, the parathyroid is the master regulator of serum Ca levels. It secretes PTH, which stimulates calcium uptake from the bone and gut. Causes of hypercalcemia include: parathyroid tumor, lytic bone lesions (multiple myeloma), breast cancer, renal injury, and some lung cancers. Hypercalcemia can lead to poor bone quality and pathological fractures. It can also cause heart arrhythmias. It is important to order an ionized calcium to quantify the level of hypercalcemia, since calcium binds to albumin. Treatment for hypercalcemia includes fluids and loop diuretics. References: https://emedicine.medscape.com/article/766373-treatment

Author: Nick Hatch, M.D. Educational Pearls The Cincinnati Stroke Scale uses 3 measures to screen for ischemic stroke. The measures are: facial asymmetry, speech quality and arm drift. This scale is used commonly in EMS systems as a screening tool. Studies show that having one out of the 3 elements correlates with a 72% chance of having an ischemic stroke, while having all 3 of the elements correlates with an 85% chance. Overall the scale is highly sensitive but not very specific (92% and 48%, respectively, in one study). The measures focus on anterior circulation function, and often misses posterior circulation strokes. The Cincinnati Stroke Scale is good for EMS, but not necessarily for emergency physicians. References: http://onlinelibrary.wiley.com/store/10.1002/9781118783467.app5/asset/app5.pdf?v=1&t=jcf2yn71&s=3c2341ba472c1fcc88003dc0af7eac28691dd980

Author: Dave Rosenberg, M.D. Educational Pearls DKA commonly causes hyperkalemia, leading to peaked T-waves on ECG. However, DKA causes hypokalemia at the same time. In DKA, glucose cannot be taken into the cells. This signals the body to create and use acidic ketones for energy. This leads to acidosis. To compensate for increased acid, H ions are pumped into cells. To maintain electroneutrality, K is pumped out of the cell. At the kidney, K is lost in the urine. Overall, while serum K is high in DKA, total body K is low. The derangement in K can lead to life-threatening arrhythmias. Treatment for DKA can induce hypokalemia, as the K will shift back into the cells with insulin administration. Therefore, treatment for DKA needs to include K. References: http://www.merckmanuals.com/professional/endocrine-and-metabolic-disorders/diabetes-mellitus-and-disorders-of-carbohydrate-metabolism/diabetic-ketoacidosis-dka

Author: Dylan Luyten, M.D. Educational Pearls Cannabinoid Hyperemesis syndrome is a relatively new diagnosis that presents with vomiting and abdominal pain without a clear etiology in the setting of daily marijuana use. The pathophysiology is not well-understood well, but may involve cannabinoid receptors in the gut. Treatment is abstinence from marijuana, fluids, dextrose, and antiemetics (haldol, ondansetron, etc). Opioids should be avoided. Capsaicin cream on the abdomen may be helpful, as it can distract from the pain and vomiting. Milk can be used to reverse its effects. References: Galli JA, Sawaya RA, Friedenberg FK. Cannabinoid Hyperemesis Syndrome. Current drug abuse reviews. 2011;4(4):241-249.