Emergency Medical Minute

Author: Peter Bakes, M.D. Educational Pearls Chronic diarrhea is defined as 3 or more loose, watery stools lasting more than 2-3 weeks. Look for clues in the history, including travel (could suggest infectious etiology), antibiotic use (could suggest C. Diff), and family history. Irritable Bowel Disease (Crohn's/Ulcerative Colitis) is an autoimmune disorder that affects 1.3 million Americans and is a leading cause of chronic diarrhea. Crohn's always involves the terminal ileum, but can present anywhere along the GI tract. It causes transmural inflammation of the bowel wall and can lead to adhesions, perforations, and fistulas. Ulcerative colitis usually involves the rectum and causes mucosal inflammation only. Workup for IBD includes colonoscopy and tissue biopsy. Treatment for IBD includes dietary changes, 5-ASA/Mesalamine, steroids, and infliximab (anti-TNF alpha). References: https://www.aafp.org/afp/2011/1115/p1119.html

Author: Aaron Lessen, M.D. Educational Pearls Treatment "bundles" are a popular approach to the rapid resuscitation of septic patients. A recent study in New York, where sepsis bundles are mandatory, sought to figure out which aspects of the bundle had impacts on mortality. In a study of 40,000 septic patients, the study found that early antibiotics were associated with better outcomes, while early IV fluids were not associated with better outcomes. This study affirms the important role of early antibiotics in sepsis. IV fluids may play an important role in the treatment of sepsis in some patients, but its role is less clear than antibiotics. References: Time to Treatment and Mortality during Mandated Emergency Care for Sepsis Christopher W. Seymour, M.D., Foster Gesten, M.D., Hallie C. Prescott, M.D., Marcus E. Friedrich, M.D., Theodore J. Iwashyna, M.D., Ph.D., Gary S. Phillips, M.A.S., Stanley Lemeshow, Ph.D., Tiffany Osborn, M.D., M.P.H., Kathleen M. Terry, Ph.D., and Mitchell M. Levy, M.D. N Engl J Med 2017; 376:2235-2244 June 8, 2017 DOI: 10.1056/NEJMoa1703058

Author: Don Stader, M.D. Educational Pearls While we usually associate the coronary vasculature with STEMIs, there are other pathologies that can affect the heart's blood supply. Kounis syndrome: an allergic vasospasm of the coronary arteries. This can happen post anaphylaxis or be caused by a stent allergy. It is best treated with aggressive management of the allergic reaction. Kawasaki disease: An autoimmune condition that presents in kids as conjunctivitis, lymphadenopathy, hand/foot swelling, rash, and fever. It can also cause coronary aneurysms, which can rupture and be rapidly fatal. Prinzmetal angina: Caused by coronary vasospasm. Presents with transient chest pain at rest. Treat with CCBs. Cocaine: Causes coronary vasospasm. Cocaine-induced vasospasm is best treated with BZDs. Coronary artery dissection: increased risk in pregnant women and those with connective tissue disorders. References: Memon S, Chhabra L, Masrur S, Parker MW. Allergic acute coronary syndrome (Kounis syndrome). Proceedings (Baylor University Medical Center). 2015;28(3):358-362.

Author: Aaron Lessen, M.D. Educational Pearls While C. difficile infections are generally thought of as nosocomial, there is a subset of patients who acquire the infection in the community. One recent study showed that about 10% of patients presenting to the ED with diarrhea and without vomiting had a C. diff infection. Another study found risk factors for community-acquired C. diff included recent ED/Urgent care visits and antibiotic use. However, 36% of the patients in that study had no identifiable risk factors. References: Gupta A, Khanna S. Community-acquired Clostridium difficile infection: an increasing public health threat. Infection and Drug Resistance. 2014;7:63-72. doi:10.2147/IDR.S46780.

Author: Erik Verzemneicks, M.D. Educational Pearls 1/600 flights has an on-board request for medical assistance. Most common complaints on board include: syncope, respiratory complaints, and GI complaints. Most of the time, these are exacerbations of underlying chronic conditions. Except for situations involving gross negligence, the Aviation Assistance Act protects providers from legal action as long as they are acting within their scope of practice. Flight crew are CPR and AED trained. The onboard medical kit includes: epinephrine, dextrose, nitroglycerin, NSAIDs, injectable antihistamine, antiemetic, steroids, beta-blocker, aspirin, stethoscope, BP cuff, airway tools, thermometer and more. There is ground-based medical control for consult and guidance. References: https://www.acep.org/Clinical---Practice-Management/Emergency-at-30,000-Feet---What-You-Can-Do/#sm.0001eqpidqrpoczltzg1epg0m0aqu

Author: John Winkler, M.D. Educational Pearls Photokeratitis is a UV burn of the sclera and cornea, which can cause blindness. UV light causes eyelid swelling with diffuse scarring of the eye (widespread, punctate uptake of fluorescein dye). While this can eventually heal, it is incredibly painful. Snow reflects light underneath sunglasses, so wrap-around goggles are the best form of prevention. This can happen to welders, sunbathers or any other person with prolonged UV light exposure. References: https://emedicine.medscape.com/article/799025-treatment

Author: Dave Rosenberg, M.D. Educational Pearls EKG changes that can be seen in DKA include ST elevation and peaked T-waves secondary to derangements in K levels. In DKA, serum K is high, but total body K is low, which can cause said EKG abnormalities. Many things cause ST elevation besides MI, so think beyond STEMI. When someone in in DKA, think about the "Three I's" for underlying cause: (not taking) insulin, ischemia, infection. References: Nageswara Rao Chava. ECG in Diabetic Ketoacidosis. Arch Intern Med. 1984;144(12):2379–2380. doi:10.1001/archinte.1984.00350220101022

Author: John Winkler, M.D. Dr. Winkler shares his knowledge of wilderness medicine and provides insight on how to prevent and treat conditions such as hypothermia, frostbite and sun blindness. More importantly, he gives us tips on how to stay safe while doing our favorite wintertime activities!

Podcast #281: Intracranial Hemorrhage Treatment Author: Don Stader, M.D. Educational Pearls Types of traumatic bleeds include subdural, epidural, and subarachnoid. Treatment for a traumatic bleed includes maintenance of systolic BP above 120 and seizure prophylaxis with phenytoin. In atraumatic bleeds, treatment should focus on lowering blood pressure to reduce bleeding. References: https://www.aliem.com/2017/09/intracranial-hemorrhage-management/

Author: Aaron Lessen, M.D. Educational Pearls Patients with an ischemic stroke from occlusion of the left middle cerebral artery often present with aphasia in addition to other neurological deficits. A recent study looked at patients presenting with suspected stroke. Of the 700 patients recruited, 3% had isolated aphasia on exam. On follow-up, none of the 3% had evidence of stroke on imaging. Underlying causes of the isolated aphasia in these patients included syncope, infections, seizures were the underlying cause. References: Gabriel Casella, Rafael H. Llinas, Elisabeth B. Marsh, Isolated aphasia in the emergency department: The likelihood of ischemia is low, Clinical Neurology and Neurosurgery, Volume 163, 2017, Pages 24-26, ISSN 0303-8467, https://doi.org/10.1016/j.clineuro.2017.10.013.

Author: Aaron Lessen, M.D. Educational Pearls Post-intubation care should always include pain control and adequate sedation. Commonly used sedation agents include propofol, ketamine and versed. However, too much sedation is harmful. Deep sedation (RASS -4 to -5) is associated with worse long-term outcomes. RASS of 0 to -2 is ideal, as long as the patient is comfortable. References: https://coreem.net/core/post-intubation/

Educational Pearls Subdural hematomas can happen in the elderly because of brain atrophy, and can manifest with neurological deficit. Subdural hematomas are caused by rupture of the bridging veins of the brain. This can be caused by trauma, brain atrophy, or possibly by anticoagulant use. They are crescent-shaped on head CT. Epidural hematomas, in contrast, are caused by rupture of meningeal arteries secondary to trauma. They are usually lens-shaped on head CT. Subdurals are difficult to pick up on head CT because they may be isodense to brain tissue. References: Management of Recurrent Subdural Hematomas Desai, Virendra R. et al. Neurosurgery Clinics , Volume 28 , Issue 2 , 279 - 286

Author: Don Stader, M.D. Educational Pearls Mucor/Rhizopus fungal infections usually present in diabetic or immunocompromised patients as a black, necrotic lesion on the face. The fungus invades the vasculature of the face, causing tissue ischemia and necrosis. The infection is more common in the diabetic population because the fungus prefers more acidic and glucose-rich environments. This is a surgical emergency since it is cured only with excision of the affected tissue References: Vijayabala GS, Annigeri RG, Sudarshan R. Mucormycosis in a diabetic ketoacidosis patient. Asian Pacific Journal of Tropical Biomedicine. 2013;3(10):830-833. doi:10.1016/S2221-1691(13)60164-1.

Author: John Winkler, M.D. Educational Pearls Angioedema is immediately life-threatening due to airway obstruction. Mechanisms include allergic reaction (histamine-related) or bradykinin-related (ACE-inhibitor, C1 esterase inhibitor deficiency). The bradykinin-related mechanism will not respond to the traditional meds used for anaphylaxis. Instead, use FFP to replace depleted factors. If a patient displays signs of respiratory compromise, intubation is indicated. Anesthesia should be consulted as this will be a very difficult airway. References: https://emcrit.org/pulmcrit/treatment-of-acei-induced-angioedema/

Author: Nick Hatch, M.D. Educational Pearls Unlike coin ingestions, button batteries can cause necrosis of the GI tract. If lodged in the esophagus, removal within 2 hours is important, because they can cause problems such as strictures or esophago-aortic fistula. If the battery is in the stomach or beyond, it may be ok to let it pass but give strict return precautions. Small hearing aid batteries are not as dangerous, but still require close follow-up to ensure the battery passes. Delayed effects (after passage of the battery) are possible. References: https://www.poison.org/battery/guideline

Author: Aaron Lessen, M.D. Educational Pearls A recent prospective observational study was performed to examine the safety of different sedation medications in the pediatric ED. This study included 6000 children, and looked at the rate of serious adverse events following administration of different sedatives. Overall, the safest drug to use was ketamine alone, with an adverse event rate of about 1%. Propofol, BZDs, and opiates had increased rates of adverse events. References: https://lifeinthefastlane.com/pediatric-procedural-sedation-with-ketamine/

Author: Sam Killian, M.D. Educational Pearls Difficulty with bag valve mask (BVM) ventilation can be addressed using the MOANS mnemonic. Mask seal, Obesity/obstruction, Age, No teeth, Sleep apnea. Often BVM difficulty can be addressed by an extra set of hands. References: https://www.aliem.com/2012/10/mnemonics-for-difficult-airway/

Author: David Rosenberg, M.D. Educational Pearls A study of 20,000 subjects found that reducing fever in sepsis did not improve outcomes such as morbidity, mortality, or length of stay. However, correcting fever may help for patient comfort. References: Zhang Z, Chen L, Ni H. Antipyretic Therapy in Critically Ill Patients with Sepsis: An Interaction with Body Temperature. Azevedo LCP, ed. PLoS ONE. 2015;10(3):e0121919. doi:10.1371/journal.pone.0121919.

Author: Chris Holmes, M.D. Educational Pearls The nexus chest CT scan rule is based on an 11,000 subject, multicenter study that looked for signs following a trauma that predicted significant findings on subsequent chest CT. Findings that were associated with abnormal chest CT included: abnormal CXR, distracting injury, chest wall, sternal, thoracic spine or scapular tenderness. Furthermore, a mechanism of injury that includes rapid deceleration was also associated. If a patient has none of the above findings, then there is only a small chance that there will be an abnormal chest CT. References: https://www.mdcalc.com/nexus-chest-ct-decision-instrument-ct-imaging

Author: Don Stader, M.D. Educational Pearls Wound botulism should be considered in patients with cutaneous lesions and neuromuscular weakness. The toxin produced by clostridium botulinum is the causative agent. It forms spores, so it is very resistant to killing by heat. It presents with weakness, most often in the extraocular muscles. Treatment includes wound care and respiratory support. Anti-toxin is rarely used as it is stored at the CDC and must be flown in. References: Kalka-Moll WM, Aurbach U, Schaumann R, Schwarz R, Seifert H. Wound Botulism in Injection Drug Users. Emerging Infectious Diseases. 2007;13(6):942-943. doi:10.3201/eid1306.061336.

Author: Michael Hunt, M.D. Educational Pearls Tattoo ink is applied below the skin, and because of this, they can lead to keloids, granulomas, tetanus, hepatitis B and C, and skin infections. Tattoo pigment has been found to contain substances like lead, cadmium, chromium, and arsenic; however, there are no long-term studies of the health effects of tattoos. In one study 14% of inks had ingredients that were banned in cosmetics. Nanoparticles of tattoo pigment can be found in the lymph nodes, and laser removal can precipitate their spread. Those with tattoos could experience complications with MRI because of the metal content of the ink. References: Khunger N, Molpariya A, Khunger A. Complications of Tattoos and Tattoo Removal: Stop and Think Before you ink. Journal of Cutaneous and Aesthetic Surgery. 2015;8(1):30-36. doi:10.4103/0974-2077.155072.

Author: Dave Rosenberg, M.D. Educational Pearls Poiseuille's Law addresses the flow of a fluid through a tube. Many common ED presentations involve alterations in flow: asthma, MI, ischemic stroke, etc. According to the law, flow increases with the 4th power of the radius. That is to say, doubling the radius of the tube will increase the flow by 16x. Therefore, in situations that require re-opening of an anatomic tube (artery, airway), small changes in the size of the opening will result in dramatic effects. References: https://www.openanesthesia.org/poiseuilles_law_iv_fluids/

Author: Dylan Luyten, M.D. Educational Pearls Lactate is a byproduct of anaerobic metabolism, a sign of dying tissue. Dangerous causes of high lactates will not normalize with repeat labs. Crush injuries, seizures, bowel necrosis, end-stage liver disease, and metformin toxicity are common causes of highly elevated lactate. References: https://lifeinthefastlane.com/ccc/lactic-acidosis/

Author: John Winkler, M.D. Educational Pearls Some risk factors for MI in the young are history of CAD, stimulant drug use, coronary spasm and diabetes. In those with diffuse ST elevations on EKG, think pericarditis. Troponin will also be elevated. References: Egred M, Viswanathan G, Davis GK Myocardial infarction in young adults Postgraduate Medical Journal 2005;81:741-745.

Author: Rachel Beham, PharmD, Advanced Clinical Pharmacist - Emergency Medicine Educational Pearls CDC recommends using the inactivated, injectable flu vaccine in those 6 months and older. The live attenuated vaccine is not used because of low efficacy. Pregnant women should be vaccinated, and can receive the vaccine at any stage of their pregnancy. The vaccine is contraindicated ONLY in those with a history of a severe anaphylactic reaction to the injection in the past. Antivirals (oseltamivir, zanamivir) are useful for Flu A and B. Their dosing needs to be adjusted for renal function, and it is contraindicated in those with ESRD who are not receiving dialysis. It should be used for prophylaxis in those with exposure and/or for the very young, very old, morbidly obese, nursing home residents, and those who are immunocompromised. They may be effective as long as 72 hours after symptom onset. References: https://www.cdc.gov/flu/professionals/index.htm

Author: Aaron Lessen, M.D. Educational Pearls For patients with in-hospital cardiac arrest, intubation in the 1st 15 minutes of resuscitation was associated with worse outcomes (mortality, neurologic outcome). This is likely due to cessation of high-quality CPR and defibrillation during the intubation sequence. In those with an in-hospital, shockable, cardiac arrest, administration of epinephrine before the 2nd defibrillatory shock was associated with worse outcome. This was likely due to the cessation of high-quality CPR. For in-hospital cardiac arrest, resuscitation should focus on high-quality CPR. References: Andersen LW, Granfeldt A, Callaway CW, Bradley SM, Soar J, Nolan JP, Kurth T, Donnino MW, for the American Heart Association's Get With The Guidelines–Resuscitation Investigators. Association Between Tracheal Intubation During Adult In-Hospital Cardiac Arrest and Survival. JAMA. 2017;317(5):494–506. doi:10.1001/jama.2016.20165

Educational Pearls After the first hour, every 1 hour delay in antibiotics in a patient with septic shock patient is associated with a 4% increase in mortality. In patients with high suspicion for septic shock (fever and hypotension), antibiotics should be initiated ASAP. Rocephin (ceftriaxone) should be used for those with community-acquired sepsis, zosyn for nosocomial or IV-associated sepsis. References: https://lifeinthefastlane.com/ccc/antibiotic-timing/

Author: Julian Orenstein, M.D. Educational Pearls Colorado has a high population of unvaccinated children, and is at increased risk for pertussis outbreaks. The causative organism is Bordetella pertussis. It causes causes respiratory epithelial necrosis leading to congestion of the bronchioles, leading to cough. The cough is unique - it is usually a series of expiratory coughs followed by one deep inspiration The clinical presentation is divided into 3 phases: Catarrhal: cough and congestion with low-grade fever and coryza. Whooping: characteristic cough. Resolution: recovery with persistent cough. Infants may not get this presentation, but may get apnea and nonspecific cough. Tongue depressor can be used to elicit cough for diagnosis. References: Tozzi AE, Pastore Celentano L, Ciofi degli Atti ML, Salmaso S. Diagnosis and management of pertussis. CMAJ : Canadian Medical Association Journal. 2005;172(4):509-515. doi:10.1503/cmaj.1040766.

Authors: Katie Sprinkel, MD Emergency Medicine Physician SANE Medical Director, Medical Center of Aurora Amy Ferrin, Senior Deputy District Attorney County Court Supervisor Office of the District Attorney, 18th Judicial District Amy Ferrin and Dr. Katie Sprinkel speak about the medical and legal aspects of domestic violence.

Author: Aaron Lessen, M.D. Educational Pearls Icatibant was introduced to treat ACE-inhibitor induced angioendema. This type of angioedema is refractory to epinephrine and antihistamines, and is likely mediated by elevated bradykinin.(which is inactivated by ATII and ACE). Icatibant initially was shown to reduce facial swelling and airway obstruction in the setting of ACE-I angioedema, but later, better-powered studies showed that it had no benefit compared to standard treatment. References: Sinert R et al. Randomized Trial of Icatibant for Angiotensin-Converting Enzyme Inhibitor-Induced Upper Airway Angioedema. J Allergy Clin Immunol Pract 2017. PMID: 28552382

Author: David Rosenberg, M.D. Educational Pearls Preoxygenation is done before rapid sequence intubation, and should be done even if SaO2 is at 100%. Preoxygenation is done to fill the lungs with oxygen rather than ambient air, which is only 20% O2. While the patient is paralyzed, the O2-filled lungs will continue to oxygenate venous blood, buying you more time for intubation. BiPAP is an effective tool for pre-oxygenation. References: https://lifeinthefastlane.com/ccc/preoxygenation/

Podcast #259: TIA Author: Peter Bakes, M.D. Educational Pearls A TIA is defined as focal neurological deficit that resolves within 24 hours and has negative imaging. The etiology is a transient thrombus, embolus, or narrowing of a branch of a cerebral artery. Screening tests are generally negative and low-yield. MRI and vascular imaging are usually done to look for reversible causes. Patients presenting with TIA are usually admitted because of a higher risk for stroke. However, there are some patients that are low-risk and do not require admission. Risk can be assessed using the "ABCD" mnemonic: Age>60, BP (history of HTN), Clinical presentation (area of deficit), Diabetes/Duration of symptoms. See reference link for scoring sheet. Patients with a low enough score may be eligible for outpatient follow-up. References: http://www.stroke.org/sites/default/files/resources/tia-abcd2-tool.pdf?docID

Author: Dylan Luyten, M.D. Educational Pearls Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA). Exsanguination is a major cause of mortality in trauma One temporizing technique to buy time to definitive hemorrhage control is to occlude the aorta thereby shunting blood away from pelvis and lower extremities, increasing cardiac afterload to increase myocardial and brain perfusion. Rather than perform a thoracotomy to cross clamp aorta, a REBOA catheter may be introduced into the aorta via the common femoral artery and a balloon inflated in the descending aorta to occlude it. The indications for REBOA include PEA arrest of brief duration attributable to exsanguination for sub-diaphragmatic source in a young, healthy patient, or severe hypovolemic shock or those in an agonal state due to non-compressible hemorrhage not responding to volume and in whom obstructive cause of shock has been ruled out. Contraindicated in prolonged arrest, suspected proximal aortic injury, advanced age/comorbidities. Controversies and evidence: High quality evidence is lacking - as it is for much of what we do and even consider standard of care in trauma. It has not been shown to improve survival, which is hard to demonstrate. Role in remote settings vs trauma centers unclear. Further refinements of indication for use are likely to occur with time and experience. Summarize - REBOA is a promising relatively new technology that may have potential to improve outcomes in the sickest of trauma patients. Reference: https://lifeinthefastlane.com/ccc/resuscitative-endovascular-balloon-occlusion-aorta-reboa/

Educational Pearls Strangulation is common in cases of domestic violence and sexual assault, and it is associated with higher mortality People who have been strangled have a higher rate of stroke due to vascular damage to carotid artery Only 50% of people who die from strangulation show external signs of trauma CTA should be done in all those who experience LOC or incontinence from strangulation 50-60sec of strangulation is all that is required to produce LOC References: http://epmonthly.com/article/clinical-focus-strangulation-and-hanging-injuries/

Authors: Don Stader, M.D & Rachael Duncan, PharmD BCPS BCCCP Educational Pearls Fentanyl patches may be abused in many ways, including changing the patches more frequently, chewing them, extracting the fentanyl in a tea, and administering them rectally. Fentanyl is very lipophilic and has a fast onset, but it has a very low bioavailability when given enterally, because it does not survive the stomach and 1st pass metabolism. It can be given IV, intranasal, through the buccal mucosa, or transdermal. When patients present with fentanyl overdose due to ingestion of a patch, it is more important to find out how long the patient had the patch in their mouth, since that is the principal form of absorption. References: http://www.medscape.org/viewarticle/518441_3

Author: Heidi Wald, MD, MSPH Associate Professor of Medicine - University of Colorado School of Medicine, Physician Advisor - Colorado Hospital Association Dr. Heidi Wald explains common misconceptions of UTI's in elderly patients and provides tips on how to properly identify them. References: Trestioreanu , Adi Lador , May-Tal Sauerbrun-Cutler and Leonard Leibovici Antibiotics for asymptomatic bacteriuria Cochrane Collaborative Online Publication Date: April 2015. Trautner BW, Bhimani RD, Amspoker AB, et al. Development and validation of an algorithm to recalibrate mental models and reduce diagnostic errors associated with catheter-associated bacteriuria. BMC Med Inform Decis Mak 2013;13:48. Trautner BW, Grigoryan L, Petersen NJ, et al. Effectiveness of an Antimicrobial Stewardship Approach for Urinary Catheter Associated Asymptomatic Bacteriuria. JAMA Intern Med 2015. D'Agata E, Loeb MB, and Mitchell. Challenges in assessing nursing home residents with advanced dementia for suspected urinary tract infections. J Am Geriatr Soc.2013 Jan;61(1):62-6. doi: 10.1111/jgs.12070. Stone ND, Ashraf MS, Calder J, et al. Surveillance definitions of infections in long-term care facilities: revisiting the McGeer criteria. Infect Control Hosp Epidemiol 2012;33:965-77.

Author: Erik Verzemnieks, M.D. Educational Pearls Posterior vitreous detachment is the tearing of the lining in the back of of the eye. Patients often present with loss of vision and floaters. Diagnosis can be made with US. This is a benign diagnosis, but 10-15% can progress to retinal detachment , so follow up with ophthalmology is recommended. References: http://www.medscape.com/viewarticle/513226

Author: Chris Holmes, M.D. Educational Pearls There's little/no data about the necessary length of an antibiotic course, nor has it proven that stopping a course of antibiotics early selects for the most resistant bugs. There's little incentive for drug companies to fund this type of study. Pro-calcitonin levels have been used in some settings to distinguish if an infection has resolved or not, but this may not be feasible in an outpatient setting. References: Llewelyn, Martin J et al. The antibiotic course has had its day. 2017. BMJ

Author: Nick Hatch, M.D. Educational Pearls Photic or solar retinitis occurs when you stare at the sun. The refractive power of the lens of the eye concentrates the light of the sun on the retina, stimulating the production of free radicals, damaging photoreceptors. Solar retinitis may present hours-days after light exposure. Patients will present with patchy loss of vision without pain, since the retina has no pain receptors. In one study during an eclipse in the UK, of those who initially presented with vision loss due to solar retinitis, 92% recovered full vision. References: Dobson R. UK hospitals assess eye damage after solar eclipse. BMJ : British Medical Journal. 1999;319(7208):469.

Author: Sam Killian, M.D. Educational Pearls The tongue blade test is done for mandible fractures, which make up 40-60% of facial fractures. The test is done by having the patient bite down on a tongue depressor on one side of the mouth. The provider then tries to snap the tongue depressor. This is repeated on the other side of the mouth. The test is positive if the patient complains of pain before the depressor can be broken on either side. It has been compared to CT and X-ray and has a similar sensitivity and specificity (95% and 65%, respectively). References: J. Neiner, et al. Tongue Blade Bite Test Predicts Mandible Fractures. Craniomaxillofac Trauma Reconstr. 2016

Author: Rachel Beham, PharmD, Advanced Clinical Pharmacist – Emergency Medicine Educational Pearls Cyanide poisoning is suspected in patients who present with lactic acidosis after being trapped around burning household objects. It affects our ability to metabolize and can quickly lead to CV collapse and death. Because cyanide blood levels are not quickly available, the diagnosis is made by history and lactic acidosis on ABG. The cyanokit is the key treatment. It contains hydroxocobalamin, which binds to cyanide so it can be excreted. One side effect to be aware of is that the cyanokit will turn everything red, including mucous membranes, saliva, urine, and skin. This will interfere with some lab values, so make sure to get labs before administration. References: Mégarbane B, et al. Antidotal treatment of cyanide poisoning. J Chin Med Assoc. 2003

Author: Rachael Duncan, PharmD BCPS BCCCP Educational Pearls Desmopressin is an ADH mimetic and helps retain water, release von Willibrand Factor (in high doses), and treat diabetes insipidus (in low doses). It can also be used in renal colic, because it may reduce muscle spasm in the ureters. The dosing for renal colic is very small (40 micrograms). References: http://reference.medscape.com/drug/ddavp-stimate-noctiva-desmopressin-342819

Author: Jared Scott, M.D. Educational Pearls Overall, medical providers are bad at detecting pulses. However, only 2% of patients do not have a detectable DP pulse. In one study, for patients with limb claudication, there was only about 50% agreement on the presence of a DP pulse. References: Brearley et al. Peripheral pulse palpation: an unreliable physical sign. Annals of the Royal College of Surgeons of England. 1992

Author: Aaron Lessen, M.D. Educational Pearls Traditionally the family is removed from the room during procedures and codes, but recent research shows that family presence may be beneficial. 50% patients want family present during a code. Family-related outcomes were improved with presence. There was no change in medical outcomes, and no increased incidence of medicolegal issues. References: Jabre et al. Family Presence during Cardiopulmonary Resuscitation. NEJM. 2013.

Author: Michael Hunt, M.D. Educational Pearls In the recent YEARS study, investigators checked every patient with suspicion for PE with a D-dimer, using a modified Wells score for risk stratification. The goal of the study was to show that CT scan usage could safely reduced using this screening method. The Wells Criteria measures they used to stratify risk were: PE mostly likely dx, hemoptysis, and evidence of DVT. If the d-dimer was 1, but the patient had none of the Wells criteria, the patient did not get a CT. If the patient had any of the criteria, but the d-dimer was only 0.5, the patient did not get a CT scan. The investigators reduced CT usage by 14% using the new criteria, with no significant increase in morbidity and mortality. References: van der Hulle et al. Simplified diagnostic management of suspected pulmonary embolism (the YEARS study): a prospective, multicentre, cohort study. The Lancet. 2017

Author: Jared Scott, M.D. Educational Pearls The foramen ovale (FO) connects the left and right atria to allow oxygenated blood to bypass the developing lungs, it usually closes at birth but for some it remains patent (PFO). A PFO allows clots to cross from the venous to arterial circulation, increasing the likelihood of stroke. PFO is present in 25% of general population, present in 50% of those with stroke of unknown cause, and very common those with stroke under 50 years old. Treat with anticoagulation or surgical correction. References: http://www.heart.org/HEARTORG/Conditions/More/CardiovascularConditionsofChildhood/Patent-Foramen-Ovale-PFO_UCM_469590_Article.jsp#.WarsZZN95E4

Author: Don Stader, M.D. Educational Pearls Ear pain is a common complaint in adults and kids. A red, hot, painful ear with involvement of the pinna could indicate perichondritis - an infection of the cartilage that is usually caused by pseudomonas. A painful, swollen ear with involvement of the mastoid process could be mastoiditis, which needs to be treated with IV antibiotics to avoid cerebellar abscess. Ear pain with significant drainage and a cranial nerve deficit points to malignant otitis externa, which needs to be treated with IV antibiotics. References: John W. Ely, Marlan R. Hansen, Elizabeth C. Clark. Diagnosis Of Ear Pain. 2008. American Family Physician.

Author: Nick Hatch, M.D. Educational Pearls A recent observational cohort study found that the biggest predictor for sepsis survival was fever. Those with higher fevers had better outcomes. Some possible explanations for this finding are that high fevers indicate good immune response or that high fever cued providers to treat sepsis more aggressively. References: Paul J Young, Rinaldo Bellomo. Fever in Sepsis: is it cool to be hot?. 2014. Critical Care

Author: Dylan Luyten, M.D. Educational Pearls Hypoglycemia is very common in type 2 diabetics, and is often caused by insulin overdose or missed meals. Knowing the peak time of action for common diabetes medications can help inform treatment and disposition. Regular insulin's action peaks around 60 minutes. By the time most of these patients present to the ED, the drug has had most of its effect. Lantis' action does not peak, and will continue to exert its effect for 12 or more hours. Levamir has a peak around 6-8 hours. Metformin sensitizes tissues to insulin, so it cannot cause hypoglycemia alone. Glipizides have half-lives over 12 hours and work by increasing insulin release by the pancreas. Hypoglycemia in a patient taking a glipizide usually indicates there is another medical issue interfering with clearance References: http://emedicine.medscape.com/article/122122-workup

Author: Nick Hatch, M.D. Educational Pearls The force required to break a clavicle is significant, so clavicle fracture may be associated with other injury (pneumothorax, vascular injury). Most fractures occur in the middle 1/3 of the clavicle. Traditionally, clavicle fractures have been managed without surgery. However, recent studies have shown that surgery may be beneficial in a larger population than previously thought. References: http://emedicine.medscape.com/article/398799-overview