Emergency Medical Minute

Contributor: Chris Holmes, MD Educational Pearls: Parkland Formula: 4 mL x [Total Body Surface Area Burned (%)] x [body weight (kg)] given in 24 hours 50% given over 8 hours and 50% given over the next 16 hours Brooke Formula: 2 mL x [Total Body Surface Area Burned (%)] x [body weight (kg)] given in 24 hours 50% given over 8 hours and 50% given over the next 16 hours 2009 military study evaluated Parkland vs. Brooke formulas for severe burn patients and found the outcomes were the same Guidelines are in flux on which formula to use, but reducing the overall volume using the Brooke formula can be done without significant change in morbidity or mortality Using fluid responsiveness by measuring urine output and signs of fluid overload can help guide overall resuscitative approach in burn patients References Chung KK, Wolf SE, Cancio LC, et al. Resuscitation of severely burned military casualties: fluid begets more fluid. J Trauma. 2009;67(2):231-237. doi:10.1097/TA.0b013e3181ac68cf Schaefer TJ, Nunez Lopez O. Burn Resuscitation And Management. [Updated 2021 Aug 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430795/ Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD ********************* The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at https://emergencymedicalminute.org/cme-courses/ and create an account. Donate to EMM today! Diversity and Inclusion Award

Educational Pearls: Recent updates to treatment guidelines increased the 250 mg ceftriaxone IM dose to 500 mg ceftriaxone IM IM dosing can be very painful, so other methods of administration can help decrease pain for patients Using IV ceftriaxone instead of IM has no significant difference in pharmacokinetics or bioavailability, so it can be considered in patients with an IV already placed References St Cyr S, Barbee L, Workowski KA, et al. Update to CDC's Treatment Guidelines for Gonococcal Infection, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(50):1911-1916. Published 2020 Dec 18. doi:10.15585/mmwr.mm6950a6 Product Information: ROCEPHIN(R) IV, IM injection, ceftriaxone sodium IV, IM injection. Genentech USA, Inc. (per Manufacturer), South San Francisco, CA, 2010. Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at https://emergencymedicalminute.org/cme-courses/ and create an account. Donate to EMM today! Diversity and Inclusion Award

Contributor: Jared Scott, MD Educational Pearls: A press release from Merck introduced Molnupiravir for treatment of mild to moderate COVID-19 The yet to be published study is a randomized control trial at around 100 different sites Reported outcomes were hospitalization and mortality from COVID and mortality from COVID Molnupiravir was found to be twice as effective as placebo looking at these two endpoints (7% vs. 14%) 5 day course of the drug taken twice per day costs $700, but cost-saved from using this drug was $32,000 per patient References https://www.merck.com/news/merck-and-ridgebacks-investigational-oral-antiviral-molnupiravir-reduced-the-risk-of-hospitalization-or-death-by-approximately-50-percent-compared-to-placebo-for-patients-with-mild-or-moderat/ https://www.merck.com/news/merck-and-ridgebacks-molnupiravir-an-oral-covid-19-antiviral-medicine-receives-first-authorization-in-the-world/ Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at https://emergencymedicalminute.org/cme-courses/ and create an account. Donate to EMM today! Diversity and Inclusion Award

Contributor: Nick Tsipis, MD Educational Pearls: Meaningful survival under 10% for out of hospital cardiac arrest The most common cause of out-of-hospital cardiac arrest is due to cardiac ischemia Study looked at whether taking patients without ST elevation who had an out-of-hospital cardiac arrest with return of spontaneous circulation (ROSC) should receive angiography upon arrival to the hospital Took 530 patients and randomized to early vs. delayed angiography after resuscitation from out-of-hospital arrest Found no benefit to early angiography using 30-day all-cause risk of death as the primary endpoint References Desch S, Freund A, Akin I, et al. Angiography after Out-of-Hospital Cardiac Arrest without ST-Segment Elevation [published online ahead of print, 2021 Aug 29]. N Engl J Med. 2021;10.1056/NEJMoa2101909. doi:10.1056/NEJMoa2101909 Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at https://emergencymedicalminute.org/cme-courses/ and create an account. Donate to EMM today! Diversity and Inclusion Award

Contributor: Aaron Lessen, MD Educational Pearls: Classically, diverticulitis is diagnosed via CT scan and patients are discharged home on antibiotics if they are without complication The DINAMO study is a multicenter open-label RCT that evaluated if it is safe to not give antibiotics to patients with mild acute diverticulitis Found no difference in readmission, return visits to ED, pain control, or likelihood of surgical intervention between the group that was sent home with antibiotics and the group without Medical societies have not reached a consensus on this issue, likely further studies need to be completed References Mora-López L, Ruiz-Edo N, Estrada-Ferrer O, et al. Efficacy and Safety of Nonantibiotic Outpatient Treatment in Mild Acute Diverticulitis (DINAMO-study): A Multicentre, Randomised, Open-label, Noninferiority Trial. Ann Surg. 2021;274(5):e435-e442. doi:10.1097/SLA.0000000000005031 *Image from Hellerhoff, CC BY-SA 3.0 https://creativecommons.org/licenses/by-sa/3.0>, via Wikimedia Commons Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at https://emergencymedicalminute.org/cme-courses/ and create an account. Donate to EMM today! Diversity and Inclusion Award

Contributor: Peter Bakes, MD Educational Pearls: Ophthalmia Neonatorum encompasses any conjunctivitis that presents within the first 28 days of life Neonates often receive prophylactic silver nitrate eye drops for gonorrhea prophylaxis, but the drops can cause chemical conjunctivitis Etiology & Timing of Presentation: Silver nitrate conjunctivitis presents 0-2 days after birth Neisseria gonorrhae presents 2-5 days after birth Chlamydia trachomatis presents 5 days to 5 weeks Neisseria gonorrhoeae conjunctivitis is vision-threatening, typically requiring admission and IV antibiotics with a 3rd generation cephalosporin References Castro Ochoa KJ, Mendez MD. Ophthalmia Neonatorum. [Updated 2021 Jul 22]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK551572/ US Preventive Services Task Force, Curry SJ, Krist AH, et al. Ocular Prophylaxis for Gonococcal Ophthalmia Neonatorum: US Preventive Services Task Force Reaffirmation Recommendation Statement. JAMA. 2019;321(4):394-398. doi:10.1001/jama.2018.21367 Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at https://emergencymedicalminute.org/cme-courses/ and create an account. Donate to EMM today! Diversity and Inclusion Award

Contributor: Aaron Lessen, MD Educational Pearls: Preterm deliveries in the ED can be complex and preventing hypothermia is essential to the health of the baby Recent meta-analysis examined methods for warming preterm deliveries to prevent hypothermia The most effective way to warm the baby is by wrapping them in plastic References Abiramalatha T, Ramaswamy VV, Bandyopadhyay T, et al. Delivery Room Interventions for Hypothermia in Preterm Neonates: A Systematic Review and Network Meta-analysis. JAMA Pediatr. 2021;175(9):e210775. doi:10.1001/jamapediatrics.2021.0775 Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at https://emergencymedicalminute.org/cme-courses/ and create an account. Donate to EMM today! Diversity and Inclusion Award

Contributor: Don Stader, MD Educational Pearls: Ivermectin is a Nobel-Prize winning antiparasitic used to treat filariasis and onchocerciasis Ivermectin is receiving press due to a scientific study examining ivermectin on COVID-19 viral replication in vitro, but the dosages needed for this effect were much higher than is safe for human use Ivermectin has since been studied in humans with no evidence suggesting it is a viable treatment for COVID-19 Ivermectin is a neurotoxin but at normal levels it does not cross the blood-brain barrier Ivermectin toxicity can include altered mental status, seizures, coma, tachycardia, hypotension, nausea, vomiting and diarrhea Treatment of suspected ivermectin overdose is predominately supportive References Caly L., Druce J.D., Catton M.G., Jans D.A., Wagstaff K.M. The FDA-approved drug ivermectin inhibits the replication of SARS-CoV-2 in vitro. Antivir Res. 2020;178:104787. doi: 10.1016/j.antiviral.2020.104787 López-Medina E, López P, Hurtado IC, et al. Effect of Ivermectin on Time to Resolution of Symptoms Among Adults With Mild COVID-19: A Randomized Clinical Trial. JAMA. 2021;325(14):1426–1435. doi:10.1001/jama.2021.3071 Roder JD, Stair EL. An overview of ivermectin toxicosis. Vet Hum Toxicol. 1998;40(6):369-370. Roman YM, Burela PA, Pasupuleti V, Piscoya A, Vidal JE, Hernandez AV. Ivermectin for the treatment of COVID-19: A systematic review and meta-analysis of randomized controlled trials [published online ahead of print, 2021 Jun 28]. Clin Infect Dis. 2021;ciab591. doi:10.1093/cid/ciab591 Chandler RE. Serious Neurological Adverse Events after Ivermectin-Do They Occur beyond the Indication of Onchocerciasis?. Am J Trop Med Hyg. 2018;98(2):382-388. doi:10.4269/ajtmh.17-0042 Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at https://emergencymedicalminute.org/cme-courses/ and create an account. Donate to EMM today! Diversity and Inclusion Award

Contributor: Alec Coston, MD Educational Pearls: Flash pulmonary edema or Sympathetic Crash Acute Pulmonary Edema (SCAPE) is a severe illness that requires aggressive treatment Often in patients with heart failure and a sympathetic surge increasing heart rate, decreased diastolic filling, increased preload, and increased afterload causing pulmonary edema Clinical diagnosis: acute onset diaphoresis and respiratory distress, hypoxia and tachypnea on exam Bedside lung ultrasound will demonstrate B-lines, indicative of pulmonary edema Treatment is nitroglycerin and BiPAP Nitroglycerin drip can be started at 80 micrograms/minute, which is similar to the dose delivered by sublingual nitroglycerin References Stemple K, DeWitt KM, Porter BA, Sheeser M, Blohm E, Bisanzo M. High-dose nitroglycerin infusion for the management of sympathetic crashing acute pulmonary edema (SCAPE): A case series. Am J Emerg Med. 2021;44:262-266. doi:10.1016/j.ajem.2020.03.062 Agrawal N, Kumar A, Aggarwal P, Jamshed N. Sympathetic crashing acute pulmonary edema. Indian J Crit Care Med. 2016;20(12):719-723. doi:10.4103/0972-5229.195710 Wilson SS, Kwiatkowski GM, Millis SR, Purakal JD, Mahajan AP, Levy PD. Use of nitroglycerin by bolus prevents intensive care unit admission in patients with acute hypertensive heart failure. Am J Emerg Med. 2017;35(1):126-131. doi:10.1016/j.ajem.2016.10.038 Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at https://emergencymedicalminute.org/cme-courses/ and create an account. Donate to EMM today!

In this podcast, we are back again with host, Jordan Ourada, and neurosurgeon, Dr. Eddie Tsvankin as they discuss an exciting and mind-blowing array of topics pertaining to neurosurgery. Listen as Dr. Tsvankin shares his views on not only the history of neurosurgery, but also the medical, surgical, and engineering advancements that are taking place today. You'll also hear Dr. Tsvankin give intriguing details into how neurosurgeries are performed with cutting-edge technology including the exoscopes that are presently utilized at Swedish Medical Center. Finally, Jordan and Dr. Tsvankin delve into predictions for future advancements in neurosurgery and neurooncology, as well as why cancer seems more prevalent today than ever. The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at https://emergencymedicalminute.org/cme-courses/ and create an account. Donate to EMM today! Diversity and Inclusion Award

Contributor: Donald Stader, MD Educational Pearls: Hip Dislocation Prolonged dislocations can impair blood supply to femoral head Hip dislocation for >6 hours puts patient at high risk for needing a hip replacement in the next two year Knee Dislocation High mechanism Often looks anatomically normal on knee x-ray Vascular injuries of the popliteal artery can cause significant morbidity with some studies suggesting an 80% amputation rate if not treated within 6 hours Ankle Dislocation Common dislocation and often co-occurs with ankle fractures (bimalleolar/trimalleolar) Pressure on the skin from the displaced joint can cause skin tenting, which can lead to skin necrosis Hematoma blocks work well for ankle reductions as an adjunct to or substitute for procedural sedation References Arnold C, Fayos Z, Bruner D, Arnold D. Managing dislocations of the hip, knee, and ankle in the emergency department. Emerg Med Pract. 2017;19(12):1-28. Dawson-Amoah K, Raszewski J, Duplantier N, Waddell BS. Dislocation of the Hip: A Review of Types, Causes, and Treatment. Ochsner J. 2018;18(3):242-252. doi:10.31486/toj.17.0079 Patterson BM, Agel J, Swiontkowski MF, Mackenzie EJ, Bosse MJ; LEAP Study Group. Knee dislocations with vascular injury: outcomes in the Lower Extremity Assessment Project (LEAP) Study. J Trauma. 2007;63(4):855-858. doi:10.1097/TA.0b013e31806915a7 Ross A, Catanzariti AR, Mendicino RW. The hematoma block: a simple, effective technique for closed reduction of ankle fracture dislocations. J Foot Ankle Surg. 2011;50(4):507-509. doi:10.1053/j.jfas.2011.04.037 Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

Contributor: Dylan Luyten, MD Educational Pearls: To place a Blakemore/Minnesota Tube: Insert into esophagus under visualization Inflate gastric port with 60 cc of air and obtain a chest xray to ensure the balloon below the diaphragm Once confirmed, place a total of 500cc of air into the gastric balloon via the gastric port Tie a liter saline bad to the tube using Kerlix and hang it off an IV pole or other object to provide about 2 lbs of traction Now the the tube is in place under traction, attach a manometer to the esophageal balloon port Provide low pressure to tamponade a variceal bleed, which is about 33 mmHg This is a temporizing measure and often patients need to get a Transjugular Intrahepatic Portosystemic Shunt (TIPS) from interventional radiology for more definitive treatment References Powell M, Journey JD. Sengstaken-Blakemore Tube. [Updated 2021 Jul 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK558924/ Amazing video of placement by EM:RAP ProductionsPlacement of a Minnesota Tube for Bleeding Varices Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at https://emergencymedicalminute.org/cme-courses/ and create an account. Donate to EMM today!

On this episode of On The Streets, host, Jordan Ourada sits down with neurosurgeon/neurooncologist Dr. Eddie Tsvankin to discuss various topics concerning neurosurgery and how EMS workers in the field can better understand and manage neurological emergencies. In this episode specifically, you'll hear Jordan and Dr. Tsvankin discuss topics including: Priorities in caring for patients experiencing seizures Short and long-term complications of tumor resection surgery Specifics on how brain tumors are operated on and the difficult decisions that must be made ahead of time Assessment of post-operative incisions and signs of infections How chemotherapy and radiation effect the healing process for neurosurgery patients Dr. Eddie's thoughts on COVID and how it has impacted his career The ins and outs of ventriculoperitoneal shunts The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at https://emergencymedicalminute.org/cme-courses/ and create an account. Donate to EMM today! Diversity and Inclusion Award

Contributor: Dylan Luyten, MD Educational Pearls: Minnesota Tube has an extra port for suctioning otherwise is the same as a Blakemore Tube Indicated in MASSIVE upper GI bleeding often due to esophageal varices Esophageal varices are dilated, tortuous vessels in the esophagus due to increased portal venous pressure that can bleeding into the upper GI tract Patients with massive upper GI bleed should be intubated prior to placing a Blakemore/Minnesota tube References Meseeha M, Attia M. Esophageal Varices. [Updated 2021 Aug 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448078/ Biecker E. Portal hypertension and gastrointestinal bleeding: diagnosis, prevention and management. World J Gastroenterol. 2013;19(31):5035-5050. doi:10.3748/wjg.v19.i31.5035 Powell M, Journey JD. Sengstaken-Blakemore Tube. [Updated 2021 Jul 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK558924/ Photo from Wikimedia Commons Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at https://emergencymedicalminute.org/cme-courses/ and create an account. Donate to EMM today! Check out our Diversity and Inclusion Award

Contributor: Ricky Dhaliwal, MD Educational Pearls: Multiple RCTs and a Cochrane Review found there is no difference in wound infection rates when irrigating with tap water Pressure of the water and how extensively the wound is irrigated were the most important factors affecting infection rates Quantity and type of water were independently not as important References Fernandez R, Griffiths R. Water for wound cleansing. Cochrane Database Syst Rev. 2012;(2):CD003861. Published 2012 Feb 15. doi:10.1002/14651858.CD003861.pub3 Lewis K, Pay JL. Wound Irrigation. [Updated 2021 Jun 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK538522/ Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at https://emergencymedicalminute.org/cme-courses/ and create an account. Donate to EMM today!

Contributor: Aaron Lessen, MD Educational Pearls: Patients with acute renal failure often need medical management for hyperkalemia Those with severe electrolyte derangements or absent renal function may need emergent dialysis as well Dialysis catheters are 12 or 14 french catheters placed in the right internal jugular or left subclavian Placement is very similar to a central line or cordis catheter Trialysis catheter is one option that has an extra port that can be used for regular medication administration and drawing blood Do not default to use dialysis catheters for normal ED access due to risk of infection and clot development While dialysis catheters are typically reserved for dialysis only, they can be used in extreme circumstances, such as a cardiac arrest References Co I, Gunnerson K. Emergency Department Management of Acute Kidney Injury, Electrolyte Abnormalities, and Renal Replacement Therapy in the Critically Ill. Emerg Med Clin North Am. 2019;37(3):459-471. doi:10.1016/j.emc.2019.04.006 Simon LV, Hashmi MF, Farrell MW. Hyperkalemia. [Updated 2021 Aug 14]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470284/ Akaraborworn O. A review in emergency central venous catheterization. Chin J Traumatol. 2017;20(3):137-140. doi:10.1016/j.cjtee.2017.03.003 Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at https://emergencymedicalminute.org/cme-courses/ and create an account. Donate to EMM today!

Contributor: Aaron Lessen, MD Educational Pearls: Hyperkalemia can cause EKG changes such as a widened QRS The fastest electrolyte results can be obtained off a VBG with electrolytes or point-of-care labs Hyperkalemia may be reported as "hemolyzed" which indicated lysis of red blood cells and artificial elevation of the potassium level. However, always keep in mind the clinical context and look at other metabolic abnormalities like creatinine and BUN for other clues that it may actually not be hemolyzed References Co I, Gunnerson K. Emergency Department Management of Acute Kidney Injury, Electrolyte Abnormalities, and Renal Replacement Therapy in the Critically Ill. Emerg Med Clin North Am. 2019;37(3):459-471. doi:10.1016/j.emc.2019.04.006 Simon LV, Hashmi MF, Farrell MW. Hyperkalemia. [Updated 2021 Aug 14]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470284/ Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at https://emergencymedicalminute.org/cme-courses/ and create an account. Donate to EMM today!

Contributor: Nick Tsipis, MD Educational Pearls: Fluid choice may have an impact on outcomes in resuscitation, and a meta-analysis has relevant insight into their use in sepsis and trauma patients Large volume normal saline fluid resuscitation in sepsis is associated with acute kidney injury and metabolic acidosis compared to Lactated Ringers Choice of fluid did not have significant differences in trauma patients for initial resuscitation References Tseng CH, Chen TT, Wu MY, Chan MC, Shih MC, Tu YK. Resuscitation fluid types in sepsis, surgical, and trauma patients: a systematic review and sequential network meta-analyses. Crit Care. 2020;24(1):693. Published 2020 Dec 14. doi:10.1186/s13054-020-03419-y The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at https://emergencymedicalminute.org/cme-courses/ and create an account. Donate to EMM today!

Contributor: Nick Hatch, MD Educational Pearls: High flow nasal cannula (HFNC) or "heated high flow" can deliver higher oxygen levels than nasal cannula It typically is used as an "intermediate" between oxygen via nasal cannula and other non-invasive positive pressure devices, such as BiPAP Can modify both the FiO2 and flow rate Maximum flow rate is typically 60 liters per minute (compare that to a typical breath that is 30-40 L/min) Humidification of HFNC is important due to risk of epistaxis from drying out the nasal mucosa Large energy expenditure to humidify airflow by a patient in respiratory distress, so humidified oxygen may help decrease this metabolic demand References Nishimura M. High-Flow Nasal Cannula Oxygen Therapy in Adults: Physiological Benefits, Indication, Clinical Benefits, and Adverse Effects. Respir Care. 2016;61(4):529-541. doi:10.4187/respcare.04577 Hacquin A, Perret M, Manckoundia P, et al. High-Flow Nasal Cannula Oxygenation in Older Patients with SARS-CoV-2-Related Acute Respiratory Failure. J Clin Med. 2021;10(16):3515. Published 2021 Aug 10. doi:10.3390/jcm10163515 Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at https://emergencymedicalminute.org/cme-courses/ and create an account. Donate to EMM today!

Contributor: Aaron Lessen, MD Educational Pearls: Randomized controlled-trial evaluated intradermal injections of sterile water to manage low back pain versus an IV NSAID Four intradermal injections of 0.1 cc sterile water in a square around the area of musculoskeletal pain Reduction of pain was 7 points with the procedure and 2 points with the IV NSAID at 24 hours 12% in the injection group versus 50% in the IV NSAID group needed opioids 87% patient satisfaction in the injection group versus 16% patient satisfaction in the IV NSAID group References Tekin E, Gur A, Bayraktar M, Ozlu I, Celik BK. The effectiveness of intradermal sterile water injection for low back pain in the emergency department: A prospective, randomized controlled study. Am J Emerg Med. 2021;42:103-109. doi:10.1016/j.ajem.2021.01.038 Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at https://emergencymedicalminute.org/cme-courses/ and create an account. Donate to EMM today!

Contributor: Don Stader, MD Educational Pearls: Those on chronic opioid therapy may have high tolerance to opioids and/or opioid hyperalgesia Ketamine is a good adjunct for pain control in patients on chronic opioid therapy To avoid the time constraints often required to push ketamine intravenously, it can be given orally: Ketamine IV 25-50 mg (~0.01-0.03 mg/kg) as a single dose by mouth References Blonk M, Koder B, et al. Use of oral ketamine in chronic pain management: A review. European Journal of Pain. 2009. Schwenk ES, et al. Consensus guidelines on the use of intravenous ketamine infusions for acute pain management from the America Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine and the American Society of Anesthesiologists. Reg Anesth Pain Med. 2018. Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at https://emergencymedicalminute.org/cme-courses/ and create an account. Donate to EMM today!

Contributor: Aaron Lessen, MD Educational Pearls: Retrospective cohort study in the Kaiser system looked at over 4 million patients receiving antibiotics to determine the effect of penicillin allergy prompts in the EHR on antibiotic prescribing Half of the sites removed prompts stating penicillin allergy and half kept the prompts Patients with penicillin allergies who received cephalosporins went up from 20% to 27% in areas where the prompt was remove No difference in mortality or no new allergies found between the two groups Reduced the use of fluoroquinolones and clindamycin in the group without the prompt References Macy E, McCormick TA, Adams JL, et al. Association Between Removal of a Warning Against Cephalosporin Use in Patients With Penicillin Allergy and Antibiotic Prescribing. JAMA Netw Open. 2021;4(4):e218367. Published 2021 Apr 1. doi:10.1001/jamanetworkopen.2021.8367 Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at https://emergencymedicalminute.org/cme-courses/ and create an account. Donate to EMM today!

Dr. Glenda Quan, trauma surgeon from Swedish Medical Center joins our host Jordan Ourada to review a case of an incorrectly placed IO and how to avoid it. The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at https://emergencymedicalminute.org/cme-courses/ and create an account.

Contributor: Aaron Lessen, MD Educational Pearls: Insulin pumps provide a continuous infusion of fast-acting insulin using a basal rate and bolus prior to meals Some connect to a continuous glucometer but often blood glucose needs to be checked manually Hypoglycemia is rarely due to a malfunctioning pump - there is usually an another external factor Hyperglycemia can be caused by underdosing, illness, pump malfunction or expired insulin The pump can be used to give a bolus of insulin in the emergency department if necessary Stopping the device can be done manually on the device or disconnecting it from the tubing attachment - do not remove the tubing from the skin site if possible References Nimri R, Nir J, Phillip M. Insulin Pump Therapy. Am J Ther. 2020;27(1):e30-e41. doi:10.1097/MJT.0000000000001097 Sora ND, Shashpal F, Bond EA, Jenkins AJ. Insulin Pumps: Review of Technological Advancement in Diabetes Management. Am J Med Sci. 2019;358(5):326-331. doi:10.1016/j.amjms.2019.08.008 Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at https://emergencymedicalminute.org/cme-courses/ and create an account. Donate to EMM today!

Contributor: Nick Tsipis, MD Educational Pearls: Prospective trial studied 5 mg IM droperidol to 10 mg IM olanzapine (Zyprexa) in the reducing levels of agitation Time to adequate sedation was about 16 minutes for both agents Droperidol was slightly less sedating than olanzapine and length of stay for olanzapine was longer Olanzapine had a higher rate of requiring another agent for adequate sedation Droperidol had a higher rate of adverse events (mainly extrapyramidal symptoms) than olanzapine Remember to put the safety of the staff and patient at the forefront of sedation practices and be cognizant of the psychological effect of giving involuntary medications to patients References Cole JB, Stang JL, DeVries PA, Martel ML, Miner JR, Driver BE. A Prospective Study of Intramuscular Droperidol or Olanzapine for Acute Agitation in the Emergency Department: A Natural Experiment Owing to Drug Shortages. Ann Emerg Med. 2021;78(2):274-286. doi:10.1016/j.annemergmed.2021.01.005 Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at https://emergencymedicalminute.org/cme-courses/ and create an account. Donate to EMM today!

Contributor: Jared Scott, MD Educational Pearls: Using LET, procedural sedation, and distraction techniques are often needed to successfully perform painful procedures in pediatrics patients The technique of clown therapy has been studied as an adjunct to LET and other distraction techniques for procedures in pediatric patients One randomized-controlled trial from 2016 found anxiety was greatly reduced using medical clown therapy to aid in painful procedures in pediatrics patients References Felluga M, Rabach I, Minute M, et al. A quasi randomized-controlled trial to evaluate the effectiveness of clowntherapy on children's anxiety and pain levels in emergency department. Eur J Pediatr. 2016;175(5):645-650. doi:10.1007/s00431-015-2688-0 Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at https://emergencymedicalminute.org/cme-courses/ and create an account. Donate to EMM today!

Contributor: Peter Bakes, MD Educational Pearls: Paracentesis is a procedure where fluid is removed from the peritoneal cavity by needle Indications for paracentesis include: large volume paracentesis (5-6L), diagnosis of transudative or exudative ascites, evaluation for spontaneous bacterial peritonitis (SBP) Infection of ascitic fluid is more likely in transudative processes due to the increased frequency of paracentesis E coli is the most common pathogen to cause SBP Treatment with 3rd generation cephalosporin, like ceftriaxone References Aponte EM, Katta S, O'Rourke MC. Paracentesis. [Updated 2020 Sep 9]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK435998/ Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

Contributor: Aaron Lessen, MD Educational Pearls: Sigmoid volvulus occurs when the sigmoid colon twists 180 to 360 degrees 10% of intestinal obstructions in the US; 50-70% of intestinal obstructions worldwide More common in elderly patients with chronic constipation Eventually may lead to bowel perforation, a surgical emergency Treatment is sigmoidoscopy or sigmoid colectomy References Lieske B, Antunes C. Sigmoid Volvulus. [Updated 2021 Aug 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441925/ Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at https://emergencymedicalminute.org/cme-courses/ and create an account. Donate to EMM today!

Contributor: Ramnik Dhaliwal, MD JD Educational Pearls: Pepper spray is a highly irritating compound with active ingredient of capsaicin Techniques to help decontaminate and alleviate symptoms of an exposure include: Disrobing the patient to prevent further exposure Half milk of magnesia and half water mixture can be used to soothe the skin in the area of exposure Proparacaine followed by Morgan lens to irrigate the eye in adults Nasal cannula connected to a liter of normal saline can passively irrigate the eye in small children and other less than cooperating patients References Tidwell RD, Wills BK. Tear Gas and Pepper Spray Toxicity. [Updated 2020 Nov 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK544263/ Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

Contributor: Neil Cella, MD Educational Pearls: Pylorus becomes hypertrophied and does not allow food or liquid to pass through to the duodenum tOccurs between the ages of 3 weeks to 3 months Classic presentation includes projectile nonbilious vomiting and palpable abdominal mass Ultrasound can visualize/diagnose pyloric stenosis and the treatment is surgical correction Be aware that electrolyte abnormalities and acid/base disturbances may occur References Garfield K, Sergent SR. Pyloric Stenosis. [Updated 2021 Feb 6]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK555931/ Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

Contributor: Adam Barkin, MD Educational Pearls: Multi-center open-label non-inferiority trial looked at treatment of pneumothorax with a small-bore chest tube versus conservative management with exceptional follow up 316 patients ages 14-50 with moderate to large pneumothorax (>32% measured on CXR) were randomized into one of the two treatment arms 15% of the conservative group required further intervention as determined by prespecified protocols 94.4% of the intervention group had resolution at 8 weeks, whereas 98.5% of the conservative group had resolution at 8 weeks These data were affected by poor follow up CXR resolution average of 16 days in the intervention group and 30 days in the conservative group Symptom resolution was similar between the two groups (median 15 days vs. 14 days) Recurrence at 12 months was 17% in interventional group vs 8% in conservative group 41 adverse events in intervention group and 13 adverse events in conservative group References Brown SGA, Ball EL, Perrin K, et al. Conservative versus Interventional Treatment for Spontaneous Pneumothorax. N Engl J Med. 2020;382(5):405-415. doi:10.1056/NEJMoa1910775 Franzen, D. (2019, November). Pneumothorax. Society of Academic Emergency Medicine. https://www.saem.org/about-saem/academies-interest-groups-affiliates2/cdem/for-students/online-education/m4-curriculum/group-m4-respiratory/pneumothorax. Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at https://emergencymedicalminute.org/cme-courses/ and create an account. Donate to EMM today!

Contributor: Randi Libbon, MD The Core features of trauma-informed care include: Patient empowerment, choice and collaboration. This means educating patients and allowing patients to make choices about their care when possible. Collaboration helps to level the power differential between patients and providers through shared decision making. Safety and sensitivity: Developing health care settings and activities that ensure patients' physical and emotional safety taking into account their diverse backgrounds of gender, sexuality, race, culture, and ethnicity Trustworthiness and transparency: Creating clear expectations with patients about what proposed treatments entail, who will provide services, and how care will be provided. Resources: Reeves E. A synthesis of the literature on trauma-informed care. Issues Ment Health Nurs. 2015;36(9):698-709. doi: 10.3109/01612840.2015.1025319. PMID: 26440873. Molloy L, Fields L, Trostian B, Kinghorn G. Trauma-informed care for people presenting to the emergency department with mental health issues. Emerg Nurse. 2020 Mar 10;28(2):30-35. doi: 10.7748/en.2020.e1990. Epub 2020 Feb 25. PMID: 32096370. Key ingredients for Trauma-informed care from SAMHSA https://www.samhsa.gov/sites/default/files/programs_campaigns/childrens_mental_health/atc-whitepaper-040616.pdf The National Childhood Traumatic Stress Network: https://www.nctsn.org/trauma-informed-care The Science of Adverse Childhood Events and Toxic Stress: https://www.acesaware.org/ace-fundamentals/the-science-of-aces-toxic-stress/ From the Institute for Health Care Improvement: http://www.ihi.org/communities/blogs/how-trauma-informed-care-can-help-patients-and-clinicians-during-behavioral-health-emergencies

Contributor: Neil Cella, MD Educational Pearls: 10% of patients 100.4) have an serious bacterial infection Most of these are UTIs, but also consider pneumonia and meningitis Requires CXR, LP, labs, and UA to work up cause of fever 29-60 day old well-appearing febrile infant: Can discharge without abx if CXR, lumbar puncture, labs and UA without signs of bacterial infection If UA is positive for UTI a LP is still indicated for febrile infants References Hamilton JL, Evans SG, Bakshi M. Management of Fever in Infants and Young Children. Am Fam Physician. 2020;101(12):721-729. Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

Contributor: Aaron Lessen, MD Educational Pearls: Known risk factors for being awake and paralyzed in the OR include only receiving IV medications, long-acting paralytics, and no formal monitoring system for being awake The ED-AWARENESS study, a prospective single-center study found 2.6% of patients with induced paralysis during mechanical ventilation were aware Rocuronium was a risk factor for developing awareness while paralyzed in this study Ensure adequate sedation during paralysis for mechanical ventilation in the ED setting, especially when using rocuronium References Pappal RD, Roberts BW, Mohr NM, et al. The ED-AWARENESS Study: A Prospective, Observational Cohort Study of Awareness With Paralysis in Mechanically Ventilated Patients Admitted From the Emergency Department. Ann Emerg Med. 2021;77(5):532-544. doi:10.1016/j.annemergmed.2020.10.012 Pappal RD, Roberts BW, Winkler W, Yaegar LH, Stephens RJ, Fuller BM. Awareness With Paralysis in Mechanically Ventilated Patients in the Emergency Department and ICU: A Systematic Review and Meta-Analysis. Crit Care Med. 2021;49(3):e304-e314. doi:10.1097/CCM.0000000000004824 The Emergency Medical Minute offers AMA PRA Category 1 credits™ via online course modules. For more information and to access this content,, visit our website at www.emergencymedicalminute.org/cme-courses/ and create an account. Donate to EMM today!

Contributor: Aaron Lessen, MD Educational Pearls: Recent retrospective cohort study looked at elevated BP readings in the ED and correlation to underlying hypertension Large cohort of over 30,000 patients found that nearly 50% had an elevated blood pressure reading in the ED Less than 15% of patients with elevated BP readings in the ED were diagnosed with hypertension within 2 years Only 25% of patients with BP readings >160/100 were diagnosed with hypertension within 2 years Patients with an elevated blood pressure reading of >160/100 had only a slightly increased risk of stroke, transient ischemic attack, acute coronary syndrome, heart failure, or death in the next 2 years References McAlister FA, Youngson E, Rowe BH. Elevated Blood Pressures Are Common in the Emergency Department but Are They Important? A Retrospective Cohort Study of 30,278 Adults. Ann Emerg Med. 2021;77(4):425-432. doi:10.1016/j.annemergmed.2020.11.005 Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD The Emergency Medical Minute offers AMA PRA Category 1 credits™ via online course modules. For more information and to access this content,, visit our website at www.emergencymedicalminute.org/cme-courses/ and create an account. Donate to EMM today!

Contributor: Aaron Lessen, MD Educational Pearls: Recent RCT compared pain relief in patients receiving five medications for acute musculoskeletal pain Acetaminophen 1000mg/ibuprofen 400 mg Acetaminophen 1000mg/ibuprofen 800 mg Acetaminophen 300 mg/codeine 30 mg Acetaminophen 300mg/hydrocodone 5mg Acetaminophen 325mg/oxycodone 5mg No significant difference in pain relief at 1 and 2 hours between all of 5 groups References Bijur PE, Friedman BW, Irizarry E, Chang AK, Gallagher EJ. A Randomized Trial Comparing the Efficacy of Five Oral Analgesics for Treatment of Acute Musculoskeletal Extremity Pain in the Emergency Department. Ann Emerg Med. 2021;77(3):345-356. doi:10.1016/j.annemergmed.2020.10.004 The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.org/cme-courses/ and create an account. Donate to EMM today!

Contributor: Aaron Lessen, MD Educational Pearls: Traditionally, fingernails were replaced after avulsion using sutures Sometimes artificial material was placed when the fingernail was not available Recent study evaluated treatment of fingernail avulsions pediatric patients by replacing the nail versus cleaning and putting a non-adhesive dressing No difference in the aesthetics or patient satisfaction with the new fingernail between the two treatment groups References Seiler M, Gerstenberg A, Kalisch M, Kennedy U, Scheer HS, Weber DM. Non-operative treatment versus suture refixation of the nail plate in paediatric fingernail avulsion injuries. J Hand Surg Eur Vol. 2021;46(5):523-529. doi:10.1177/1753193420965390 Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at https://emergencymedicalminute.org/cme-courses/ and create an account. Donate to EMM today!

Contributor: Aaron Lessen, MD Educational Pearls: Survey of EM physicians to self-report empathy and burnout levels and correlated with patient satisfaction scores Patient satisfaction was not affected by what the physicians thought about their level of empathy or burnout Patient satisfaction was affected by the patient's perception of empathetic behavior by the physician References Byrd J, Knowles H, Moore S, et al. Synergistic effects of emergency physician empathy and burnout on patient satisfaction: a prospective observational study [published online ahead of print, 2020 Nov 25]. Emerg Med J. 2020;emermed-2019-209393. doi:10.1136/emermed-2019-209393 Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.org/cme-courses/ and create an account. Donate to EMM today!

Contributor: Aaron Lessen, MD Educational Pearls: Kounis syndrome is an allergic acute coronary syndrome Triggers include medications (antibiotics), insect bites, or other common allergens Believed to be due to mast cell activation, inflammatory cytokines, and platelet activation causing coronary vasospasm or plaque rupture in setting of existing atherosclerosis Consider Kounis syndrome in the setting of chest pain in anaphylaxis Treatment involves treatment of allergic reaction, although epinephrine should be used cautiously Avoid morphine as this can cause mast cell activation References The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at https://emergencymedicalminute.org/cme-courses/ and create an account. Donate to EMM today!

Contributor: Peter Bakes, MD Educational Pearls: ST elevation clinical guidelines for myocardial infarction include: 2.5 mm elevation for males 2 mm elevation in males >40 in V2 and V3 1.5 mm elevation for females in V2 and V3 1 mm elevation in 2 or more contiguous leads (not V2 or V3) Differential diagnosis of ST elevation includes, but is not limited to: STEMI Electrolyte abnormalities Pericarditis/myocarditis Brugada syndrome LVH Bundle branch blocks Ventricular aneurysm References de Bliek EC. ST elevation: Differential diagnosis and caveats. A comprehensive review to help distinguish ST elevation myocardial infarction from nonischemic etiologies of ST elevation. Turk J Emerg Med. 2018;18(1):1-10. Published 2018 Feb 17. doi:10.1016/j.tjem.2018.01.008 Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.org/cme-courses/ and create an account. Donate to EMM today!

Educational Pearls: Albert Einstein had chronic abdominal pain as a middle-aged man Dr. Rudolph Nissen, founder of the Nissen fundoplication, performed exploratory surgery for this pain and found an abdominal aortic aneurysm (AAA) The only treatment for an AAA at that time was to wrap the vessel in cellophane, causing a fibrotic response to prevent rupture Einstein died 7 years after this surgery, likely from his leaking abdominal aortic aneurysm References Cervantes Castro J. Albert Einstein y su aneurisma de la aorta [Albert Einstein and his abdominal aortic aneurysm]. Gac Med Mex. 2011;147(1):74-76. Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.org/cme-courses/ and create an account. Donate to EMM today!

Contributor: Nick Hatch, MD Educational Pearls: Complete heart block or 3rd degree atrioventricular (AV) block is diagnosed via EKG and occurs when electrical signals from the sinoatrial (SA) node are blocked from reaching the ventricles via the AV node and AV bundles P waves and QRS complexes are independent Often QRS rate is around 40 The rate is slow because the ventricular purkinje fibers have an intrinsic rate of 20-40 bpm, whereas the SA node has an intrinsic rate of 60-100 bpm Treatment is usually with pacemaker, unless there is an identifiable etiology causing the heart block that can be reversed References Knabben V, Chhabra L, Slane M. Third-Degree Atrioventricular Block. [Updated 2020 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK545199/ The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.org/cme-courses/ and create an account. Donate to EMM today!

Contributor: Nick Tsipis, MD Educational Pearls: Humerus fractures can be characterized as proximal, midshaft, and distal fractures Proximal humerus fracture is the second-most common fracture in elderly patients Primary complication is with the axillary nerve and axillary artery Vast majority are managed nonoperatively with a sling, reduction usually not indicated Women comprise 70% of proximal humerus fractures, often secondary to fall with osteoporosis Midshaft humerus fractures are more often managed operatively, but can be managed nonoperatively Primary complication is with radial nerve, look for wrist drop! May require reduction and splinting Distal humerus fractures can include supracondylar fractures and involve the radius or ulna One atypical is the Holstein-Lewis fracture, that can cause radial nerve damage Management is varied depending on the exact type of distal humerus fracture Assess degree of angulation, neurovascular status, and likelihood of compartment syndrome both before and after splint application References Attum B, Thompson JH. Humerus Fractures Overview. [Updated 2020 Aug 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482281/ The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.org/cme-courses/ and create an account. Donate to EMM today!

Contributor: Peter Bakes, MD Educational Pearls: Pelvis is comprised of the iliac, ischium, and sacrum Three mechanisms for pelvic fractures by Young-Burgess Classification Anterior-posterior compression causing open-book pelvic fractures that can be complicated by retroperitoneal bleeding or urethral injury Lateral compression causing rami fractures Vertical sheer causing offset of sacroiliac joint or sacrum Mechanically stable pelvic ring fractures can be conservatively treated with weight bearing as tolerated Unstable fractures and those with complications will require operative fixation References Davis DD, Foris LA, Kane SM, et al. Pelvic Fracture. [Updated 2021 Feb 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430734/ Weatherford B. Pelvic Ring Fractures. OrthoBullets. Updated 25 May 2021. https://www.orthobullets.com/trauma/1030/pelvic-ring-fractures The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.org/cme-courses/ and create an account. Donate to EMM today!

Contributor: Ricky Dhaliwal, MD Educational Pearls: CRASH 3 Trial looked at over 12,000 patients with traumatic intracranial bleeds, randomizing patients to a therapy with TXA or standard of care without TXA Dosing was 1 gram over 10 min for loading dose and then an infusion of 1 gram over 8 hours Found Improvement in survival and neurologic outcomes when patient received TXA within 3 hours References CRASH-3 trial collaborators. Effects of tranexamic acid on death, disability, vascular occlusive events and other morbidities in patients with acute traumatic brain injury (CRASH-3): a randomised, placebo-controlled trial [published correction appears in Lancet. 2019 Nov 9;394(10210):1712]. Lancet. 2019;394(10210):1713-1723. doi:10.1016/S0140-6736(19)32233-0 The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.org/cme-courses/ and create an account. Donate to EMM today!

Contributor: Chris Holmes, MD Educational Pearls: In the 1700s, boxes lined the River Thames to pump smoke up the rectum to resuscitate people who had been found unconscious in the river Sea cucumbers can extract oxygen through their rectum Perflourocarbon, a liquid that can become oxygenated, provided rectally was able to oxygenate pigs and mice in a recent study References Okabe R, Chen-Yoshikawa T, Yoneyama Y, et al. Mammalian enteral ventilation ameliorates respiratory failure. Clinical and Translational Resource and Technology Insights. 2021;2(6):773-783. doi:https://doi.org/10.1016/j.medj.2021.04.004 The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.org/cme-courses/ and create an account. Donate to EMM today!

Contributor: Ricky Dhaliwal, MD Educational Pearls: Hypotension in patients requiring intubation should be resuscitated as much as possible While intubating, the negative inspiratory pressure goes away decreasing cardiac preload and worsening hypotension Phenylephrine can be given via push doses to increase blood pressure from alpha agonism For sedation, avoid propofol with hypotension and opt for etomidate or ketamine References April MD, Arana A, Schauer SG, et al. Ketamine Versus Etomidate and Peri-intubation Hypotension: A National Emergency Airway Registry Study. Acad Emerg Med. 2020;27(11):1106-1115. doi:10.1111/acem.14063 Panchal AR, Satyanarayan A, Bahadir JD, Hays D, Mosier J. Efficacy of Bolus-dose Phenylephrine for Peri-intubation Hypotension. J Emerg Med. 2015;49(4):488-494. doi:10.1016/j.jemermed.2015.04.033 Jaber S, Amraoui J, Lefrant JY, et al. Clinical practice and risk factors for immediate complications of endotracheal intubation in the intensive care unit: a prospective, multi-center study. Crit Care Med. 2006;34:2355–61. Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD *********************

Contributor: Aaron Lessen, MD Educational Pearls: DEVT Trial, a recent non-inferiority study, looked at giving tPA prior to endovascular thrombectomy and was stopped early because there was no benefit shown to giving tPA before this intervention Coupled with the SKIP and DIRECT MT trials corroborating these findings, it appears that giving tPA prior to thrombectomy is not indicated Whether patients should receive tPA prior to transfer for thrombectomy (i.e. they are in a rural healthcare setting) is still unclear References Yang P, Treurniet KM, Zhang L, et al. Direct Intra-arterial thrombectomy in order to Revascularize AIS patients with large vessel occlusion Efficiently in Chinese Tertiary hospitals: A Multicenter randomized clinical Trial (DIRECT-MT)-Protocol. Int J Stroke. 2020;15(6):689-698. doi:10.1177/1747493019882837 Suzuki K, Matsumaru Y, Takeuchi M, et al. Effect of Mechanical Thrombectomy Without vs With Intravenous Thrombolysis on Functional Outcome Among Patients With Acute Ischemic Stroke: The SKIP Randomized Clinical Trial [published correction appears in JAMA. 2021 May 4;325(17):1795]. JAMA. 2021;325(3):244-253. doi:10.1001/jama.2020.23522 Zi W, Qiu Z, Li F, et al. Effect of Endovascular Treatment Alone vs Intravenous Alteplase Plus Endovascular Treatment on Functional Independence in Patients With Acute Ischemic Stroke: The DEVT Randomized Clinical Trial. JAMA. 2021;325(3):234-243. doi:10.1001/jama.2020.23523 Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

Contributor: Jared Scott, MD Educational Pearls: PID (pelvic inflammatory disease) occurs when the infection ascends into the uterus Tubo-ovarian abscess occurs when the infection ascends to the fallopian tubes Fitz-Hugh-Curtis syndrome occurs when the infection enters the peritoneum and causes peritoneal inflammation with peri-hepatic inflammation These conditions require GYN consultation and often more robust antibiotic therapy for treatment References Lareau SM, Beigi RH. Pelvic inflammatory disease and tubo-ovarian abscess. Infect Dis Clin North Am. 2008;22(4):693-708. doi:10.1016/j.idc.2008.05.008 Basit H, Pop A, Malik A, et al. Fitz-Hugh-Curtis Syndrome. [Updated 2021 May 7]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan. Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD

Contributor: Jared Scott, MD Educational Pearls: Recent study evaluated vaginal self swab testing for STIs to determine if they are equally sensitive to provider-obtained swab 515 patients consented to both tests and 95% agreement was found between the two methods of obtaining samples 75% of participants who preferred this over the pelvic exam, although some patients were concerned they did not perform the self swab correctly Consider vaginal self swab with proper coaching as an option for patients References Chinnock B, Yore M, Mason J, et al. Self-obtained vaginal swabs are not inferior to provider-performed endocervical sampling for emergency department diagnosis of Neisseria gonorrhoeae and Chlamydia trachomatis [published online ahead of print, 2021 Jan 18]. Acad Emerg Med. 2021;10.1111/acem.14213. doi:10.1111/acem.14213 Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.org/cme-courses/ and create an account. Donate to EMM today!