Emergency Medical Minute

Contributor: Dr. Nick Gorton, MD Educational Pearls: Use transgender people's correct names and pronouns, the Russell study found a 56% reduction in suicide behavior with chosen name usage ⅕ to ½ of transgender people report they avoided seeking care in the ED because of fear of transphobic treatment Understanding the definitions of gender identity, gender expression, assigned sex at birth, physical attraction, and emotional attraction are necessary for improving treatment of the LGBTIQ+ community Explain reasons for asking questions that address physical characteristics and/or sexual attraction Lastly, if you make a mistake simply correct the mistake, apologize, and immediately move on References Transgender Unicorn TransLine Treatment Guideline Silicone pumping handout for patients and providers https://www.ustranssurvey.org/reports Pollitt, A. M., Ioverno, S., Russell, S. T., Li, G., & Grossman, A. H. (2019). Predictors and mental health benefits of chosen name use among transgender youth. Youth & society, 0044118X19855898. Russell, S. T., Pollitt, A. M., Li, G., & Grossman, A. H. (2018). Chosen name use is linked to reduced depressive symptoms, suicidal ideation, and suicidal behavior among transgender youth. Journal of Adolescent Health, 63(4), 503-505. Samuels, E. A., Tape, C., Garber, N., Bowman, S., & Choo, E. K. (2018). "Sometimes you feel like the freak show": a qualitative assessment of emergency care experiences among transgender and gender-nonconforming patients. Annals of emergency medicine, 71(2), 170-182. Thompson-Blum, D. N., Coleman, T. A., Phillips, N. E., Richardson, S., Travers, R., Coulombe, S., ... & Davis, C. (2021). Experiences of Transgender Participants in Emergency Departments: Findings from the OutLook Study. Transgender Health. Bauer, G. R., Scheim, A. I., Deutsch, M. B., & Massarella, C. (2014). Reported emergency department avoidance, use, and experiences of transgender persons in Ontario, Canada: results from a respondent-driven sampling survey. Annals of emergency medicine, 63(6), 713-720. *Ongoing LGBTQIA+ topics are identified through collaborations with local Denver organization the Queer Umbrella as part of a new longitudinal effort to raise awareness of health disparities affecting the LGBTQIA+ community. Stay tuned as we continue to provide educational content to support this community and uplift LGBTQIA+ health providers and their practices all year long.

Contributor: Nick Tsipis, MD Educational Pearls: pH 7.45=alkalemia If pH low and pCO2 high, indicates a respiratory acidosis If pH low and pCO2 low, indicates metabolic acidosis After determining type of acidosis, check bicarb to determine compensation for acidosis and check electrolytes to calculate anion gap Metabolic acidosis can present with tachypnea (Kussmaul breathing) and hypotension due to loss of catecholamine function and suboptimal cardiac function at low pH Treat with IV fluids and address the underlying cause, limited role for bicarb References Burger MK, Schaller DJ. Metabolic Acidosis. [Updated 2020 Nov 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan. Cadogan M. Acid Base Disorders. Life in the Fast Lane • LITFL. https://litfl.com/acid-base-disorders/. Published November 3, 2020. Accessed June 23, 2021. 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.com/cme-courses/ and create an account. Donate to EMM today!

Contributor: Jared Scott, MD Educational Pearls: Around 30 patients with cannabinoid hyperemesis syndrome (CHS) randomized treatment in three arms with 8mg Zofran, Haldol 0.05 mg/kg, and Haldol 0.1 mg/kg Haldol arms performed better on all measures compared to Zofran Extrapyramidal symptoms were significantly higher in the Haldol group than Zofran, especially the high-dose Haldol group References Ruberto AJ, Sivilotti MLA, Forrester S, Hall AK, Crawford FM, Day AG. Intravenous Haloperidol Versus Ondansetron for Cannabis Hyperemesis Syndrome (HaVOC): A Randomized, Controlled Trial. Ann Emerg Med. 2021;77(6):613-619. doi:10.1016/j.annemergmed.2020.08.021 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.com/cme-courses/ and create an account. Donate to EMM today!

Contributor: Gretchen Hinson, MD Educational Pearls: Pit vipers include cottonmouths, rattlesnakes, and copperheads All have folding long fangs, triangular face, and elliptical pupils About 5,000 snakebites per year reported to Poison Control Initially develop a local reaction (swelling, bruising, pain, bullae) Complications can include 25% of snake bites result in no envenomation (dry bites) 20% of bites have serious side-effects, which can include hematologic, cardiovascular, neurologic and, muscular abnormalities, or even anaphylaxis to the envenomation itself Minor symptoms should be observed for 12-24 hours Moderate to severe symptoms are typically treated with antivenom CroFab and other antivenoms are expensive, with costs upwards of $3200 per vial wholesale, though newer agents are cheaper Treat with 4-6 vials of CroFab initially with moderate symptoms and subsequent redosing with References Buchanan JT, Thurman J. Crotalidae Envenomation. [Updated 2021 Jan 29]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan. Kanaan NC, Ray J, Stewart M, et al. Wilderness Medical Society Practice Guidelines for the Treatment of Pitviper Envenomations in the United States and Canada. Wilderness Environ Med. 2015;26(4):472-487. doi:10.1016/j.wem.2015.05.007 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.com/cme-courses/ and create an account. Donate to EMM today!

Contributor: Adam Barkin, MD Educational Pearls: Internal hernias, when bowel herniates through iatrogenic or congenital defect in mesentery, represent 1-6% of all small bowel obstructions Mortality of strangulated internal hernias is over 50% due to bowel necrosis and sepsis Intermittent symptoms presenting with nausea, vomiting, abdominal pain, abdominal distension Increased risk in patients with gastric bypass, liver transplant, or laparascopic surgery CT is very >90% sensitivity and specific in diagnosing SBO due to internal hernia Mesenteric swirl is a classic radiology finding Treatment with immediate surgical consultation for possible OR bowel decompression Start on broad spectrum antibiotics with any signs of sepsis References Lanzetta MM, Masserelli A, Addeo G, et al. Internal hernias: a difficult diagnostic challenge. Review of CT signs and clinical findings. Acta Biomed. 2019;90(5-S):20-37. Published 2019 Apr 24. doi:10.23750/abm.v90i5-S.8344 Martin LC, Merkle EM, Thompson WM. Review of internal hernias: radiographic and clinical findings. AJR Am J Roentgenol. 2006;186(3):703-717. doi:10.2214/AJR.05.0644 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.com/cme-courses/ and create an account. Donate to EMM today!

Contributor: Adam Barkin, MD Educational Pearls: Spontaneous coronary artery dissection (SCAD) is the most common cause of acute MI in women under 50 years old Risk factors include fibromuscular dysplasia, extreme exercise, stress, pregnancy, and recent birth Diagnosed in cath lab but medically managed and usually do not get a stent Treated with dual antiplatelet therapy and beta-blockers References Yip A, Saw J. Spontaneous coronary artery dissection-A review. Cardiovasc Diagn Ther. 2015;5(1):37-48. doi:10.3978/j.issn.2223-3652.2015.01.08 Janssen EBNJ, de Leeuw PW, Maas AHEM. Spontaneous coronary artery dissections and associated predisposing factors: a narrative review. Neth Heart J. 2019;27(5):246-251. doi:10.1007/s12471-019-1235-4 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.com/cme-courses/ and create an account. Donate to EMM today!

Contributor: Peter Bakes, MD Educational Pearls: Community-acquired pneumonia (CAP) is normally stratified into outpatient-candidates vs. inpatient candidates for treatment For outpatient treatment, antibiotic selection is driven by presence or absence comorbid health conditions (chronic lung/kidney/liver disease, DM, immunocompromised state, alcoholism, asplenia) No comorbidities: High dose amoxicillin, doxycycline, azithromycin Comorbidities: augmentin, cephalosporin, doxycycline, macrolide with fluoroquinolones as an alternatives For inpatient treatment, standard treatment is a macrolide and 3rd-generation cephalosporin Prior MRSA isolate or pseudomonas isolate as well as severe pneumonia are indications for adding MDR organism coverage with vancomycin and anti-pseudomonal coverage References Metlay JP, Waterer GW, Long AC, et al. Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019;200(7):e45-e67. doi:10.1164/rccm.201908-1581ST 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.com/cme-courses/ and create an account. Donate to EMM today!

Contributor: Aaron Lessen, MD Educational Pearls: Refractory ventricular fibrillation, defined as 3 defibrillation shocks without resolution, was studied via RCT looking to compare ECMO with cardiac cath vs. typical resuscitation After 30 patients (15 each arm), the trial was stopped because such a significant benefit seen in the ECMO arm 6 patients survived and 3 had good neurological outcomes at 6 months with ECMO This is compared to 1 patient surviving initially and none surviving at 6 months in the typical resuscitation arm References Yannopoulos D, Bartos J, Raveendran G, et al. Advanced reperfusion strategies for patients with out-of-hospital cardiac arrest and refractory ventricular fibrillation (ARREST): a phase 2, single centre, open-label, randomised controlled trial. Lancet. 2020;396(10265):1807-1816. doi:10.1016/S0140-6736(20)32338-2 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.com/cme-courses/ and create an account. Donate to EMM today!

Contributor: Jared Scott, MD Educational Pearls: Hand eczema is present in about 10% of the population and has a great prevalence in hairdressers, healthcare workers, and food service employees Using 1% oatmeal cream instead of a base cream showed statistically significant improvement in outcomes of HE in healthcare workers in a double-blind study References Sobhan M, Hojati M, Vafaie SY, Ahmadimoghaddam D, Mohammadi Y, Mehrpooya M. The Efficacy of Colloidal Oatmeal Cream 1% as Add-on Therapy in the Management of Chronic Irritant Hand Eczema: A Double-Blind Study. Clin Cosmet Investig Dermatol. 2020;13:241-251. Published 2020 Mar 25. doi:10.2147/CCID.S246021 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.com/cme-courses/ and create an account. Donate to EMM today!

Contributor: Sam Killian, MD Educational Pearls: Patients with cirrhosis and ascites are frequently evaluated for spontaneous bacterial peritonitis, an infection of the ascites fluid that is not from a surgically treated source Fever, abdominal pain, and altered mental status should all raise clinical suspicion in a patient with ascites Fluid from paracentesis may show increased WBCS (polys and neutrophils), high LDH, high amylase, and decreased glucose Outcomes are very poor in these patients with 30-40% of these patients continue to renal failure with 60-80% in-hospital mortality Typically treat with a third generation cephalosporin or ampicillin+gentamicin References Long B, Koyfman A. The emergency medicine evaluation and management of the patient with cirrhosis. Am J Emerg Med. 2018;36(4):689-698. doi:10.1016/j.ajem.2017.12.047 MacIntosh T. Emergency Management of Spontaneous Bacterial Peritonitis - A Clinical Review. Cureus. 2018;10(3):e2253. Published 2018 Mar 1. doi:10.7759/cureus.2253 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.com/cme-courses/ and create an account. Donate to EMM today!

This week's Pharmacy Phriday features a short excerpt from a longer podcast released as promo for the Colorado's CURE initiative, Clinicians United to Resolve the Epidemic, that combats the opioid crisis through education. Frequent contributor to the podcast, Rachael Duncan, PharmD, is joined by host, Elizabeth Esty, MD, to discuss the opioid prescribing guidelines for pharmacists released by the Colorado Hospital Association in collaboration with the Colorado Pharmacists Society. Colorado's CURE focuses on four pillars: Limiting the use of opioids in clinical practice Using multimodal alternatives to opioids (ALTO) to better treat pain without the risks that come with opioids Harm Reduction Improving care for those who have developed an opioid use disorder Access Colorado's CURE Opioid Prescribing Guidelines for Pharmacists and other specialties here! You can listen to the full Pharmacy episode of the Colorado's CURE Podcast for a more in-depth overview of the guidelines below: Apple Libsyn

Contributor: Chris Holmes, MD Educational Pearls: Medicine is cyclical and practice is always evolving A description of recommended treatment for CHF from 1966 Give oxygen Give one dose morphine then switch to demerol Decrease venous return and start PPV Immediately apply tourniquet to 3 extremities rotating tourniquets every 20 minutes Phlebotomy of 350-500 cc blood into a donor bag and draw off plasma as RBCs settle down Give aminophylline (make sure it is warmed) Induce hypotension with nitroglycerin and trimethoprim camphorsulfonate (infused at 10 drips/minute) Start digitalis Don't use any diuretics as they are ineffective If in shock, release tourniquets and hang the phlebotomized blood Isoproterenol might be beneficial References Messer JV. Management of emergencies. 13. Acute cardiac decompensation. N Engl J Med. 1966;274(26):1491-1493. doi:10.1056/NEJM196606302742608 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.com/cme-courses/ and create an account. Donate to EMM today! Photo Credit: Photo presented without modification courtesy of Kipp Teague , CC license

Contributor: Aaron Lessen, MD Educational Pearls: Facial nerve palsy (Bell's palsy) can occur in pediatric patients with Lyme disease, viral infection, or even leukemia One trial sought out to find if steroids and acyclovir would benefit pediatric patients with facial nerve palsy However, during screening process, around 1% of enrollees had leukemia (5 of the 644 patients) This is important as steroids can partially treat the leukemia thereby prolonging diagnosis and put the patient at risk for tumor lysis syndrome References Babl FE, Kochar A, Osborn M, et al. Risk of Leukemia in Children With Peripheral Facial Palsy. Ann Emerg Med. 2021;77(2):174-177. doi:10.1016/j.annemergmed.2020.06.029 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.com/cme-courses/ and create an account. Donate to EMM today!

Contributor: Don Stader, MD Educational Pearls: Patients are more likely to survive an opioid overdose if they have naloxone 10% risk of death in the year following an opioid overdose of patients seen in the ED Those who receive naloxone: Have better survival rates Are more likely to enter recovery Are more likely to use the naloxone on another person who has overdosed Better to give the patient naloxone at discharge from the ED as rates of filling prescriptions are low Any patient who uses illicit drugs, chronic opioid medications, or opioids with benzodiazepines are good candidates for naloxone at discharge Remember to instruct the patient and those who live with them on how to use it References Gunn AH, Smothers ZPW, Schramm-Sapyta N, Freiermuth CE, MacEachern M, Muzyk AJ. The Emergency Department as an Opportunity for Naloxone Distribution. West J Emerg Med. 2018;19(6):1036-1042. doi:10.5811/westjem.2018.8.38829 Olfson M, Wall M, Wang S, Crystal S, Blanco C. Risks of fatal opioid overdose during the first year following nonfatal overdose. Drug Alcohol Depend. 2018;190:112-119. doi:10.1016/j.drugalcdep.2018.06.004 Olfson M, Crystal S, Wall M, Wang S, Liu SM, Blanco C. Causes of Death After Nonfatal Opioid Overdose [published correction appears in JAMA Psychiatry. 2018 Aug 1;75(8):867]. JAMA Psychiatry. 2018;75(8):820-827. doi:10.1001/jamapsychiatry.2018.1471 http://naloxoneproject.com/ Summarized by John Spartz, MS3 | 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.com/cme-courses/ and create an account. Donate to EMM today!

Contributor: Aaron Lessen , MD Educational Pearls: Patients on 10L or more of oxygen per minute in the ICU were randomized to oxygen goals of 90% or 96% to compare 90-day mortality rates Mortality rates were about 42% for both of oxygen target groups, indicating no significant difference References Schjørring OL, Klitgaard TL, Perner A, et al. Lower or Higher Oxygenation Targets for Acute Hypoxemic Respiratory Failure. N Engl J Med. 2021;384(14):1301-1311. doi:10.1056/NEJMoa2032510 Summarized by John Spartz, MS3 | 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.com/cme-courses/ and create an account. Donate to EMM today!

Contributor: Adam Barkin, MD Educational Pearls: Represents less than 1% of all fractures that occur, although it has a significant mortality rate of 2-5% Typically occurs in high-energy trauma and are commonly associated with high injury severity scores and other fractures Concomitant Injuries: 50% have rib fracture 25% have clavicle fracture 30% have a spine fracture 5% have a brachial plexus injury 40% have a pulmonary contusion 30% have a pneumothorax 34% have a head injury 11% have a vascular injury References Cole PA, Freeman G, Dubin JR. Scapula fractures. Curr Rev Musculoskelet Med. 2013;6(1):79-87. doi:10.1007/s12178-012-9151-x Summarized by John Spartz, MS3 | 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.com/cme-courses/ and create an account. Donate to EMM today!

Contributor: Dave Rosenberg, MD Educational Pearls: In 1951, Operation Tat-Type began tattooing adults with their blood type in an effort to prepare for rapid transfusions in the time of the Cold War and the Korean War School children in northern Indiana and areas in Utah were tattooed with their blood type beginning in 1952 under the same operation Based on tattoos given to SS officers during WWII This wasn't to identify who needed what blood but rather to identify who could give what blood in the event of a massive attack References Wolf EK, Laumann AE. The use of blood-type tattoos during the Cold War. J Am Acad Dermatol. 2008;58(3):472-476. doi:10.1016/j.jaad.2007.11.019 Summarized by John Spartz, MS3 | 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.com/cme-courses/ and create an account. Donate to EMM today!

Contributor: Gretchen Hinson, MD Educational Pearls: Three episodes of ventricular tachycardia within 24 hours or two episodes back-to-back Treat with IV amiodarone and IV beta-blockers initially as well as IV lidocaine Correct underlying causes: IV magnesium for QT prolongation Replete potassium in hypokalemia Urgent revascularization in ischemia For refractory vtach, urgent radiofrequency ablation or stellate ganglion block can be done Last resort is placing on the patient on ECMO References Muser D, Santangeli P, Liang JJ. Management of ventricular tachycardia storm in patients with structural heart disease. World J Cardiol. 2017;9(6):521-530. doi:10.4330/wjc.v9.i6.521 Eifling M, Razavi M, Massumi A. The evaluation and management of electrical storm. Tex Heart Inst J. 2011;38(2):111-121. Summarized by John Spartz, MS3 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.com/cme-courses/ and create an account. Donate to EMM today!

Contributor: Donald Stader, MD Educational Pearls: Opioids target kappa and NMDA receptors that can lead to central nervous system sensitization and therefore increased pain For patients with opioid-induced hyperalgesia (OIH), oral ketamine (25-50 mg) can be used to treat their pain as it targets the NMDA receptor Other treatments is IV magnesium, NSAIDs, tylenol, and clonidine Buprenorphine and methadone are options for chronic pain management in the setting of OIH References Lee M, Silverman SM, Hansen H, Patel VB, Manchikanti L. A comprehensive review of opioid-induced hyperalgesia. Pain Physician. 2011;14(2):145-161. Summarized by John Spartz, MS3 | 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.com/cme-courses/ and create an account. Donate to EMM today!

Contributor: Aaron Lessen, MD Educational Pearls: Recent study looked at whether lactated ringers might be a better choice for fluid resuscitation in patients with DKA compared to normal saline Normal saline can cause a hyperchloremic metabolic acidosis Time to resolution of acidosis was 4 hours less with lactated ringers compared to normal saline Time on an insulin drip decreased by about 4 hours with lactated ringers compared to normal saline LR might be a better choice for fluid resuscitation in patients with DKA References Self WH, Evans CS, Jenkins CA, et al. Clinical Effects of Balanced Crystalloids vs Saline in Adults With Diabetic Ketoacidosis: A Subgroup Analysis of Cluster Randomized Clinical Trials. JAMA Netw Open. 2020;3(11):e2024596. doi:10.1001/jamanetworkopen.2020.24596 Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD

Contributor: Jared Scott, MD Educational Pearls: About ½ of the patients in the ED present with some form of pain One study looked at patients presenting in pain and followed up two days after discharge to determine if their pain was addressed, asking if the patient received anything for pain and if the patient refused pain medication Non-analgesic pain management: About 30% discordance between patient reports and documentation Conventional analgesic pain management: About 15% discordance between patient reports and documentation References Taylor DM, Valentine S, Majer J, Grant N. Discordance between patient-reported and actual emergency department pain management. Emerg Med Australas. 2020 Nov 22. doi: 10.1111/1742-6723.13690. Epub ahead of print. PMID: 33225600. Summarized by John Spartz, MS3 | 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.com/cme-courses/ and create an account. Donate to EMM today!

Contributor: Peter Bakes, MD Educational Pearls: Incidence 2.5-10 per million people occurring primarily in those with environmental allergens Typically occurs with mRNA vaccines in lipid nanoparticles (Moderna/Pfizer) rather than the adenovirus vaccine (J&J) Recommendation is to forego 2nd dose of the mRNA vaccine and instead get the adenovirus vaccine after weighing the risks and benefits References Kounis NG, Koniari I, de Gregorio C, Velissaris D, Petalas K, Brinia A, Assimakopoulos SF, Gogos C, Kouni SN, Kounis GN, Calogiuri G, Hung MY. Allergic Reactions to Current Available COVID-19 Vaccinations: Pathophysiology, Causality, and Therapeutic Considerations. Vaccines (Basel). 2021 Mar 5;9(3):221. doi: 10.3390/vaccines9030221. PMID: 33807579; PMCID: PMC7999280. Blumenthal KG, Robinson LB, Camargo CA, et al. Acute Allergic Reactions to mRNA COVID-19 Vaccines. JAMA. Published online March 08, 2021. doi:10.1001/jama.2021.3976 Summarized by John Spartz, MS3 | 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.com/cme-courses/ and create an account. Donate to EMM today!

Contributor: Jared Scott, MD Educational Pearls: 1-3 cases of rabies per year in US with 55,000 people per year receiving rabies prophylaxis 90% of rabies cases come from wildlife, most commonly by racoons, bats, foxes, and skunks Because of rabies prophylaxis, domesticated pets almost never have rabies in the United States Rabies is typical transmitted via a bite, but direct contact with saliva or brain tissue on an open wound can transmit the virus Some people exposed to rabies from bats will never report a bite References Kessels J, Tarantola A, Salahuddin N, Blumberg L, Knopf L. Rabies post-exposure prophylaxis: A systematic review on abridged vaccination schedules and the effect of changing administration routes during a single course. Vaccine. 2019 Oct 3;37 Suppl 1:A107-A117. doi: 10.1016/j.vaccine.2019.01.041. Epub 2019 Feb 5. PMID: 30737043. Centers for Disease Control and Prevention. Rabies Postexposure Prophylaxis (PEP). Published June 11, 2019. https://www.cdc.gov/rabies/medical_care/index.html Summarized by John Spartz, MS3 | 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.com/cme-courses/ and create an account. Donate to EMM today!

Contributor: Alicia Oberle, MD Educational Pearls: Down Syndrome with Trisomy 21 have three copies of chromosome 21 Current birth rates are around 1 in 700 births Average life span 25 years in 1980, today the average life span is 60 years of age Patients with Down syndrome require additional therapies in the first 3 years due to developmental delays They also have increased risk for childhood leukemias, seizures, hypothyroidism, celiac disease, and early-onset Alzheimers Half have a cardiac defect requiring surgery at birth References Tsou AY, Bulova P, Capone G, et al. Medical Care of Adults With Down Syndrome: A Clinical Guideline. JAMA. 2020;324(15):1543–1556. doi:10.1001/jama.2020.17024 Summarized by John Spartz, MS3 | 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.com/cme-courses/ and create an account. Donate to EMM today!

This week's episode features a fascinating conversation with Dr. Nadia Tremonti, medical director for the pediatric palliative care program at Children's Hospital of Michigan in Detroit. Dr. Tremonti was the featured physician in an independent short film Palliative and subsequent New York Times shorter excerpt Dying in your Mother's Arms that explore her work with terminally ill pediatric patients. From conversations of religion's role in processing disease to the physician's role in alleviating suffering for patients and their families, Nick and Nadia explore the existential ground in this thought-provoking segment. Time Stamps 00:47 Introductions 3:50 How patients led her to pursue palliative care 14:32 Dr. Tremonti's approach to palliative care 21:42 Understanding patients' and family's language to guide counseling 31:38 Most frequent anxieties and fears of families of pediatric palliative care patients 37:21 How emergent interventions can shift burden of decision to continue life-sustaining measures to families 47:45 Navigating existential questions of life or death with patients and their families 55:38 Saddest part of palliative care 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.com/cme-courses/ and create an account. Donate to EMM today!

Contributor: Aaron Lessen, MD Educational Pearls: Droperidol for sedation in agitated patients in the emergency department was studied compared to ziprasidone (Geodon) and lorazepam (Ativan) Double-blinded RCT showed droperidol was 65% effective to get patients to a good level of sedation in 15 minutes compared to ativan and geodon which were 25-35% effective Droperidol had less respiratory depression and prolongation of the QT compared to Ativan and Geodon References Martel ML, Driver BE, Miner JR, Biros MH, Cole JB. Randomized Double-blind Trial of Intramuscular Droperidol, Ziprasidone, and Lorazepam for Acute Undifferentiated Agitation in the Emergency Department. Acad Emerg Med. 2021 Apr;28(4):421-434. doi: 10.1111/acem.14124. Epub 2020 Oct 5. PMID: 32888340. Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD

Contributor: Ricky Dhaliwal, MD Educational Pearls: Primarily affects children Caused by staph aureus releasing exotoxins that result in erythema and sloughing of the skin Present with significant pain, dehydration and underlying staph infection Treatment typically oxacillin/nafcillin with admission for wound care with petroleum gel and xeroform Burn centers may be treatment centers of choice for this condition Most patients recover in 2-3 days with treatment References Patel GK, Finlay AY. Staphylococcal scalded skin syndrome: diagnosis and management. Am J Clin Dermatol. 2003;4(3):165-75. doi: 10.2165/00128071-200304030-00003. PMID: 12627992. Jordan KS. Staphylococcal Scalded Skin Syndrome: A Pediatric Dermatological Emergency. Adv Emerg Nurs J. 2019 Apr/Jun;41(2):129-134. doi: 10.1097/TME.0000000000000235. PMID: 31033660. Summarized by John Spartz, MS3 | 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.com/cme-courses/ and create an account. Donate to EMM today!

Contributor: Ricky Dhaliwal, MD Educational Pearls: Rhabdomyolysis occurs when high levels of myoglobin are released from dying muscle tissue into the blood Severe levels of myoglobin cause renal injury Causes include elevated temperature, excessive exercise, toxins, infection, muscle ischemia, crush injury, and prolonged immobilization Can also be caused by medications, like antipsychotics, statins, SSRIs, colchicine, lithium Workup typically includes creatinine kinase, potassium, creatinine levels and serial EKGs Firstline treatment is with IV fluids with a goal urine output of 300 ml/hr Sodium bicarbonate and mannitol have had some use in treatment but weak evidence References Long B, Koyfman A, Gottlieb M. An evidence-based narrative review of the emergency department evaluation and management of rhabdomyolysis. Am J Emerg Med. 2019 Mar;37(3):518-523. doi: 10.1016/j.ajem.2018.12.061. Epub 2019 Jan 2. PMID: 30630682. Summarized by John Spartz, MS3 | 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.com/cme-courses/ and create an account.

Contributor: Aaron Lessen, MD Educational Pearls: Study in NEJM looked at occult hypoxemia, when oxygen saturation reads at >92% when the actual saturation is Rate of occult hypoxemia was 3 times higher in those who identified as black (12% vs 4%) Keep this disparity in mind when providing care to patients of all backgrounds and incorporate into clinical decision-making References Sjoding MW, Dickson RP, Iwashyna TJ, Gay SE, Valley TS. Racial Bias in Pulse Oximetry Measurement. N Engl J Med. 2020;383(25):2477-2478. doi:10.1056/NEJMc2029240 Summarized by John Spartz, MS3 | 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.com/cme-courses/ and create an account. Donate to EMM today!

Contributor: Peter Bakes, MD Educational Pearls: Febrile Seizure clinical criteria 6 months - 5 years of age Rapid rise in temp No preexisting seizure disorder No other explanation for the seizure Nonfocal seizure lasting less than 15 minutes If the seizure does not meet the above criteria, a full workup needs to be completed Regardless of cause, treat the seizure with IV/IO benzodiazepines or IN versed if unable to obtain access Risk of developing epilepsy after a simple febrile seizure roughly doubles References Leung AK, Hon KL, Leung TN. Febrile seizures: an overview. Drugs Context. 2018;7:212536. Published 2018 Jul 16. doi:10.7573/dic.212536 Summarized by John Spartz, MS3 | 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.com/cme-courses/ and create an account. Donate to EMM today!

Contributor: Aaron Lessen, MD Educational Pearls: Acid and alkali ingestions have differing prognosis and immediate concerns Immediate issues can include superficial irritation, severe burns, esophageal perforation, and even airway compromise from edem Long term morbidity can include strictures Supportive care is typically all that can be provided in the emergency department Diagnostics may include imaging and endoscopy For more severe ingestions without immediate issues,, patients may be monitored for up to 24 hours References Hoffman RS, Burns MM, Gosselin S. Ingestion of Caustic Substances. N Engl J Med. 2020 Apr 30;382(18):1739-1748. doi: 10.1056/NEJMra1810769. PMID: 32348645. Summarized 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.com/cme-courses/ and create an account. Donate to EMM today!

Contributor: Peter Bakes, MD Educational Pearls: Lyme disease gives a single expanding target lesion with central clearing called erythema chronicum migrans Erythema multiforme is another targetoid rash that presents with multiple target lesions Characterized into erythema minor and major based on severity but typically resolves More severe hypersensitivity reactions include Stevens-Johnson Syndrome (30% skin involvement) SJS and TEN is associated with NSAIDS including aspirin, antiemetics like phenergan, anticonvulsants like dilantin or phenobarbital, and antibiotics like penicillin or sulfa drugs Other causes include viral illnesses like Herpes simplex virus or mycoplasma pneumoniae Treat by removing offending agent and treat supportively with monitoring for rash progression to SJS or TEN References Trayes KP, Love G, Studdiford JS. Erythema Multiforme: Recognition and Management. Am Fam Physician. 2019 Jul 15;100(2):82-88. PMID: 31305041. Read J, Keijzers GB. Pediatric Erythema Multiforme in the Emergency Department: More Than "Just a Rash". Pediatr Emerg Care. 2017 May;33(5):320-324. doi: 10.1097/PEC.0000000000000618. PMID: 26555305. Summarized by John Spartz, MS3 | 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.com/cme-courses/ and create an account. Donate to EMM today!

Contributor: Adam Barkin, MD Educational Pearls: Fever is an adaptive response to infection, but elderly and immunocompromised patients may not be able to mount a hyperthermic response in sepsis Patients with fever in sepsis end up receiving treatment earlier and have better outcomes Hypothermic patients with severe sepsis admitted to the ICU had a 32% mortality versus 21% mortality in those who had a fever on presentation 3-hour sepsis bundle compliance was less frequent in hypothermic patients than in febrile patients (56% versus 71%) Early broad spectrum antibiotics were administered less in patients who were hypothermic than those that were febrile (77% versus 87%) References Blair E, Buxton RW, Cowley RA, Mansberger AR. The Use of Hypothermia in Septic Shock. JAMA. 1961;178(9):916–919. doi:10.1001/jama.1961.73040480005008b Kushimoto S, Abe T, Ogura H, et al. Impact of Body Temperature Abnormalities on the Implementation of Sepsis Bundles and Outcomes in Patients With Severe Sepsis: A Retrospective Sub-Analysis of the Focused Outcome Research on Emergency Care for Acute Respiratory Distress Syndrome, Sepsis and Trauma Study. Crit Care Med. 2019;47(5):691-699. Summarized by John Spartz, MS3 | 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.com/cme-courses/ and create an account. Donate to EMM today!

Contributor: Aaron Lessen, MD Educational Pearls: Survey study compared depression symptom prevalence in the United States at the beginning of COVID compared to data acquired by a similar survey for 2017-2018 and found it was three-fold higher Mild symptoms: 25% during pandemic; 16% before Moderate: 15% during pandemic; 6% before Moderately Severe symptoms: 8% during pandemic; 2% before Severe symptoms: ~5% during pandemic; 1% before Those with lower income, less savings, and exposure to more stressors were at greater risk for developing depression symptoms References Ettman CK, Abdalla SM, Cohen GH, Sampson L, Vivier PM, Galea S. Prevalence of Depression Symptoms in US Adults Before and During the COVID-19 Pandemic. JAMA Netw Open. 2020;3(9):e2019686. doi:10.1001/jamanetworkopen.2020.19686 Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD

Contributor: Ricky Dhaliwal, MD, JD Educational Pearls: Glucagon administered intravenously has a high rate of adverse events (nausea/vomiting) with very weak evidence NItroglycerin too has very limited evidence but a much better adverse event profile Mix 0.4 mg (1 sublingual tablet) nitro in 10 mL of water and administer orally Nothing beats upper endoscopy for effectiveness but in settings where GI is not immediately available, nitroglycerin may be worth an attempt given its better safety profile to other medications References Arora S, Galich P. Myth: glucagon is an effective first-line therapy for esophageal foreign body impaction. CJEM 2015;11:169–71 Schimmel J, Slauson S. Swallowed Nitroglycerin to Treat Esophageal Food Impaction. Ann Emerg Med. 2019 Sep;74(3):462-463. Summarized/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.com/cme-courses/ and create an account. Donate to EMM today!

Contributor: Jared Scott, MD Educational Pearls: While it is rare to have a native hip dislocation, it is relatively common to dislocate a prosthetic hip The mechanism for dislocation is usually adduction, flexion, and internal rotation the hip which can occur when walking Arthroplasty in the setting of trauma or fracture, posterior approach during surgery, and using a small femoral head increase the likelihood of later dislocation If a patient with a total hip arthroplasty says they were walking and then developed hip pain, do not discount a potential dislocation References Zahar A, Rastogi A, Kendoff D. Dislocation after total hip arthroplasty. Curr Rev Musculoskelet Med. 2013;6(4):350-356. doi:10.1007/s12178-013-9187-6 Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD

A heartfelt excerpt from our most recent UnfilterED episode with Dr. Don Stader.

Contributor: Katie Sprinkel, MD Educational Pearls: Hereditary angioedema (HA) is an autosomal dominant bradykinin-mediated disease affecting the airway, skin or gastrointestinal tract and typically presents with swelling in the absence of pruritus HA episodes last 3-5 days, typically occur first in childhood or adolescence, and decrease in frequency with aging Airway angioedema is the most dangerous but least common Skin angioedema is usually uncomfortable and should be monitored if involving the face GI angioedema involves nausea, vomiting, and severe abdominal pain No definitive triggers, but episodes may be preceded by a variable prodrome but can include headache, GI symptoms, and even a rash Treatment can include infusion of a C-1 inhibitor, such as Berinert but it is very expensive References Busse PJ, Christiansen SC. Hereditary Angioedema. N Engl J Med. 2020 Mar 19;382(12):1136-1148. doi: 10.1056/NEJMra1808012. PMID: 32187470. Longhurst HJ, Bork K. Hereditary angioedema: an update on causes, manifestations and treatment. Br J Hosp Med (Lond). 2019 Jul 2;80(7):391-398. doi: 10.12968/hmed.2019.80.7.391. PMID: 31283393. Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD

Contributor: Katie Sprinkel, MD Educational Pearls: Psychogenic Non-Epileptic Seizures (PNES) are due to a psychogenic rather than an epileptic cause Despite common assumption, PNES are not always volitional 20-40% of those with PNES can also have true epileptic seizures 20-40% True diagnosis requires a video EEG Characteristics of PNES include: Waxing and waning of the seizure intensity Eyes clenched shut Pelvic thrusting, rolling from side-to-side Ability to respond to verbal stimuli during the seizure Ability to recall information during the seizure Weeping or stuttering Guarding the face on passive hand drop Characteristics of epileptic seizures: Tongue biting Prolonged postictal state Incontinence Haldol or Zyprexa may be better for PNES and benzodiazepines tend to be better for epileptic seizures References Huff JS, Murr N. Psychogenic Nonepileptic Seizures. 2021 Jan 28. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan–. PMID: 28722901. Asadi-Pooya AA. Psychogenic nonepileptic seizures: a concise review. Neurol Sci. 2017 Jun;38(6):935-940. doi: 10.1007/s10072-017-2887-8. Epub 2017 Mar 8. PMID: 28275874. Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD

High in the mountains of Colorado, a crew of unsuspecting docs stumble upon the EMS scene of a head-on collision after an arduous mountain bike ride. Trauma is a Journey is a four part rural trauma mini series that recounts this tale as this group springs into action to assist the EMS crews dealing with two critical patients. Elizabeth Esty hosts a panel discussion with the key players: Dr. Dylan Luyten, Dr. JP Brewer, Dr. Madison Macht, Dr. Glenda Quan and Jeremiah Grantham as this story unfolds. This final episode explores how addressing psychological and emotional trauma is the final step in a patient's journey once their physical illnesses have been addressed. The group discusses how this can take time and how they support patients through these tough journeys. Dr. Luyten brings everything full circle as he recounts his own story of being a patient in a rural car crash and how that experience affected him and ultimately set him on a path to become an ER physician. This episode also emphasizes the need for healthcare professionals to support each other through debriefs to prevent burnout and remain resilient themselves when providing care. Thank you all for listening!

High in the mountains of Colorado, a crew of unsuspecting docs stumble upon the EMS scene of a head-on collision after an arduous mountain bike ride. Trauma is a Journey is a four part rural trauma mini series that recounts this tale as this group springs into action to assist the EMS crews dealing with two critical patients. Elizabeth Esty hosts a panel discussion with the key players: Dr. Dylan Luyten, Dr. JP Brewer, Dr. Madison Macht, Dr. Glenda Quan and Jeremiah Grantham as this story unfolds. The third episode opens up with an ode to ATLS and how important those training protocols really are to real-world applications like the one in this story. The group segues into discussion of the various opinions on the essentials for emergency first aid supplies you should have on hand. Dr. JP Brewer circles back to the role of teamwork and establishing roles in order to accomplish a successful resuscitation and the others chime in based on their experiences.

High in the mountains of Colorado, a crew of unsuspecting docs stumble upon the EMS scene of a head-on collision after an arduous mountain bike ride. Trauma is a Journey is a four part rural trauma mini series that recounts this tale as this group springs into action to assist the EMS crews dealing with two critical patients. Elizabeth Esty hosts a panel discussion with the key players: Dr. Dylan Luyten, Dr. JP Brewer, Dr. Madison Macht, Dr. Glenda Quan and Jeremiah Grantham as this story unfolds. This second episode follows the patients as they arrive to St. Vincent, a small critical access hospital in Leadville, the next stop on their journey. Teamwork is the main theme throughout this episode as these doctors work to stabilize these patients and coordinate air transport to definitive care at Level 1 Trauma Center Swedish Medical Center. Dr. Quan goes into detail about the extent of the patients' internal injuries, the role of damage control surgery in their management and how appropriate pre-hospital management is crucial for these critical trauma patients.

High in the mountains of Colorado, a crew of unsuspecting docs stumble upon the EMS scene of a head-on collision after an arduous mountain bike ride. Trauma is a Journey is a four part rural trauma mini series that recounts this tale as this group springs into action to assist the EMS crews dealing with two critical patients. Elizabeth Esty hosts a panel discussion with the key players: Dr. Dylan Luyten, Dr. JP Brewer, Dr. Madison Macht, Dr. Glenda Quan and Jeremiah Grantham as this story unfolds. In this first episode, the scene is set for the arc of this storyline and while the journey of these patients is the primary focus, the doctors involved come to realize that this experience also took them on a journey as they debrief the events following their ride. Tune in for discussion of the pre-hospital management and insightful commentary on the situation as a whole.

Contributor: Samuel Killian, MD Educational Pearls: Anecdotally, when the computer reads a triage EKG as normal it is most often normal One study tested this theory by examining 855 computer-read EKGS (222 of which were read as normal) Two cardiologists reviewed these 222 normal EKGs and only found 13 EKGs that were slightly abnormal with nonspecific abnormalities Two EM physicians then reviewed these EKGs and only one physician on one EKG said they would change the patient's course of care by rooming them faster The study may support eliminating physician review of normal triage EKGs as a safe practice that would decrease physician interruption References Hughes KE, Lewis SM, Katz L, Jones J. Safety of Computer Interpretation of Normal Triage Electrocardiograms. Acad Emerg Med. 2017 Jan;24(1):120-124. doi: 10.1111/acem.13067. PMID: 27519772. Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD

Contributor: Aaron Lessen, MD Educational Pearls: Ivermectin is an antiparasitic medication that has been used for a long time, but has sparked new interest in the past year as a potential treatment for COVID-19 In-vitro studies have shown it decreases how quickly COVID replicates and may make it less likely to adhere to cells Observational studies have found lower rates of COVID-19 infections in areas that provide ivermectin prophylaxis In several studies it was shown that it decreased severity and mortality, though there were significant methodological limitations NIH gave a statement saying there is not enough evidence to support or refute based on current trials and larger more rigorous trials are needed References Caly L, Druce JD, Catton MG, Jans DA, Wagstaff KM. The FDA-approved drug ivermectin inhibits the replication of SARS-CoV-2 in vitro. Antiviral Res. 2020 Jun;178:104787. doi: 10.1016/j.antiviral.2020.104787. Epub 2020 Apr 3. PMID: 32251768; PMCID: PMC7129059. Hellwig MD, Maia A. A COVID-19 prophylaxis? Lower incidence associated with prophylactic administration of ivermectin. Int J Antimicrob Agents. 2021 Jan;57(1):106248. doi: 10.1016/j.ijantimicag.2020.106248. Epub 2020 Nov 28. PMID: 33259913; PMCID: PMC7698683. Rajter JC, Sherman MS, Fatteh N, Vogel F, Sacks J, Rajter JJ. Use of Ivermectin Is Associated With Lower Mortality in Hospitalized Patients With Coronavirus Disease 2019: The Ivermectin in COVID Nineteen Study. Chest. 2021 Jan;159(1):85-92. doi: 10.1016/j.chest.2020.10.009. Epub 2020 Oct 13. PMID: 33065103; PMCID: PMC7550891. Chaccour C, Casellas A, Blanco-Di Matteo A, Pineda I, Fernandez-Montero A, Ruiz-Castillo P, Richardson MA, Rodríguez-Mateos M, Jordán-Iborra C, Brew J, Carmona-Torre F, Giráldez M, Laso E, Gabaldón-Figueira JC, Dobaño C, Moncunill G, Yuste JR, Del Pozo JL, Rabinovich NR, Schöning V, Hammann F, Reina G, Sadaba B, Fernández-Alonso M. The effect of early treatment with ivermectin on viral load, symptoms and humoral response in patients with non-severe COVID-19: A pilot, double-blind, placebo-controlled, randomized clinical trial. EClinicalMedicine. 2021 Feb;32:100720. doi: 10.1016/j.eclinm.2020.100720. Epub 2021 Jan 19. PMID: 33495752; PMCID: PMC7816625. Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD

If you listen to this podcast, then you're probably familiar with our founder and frequent contributor, Dr. Donald Stader, and his fascination with the intersection of Emergency Medicine, opioids and Addiction Medicine. He is board certified in both specialties and is an active clinician in the ED that is constantly working to improve systems of best practice surrounding opioid uses there and in other specialties. In this episode of UnfilterED, Nick touches on these topics briefly before diving much deeper into the evolution of Don's perspectives on life and death in the context of his mother's recent passing due to COVID-19. Tune in to hear Don's unfiltered personal account that can only be described as real, raw and relevant. Time Stamps 1:35 Don introduction 3:00 Opioid epidemic impacted by COVID 10:00 Upcoming Don projects and the role of stories 14:42 Sources of aspirational inspiration 34:07 Mother's death and learning how to die 49:12 Ending on a happier note 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.com/cme-courses/ and create an account. Donate to EMM today!

Contributor: Erik Verzemnieks, MD Educational Pearls: INR measures the clotting cascade including factors II, VII, IX, and X Coumadin most commonly elevates the INR, and it is used to monitor the anticoagulant's effectiveness Liver failure can cause a similar elevation in the INR due to lack of synthesis of factors II, VII, IX, X An elevated INR in liver failure does not mean that the patient is anticoagulated, at increased risk for bleeding, or is at less risk of forming a clot There is more commonly an increased risk of clot formation due to lack of production of protein C and S, which are natural anticoagulants Lack of production of proteins C and S have a larger effect and lead to typically a net clotting risk Levels of these can be indirectly measured through albumin Portal venous thrombosis is one of the most common examples of this phenomenon References Harrison MF. The Misunderstood Coagulopathy of Liver Disease: A Review for the Acute Setting. West J Emerg Med. 2018;19(5):863-871. doi:10.5811/westjem.2018.7.37893 Summarized by John Spartz, MS3 | 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.com/cme-courses/ and create an account. Donate to EMM today!

Contributor: Aaron Lessen, MD Educational Pearls: When evaluating a thunderclap headache, don't forget RCVS! RCVS: reversible cerebral vasoconstriction syndrome Due to reversible spasms of cerebral blood vessels Can sometimes be seen on CTA or MRA, but often the imaging is normal and formal angiograms only occasionally show it It can be caused by medications, intense physical activity, orgasm, and postpartum conditions, but the exact etiology is unknown Typically seen in females in their 40s Can result in bleeding, strokes, and seizures There is no good treatment, but stopping the suspected offending agent may help References Sattar A, Manousakis G, Jensen MB. Systematic review of reversible cerebral vasoconstriction syndrome. Expert Rev Cardiovasc Ther. 2010;8(10):1417-1421. doi:10.1586/erc.10.124 Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD

Contributor: Peter Bakes, MD Educational Pearls: Necrotizing Enterocolitis (NEC) Presents in the first few days of life (often in the NICU) to 3 weeks old Risk factors include prematurity, excess feeding, neonatal sepsis Pneumatosis Intestinalisis on abdominal xray caused by bacterial translocation into the bowel wall Treated with NG tube, bowel rest and surgical resection Other causes of pediatric abdominal pain Malrotation with volvulus Malrotation is caused by failure of intestinal rotation in the 8th-12th week of development Presents with bilious vomiting, which is a surgical emergency in a neonate 90% of cases present in the first year of life, with most of these presenting in the first month Diagnosed with an upper GI series Pyloric Stenosis Typically in males Diagnosed with abdominal ultrasound and treated surgically Intussusception Typically presents between 2 months and 2 years with a palpable mass in the RUQ Diagnosed with abdominal ultrasound Duodenal atresia Congenital stricture in the duodenum Presents with bilious vomiting and a double-bubble on abdominal xray References Alwan R, Drake M, Gurria Juarez J, Emery KH, Shaaban AF, Szabo S, Sobolewski B. A Newborn With Abdominal Pain. Pediatrics. 2017 Nov;140(5):e20164267. doi: 10.1542/peds.2016-4267. PMID: 29042421. Hostetler MA, Schulman M. Necrotizing enterocolitis presenting in the Emergency Department: case report and review of differential considerations for vomiting in the neonate. J Emerg Med. 2001 Aug;21(2):165-70. doi: 10.1016/s0736-4679(01)00371-7. PMID: 11489407. Summarized by John Spartz, MS3

Contributor: Aaron Lessen, MD Educational Pearls: Meta-analysis of 57,420 COVID+ patients evaluated mortality after intubation 45% mortality rate for all patients in the study 84.4% mortality in patients over 80 years old POSITIONED Trail assessed need for intubation in patients awake self-proning compared to not Risk of intubation and mortality was lower for those self-proning 0.3 hazard ratio for intubation in those self-proning References Lim ZJ, Subramaniam A, Ponnapa Reddy M, et al. Case Fatality Rates for Patients with COVID-19 Requiring Invasive Mechanical Ventilation. A Meta-analysis. Am J Respir Crit Care Med. 2021;203(1):54-66. doi:10.1164/rccm.202006-2405OC Jagan N, Morrow LE, Walters RW, Klein LP, Wallen TJ, Chung J, Plambeck RW. The POSITIONED Study: Prone Positioning in Nonventilated Coronavirus Disease 2019 Patients-A Retrospective Analysis. Crit Care Explor. 2020 Oct 1;2(10):e0229. doi: 10.1097/CCE.0000000000000229. PMID: 33063033; PMCID: PMC7531752. Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD