Emergency Medical Minute

Contributor: Jared Scott, MD Educational Pearls: Differential Diagnosis: non-accidental trauma, febrile seizure, meningitis, hyponatremia, epilepsy Convulsions with gastroenteritis is a known entity to cause seizures in infancy Predominantly occurs in ages 6 months to 3 years Occur with diarrheal episodes No electrolyte abnormalities associated with the seizure nor severe dehydration Seizures tend to come in clusters Most have a normal EEG and do not develop epilepsy Reported incidence in gastroenteritis of 1-2% of gastroenteritis Treatment addresses the seizures but long term anti-epileptic drugs are typically not needed References Kang B, Kwon YS. Benign convulsion with mild gastroenteritis. Korean J Pediatr. 2014;57(7):304-309. doi:10.3345/kjp.2014.57.7.304 Ma X, Luan S, Zhao Y, Lv X, Zhang R. Clinical characteristics and follow-up of benign convulsions with mild gastroenteritis among children. Medicine (Baltimore). 2019;98(2):e14082. doi:10.1097/MD.0000000000014082 Image credit: Kurt Christensen Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD

Contributor: Nick Tsipis, MD Educational Pearls: Epinephrine: alpha-1, alpha-2, beta-1, and beta 2 agonist - used in cardiac arrest with positive effects on ROSC in prehospital and peri-hopsital setting Norepinephrine: alpha-1 and beta-1 agonist - used in septic shock to increase cardiac output and peripheral vasoconstriction Phenylephrine: alpha-1 adrenergic agonist - used in spinal/neurogenic shock as well as medication-induced peri-procedural hypotension (propofol for RSI) as it only helps with vasoconstriction Dopamine: alpha-1, alpha-2, beta-1, beta 2, and dopamine agonist - used for sepsis in the past, but not recommended due to dysrhythmias Vasopressin: V1 agonist (vasoconstricts) - used when maxed out of norepinephrine for septic shock Milrenone: phosphodiesterase inhibitor - used in heart failure to drop preload and afterload Dobutamine: beta-2 (with minimal beta-1) adrenergic agonist - used in heart failure and cardiogenic shock to reduce afterload References Shields SH, Holland RM. Pharmacology of Vasopressors and Inotropes. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 7e. McGraw-Hill; Accessed February 14, 2021. Episode 31 - Vasopressors. FOAMcast: An Emergency Medicine Podcast. 25 July 2015. https://foamcast.org/tag/vasopressors/ Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD

Contributor: Jared Scott, MD Educational Pearls: Small capsule pacemaker (2.5 cm, 1 ml volume) resides in the heart without any associated wires or leads like a traditional pacemaker The new version has a 6 year battery life, after which it can be deactivated and a traditional pacemaker put in place Cost is around 2-4 times that of a traditional pacemaker NEJM study from 2015 showed it met the primary efficacy endpoint in 90% of patients and the primary safety endpoint in 93.3% of patients Follow up study showed 3% complication with the intracardiac pacemaker compared to 9% in traditional References Groner, Ashley PA-C; Grippe, Kristen PA-C The leadless pacemaker, Journal of the American Academy of Physician Assistants: June 2019 - Volume 32 - Issue 6 - p 48-50 doi: 10.1097/01.JAA.0000554750.85170.d4 Reddy VY, Exner DV, Cantillon DJ, Doshi R, Bunch TJ, Tomassoni GF, Friedman PA, Estes NA 3rd, Ip J, Niazi I, Plunkitt K, Banker R, Porterfield J, Ip JE, Dukkipati SR; LEADLESS II Study Investigators. Percutaneous Implantation of an Entirely Intracardiac Leadless Pacemaker. N Engl J Med. 2015 Sep 17;373(12):1125-35. doi: 10.1056/NEJMoa1507192. Epub 2015 Aug 30. PMID: 26321198. Chan KH, McGrady M, Wilcox I. A Leadless Intracardiac Transcatheter Pacing System. N Engl J Med. 2016 Jun 30;374(26):2604. doi: 10.1056/NEJMc1604852. PMID: 27355553. Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD

Contributor: Peter Bakes , MD Educational Pearls: Pediatric Fever + Rash Differential: scarlet fever, measles, rubella, chicken pox, fifth's disease, HHV-6, adenovirus, anaphylaxis, Kawasaki's disease Kawasaki's is diagnosed clinically with prolonged fever (>7 days fever in 5 days of fever >6 months with 4 of the following: Strawberry tongue/fissured lips Bilateral conjunctival injection Cervical lymphadenopathy Hand/foot edema Maculopapular rash Can develop life threatening coronary artery aneurysms Treated with aspirin/IVIG References Modesti AM, Plewa MC. Kawasaki Disease. [Updated 2020 Jul 2]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK537163/?report=classic Ramphul K, Mejias SG. Kawasaki disease: a comprehensive review. Arch Med Sci Atheroscler Dis. 2018;3:e41-e45. Published 2018 Mar 21. doi:10.5114/amsad.2018.74522 Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD

Contributor: Rachael Duncan, PharmD BCPS Educational Pearls: According to the Department of Public Health and Environment who puts out a weekly report on the influenza virus in Colorado, there appears to be less influenza in Colorado than previous years A milder influenza outbreak is likely due to mask wearing and social distancing practices There have only been 22 hospitalizations for influenza in Colorado since the start of the flu season back in September and 0 outbreaks in long-term care facilities Xofluza (baloxavir marboxil) is an antiviral PA endonuclease inhibitor and was approved by the FDA in 2018 for uncomplicated influenza in patients 12 years and older that have been symptomatic for less than 48 hours Patient's getting Xofluza must be otherwise healthy or at risk of developing influenza-related complications Due to limited data, Xofluza would not be a good option for those that are inpatient or critically ill and is best utilized for patients who are being seen in the emergency department and will be sent home Currently Xofluza is not approved for complicated patients, pregnant patients or those that are breast-feeding which limits its use When compared with Tamiflu in phase 3 studies, Xofluza was superior to placebo and similar to Tamiflu in shortening the duration of illness Xofluza is a single dose that is weight based and appears to be very well tolerated with some adverse effects including headache, nausea and diarrhea Xofluza showed a quicker recovery compared to Tamiflu by 8 hours which could be related to its one-time dosing Cost is a limiting factor for the use of Xofluza. Tamiflu costs around $25 where as Xofluza (only available as brand name currently) is $156 at the cheapest Pharmacists are still encouraging everyone to get their influenza vaccines despite less influenza cases this year References: Cdphe.colorado.gov. 2021. Influenza (flu) | Department of Public Health & Environment. [online] Available at: [Accessed 11 February 2021]. Ison, M., Portsmouth, S., Yoshida, Y., Shishido, T., Mitchener, M., Tsuchiya, K., Uehara, T. and Hayden, F., 2020. Early treatment with baloxavir marboxil in high-risk adolescent and adult outpatients with uncomplicated influenza (CAPSTONE-2): a randomised, placebo-controlled, phase 3 trial. The Lancet Infectious Diseases, 20(10), pp.1204-1214. Hayden, F., Sugaya, N., Hirotsu, N., Lee, N., de Jong, M., Hurt, A., Ishida, T., Sekino, H., Yamada, K., Portsmouth, S., Kawaguchi, K., Shishido, T., Arai, M., Tsuchiya, K., Uehara, T. and Watanabe, A., 2018. Baloxavir Marboxil for Uncomplicated Influenza in Adults and Adolescents. New England Journal of Medicine, 379(10), pp.913-923. Summarized by Emily Mack OMSIII 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.

This episode of Mental Health Monthly we will be discussing drugs screens in the Emergency Department with Dr. Justin Romano and Eddie Carillo. Dr. Justin Romano is a current psychiatry resident and Eddie Carillo is a licensed mental health therapist. Check out their podcast Millennial Mental Health Channel on all major podcast platforms. Shout out to Dr. Dave Marshall whose grand round presentation this was based on. Key Points: Try not to judge your patient based on the results of their drug screen Drug screens are used a lot; they are not always accurate Based on one study there was no significant change in outcome, treatment, disposition or psychiatric course when a drug screen was obtained Specific good uses for drug screens include new onset of psychiatric symptoms Educational Pearls: 1 in 8 ED visits are due to psychiatric complaints which is up 44% since mid 2000's 63% of new psychiatric complaints had a medical cause Physicians use drug screens commonly in the Emergency Department, but often do not understand their limitations and are often not using them in the most clinically effective manner Urine is by far the most commonly used in the Emergency Department UA drug screens are notorious for having false positives and false negatives Length of clearance from the urine: Alcohol 12 hours Methamphetamines/Amphetamines 48 hours Benzodiazepines 3 days Opiates 2-3 days Cocaine 2-4 days Marijuana dependent on use: 3- 15 days Phencyclidine (PCP) 8 days Urine drug screens have a false positive rate of 5-10 % and a false negative rate of 10-15% False Positive; urine drug screen positive, but drug is not in their body False positives for amphetamines: bupropion, trazodone, metformin, promethazine, pseudoephedrine, phentermine and atomoxetine False positives for benzodiazepines: sertraline False positives for cannabis: ibuprofen, naproxen, proton pump inhibitors False positives for opiates: poppy seeds, antibiotics, Benadryl False positives for PCP: venlafaxine, ibuprofen and Ambien False positives for cocaine: amoxicillin False Negative; urine drug screen negative, but drug is in the body Benzodiazepines: such as alprazolam, clonazepam, lorazepam or triazolam Cannabinoids: CBD, synthetic marijuana such as K2 Opiates: oxycodone, fentanyl, methadone and tramadol If you get a test that you don't think is accurate you can always send off for a confirmatory test References Summarized by Emily Mack OMSIII | Edited by Mason Tuttle 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: Retrospective review of 5,021 patients over 65 with 2 or more rib fractures recently published 3577 (78 %) were admitted to non-ICU setting 1.1% of these patients had unexpected intubation or ICU transfer Findings raise questions regarding current guidelines for ICU admission in elderly patients with isolated rib fractures References Naar L, El Hechi MW, van Erp IA, Mashbari HNA, Fawley J, Parks JJ, Fagenholz PJ, King DR, Mendoza AE, Velmahos GC, Kaafarani HMA, Saillant NN. Isolated rib cage fractures in the elderly: Do all patients belong to the intensive care unit? A retrospective nationwide analysis. J Trauma Acute Care Surg. 2020 Dec;89(6):1039-1045. doi: 10.1097/TA.0000000000002891. PMID: 32697447. Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD

Contributor: Aaron Lessen, MD Educational Pearls: Pyogenic liver abscesses can be caused by Intra-abdominal infection progressing to peritonitis which then drains into liver Bacteremia leading to hematogenous spead and seeding Local biliary infection with contiguous spread Patients typically present with signs of sepsis or septic shock and the abscess can be diagnosed using ultrasound or CT Treat with IV fluids, broad spectrum antibiotics, and consultation for drainage References Kurland JE, Brann OS. Pyogenic and amebic liver abscesses. Curr Gastroenterol Rep. 2004 Aug;6(4):273-9. doi: 10.1007/s11894-004-0078-2. PMID: 15245694. Rahimian J, Wilson T, Oram V, Holzman RS. Pyogenic liver abscess: recent trends in etiology and mortality. Clin Infect Dis. 2004 Dec 1;39(11):1654-9. doi: 10.1086/425616. Epub 2004 Nov 9. PMID: 15578367. Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD

Contributor: Katie Sprinkel, MD Educational Pearls: Commonly known as "acid," LSD is seeing a resurgence in the population as a recreational hallucination Onset is about 30 minutes with peak pharmacologic effects at 2-4 hours, the drug's half life is 3 hours resulting in some prolonged effects While there is not an significant addictive component of LSD, tolerance for LSD does occur and prolonged usage is associated with increased incidence of schizophreniform disorders Hallucinations and pseudo-hallucinations (sensory misperceptions) are typical of LSD intoxication, other common signs of intoxication include nausea, diaphoresis, tachycardia, mydriasis, and hypertension More serious effects can be coma, hyperthermia, seizures, cardiac arrest, serotonin syndrome (with concomitant SSRI use) and coagulopathy, although the dose to cause these effects is very high Treatment is decreasing sensory stimulation, benzodiazepines in some cases, and symptomatic treatment - no specific antidote exists References Blaho K, Merigian K, Winbery S, Geraci SA, Smartt C. Clinical pharmacology of lysergic acid diethylamide: case reports and review of the treatment of intoxication. Am J Ther. 1997 May-Jun;4(5-6):211-21. doi: 10.1097/00045391-199705000-00008. PMID: 10423613. Klock JC, Boerner U, Becker CE. Coma, hyperthermia and bleeding associated with massive LSD overdose. A report of eight cases. West J Med. 1974;120(3):183-188. Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD

Contributor: Sam Killian, MD Educational Pearls: iliac vein compression syndrome is also called May-Thurner Syndrome The left leg more frequently develops deep venous thrombosis (DVT) in part because about 1/4 of the population has May-Thurner May-Thurner syndrome anatomic variant results in a right iliac artery compresses the left iliac vein against the spine, which can promote DVT formation This is thought to be the cause of 2-3% of DVTs in patients seen in the ED and suspicion for this disease should increased in those with recurrent DVT Diagnosis is made with MRV/MRA and will typically not be seen on duplex ultrasound Typical anticoagulation treatment fails to address the underlying structural cause References Demir MC, Kucur D, Çakır E, Aksu NM, Onur MR, Sabuncu T, Akkaş M. May-Thurner syndrome: A curious syndrome in the ED. Am J Emerg Med. 2016 Sep;34(9):1920.e1-3. doi: 10.1016/j.ajem.2016.02.045. Epub 2016 Feb 19. PMID: 26971822. Sharafi S, Farsad K. Variant May-Thurner syndrome: Compression of the left common iliac vein by the ipsilateral internal iliac artery. Radiol Case Rep. 2018;13(2):419-423. Published 2018 Feb 20. doi:10.1016/j.radcr.2018.01.001 Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD

Educational Pearls: Atropine has been shown to reduce hypersalivation as well as nausea and vomiting induced by ketamine sedation. Atropine can increase the occurrence of a transient rash, as well as tachycardia. There are no guidelines that recommend for or against atropine use in pediatric patients undergoing ketamine induced sedation. Ultimately, it is the providers decision to include atropine when performing ketamine sedation. Pediatric dosing for atropine is 0.01mg/kg IM. References Heinz P, Geelhoed GC, Wee C, Pascoe EM. Is atropine needed with ketamine sedation? A prospective, randomised, double blind study. Emerg Med J. 2006 Mar;23(3):206-9. doi: 10.1136/emj.2005.028969. PMID: 16498158; PMCID: PMC2464444. Chong JH, Chew SP, Ang AS. Is prophylactic atropine necessary during ketamine sedation in children? J Paediatr Child Health. 2013 Apr;49(4):309-12. doi: 10.1111/jpc.12149. Epub 2013 Mar 15. PMID: 23495827. Shi J, Li A, Wei Z, Liu Y, Xing C, Shi H, Ding H, Pan D, Ning G, Feng S. Ketamine versus ketamine pluses atropine for pediatric sedation: A meta-analysis. Am J Emerg Med. 2018 Jul;36(7):1280-1286. doi: 10.1016/j.ajem.2018.04.010. Epub 2018 Apr 5. PMID: 29656945. Presented and Summarized by Devan Naughton, 4th year pharmacy student | Edited by Ruben Marrero-Vasquez

Contributor: Peter Bakes, MD Educational Pearls: Two main differentials for wide complex tachycardia (WCT) include ventricular tachycardia (most common) and supraventricular tachycardia with aberrancy Brugada syndrome and Wolff-Parkinson White are potential causes Arrhythmogenic right ventricular dysplasia is a rare congenital cause of WCT that should be considered in younger patients presenting with WCT References B Garner J, M Miller J. Wide Complex Tachycardia - Ventricular Tachycardia or Not Ventricular Tachycardia, That Remains the Question. Arrhythm Electrophysiol Rev. 2013;2(1):23-29. doi:10.15420/aer.2013.2.1.23 Katritsis DG, Brugada J. Differential Diagnosis of Wide QRS Tachycardias. Arrhythm Electrophysiol Rev. 2020;9(3):155-160. doi:10.15420/aer.2020.20 Li KHC, Bazoukis G, Liu T, et al. Arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D) in clinical practice. J Arrhythm. 2017;34(1):11-22. Published 2017 Dec 21. doi:10.1002/joa3.12021 Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD

Contributor: Dylan Luyten, MD Educational Pearls: D10 may be a better alternative to D50 in correcting hypoglycemia Risks of D50: Can cause extravasation injury Risk of rebound hypoglycemia D10 does not have the same risks and has no significant difference in reversal time of hypoglycemia compared to D50 References Kiefer MV, Gene Hern H, Alter HJ, Barger JB. Dextrose 10% in the treatment of out-of-hospital hypoglycemia. Prehosp Disaster Med. 2014 Apr;29(2):190-4. doi: 10.1017/S1049023X14000284. Epub 2014 Apr 15. PMID: 24735872. Moore C, Woollard M. Dextrose 10% or 50% in the treatment of hypoglycaemia out of hospital? A randomised controlled trial. Emerg Med J. 2005 Jul;22(7):512-5. doi: 10.1136/emj.2004.020693. PMID: 15983093; PMCID: PMC1726850. 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: Jared Scott, MD Educational Pearls: Pathologic bone fractures occur due to weakened bones from chronic disease and with less force when compared to non-pathologic fractures Can be due to bone tumors, bone cysts, infections (osteomyelitis), osteogenesis imperfecta, Paget's disease of bone, and multiple myeloma Have moth bitten or lytic appearance and you can sometimes see the periosteum peeling away from the bone References Angelini A, Trovarelli G, Berizzi A, Pala E, Breda A, Maraldi M, Ruggieri P. Treatment of pathologic fractures of the proximal femur. Injury. 2018 Nov;49 Suppl 3:S77-S83. doi: 10.1016/j.injury.2018.09.044. PMID: 30415673. Marshall RA, Mandell JC, Weaver MJ, Ferrone M, Sodickson A, Khurana B. Imaging Features and Management of Stress, Atypical, and Pathologic Fractures. Radiographics. 2018 Nov-Dec;38(7):2173-2192. doi: 10.1148/rg.2018180073. PMID: 30422769. Unbreakable Summarized by Jackson Roos, 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.

Contributor: Jared Scott, MD Educational Pearls: Bilirubin is natural breakdown product of red blood cells but can be neurotoxic if levels become too high Fetal red blood cells are fragile and break down easier, leading to higher bilirubin levels in neonates Immature livers and increased intestinal absorption from sterile bowels also contribute to elevated levels and jaundice in all neonates Other risk factors for neonatal jaundice include: temperature instability, poor feeding, hypoxia at birth, and being of East Asian descent Neonatal bilirubin levels are referenced to time since birth using a nomogram to determine the need for light therapy (or exchange transfusion) References Mitra S, Rennie J. Neonatal jaundice: aetiology, diagnosis and treatment. Br J Hosp Med (Lond). 2017 Dec 2;78(12):699-704. doi: 10.12968/hmed.2017.78.12.699. PMID: 29240507. Woodgate P, Jardine LA. Neonatal jaundice: phototherapy. BMJ Clin Evid. 2015 May 22;2015:0319. PMID: 25998618; PMCID: PMC4440981. Colletti JE, Kothari S, Jackson DM, Kilgore KP, Barringer K. An emergency medicine approach to neonatal hyperbilirubinemia. Emerg Med Clin North Am. 2007 Nov;25(4):1117-35, vii. doi: 10.1016/j.emc.2007.07.007. Erratum in: Emerg Med Clin North Am. 2008 Feb;26(1):xi. Kothori, Samip [corrected to Kothari, Samip]. PMID: 17950138. Summarized by Jackson Roos, 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.

Contributor: Cheyenne Bean, PharmD Educational Pearls: Bactrim (TMP-SMX) is a sulfa antibiotic used for a number of infections but can have untoward effects. Hypoglycemia can be induced by the sulfa component of Bactrim, which binds receptors in the pancreas causing insulin to be secreted, dropping blood sugar levels. Oral diabetic medications, specifically sulfonylureas, when taken with Bactrim most often lead to these hypoglycemic episodes. Hyperkalemia can be induced by Trimethoprim by blocking potassium excretion in the kidney, so Bactrim in combination with ACE inhibitors/ARBs/spironolactone can induce high potassium. When prescribing Bactrim, remember to check home medications and if a patient is taking an above medication, check a baseline BGL and potassium. References 1) Khorvash F, Moeinzadeh F, Saffaei A, Hakamifard A. Trimethoprim-sulfamethoxazole Induced Hyponatremia and Hyperkalemia, The Necessity of Electrolyte Follow-up in Every Patient. Iran J Kidney Dis. 2019 Jul;13(4):277-280. PMID: 31422395. 2) Kennedy KE, Teng C, Patek TM, Frei CR. Hypoglycemia Associated with Antibiotics Alone and in Combination with Sulfonylureas and Meglitinides: An Epidemiologic Surveillance Study of the FDA Adverse Event Reporting System (FAERS). Drug Saf. 2020 Apr;43(4):363-369. doi: 10.1007/s40264-019-00901-7. PMID: 31863282; PMCID: PMC7117991. Summarized by Jackson Roos, 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.

Contributor: Gretchen Hinson, MD Educational Pearls: Viruses mutate frequently and a new variant of COVID has been found in the United Kingdom. Mutations typically occur due to transcription errors during virus replication leading to slight changes in the virus which can alter its virulence, and this UK mutation has shown more infectivity. The UK variant was first identified on 9/20/20 and sequenced in October The variant has a mutation of the spike protein with increased receptor binding capacity, making it more efficient at infecting cells Children seem to be more susceptible to this variant as compared to the prior COVID strains. References 1) Tang JW, Tambyah PA, Hui DS. Emergence of a new SARS-CoV-2 variant in the UK. J Infect. 2020 Dec 28:S0163-4453(20)30786-6. doi: 10.1016/j.jinf.2020.12.024. Epub ahead of print. PMID: 33383088. Summarized by Jackson Roos, 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.

Contributor: Peter Bakes, MD Educational Pearls: Hyperacute T waves can occur immediately and typical last less than an hour Hyperacute T waves are typically broader than peaked T-waves, which are associated with hyperkalemia ST elevation which usually starts within an hour of the inciting event and can last up to a few days, and often follows the hyperacute T-waves Q waves can begin at the time ST elevation begins and can remain permanently T waves can invert before normalizing again days later References Levis JT. ECG Diagnosis: Hyperacute T Waves. Perm J. 2015;19(3):79. doi:10.7812/TPP/14-243 Vogel B, Claessen BE, Arnold SV, Chan D, Cohen DJ, Giannitsis E, Gibson CM, Goto S, Katus HA, Kerneis M, Kimura T, Kunadian V, Pinto DS, Shiomi H, Spertus JA, Steg PG, Mehran R. ST-segment elevation myocardial infarction. Nat Rev Dis Primers. 2019 Jun 6;5(1):39. doi: 10.1038/s41572-019-0090-3. PMID: 31171787. Summarized by Jackson Roos, 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.

Contributor: Jared Scott, MD Educational Pearls: EKGs look at different angles, or vectors, of the heart's electrical conduction as it travels through the heart. Knowing how to read these vectors is essential in diagnosing locations of cardiac pathologies Leads II, III, and aVF follow an inferior path, so ST elevation in those leads indicates inferior involvement Major complications more common with inferior STEMIs can include: hypotension which can be made worse by nitroglycerin Severe bradycardia due to SA/AV node involvement Inferior STEMI, barring no hypotension or bradycardia, have better mortality than other types References Warner MJ, Tivakaran VS. Inferior Myocardial Infarction. 2020 Aug 8. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan–. PMID: 29262146. Summarized by Jackson Roos, 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.

Contributor: Peter Bakes, MD Educational Pearls: STEMI criteria is not just 1mm elevation in contiguous leads 1.5 mm in V2-V3 for women 2.0 mm in V2-V3 for men 2.5 mm in V2-V3 for men under 40 Inferior MI typically have ST elevation in leads II, III and aVF Usually inferior MI's show reciprocal changes (ST depression) in the lateral leads. Lateral MI typically elevation in V5, V6, I, and aVL Anterior MI show elevation in leads V1-4 Right sided MIs have mixed pattern, showing elevation in V1-V2 and V4 along with the inferior leads. Right sided MI's are very sensitive to nitrates, especially if they become intubated because this combination can drop pre-load significantly leading to profound hypotension References Akbar H, Foth C, Kahloon RA, et al. Acute ST Elevation Myocardial Infarction. [Updated 2020 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK532281/ Namana V, Gupta SS, Abbasi AA, Raheja H, Shani J, Hollander G. Right ventricular infarction. Cardiovasc Revasc Med. 2018 Jan;19(1 Pt A):43-50. doi: 10.1016/j.carrev.2017.07.009. Epub 2017 Jul 14. PMID: 28822687. Summarized by Jackson Roos, 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.

Contributor: Aaron Lessen, MD Educational Pearls: High flow nasal cannula (HFNC) has become more utilized with COVID pandemic Multiple studies have shown this method improves both oxygenation and ventilation Newer studies have shown the respiratory benefit of HFNC vs normal oxygen in patients suffering from CHF and those with do not intubate orders who are experiencing respiratory distress. Heated high flow is another option to provide ventilator and oxygen support to patients who either do not need or do not want to be intubated References Kang MG, Kim K, Ju S, et al. Clinical efficacy of high-flow oxygen therapy through nasal cannula in patients with acute heart failure . J Thorac Dis. 2019;11(2):410-417. doi:10.21037/jtd.2019.01.51 Peters SG, Holets SR, Gay PC. High-flow nasal cannula therapy in do-not-intubate patients with hypoxemic respiratory distress. Respir Care. 2013 Apr;58(4):597-600. doi: 10.4187/respcare.01887. PMID: 22781059. Sharma S, Danckers M, Sanghavi D, et al. High Flow Nasal Cannula. [Updated 2020 Jul 2]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK526071/ Summarized by Jackson Roos, 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.

Contributor: Ruben Marrero-Vasquez, PharmD Educational Pearls: ACEP and FDA have both issued warnings about the viral Tik Tok Benadryl (diphenhydramine) challenge where individuals voluntarily overdose on diphenhydramine which can cause fatal toxicity Diphenhydramine is typically dosed at 0.5-1 mg/kg in pediatric patients Q4-6 PRN and carries a fatal dose of 20-40 mg/kg but anywhere from 3-5x recommended dose does can cause toxicity Diphenhydramine toxicity causes both central and peripheral anticholinergic toxicity Central anticholinergic toxicity symptoms: delirium, agitation, combativeness, confusion, restlessness, hallucinations, ataxia, tremor and seizures Peripheral anticholinergic toxicity symptoms: tachycardia, dry flushed skin, dry mucus membranes, thick secretions, dilation of pupils, urinary retention, and decreased bowel sounds Pneumatic to help you remember anticholinergic toxidrome: Red as a beet Dry as a bone Blind as a bat Mad as a hatter Hot as a hare Full as a flask Management typically only requires supportive care, agitation from central anticholinergic delirium can be hardest aspect to treat, IV benzodiapines are first line treatment to control and may require large doses to prevent rhabdomyolysis and hyperthermia Diphenhydramine toxicity has been associated with blockade of sodium and potentially potassium channels increasing risk of arrhythmia and seizures. Cardiac changes can include: QRS widening, myocardial depression, QT prolongation and torasades-type ventricular tachycardia. Wide QRS complexes indicate delayed ventricular depolarization caused by sodium channel blockade, bolus of sodium bicarbonate can be used dosed 1-2 mEq/kg followed by continuous infusion Prolonged QT: restoration of low serum potassium and magnesium to high normal range Benzodiazipines should be used as first line therapy for toxin induced seizures Don't use fosphenytoin or phenytoin sodium channel blockers as they can worsen cardiac conduction References Olson KR, Anderson IB, Benowitz NL, Blanc PD, Clark RF, Kearney TE, Kim-Katz SY, Wu AH. Diphenhydramine. In: Poisoning & Drug Overdose. 7th ed.McGraw Hll; 2018: 544-545. FDA Warns About Serious Problems With High Doses Of The Allergy Medicine Diphenhydramine (Benadryl).(09/24/2020). CDC website. Accessed December 01, 2020. https://www.fda.gov/drugs/drug-safety-and-availability/fda-warns-about-serious-problems-high-doses-allergy-medicine-diphenhydramine-benadryl. Su M, Goldman M. Anticholinergic Poisoning. UpToDate. https://www.uptodate.com/contents/anticholinergic-poisoning?search=diphenhydramine overdose&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1. Published October 6, 2020. Accessed December 26, 2020. Summarized by Mason Tuttle

EMM is excited to welcome back the hosts of Millennial Mental Health Channel podcast to explain the key points of a robust suicide assessment in the ED. Dr. Justin Romano is a third year psychiatry resident in Omaha, Nebraska and Eddie Carrillo is a licensed mental health therapist currently working at partial hospitalization and IOP eating disorder program in Portland, Oregon. Their podcast Millennial Mental Health Channel seeks to explore the world of mental health from their two professional perspectives. You can listen to their podcast on all major streaming platforms including Apple Podcasts, Spotify and Google Podcasts. Follow them on Twitter and Instagram @millennialmhc Contributors: Dr. Justin Romano and Eddie Carrillo, M.A., LPC Educational Pearls: Suicide is 10th most common cause in U.S. and the rate rose by 30% from 2000-2016 and the CDC reports that there was a 25% increase in ED visits for SI from January 2017 - December 2018 Use an objective screening tool like Columbia-Suicide Severity Rating Scale (C-SSRS) when assessing patients as they can help detect SI although ultimately it is up to your clinical impression to make a decision Suicide reduction measures and strategies work! Take advantage of social workers when setting up outpatient resources for patients i.e. gun locks Risk Factors include: prior attempts, substance use/abuse, mental disorders (especially depression and bipolar disorder), access to lethal means (most modifiable by risk reduction strategies), knowing someone who has died by suicide, social isolation, chronic disease or disability, lack of access to mental health resources, recent changes in social status and being a member of a high risk demographic (older caucasian men, LGBTQ+, Native Americans and Alaskan Natives) Protective Factors include: good followup as an outpatient, good social support, life skills, purpose in life, cultural beliefs, children and sense of responsibility in the family Sober up and reassess suicidality If not medically cleared, admit to hospital to address these complaints and then address suicidality If they have suicidal thoughts, plan and are reaching out for help because they don't want to do it then send to inpatient facility Consult psychiatry to explain inpatient psych or when you're worried about patient safety to have them weigh in Get collateral by talking to a family member to verify that the patient is telling the truth At the end of the day, thorough documentation of risk and protective factors and results of screening tool in Assessment and Plan is essential to protecting yourself as a professional References Betz ME, Boudreaux ED. Managing Suicidal Patients in the Emergency Department. Ann Emerg Med. 2016;67(2):276-282. doi:10.1016/j.annemergmed.2015.09.001 Suicide. National Institute of Mental Health. https://www.nimh.nih.gov/health/statistics/suicide.shtml. Published September 2020. Accessed December 30, 2020. Zwald ML, Holland KM, Annor FB, et al. Syndromic Surveillance of Suicidal Ideation and Self-Directed Violence — United States, January 2017–December 2018. MMWR Morb Mortal Wkly Rep 2020;69:103–108. DOI: http://dx.doi.org/10.15585/mmwr.mm6904a3. Summarized by Mason Tuttle

Educational Pearls: The CDC has made new formal recommendations for treating Gonorrhea due to increasing resistance to Rocephin and Azithromycin. New recommendations: Confirmed gonorrhea: Ceftriaxone 500 mg once Empiric treatment: Ceftriaxone 500 mg once followed by 7 days Doxycycline 100 mg BID No longer using Azithromycin due to high resistance Second line: Gentamycin IM Cefixime 800 mg oral Pharyngeal involvement has high resistance rates to second line agents and ceftriaxone is strongly preferred 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;69:1911–1916. DOI: http://dx.doi.org/10.15585/mmwr.mm6950a6. Summarized by Jackson Roos, 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.

Contributor: Tom Seibert, MD Educational Pearls: High altitude cerebral edema (HACE) is the end stage of acute mountain sickness and is diagnosed when patients develop neurologic dysfunction, ataxia, and altered mental status. The pathophysiology of HACE is thought to be due to increased cerebral blood flow and increased capillary permeability causing vasogenic edema and brain swelling HACE is linked to extreme altitude Rapid descent should be done as soon as possible for this potentially fatal condition Oxygen can be supportive Dexamethasone is also typically indicated (8mg initially followed by 4 mg every 6 hours) Editor's note: HACE can occur at altitudes as low as 8000 feet so don't automatically assume it can't/doesn't happen in the US References Jensen JD, Vincent AL. High Altitude Cerebral Edema. 2020 Aug 26. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan–. PMID: 28613666. Hackett PH, Yarnell PR, Weiland DA, Reynard KB. Acute and Evolving MRI of High-Altitude Cerebral Edema: Microbleeds, Edema, and Pathophysiology. AJNR Am J Neuroradiol. 2019 Mar;40(3):464-469. doi: 10.3174/ajnr.A5897. Epub 2019 Jan 24. PMID: 30679208; PMCID: PMC7028681. Summarized by Jackson Roos, 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.

Contributor: Don Stader, MD Educational Pearls: Time can be an important factor in outcomes regarding sepsis including mortality Emphasis has grown on early administration of antibiotics and IV fluids in sepsis However, early initiation of vasopressors for hypotensive patients may have significant mortality benefit as well References Hayden GE, Tuuri RE, Scott R, et al. Triage sepsis alert and sepsis protocol lower times to fluids and antibiotics in the ED. Am J Emerg Med. 2016;34(1):1-9. doi:10.1016/j.ajem.2015.08.039 Colling KP, Banton KL, Beilman GJ. Vasopressors in Sepsis. Surg Infect (Larchmt). 2018;19(2):202-207. doi:10.1089/sur.2017.255 Colon Hidalgo D, Patel J, Masic D, Park D, Rech MA. Delayed vasopressor initiation is associated with increased mortality in patients with septic shock. J Crit Care. 2020 Feb;55:145-148. doi: 10.1016/j.jcrc.2019.11.004. Epub 2019 Nov 9. PMID: 31731173. Summarized by Jackson Roos, 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.

Contributor: Tom Seibert, MD Educational Pearls: Acute Mountain sickness (AMS) can cause headache along with fatigue, nausea, vomiting, insomnia Typically occurs above 6500 feet (not 65,000) in elevation Acclimation to altitude can help prevent symptoms if not treated, AMS can advance to severe illness involving cerebral or pulmonary edema. Mild symptoms can be managed with rest but more severe symptoms will require descent, oxygen, acetazolamide and steroids Acetazolamide can be used as both a preventative and therapeutic drug References Davis C, Hackett P. Advances in the Prevention and Treatment of High Altitude Illness. Emerg Med Clin North Am. 2017 May;35(2):241-260. doi: 10.1016/j.emc.2017.01.002. PMID: 28411926. Summarized by Jackson Roos, 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.

Contributor: Thomas Seibert, MD Educational Pearls: High Altitude Pulmonary Edema (HAPE) typically occurs 2-4 days after arriving at elevation Symptoms include: Fatigue Dyspnea Cough Treatment includes: Descent to lower elevation Oxygen supplementation Nifedipine Caused by sympathetic stimulation from hypobaric hypoxic exposure, causing uneven pulmonary vasculature constriction and when paired with a leaky endothelium, pulmonary edema. #science References Swenson ER, Bärtsch P. High-altitude pulmonary edema. Compr Physiol. 2012 Oct;2(4):2753-73. doi: 10.1002/cphy.c100029. PMID: 23720264. Johnson NJ, Luks AM. High-Altitude Medicine. Med Clin North Am. 2016 Mar;100(2):357-69. doi: 10.1016/j.mcna.2015.09.002. PMID: 26900119. Hultgren HN. High-altitude pulmonary edema: current concepts. Annu Rev Med. 1996;47:267-84. doi: 10.1146/annurev.med.47.1.267. PMID: 8712781. Summarized by Jackson Roos, MSIV | 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: Schizophrenia typically doesn't present until age 13 and has a prodrome Prodrome includes months of gradual changes in behavior, starting with negative symptoms and progressing to positive symptoms Negative symptoms include losing concentration, poor memory, poor school performance, and personality changes Positive symptoms include hallucinations, which tend to be more visual in children Sudden changes mimicking psychiatric illness should raise concern for alternative causes References Kendhari J, Shankar R, Young-Walker L. A Review of Childhood-Onset Schizophrenia. Focus (Am Psychiatr Publ). 2016 Jul;14(3):328-332. doi: 10.1176/appi.focus.20160007. Epub 2016 Jul 8. PMID: 31975813; PMCID: PMC6526799. Staal M, Panis B, Schieveld JNM. Early warning signs in misrecognized secondary pediatric psychotic disorders: a systematic review. Eur Child Adolesc Psychiatry. 2019 Sep;28(9):1159-1167. doi: 10.1007/s00787-018-1208-y. Epub 2018 Jul 27. PMID: 30054738. Summarized by Jackson Roos, 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.

Contributors: Rachael Duncan, PharmD and Sean McCullough, PharmD Educational Pearls: A 2019 Report by the National Women's Law Center: Most common occupations for pregnant workers are elementary and middle school teachers, registered nurses, and nursing/psychiatric/home health care aides. This raises the question: Should pregnant women, specifically front-line workers, get the Covid-19 vaccine? According to the FDA, there is currently not enough data to make a conclusion about the safety of the newly approved Pfizer vaccine for populations that include children less than 16, pregnant and lactating women, and those that are immunocompromised. Specifically, pregnant women were excluded from the clinical trials testing the Pfizer vaccine. According to the CDC, additional data needs to be reviewed from the phase III clinical trials in order to provide recommendations to pregnant and breast-feeding women about taking the Covid-19 vaccine and its safety. An Advisory Committee of Immunization Practices (ACIP) meeting will take place on 12/13/2020 and will hopefully provide formal recommendations to pregnant and lactating women. The Society for Maternal-Fetal Medicine (SMFM) has consistently advocated for the inclusion of pregnant and lactating women into clinical trials when these criteria are met: 1) pregnancy poses increased susceptibility to or severity of a disease; 2) the best approach to protect the infant is through passive placental antibody transfer, which provides the most efficient and direct protection to the newborn before an infant can be vaccinated, and 3) there is an active outbreak. SMFM recommends healthcare workers who are currently being prioritized to receive the vaccine to also receive the vaccine if pregnant. Pregnant healthcare workers should take their individual situation into consideration and weigh the risks and benefits for themselves and the risk for detecting disease when considering if or when to take the Covid-19 vaccine. References ACIP Meeting Agenda December 13, 2020 - cdc.gov. MEETING OF THE ADVISORY COMMITTEE ON IMMUNIZATION PRACTICES (ACIP). https://www.cdc.gov/vaccines/acip/meetings/downloads/agenda-archive/agenda-2020-12-11.pdf. Published 2020. Accessed December 11, 2020. Coronavirus (COVID-19), Pregnancy, and Breastfeeding: A Message for Patients. ACOG. https://www.acog.org/womens-health/faqs/coronavirus-covid-19-pregnancy-and-breastfeeding. Published 2020. Accessed December 11, 2020. Interim Considerations for COVID-19 Vaccination of Healthcare Personnel and Long-Term Care Facility Residents. Centers for Disease Control and Prevention. https://www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/covid-19/clinical-considerations.html. Published December 3, 2020. Accessed December 11, 2020. Society for Maternal-Fetal Medicine (SMFM) Statement: SARS-CoV-2 Vaccination in Pregnancy. December 2020. https://s3.amazonaws.com/cdn.smfm.org/media/2591/SMFM_Vaccine_Statement_12-1-20_(final).pdf Vaccines and Related Biological Products Advisory Committee Meeting December 10, 2020. 2020. https://www.fda.gov/media/144245/download VRBPAC December 10, 2020 Meeting Announcement. U.S. Food and Drug Administration. https://www.fda.gov/advisory-committees/advisory-committee-calendar/vaccines-and-related-biological-products-advisory-committee-december-10-2020-meeting-announcement. Published December 10, 2020. Accessed December 11, 2020. Summarized by Emily Mack OMSIII | Edited by Rachael Duncan, PharmD

Contributor: Aaron Lessen, MD Educational Pearls: Serum prolactin levels can be used to help differentiate epileptic seizures from non-epileptic seizures It is also released and elevated after epileptic seizures but not non-epileptic seizures A level must be checked 10-20 minutes after the episode and if possible a next day level should be checked to establish a baseline Levels can also be raised after a syncopal event Not the most useful ED also due to the long turn around time EEG will remain superior for now References Nass RD, Sassen R, Elger CE, Surges R. The role of postictal laboratory blood analyses in the diagnosis and prognosis of seizures. Seizure. 2017 Apr;47:51-65. doi: 10.1016/j.seizure.2017.02.013. Epub 2017 Feb 27. PMID: 28288363. Chen DK, So YT, Fisher RS; Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Use of serum prolactin in diagnosing epileptic seizures: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology. 2005 Sep 13;65(5):668-75. doi: 10.1212/01.wnl.0000178391.96957.d0. PMID: 16157897. Summarized by Jackson Roos, 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.

Contributor: Don Stader, MD Educational Pearls: Zyprexa (olanzapine) is a second generation antipsychotic with multiple other uses Excellent for treating nausea in patients undergoing chemotherapy or with THC hyperemesis syndrome Helps with the psychological and emotional aspect of pain Effective in treatment of headaches Can be given under the tongue Fewer incidences of dystonic reactions compared with first generation antipsychotics Patients using anti-dopaminergic should not receive antipsychotics because they also work on dopaminergic receptors References Navari RM, Qin R, Ruddy KJ, Liu H, Powell SF, Bajaj M, Dietrich L, Biggs D, Lafky JM, Loprinzi CL. Olanzapine for the Prevention of Chemotherapy-Induced Nausea and Vomiting. N Engl J Med. 2016 Jul 14;375(2):134-42. doi: 10.1056/NEJMoa1515725. PMID: 27410922; PMCID: PMC5344450. Jimenez XF, Sundararajan T, Covington EC. A Systematic Review of Atypical Antipsychotics in Chronic Pain Management: Olanzapine Demonstrates Potential in Central Sensitization, Fibromyalgia, and Headache/Migraine. Clin J Pain. 2018 Jun;34(6):585-591. doi: 10.1097/AJP.0000000000000567. PMID: 29077621. Summarized by Jackson Roos, 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.

Contributor: Don Stader, MD Educational Pearls: Majority of patients experience side effects while taking opioids Most common include nausea/vomiting, puriitis, constipation; more severe and less common include respiratory depression, addiction and overdose Opiates can cause nausea, but ondansetron (Zofran) is the wrong treatment because it's not antidopaminergic. Instead consider using metoclopramide (Reglan), olanzapine (Zyprexa), or haloperidol (Haldol) Itching from opiates isn't histamine mediated so hydroxyzine (Atarax) and diphenhydramine (Benadryl) aren't effective - oddly ondansetron may help with itching. Constipation is best treated with promotility agents like Senna, rather than stool softeners References Rogers E, Mehta S, Shengelia R, Reid MC. Four Strategies for Managing Opioid-Induced Side Effects in Older Adults. Clin Geriatr. 2013 Apr;21(4): PMID: 25949094; PMCID: PMC4418642. Farmer AD, Holt CB, Downes TJ, Ruggeri E, Del Vecchio S, De Giorgio R. Pathophysiology, diagnosis, and management of opioid-induced constipation. Lancet Gastroenterol Hepatol. 2018 Mar;3(3):203-212. doi: 10.1016/S2468-1253(18)30008-6. PMID: 29870734. Summarized by Jackson Roos, 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.

Contributor: Peter Bakes, MD Educational Pearls: Recent study looked at if mask wearing protects the mask wearer from infection This group found 1.8% of mask wearers got COVID while 2.1% of non-mask wearers became infected, which was not statistically significant This was not statistically significant and has been used to justify not wearing masks by some groups While the numbers look small, it's close to a 20% reduction in infections for the mask wearers The results reported had concerns for being underpowered, meaning the studies population may not be big enough to draw definitive conclusions Many limitations of study including how wearing a mask may protect others Unfortunately, studies like these can lead to misinterpretation and distortion References Bundgaard H, Bundgaard JS, Raaschou-Pedersen DET, von Buchwald C, Todsen T, Norsk JB, Pries-Heje MM, Vissing CR, Nielsen PB, Winsløw UC, Fogh K, Hasselbalch R, Kristensen JH, Ringgaard A, Porsborg Andersen M, Goecke NB, Trebbien R, Skovgaard K, Benfield T, Ullum H, Torp-Pedersen C, Iversen K. Effectiveness of Adding a Mask Recommendation to Other Public Health Measures to Prevent SARS-CoV-2 Infection in Danish Mask Wearers : A Randomized Controlled Trial. Ann Intern Med. 2020 Nov 18. doi: 10.7326/M20-6817. Epub ahead of print. PMID: 33205991. Summarized by Jackson Roos, 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.

Contributor: Rachael Duncan, PharmD Educational Pearls: ED visits nationwide declined by 42% in April 2020 compared to the same time in 2019 largely due to the fear of the COVID-19 pandemic. The biggest decline was seen in pediatrics less than 14, women and emerging COVID hotspots like the Northeast. In recent weeks, this trend has reversed, showing a record-breaking number of COVID cases, hospitalizations, and deaths. As hospitals reach capacity, critically ill COVID patients are being held in the ED until an inpatient bed becomes available. A new mRNA vaccine has promising preliminary trial results to help end the COVID-19 pandemic. While traditional vaccines contain purified proteins or weakened viruses, the mRNA vaccine is genetic material that is coded within the human body to make the viral protein. The mRNA vaccine codes for the critical fragment of the viral protein without causing disease and leads to the production of powerful antibodies. Although synthetic mRNA is genetic material, it cannot be passed on to further generations. mRNA vaccines are much faster to develop and could potentially provide a more efficient process for developing future vaccines Cold temperatures are currently needed to maintain the stability of the mRNA which has posed a challenge to the viability of the vaccines. However, developments are underway to overcome this hurdle. References: A Trial Investigating the Safety and Effects of Four BNT162 Vaccines Against COVID-2019 in Healthy Adults - Full Text View - ClinicalTrials.gov. Clinicaltrials.gov. https://clinicaltrials.gov/ct2/show/NCT04380701. Published 2020. Accessed November 25, 2020. Karikó K, Buckstein M, Ni H, Weissman D. Suppression of RNA recognition by Toll-like receptors: the impact of nucleoside modification and the evolutionary origin of RNA. Immunity. 2005;23(2):165-175. doi:10.1016/j.immuni.2005.06.008 Safety and Immunogenicity Study of 2019-nCoV Vaccine (mRNA-1273) for Prophylaxis of SARS-CoV-2 Infection (COVID-19) - Full Text View - ClinicalTrials.gov. Clinicaltrials.gov. https://clinicaltrials.gov/ct2/show/NCT04283461. Published 2020. Accessed November 25, 2020. Schlake T, Thess A, Fotin-Mleczek M, Kallen KJ. Developing mRNA-vaccine technologies. RNA Biol. 2012;9(11):1319-1330. doi:10.4161/rna.22269 Wolff JA, Malone RW, Williams P, et al. Direct gene transfer into mouse muscle in vivo. Science. 1990;247(4949 Pt 1):1465-1468. doi:10.1126/science.1690918 Summarized by Emily Mack OMSIII | Edited by Mason Tuttle

For this episode of Mental Health Monthly, EMM is honored to collaborate with the hosts of Millennial Mental Health Channel podcast to explain Borderline Personality Disorder and tips to manage patients with this diagnosis in the Emergency Department. Dr. Justin Romano is a third year psychiatry resident in Omaha, Nebraska and Eddie Carrillo is a licensed mental health therapist currently working at partial hospitalization and IOP eating disorder program in Portland, Oregon. Their podcast Millennial Mental Health Channel seeks to explore the world of mental health from their two professional perspectives. You can listen to their podcast on all major streaming platforms including Apple Podcasts, Spotify and Google Podcasts. Follow them on Twitter and Instagram @millennialmhc Contributors: Dr. Justin Romano and Eddie Carrillo, M.A., LPC Educational Pearls: 4% of the general population has Bipolar Personality Disorder (BPD) and 9% of all emergency room visits involve patients with BPD. BPD is defined as a pervasive pattern of instability of interpersonal relationships, self-image, affect and marked impulsivity beginning by early adulthood and present in a variety of contexts. There are 9 symptoms of BPD. In order to meet criteria for diagnosis you need 5 of the 9. Symptoms include: Frantic efforts to avoid real or imagined abandonment Pattern of unstable and intense interpersonal relationships, characterized by alternating between extremes of idealization and devaluation Identity disturbance: markedly and persistently unstable self-image or sense of self Impulsivity in at least two areas that are potentially self-damaging Recurrent suicidal behaviors, gestures, threats or self-mutilating behavior Affect instability due to marked reactivity of mood Chronic feelings of emptiness Inappropriate intense anger or difficulty controlling anger Transient stress related paranoid ideation or severe dissociative symptoms Pathophysiology behind BPD: Overactivation of the amygdala within the limbic system which controls fear, anxiety and anger. Often patients with BPD have dealt with an increased amount of trauma in their lives. They have one of the highest suicide rates at 10%. Behaviors in individuals with BPD are often due to an invalidating environment in an attempt to reconnect with people they love. Tips to managing patients in the emergency room with BPD. Stay calm, consistent and caring and validate their feelings with: Body language: sit at eye level, make good eye contact, nod your head when they talk, and use repeat back clarification questions. Facial expressions: be cognizant of your facial expressions. Patients with BPD are more likely to interpret a neutral face as angry. Set boundaries and stick to your word. Patients with BPD can be described as manipulative, but often they are unaware they are doing this. Give validating statements. This will ensure the patient you are listening and working with them to solve their problems. Summarized by Emily Mack, OMSIII

Contributor: Aaron Lessen, MD Educational Pearls: Contrary to many assumptions, meter-dose inhalers (MDIs) are as effective as nebulizers in pediatric and adult patients Nebulizers are associated with higher rates of tremor, tachycardia; they cost more and are associated with longer ED stays Though it may take some convincing, in a patient that is physically able, using an MDI with spacer appears to be the better option - and that was even before COVID. References Snider MA, Wan JY, Jacobs J, Kink R, Gilmore B, Arnold SR. A Randomized Trial Comparing Metered Dose Inhalers and Breath Actuated Nebulizers. J Emerg Med. 2018 Jul;55(1):7-14. doi: 10.1016/j.jemermed.2018.03.002. Epub 2018 Apr 30. PMID: 29716819. Brocklebank D, Ram F, Wright J, Barry P, Cates C, Davies L, Douglas G, Muers M, Smith D, White J. Comparison of the effectiveness of inhaler devices in asthma and chronic obstructive airways disease: a systematic review of the literature. Health Technol Assess. 2001;5(26):1-149. doi: 10.3310/hta5260. PMID: 11701099. Dhuper S, Chandra A, Ahmed A, Bista S, Moghekar A, Verma R, Chong C, Shim C, Cohen H, Choksi S. Efficacy and cost comparisons of bronchodilatator administration between metered dose inhalers with disposable spacers and nebulizers for acute asthma treatment. J Emerg Med. 2011 Mar;40(3):247-55. doi: 10.1016/j.jemermed.2008.06.029. Epub 2008 Dec 11. PMID: 19081697. Summarized by Jackson Roos, 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.

Contributor: Ryan Circh, MD Educational Pearls: Diabetic ketoacidosis (DKA) can be the initial presenting condition of undiagnosed diabetes type I in pediatric patients Unlike adults, children typically need less fluid (i.e. 10 mL/kg bolus for those in shock followed by maintenance) Cerebral edema is a concern from rapid administration of fluids An insulin drip at 0.1 units/Kg/hr should be started but a bolus isn't required Editor's note: While conceptually similar, treatment for pediatric DKA is overall less aggressive (no bolus of insulin, less fluids, slower corrections, etc.). Recent literature also continues to argue against cerebral edema being related to fluid management References Hsia D, Tarai S, Alimi A, Coss-Bu J, Haymond M. Fluid management in pediatric patients with DKA and rates of suspected clinical cerebral edema. Pediatr Diabetes. 2015;16(5):338-344. Wolfsdorf J, Glaser N, Sperling M, American D. Diabetic ketoacidosis in infants, children, and adolescents: A consensus statement from the American Diabetes Association. Diabetes Care. 2006;29(5):1150-1159. Olivieri L, Chasm R. Diabetic ketoacidosis in the pediatric emergency department. Emerg Med Clin North Am. 2013 Aug;31(3):755-73. doi: 10.1016/j.emc.2013.05.004. Epub 2013 Jul 6. PMID: 23915602. Summarized by Jackson Roos, 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.

Contributor: Nick Tsipis, MD Educational Pearls: Perichondritis involves infection of not only the connective tissue of the ear but typically the cartilage as well Symptoms include erythema, ear pain, and fevers The most common bacterial cause is Pseudomonas. Perichondritis often occurs after a wound or piercing, but trauma is not necessary for the infection to occur Anti-pseudomonal coverage is essential with typically oral agents for milder disease and IV antibiotics for severe infections Can have devastating outcomes if not treated aggressively and/or treated early due to poor blood supply to the cartilage of the ear References Prasad HK, Sreedharan S, Prasad HS, Meyyappan MH, Harsha KS. Perichondritis of the auricle and its management. J Laryngol Otol. 2007 Jun;121(6):530-4. doi: 10.1017/S0022215107005877. Epub 2007 Feb 26. PMID: 17319983. Summarized by Jackson Roos, 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.

Contributor: Sam Killian, MD Educational Pearls: Spontaneous bacterial peritonitis (SBP) is an infection of peritoneal fluid that typically occurs in cirrhotic patients Symptoms may include abdominal pain, fever, and/or altered mental status Paracentesis is diagnostic test of choice. Diagnostic criteria includes > 250 polymorphonuclear cells (PMNs) or a positive gram stain/culture Treatment is typically a 3rd generation cephalosporin ·30-40% of SBP patients will go into renal failure and SBP associated with sepsis has an ~80% mortality References Dever JB, Sheikh MY. Review article: spontaneous bacterial peritonitis--bacteriology, diagnosis, treatment, risk factors and prevention. Aliment Pharmacol Ther. 2015 Jun;41(11):1116-31. doi: 10.1111/apt.13172. Epub 2015 Mar 26. PMID: 25819304. MacIntosh T. Emergency Management of Spontaneous Bacterial Peritonitis - A Clinical Review. Cureus. 2018 Mar 1;10(3):e2253. doi: 10.7759/cureus.2253. PMID: 29721399; PMCID: PMC5929973. Summarized by Jackson Roos, 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.

Contributor: Rachael Waterson, PharmD Educational Pearls: Drug shortages have been an ongoing issue since the 2000's. Improvement was being made; however, several factors have exacerbated the drug supply more recently. According to the US Food and Drug Administration (FDA) Report there are 163 drugs currently on the drug shortage list. Of the 40 drugs critical to treating COVID-19, 18 are on this list. In comparison, according to the American Society of Health-Systems Pharmacists (ASHP), the current drug shortages have limited 29 of the 40 drugs deemed critical to treating COVID-19 patients. COVID-19 has had an impact on the supply and demand for pharmaceuticals and has exposed the vulnerability of the US drug supply chain. The demand for drugs that are specific to treating COVID-19 patients have increased, while supply has been impacted due to closed factories, shipping delays, trade limitations, and export bans. Supply has been further limited due to COVID-19 heavily affecting 2 of the 3 main drug manufacturer areas of the world, India and Italy. In order to combat drug shortages, the US federal government developed a contract with a company to make generics in short supply during the pandemic. There is also current discussion about creating an "America First" program to increase domestic production of active pharmaceutical ingredients. How pharmacists combat drug shortages: Re-assess the definition of need; need vs convenience of a medication. Look to see if there is another product, manufacturer, vial size, or drug concentration of that exact medication that can be substituted. Substitution of a similar drug if possible. Placing restrictions as to which patients can receive medications, who can prescribe medications and medication use dependent on location in the hospital. References: American Society of Health-System Pharmacists. (2020). Drug Shortages. ASHP. https://www.ashp.org/Drug-Shortages?loginreturnUrl=SSOCheckOnly. FDA Drug Shortages. accessdata.fda.gov. (2020, October). https://www.accessdata.fda.gov/scripts/drugshortages/. Summarized by Emily S Mack, MSBS, OMS III | Rachael Waterson, PharmD

Dr. Tsipis sits down with colleague Dr. Ricky Dhaliwal for some insightful conversation regarding the differences between academic and community settings as well as the various roles of advocacy in medicine. Time Stamps 00:23 Banter and introductions 2:41 upbringing in 1st generation immigrant Indian household 14:30 losing culture as 2nd gen immigrant 7:32 Balancing family and work with a two doc family 8:32 President of EMRA 10:42 Working in academia vs community 13:29 New job advice 15:55 Nick talks about being the product of your environment and needing to be challenged 20:42 Advocacy in medicine 25:49 Legislative advocacy 27:27 Advocacy for medicine in COVID 29:44 Who are the most influential figures in your career? 33:23 What is your teaching style 38:05 What does the future hold for you?

Contributor: Dave Rosenberg, MD Educational Pearls: The potential of vaccinations was first observed in the late 1600s when Jenner observed people who had cowpox never contracted smallpox, so he inoculated people with cowpox to see if it prevented smallpox, and… Years later, Louis Pasteur inoculated chickens with cholera after his assistant accidently created the first live attenuated vaccine by creating a weakened bacteria when he left the bacteria out while he went on vacation Pasteur observed that exposing chickens to full strength cholera after the exposure with the weakened bacteria led to minimal or no ill effects References Stewart AJ, Devlin PM. The history of the smallpox vaccine. J Infect. 2006 May;52(5):329-34. doi: 10.1016/j.jinf.2005.07.021. Epub 2005 Sep 19. PMID: 16176833. Hajj Hussein I, Chams N, Chams S, El Sayegh S, Badran R, Raad M, Gerges-Geagea A, Leone A, Jurjus A. Vaccines Through Centuries: Major Cornerstones of Global Health. Front Public Health. 2015 Nov 26;3:269. doi: 10.3389/fpubh.2015.00269. PMID: 26636066; PMCID: PMC4659912. Summarized by Jackson Roos, 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.

Contributor: Chris Holmes, MD Educational Pearls: During a typical flu season positive rates of flu tests run around ~20% Surveillance data from Australia, South Africa, and Chile showed remarkably low rates of flu during their typical high season - only 51 total cases were reported This overlapped with COVID, meaning extensive social distancing and other measures likely have benefit with flu Editor's note: at 35 cases, we are over half way there! References https://www.cdc.gov/mmwr/volumes/69/wr/mm6937a6.htm https://www.cdc.gov/flu/weekly/index.htm Summarized by Jackson Roos, 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.

Contributor: John Winkler, MD Educational Pearls: Swimmers itch is due to a flatworm parasitic infection that causes an itchy rash after the worm burrows into the skin The flatworm is passed between bird and snail hosts The itch is due to the death of the parasite under the skin which leads to an extremely itchy reaction. The rash can be difficult to identify, often erythematous and macular but can develop papules and vesicles eventually scaling The treatment is diphenhydramine for milder cases and steroids for more severe cases. References Kolářová L, Horák P, Skírnisson K, Marečková H, Doenhoff M. Cercarial dermatitis, a neglected allergic disease. Clin Rev Allergy Immunol. 2013 Aug;45(1):63-74. doi: 10.1007/s12016-012-8334-y. PMID: 22915284 Summarized by Jackson Roos, 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.

Contributor: Nick Hatch, MD Educational Pearls: Kratom is derived from the evergreen tree sharing the same name, found in Southeast Asia Kratom is legal is most regions Adverse effects of this substance are increasing in prevalence as its use becomes more widespread At lower doses kratom has a stimulatory effect Higher doses of kratom can cause opioid-like and psychotropic effects Documented instances of more severe acute liver toxicity do exists References LiverTox: Clinical and Research Information on Drug-Induced Liver Injury [Internet]. Bethesda (MD): National Institute of Diabetes and Digestive and Kidney Diseases; 2012–. Kratom. 2020 Apr 3. PMID: 31643556. https://www.fda.gov/news-events/public-health-focus/fda-and-kratom Summarized by Jackson Roos, 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.

Contributor: Jared Scott, MD Educational Pearls: Lactate is a byproduct of anaerobic metabolism or tissue hypoperfusion Though typically associated with severe sepsis, hyperlactatemia can be caused by vigorous exercise, seizures, liver failure, asthma exacerbations, albuterol, metformin, antiretroviral drugs, and propofol Liver failure can lead to an inability to clear lactate, or convert it back to glucose byproducts, instead of an overproduction of lactate Always remember the other causes of elevated lactic acid besides sepsis but also remember sepsis! References: Kraut JA, Madias NE. Lactic acidosis. N Engl J Med. 2014 Dec 11;371(24):2309-19. doi: 10.1056/NEJMra1309483. PMID: 25494270. Wardi G, Brice J, Correia M, Liu D, Self M, Tainter C. Demystifying Lactate in the Emergency Department. Ann Emerg Med. 2020 Feb;75(2):287-298. doi: 10.1016/j.annemergmed.2019.06.027. Epub 2019 Aug 29. Erratum in: Ann Emerg Med. 2020 Apr;75(4):557. PMID: 31474479. Summarized by Jackson Roos, 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.

Contributor: Don Stader, MD Educational Pearls: Pain is ubiquitous in the emergency department but it is not the enemy - suffering is Nociception is the ability to feel noxious stimuli which usually causes a reaction, like pulling a limb away when you feel something painful. Nociception is really a brainstem reflex. Pain is nociception plus cognition, meaning we process the noxious stimuli in our frontal cortex but it is not necessarily suffering. Pain can be associated with euphoria, such as with distance running Suffering, unlike pain, is associated with emotional distress Nociception is a brainstem reflex, pain involves the brainstem and the frontal cortex, while suffering involves the brainstem, frontal cortex, and the limbic system attaching an emotional response Providers should educate patients' expectations on pain as a part of the physiologic process and emphasize the focus on alleviating suffering References Sneddon LU. Comparative Physiology of Nociception and Pain. Physiology (Bethesda). 2018 Jan 1;33(1):63-73. doi: 10.1152/physiol.00022.2017. PMID: 2921289 Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

Emergency Medical Minute collaborated with CarePoint Health in early March for a night of education on Pediatric Emergencies geared towards mid-level providers at a local Denver brewery for our latest Brewcast. Pediatric patients require special considerations compared to adults when receiving medical care, and that remains true when dealing with respiratory illnesses across different age ranges. Dr. Parisa Jamshidi, Pediatric Emergency Physician, reviews common respiratory illnesses including bronchiolitis, croup and bacterial tracheitis in pediatric patients covering their presentation on exam and via diagnostics, treatment plans and special considerations. Her lecture is complete with a case review of a patient presenting with croup and its management, differentiation of airway sounds and high flow oxygen delivery recommendations. Listen to brush up on on your knowledge of pediatric respiratory emergencies. 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. Photo by National Cancer Institute on Unsplash

Contributor: Aaron Lessen, MD Educational Pearls: The use of oxygen is controversial when treating patients with certain conditions, like MI's, stokes, or ARDS because adverse outcomes have been demonstrated with using high oxygen concentrations. The Oxygen ICU trial looked at using higher and lower oxygen levels in treating intubated ARDS patients and found that mortality was improved when less oxygen was given allowing oxygen saturations to sit around 95% versus using high oxygen levels to obtain 100% blood oxygen saturation. The LOCO trial tested using even lower oxygen concentrations allowing patients to have oxygen saturations around 88% compared to more oxygen with saturation goals of 96%. They found a 15% increase in mortality in the lower saturation group and had some incidences of mesenteric ischemia leading to a premature termination of the trial due to the detrimental outcomes. This means a blood oxygen saturation rate of around 94% is probably a safe bet for patients to reduce episodes of hypoxia but limit over oxygenation injuries, especially in patients requiring longer term oxygen therapy. References 1) Girardis M, Busani S, Damiani E, Donati A, Rinaldi L, Marudi A, Morelli A, Antonelli M, Singer M. Effect of Conservative vs Conventional Oxygen Therapy on Mortality Among Patients in an Intensive Care Unit: The Oxygen-ICU Randomized Clinical Trial. JAMA. 2016 Oct 18;316(15):1583-1589. doi: 10.1001/jama.2016.11993. PMID: 27706466. 2) Barrot L, Asfar P, Mauny F, Winiszewski H, Montini F, Badie J, Quenot JP, Pili-Floury S, Bouhemad B, Louis G, Souweine B, Collange O, Pottecher J, Levy B, Puyraveau M, Vettoretti L, Constantin JM, Capellier G; LOCO2 Investigators and REVA Research Network. Liberal or Conservative Oxygen Therapy for Acute Respiratory Distress Syndrome. N Engl J Med. 2020 Mar 12;382(11):999-1008. doi: 10.1056/NEJMoa1916431. PMID: 32160661. Summarized by Jackson Roos, 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.