Emergency Medical Minute

Contributor: Chris Holmes, MD Educational Pearls: Through world history, there have been various interesting approaches to wound care Ancient Egyptians applied honey, lint, and grease which provided antimicrobial, absorptive and moisturizing properties, respectively  Ancient Greeks irrigated wounds with clean water and applied wine and vinegar which may have been antimicrobial  One of the first synthetic topical antimicrobials was a dye researched by scientist Gerhard Domagk and later produced by Bayer under the name Prontosil  Some current wound care methods include wet-to-dry dressings, Dankin’s Solution (sodium hypochlorite) and the use of maggots    References Fleck CA. Why "wet to dry"?. J Am Col Certif Wound Spec. 2009;1(4):109-113. Published 2009 Oct 6. doi:10.1016/j.jcws.2009.09.003 Shah JB. The history of wound care. J Am Col Certif Wound Spec. 2011;3(3):65-66. doi:10.1016/j.jcws.2012.04.002 Ueno CM, Mullens CL, Luh JH, Wooden WA. Historical review of Dakin's solution applications. J Plast Reconstr

Contributor: Aaron Lessen, MD Educational Pearls: Wound care in the emergency department aims to prevent future infection Copious wound irrigation is the important step in preventing wound infection Studies have shown that irrigation with tap water is just as effective, if not superior,  to  irrigation with saline or other solutions Several studies have shown no reduction in wound infection rates when using sterile gloves during wound care Recent study in the Netherlands compared infection rates between patients undergoing wound repair with and without sterile gloves Receiving wound care with nonsterile gloves was noninferior to wound care utilizing sterile gloves References Fernandez R, Griffiths R. Water for wound cleansing. Cochrane Database Syst Rev. Feb 15 2012;(2):Cd003861. doi:10.1002/14651858.CD003861.pub3 Heckmann N, Simcox T, Kelley D, Marecek GS. Wound Irrigation for Open Fractures. JBJS Rev. Jan 2020;8(1):e0061. doi:10.2106/jbjs.Rvw.19.00061 Zwaans JJM, Raven W, Rosendaal AV, et al. Non-ster

Contributor: Aaron Lessen, MD Educational Pearls: Pediatric patients frequently have vital signs considered abnormal for age at discharge Large multicenter study recently evaluated if pediatric patients discharged with abnormal vital signs have worse outcomes  97,824 pediatric discharges were included in the study 18.1% were discharged with vitals considered abnormal for age No significant difference in readmission rates at 48 hours (2.28% in abnormal cohort vs. 2.45% in normal cohort) No significant adverse outcomes in those discharged with abnormal vital signs (4 total PICU admissions with no deaths, CPR, or intubations) When considering discharging pediatric patients, it is important to evaluate how the patient looks rather than just relying on vital signs Consider leaving the child attached to a monitor, leaving the room, and then reevaluating them if they could be agitated by the presence of healthcare providers References Kazmierczak M, Thompson AD, DePiero AD, Selbst SM. Outcomes of patients disc

Contributor: Travis Barlock, MD Educational Pearls: The causes of pancreatitis can be remembered with the mnemonic: “GET SMASHED”  G: Gallstones (Most common cause of pancreatitis overall)  E: Ethanol (Alcohol consumption is the most common cause of chronic pancreatitis) T: Trauma  S: Steroids M: Malignancy A: Autoimmune  S: Scorpion Sting H: Hypertryglyceridemia  E: ERCP D: Drugs (e.g. Valproate, Antiretrovirals)    References Beyer G, Habtezion A, Werner J, Lerch MM, Mayerle J. Chronic pancreatitis. Lancet. 2020;396(10249):499-512. doi:10.1016/S0140-6736(20)31318-0 Lankisch PG, Apte M, Banks PA. Acute pancreatitis [published correction appears in Lancet. 2015 Nov 21;386(10008):2058]. Lancet. 2015;386(9988):85-96. doi:10.1016/S0140-6736(14)60649-8   Summarized by Kirsten Hughes, MS4 | Edited by John Spartz, MD, & Erik Verzemnieks, MD   In an effort to promote diversity, equity, and inclusion in Emergency Medicine, The Emergency Medical Minute is proud to present our 2nd annual Diversity and Inclusion

Contributor: Aaron Lessen, MD Educational Pearls: Septic arthritis of the sternoclavicular joint is uncommon accounting for

Contributor: Meghan Hurley, MD Educational Pearls: Venomous snakes in the United States include species from the family Elapidae and subfamily Crotalinae In prehospital setting, elevate the bitten extremity and transport to hospital immediately Do not attempt interventions with the bite site  Monitor for progression of swelling past any joint line, systemic symptoms or lab abnormalities for 8-12 hours  Symptoms may present up to hours after bite   Crotalinae venom has heme toxicity and may present with lab pattern of DIC  Treatment for all symptoms is antivenom If symptoms persist or progress, continue to treat with antivenom  Compartment syndrome is rare with snake bites   References Ruha AM, Kleinschmidt KC, Greene S, et al. The Epidemiology, Clinical Course, and Management of Snakebites in the North American Snakebite Registry. J Med Toxicol. 2017;13(4):309-320. doi:10.1007/s13181-017-0633-5   Aziz H, Rhee P, Pandit V, Tang A, Gries L, Joseph B. The current concepts in management of animal (dog, ca

Contributor: Jared Scott, MD Educational Pearls: Two conventional ways to aid in external jugular vein (EJ) catheter placement are Trendelenburg’s position and Valsalva’s maneuver by patient  One study compared ultrasound visualization of cross sections of EJ and common femoral vein at baseline and with patients in Trendelenburg's position, Valsalva's maneuver, and while humming The study found all three conditions distended the veins from baseline, but there was no significant difference in diameter between the conditions   Humming may be a viable technique in distended EJ for catheter placement, and may be easier for patients to comprehend than Valsalva    References Lewin MR, Stein J, Wang R, et al. Humming is as effective as Valsalva's maneuver and Trendelenburg's position for ultrasonographic visualization of the jugular venous system and common femoral veins. Ann Emerg Med. 2007;50(1):73-77. doi:10.1016/j.annemergmed.2007.01.024   Summarized by Kirsten Hughes, MS4 | Edited by John Spartz, MD, & Er

Contributor: Meghan Hurley, MD Educational Pearls: Syncope is defined as a loss of consciousness with an immediate return to baseline Differential is broad Cardiogenic Structural (aortic stenosis, HOCUM, etc.) Electrical (long QT syndrome, Brugada, etc.) Neurogenic/neurovascular (brain bleed, etc.) Seizure Everything else Hypoglycemia, anemia, and bleeding into the abdominal cavity are some potential causes to rule out Vasovagal Diagnosis of exclusion Work Up EKG Good H&P Labs especially Hb and glucose References Morris J. Emergency department management of syncope. Emerg Med Pract. Jun 2021;23(6):1-24. Reed MJ. Approach to syncope in the emergency department. Emerg Med J. Feb 2019;36(2):108-116. doi:10.1136/emermed-2018-207767   Summarized by Mark O’Brien, MS4 | Edited by John Spartz, MD, & Erik Verzemnieks, MD In an effort to promote diversity, equity, and inclusion in Emergency Medicine, The Emergency Medical Minute is proud to present our 2nd annual Diversity and Inclusion Award. We su

Contributor: Aaron Lessen, MD Educational Pearls: Torus (Buckle) fractures are a commonly encountered pediatric fracture pattern Typically presents as wrist pain secondary to a child falling on outstretched hand One edge of the bone “buckles” or bends because children’s bones are softer and more pliable Management Older studies have shown that short term immobilization with a velcro splint and primary care follow up is sufficient Recent randomized trial compared immobilization with Velcro splint with as needed wrist support using a gauze wrap No significant differences noted in outcomes between the two cohorts Physicians can consider using an ace or gauze wrap as needed for buckle fracture management along with OTC analgesics for pain management References Asokan A, Kheir N. Pediatric Torus Buckle Fracture. StatPearls. StatPearls Publishing Copyright © 2022, StatPearls Publishing LLC.; 2022.   Kennedy SA, Slobogean GP, Mulpuri K. Does degree of immobilization influence refracture rate in the forearm buc

Contributor: Travis Barlock, MD Educational Pearls: Normal Saline (NS) contains 154 mEq of both Sodium (Na) and Chloride (Cl),  and has a pH of 5.5 Normal Na and Cl in adult humans are about 140 mEq/L and 103 mEq/L. respectively   Excess negative charge resulting from hyperchloremia is managed via bicarbonate excretion leading to loss of base Overall, administration of NS drives metabolic acidosis Lactated Ringers (LR) contains 130 mEq of Na and 109 mEq Cl, and has a pH of 6.5   LR components are closer to physiologic levels thus may generally be a more efficacious fluid choice   NS is still frequently given in scenarios where there is concern for increased intracranial pressure or existing hypochloremic alkalosis from emesis.  ReferencesLi H, Sun SR, Yap JQ, Chen JH, Qian Q. 0.9% saline is neither normal nor physiological. J Zhejiang Univ Sci B. 2016;17(3):181-187. doi:10.1631/jzus.B1500201 ​​Lehr AR, Rached-d'Astous S, Barrowman N, et al. Balanced Versus Unbalanced Fluid in Critically Ill Children: Sy

Happy Thanksgiving EMM listeners, Mason here wanting to extend a special thank you to all of you for tuning in to our show. Today we are featuring a special episode on health disparities in the opioid epidemic and their intersection with the ER that we produced for the Iowa Healthcare Collaborative’s Compass Opioid Stewardship Program, a national initiative to provide comprehensive education on opioid stewardship and best practices.  In an effort to promote diversity, equity, and inclusion in Emergency Medicine, The Emergency Medical Minute is proud to present our 2nd annual Diversity and Inclusion Award. We support increasing the representation of underrepresented groups in medicine and extend this award to individuals applying to emergency medicine residencies during the 2022-2023 cycle. For information on award eligibility and the application process, visit https://emergencymedicalminute.com/edi-award/ Donate to EMM today!

Educational Pearls: Most common sexually transmitted disease (STD) in North America: Human Papillomavirus (HPV) From the emergency department patients should be connected to follow-up care and educated on vaccine series Most common non-viral STD in North America: Trichomonas Vaginalis   While men may be asymptomatic, they can transmit the disease to women who may experience irritation leading to increased likelihood of PID and contraction of other STDs and HIV Trichomonas is diagnosed via wet preparation with visualization of motile parasites  Similarly, men’s urine can be tested for visualized motile parasites  Expedite lab as parasites are motile for about one hour    PCR test is becoming more available Most common bacterial STD in North America: Chlamydia trachomatis  Neisseria gonorrhoeae is a less common bacterial STD but does have high rates of drug resistance  Empiric STD treatment includes IM Ceftriaxone and PO Doxycycline  Providers should consider adding Flagyl for Trichomonas Vag

Contributor: Aaron Lessen,MD Educational Pearls: Recent study looked at mechanically ventilated patients in ED and ICU to determine if O2 saturation level impacted patient outcomes 2541 patients randomized to one of three target O2 saturation levels Low: 90% (Range: 88-92%) Intermediate: 94% (Range: 92-96%) High: 98% (Range: 96-100%) Outcome indicators Primary: Number of days alive and ventilator free by day 28 of hospital admission Secondary: Mortality at 28 days No significant difference was seen for either primary or secondary outcomes between all three groups at 28 days This study shows that the target oxygenation level  is not likely to significantly impact outcomes in mechanically ventilated patients in the ED   References Semler MW, Casey JD, Lloyd BD, et al. Oxygen-Saturation Targets for Critically Ill Adults Receiving Mechanical Ventilation. N Engl J Med. Nov 10 2022;387(19):1759-1769. doi:10.1056/NEJMoa2208415   Summarized by Mark O’Brien, MS4 | Edited by John Spartz, MD, & Erik Ve

Contributor: Travis Barlock, MD Educational Pearls: Gauge and length of catheter are determinants of flow rate  Smaller gauges produce higher flow rate Longer catheters reduce flow rate   Common IV gauges produce predictable rates of flow:  20 gauge = 60 cc/min 18 gauge = 105 cc/min 16 gauge = 220 cc/min  Central lines typically have two 18 gauge and one 16 gauge lumen, both with long catheters, producing the following slower flow rates:  18 gauge = 26 cc /min  16 gauge = 55 cc/min Sheath Introducers, such as Cordis brand catheters, are wider and shorter than classic central lines. Flow rates are 150 cc/min, or 130 cc/min with pressure bag  Maximal flow allows for one unit of blood to be delivered over one minute  It is important to consider length and gauge of catheter when patients require fluids   References Greene N, Bhananker S, Ramaiah R. Vascular access, fluid resuscitation, and blood transfusion in pediatric trauma. International Journal of Critical Illness and Injury Science. 2012;2(3):135.

Contributor: Aaron Lessen, MD Educational Pearls: Monkeypox transmission is still occurring  in the United States Transmitted by contact to exposed lesion MSM are a high-risk group for monkeypox infection Symptoms include rash and flu like symptoms Monkeypox lesions are often described as blister-like, firm, clear, and rubbery Most commonly develop on the face and/or anogenital regions Patients with potential monkeypox infection should be moved to isolation to reduce risk of transmission Providers should use full PPE including N95, facial covering, gown, and gloves when interacting with a potential case of monkeypox Diagnosis involves swabbing the lesion and sending it for analysis People at risk for severe disease (i.e. immunocompromised) or who have severe symptoms (i.e. eye involvement) should begin treatment with Tecovirimat (TPOXX) in the ED Infectious Disease (ID) should be consulted, and the patient will need to follow up with ID regardless of symptom severity References Rizk JG, Lippi G, Henry B

Contributor: Nick Hatch, MD Educational Pearls: In the setting of traumatic injury, tranexamic acid (TXA) is given to stabilize clots which minimizes bleeding and decreases risk of hemorrhagic shock   Current TXA dose for trauma is 1 g bolus followed by a 1 g infusion; both doses should be given within 3 hours from time of injury  Due to the split dose and narrow window, patients with complicated care, particularly if they require transfer may miss the infusion dose  Various smaller studies have shown that dosing 2 g initially or 2 g followed by a 1 g infusion produces the same patient outcomes and no additional harm  Receiving hospitals should strive to acquire accurate information regarding previous doses of TXA given and confirm timeline of injury    References Roberts I, Shakur H, Coats T, et al. The CRASH-2 trial: a randomised controlled trial and economic evaluation of the effects of tranexamic acid on death, vascular occlusive events and transfusion requirement in bleeding trauma patients. Health Tec

Contributor: Aaron Lessen, MD Educational Pearls: Recent study evaluated if early exposure to an allergen impacted the rate of allergy development later in childhood Children were exposed to peanut, milk, wheat, and egg allergens at 3 months of age and then followed for 3 years 2.5-3% of children who were not exposed developed allergies to these allergens 1% of children exposed to the allergens developed allergies to these allerrgens Exposing 63 children to allergens at 3 months would prevent the development of food allergy in one child with no significant adverse events Future recommendations will likely be to gradually introduce allergens to children starting around 3 months References Skjerven HO, Lie A, Vettukattil R, et al. Early food intervention and skin emollients to prevent food allergy in young children (PreventADALL): a factorial, multicentre, cluster-randomised trial. Lancet. Jun 25 2022;399(10344):2398-2411. doi:10.1016/s0140-6736(22)00687-0   Summarized by Mark O’Brien, MS4 | Edited by John Sp

Contributor: Travis Barlock, MD Educational Pearls: The presence of a STEMI has traditionally been used to determine if a patient with acute chest pain requires urgent cath lab management STEMI indicates an occluded coronary artery, and urgent intervention is needed to restore perfusion to ischemic tissue Patients with occluded coronary arteries can present with EKG findings other than STEMI 2022 ACC Expert Consensus Decision Pathway on the Evaluation and Disposition of Acute Chest Pain in the Emergency Department was recently published in the Journal of the American College of Cardiology Recognizes STEMI equivalents that necessitate cath lab management ST depression in precordial leads Indicates a posterior infarct/possible RCA occlusion LBBB c ST elevation meeting modified Sgarbossa criteria Hyperacute and/or De Winter T wave First indication of coronary artery occlusion Most beneficial time to initiate cath lab because more tissue is salvageable These recommendations will likely alter clinical p

Contributor: Aaron Lessen, MD Educational Pearls: In urban settings, it is becoming more common for police to transport critical patients from scene to hospital A 2022 multicenter observational study compared mortality rates in patients with penetrating injury to torso and/or proximal extremity when transported by EMS versus police Approximately 18% of patients were transported by police  Overall mortality was approximately 15% in both groups  In patients with more severe injury, mortality was still similar at approximately 36% and 38% respectively  References Taghavi S, Maher Z, Goldberg AJ, et al. An analysis of police transport in an Eastern Association for the Surgery of Trauma multicenter trial examining prehospital procedures in penetrating trauma patients. J Trauma Acute Care Surg. 2022;93(2):265-272. doi:10.1097/TA.0000000000003563 Jacoby SF, Branas CC, Holena DN, Kaufman EJ. Beyond survival: the broader consequences of prehospital transport by police for penetrating trauma. Trauma Surg Acute Care

Contributor: Travis Barlock, MD Educational Pearls: Catheter related blood infections were thought to be caused by skin flora seeding the catheter. Thus, significant effort is applied to sterility and skin preparation.   However, studies have shown that bacteria growing on the tip of the catheter is not consistent with growth on cultures of skin.   Staphylococcus epidermidis is commonly found on cultures of catheter sites. It has also been found in the gut flora of >50% of ICU patients. Rates of catheter related blood infections have been decreased through oral decontamination and early feeding.  These findings suggest enteral bacterial translation as a major source of blood stream infection. References O'Grady NP, Alexander M, Burns LA, et al. Guidelines for the prevention of intravascular catheter-related infections. Clin Infect Dis. 2011;52(9):e162-e193. doi:10.1093/cid/cir257 von Eiff C, Becker K, Machka K, Stammer H, Peters G. Nasal carriage as a source of Staphylococcus aureus bacteremia. Study Group.