Emergency Medical Minute

Latest Episodes:

CA Bridge Program and Health Disparities in the Opioid Epidemic Nov 23, 2022

Show notes

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/

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Podcast 832: STD Checks Nov 22, 2022

Show notes

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 Vaginalis coverage

ReferencesSexually transmitted disease surveillance, 2020. Centers for Disease Control and Prevention. https://www.cdc.gov/std/statistics/2020/default.htm. Published August 22, 2022. Accessed November 21, 2022.

Workowski KA, Bachmann LH, Chan PA, et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep. 2021;70(4):1-187. Published 2021 Jul 23. doi:10.15585/mmwr.rr7004a1

Summarized by Kirsten Hughes, MS4 | Edited by John Spartz, MD, & Erik Verzemnieks, MD

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Podcast 831: O2 Targets Nov 21, 2022

Show notes

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 Verzemnieks, MD

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Podcast 830: Peripheral IV Flow Rates Nov 15, 2022

Show notes

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. doi:10.4103/2229-5151.100890

Khoyratty SI, Gajendragadkar PR, Polisetty K, Ward S, Skinner T, Gajendragadkar PR. Flow rates through intravenous access devices: an in vitro study. J Clin Anesth. 2016;31:101-105. doi:10.1016/j.jclinane.2016.01.048

Summarized by Kirsten Hughes, MS4 | Edited by John Spartz, MD, & Erik Verzemnieks, MD

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Podcast 829: Monkeypox Nov 14, 2022

Show notes

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 BM, Forthal DN, Rizk Y. Prevention and Treatment of Monkeypox. Drugs. Jun 2022;82(9):957-963. doi:10.1007/s40265-022-01742-y

Thornhill JP, Barkati S, Walmsley S, et al. Monkeypox Virus Infection in Humans across 16 Countries - April-June 2022. N Engl J Med. Aug 25 2022;387(8):679-691. doi:10.1056/NEJMoa2207323

Summarized by Mark O'Brien, MS4 | Edited by John Spartz, MD, & Erik Verzemnieks, MD

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Podcast 828: TXA Dosing Update Nov 08, 2022

Show notes

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 Technol Assess. 2013;17(10):1-79. doi:10.3310/hta17100

Ramirez RJ, Spinella PC, Bochicchio GV. Tranexamic Acid Update in Trauma. Crit Care Clin. 2017;33(1):85-99. doi:10.1016/j.ccc.2016.08.004

Spinella PC, Thomas KA, Turnbull IR, et al. The Immunologic Effect of Early Intravenous Two and Four Gram Bolus Dosing of Tranexamic Acid Compared to Placebo in Patients With Severe Traumatic Bleeding (TAMPITI): A Randomized, Double-Blind, Placebo-Controlled, Single-Center Trial. Front Immunol. 2020;11:2085. Published 2020 Sep 8. doi:10.3389/fimmu.2020.02085

Summarized by Kirsten Hughes, MS4 | Edited by John Spartz, MD, & Erik Verzemnieks, MD

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Podcast 827: Allergies in Peds Nov 07, 2022

Show notes

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 Spartz, MD, & Erik Verzemnieks, MD

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Podcast 826: STEMI Equivalents Nov 01, 2022

Show notes

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 practice for ED management of acute chest pain

References

Kontos MC, de Lemos JA, Deitelzweig SB, et al. 2022 ACC Expert Consensus Decision Pathway on the Evaluation and Disposition of Acute Chest Pain in the Emergency Department: A Report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol. Oct 6 2022;doi:10.1016/j.jacc.2022.08.750

Meyers HP, Bracey A, Lee D, et al. Comparison of the ST-Elevation Myocardial Infarction (STEMI) vs. NSTEMI and Occlusion MI (OMI) vs. NOMI Paradigms of Acute MI. J Emerg Med. Mar 2021;60(3):273-284. doi:10.1016/j.jemermed.2020.10.026

Tziakas D, Chalikias G, Al-Lamee R, Kaski JC. Total coronary occlusion in non ST elevation myocardial infarction: Time to change our practice? Int J Cardiol. Apr 15 2021;329:1-8. doi:10.1016/j.ijcard.2020.12.082

Summarized by Mark O'Brien, MS4 | Edited by John Spartz, MD, & Erik Verzemnieks, MD

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Podcast 825: ALS vs PD Transport Oct 31, 2022

Show notes

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 Open. 2020;5(1):e000541. Published 2020 Nov 26. doi:10.1136/tsaco-2020-000541

Summarized by Kirsten Hughes, MS4 | Edited by John Spartz, MS4 & Erik Verzemnieks, MD

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Podcast 824: Catheter-Related Blood Infections Oct 25, 2022

Show notes

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. N Engl J Med. 2001;344(1):11-16. doi:10.1056/NEJM200101043440102

ALTEMEIER WA, HUMMEL RP, HILL EO. Staphylococcal enterocolitis following antibiotic therapy. Ann Surg. 1963;157(6):847-858. doi:10.1097/00000658-196306000-00003

Marshall JC, Christou NV, Horn R, Meakins JL. The microbiology of multiple organ failure. The proximal gastrointestinal tract as an occult reservoir of pathogens. Arch Surg. 1988;123(3):309-315. doi:10.1001/archsurg.1988.01400270043006

Mrozek N, Lautrette A, Aumeran C, et al. Bloodstream infection after positive catheter cultures: what are the risks in the intensive care unit when catheters are routinely cultured on removal?. Crit Care Med. 2011;39(6):1301-1305. doi:10.1097/CCM.0b013e3182120190

Atela I, Coll P, Rello J, et al. Serial surveillance cultures of skin and catheter hub specimens from critically ill patients with central venous catheters: molecular epidemiology of infection and implications for clinical management and research. J Clin Microbiol. 1997;35(7):1784-1790. doi:10.1128/jcm.35.7.1784-1790.1997

Tani T, Hanasawa K, Endo Y, et al. Bacterial translocation as a cause of septic shock in humans: a report of two cases. Surg Today. 1997;27(5):447-449. doi:10.1007/BF02385710

Summarized by Kirsten Hughes, MS4 | Edited by John Spartz, MS4 & Erik Verzemnieks, MD

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