Emergency Medical Minute

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**Emergency Medical Minute**

Our near daily podcasts move quickly to reflect current events, are inspired by real patient care, and speak to the true nature of what it’s like to work in the Emergency Room or Pre-Hospital Setting. Each medical minute is recorded in a real emergency department, by the emergency physician or clinical pharmacist on duty – the ER is our studio and everything is live.

Latest Episodes:

Podcast 621: Pediatric Psychosis Dec 14, 2020

Show notes

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.

Pharmacy Phriday #5: COVID-19 Vaccine for Pregnant Women Dec 11, 2020

Show notes

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

Podcast 620: Prolactin and Seizures Dec 08, 2020

Show notes

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

Podcast 619: Other Uses for Zyprexa Dec 07, 2020

Show notes

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

Podcast 618: Treating Opiate Side Effects Dec 01, 2020

Show notes

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

Podcast 617: Masks and Understanding Data Nov 30, 2020

Show notes

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

Pharmacy Phriday #4: mRNA Vaccines Nov 27, 2020

Show notes

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

Mental Health Monthly #5: Borderline Personality Disorder Nov 25, 2020

Show notes

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

Podcast 616: MDIs for the Win Nov 24, 2020

Show notes

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

Podcast 615: Pediatric DKA Nov 23, 2020

Show notes

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

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