In this episode, Sam Ashoo, MD and T.R. Eckler, MD discuss the October 2024 Pediatric Emergency Medicine Practice article, Elder Abuse and Neglect: Making the Diagnosis and Devising a Treatment Plan in the Emergency Department00:00 Welcome and Introduction 00:13 Free Subscription for Emergency Medicine Residents 01:05 Introduction to Pediatric Emergency Medicine Practice 01:37 Discussion on Acute Scrotal Pain 02:35 Testicular Torsion: Key Insights 09:50 Differential Diagnosis for Acute Scrotal Pain 17:21 Diagnostic Indicators of IgA Vasculitis 17:44 Pre-Hospital Care for Severe Pain 18:13 The Twist Score for Torsion 18:44 Emergency Department Evaluation 20:04 Ultrasound in Diagnosing Torsion 29:44 Operative Management and Other Conditions 31:41 Manual Detorsion Techniques 32:37 Risk Management and Key Takeaways 34:19 Conclusion and Final ThoughtsEmergency Medicine Residents, get your free subscription by writing [email protected] 

In this special episode Sam Ashoo, MD interviews Ryan Johnson, Pharm. D. who shares strategies to address the recent IV fluid shortage caused by Hurricane Helene.00:00 Introduction and Episode Overview01:10 Meet Ryan Johnson: Clinical Pharmacist02:06 Role of Clinical Pharmacists in Emergency Medicine05:03 IV Fluid Shortage: Causes and Impact05:56 Institutional Strategies to Mitigate IV Fluid Shortages14:52 Provider-Level Solutions for Fluid Conservation22:11 Pharmacy and Nursing Staff Roles in Fluid Management26:34 Advanced Measures and Federal Guidelines34:40 Conclusion and Final ThoughtsResources mentioned in the podcast:(Brigham and Women's Protocol) Patiño, A. M., Marsh, R. H., Nilles, E. J., Baugh, C. W., Rouhani, S. A., & Kayden, S. (2018). Facing the shortage of IV fluids — a Hospital-Based Oral Rehydration strategy. New England Journal of Medicine, 378(16), 1475–1477. https://doi.org/10.1056/nejmp1801772 Vizient shares conservation strategies for potential IV fluid supply disruption caused by Hurricane Helene https://newsroom.vizientinc.com/en-US/releases/releases-vizient-shares-conservation-strategies-for-potential-iv-fluid-supply-disruption-caused-by-hurricane-helene

In this episode, Dr. Julia Draper shares her firsthand account of managing a crisis during a hurricane in Asheville, North Carolina. As the area faced unprecedented flooding, Dr. Draper describes the challenges faced at Mission Hospital, including loss of power and water. She details the innovative solutions the hospital implemented and highlights the tireless efforts of staff during a natural disaster of this magnitude.00:00 Introduction to Dr. Julia Draper01:03 Experiencing the Hurricane03:19 Immediate Aftermath and Hospital Challenges11:22 Dealing with Water and Supply Shortages20:48 Community and External Support24:10 Ongoing Efforts and Future Plans27:51 Conclusion and Final Thoughts

In this special episode, Sam Ashoo MD and Rob Orman MD discuss the concept of Maladaptive Perfectionism and its application to emergency medicine.Understanding Maladaptive PerfectionismCase Example and DiscussionAdaptive vs Maladaptive PerfectionismPersonal Experiences and Legal ChallengesDealing with Negative OutcomesStrategies for Managing Perfectionism in the EDHandling Overwhelming ShiftsManaging Expectations in the EDA Soul-Crushing Day in the EDFinding Meaning in Moments of CrisisThe Importance of Meaningful WorkOperationalizing Meaning in Your ShiftThe Driveway Debrief: Transitioning from Work to HomePreparing for the Next ShiftConclusion and Next Episode TeaserFor more from Rob Orman, MD check out Orman Physician Coaching

In this episode, Sam Ashoo, MD and T.R. Eckler, MD discuss the September 2024 Emergency Medicine Practice article, Elder Abuse and Neglect: Making the Diagnosis and Devising a Treatment Plan in the Emergency Department Introduction and AnnouncementsElder Abuse and Neglect: An OverviewRisk Factors and ReportingPre-Hospital and Emergency Department ConsiderationsScreening Tools and Physical ExaminationDocumentation and DispositionCultural Considerations and Future DirectionsConclusion and ResourcesSuspected Elder Abuse should be reported to one of these organizations:ADULT PROTECTIVE SERVICES - Living at homeLONG-TERM CARE OMBUDSMAN - Living in a long term care facility

In this episode, Sam Ashoo, MD interviews social media marketing expert Adam Goodcoff, DO, Founder and CEO of MedFluencers. Meet Dr. Adam Goodcoff The Role of Physicians on Social Media Legal Considerations for Physicians on Social Media Employer Policies and Social Media Creating Engaging Content Balancing Professionalism and Personal Life on Social Media Navigating Negative Comments and Trolls Handling Low Engagement and Negative Feedback Becoming a Medfluencer: Tips and Strategies Connecting with Adam and Final Thoughts

In this episode, Sam Ashoo, MD and T.R. Eckler, MD discuss the August 2024 Emergency Medicine Practice article, Emergency Department Management of Patients With Sickle Cell DiseaseEpidemiologyCommon Presentation of Sickle Cell Disease in the EDScreening and Diagnosis DifferencesEpidemiology: 200,000 ED Visits Annually, 85% for PainPathophysiologyLife Expectancy and ComplicationsVado-Occlusive Crises and PathophysiologySequestration Crisis in Sickle Cell PatientsAcute Chest Syndrome and PriapismClinical ManagementTreatment Advocacy and Pain ManagementPatient History and Examination ImportanceImaging RecommendationsLaboratory Studies and FindingsEmergency Department Care ProtocolsAdvanced Treatment OptionsIntravenous (IV) Fluids GuidelineManagement of PriapismRole of Exchange TransfusionAcute Chest Syndrome DetailsApproach in Rural and Critical Access HospitalsSpecial PopulationsPregnant Patients with Sickle Cell DiseaseIncreased Risks and Complication Management

In this episode, Sam Ashoo, MD and T.R. Eckler, MD discuss the July 2024 Emergency Medicine Practice article, Emergency Department Management of Patients With Complications of DialysisOverview of Dialysis ComplicationsKey Dialysis ComplicationsCardiovascular DiseaseCongestive Heart FailurePericarditis and Cardiac TamponadeNeurological SequelaeGastrointestinal ComplicationsHypotensionDialysis Disequilibrium SyndromeAir Embolism and Chloramine ToxicityDisaster PreparednessVascular Access ComplicationsHemorrhage risks and treatmentThrombosis, stenosis, and aneurysmsInfection risks and managementPre-Hospital CareED History Differential diagnosis Key questions to ask dialysis patientsExamination Physical Exam TipsTreatmentsRisk Management PitfallsCommon Pitfalls to AvoidConclusion

In this episode, Sam Ashoo, MD and T.R. Eckler, MD interview Corey Hazekamp, MD, MS, one of authors of the June 2024 Emergency Medicine Practice article, Managing Emergency Department Patients With Opioid Use DisorderCurrent State of Opioid EpidemicOverview of overdose deaths and trends.Data and statistics about opioid overdose mortality rates.Three Waves of Opioid Overdose Deaths in the U.S.Opioid Classifications and Urine Drug TestingTypes of opioids: synthetic, semi-synthetic, and natural.Urine drug testing limitations and false positives/negatives.Practical use and research on co-ingestionsEmergency Medical Services (EMS) and Pre-Hospital CareImportance of ABCs in acute opioid overdose cases.Naloxone usage trends and an empirical approach.Anecdotal insights on changing naloxone administration dosages.Clinical Management in the Emergency DepartmentBuprenorphine InitiationProtocols for initiating buprenorphine in ED settings.Assessment using the Clinical Opiate Withdrawal Scale (COWS).Safe dosing procedures for buprenorphine.Withdrawal and Overdose CareLaboratory testing recommendations.Capnography and VBG in overdose management.The role of end-tidal CO2 monitoring and respirations.Methadone vs. Buprenorphine ConsiderationsMethadone to buprenorphine transition protocols.Personal testimonials and clinical experiences in managing overdoses and withdrawal symptoms.Patient Discharge and Follow-upPreparation of discharge prescriptions.Referral to addiction medicine clinics and resources.Educating patients on continued treatment and harm reduction.

In this episode, Sam Ashoo, MD interviews Rob Orman, MD, founder of Orman Physician Coaching, about routine examination of our careers in emergency medicine.Understanding Career Cycles and Embracing ChangeThe Importance of Career Reflection and Making TradesNavigating Career Satisfaction and Preventing BurnoutProactive Career Management and Reflection StrategiesExploring Career Alternatives and Rediscovering Joy in MedicineBalancing Work, Love, Play, and Health for a Satisfying LifeWhen to Seek Coaching for Career GuidancePractical Tools for Self-Reflection and Taking ActionClosing Thoughts and Resources for Emergency Physicians

In this episode, Sam Ashoo, MD and T.R. Eckler, MD interview Reuben J. Strayer, MD, author of the May 2024 Emergency Medicine Practice article, Current Concepts in Ketamine Therapy in the Emergency DepartmentDiving Into Ketamine Use in Emergency MedicineUnderstanding Ketamine: From Origins to Emergency UseExploring the Ketamine Brain ContinuumKetamine Dosing and Administration TechniquesCombining Ketamine with Neuroleptic MedicationsPractical Approaches to Ketamine for Pain ManagementInnovative Pain Management and Ketamine UseProcedural Sedation with Ketamine: Techniques and ConsiderationsAddressing Agitation and Sedation in Emergency SituationsNavigating Intubation Strategies: DSI and Ketamine-Only ApproachesKetamine's Role in Treating Asthma, Status Epilepticus, and Alcohol WithdrawalExploring Ketamine for Treatment-Resistant DepressionConcluding Remarks on Ketamine's Versatility in Emergency Medicine

In this episode, Sam Ashoo, MD interviews Ashley A. Foster, MD, Bijan Ketabchi, MD, MPH and Jennifer A. Hoffmann, MD, MS on the March 2024 Pediatric Emergency Medicine Practice article, Evaluation and Management of Suicidal Ideation and Self-Harm in Children in the Emergency DepartmentIntroductionUnderstanding Suicidal Ideation and Self Harm in YouthsScreening Tools and ApproachesAsk Suicide-Screening Questions (ASQ) ToolkitColumbia Suicide Severity Rating Scale (C-SSRS)Prehospital CareManaging Patients in the EDDealing with Challenging PopulationsLethal Means CounselingEmerging Tools in Suicide Risk IdentificationSuicide Risk Screening PathwayDisposition and ReferralsNational 988 Suicide & Crisis Lifeline 

In this episode, Sam Ashoo, MD and T.R. Eckler, MD discuss the April 2024 Pediatric Emergency Medicine Practice article, Brief Resolved Unexplained Events: Practical Evaluation and Management in the Emergency DepartmentIntroductionThe Evolution of BRUEUnderstanding BRUE GuidelinesThe Importance of Pre-Hospital Care in BRUE CasesInvestigating the Event: Questions to AskMedical and Family History: Key FactorsEnvironmental and Social ConsiderationsDefinitions and Risk AssessmentPhysical ExaminationRisk Stratification: Low Risk vs. High Risk PatientsManagement: What to Do and What Not to DoHigh Risk Population: Studies and RecommendationsThe Importance of Communication and Decision Making5 Things That Will Change Your Practice

In this episode, Sam Ashoo, MD and T.R. Eckler, MD discuss the March 2024 Emergency Medicine Practice article, Emergency Department Evaluation and Management of ConstipationPrevalence and ImpactUnderstanding the CausesMedications That Can Cause ConstipationDealing with Fecal ImpactionUnderstanding Stercoral ColitisPre-Hospital CareED History and Physical ExamDiagnostic Studies and ImagingX-RayCT ScansAdvanced TestingTreatment Options for ConstipationEnemasOsmotic Laxatives and Stool SoftenersSpecial Considerations: Pregnant, Pediatric, and Hospice PatientsPrescription Medications for ConstipationClinical Pathway for Constipation Management

In this episode, Sam Ashoo, MD interviews Paul Aronson, MD, MHS, one of the authors of the February 2024 Pediatric Emergency Medicine Practice article, Febrile Infants Aged ≤60 Days: Evaluation and Management in the Emergency DepartmentGuideline ChangesPathophysiologyEtiology and DefinitionsPrehospital CareED History and Physical Diagnostic StudiesAge 0-21 Days Age 22-28 Days Age 29-60 DaysLumbar PunctureViral TestingUrinalysisShared Decision MakingDisposition

In this episode, Sam Ashoo, MD, and T.R. Eckler MD interview Nick Harrison, MD and Daniel Brenner, MD, two of the authors of the February 2024 Emergency Medicine Practice article, Emergency Department Management of Patients With Right Heart FailurePathophysiologyPresenting SymptomsDifferential DiagnosisSpecific Acute CausesPESepsisRVMIPPVARDSCOVID-19Specific Chronic CausesCTEPHLeft Heart FailureCongenital Heart DiseaseLVADLung Disease Group 3 Pulmonary HypertensionPulmonary Arterial HypertensionPrehospital CareED history and PhysicalBiomarkersECG (table 5)ImagingEchoCTMRITreatmentRevascularizationRespiratory SupportVasopressors and Inotropes

In this episode, Sam Ashoo, MD, interviews Vasisht Srinivasan, MD, FACEP one of the authors of the December 2023 Emergency Medicine Practice EXTRA article, Emergency Department Management of Stroke in Pregnant and Postpartum PatientsEpidemiologyEvidenceCausesRisk FactorsDifferential DiagnosisPrehospital CareED History and Physical ExamLabsImagingED BP ManagementSpecific Ischemic Stroke TherapiesSpecific Hemorrhagic Stroke Therapies

In this episode, Sam Ashoo, MD, and TR Eckler, MD, discuss the January 2024 Pediatric Emergency Medicine Practice article, Management of Pediatric Urinary Tract Infections in the Emergency Department, and the January 2024 Evidence Based Urgent Care article on Pediatric Community-Acquired Pneumonia: Diagnosis and Management in the Urgent Care Setting.UTIEpidemiology and NomenclaturePrehospital CareED History and Physical ExamInfants Age <2 Months Children Age 2 Months to 2 Years Children >2 Years AdolescentsUrinalysisClean Catch Protocol Catheterization Suprapubic AspirationBlood Cultures and CSFBiomarkers (CRP and ESR)TreatmentCommunity Acquired PneumoniaDistinguishing Viral vs Bacterial PneumoniaImagingAntibiotic TreatmentVaccinationSteroidsAtypical PresentationsCheck out the clinical pathways at https://www.ebmedicine.net/pathways

In this episode, Sam Ashoo, MD, and TR Eckler, MD, discuss the December 2023 Pediatric Emergency Medicine Practice article, Management of Pediatric Toxic Ingestions in the Emergency Department.Need help now? Call the Poison Help Line at: 1‑800‑222‑1222EpidemiologyPrehospital CareED History and Physical ExamDiagnostic StudiesLabsEKGImagingUrine Toxicology TestingTreatmentHemodialysisActivated CharcoalWhole Bowel IrrigationGastric LavageIpecacDrug Specific TherapiesAcetaminophenAlcoholsAnticholinergicsBeta BlockersCalcium Channel BlockersCholinergic AgentsDigoxinIronOpioidsSalicylatesSedative HypnoticsSulfonylureasLaundry PodsCheck out the clinical pathways at https://www.ebmedicine.net/pathways

In this episode, Sam Ashoo, MD, and TR Eckler, MD, discuss the November 2023 Pediatric Emergency Medicine Practice article, Pediatric Diabetes: Management of Acute Complications in the Emergency Department and some of the highlights from the other EB Medicine articles published in November.EpidemiologyDifferential diagnosisPrehospital careED history and physical examDiagnostic studiesPoint of care testing Labs ImagingTreatmentIV fluids, the 2-bag system Mild DKA Moderate to severe DKA Potassium and phosphate supplementation Magnesium and calcium Sodium bicarbonate Hypoglycemia HHS MonitoringComplicationsCerebral edema IntubationInsulin pumpsDispositionSummaryHighlightsEBUC - Management of Acute Asthma Exacerbations in Urgent CareEMP - Evidence-Based Emergency Department Management of Methamphetamine ToxicityPEMP - Trauma Extra - Blunt Thoracic Injuries (coming Nov. 15th)Check out the clinical pathways at https://www.ebmedicine.net/pathways

In this episode, Sam Ashoo, MD, and TR Eckler, MD, discuss the October 2023 Pediatric Emergency Medicine Practice article, Substance Use in Adolescents: Recognition and Management in the Emergency Department and the October 2023 Emergency Medicine Practice article, Evidence-Based Emergency Department Management of Migraine and Other Primary HeadachesSubstance Use In Adolescents EpidemiologyRisk FactorsDifferential DiagnosisPrehospital CareED History and Physical ExamUrine Drug ScreenTreatmentMarijuana Alcohol Methaphetamines MDMA Cocaine OpioidsDispositionMigraine and Other Primary HeadachesEpidemiologyCluster HeadachesMedication Overuse HeadacheNerve BlocksGreater Occipital Sphenopalatine GanglionPregnant PatientsDispositionCheck out the clinical pathway at https://clinicalpathways.ebmedicine.net

In this episode, Sam Ashoo, MD, and TR Eckler, MD, discuss the September 2023 Emergency Medicine Practice article, Emergency Department Management of Patients With Rectal BleedingEtiology/pathophysiologyRisk factorsDifferential diagnosisPrehospital careED history and physical examDiagnostic studiesLaboratory testingImaging studiesTreatmentTransfusionCoagulation reversalEmbolizationSpecial PopulationsPediatricsPregnant patientsElderly patientsScoring systemsDispositionCheck out the clinical pathway at https://clinicalpathways.ebmedicine.net

In this episode, Sam Ashoo, MD, and TR Eckler, MD, interview Al Sacchetti, MD, about the August 2023 Emergency Medicine Practice article, Evidence-Based Management of Pulmonary Embolism in the Emergency DepartmentEtiology/pathophysiologyRisk factorsDifferential diagnosisPrehospital careED history and physical examDiagnostic scoring systemsPregnant patients Diagnostic studiesECGD-DimerTroponin & BNPChest x-rayCT V/Q scansMRIUSTreatmentIV fluidsAnticoagulationVasopressorsThrombolyticsThrombectomyECMODispositionCheck out the clinical pathway at https://clinicalpathways.ebmedicine.net

In this episode, Sam Ashoo, MD, and TR Eckler, MD, discuss the July 2023 Emergency Medicine Practice article, Diagnosing and Treating Pericarditis and Myocarditis in the Emergency DepartmentEpidemiologyNomenclatureEtiologyDifferential diagnosisPrehospital careED history and physicalDiagnosticsECGLabsImaging (X-ray, CT, US, MRI)Treatment Special populationsCOVID-19AthletesMIS-C

In this episode, Sam Ashoo, MD, and TR Eckler, MD, discuss the June 2023 Emergency Medicine Practice article, Hypertensive Emergencies: Guidelines and Best Practice RecommendationsEpidemiologyEtiologyDifferential diagnosisPrehospital careHistory and physical DiagnosticsTreatmentAcute decompensated heart failureAcute ischemic strokeAcute coronary syndromeIntracerebral hemorrhageSubarachnoid hemorrhageAortic dissectionHypertensive encephalopathySevere pre-eclampsia and eclampsiaControversiesArterial line placementBeta blockers and cocaineRisk management caveatsSummary

In this episode, Sam Ashoo, MD, and TR Eckler, MD, discuss the May 2023 Emergency Medicine Practice article on Emergency Department Management of Gastrointestinal Foreign Body IngestionEpidemiologyEtiology - types of ingestionsAnatomy - common locations by ageFood impactionSharp objectsButton batteriesMagnetsColorectal foreign bodiesPrehospital careHistory and PhysicalImagingExpectant managementEndoscopic removalNon-endoscopic techniquesBody PackingGlucagonGastric button batteriesSummary

In this episode, Sam Ashoo, MD, talks with Rob Orman, MD, founder of Orman Physician Coaching, about longevity in emergency medicine.Personal foundation Regular check-insBecoming an expert in… Job stressLiving beneath your meansRecharging and shift workBad outcomesPhysician loungeLearning to say noSet a reminderMore at Orman Physician Coaching 

Announcements: The interactive Clinical Pathways have launched and they are available for free! In this episode, Sam Ashoo, MD, and TR Eckler, MD, discuss the March 2023 Emergency Medicine Practice article on Emergency Department Management of Infective Endocarditis-Associated StrokeEpidemiologyPathophysiologyPopulations at RiskComplicationsIntracranial hemorrhageAneurysmsHeart blockPrehospital CareED History and ExaminationImagingAntibiotic TherapySurgical TreatmentSpecial PopulationsSummary

Announcements:  The interactive Clinical Pathways have launched and they are available for free!  — In this episode, Sam Ashoo, MD, and TR Eckler, MD, discuss the February 2023 Pediatric Emergency Medicine Practice article on Pediatric Electrolyte Emergencies: Recognition and Management in the Emergency Department — History Point-of-care testing I/O lines Presentation, differential, and treatment of:HyponatremiaHypernatremiaHypokalemiaHyperkalemiaHypocalcemiaHypercalcemiaHypomagnesemiaHypophosphatemia

Announcements: The interactive Clinical Pathways have launched and they are available for free! ___In this episode, Sam Ashoo, MD, and TR Eckler, MD, discuss the January 2023 Pediatric Emergency Medicine Practice article on the Responsible and Safe Use of Opioids in Children and Adolescents in the Emergency DepartmentDEA-X Waiver Repeal:The Mainstreaming Addiction ActThe Medication Access and Training Expansion Act (MATE)FOAMed postOpioids in Children and Adolescents: IntroductionEpidemiology and Statistics Medication safety at homeEscalation of pain meds at homeNaloxone prescriptionsMedications in childrenCodeineTramadolNSAIDsLocal anesthetics and nerve blocksIntranasal meds: Ketamine and fentanylOpioids and sedationRegional anesthesiaChronic pain

Announcements: The interactive Clinical Pathways have launched and they are available for free! — In this episode, Sam Ashoo, MD, and TR Eckler, MD, discuss the July 2022 Emergency Medicine Practice article on the Management of Allergic Reactions and Anaphylaxis in the Emergency Department.  IntroThe number of ED visits and hospitalizationsStudies show up to 57% of anaphylactic reactions are not recognized, and epinephrine is not administered in up to 80% of cases. Criteria2006 Second National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network (NIAID/FAAN)WAO revised the criteria in 2020 Delphi group and Brown et alPathophysiology EpidemiologyMost common causes in children and adultsMore than half of deaths from anaphylaxis occur within the first hour of symptom onsetPrehospital CareGive epi, H1 blockersMainstay = recognitionED CareAirwayEpinephrineDecontaminationH1 and H2 blockersCorticosteroidsBiphasic reactionsGlucagonSpecial CasesAlpha-galScombroidKounis syndrome

Announcements: 1) The interactive Clinical Pathways have launched and they are available for free! 2) 2023 E/M coding guidelines are in effect. See the summary here. ___ In this episode, Sam Ashoo, MD, interviews Ara Festekjian, MD, one of the authors of the November 2022 Pediatric Emergency Medicine Practice article on Pediatric Septic Shock in the Emergency Department Introduction: How common is sepsis in kids and what is the mortality rate in the US? DefinitionsSeptic shockSepsis associated organ dysfunctionSepsis-3Compensated vs uncompensated shock EtiologyNeonateCentral line and VP shuntsAspleniaImmunocompromised children Differential Diagnosis Prehospital Care ED EvaluationHistoryExaminationSeptic shock + cardiogenic shockWarm vs cold shockEvolution of physical exam findingsDiagnosticsLabsImagingTreatmentIV/IO placementFluid bolusesAntibiotics Pressors Airway management Special PopulationsFebrile neutropeniaNewborns with septic shockControversiesFluid volumeFluid typeAntibiotic timingCorticosteroids

In this episode, Sam Ashoo, MD, and TR Eckler, MD, discuss the December 2022 Evidence-Based Urgent Care article on Influenza in Urgent Care.EpidemiologyHistorical dataSince COVID, tracking "influenza-like illness" has been complicatedInfluenza deaths and ageAnnual mortality OutbreaksTransmissionClassificationInfluenza A, B, and CHemagglutinin and neuraminidase subgroupsAntigenic drift and shiftPathophysiologyTransmissionIncubation Secondary infectionH3N2VaccinesEgg-based, cell-based, and recombinant influenza vaccinesCDC recommendationsPatients aged >65 yearsDifferential DiagnosisComplications TestingWhen is it indicated? What types of tests are available? Testing in periods of low and high prevalence TreatmentHigh-risk conditions that suggest treatment Antiviral medications Oseltamivir: NNT and NNHResistance patternsBilling and Coding

In this episode, Sam Ashoo, MD, interviews Prayag Mehta, MD, and Nikola Milanko, MD, two of the authors of the October 2022 Emergency Medicine Practice article on Angioedema in the Emergency Department Pathophysiology: Non-pitting edema of respiratory or GI tractHistamine meditated, bradykinin mediated, or idiopathicAcquired, inherited, or idiopathicDo they present differently? (Urticaria, speed of onset)Histamine MediatedMost common form: 40%-70%Can be triggered by NSAIDsCan be induced by physical mechanism like cold, vibrationIs rash a reliable method of distinguishing the types?Bradykinin MediatedMay progress slowlyCan be inherited or acquiredCommon triggers include ACE inhibitors and TPATable 1 Differential Diagnosis Prehospital CareProtect airwayEpi, steroids, antihistaminesAvoid CPAPED HistoryFigure 2: Distinguishing characteristics of histamine vs bradykinin mediatedED ExamImportance of repetitive examsAirway examinationLaryngoscopy?DiagnosticsFigure 6: Flow diagram of ED workupLabsImagingTreatmentAirway: IntubationMedicationSpecial PopulationsPediatricPregnant/lactating patientsControversiesTXADisposition

In this episode, Sam Ashoo, MD, interviews Ami Shah, MD, MPH, and Don Walker, MD, about eye injuries in the pediatric population.  Why ocular injuries? Why did you pick this topic? What kind of injuries are included and at what age are they most common? Injury zones and terminology Differential DiagnosisWhat should we keep in mind when we are confronted with an ocular injury? (Table 3)Prehospital CareWhat do our EMS colleagues need to keep in mind when transporting a child with an ocular injury?How can they help us in the ED?ED EvaluationHistory: What's important to know?Physical: Visual acuity and eye examDiagnostics: Slit lamp, ocular pressure, US, CT, MRITreatmentLid lacerations: Who repairs and when?Orbital fractures: What should we be looking for? Why is it different in children? When does repair typically occur?Corneal abrasionsCorneal foreign bodyChemical injuries: Irrigate with what and for how long?Traumatic hyphema: Treatment, dispositionTraumatic iritis: Treatment, outcomeOpen globe injuriesRetrobulbar hematoma - First 10 EMSpecial PopulationsHemophilia, Von Willebrand diseaseSickle cell and traitNeonates and infantsContact lensesControversies and Cutting EdgeKetamineTetanusNSAIDs, topical?Topical anestheticsVisual acuity apps

In this episode of EMplify: Conversation, Sam Ashoo, MD talks with Rob Orman, MD, founder of Orman Physician Coaching, about career disillusionment.Career Disillusionment: What is it? How do we combat it? Should we combat it? A frog in boiling water... BurnoutTwo questions to ask yourselfHow coaching can helpThe advice trapA framework to explore your career and life goalsMore at Orman Physician Coaching. 

In this episode, Sam Ashoo, MD interviews Rawad Rayes, MD and Eva Tovar Hirashima, MD, MPH – two of the authors of the August 2022 PEMP article on Pediatric Firearm Injuries to the Extremity: Management in the Emergency Department.Episode Outline:How common are pediatric firearm injuries? What is the most common location of these injuries? Is there much literature published on this topic? Epidemiology What’s been the trend in pediatric firearm injuries over the past 10 years? Do we have any idea how/why these are occurring (ie, accidental, intentional, etc)Terminology: For those unfamiliar with firearms (table 1)Ballistics: Mechanisms of damage. Pre-hospital careTrauma center transportPrehospital hemorrhage control -- Combat application tourniquet, anything else? ED EvaluationSIPA -- What is it and why use it? Primary survey -- Tachycardia -> delayed cap refill -> hypotension in children? Secondary SurveyDiagnostic Studies: Damage Control ResuscitationWound Care -- Do we remove projectiles? Can they stay in? Antibiotics Joint InvolvementCompartment Syndrome -- 3 As vs 6 PsRhabdomyolysisControversiesCTA for all injuries? Hemostatic devices -- Any role for these in the ED? 

In this episode of EMplify: Conversation, Sam Ashoo, MD talks with Andrew Phillips, MD, MEd, founder of EM Coach, about artificial intelligence and emergency medicine education.EM/Critical care practice - what’s that like? EM Coach - what is it? Artificial Intelligence -What is it and how does EM Coach use it? The algorithmHow did you create it? What does it do? The evidence behind itHow and where to access EM Coach

In this episode, Sam Ashoo, MD interviews Lela Bachrach, MD, MS, Larissa Truschel, MD, MPH, and Makini Chisolm-Straker, MD, MPH - the authors of the July 2022 PEMP article on Human Trafficking of Children and Adolescents: Recognition and Response in the Emergency Department. Listen to the discussion to hear more about the emergency medicine approach to human trafficking. Human Trafficking of Children and Adolescents: Recognition and Response in the Emergency Department EMplify - Sept 2022Episode Outline:Differential DiagnosisWhat is the differential diagnosis for this scenario in the ED?Are these diagnoses mutually exclusive ?EMS/Prehospital CareWhat role do EMS providers play in the recognition of trafficking?ED EvaluationWhat are common presentations/complaints that may represent trafficking?Examination: Privacy, use of a separate room, how do we accomplish this with minors?Ground rules: What does this mean? How do you state this in your practice? Do you find this dissuades patients form reporting?Technology: What if they are on the phone?History - HEADS-EDPhysical examination - Findings that lead to suspicion, documentation best practices.Diagnostic StudiesImaging: Any role for this?Lab testing: STI, anything else?Screening tools: Trauma-informed care, PEARR toolLocal laws differ by state. How do we handle this with patients? Does it dissuade reporting?"Rescuing mentality" and what that means in the EDTreatment MedicalBeyond medicines: Local services, national hotlineSpecial PopulationsDiagnosis: What to chart? National Human Trafficking Hotline 1-888-373-7888https://humantraffickinghotline.org/

In this episode of EMplify: Conversation – Sam Ashoo, MD, and TR Eckler, MD, speak with John Roberts, MD, MPH, about his work with the International Medical Corps and his efforts in Ukraine.Topics include:What is the International Medical Corps (IMC) and what does it do?What has IMC been doing in the U.S.?What is involved in disaster response?What has IMC been doing in Ukraine?What are the conditions like in Ukraine now?How does bombing of civilian areas affect Ukraine and the IMC projects?How can we support IMC efforts?How can we volunteer with the IMC?How does IMC balance long-term efforts and short-term relief to prevent harm to communities?How has the war in Ukraine effected surrounding areas?What has been most frustrating and most rewarding for you in your work with IMC?How did you start your career in disaster medicine and how would someone interested in it follow your footsteps?LinksIMC WebsiteIMC JobsRoster PositionsRoster position - MDRoster position - Nurse Roster position - Nurse Practitioner Roster position - Midwife Disaster MedicineThe Nuts & Bolts of Global EM, free e-book

In this episode, Sam Ashoo, MD interviews Adam Sigal, MD and Stephanie Costa, MD - the authors of the August 2022 EMP article on Managing Acute Cardiac Valvular Emergencies in the Emergency Department. Listen to the discussion to hear more about the emergency medicine approach to valvular emergencies. Managing Acute Cardiac Valvular Emergencies in the Emergency DepartmentEMplify - August 2022Episode Outline:Why Valvular disease? How common is it? How often do we see it in the ED? Which valves are we talking about? Aortic Valve DiseaseTypes and causesMitral Valve DiseaseTypes and causesTricuspid and Pulmonic DiseaseDifferential Diagnosisacute coronary syndromes (ACS)pulmonary embolismtamponadechronic obstructive pulmonary disease (COPD)pneumoniapneumothoraxPrehospital CareEvaluation of chest painHistoryShock ED EvaluationHistoryAortic StenosisAortic RegurgitationMitral StenosisMitral RegurgitationPhysical exam findings Diagnostic Testing LabsECGCXRBedside USFormal ECHOTreatmentSpecial PopulationsProsthetic valvesPregnant patientsSee Episode Page

In this episode of EMplify, Sam Ashoo, MD reviews recent updates on the following topics: COVID-19Public health emergency extendedCases increasingMedications and Vaccinations availablePharmacists prescribing COVID medicationsCDC COVID Therapeutics websiteHHS COVID Therapeutics LocatorMonkeypoxCases increasingVaccinationTestingFOAMED post on Diagnosis and Treatment PPEScience Direct article on Monkeypox 3I ToolMedication ShortagesBenzodiazepinesFOAMED post on benzodiazepine equivalenceAmerican Society of Health System Pharmacists (ASHP)988 Crisis LineBaby Formula Shortage

In this episode of EMplify: Conversation, Sam Ashoo, MD and TR Eckler, MD discuss meningococcal meningitis and the recent outbreak in Florida.Topics discussed include:Which vaccines are currently approved by the FDA and recommended by the CDC.The difference between the MEN ACWY vaccine and the meningococcal B vaccine.What the current recommendations are for those exposed.Challenges for healthcare providers treating patients who have been exposed or have symptoms.Further reading:Hogan AN, Brockman II CR, Santa Maria A. Emergency department management of adults with infectious meningitis and encephalitis. Emerg Med Pract. 2022 Apr;24(4):1-24. Epub 2022 Apr 2. PMID: 35315604.CDC Meningococcal Disease and Vaccination. As always, we value your feedback. Please take our listener survey.See the episode page for more details.

In this episode of EMplify: Conversation, Sam Ashoo, MD and TR Eckler, MD discuss high sensitivity troponin testing and clinical pathways.Topics discussed include: Which troponin assay are you currently using and what are its limits of detection? Do delta troponin results only count if they increase? If the test result is indeterminate, then what? repeat in 1 hr (European standard), repeat in 3 hours (depending on chest pain onset), or just admit if the HEAR(T) score is high? What does one negative troponin on presentation mean? No death in 30 days to 1 year but still missed MI?And more... ReferencesAnand A, et al; HiSTORIC Investigators†. High-Sensitivity Cardiac Troponin on Presentation to Rule Out Myocardial Infarction: A Stepped-Wedge Cluster Randomized Controlled Trial. Circulation. 2021 Jun 8;143(23):2214-2224. doi: 10.1161/CIRCULATIONAHA.120.052380. Epub 2021 Mar 23. PMID: 33752439; PMCID: PMC8177493.Chapman AR, et al. Association of High-Sensitivity Cardiac Troponin I Concentration With Cardiac Outcomes in Patients With Suspected Acute Coronary Syndrome. JAMA. 2017 Nov 21;318(19):1913-1924. doi: 10.1001/jama.2017.17488. Erratum in: JAMA. 2018 Mar 20;319(11):1168. Soerensen NA [corrected to Sorensen NA]. PMID: 29127948; PMCID: PMC5710293.Chenevier-Gobeaux C, et al. Multi-centre evaluation of recent troponin assays for the diagnosis of NSTEMI. Pract Lab Med. 2018 Feb 26;11:23-32. doi: 10.1016/j.plabm.2018.02.003. PMID: 30014015; PMCID: PMC6045566.Chiang CH, Chiang CH, Lee GH, Qian F, Chen SC, Lee CC. Time to Implement the European Society of Cardiology 0/1-Hour Algorithm. Ann Emerg Med. 2020 Nov;76(5):690-692. doi: 10.1016/j.annemergmed.2020.05.038. PMID: 33097132; PMCID: PMC7575504.McCarthy CP, Januzzi JL Jr. Increasingly Sensitive Troponin Assays: Is Perfect the Enemy of Good? J Am Heart Assoc. 2020 Dec;9(23):e019678. doi: 10.1161/JAHA.120.019678. Epub 2020 Nov 26. PMID: 33238785; PMCID: PMC7763764.Neumann JT, et al. Application of High-Sensitivity Troponin in Suspected Myocardial Infarction. N Engl J Med. 2019 Jun 27;380(26):2529-2540. doi: 10.1056/NEJMoa1803377. PMID: 31242362.Miller J, Cook B, Singh-Kucukarslan G, Tang A, Danagoulian S, Heath G, Khalifa Z, Levy P, Mahler SA, Mills N, McCord J. RACE-IT - Rapid Acute Coronary Syndrome Exclusion using the Beckman Coulter Access high-sensitivity cardiac troponin I: A stepped-wedge cluster randomized trial. Contemp Clin Trials Commun. 2021 Apr 23;22:100773. doi: 10.1016/j.conctc.2021.100773. PMID: 34013092; PMCID: PMC8114080.

In this episode of EMplify: Conversation, Sam Ashoo, MD and Rob Orman, MD discuss cognitive reframing.What is cognitive reframing you ask? It is a tool for dealing with a particularly difficult event. In our case, we discuss the “near miss” medical case and how it impacted a physician. Then we discuss how the use of cognitive reframing can help improve our perception of these “near miss” events in medicine. We also discuss what this tool can do for our longevity in medicine, regardless of our career choices. So take a listen. You may be surprised how this tool can be used in all aspects of your life.Rob Orman refers to a videos he created for a client for the post-shift power-down. You can find it and other helpful videos on his YouTube channel.Also, if you would like to learn more about Dr Rob Orman’s coaching services, visit his home page .As always, we value your feedback. Please take our listener survey.See the episode page for more details.

In this episode of EMplify: Conversation, Sam Ashoo, MD and Rob Orman, MD discuss cognitive reframing.What is cognitive reframing you ask? It is a tool for dealing with a particularly difficult event. In our case, we discuss the “near miss” medical case and how it impacted a physician. Then we discuss how the use of cognitive reframing can help improve our perception of these “near miss” events in medicine. We also discuss what this tool can do for our longevity in medicine, regardless of our career choices. So take a listen. You may be surprised how this tool can be used in all aspects of your life.Rob Orman refers to a videos he created for a client for the post-shift power-down. You can find it and other helpful videos on his YouTube channel.Also, if you would like to learn more about Dr Rob Orman’s coaching services, visit his home page .As always, we value your feedback. Please take our listener survey.See the episode page for more details.

In this episode, Sam Ashoo, MD interviews Prayag Mehta, MD and Joshua Kern, MD – two of the authors of the June, 2022 EMP article on Procedural Sedation and Analgesia in the Emergency Department. Listen to the discussion to hear more about the emergency medicine approach to sedation in adults and pediatrics !Procedural Sedation and Analgesia in the Emergency DepartmentEMplify – June 2022Episode Outline:1.Procedural sedation and analgesia (PSA): terminology2.Levels of sedationMinimalModerateDeepGeneral anesthesia3.Prehospital care4.ED care: patient assessmentASA class systemComplicationsEquipment needed (Table 1)Larson maneuver (Figure 2)5.Procedural techniqueCurrent ACEP and AAP recommendationsData for 1- or 2-physician sedation6.Preprocedural fastingDo we even need to consider this in PSA?7.Capnography8.Oxygen supplementation9.Preprocedural opioids10.Preprocedural sedatives11.Anticholinergics12.Antiemetics13.Treatment (Table 2)FentanylRemifentanilMidazolamNitrous oxidePropofolKetamineKetofolEtomidate14.Reversal agentsNaloxoneFlumazenil15.Special populationsPediatricsPregnancyGeriatrics16.Cutting edgeDexmedetomidine

The war in Ukraine has now been ongoing for 100 days. In today’s episode of EMplify: Conversations we hear from Dr. J.P. McBryde about his experience as an emergency physician volunteering in Ukraine.You can read more about Med Global and their efforts in Ukraine, on their home page:https://medglobal.org/ukraine/We would love to have your feedback. Please take the listener survey:https://www.surveymonkey.com/r/ZQRWQFWThanks for being a listener.

The war in Ukraine has now been ongoing for 100 days. In today’s episode of EMplify: Conversations we hear from Dr. J.P. McBryde about his experience as an emergency physician volunteering in Ukraine.You can read more about Med Global and their efforts in Ukraine, on their home page:https://medglobal.org/ukraine/We would love to have your feedback. Please take the listener survey:https://www.surveymonkey.com/r/ZQRWQFWThanks for being a listener.

EpidemiologyCaused by double stranded DNA virus, genus orthopoxvirus, closely related to smallpox and cowpox.Discovered in 1958 in monkeys with first human case recorded in 1970 in the Democratic Republic of Congo. (CDC) It is a zoonotic disease , meaning it is transmitted from animal to humans, with primary reservoir in squirrels, Gambian poached rats, dormice, different species of monkeys and others. First reported in the U.S. in 2003. Cases were related to pet prairie dogs that had been housed with monkeypox virus infected African rodents, imported from Ghana (WHO)There are 2 clades (having evolved from same ancestral line) of the disease. The current outbreak is from the West African lineage. (WHO)West African – milder disease, 1-3% fatalityCongo Basin – severe disease, 10% fatality Due to the similarity in the viruses, immunization against smallpox has been found to prevent infection with monkeypox. The WHO believes that increasing frequency of worldwide infection may be related to waning immunity against smallpox, since that disease was eradicated in 1980 and the vaccine is no longer popularly used. TransmissionAnimal to human – contact with sick or dead animals, ingesting poorly cooked meat of infected animals.Human to human -” Human-to-human transmission is thought to occur primarily through large respiratory droplets. Respiratory droplets generally cannot travel more than a few feet, so prolonged face-to-face contact is required. Other human-to-human methods of transmission include direct contact with body fluids or lesion material, and indirect contact with lesion material, such as through contaminated clothing or linens.” (CDC)SymptomsInitial 1-3 days – fever, lymphadenopathy, back pain, headache, myalgias, fatigue2-4 weeks of rash progression: macules -> papules -> vesicles -> pustules -> scabsThe pox rash starts on the face and spreads to the rest of the body.TestingDetection is by PCR testing, ideally of body fluid contained in the pox blisters.Test kits are available through local U.S. Health Departments and the CDC. All suspected cases should be reported to local authorities.TreatmentTreatment includes vaccinating anyone who has been exposed with the smallpox vaccine (ring vaccination). The general population is no longer routinely vaccinated due to side-effects of the smallpox vaccine.No current recommendation exists for antiviral therapy or smallpox immunoglobulin therapy.  See CDC recommendations PreventionThe JYNNEOS vaccine was FDA approved in 2019 for adults > 18 against both smallpox and monkeypox. It is a 2 dose non-replicating attenuated virus that does not produce a lesion, and therefore can not cause transmission to others. The CDC Advisory Committee on Immunization Practices is currently evaluating vaccine data with a formal recommendation pending. Media reports note the U.S. government has ordered millions of doses. The original smallpox vaccine (DRYVAX) is no longer in production. However, a second generation clone, ACAM2000, is produced by Synofi and approved by the FDA. The WHO notes that smallpox vaccine is 85% effective in preventing monkeypox.Vaccination is recommended for lab workers and anyone exposed to monkeypox. The CDC recommends vaccination within 4 days of exposure to prevent disease, with ACAM2000. However, vaccination between days 4-14 is also recommended to reduce disease severity. Vaccination does carry risks. The CDC estimates “Based on past experience, it is estimated that between 1 and 2 people out of every 1 million people vaccinated will die as a result of life-threatening complications from the vaccine” (ACAM2000) but notes that disease fatally is 1-10% outweighing the risk of vaccination. Further ReadingCurrent WHO Outbreak TrackerCDC Monkeypox ReferenceJohns Hopkins Monkeypox Reference

This is the second episode of Conversation, an EMplify podcast series. Episodes are shorter, more conversational, and cover a single topic relevant to practice in Emergency Medicine.This episode is a conversation between Dr. T.R. Eckler and Dr. Sam Ashoo about airway management and how it has changed in their practice over the last decade. This podcast makes reference to the EB Medicine course – Current Topics in Airway Management: Mechanical Ventilation, Supraglottic Airway Devices, and Intubating Patients With COVID-19, which can be found here:https://www.ebmedicine.net/airway-trainingWe would love to have your feedback. Please take the listener survey:https://www.surveymonkey.com/r/ZQRWQFWThanks for being a listener.

This is the second episode of Conversation, an EMplify podcast series. Episodes are shorter, more conversational, and cover a single topic relevant to practice in Emergency Medicine.This episode is a conversation between Dr. T.R. Eckler and Dr. Sam Ashoo about airway management and how it has changed in their practice over the last decade. This podcast makes reference to the EB Medicine course – Current Topics in Airway Management: Mechanical Ventilation, Supraglottic Airway Devices, and Intubating Patients With COVID-19, which can be found here:https://www.ebmedicine.net/airway-trainingWe would love to have your feedback. Please take the listener survey:https://www.surveymonkey.com/r/ZQRWQFWThanks for being a listener.

In this episode, Sam Ashoo, MD interviews Kyle Howarth, MD and Joby Thoppil, MD, PhD – two of the authors of the May, 2022 EMP article on Cellulitis and Skin and Soft Tissue Infections. Listen to the discussion to hear more about the emergency department management of cellulitis and necrotizing skin infections.Episode 69 – Emergency Department Management of Cellulitis and Other Skin and Soft-Tissue Infections (https://www.ebmedicine.net/topics/infectious-disease/emergency-medicine-skin)EMplify – May 2022Episode Outline:1. Why cellulitis/skin infections?2. TerminologyErysipelas vs cellulitis vs fasciitisPurulent cellulitis3. Most common pathogens4. Special situations5. Necrotizing infection classification system – is this helpful in the ED, and if so, why?6. Differential – unilateral vs bilateral presentation7. Prehospital care8. ED evaluationHistory – what should we be asking?Examination: SSTI vs NSTI9. DiagnosticsPOCUS: “cobblestoning” and fluid collectionXray: subcutaneous gasCT: when is this helpful?10. LabsBlood cultures – if given the option, are they helpful? Wound cultures – any role for these? Routine labs (CBC, BMP, etc) – are they helpful? LRINEC score – what is it and should we be using it? 11. Treatment NSTI antibiotics  Abscesses 12. Special populations IV drug users Diabetic patients Immunocompromised patients 13. Wound irrigation and loop drainage 14. Disposition 

In this episode, Sam Ashoo, MD interviews Kyle Howarth, MD and Joby Thoppil, MD, PhD – two of the authors of the May, 2022 EMP article on Cellulitis and Skin and Soft Tissue Infections. Listen to the discussion to hear more about the emergency department management of cellulitis and necrotizing skin infections.Episode 69 – Emergency Department Management of Cellulitis and Other Skin and Soft-Tissue Infections (https://www.ebmedicine.net/topics/infectious-disease/emergency-medicine-skin)EMplify – May 2022Episode Outline:1. Why cellulitis/skin infections?2. TerminologyErysipelas vs cellulitis vs fasciitisPurulent cellulitis3. Most common pathogens4. Special situations5. Necrotizing infection classification system – is this helpful in the ED, and if so, why?6. Differential – unilateral vs bilateral presentation7. Prehospital care8. ED evaluationHistory – what should we be asking?Examination: SSTI vs NSTI9. DiagnosticsPOCUS: “cobblestoning” and fluid collectionXray: subcutaneous gasCT: when is this helpful?10. LabsBlood cultures – if given the option, are they helpful? Wound cultures – any role for these? Routine labs (CBC, BMP, etc) – are they helpful? LRINEC score – what is it and should we be using it? 11. Treatment NSTI antibiotics  Abscesses 12. Special populations IV drug users Diabetic patients Immunocompromised patients 13. Wound irrigation and loop drainage 14. Disposition 

The first episode of Conversation, an EMplify podcast series. Episodes are shorter, more conversational, and cover a single topic relevant to practice in Emergency Medicine.Take the listener survey:https://www.surveymonkey.com/r/ZQRWQFWMore on the Dr Lorna Green Legislation here:https://www.ebmedicine.net/ebmblog/general-emergency-medicine/news-updates/dr-lorna-breen-health-care-provider-protection-act/

Episode 68 -- Emergency Department Management of Adults With Infectious Meningitis and Encephalitis – An Interview with Dr. Andrew HoganEMplify -- April 2022Interview with the Author: Andrew N. Hogan, MD1.Meningitis vs encephalitisWhy this topic?What do the words mean? What's the difference?2.Bacterial meningitisHow common is it in the US? Is it more common in third world countries?Mortality rate in the USCauses – if Neisseria and H influenzae improved post vaccination, why not S pneumoniae disease ? (Table 1)3.Viral meningitisHow common is it in the US?What are the common causes? (Table 2)4.Viral encephalitisSame prognosis as viral meningitis?Same organisms as viral meningitis? (Table 2)Does COVID-19 cause this illness?5.Fungal infectionsWho gets these?60% die? 1 million cases a year, 600K deaths?6.Prehospital care:What does EMS need to know?How do they protect themselves from being exposed?How can they help us make the diagnosis?EMS is giving antibiotics in some areas?PEP7.ED evaluation: History8.ED evaluation: Physical exam9.Diagnostics: CSFWhat's large volume? Is it safe?Cell counts on tubes 1+4, all the time or only if traumatic and obviously bloody?Is opening pressure helpful?CSF lactate level – can this be run in a normal lactic acid analyzer?PCR/NAAT testing10.Serum labsWhat is helpful?Serum PCRSerum cryptococcal antigen11.Imaging Is CT imaging before LP still necessary? Can we be selective?Is MRI helpful in the ED, or is there a role in encephalitis?12.TreatmentAntibioticsSteroids: Who gets them? When? Are there downsides of giving them?13.Special populationsAutoimmune diseaseLacking childhood vaccinesHealthcare associated infections14.Cutting edge15.Disposition

Episode 67 – Managing Postpartum Complications in the Emergency Department – An Interview with Dr. Nicole Yuzuk, Dr. Joseph Bove, and Dr. Riddhi DesaiEMplify – March 2022Interview with the Authors: Nicole Yuzuk, DO, Joseph Bove, DO, and Riddhi Desai, DOEpisode Outline:1.Why is this an important topic in EM? 2.Hemorrhage etiologies and definition3.Headache etiologies, both common and the more dangerous (ICH)4.Fever and infectionMastitisEndometritis5.Preeclampsia/eclampsia Definition, diagnosis, risk factors (Table 1)6.HELLP syndromeDefinition, diagnosis (Table 2)7.Peripartum cardiomyopathyTime of onset, how to make the diagnosis, risks (Table 3)8.Prehospital careIV fluidsTXAAMS evaluationChest painFever/hypotension 9.ED evaluation History (what kind of things should we remember to ask?) Physical exam (what should we be paying attention to?) 10.Diagnostic studiesHemorrhage (exam, vitals, labs, US)Headache (labs, imaging – what type?)Fever and infection (labs, imaging – US or CT, antibiotics)Cardiopulmonary complaints (labs, imaging, ECG)11.TreatmentHemorrhage Headache (CVT)Infection (mastitis, endometritis, wound Infection)Preeclampsia, eclampsia, HELLP, seizuresCardiomyopathy12.What about breastfeeding mothers? 13.Controversies and cutting edgeEndovascular therapyThromboelastography

Episode 66 – Acute Asthma Exacerbations – An Interview with Dr. Steven Hochman and Dr. Brandon SomwaruEMplify – February 2022Emergency Department Management of Acute Asthma ExacerbationsInterview with the authors: Steven M. Hochman, MD, and Brandon Somwaru, DO Episode Outline:EpidemiologyRisk factors for death from asthma (Table 1)Triggers for asthma attacksVariants of asthma (Table 2)Differential diagnosis (Table 3)Can PE be a trigger for an acute asthma attack? Prehospital careED care: history (what should we ask?)ED care: physical exam (what are we looking for?)Classifying mild/moderate/severe asthma Lab studiesPOCUS (Table 5 and Figure 3)Peak expiratory flowETCO2 capnography and capnometryChest x-rayTreatment (Table 6)MedicationsOxygenSABA vs LABAWhat about MDIs?Continuous nebs?AnticholinergicsSteroids (IV, oral, inhaled; prednisone vs dexamethasone)Magnesium sulfateEpinephrineTerbutalineKetamineNIPPVIntubation pearls and pitfalls (Table 8)Special populationsPediatrics PregnancyCOVID-19 Controversies and cutting edgeBiologicsFractional exhaled nitric oxideHeliox High flow nasal cannulaDelayed sequence intubationECMODisposition

Interview with author: Rachel Sullivan, MDWhy joint pain ?Differential Diagnosis Mono vs Poly Articular Presentation? Figure 1Infectious, degenerative, autoimmune, crystal deposition, reactive, traumaticSeptic Arthritis-Bimodal incidence RisksSeptic arthritis is polyarticular in 15% to 20% of cases, and in these cases, the mortality is highGonococcal Highest riskCommonly affected jointsSymptomatic or asymptomatic infection Lyme ArthritisViral – Zika, chikungunya, human parvovirus B19, hepatitisDegenerative osteoarthritis AutoimmuneGoutCPPDPrehospital ED History – table 2, table 4ED exam Labs – do we need them? ImagingArthrocentesis – Table 5TreatmentSpecial PopulationsProstheses Immunocompromised HIVClinical Pathway

EMplify – December 2021Announcements:The EB Medicine app is live and available for free in the Apple Store. Coming to Google Play soon. It is in Beta and your feedback is welcome. ,This month get a $50 Amazon Gift Card with all orders over $300 at https://www.ebmedicine.netCheck out the newly redesigned FOAMed blog at https://www.ebmedicine.net/ebmblog/Thoracic Aortic Syndromes in The Emergency Department: Recognition and ManagementInterview with author: Anthony Hackett, MDThoracic Aortic SyndromesDissection, Intramural Hematoma, and Penetrating Aortic UlcersPathophysiologyIntima, media, and adventitiaEpidemiology and classification Debakey vs Stanford classification- do we still use Debakey ? Risk FactorsPrehospital Care – what should EMS be looking for? ED CareHistory HTN, Pulse defecits, Chest Pain, Syncope?Table 3ADD-RS scoreExamDiagnosticsLabsEKG – STEMI? ImagingCXREcho CTMRIAortogramTreatmentBP managementHeart RateShockSurgery – Who goes and when? Special populationsPregnancyControversiesD-Dimer

EMplify – November 2021Announcements:The EB Medicine app is live and available for free in the Apple Store. Coming to Google Play soon. It is in Beta and your feedback is welcome. ,Also, this month use code ACEP21! and get 20% of all orders at https://www.ebmedicine.netEmergency Department Management of Rib FracturesAuthor: Patrick Maher, MDEpisode Outline:Why rib fractures?AnatomyFig 1Pre-hospitalED evaluationHistory Physical ExamImagingNexus Chest Decision Instrument in Blunt TraumaACR criteria for imagingCT vs xrayUltrasound TreatmentMedsBindersKinesiotaping – Fig 4Respiratory supportOperative fixationSpecial PopulationsElderlyCancer patientsPediatricsDispositionBattle ScoreRib ScoreFVC 

EMplify - October 2021Announcements: The EB Medicine app is live and available for free in the Apple Store. Coming to Google Play soon. It is in Beta and your feedback is welcome. ,Also, this month use code SB25 and get a $25 Starbucks gift card when you subscribe at ebmedicine.net Emergency Dept. Management of Cervical Spine Injuries Authors: Geoffrey Jara-Alamonte, MDChandni Pawar, MDEpidemiologyAnatomy (Figure 2 +3)Spinal Cord Injury Injury (Table1)PrimarySecondaryDifferential DiagnosisPrehospital Care - selective immobilizationED evaluationsHistoryPhysical Exam (Table 6)ImagingVascular Injury - Modified Denver Criteria (table 9)TreatmentSpecial PopulationsPediatrics

EMplify - September 2021Announcements: Be on the lookout for an announcement regarding the new EB Medicine app, coming to an App Store near you this month !! Also, this month use code SB25 and get a $25 Starbucks gift card when you subscribe at ebmedicine.net !Abnormal Uterine Bleeding in the Emergency DepartmentAuthors:Tazeen Abbas, MDAbbas Husain, MD, FACEPPhysiology reviewTerminologyDifferentiating Causes: PALM-COEINStructural: Polyp, Adenomyosis, Leiomyoma, Malignancy/HyperplasiaNon-structural: Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not otherwise specifiedOther causes: thyroid disease, hyperprolactinemia, stress, weight loss and anorexia, heavy exerciseAge Based Differential12-18Immaturity of the hypothalamic-pituitary- ovarian axisSexually transmitted infectionsCoagulopathies, and bleeding disorders (von Willibrand disease)19-39polypsfibroidsmalignancyPCOSAge 40 and olderendometrial atrophymalignancyHistoryPhysical ExamDiagnostic StudiesTreatmentUnstableStableSpecial CasesDOACsPrepubescent girlsgenital injuries 

EMplify – August 2021Announcements: Be on the lookout for an announcement regarding the new EB Medicine app, coming to an App Store near you this month !!August 2021 Pediatric Emergency Medicine PracticeLess Lethal Law Enforcement WeaponsAuthors: Jessica Osterman, MD , Cara Buchanan, MDWhat kinds of less-lethal weapons are law enforcement using?Pepper sprayConducted Electrical Weapons (CEWs)K-9sBeanbag gunsRubber bulletsStingballsDifferential DiagnosisPrehospital CareTrauma Informed CareConductive Electrical Weapons – TaserChemical Irritants- Pepper Spray, Tear GasK9 InjuriesKinetic Impact Projectiles- Rubber Bullets, Beanbags, Sting Balls/GrenadesSounds:Police Siren https://freesound.org/people/MultiMax2121/sounds/156869/Ambulance https://freesound.org/people/sofialomba/sounds/469413/Angry Man https://freesound.org/people/ebcrosby/sounds/334439/Taser https://freesound.org/people/The_Chemical_Workshop/sounds/403252/Taser https://freesound.org/people/Greub/sounds/402636Coughs https://freesound.org/people/freesound/sounds/25301/Dog Bark https://freesound.org/people/ivolipa/sounds/337101/Grenade https://freesound.org/people/superfreq/sounds/268101/Last Updated on April 29, 2022

EMplify – July 2021Announcements: Be on the lookout for an announcement regarding the new EB Medicine app, coming to an App Store near you this month !!HIV- An Interview With Dr. Daniel EganSee the EB Medicine Article @ https://www.ebmedicine.net/topics/infectious-disease/HIVWhy HIV? 2018 , 1,2 million people living with HIV, almost 40k new infectionsPeople living with HIV visit the ED 3 x per year on averageHIV infected patients accounted for 6 in 1000 ED visits in 2017New Transmission of HIV, Figure 1What does acute infection look like ?What about chronic infection ?The chronic phase can last 10 years or more and be asymptomatic.Are people with HIV more likely to develop: CAD, COPD, DVT and why?What if they are on medication for HIV?Screening in the ED, everyone? Do they have to have symptoms or risks?What does universal screening mean?What does risk based screening mean?What are the risk factors? What if I see someone on PrEP who is in the ED for an unrelated complaint?HistoryAsk about cd4 and viral load and last testAsk about he of opportunistic infectionsAsk about medication side effectsWhat else?ExamLabs – rapid testing, 4th gen, viral load and cd4, etcImagingTreatmentTable 1Highly effective and reduces transmissionMedication side effects (we don’t have to dwell on each Med and side effect and just reference the charts)hep B virus deactivationSystem Based DiseaseHeart Failure and CADPCP (role of LDH)TBCOPDRenal Disease – stones , radiolucentNeurologic- CVA, cryptococcal meningitis, toxo, progressive multi focal leukoencephalopathy, HANDGI – diarrhea causes, c diff, hep CHeme- cytopeniaEndocrine – metabolic syndromeMusculoskeletalPsychiatric table 3DermSpecial CircumstancesPEPPrEP

EMplify - June 2021 Announcements: The Clinical Decision Making in the Emergency Department conference is June 23-27 live and virtual. More information here: https://clinicaldecisionmaking.com Be on the lookout for an announcement regarding the new EB Medicine app, coming to an App Store near you this summer !! Syncope- An Interview With Dr. James Morris See the EB Medicine Article @ https://www.ebmedicine.net/topics/cardiovascular/syncope Why syncope? Prevalence, hospitalizations, etc. Etiology: figure 1 is fantastic. Physiologic basis of syncope Neurally mediated Orthostatic - are we still doing orthostatic vitals in the ED? Cardiac Differentiating syncope from seizure Features that point to seizure Urinary incontinence Number of jerks Age? Prehospital care is all about details What did bystanders see? What do paramedics see? Any trauma? Any neuro deficits ? Glucose ECG ED History - table 4 History of similar Prodrome Associated symptoms (chest pain, neuro symptoms, etc) Falls Pre-syncope ? ED exam Vitals, vitals, vitals Orthostatic vitals ? Carotid sinus massage, why this? Do we do in the ED? ECG Brugada, blocks, VT, ST changes, etc Labs BNP, delta bnp ? Trop Lactic acid Pregnancy test CBC lutes Bun/Cr Echo - any role in the ED? CT Head PE- get this on everyone ? Is it high prevalence? Risk stratification tools- the bad and the worse Table 7, amazing Controversies Admitting the elderly Orthostatic vitals (we discussed already) Disposition

EMplify - May 2021 Announcements: The Clinical Decision Making in the Emergency Department conference is June 23-27 live and virtual. More information here: https://clinicaldecisionmaking.com Be on the lookout for an announcement regarding the new EB Medicine app, coming to an App Store near you this summer !! Atrial Fibrillation : An Approach To Diagnosis And Management In The Emergency Department - An Interview with Dr Brian Millman Epidemiology Causes Prehospital treatment - careful with causes of the A Fib. ED Evaluation History - beware the causes Physical ECG Labs Imaging Echocardiography Treatment Rate control Calcium channel blockers Beta blockers Esmolol Magnesium Rhythm control Amiodarone Procainamide Cardioversion Watch and Wait Anticoagulation Disoposition 

EMplify - April 2021AnnouncementsTraumatic Hemorrhage in the ED- with Dr Scott Weingart - April 13th, 8pm EST Free ! Register now: https://www.crowdcast.io/e/traumatic-hemorrhagic/registerPandemic Preparedness publication is coming soon.Mt Sinai COVID-19 Treatment Protocols have been updated and are available for free here: https://www.ebmedicine.net/topics/COVID-19/ProtocolsThe Clinical Decision Making in the Emergency Department conference is June 23-27 live and virtual. More information here: https://clinicaldecisionmaking.com Management of Suspected Rabies Exposure in the Emergency Department - An Interview with Dr. Bess StorchEpidemiology:Fatality rate of over 99%Half of cases occur in children95% of cases are in resource limited countries, 35% in India99% caused by infected dogs (worldwide)In the US, cases are predominantly bat variantWhy this topic?"In a recent survey of licensed physicians, less than half could identify rabies transmission routes, the correct PEP schedule, and the correct anatomic administration sites."Pathophysiology:What causes it? The RNA virus LyssavirusHow is it transmitted?How does it reach the brain?ED Evaluation:What does it look like clinically?5 stages- incubation, prodrome, acute neurologic phase, coma deathWhy doesn’t everyone just get vaccinated?What patient medical history is important ? Steroids, chloroquineWhat animals are high risk?What about pets and quarantine?What about rodents ?Is there any role for labs or imaging ?What is the treatment regimen for those who are unvaccinated? And vaccinated?What about people who are immunosuppressed?Children?Pregnant?Recently traveled? 

EMplify - March 2021Management of Acute Urinary Retention in the Emergency Department An algorithmic approach to urinary retention.Relieve the obstruction FoleyCudet catherSilicone catheterSuprapubic catheterDetermine the cause - StructuralMedications / ToxicologicNeurologicInfectiousAlpha blockersAntibioticsSlow vs rapid bladder decompressionAdmit or dischargePhimosis and ParaphimosisAnnouncements: New Airway Course Available: Current Topics in Airway Management: Mechanical Ventilation, Supraglottic Airway Devices, and Intubating Patients With COVID-19Upcoming Live Course: Dr. Scott Weingart - Traumatic Hemorrhage - April 13th., 8-9pm, ESTLook for the "Key Points And Pearls From 2020" coming to your inbox or mailbox next month !

EMplify - February 2021Community Acquired Pneumonia - An Interview with Dr. Matthew DeLaney, FACEP1. Pneumonia and nomenclature : healthcare associated vs hospital associated2. COVID-19 and antibiotics3. Bacteriology - Strep is only 10-15% of hospitalized pneumonia, Viral pneumonia is about 20% (pre covid)4. Conditions that predispose to pneumoniachronic lung disease (chronic obstructive pulmonary disease, bronchiectasis)smokingolder ageimmuno-compromiseproton-pump inhibitors, H2 blockers, and antipsychotic agents5. Is there a historical or exam item most likely to be indicative of pneumonia?6. How good is a CXR?7. When should I consider a CT if the CXR is normal?8. Procalcitonin9. Blood cultures, sputum cultures, urine antigens- are these helpful?10. CURB-65 vs PSI11. Antibiotics- table 3 major and minor, history of prior infection, and doxy for everyone !12. Duration - 5 days works13. A walk through the pathway

EMplify January 2021Evaluation and Management of ST-Segment Elevation Myocardial Infarction in the Emergency DepartmentAuthorsMarshall Frank, DO, MPH, FACEPCarson Sanders, BS, NRP, CCEMT-PBryan P. Berry, MD, BCEM, FACEP TopicsEpidemiologyPathophysiologyPrehospital careEmergency Dept EvaluationHistoryPhysicalImagingLabsElectrocardiogramaVRPosterior LeadsLBBBSerial ECGsReciprocal ChangesPericarditis vs STEMITreatmentOxygenOpioidsAntiplatelet AgentsNitroglycerinBeta BlockersReperfusionPCIThrombolyticsDysrhythmiasAnticoagulantsTransfersSpecial CircumstancesGenderAgeCocaineHave questions or comments on the podcast? Write us at [email protected] .

EMplify December 2020Rhabdomyolysis: Evidence- Based Management in the Emergency Department Authors: Gi Xiang Lee, MDDavid Duong MD, MS, FACEPTopics:  Evidence ReviewBiology & PathophysiologyDifferential DiagnosisPre-hospital careEmergency Department EvaluationHistoryPhysical ExaminationLabsTreatmentSpecial PopulationsDisposition Have questions or comments on the podcast? Write us at [email protected] .Don’t forget about the $50 Amazon card with any order over $300 through 12/31/20. Use code AMAZON20

EMplify November 2020An Evidence-Based Approach to Nonoperative Management of Traumatic Hemorrhagic Shock in the Emergency Department Authors: Christopher Pitotti, MD, FACEPJason David, MD Topics:The Lethal Triad Prehospital Care Tourniquets - Placement and PitfallsStop The BleedHemostatic DressingsTXATemperature ManagementED AssessmentShock RecognitionPredictors of Massive TransfusionImagingUltrasound - eFASTCTLabsViscoelastic Clot TestingTreatmentREBOA- Resuscitative Endovascular Balloon Occlusion of the AortaCPRResuscitative ThoracotomyAirway - IntubationBreathingCirculationMassive TransfusionCrystalloidBlood ProductsSpecial Populaations Have questions or comments on the podcast? Write us at [email protected] .

EMplify October 2020 Management of Deep Vein Thrombosis in the Emergency Department   Authors: Shane R. Sergent, DO, FAAEM, FACOEP, FAWM, RDMS Michael Galuska, MD, FACEP, FAAEM John Ashurst, DO, MSc, FACEP, FACOEP   Topics: Epidemiology Causes: • Unprovoked • Provoked Risk Factors Testing • D-dimer • Ultrasound Anticoagulation • Heparins • DOACs • Warfarin • Other Special Populations • Malignancy • Pregnancy • Elderly • Distal Calf DVT Have questions or comments on the podcast? Write us at [email protected] .

Emergency Care for Transgender and Gender-Diverse Children and Adolescents - An Interview With Dr. Hannah Janeway and Dr. Clinton Coil   This issue of Pediatric Emergency Medicine Practice is available at no cost here: https://www.ebmedicine.net/topics/ethics/trasnsgender-gender-diverse-children Topics: What is the difference between gender and sexual orientation? What are some of the terms we may encounter (current or retired)? How does a lack of knowledge / competency regarding care for transgender and gender diverse (TGD) youth create barriers to effective care? Or negatively affect the quality of care these patients receive? What is the best way to approach a transgender patient in the ER? There are a number of ways transgender patient may alter their appearance. Why are these methods relevant (complications) and how do I ask about them? Tucking Packing Binding What medical gender-affirming therapies are currently available? And what complications can they cause? Pubertal suppression Feminizing or masculinizing hormones Contraception Is gender-affirming surgery used in this population ? What types (chest, genital) ? STI’s and Pregnancy are still considerations, correct? What are some of the problems that transgender youth have an increased risk of? Substance abuse Suicide Self harm Anxiety Depression Eating disorders Physicians and sexual violence Family rejection Homelessness Food insecurity Poverty What are some helpful resources if I want to learn more? UCSF Center for Excellence for Transgender Health (https://prevention.ucsf.edu/transhealth) PFLAG (https://pflag.org/)   Learn more about EBMedicine and subscribe to Emergency Medicine Practice or Pediatric Emergency Medicine Practice here: https://www.ebmedicine.net/  

EMplify September 2020 – Infective Endocarditis Topics: Definition and new classification methods. Changes in at-risk patients in the U.S. History and Examination Imaging Chest Xray Trans-throacic Echocardiography (TTE) Trans-esophagel Echocardiography (TEE) CT Angiography MRI Bacteriology Antibiotics Summary Write us at [email protected]

EMplify August 2020 – Racism In Medicine with Dr. Maurice Selby, Assistant Professor, Emergency Medicine, Emory School of Medicine Host- Health In Harlem radio show (WHCR 90.3 FM)and podcast   Topics: History of racism in medicine Niggerology Experimentation on Women Pain thresholds, endurance to harsh environments, food and water Institutional Review Boards (IRBs) and their role in racism Non-compliant patients Believing your patient Poor outcomes in medicine due to racial bias Bereaving families Racism among physicians and providers Micro agressions What it’s like to experience racism as a physician. Next steps. Leave us a voicemail at 678-336-8466, ext 128 Write us at [email protected]

EMplify July 2020 – Ventilator Management Of Adult Patients with Dr. Ryan Pedigo, Part 2 Topics: ARDS COVD-19 Lung Compliance Prone Positioning Metabolic Derangements DKA Capnography and Waveform Analysis Leave us a voicemail at 678-336-8466, ext 128 Write us at [email protected]

EMplify July 2020 – Ventilator Management Of Adult Patients with Dr. Ryan Pedigo, Part 1 Topics: Ventilator Modes Volume Assist vs Pressure Support Tidal Volumes Tidal Volume Measurement Tables Inspiratory / Expiratory Ration FiO2: How much oxygen do we need? COPD Patients Permissive Hypercapnia Volume vs Respiratory Rate Adjustments Asthma Patients Respiratory Rate Adjustments   Leave us a voicemail at 678-336-8466, ext 128 Write us at [email protected]

  EMplify June 2020 Multi-system Inflammatory Syndrome in Children (MIS-C) with COVID-19: An Interview with Dr. Ilene Claudius and Dr. Mohsen Saidinejad. What is it and when did we discover it as an entity? Have either of you treated anyone with the disease? Discussion of different cohorts of patients with MIS-C. Definition of MIS-C. Shock: cardiogenic and distributive shock presentations. Fever, is 4 days required? Discussion of where in the COVID-19 illness MIS-C occurs. Is clinical shock a requirement? Screening criteria (labs) and the Children’s Hospital Of Philadelphia pathway. What is available as treatment? A discussion of IVIG Steroids Cytokine blockers Remdesivir Why IVIG? Complications of the disease. Why are there more cases in New York? How has MIS-C changed your practice of testing children? Is there utility in testing for COVID-19 infection or antibodies in these cases?   Resources:EB Medicine Novel 2019 Coronavirus SARS-CoV-2 (COVID-19): An Updated Overview for Emergency Clinicians EB Medicine COVID-19: The Impact on Pediatric Emergency Care Children’s Hospital of Philadelphia Clinical Pathway for MIS-C. Have questions or comments on the podcast? Leave us a voicemail at 678-336-8466, ext 128 or write us at [email protected] .  

EMplify June 2020 Rural Emergency Medicine and COVID-19: An Interview with Dr. Harry Wingate and Dr. Ken Gramyk. The rural experience in Georgia and Idaho. Covering both the ED and inpatient areas. Transfers. Schedule and ED operation changes. Practicing in a resource limited environment. Volume changes during the pandemic. Employee furloughs and staffing changes. EMS availability and transfers. Telemedicine. Have questions or comments on the podcast? Leave us a voicemail at 678-336-8466, ext 128 or write us at [email protected] .

You may be accustomed to hearing me speak about COVID-19. Yes, the crisis appears to be improving, and yes much remains unknown and still to be told. But today, even in the midst of pandemic, there is another, different crisis gripping our country. Racism. It did not begin this week, this year, or this century. It did not catch us by surprise. But it certainly is a crisis of pandemic proportion. And we cannot sit in silence. People of color in our communities have been deemed unequal, unworthy of justice, unworthy of life itself. I would love to say that the practice of medicine puts us above racism. But that would be a lie. I would love to say that the Hippocratic oath makes us behave differently, see the world differently, and treat people of color justly. But that too, would be a lie. Today Black Americans are suffering, and that pain is boiling over, becoming a torrent of injustice that we can no longer ignore. And our response cannot be silence. I don’t know the solution, but I am listening and learning. I don’t know a way to relieve the pain, as a fellow human or as a physician, but I will sit and be present. I don’t know the depth of the suffering, but I lament the loss of George Floyd, Breonna Taylor, Ahmaud Arbery, and countless others. Martin Luther King Jr. said: “The ultimate measure of a man is not where he stands in moments of comfort and convenience, but where he stands at times of challenge and controversy.” So today, I want to be clear. We, at EB Medicine, stand with our brothers and sisters of color. -------------------------------------- Leave us a voicemail at 678-336-8466, ext 128 Write us at [email protected]

EMplify May 2020 – The New Orleans Experience and Palliative Care : An Interview with Dr. Ashley Shreves EBMedicine Live Webinars: Thursday, June 4th - Life-threatening Headaches + current considerations due to COVID-19 Wednesday, June 17th – A New Timing-and-Triggers Approach to Diagnosing Causes of Acute Dizziness Click the link to register: https://www.crowdcast.io/e/20200606/register Leave us a voicemail at 678-336-8466, ext 128 Write us at [email protected]

EMplify May 2020-  Mt Sinai COVID-19 Protocols - Dr. Legome   Contact us: [email protected] 1-678-336-8466, ext. 128   Emergency Department COVID Management Protocols: One Institution’s Experience and Lessons Learned Laboratory Testing and Imaging Disposition/admission Criteria Cardiac Arrest Protocol Medication Treatment Guidelines Anticoagulation Protocol Intubation Protocol Nonaerosolized Asthma Protocol Acute Dyspnea/Palliative Care Treatment Death Management Talking Points COVID-19 Smart Phrases / Discharge Plan for Likely COVID-19 Patients Guidelines for Prone Positioning of Nonintubated Patients Critical Care for ED COVID-19 Patients

  EMplify April 2020 – Colby Redfield, MD Contact us: [email protected] 1-678-336-8466, ext. 128 COVID-19 Topics: 1.Triage Tent Implementation (02:35) 2.Telemedicine – In the tent, in the department, and in follow up. (08:45) 3. PPE (16:30) Reusing N95s Using elastomeric full and half face respirators CDC, FDA, Osha 4. EMS (22:44) Crew Safety Criteria for transport Viral filters Handoff to the ED Helpful Links: 1. Novel 2019 Coronavirus SARS-CoV-2 (COVID-19): An Updated Overview for Emergency Clinicians https://www.ebmedicine.net/topics/infectious-disease/COVID-19 2. Reusable Facemasks and COVID-19 https://adminem.com/reusable-facemasks-and-covid-19/ 3. University of Florida Halyard H600 masks https://anest.ufl.edu/clinical-divisions/mask-alternative/ https://ufhealth.org/news/2020/uf-health-anesthesiology-team-devises-respirator-mask-made-existing-hospital-materials  

Interview with Joe Habboushe, MD, CEO of MDCalc about new COVID-19 tools and his New York City experience. MDCalc's new COVID-19 resource center: https://www.mdcalc.com/covid-19   EBMedicine's COVID-19 article with recent updates: https://www.ebmedicine.net/topics/infectious-disease/COVID-19   Time Stamps: 00:00- Discussion of new tools for COVID-19: calculators, risk factors and odds ratios, labs, etc. 40:02- Discussion of the New York City COVID-19 crisis.

COVID-19 Update 03-18-2020 - An interview with Andrea Duca, MD, Emergency Physician in Bergamo, Italy Time Stamps: 01:29 Dr. Andrea Duca introduction. 02:05 What were your shifts like at the start of the epidemic? 04:50 Were you testing patients for CoOVID-19 initially? 05:08 Were the COVID-19 tests completed in-house or sent out to a government lab? 05:35 The arrival of the first cases. Then… and now. 07:03 What percent of your daily volume is due to COVID-19 patients? 08:17 Are COVID-19 patients diverted to a regional facility? 09:13 Are you still testing patients for COVID-19 today? 09:57 What is your current medication protocol? 10:35 Which antivirals are you currently using? 10:54 Hydroxychloroquine 11:14 Do you use non-invasive ventilation? 13:35 What kind of isolation do you use, airborne or droplet? 14:46 Do you put on new PPE as you go room to room? 15:21 What PPE do you currently use? 15:38 When did you create dirty and clean zones in the emergency department? 16:45 Do you have a dirty and clean side in the waiting room? 17:03 What is your annual emergency department volume? Daily volume? 18:04 How many treatment rooms are in your emergency department? 18:38 What percent of patients are admitted? Do you have borders? 19:54 Where do discharged patients go? 20:14 Have you personally been infected? 20:58 Do you test your staff who are ill? What is your protocol for infected staff? 22:46 What percent of the ED staff were sick at any given time? And inpatient nurses? 24:00 How did you deal with so many inpatient nurses being sick? 24:36 What are your surgeons, who cannot operate, currently doing? 25:35 Are you running out of non-invasive ventilation equipment? 26:20 Summary of current workflow for infected staff. 26:36 How do you use ultrasound for COVID-19 patients in the ED? 29:50 What criteria must a patient meet to be discharged? 31:00 EMS and their role in community screening. 32:20 What are you looking for on ultrasound examination? 34.42 What size chest tube are you utilizing for a pneumothorax in a patient with positive pressure ventilation? 26:33 What inpatient location are patients sent to? By what criteria? 37:05 Have you seen any infected pregnant patients or staff? 38:02 Have you seen any infected children? 38:43 Are you still testing patients? How many times are you testing them? 39:21 What psychological support do you have for staff? 42:25 What would you have liked to know early on, that yo

In this episode of EMplify, Dr. Sam Ashoo interviews Drs. Al Giwa and Akash Desai, the authors of Emergency Medicine Practice’s recent article: Novel Coronavirus COVID-19: An Overview for Emergency Clinicians. This episode, designed specifically for emergency clinicians, discusses Coronavirus COVID-19, including: The cause and history of the virus How it’s transmitted/spread and prevention methods Tools for management and treatment in the ED Which patients should be tested for Coronavirus The role of telehealth, and when patients should go to the ED Using vital signs to triage patients in the ED And more! 00:00 Intro 01:01 Why should we care about Coronavirus? 02:22 What is zoonotic transmission? 03:56 SARS and MERS and previous coronaviruses. 04:38 What are typical Coronavirus symptoms? 04:55 What is R0 (R naught)? 06:46 Why is there so much concern about this Coronavirus strain? 10:05 Is there concern that COVID-19 is more lethal? 12:45 What tools do we have to combat pandemics? Containment 14:38 Treatment and vaccines 16:32 Fecal oral transmission 19:01 Airborne and droplet transmission 21:20 Recommendations for the public 22:00 Recommendations for healthcare workers 23:24 Who should get tested? 24:47 How to get patients tested? 25:51 What do you do with a patient you want to be tested? 30:28 Closing

Acute Gastroenteritis- Author: Dr. Brian Geyer Introduction: Do both vomiting and diarrhea have to be present? No 1996 AAP guidelines, 2016 ACG guidelines, and 2017 IDSA guidelines all note diarrhea illness but may be vomiting predominant. Studies use more vague definitions like: > 1 episode of vomiting and/or > 3 episodes of diarrhea in 24 hours without known chronic cause like inflammatory bowel disease. Diarrhea is at least 3 unformed stools per day. Acute episode <14 days Persistent episode 14-29 days Chronic diarrhea >29 days Patients in the ED may present with only some of these symptoms depending their time in course of illness. Literature Review: There is abundant literature on pediatric AGE but sparse research on AGE in adults. Therefore, many recommendations are extrapolated from the pediatric literature. Causes: 70% of US cases are estimated to be caused by viruses, norovirus being most common. o 26% norovirus o 18% rotavirus Among bacterial causes: o 5.3% Salmonella, most common o 5.3% Clostridium o 3% Campylobacter o 3% parasitic infections Large portion, 51%, have no cause identified. (In ED patients) Interestingly, 79% of cases never have a cause identified (not ED specific) In ED patients, only 25% ever have a cause identified, this increases to 49% when a stool sample is obtained. (not ED specific) Food poisoning is responsible for 5% of AGE but results in 30% of deaths. Most commonly: Salmonella, Clostridium perfringens, and Campylobacter Majority of foodborne illness is still viral, mostly norovirus E Coli is normal in the gut, but two most common causes are: Shiga toxin Ecoli (STEC) AKA enterohemorrhagic Ecoli (EHEC) - causes Hemolytic Uremic Syndrome in 5-10% Entertoxigenic Ecoli (ETEC) - causes traveler's diarrhea Both cause self-limited illness. Alternate Diagnoses: Appendicitis: In the peds literature, misdiagnosis of appendicitis as AGE leads to 47% absolute increased risk of perforation. Suggestive findings include: Migration of pain to RLQ RLQ tenderness on exam (initial or repeat) Absence of diarrhea Pain not improved with episodes of diarrhea Negative factors include multiple ill family members, recent international travel, presence of diarrhea (as defined above). Ciguatera Fish Poisoning Toxin produced by algae consumed by reef fish like grouper, red snapper, sea bass and Spanish mackerel. Symptoms begin 6-24 hours post ingestion. Fish tastes normal. Patients may develop neurological symptoms like paresthesias, generalized pruritis, and reversal of hot/cold sensation. Symptoms resolve spontaneously, and treatment with mannitol is controversial. Scombroid Poisoning Ingesting fish in the Scombroidae family - mackerel, bonito, albacore, and skipjack - that have been stored improperly Bacteria produce histidine decarboxylase which converts histidine to histamine Causes abdominal cramps and diarrhea, and may cause metallic bitter or peppery taste in mouth, and facial flushing within 20-30 min of ingestion Can be confused with allergic reaction Symptoms resolve in 6-8 hours Notification of health dept may prevent others from being infected. Page 5 Table 1- Distinguishing Factors in the Differential Diagnosis of AGE History: Table 2, page 6 has key questions to ask. Onset, timing, number of stools, presence of blood, fever, quality of abdominal pain and location, recent antibiotics, etc. Extremes of age, immunosuppression, and pregnancy should be identified. Mortality is highest in the patients >65 yo. Physical Exam: We talked about RLQ abd pain, but what about bloody stool? An observational study of 889 adults and 151 pediatric with AGE showed that a negative fecal occult test showed accurately excluded invasive bacterial etiology with a NPV 87% in adults and 96% in children. But PPV was only 24%. Laboratory Testing and Imaging: Dehydration is the biggest contributor to mortality, especially in the very young and elderly. Lab evaluation for dehydration is recommended in these populations. No consistent association between lab abnormalities and bacterial etiology. WBC and differential does not differentiate bacterial vs viral, but may help in identifying severity of illness. Hemoglobin and platelets are helpful if HUS is suspected. Stool Cultures: 2017 IDSA guidelines recommends them in patients with fever, bloody or mucoid stools, severe abdominal cramping or tenderness, or signs of sepsis, noting these patients are at higher risk of bacterial infection. Specifically, Salmonella, shigella, Campylobacter, and Yersinia 2016 ACG guidelines recommend them for patients with watery diarrhea and moderate to severe illness with fever for at least 72 hours. Consider them for immunocompromised patients and those with recent abx use or hospitalization. C Difficile testing is recommended for all patients with AGE who are age >2 with a history of recent abx use or recent hospitalization Blood cultures are recommended for patients <3 months old and any patient with signs of sepsis. Imaging is generally plain film to exclude free air of surgical abdomen, or CT with contrast to evaluate for complications of AGE like aortitis, mycotic aneurysm, toxic megacolon, abscess, or perforation. Hydration: Oral rehydration is preferred. Oral rehydration solutions in patients tolerating oral fluids. ORS packets Pedialyte, Hydralyte, etc Sports drinks are safe but have less potassium. Higher sugar solutions can be diluted 50% Coconut water Half strength apple juice has been studied in pediatrics and decreased treatment failure. IV hydration for patients with severe dehydration, hypovolemic shock, septic shock, or failed oral rehydration. Don't forget to replace electrolytes if giving IV hydration. Meds: Ondansetron (Zofran) reduces need for IV hydration in peds. (0.15mg/kg oral liquid) but doesn't reduce hospitalizations or return visits (low numbers) No benefit to higher dose ondansetron. IV ondansetron vs metoclopramide performance is similar in peds. No benefit in studies to giving dexamethasone, or dimenhydrinate (dramamine) Proshlorperazine 10mg IV was shown to be superior to promethazine 25mg IV for symptom relief in adults, with less sedation No suggestions regarding medication choice from guidelines. Sniffing isopropyl alcohol soaked pads twice q 2min was shown superior vs placebo in controlling nausea, but effect is gone at 30 minutes. Ginger is reported to be helpful at 250mg QID in pregnant patients and post op patient. No data in AGE. Loperamide is recommended as an adjunct to abx by the ACG. Risk is too high in patients <3 yo and 3-12 with moderate dehydration, blood stool, or severe disease. Loperamide is also contraindicated if STEC is suspected, due to increased development of HUS Probiotics may reduce diarrhea by one day. World Health Organization recommends zinc supplements for children with diarrhea. In the US only recommended to reduce duration in severely malnourished children age 6mos-5yo. Antibiotics: Patients with traveler's diarrhea from Latin America, Caribbean, and Africa will improve faster with abx therapy. Azithromycin 1gm PO x 1, Cipro 750 mg PO x 1, or Cipro 500mg PO BID x 3 days. Patients with traveler's diarrhea from South Asia and Southeast Asia have increased strains of fluoroquinolone resistant Campylobacter. Aizthromycin 1gm PO x 1 or 500mg PO daily for 3 days is recommended. Great chart Table 4, page 12, on abx recommendations. Shellfish ingestion - Doxy, Azithomycin, or Cipro. C Diff - first line is oral vancomycin 125 mg PO QID for 10 days or Fidaxomicin 200mg PO BID for 10 days. Metronidazole is less effective due to resistance and is only used if the above is not available. STEC should not be treated with abx due to increased HUS, neither should close contacts be prophylaxed with abx. Hospitalized patients should be treated empirically pending stool studies. Giardia is self-limited but can be treated with abx therapy. Cryptosporidium is also self-limited but abx therapy is recommended for diarrhea >1-2 weeks, or immunocompromised patients. Diet: No specific recommendations. Just prove patient is tolerating adequate oral fluids first. Special Populations: Immunocompromised (HIV/AIDS, etc) and patients <3 mos or >65 yo are at increased risk Extend work up Treat with abx more liberally because of higher risk of cryptosporidium, Cyclospora, cystoisospora, microsporidia, and MAC. IDSA recommend abx therapy in immunocompromised patients and avoidance of probiotics due to lack of evidence. Loperamide is safe in these patients with acute watery diarrhea Patients on PPI and H2 blockers Increasing evidence that these meds increase susceptibility to viral and bacterial pathogens. Suspension of these meds in patients with AGE is reasonable. No formal guidelines on this. Post infectious irritable bowel syndrome results in persistent abdominal pain and diarrhea after an episode of AGE Management is supportive Disposition: OK for discharge if vitals are better after fixing dehydration and tolerating oral hydration. Remember to treat electrolyte abnormalities. Higher risk patients (<3 mos, >65 yo, immunocompromised) should be considered for admission until they demonstrate clinical improvement.  

Show Notes Please take our listener survey at https://forms.gle/spMwHJS795Qnfgww7 Diabetic Hyperglycemic Emergencies: A Systematic Approach, by H. Evan Dingle, MD and Corey Slovis, MD, FACP, FACEP, FAAEM, FAEMS American Diabetes Association (ADA) and International Society for Pediatric and Adolescent Diabetes (ISPAD) guidelines are reviewed in addition to the references used by each consensus statement. Also, a primary literature review was conducted with particular attention given to prospective studies. Topics reviewed include: Etiology and pathophysiology of DKA and HHS Precipitating causes Differential diagnosis Diagnostic studies ECG Lab Imaging Treatment IV fluids Insulin therapy Potassium Sodium bicarbonate Phosphate Pediatrics IVF changes Insulin changes Cerebral edema Airway management Euglycemia DKA Thrombosis and anticoagulation. Time stamps: 00 Introduction 1:34 Cases 21:47 Summary of key points 26:37 Closing  

Show Notes   Please click here and take our listener survey Emergency Department management of Non-St Segment Elevation Myocardial Infarction, by Drs Julianna Jung and Sharon Bord. Chest pain is the second most common complaint Over 6.4 million visits to US EDs annually include chest pain. 25% will be diagnosed with ACS 1/3 will have STEMI, 2/3 NSTEMI. Guidelines reviewed include those from: AHA/ACC ACEP European Society of Cardiology In addition to reviewing the primary literature each of them used as a basis for their recommendations.   Show More v Please click here and take our listener survey Part 1: Definitions Myocardial Infarction: elevated cardiac biomarkers (aka troponin) with clinical evidence of acute myocardial ischemia (aka signs and symptoms, ECG changes, abnormal imaging, or coronary thrombosis at cath or autopsy). Myocardial injury, unfortunately also can be abbreviated as MI, but not in our discussion. This term refers solely to cases where biomarker elevation is present without any other clinical evidence for ischemia. STEMI definition from the European Society of cardiology: ST elevation >1mm in two or more contiguous leads other than V2-V3 ST elevation in V2-V3 > 2.5mm in med < 40 yrs old >2 mm in men > 40 yrs old >1.5mm in woman, regardless of age. MACE= Major Adverse Cardiovascular Event: including re-infarction, stroke, dysrhythmia, heart failure, cardiogenic shock, and death. Part 2 : Why do we care? In-hospital mortality rates are about the same for STEMI and NSTEMI, about 10%. 1-year fatality rate in NSTEMI is more than double that of STEMI, at about 25% Part 3: Pathophysiology Type 1 MI (Infarction) is caused by atherosclerotic plaque rupture. Type 2 MI is the "mismatch" due to an imbalance in myocardial oxygen supply and demand. This can be the result of hypotension, tachycardia, sepsis, PE, etc. Part 4: Pre-hospital care Prehospital ECGs decrease time to intervention. (PCI) in STEMI Early administration of aspirin decreases mortality and complications of MI (all types). (19), and is safe in the pre-hospital setting (20) - only 45% of get it during EMS transport, so room for improvement here (21) Part 5: ED evaluation: Some of the interesting highlights History Diaphoresis Vomiting Radiation of pain to both arms or shoulders Radiation of pain to right shoulder Although teaching has been that women have atypical presentations, a 2016 study did not support it. However, it did find that elderly patients and those with diabetes may present atypically. (dyspnea, fatigue, nausea, or epigastric pain) Past Medical History Family and personal history of CAD Other medical diagnoses Tobacco use Illicit substance abuse Age (CAD prevalence in age<40 is 1%, age >80 is 25%) ** HIV - find citing 8. Grunfeld C, Delaney JA, Wanke C, et al. Preclinical atherosclerosis due to HIV infection: carotid intima-medial thickness measurements from the FRAM study. AIDS (London, England). 2009;23(14):1841–9. [PMC free article] [PubMed] [Google Scholar] 9. Holloway CJ, Ntusi N, Suttie J, et al. Comprehensive cardiac magnetic resonance imaging and spectroscopy reveal a high burden of myocardial disease in HIV patients. Circulation. 2013;128(8):814–22. [PubMed] [Google Scholar] ** Cancer with hx of radiation to the chest Exam Neurological neurologic deficit may point to aortic dissection Friction rub may be heard New murmur associated with papillary muscle rupture. Diagnostics Telemetry ECG. Patterns to know… Troponin... you should get it Scoring systems Heart Score Grace TIMI Imaging in the ED CXR CT angiography, CT PE, CCTA Echocardiography - POC or formal Part 6: Medications Oxygen (if sat <90%) Morphine (no) Nitrates Aspirin Antiplatelet agents PSY12 inhibitors IIb/IIIa inhibitors Heparins Beta Blockers Statins Part 7: Revascularization Immediate/urgent revascularization is recommended for all patients with NSTEMI who show signs of clinical instability, including refractory angina, sustained ventricular dysrhythmias, new or worsening heart failure, or shock (AHA class Ia recommendation; ESC class Ic recommendation). Otherwise, there is no clear benefit to immediate revascularization on all NSTEMI patients. Part 8: The Specials… Women Black Patients Young Patients Diabetics Cocaine Users

Show Notes Differentiating bronchiolitis from asthma and reactive airway disease in young children can be challenging, and a rapidly changing clinical presentation can confound accurate assessment of the severity of the illness. This episode reviews risk factors for apnea and severe bronchiolitis; discusses treatments/therapies and provides evidence-based recommendations for the management of pediatric patients with bronchiolitis. Show More v Pathophysiology Bronchiolar narrowing and obstruction is caused by: Increased mucus secretion Cell death and sloughing Peri-bronchiolar lymphocytic infiltrate Submucosal edema Smooth muscle constriction seems to have a limited role, perhaps explaining the lack of response to bronchodilators. Median duration of illness is 12 days in children <24 months 18% still ill at 3 weeks.2 9% still ill at 4 weeks.2 Etiology RSV accounts for 50-80% of cases, but rare in children >2 yo.3 Late fall epidemic peaking Nov-March, in the US.4 Human Metapneumovirus (HMPV) accounts for 3-19% 5,6 Similar seasonal variation to RSV. Parainfluenza, influenza, adenoviruses, coronaviruses, rhinoviruses, and enteroviruses are other causes.4-6 Rhinoviruses have been shown to play a larger role in Asthma.7 Presentation The American Academy of Pediatrics defines it as any of the following in infants: 1 Rhinitis Tachypnea Wheezing Cough Crackles Use of accessory muscles Nasal flaring Differential Diagnosis Emergent Causes Infection: pneumonia, chlamydia, pertussis Foreign body: aspirated or esophageal Cardiac anomaly: congestive heart failure, vascular ring Allergic reaction Bronchopulmonary dysplasia exacerbation Non-acute Causes Congenital anomaly: tracheoesophageal fistula, bronchogenic cyst, laryngotracheomalacia Gastroesophageal reflux disease Mediastinal mass Cystic fibrosis Clinical Pearls Vomiting, wheezing, and coughing associated with feeding; consider GERD. Wheezing associated with position changes; consider tracheomalacia or great vessel anomalies. Wheezing exacerbated by flexion of neck and relieved by neck hyperextension; consider vascular ring. Multiple respiratory tract infections and failure to thrive; consider cystic fibrosis or immunodeficiency. Wheezing with heart murmur, cardiomegaly, cyanosis, exertion or sweating with feeding; consider cardiac disease. Sudden onset of wheezing and choking; consider foreign body. Risk Factors for Severe Bronchiolitis Age < 6-12 weeks11-13 Prematurity < 35-37 weeks’ gestation11-13 Underlying respiratory illness such as bronchopulmonary dysplasia1 Significant congenital heart disease; immune deficiency including HIV, organ or bone marrow transplants, or congenital immune deficiencies14,15 Altered mental status (impending respiratory failure) Dehydration due to inability to tolerate oral fluids Ill appearance12 Oxygen saturation level ≤ 90%1 Respiratory rate: > 70 breaths/min or higher than normal rate for patient age1,12 Increased work of breathing: moderate to severe retractions and/or accessory muscle use1 Nasal flaring Grunting Risk Factors for Apnea Full-term birth and < 1 month of age16,17 Preterm birth (< 37 weeks’ gestation) and age < 2 months post birth11-13,17 History of apnea of prematurity Emergency department presentation with apnea17 Apnea witnessed by a caregiver17 Diagnostic Testing Xray Radiographs increase the likely hood of a physician giving antibiotics, even if the X-ray is negative.18-20 Routine radiography is discouraged, but may be helpful when severe disease requires further evaluation or exclusion of foreign body. Viral testing is not necessary for the diagnosis but may help when searching for the cause of fever in young infants. 2016 ACEP fever guidelines note that positive viral testing can impact further workup of fever for a serious bacterial infection (SBI).21 In infants <28 days, serious bacterial infection is high, even in patients with bronchiolitis: 10% (RSV+) and 14% (RSV -)22. Standard fever evaluation is recommended. In the 28-60 day old group, SBI rates were 5.5% (RSV+) and 11.7% (RSV-). All were UTIs.22 Urinalysis is recommended. Emergency Department Treatment Oxygen Keep O2 saturation >90% Clinicians may choose not to use continuous pulse oximetry (weak recommendation due to low-level evidence and reasoning)1 Fluids IV or NG administration of fluids to combat dehydration, until respiratory distress and tachypnea resolve. Suctioning Routine use of “deep” suctioning may not be beneficial and may be harmful.1 Nasal suction should be used to help infants with respiratory distress, poor feeding or sleeping. Bronchodilators1,25,26 Generally nor recommended for routine use. May trial in infants with: Severe bronchiolitis (these were excluded in the studies). History of prior wheezing. Family history of atopy/asthma in an older infant. Anticholinergic Agents (ipratropium bromide) No evidence for improvement in bronchiolitis.31-34 Corticosteroids AAP1, Cochrane Review27, and PECARN28 study all recommend against, finding no evidence for improvement. One small study (70 patients) found a benefit utilising 1 mg/kg oral dexamethasone followed by 0.6 mg/kg daily for 5 days. However, the study limited by size and increased prevalence of family history of atopy. Recommendations remain against use in first time wheezers with bronchiolitis. Racemic Epinephrine Not recommended1. Further study needed. Racemic Epinephrine + Oral Dexamethasone Pediatric Emergency Research Canada trial at 8 Canadian pediatric EDs involving 800 infants aged 6 weeks to 12 months with bronchiolitis found that the epinephrine-dexamethasone group had a lower admission rate over 7 days than the placebo group (17.1% vs 26.4%). This was not statistically significant. Further study needed. 30 Hypertonic Saline AAP guidelines do not recommend use in the ED but note clinicians may utilize it in the inpatient setting. 1 Cochrane reviews in 2013 and 2017 found some inpatient benefit, but a conflicting publication found it may worsen cough.35-37 High Flow Nasal Cannula (HFNC) Several small pediatric ICU studies show a benefit in severe cases. No large ED randomized trials exist, to date. Study protocols included weight based or age based flow rates. Nasal CPAP Shows benefit in pediatric ICU settings. Evidence vs HFNC is limited. Disposition Consider admission if any of the following are present: Risk for apnea Risk for severe bronchiolitis Respiratory distress, particularly if it interferes with feeding Hypoxia (oxygen saturation ≤ 90%) Decreased feeding and/or dehydration An unreliable caregiver (ie, unable to ensure patient care and appropriate 24-hour follow-up) All patients with severe bronchiolitis should be admitted.

Show Notes Jeff: Welcome back to EMplify, the podcast corollary to EB Medicine’s Emergency Medicine Practice. I’m Jeff Nusbaum and I’m back with Nachi Gupta. Nachi: For our regular listeners, you probably noticed a lapse in recent episodes as we pulled away from our usual monthly releases. Jeff: With both of us having increasing demands on our time -- myself with business school and the busiest 21 month old in the world and Nachi with yet another entrepreneurial endeavor on the horizon -- we decided that it would be best to pass the podcast on to another host, so EMplify can continue to create and deliver the high quality materials that you deserve. Nachi: We have obviously really enjoyed creating this podcast and working closely with EB Medicine to produce it. We are deeply appreciative of you, our listeners, and your wonderful feedback and comments over the years. Without you, there would be no point in us working so hard on this. Jeff: And keep the feedback coming as we hand the reins to Dr. Sam Ashoo as the new host of EMplify. Dr. Ashoo is an Emergency Physician based out of Tallahassee Florida with a keen interest in informatics who has been featured on several other podcasts you may have heard. We can’t think of a better person to take over for EMplify. I’m sure you’ll really like him and the content he produces. Well, with that, let’s get started on our final scheduled episode of EMplify! Nachi: As we are just about to see one of the busiest travel days of the year, that would be the Wednesday before Thanksgiving, we thought there would be no better time to discuss the September 2019 issue of EMP: Assisting With Air Travel Medical Emergencies: Responsibilities and Pitfalls. Jeff: This was a fantastic issue, thanks to the hard work by Drs. DeLaney and Greene, both of the University of Alabama Birmingham School of Medicine. Thanks as well to the peer editors, Dr. Knight, and Dr. Hill of the University of Cincinnati. Nachi: And I think you have a bit of a disclosure for this month... Show More v Jeff: Well, this is a first! Finally at the point in my career where I can announce a disclosure, though it’s more of a potential conflict of interest than an actual disclosure, but certainly still worth noting. I currently spend some of my time working for STAT-MD - which is an airline consultation service run by the Center for Emergency Medicine and UPMC. Though I’m certainly a junior member of the team, in some sense, I’ve responded nearly 500 inflight emergencies over the last two years. Nachi: And this definitely places you are in a particularly nice position to share some information with our listeners this month, and I’ll have some questions scattered throughout the episode for you too. Jeff: Sounds great, so let’s dive in, starting with what I think is the most important point - qualified, active, licensed, and sober providers should volunteer to assist in the event of a medical emergency rather than decline out of fear of medicolegal concerns. Nachi: I couldn’t agree more, so let me reiterate, please trust the evidence. And volunteer to help should you hear the call. We’ll get to this in a bit but there is little medicolegal concern and you owe it to the sick passenger to help. Jeff: So what are the chances you are called - well, they are not particularly high, but certainly not negligible either. In 2019, of the 4 billion passengers expected to fly, there will be an estimated 60,000 medical emergencies. That means there will be about 1 emergency per every 604 flights. Nachi: So, I fly about 4 times a month for work. At 4 times per month, over the next 12 years I can expect about one medical emergency. Already excited! Let’s start with some physiology. Cabin pressurization varies, but is typically equivalent to an altitude of 8000 feet. Jeff: And this has a huge effect, in one study of healthy volunteers, this change in pressure resulted in a 4-10 point decrease in oxygen saturation and a 35 point drop in arterial oxygen partial pressure from 95 mm Hg to 60. Nachi: In another study of healthy volunteers on a long haul flight, this change caused 7% of passengers to report symptoms consistent with acute altitude illness. Jeff: Due to the principles of Boyle’s law, decreased cabin pressure also causes expansion of gases within anatomical spaces in the body such as the eye, GI tract, sinuses, middle ear, etc. This expansion can potentially threaten surrounding structures. Nachi: So there must be guidelines for those recent post-op for flying - right? Jeff: There certainly are, but I don’t think we need to get into the weeds on this one since nobody listening will likely be doing pre-flight screenings. I think one thing to remember here, is that though cabins are pressurized to several thousand feet, they CAN be pressurized even further if necessary. The airlines don’t do this because it takes a tremendous quantity of fuel to do so, but if pressurization will defer a diversion, this option may peak their interest. Though an anecdote, the only time I’ve ever suggested it is on a flight from someone recent post-op eye surgery who went blind midflight. We pressurized the cabin from 8000 to 4000 and then finally to sea level and his vision returned. Pretty cool stuff. But getting back to the text, next we have air quality. Only 50% of inflight air is recirculated, all of the flow is compartmentalized between sections of rows, and all the air is run through a HEPA filter. The authors note that the air is actually comparable to that of an operating room. Nachi: Then why are people always getting sick after flying…? Jeff: Well it’s hard to prove, but experts believe that most post flight respiratory illnesses are likely caused by exposure to fomites on high-risk surfaces of airplanes and in airports - like the trays on the seat back. Nachi: Interesting. Jeff: It’s also worth noting that the air is quite dry, though this is unlikely to produce any clinically significant events. Most of the dehydration that occurs is more likely due to inadequate water intake and excess caffeine and alcohol consumption depending on the time of day. Nachi: Don’t judge. Even though it may be 8 am, some of our night shift locums friends may prefer an airport cocktail after a long week away. Jeff: Oh I’m definitely not judging, facts only over here. Anyway, let’s move on to a little epidemiology. Nachi: Syncope and cardiac events account for a large proportion of in-flight emergencies, with cardiac events accounting for the largest percentage of diversions. Jeff: Gi, endocrine and respiratory emergencies follow syncope and cardiac events, with specific percentages varying based on which study you look at. Nachi: Thankfully obstetric emergencies are relatively rare, accounting for less than 0.1% of all emergencies. Jeff: Trauma and substance abuse related complaints have also been reported, but represent only a small percentage of inflight emergencies. Nachi: I think that covers the main pathologies you may encounter. Next we should touch upon the actual responders. Physicians reportedly respond 44% of the time, followed by nurses at 20% and EMS providers at about 4%. Interestingly, despite physicians being there only 44% of the time, they were involved in the care for over 70% of diversions. Jeff: It might seem crazy, but that’s definitely my experience. Many physicians, especially non-ED physicians are not familiar with caring for the acutely ill. Additionally, most physicians are very uncomfortable actually witnessing someone syncopize and then immediately checking vitals and finding the passenger to be bradycardic and hypotensive as is the case with many patients immediately after a vasovagal syncopal episode. I cannot tell you how many times we get called by pilots considering diversion based on a physician’s request only to have the symptoms completely resolve in just 10 minutes. Be patient, this is a common in flight pathology. Nachi: Your experience has not failed you - data from your own group showed that 31% of cases resolved before arrival. Even in cases where EMS was requested, patients were only transported 37% of the time and of those, only 8% were actually admitted for further work up. Death is also a very rare phenomenon, occurring in only 0.3% of cases. Jeff: Alright, so let’s move onto the actual logistics of responding. Each airline has its own protocols and policies with respect to medical responders - some will require credentials, others may not. In some instances, you may be the first responder, in others, the flight crew may have already been in contact with their ground based medical control. Nachi: In terms of supplies, the FAA requires an emergency medical kit and an AED on all commercial flights. These kits cannot be opened without direction from a medical professional on the ground or on board. Jeff: And while airlines may add additional drugs at their discretion, the FAA mandates certain supplies. You can remember these supplies by thinking of the 5 A’s - asthma, allergy, altered mental status, ACS, and ACLS. The 5 As should help you remember the bronchodilators, epinephrine, antihistamine, dextrose, nitroglycerine, aspirin, and lidocaine as the one antiarrhythmic available. Of course, there are also gloves, an IV start kit, and a few other basic supplies. Nachi: AEDs are also required and have been since 2001 and amazingly when a shock was delivered in flight, 40% survived to hospital discharge with a good outcome. Jeff: Just as on the ground, shockable rhythms do well with good BLS care. And lastly, airlines also have a portable oxygen tank in addition to the emergency oxygen that is stored in the event of cabin depressurization. The exact quantity varies, but portable cylinders are certainly available. Nachi: So next we have to talk about a topic that I’m sure many of you have wondered about - what are the medico-legal risks of intervening? Jeff: As with most incidents of concern over medico-legal risk, we really just shouldn’t be too concerned over the potential legal ramifications. Though we’ll get into specifics, the short answer is that you should definitely volunteer your services - there are lots of protections in place with a paucity of case reports of legal actions against medical volunteers who volunteers in flight. Nachi: Perhaps most importantly, remember that ultimately the captain is in charge and you are functioning in a strict advisory capacity. Remember that most airlines can handle most emergencies with their ground based medical control, their typical staff, and predefined protocols - you are an added bonus. Jeff: For many ED providers, functioning as a consultant will be unfamiliar. Nachi: If I’m a consultant, I’m going to demand a WBC before seeing the patient, as I’m fairly certain that’s rule number 1 in consultant school... Jeff: It’s actually rule #12, now get out of your seat and come see the patient…. But back to medicolegal issues. In the US, health care professions are protected by the good Samaritan law and the 1998 federal aviation medical assistance act. Nachi: The Good Samaritan law provides legal protection to medical providers who perform their services in response to medical emergencies outside of the hospital. The exact verbiage of the law differs from state to state, but all 50 states have some version of it in their legislation. Jeff: Similarly the aviation medical assistance act applies to “medically qualified individuals and offers broad medico-legal protection to the airlines in the event that a medical volunteer is accused of malpractice as well as to medical providers who respond to an in-flight emergency.” Nachi: More specifically, the act states that “...an individual shall not be liable for damages arising out of the acts or omissions of the individual in providing or attempting to provide assistance in the case of an in-flight medical emergency unless the individual, while rendering such assistance, is guilty of gross negligence or willful misconduct.” Jeff: That’s a bit of a mouth full to get out. But basically, you need to remember that the AMAA protects you from everything shy of gross negligence. Because of this, there have been no reports to date of a medical professional falling below that standard. Nachi: There is one caveat to all of this though: don’t forget about your own mental status - for example if you have taken any sleeping aids or had any alcoholic drinks. Though this may not preclude you completely from rendering care, do so only with extreme caution. Jeff: And I don’t think we were clear enough about this up front. Up until this point we have mostly talked about US based flights. Flights run by International airlines are a somewhat different ball game for a number of reasons. First, medication kits will vary widely. Many will carry medications similar to those mandated by the FDA, but there certainly is no international standard. Next, the availability of ground based medical consultation is similarly widely variable, with many in the middle east contracting for this service and almost no airlines in Africa offering such services. Nachi: And lastly, with respect to legal risk - the international laws also vary widely. According to French law, for example, a French physician who does not volunteer may be committing willful negligence. Similar laws exist in Germany, Australia, and Canada. However proving you were there and refused to provide care would be quite difficult. And lastly, it’s unclear how to determine which countries’ laws apply when - for example, is it the sending country’s laws, the receiving country’s laws, or the country whose airspace you are currently in? Jeff: All excellent points. Next, we are moving to my favorite topic of the article - diversion. This is a tremendously complicated topic and I think the authors handled it quite well. Remember, the decision to divert is multifactorial and you are only there to communicate your medical opinion about the passenger - leave the decision for diversion up to the flight crew. I cannot stress this enough. Getting on the radio with the pilot and ground based medical control and demanding a diversion is often very unhelpful and simply not the right approach and can really be quite costly. Nachi: All of this is so interesting. I can’t believe you do this and divert planes.... Can you go into a bit more detail about everything the pilot considers when they are deciding to divert? Jeff: So there’s quite a bit, but I can touch on some of the main considerations. First, you have to consider the medical needs of the passenger - can he or she be temporized to get to the destination? Is there a suitable airport for diversion with an accessible local hospital with the required resources? Logistically, you need to find an airport that can not only safely accommodate the plane you are on but also one in which the airline can refuel and guarantee that the passengers and crew are safe. Remember, if you are on an A380, there are only so many airports with runways long enough for a safe landing. Fun fact: planes also take off heavy - with tons of fuel that will be burned prior to landing. Say you were to take off from London, bound for the US. To turn around and land back at London Heathrow, you may have to literally dump thousands of gallons of fuel to get the plane to a safe weight for landing. Alternatively, you may have to fly in circles for some time to burn fuel off in planes that cannot dump. A heavy landing necessitates a thorough maintenance overhaul of the landing gear and can cost the airlines not only money but significant time, which is equally as valuable. Nachi: Speaking of cost - while exact costs are unknown, one airline estimates that the cost can be as high as $600,000 - we are not dealing with small numbers here... Jeff: No definitely not. That’s why it’s so frustrating when medical volunteers demand the plane divert without talking through the medical scenario with the crew and ground based control - often temporizing measures are adequate. Nachi: And we alluded to this earlier - Physicians advise diversion more frequently at 9% of the time followed by EMS providers and nurses. When the airlines are left to their own means, they divert at rates roughly half that - just 5% of the time. At half a million dollars for some diversions, and an overall very low level of morbidity and mortality, a 50% reduction amounts to massive savings for possibly no clinical difference. Jeff: I can’t stress this enough - you are a consultant, helping the captain and the ground based medical control to come to most appropriate plan of action. When your advice causes the airlines to deviate from their standard protocols, that’s where they potentially run into trouble. Nachi: There are just two controversies to discuss this month and I actually think they are extremely pertinent. The first one relates to using personal medication or medications from other passengers. Given the relative paucity of medications in most airline medical kits, it may occur to you that someone else may have a helpful medication on board. While there is no strict rule against this, it could result in an increased level of scrutiny if there is an adverse event. So consider this a last resort. Jeff: The next controversy to discuss is the issue of gifts. There is a widespread belief that accepting gifts from the airlines would void legal protections. To date, there is ample airline-based data to suggest that medical providers’ legal protections are not negated in the event that the airlines wanted to reward a medical volunteer. Additionally, there are no reported cases of providers losing legal protection for receiving compensation for their services in flight. Nachi: Interestingly, some international carriers even offer points or other bonuses for registering as a medical volunteer. While I’m hesitant to call this controversy a myth, it seems like there isn’t much evidence to support it. Jeff: Agreed, don’t expect a gift, but if you do receive one, you can keep it and enjoy it without concern for your legal protections. Nachi: Alright so that wraps up the new material for this special edition of EMplify - let’s close out with some key points and clinical pearls. Jeff: Aircraft cabins are typically pressurized to about 8000 ft, resulting in a 4-10 point drop in oxygen saturation in healthy adults as well myalgias, fatigue, and generalized discomfort on long haul flights. Nachi: Only 50% of the cabin air is recirculated. When recirculated, it is subjected to HEPA filtration, which is adequate to prevent infection by airborne pathogens but not the infectious respiratory viruses, which are spread by droplets. Jeff: Dehydration on long flights is likely due to inadequate water intake and the increased use of diuretics such as caffeine and alcohol. Nachi: There is about 1 in-flight emergency per 11,000 passengers or 1 in 604 flights. Syncope and cardiac events are most common followed by GI, respiratory, and neurologic events. Jeff: Most in-flight emergencies are minor. When EMS is requested upon arrival, roughly 1/3rd are transported and less than 10% are admitted, with mortality estimated at 0.3% of cases. Nachi: AEDs are required on all US-based flights. Jeff: Airlines have a limited supply of supplemental oxygen for use in medical emergencies in addition to that provided to the entire plane in the event the cabin becomes depressurized Nachi: All US airlines have some form of ground-based medical assistance. Ultimately any decisions are the responsibility of the pilot in command – medical volunteers function in a strictly advisory capacity. Jeff: Medical volunteers are protected by both the Good Samaritan law and the 1998 Aviation Medical Assistance Act. Nachi: The Aviation Medical Assistance Act protects medically qualified individuals, unless they are guilty of gross negligence or willful misconduct. Jeff: International laws and protections vary widely. In some European countries, for a physician to not offer their services during an in-flight emergency may constitute willful negligence. Nachi: The decision to divert is multifactorial and can cost as much as $600,000 in some circumstances. Jeff: When physicians and EMS providers respond to in-flight emergencies, diversion rates are nearly double that of when the airlines work solely with their ground based support, increasing diversion events from 5% to 9%. Nachi: It is largely a myth that accepting any gift or payment after responding to an in-flight emergency would void your legal protections; the AMAA has no language regarding compensation and to date there are no such reported cases of lost legal protection. Jeff: And that’s the end of this months episode of EMplify: Assisting With Air Travel Medical Emergencies. This also marks the end of our run as your hosts. Over the past 3 years, we’ve thoroughly enjoyed hosting EMplify and having the unique opportunity to share high quality evidence based medicine with you all. As health care continues to move towards a quality over quantity paradigm, understanding evidence based practice will be increasingly more important. Nachi: We thank you all for giving us your ears and your time to help hone your clinical practice. Naturally, a big thanks also goes out to all of the contrubutors to Emergency Medicine Practice -- authors, peer reviewers, and of course the kind and thoughtful staff at EB Medicine. Jeff: We have no doubt that Dr. Ashoo, who will be taking over, will keep you on the edge of your seat as he brings new material to you. Couldn’t be more excited to have him as our successor. Nachi: As always, additional materials are available on our website for Emergency Medicine Practice subscribers. If you’re not a subscriber, consider joining today. You can find out more at ebmedicine.net/subscribe. Subscribers get in-depth articles on hundreds of emergency medicine topics, concise summaries of the articles, calculators and risk scores, and CME credit. You’ll also get enhanced access to the podcast, including any images and tables mentioned. PA’s and NP’s - make sure to use the code APP4 at checkout to save 50%. Jeff: The [DING SOUND] you heard throughout the episode corresponds to the answers to the CME questions. Lastly, be sure to find us on iTunes and rate us or leave comments there. You can also email us directly at [email protected].

Show Notes Dr. Susan Kirelik, a concussion specialist and emergency medicine physician, discusses the key points of concussion diagnosis and management from the perspective of the emergency medicine clinician. The topics covered include: The signs and symptoms of concussion and how it is diagnosed in the ED The initial evaluation of a patient presenting with a head injury, including tools for determining when neuroimaging is indicated Screening tools for the evaluation of patients with suspected concussion, such as the VOMS examination and the SCAT5 and Child SCAT5 tools Management of patients in the ED after making a concussion diagnosis and the role of rest, antiemetics, and acute pain management for these patients The importance of aftercare instructions when discharging concussed patients, in the context of new guidelines for concussion recovery The risk factors for prolonged recovery from concussion and resources for concussion recovery Patients seeking concussion clearance in the ED Addressing patient or parent questions about the long-term complications of concussion, such as second impact syndrome, the potential for cumulative effects of multiple concussions, and risk for CTE (chronic traumatic encephalopathy) Susan B. Kirelik is the Medical Director of the Rocky Mountain Pediatric OrthoONE Center for Concussion and is an attending pediatric emergency medicine physician at the Rocky Mountain Hospital for Children in Denver, Colorado. Read the article: Concussion in the Emergency Department: A Review of Current Guidelines - Trauma EXTRA Supplement (Trauma CME) References McCrory P, Meeuwisse W, Dvorak J, et al. Consensus statement on concussion in sport-the 5(th) international conference on concussion in sport held in Berlin, October 2016. Br J Sports Med. 2017;51(11):838- 847. (Consensus statement) Meeuwisse WH, Schneider KJ, Dvorak J, et al. The Berlin 2016 process: a summary of methodology for the 5th International Consensus Conference on Concussion in Sport. Br J Sports Med. 2017;51(11):873-876. (Conference summary) Kuppermann N, Holmes JF, Dayan PS, et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 2009;374(9696):1160-1170. (Prospective cohort study; 42,412 patients) Stiell IG, Wells GA, Vandemheen K, et al. The Canadian CT Head Rule for patients with minor head injury. Lancet. 2001;357(9266):1391-1396. (Prospective cohort study; 3121 patients) Mucha A, Collins MW, Elbin RJ, et al. A brief vestibular/ocular motor screening (VOMS) assessment to evaluate concussions: preliminary findings. Am J Sports Med. 2014;42(10):2479-2486. (Cross-sectional study; 64 patients) Links to tools and publications mentioned in the podcast: PECARN Pediatric Head Trauma: Official Visual Decision Aid for Clinicians Vestibular/Ocular-Motor Screening (VOMS) for Concussion SCAT5 tool Child SCAT5 tool REAP concussion management (NOTE: this is the new URL for “center4concussion.com,” which is mentioned in the podcast) Tip sheets for educators, parents, and healthcare providers on managing concussion recovery in the classroom

Show Notes Jeff: Welcome back to EMplify the podcast corollary to EB Medicine’s Emergency medicine Practice. I’m Jeff Nusbaum and I’m back with Nachi Gupta. This month, we are tackling a topic for which the literature continues to rapidly change - we’re talking about the ED management of patients taking direct oral anticoagulants or DOACs, previously called novel oral anticoagulants or NOACs. Nachi: Specifically, we’ll be focusing on the use of DOACs for the indications of stroke prevention in atrial fibrillation and the treatment and prevention of recurrent venous thromboembolisms. Jeff: This month’s article was authored by Dr. Patrick Maher and Dr. Emily Taub of the Icahn School of Medicine at Mount Sinai, and it was peer reviewed by Dr. Dowin Boatright from Yale, Dr. Natalie Kreitzer from the University of Cincinnati, and Dr. Isaac Tawil from the University of New Mexico. Nachi: In their quest to update the last Emergency Medicine Practice issue on this topic which was published in 2013, they reviewed over 200 articles from 2000 to present in addition to 5 systematic reviews in the cochrane database, as well as guidelines from the American Heart Association, European society of cardiology, and the american college of cardiology. Jeff: Thanks to a strong literature base, Dr’s Maher and Taub found good quality evidence regarding safety and efficacy of the DOACs in relation to warfarin and the heparin-based anticoagulants. Nachi: But do note that the literature directly comparing the DOACs is far more limited and mostly of poor quality. Show More v Jeff: Fair enough, we’ll take what we can get. Nachi: Well, I’m sure more of those studies are still coming. Jeff: Agree. Let’s get started with some basics. Not surprisingly, DOACs now account for a similar proportion of office visits for anticoagulant use as warfarin. Nachi: With huge benefits including reduced need for monitoring and a potential for reduced bleeding complications, this certainly isn’t surprising. Jeff: Though those benefits are not without challenges - most notably the lack of an effective reversal agent and the risk of unintentional overdose in patients with altered drug metabolism. Nachi: Like all things in medicine, it’s about balancing and finding an acceptable risk/benefit profile. Jeff: True. Let’s talk pathophysiology for a minute - the control of coagulation in the human body is a balance between hemorrhage and thrombosis, mediated by an extensive number of procoagulant and anticoagulant proteins. Nachi: Before the development of the DOACs, vitamin K antagonists controlled the brunt of the market. As their name suggests, they work by inhibiting the action of vitamin K, and thus reducing the production of clotting factors 2, 7, 9, and 10, and the anticoagulant proteins C and S. Jeff: Unfortunately, these agents have a narrow therapeutic window and many drug-drug interactions, and they require frequent monitoring - making them less desirable to many. Nachi: However, in 2010, the FDA approved the first DOAC, a real game-changer. The DOACs currently on the market work by one of two mechanisms - direct thrombin inhibition or factor Xa inhibition. Jeff: DOACs are currently approved for stroke prevention in nonvalvular afib, treatment of VTE, VTE prophylaxis, and reduction of major cardiovascular events in stable cardiovascular disease. Studies are underway to test their safety and efficacy in arterial and venous thromboembolism, prevention of embolic stroke in afib, ACS, cancer-associated thrombosis, upper extremity DVT, and mesenteric thrombosis. Nachi: Direct thrombin inhibitors like Dabigatran, tradename Pradaxa, was the first FDA approved DOAC. It works by directly inhibiting thrombin, or factor IIa, which is a serine protease that converts soluble fibrinogen into fibrin for clot formation. Jeff: Dabigatran comes in doses of 75 and 150 mg. The dose depends on your renal function, and, with a half-life of 12-15 hours, is taken twice daily. Note the drastically reduced half-life as compared to warfarin, which has a half-life of up to 60 hours. Nachi: The RE-LY trial for afib found that taking 150 mg of Dabigatran BID had a lower rate of stroke and systemic embolism than warfarin with a similar rate of major hemorrhage. Dabigatran also had lower rates of fatal and traumatic intracerebral hemorrhage than warfarin. Jeff: A separate RCT found similar efficacy in treating acute VTE and preventing recurrence compared with warfarin, with reduced rates of hemorrhage! Nachi: Less monitoring, less hemorrhage, similar efficacy, I’m sold!!! Jeff: Slow down, there’s lots of other great agents out there, let’s get through them all first... Nachi: Ok, so next up we have the Factor Xa inhibitors, Rivaroxaban, apixaban, edoxaban, and betrixaban.As the name suggests, these medications work by directly inhibiting the clotting of factor Xa, which works in the clotting cascade to convert prothrombin to thrombin. Jeff: Rivaroxaban, trade name Xarelto, the second FDA approved DOAC, is used for stroke prevention in those with nonvalvular afib and VTE treatment. After taking 15 mg BID for the first 21 days, rivaroxaban is typically dosed at 20 mg daily with adjustments for reduced renal function. Nachi: The Rocket AF trial found that rivaroxaban is noninferior to warfarin for stroke and systemic embolism prevention without a significant difference in risk of major bleeding. Interestingly, GI bleeding may be higher in the rivaroxaban group, though the overall incidence was very low in both groups at about 0.4% of patients per year. Jeff: In the Einstein trial, patients with VTE were randomized to rivaroxaban or standard therapy. In the end, they reported similar rates of recurrence and bleeding outcomes for acute treatment. Continuing therapy beyond the acute period resulted in similar rates of VTE recurrence and bleeding episodes to treatment with aspirin alone. Nachi: Next we have apixaban, tradename Eliquis. Apixaban is approved for afib and the treatment of venous thromboembolism. It’s typically dosed as 10 mg BID for 7 days followed by 5 mg BID with dose reductions for the elderly and those with renal failure. Jeff: In the Aristotle trial, when compared to warfarin, apixaban was superior in preventing stroke and systemic embolism with lower mortality and bleeding. Rates of major hemorrhage-related mortality were also nearly cut in half at 30 days when compared to warfarin. Nachi: For the treatment of venous thromboembolism, the literature shows that apixaban has a similar efficacy to warfarin in preventing recurrence with less bleeding complications. Jeff: Unfortunately, with polypharmacy, there is increased risk of thromboembolic and hemorrhage risks, but this risk is similar to what is seen with warfarin. Nachi: And as compared to low molecular weight heparin, apixaban had higher bleeding rates without reducing venous thromboembolism events when used for thromboprophylaxis. It’s also been studied in acute ACS, with increased bleeding and no decrease in ischemic events. Jeff: Edoxaban is up next, approved by the FDA in 2015 for similar indications as the other Factor Xa inhibitors. It’s recommended that edoxaban be given parenterally for 5-10 days prior to starting oral treatment for VTE, which is actually similar to dabigatran. It has similar levels of VTE recurrence with fewer major bleeding episodes compared to warfarin. It has also been used with similar effects and less major bleeding for stroke prevention in afib. In the setting of cancer related DVTs specifically, as compared to low molecular weight heparin, one RCT showed lower rates of VTE but higher rates of major bleeding when compared to dalteparin. Nachi: Next we have Betrixaban, the latest Factor Xa inhibitor to be approved, back in 2017. Because it’s utility is limited to venous thromboembolism prophylaxis in mostly medically ill inpatients, it’s unlikely to be encountered by emergency physicians very frequently. Jeff: As a one sentence FYI though - note that in recent trials, betrixaban reduced the rate of VTE with equivalent rates of bleeding and reduced the rate of stroke with an increased rate of major and clinically relevant non-major bleeding as compared to enoxaparin. Nachi: Well that was a ton of information and background on the DOACs. Let’s move on to your favorite section - prehospital medicine. Jeff: Not a ton to add here this month. Perhaps, most importantly, prehospital providers should specifically ask about DOAC usage, especially in trauma, given increased rates of complications and potential need for surgery. This can help with destination selection when relevant. Interestingly, one retrospective study found limited agreement between EMS records and hospital documentation on current DOAC usage. Nachi: Extremely important to identify DOAC use early. Once the patient arrives in the ED, you can begin your focused history and physical. Make sure to get the name, dose, and time of last administration of any DOAC. Pay particular attention to the med list and the presence of CKD which could point to altered DOAC metabolism. Jeff: In terms of the physical and initial work up - let the sites of bleeding or potential sites of bleeding guide your work up. And don’t forget about the rectal exam, which potentially has some added value here - since DOACs increase the risk of GI bleeding. Nachi: Pretty straight forward history and physical, let’s talk diagnostic studies. Jeff: First up is CT. There are no clear cut guidelines here, so Drs. Maher and Taub had to rely on observational studies and expert opinion. Remember, most standard guidelines and tools, like the canadian and nexus criteria, are less accurate in anticoagulated patients, so they shouldn’t be applied. Instead, most studies recommend a low threshold for head imaging, even with minor trauma, in the setting of DOAC use. Nachi: That is so important that it’s worth repeating. Definitely have a low threshold to CT the head for even minor head trauma patients on DOACs. Basically, if you’re on anticoagulation, and you made it to the ED for anything remotely related to your head, you probably win a spin. Jeff: I suspect you are not alone with that stance... There is, however, much more debate about the utility of follow up imaging and admission after a NEGATIVE scan. Nachi: Wait, is that a thing I should routinely be doing? Jeff: Well there’s not great data here, but in one observational study of 1180 patients on either antiplatelet or anticoagulant therapy, a half a percent of them had positive findings 12 hours later, and importantly none required surgical intervention. Nachi: Certainly reassuring. And for those with positive initial imaging, the authors recommend repeat imaging within 4-6 hours in consultation with neurosurgical services or even earlier in cases of unexpected clinical decline. Jeff: Interestingly, though only a small retrospective study of 156 patients, one study found markedly reduced mortality, 4.9% vs 20.8% in those on DOACs vs warfarin with traumatic intracranial hemorrhage. Nachi: Hmm that actually surprises me a bit with the ease of reversibility of warfarin. Jeff: And we’ll get to that in a few minutes. But next we should talk about ultrasound. As always with trauma, guidelines recommend a FAST exam in the setting of blunt abdominal trauma. The only thing to be aware of here is that you should have an increased index of suspicion for bleeding, especially in hidden sites like the retroperitoneum. Nachi: And just as with traumatic head bleeds, a small observational study of those with blunt abdominal trauma found 8% vs 30% mortality for those on DOACs vs warfarin, respectively. Jeff: That is simply shocking! Let’s also talk lab studies. Hemoglobin and platelet counts should be obtained as part of the standard trauma work up. Assessing renal function via creatinine is also important, especially for those on agents which are renally excreted. Nachi: Though you can, in theory, test for plasma DOAC concentrations, such tests are not routinely indicated as levels don’t correspond to bleeding outcomes. DOAC levels may be indicated in certain specific situations, such as while treating life-threatening bleeding, development of venous thromboembolism despite compliance with DOAC therapy, and treating patients at risk for bleeding because of an overdose. Jeff: In terms of those who require surgery while on a DOAC - if urgent or emergent, the DOAC will need to be empirically reversed. For all others, the recommendation is to wait a half life or even multiple half-lives, if possible, in lieu of level testing. Nachi: Coagulation tests are up next. Routine PT and PTT levels do not help assess DOACs, as abnormalities on either test can suggest the presence of a DOAC, but the values should not be interpreted as reliable measures of either therapeutic or supratherapeutic clinical anticoagulant effect. Jeff: Dabigatran may cause prolongation of both the PT and the PTT, but the overall correlation is poor. In addition, FXa inhibitors may elevate PT in a weakly concentration dependent manner, but this may only be helpful if anti-fXa levels are unavailable. Nachi: Which is a perfect segway into our next test - anti-factor Xa level activity. Direct measurements of the anti-Fxa effect demonstrates a strong linear correlation with plasma concentrations of these agents, but the anticoagulant effect does not necessarily follow the same linear fashion. Jeff: Some labs may even have an anti-FXa effect measurement calibrated specifically to the factor 10a inhibitors. Nachi: While measuring thrombin time is not routinely recommended, the result of thrombin time or dilute thrombin time does correlate well with dabigatran concentrations across normal ranges. Jeff: And lastly, we have the Ecarin clotting time. Ecarin is an enzyme that cleaves prothrombin to an active intermediate that can be inhibited by dabigatran in the same way as thrombin. The ECT is useful for measuring dabigatran concentration - it’s not useful for testing for FXa inhibitors. A normal ECT value could be used to exclude the presence of dabigatran. Nachi: So I think that rounds out testing. Let’s move into the treatment section. Jeff: For all agents, regardless of the DOAC, the initial resuscitation follows the standard principles of hemorrhage control and trauma resuscitation. Tourniquet application, direct pressure, endoscopy for GI bleeds, etc... should all be used as needed. And most importantly, for airway bleeding, pericardial bleeding, CNS bleeding, and those with hemodynamic instability or overt bleeding, those with a 2 point drop in their hemoglobin, and those requiring 2 or more units of pRBC - they all should be considered to have serious, life threatening bleeds. This patient population definitely requires reversal agents, which we’re getting to in a minute. Nachi: A type and screen should also be sent with the plan to follow standard transfusion guidelines, with the goal of a hemoglobin level of 7, understanding that in the setting of an active bleed, the hemoglobin level will not truly be representative. Jeff: Interestingly, in the overdose literature that’s out there, bleeding episodes appear to be rare - occurring in just 5% of DOAC overdose cases. Nachi: Finally, onto the section we’ve all been waiting for. Let’s talk specific reversal agents. Praxbind is up first. Jeff: Idarucizumab or Praxbind, is the reversal agent of choice for dabigatran (which is also called pradaxa). According to data from the RE-LY trial, it reverses dabigatran up to the 99th percentile of levels measured in the trial. Nachi: And praxbind should be given in two 2.5 g IV boluses 15 minutes apart to completely reverse the effects of dabigatran. Jeff: As you would expect given this data, guidelines for DOAC reversal recommend it in major life-threatening bleeding events for patients on dabigatran. Nachi: Next up is recombinant coagulation factor Xa (brand name Andexxa), which was approved in 2018 for the FXa inhibitors. This recombinant factor has a decoy receptor for the FXa agents, thus eliminating their anticoagulant effects. Jeff: Recombinant factor Xa is given in either high or low dose infusions. High dose infusions for those on rivaroxaban doses of >10 mg or apixaban doses >5 mg within the last 8 hours and for unknown doses and unknown time of administration. Low dose infusions should be used for those with smaller doses within the last 8 hours or for last doses taken beyond 8 hours. Nachi: In one trial of 352 patients, recombinant factor Xa given as an IV bolus and 2 hour infusion was highly effective at normalizing anti-FXa levels. 82% of the assessed patients at 12 hours achieved hemostasis, but there were also thrombotic events in 10% of the patients at 30 days. Jeff: And reported thrombotic events aren’t the only downside. Though the literature isn’t clear, there may be limited use of recombinant factor Xa outside of the time of the continuous infusion, and even worse, there may be rebound of anti-Fxa levels and anticoagulant effect. And lastly, the cost is SUBSTANTIAL. Nachi: Is there really a cost threshold for stopping life threatening bleeding…? Jeff: Touche, but that means we need to save it for specific times and consider other options out there. Since this has only been around for a year or so, let’s let the literature play out on this too... Nachi: And that perfectly takes us into our next topic, which is nonspecific reversal agents, starting with prothrombin complex concentrate, also called PCC. Jeff: PCC is FDA approved for rapid reversal of vitamin K antagonist-related hemorrhagic events and is now being used off label for DOAC reversal. Nachi: PCC comes in 3 and 4 factor varieties. 3-factor PCC contains factors 2, 9, 10 and trace amounts of factor 7. 4 factor PCC contains factors 2, 9 10, as well as purified factor 7 and proteins C and S. Jeff: Both also contain trace amounts of heparin so can’t be given to someone with a history of HIT. Nachi: PCC works by overwhelming the inhibitor agent by increasing the concentration of upstream clotting factors. It has been shown, in healthy volunteers, to normalize PT abnormalities and bleeding times, and to achieve effective bleeding control in patients on rivaroxaban, apixaban, and edoxaban with major bleeding events. Jeff: In small studies looking at various end points, 4 factor PCC has been shown to be superior to 3 factor PCC. Nachi: Currently it’s given via weight-based dosing, but there is interest in studying a fixed-dose to decrease both time to medication administration and cost of reversal. Jeff: Guidelines currently recommend 4F PCC over 3F PCC, if available, for the management of factor Xa inhibitor induced bleeding, with studies showing an effectiveness of nearly 70%. As a result, 4F PCC has become an agent of choice for rapid reversal of FXa inhibitors during major bleeding events. Nachi: Next we have activated PCC (trade name FEIBA). This is essentially 4Factor PCC with a modified factor 7. Though traditionally saved for bleeding reversal in hemophiliacs, aPCC is now being studied in DOAC induced bleeding. Though early studies are promising, aPCC should not be used over 4factor PCC routinely as of now but may be used if 4Factor PCC is not available. Jeff: Next we have recombinant factor 7a (trade name novoseven). This works by activating factors 9 and 10 resulting in rapid increase in thrombin. Studies have shown that it may reverse the effect of dabigatran, at the expense of increased risk of thrombosis. As such, it should not be used as long as other agents are available. Nachi: Fresh Frozen Plasma is the last agent to discuss in this section. Not a lot to say here - FFP is not recommended for reversal of any of the DOACs. It may be given as a part of of a balanced massive transfusion resuscitation, but otherwise, at this time, there doesn’t seem to be a clear role. Jeff: Let’s move on to adjunct therapies, of which we have 3 to discuss. Nachi: First is activated charcoal. Only weak evidence exists here - but, according to expert recommendations, there may be a role for DOAC ingestions within 2 hours of presentations. Jeff: Perhaps more useful than charcoal is our next adjunct - tranexamic acid or TXA. TXA is a synthetic lysine analogue with antifibrinolytic activity through reversible binding of plasmin. CRASH-2 is the main trial to know here. CRASH-2 demonstrated reduced mortality if given within 3 hours in trauma patients. There is very limited data with respect to TXA and DOACs specifically, so continue to administer TXA as part of your standard trauma protocol without modification if the patient is on a DOAC, as it’s likely helpful based on what data we have. Nachi: Next is vitamin K - there is no data to support routine use of vitamin K in those taking DOACs - save that for those on vitamin K antagonists. Jeff: Also, worth mentioning here is the importance of hematology input in developing hospital-wide protocols for reversal agents, especially if availability of certain agents is limited. Nachi: Let’s talk about some special circumstances and populations as they relate to DOACs. Patients with mechanical heart valves were excluded from the major DOAC trials. And of note, a trial of dabigatran in mechanical valve patients was stopped early because of bleeding and thromboembolic events. As such, the American College of Cardiology state that DOACs are reasonable for afib with native valve disease. Jeff: DOACs should be used with caution for pregnant, breastfeeding, and pediatric patients. A case series of 233 pregnancies that occurred among patients on a DOAC reported high rates of miscarriage. Nachi: Patients with renal impairment are particularly concerning as all DOACs are dependent to some degree on renal elimination. Current guidelines from the Anticoagulation Forum recommend avoiding dabigatran and rivaroxaban for patients with CrCL < 30 and avoiding edoxaban and betrixaban for patients with CrCl < 15. Jeff: A 2017 Cochrane review noted similar efficacy without increased risk of major bleeding when using DOACs in those with egfr > 30 (that’s ckd3b or better) when compared to patients with normal renal function and limited evidence for safety below this estimated GFR. Nachi: Of course, dosing with renal impairment will be different. We won’t go into the details of that here as you will probably discuss this directly with your pharmacist. Jeff: We should mention, however, that reversal of the anticoagulant in the setting of renal impairment for your major bleeding patient is exactly the same as we already outlined. Nachi: Let’s move on to some controversies and cutting-edge topics. The first one is a pretty big topic and that is treatment for ischemic stroke patients taking DOACs. Jeff: Safety and efficacy of tPA or endovascular therapy for patients on DOACs continues to be debated. Current guidelines do not recommend tPA if the last DOAC dose was within the past 48 hours, unless lab testing specific to these agents shows normal results. Nachi: Specifically, the American Heart Association suggests that INR and PTT be normal in all cases. ECT and TT should be tested for dabigatran. And calibrated anti-FXa level testing be normal for FXa inhibitors. Jeff: The AHA registry actually included 251 patients who received tpa while on DOACs, which along with cohort analysis of 26 ROCKET-AF trial patients, suggest the risk of intracranial hemorrhage is similar to patients on warfarin with INR < 1.7 and to patients not on any anticoagulation who received tpa. However, given the retrospective nature of this data, we cannot exclude the possibility of increased risk of adverse events with tpa given to patients on DOACs. Nachi: Endovascular thrombectomy also has not been studied in large numbers for patients on DOACs. Current recommendations are to discuss with your stroke team. IV lysis or endovascular thrombectomy may be considered for select patients on DOACs. Always include the patient and family in shared decision making here. Jeff: There are also some scoring systems for bleeding risk to discuss briefly. The HAS-BLED has been used to determine bleeding risk in afib patients taking warfarin. The ORBIT score was validated in a cohort that included patients on DOACs and is similarly easy to use, and notably does not require INR values. Nachi: There is also the ABC score which has demonstrated slightly better prediction characteristics for bleeding risk, but it requires high-sensitivity troponin, limiting its practical use. Jeff: We won’t say more about the scoring tools here, but would recommend that you head over to MD Calc, where you can find them and use them in your practice. Nachi: Let’s also comment on the practicality of hemodialysis for removal of the DOACs. Multiple small case series have shown successful removal of dabigatran, given its small size and low protein binding. On the other hand, the FXa inhibitors are less amenable to removal in this way because of their higher protein binding. Jeff: Worth mentioning here also - dialysis catheters if placed should be in compressible areas in case bleeding occurs. The role of hemodialysis for overdose may be limited now that the specific reversal agent, praxbind, exists. Nachi: In terms of cutting-edge tests, we have viscoelastic testing like thromboelastography and rotational thromboelastometry. Several studies have examined the utility of viscoelastic testing to detect presence of DOACs with varying results. Prolongation of clotting times here does appear to correlate with concentration, but these tests haven’t emerged as a gold standard yet. Jeff: Also, for cutting edge, we should mention ciraparantag. And if you’ve been listening patiently and just thinking to yourself why can’t there be one reversal agent to reverse everything, this may be the solution. Ciraparantag (or aripazine) is a universal anticoagulant reversal agent that may have a role in all DOACs and heparins. It binds and inactivates all of these agents and it doesn’t appear to have a procoagulant effect. Nachi: Clinical trials for ciraparantag have shown rapid and durable reversal of edoxaban, but further trials and FDA approval are still needed. Jeff: We’ve covered a ton of material so far. As we near the end of this episode, let’s talk disposition. Nachi: First, we have those already on DOACs - I think it goes without saying that any patient who receives pharmacological reversal of coagulopathy for major bleeding needs to be admitted, likely to the ICU. Jeff: Next we have those that we are considering starting a DOAC, for example in someone with newly diagnosed VTE, or patients with an appropriate CHADS-VASC with newly diagnosed non-valvular afib. Nachi: With respect to venous thromboembolism, both dabigatran and edoxaban require a 5 day bridge with heparin, whereas apixaban and rivaroxaban do not. The latter is not only easier on the patient but also offers potential cost savings with low risk of hemorrhagic complications. Jeff: For patients with newly diagnosed DVT / PE, both the American and British Thoracic Society, as well as ACEP, recommend using either the pulmonary embolism severity index, aka PESI, or the simplified PESI or the Hestia criteria to risk stratify patients with PE. The low risk group is potentially appropriate for discharge home on anticoagulation. This strategy reduces hospital days and costs with otherwise similar outcomes - total win all around. Nachi: Definitely a great opportunity for some shared decision making since data here is fairly sparse. This is also a great place to have institutional policies, which could support this practice and also ensure rapid outpatient follow up. Jeff: If you are going to consider ED discharge after starting a DOAC - there isn’t great data supporting one over another. You’ll have to consider patient insurance, cost, dosing schedules, and patient / caregiver preferences. Vitamin K antagonists should also be discussed as there is lots of data to support their safety outcomes, not to mention that they are often far cheaper…. As an interesting aside - I recently diagnosed a DVT/PE in an Amish gentleman who came to the ED by horse - that was some complicated decision making with respect to balancing the potentially prohibitive cost of DOACs with the massive inconvenience of frequently checking INRs after a 5 mile horseback ride into town... Nachi: Nice opportunity for shared decision making… Jeff: Lastly, we have those patients who are higher risk for bleeding. Though I’d personally be quite uneasy in this population, if you are to start a DOAC, consider apixaban or edoxaban, which likely have lower risk of major bleeding. Nachi: So that’s it for the new material for this month’s issue. Certainly, an important topic as the frequency of DOAC use continues to rise given their clear advantages for both patients and providers. However, despite their outpatient ease of use, it definitely complicates our lives in the ED with no easy way to evaluate their anticoagulant effect and costly reversal options. Hopefully all our hospitals have developed or will soon develop guidelines for both managing ongoing bleeding with reversal agents and for collaborative discharges with appropriate follow up resources for those we send home on a DOAC. Jeff: Absolutely. Let’s wrap up with some the highest yield points and clinical pearls Nachi: Dabigatran works by direct thrombin inhibition, whereas rivaroxaban, apixaban, edoxaban, and betrixaban all work by Factor Xa inhibition. Jeff: The DOACs have a much shorter half-life than warfarin. Nachi: Prehospital care providers should ask all patients about their use of anticoagulants. Jeff: Have a low threshold to order a head CT in patients with mild head trauma if they are on DOACs. Nachi: For positive head CT findings or high suspicion of significant injury, order a repeat head CT in 4 to 6 hours and discuss with neurosurgery. Jeff: Have a lower threshold to conduct a FAST exam for blunt abdominal trauma patients on DOACs. Nachi: Assessment of renal function is important with regards to all DOACs. Jeff: While actual plasma concentrations of DOACs can be measured, these do not correspond to bleeding outcomes and should not be ordered routinely. Nachi: The DOACs may cause mild prolongation of PT and PTT. Jeff: Idarucizumab (Praxbind®) is an antibody to dabigatran. For dabigatran reversal, administer two 2.5g IV boluses 15 minutes apart. Reversal is rapid and does not cause prothrombotic effects. Nachi: Recombinant FXa can be used to reverse the FXa inhibitors. This works as a decoy receptor for the FXa agents. Jeff: Vitamin K and FFP are not recommended for reversal of DOACs. Nachi: Consider activated charcoal to remove DOACs ingested within the last two hours in the setting of life-threatening hemorrhages in patient’s on DOACs. Jeff: Hemodialysis can effectively remove dabigatran, but this is not true for the FXa inhibitors. Nachi: 4F-PCC has been shown to be effective in reversing the effects of the FXa inhibitors. This is thought to be due to overwhelming the inhibitor agent by increased concentrations of upstream clotting factors. Jeff: tPA is contraindicated in acute ischemic stroke if a DOAC dose was administered within the last 48 hours, unless certain laboratory testing criteria are met. Nachi: Emergency clinicians should consider initiating DOACs in the ED for patients with new onset nonvalvular atrial fibrillation, DVT, or PE that is in a low-risk group. Jeff: So that wraps up Episode 31! Nachi: As always, additional materials are available on our website for Emergency Medicine Practice subscribers. If you’re not a subscriber, consider joining today. You can find out more at ebmedicine.net/subscribe. Subscribers get in-depth articles on hundreds of emergency medicine topics, concise summaries of the articles, calculators and risk scores, and CME credit. You’ll also get enhanced access to the podcast, including any images and tables mentioned. PA’s and NP’s - make sure to use the code APP4 at checkout to save 50%. Jeff: And the address for this month’s cme credit is www.ebmedicine.net/E0819, so head over there to get your CME credit. As always, the [DING SOUND] you heard throughout the episode corresponds to the answers to the CME questions. Lastly, be sure to find us on iTunes and rate us or leave comments there. You can also email us directly at [email protected] with any comments or suggestions. Talk to you next month!

Show Notes Jeff: Welcome back to EMplify the podcast corollary to EB Medicine’s Emergency Medicine Practice. I’m Jeff Nusbaum and I’m back with Nachi Gupta for the 30th episode of EMplify and the first Post-Ponte Vedra Episode of 2019. I hope everybody enjoyed a fantastic conference. This month, we are sticking in the abdomen for another round of evidence-based medicine, focusing on Emergency Department Management of Patients With Complications of Bariatric Surgery. Nachi: As the obesity epidemic continues to worsen in America, bariatric procedures are becoming more and more common, and this population is one that you will need to be comfortable seeing. Jeff: Thankfully, this month’s author, Dr. Ogunniyi, associate residency director at Harbor-UCLA, is here to help with this month’s evidence-based article. Nachi: And don’t forget Dr. Li of NYU and Dr. Luber of McGovern Medical School, who both played a roll by peer reviewing this article. So let’s dive in, starting with some background. Starting off with some real basics, obesity is defined as a BMI of greater than 30. Jeff: Oh man, already starting with the personal assaults, I see how this is gonna go… Show More v Nachi: Nah! Just some definitions, nothing personal! Jeff: Whatever, back to the article… Obesity is associated with an increased risk of hypertension, hyperlipidemia, and diabetes. Rising levels of obesity and associated co-morbidities also lead to an increase in bariatric procedures, and thereby ED visits! Nachi: One study found a 30-day ED utilization rate of 11% for those undergoing bariatric surgery with an admission rate of 5%. Another study found a 1-year post Roux-en-y ED visit rate of 31% and yet another found that 25% of these patients will require admission within 2 years of surgery. Jeff: Well that’s kind worrisome. Nachi: It sure is, but maybe even more worrisome is the rising prevalence of obesity. While it was < 15% in 1990, by 2016 it reached 40%. That’s almost half of the population. Additionally, back in 2010, it was estimated that 6.6% of the US population had a BMI> 40 – approximately 15.5 million adults!! Jeff: Admittedly, the US numbers look awful, and honestly are awful, but this is a global problem. From the 80’s to 2008, the worldwide prevalence of obesity nearly doubled! Nachi: Luckily, bariatric surgical procedures were invented and honed to the point that they have really shown measurable achievements in sustained weight loss. Along with treating obesity, these procedures have also resulted in an improvement in associated comorbidities like hypertension, diabetes, NAFLD, and dyslipidemia. Jeff: A 2014 study even showed an up to 80% reduction in the likelihood of developing DM2 postoperatively at the 7-year mark. Nachi: Taken all together, the rising rates of obesity and the rising success and availability of bariatric procedures has led to an increased number of bariatric procedures, with 228,000 performed in the US in 2017. Jeff: And while it’s not exactly core EM, we’re going to briefly discuss indications for bariatric surgery, as this is something we don’t often review even in academic training programs. Nachi: According to joint guidelines from the American Society for Metabolic and Bariatric Surgery, the American Association of Clinical Endocrinologists, and The Obesity Society, there are three groups that meet indications for bariatric surgery. The first is patients with a BMI greater than or equal to 40 without coexisting medical problems. The second is patients with a BMI greater than or equal to 35 with at least one obesity related comorbidity such as hypertension, hyperlipidemia, or obstructive sleep apnea. And finally, the third is patient with a BMI of 30-35 with DM or metabolic syndrome though current evidence is limited for this group. Jeff: Based on the obesity numbers, we just cited – it seems like a TON of people should be eligible for these procedures. Which again reiterates why this is such an important topic for us as EM clinicians to be well-versed in. Nachi: As far as types of procedures go – while there are many, there are 3 major ones being done in the US and these are the lap sleeve gastrectomy, Roux-en-Y gastric bypass, and lap adjustable gastric banding. In 2017, these were performed 60%, 18%, and 3% of the time. Jeff: And sadly, no two procedures were created alike and you must familiarize yourself with not only the procedure but also its associated complications. Nachi: So we have a lot to cover! overall, these surgeries are relatively safe with one 2014 review publishing a 10-17% overall complication rate and a perioperative 30 day mortality of less than 1%. Jeff: Before we get into the ED specific treatment guidelines, I think it’s worth discussing the procedures in more detail first. Understanding the surgeries will make understanding the workup, treatment, and disposition in the ED much easier. Nachi: Bariatric procedures can be classified as either restrictive or malabsorptive, with restrictive procedures essentially limiting intake and malabsorptive procedures limiting nutrient absorption. Not surprisingly, combined restrictive and malabsorptive procedures like the Roux-en-y gastric bypass tend to be the most effective. Jeff: Do note, however that 2013 guidelines do not recommend one procedure over another and leave that decision up to local surgical expertise, patient specific risk factors, and treatment goals. Nachi: That’s certainly an important point for the candidate patient. Let’s start by discussing the lap gastric sleeve. In this restrictive procedure, 80% of the greater curvature of the stomach is excised producing early satiety and weight loss from decreased caloric intake. This has been shown to have both low mortality and a low overall rate of complications. Jeff: Next we have the lap adjustable gastric band. This is also a restrictive procedure in which a plastic band is placed laparoscopically around the fundus leaving behind a small pouch that can change in size as the reservoir is inflated and deflated percutaneously. Nachi: Unfortunately this procedure is associated with a relatively high re-operation rate – one study found 20% of patients required removal or revision. Jeff: Even more shockingly, some series showed a 52% repeat operation rate. Nachi: 20-50% chance of removal, revision, or other cause for return to ER - those are some high numbers. Finally, there is the roux-en-y gastric bypass. As we mentioned previously this is both a restrictive and a malabsorptive procedure. In this procedure, the duodenum is separated from the proximal jejunum, and the jejunum is connected to a small gastric pouch. Food therefore transits from a small stomach to the small bowel. This leads to decreased caloric intake and decreased digestion and absorption. Jeff: Those are the main 3 procedures to know about. For the sake of completeness, just be aware that there is also the biliopancreatic diversion with or without a duodenal switch, as well as a vertical banded gastroplasty. The biliopancreatic diversion is used infrequently but is one of the most effective procedure in treating diabetes, though it does have an increased risk of complications. Expect to see this mostly in those with BMIs over 50. Nachi: Now that you have a sense of the procedures, let’s talk complications, both general and specific. Jeff: Of course, it should go without saying that this population is susceptive to all the typical post-operative complications such as venous thromboembolic disease, atelectasis, pneumonia, UTIs, and wound complications. Nachi: Because of their typical comorbidities, CAD and PE are still the leading causes of mortality, especially within the perioperative period. Jeff: Also, be on the lookout for self-harm emergencies as patients with known psychiatric disorders are at increased risk following bariatric surgery. Nachi: Surgical complications are wide ranging and can be grouped into early and late complications. More on this later… Jeff: Nutritional deficiencies are common enough to warrant pre and postoperative screening. Thiamine deficiency is one of the most common deficiencies. This can manifest within 1-3 months of surgery as beriberi or later as Wernicke encephalopathy. Symptoms of beriberi include peripheral neuropathy, ataxia, muscle weakness, high-output heart failure, LE edema, and respiratory distress. Nachi: All of that being said, each specific procedure has it’s own unique set of complications that we should discuss. Let’s start with the sleeve gastrectomy. Jeff: Early complications of sleeve gastrectomy include staple-line leaks, strictures, and hemorrhage. Leakage from the staple line typically presents within the first week, but can present up to 35 days, usually with fevers, tachycardia, abdominal pain, nausea, vomiting sepsis, or peritonitis. This is one of the most serious and dreaded early complications and represents an important cause of morbidity with an incidence of 3-7%. Nachi: Strictures commonly occur at the incisura angularis of the remnant stomach and are usually due to ischemia, leaks, or twisting of the gastric pouch. Patients with strictures usually have n/v, reflux, and intolerance to oral intake. Jeff: Hemorrhage occurs due to erosions at the staple line, resulting in peritonitis, hematemesis, or melena. Nachi: Late complications of sleeve gastrectomies include reflux, which occurs in up to 25% of patients, and strictures, which lead to epigastric discomfort, nausea, and dysphagia. Jeff: I’m getting reflux and massive heartburn just thinking about all of these complications, or the tacos i just ate…. Next we have the Roux-en-Y bypass. Nachi: Early complications of the Roux-en-Y Gastric Bypass include anastomotic or staple line leaks, hemorrhage, early postoperative obstruction, and dumping syndrome. Jeff: Leak incidence ranges from 1-6%, usually occurring at the gastro-jejunostomy site. Patients typically present within the first 10 days with abdominal pain, nausea, vomiting, and the feeling of impending doom. Some may present with isolated tachycardia while others may present with profound sepsis – tachycardia, hypotension, and fever. Nachi: Similar to the sleeve, hemorrhage can occur both intraperitoneally or intraluminally. This may lead to hematemesis or melena depending on the location of bleeding. Jeff: Early obstructions usually occur at either the gastro-jejunal or jejuno-jejunal junction. Depending on the location, patients typically present either within 2 days or in the first few weeks in the case of the gastro-jejunal site. Nachi: If the obstruction occurs in the jejuno-jejunostomy site, this can cause subsequent dilatation of the excluded stomach and lead to perforation, which portends a very poor prognosis. Jeff: Next, we have dumping syndrome. This has been seen in up to 50% of Roux-en-Y patients. Nachi: Early dumping occurs within 10-30 minutes after ingestion. As food rapidly empties from the stomach, this leads to distention and increased contractility, leading to nausea, abdominal pain, bloating, and diarrhea. This usually resolves within 7-12 weeks. Jeff: Moving on to late complications of the roux-en y - first we have marginal ulcers. Peptic ulcer disease and diabetes are risk factors and tobacco use and NSAIDs appear to increase your risk. In the worse case, they present with hematemesis or melena. Nachi: Internal hernias, intussusception, and SBOs are also seen after Roux-en-y gastric bypass. Patients with internal hernias usually present late in the postoperative period following significant weight loss. Jeff: Most studies cite a rate of 1-3% for internal hernias, with mortality up to 50% if there is strangulation. Nachi: And unfortunately for us on the front lines, diagnosis can be challenging. Presenting symptoms may be vague and CT imaging may be negative when patients are pain free, thus laparoscopy may be needed to definitively exclude an internal hernia. Jeff: Strictures may occur both during the early and late period. Most are minor, but significant strictures may result in obstruction. Nachi: Trocar site hernias and ventral hernias are also late complications, usually found after significant weight loss. Jeff: Cholelithiasis is another very common complication of bypass surgery, occurring in up to one third of patients, usually occurring during a peak incidence period between 6-18 months. Nachi: For this reason, the current recommendation is that patients undergoing bypass be placed on ursodeoxycholic acid for 6 months preventatively. Jeff: Some even go as far as to recommend prophylactic cholecystectomy to prevent complications, but as of 2013, the recommendation was only ‘to consider’ it. Nachi: Nutritional deficiencies are also common complications. Vitamin D, B12, Calcium, foate, iron, and thiamine deficiencies are all well documented complications. Patients typically take vitamins postoperatively to prevent such complications. Jeff: And next we have late dumping syndrome, which is far more rare than the last two complications. In late dumping syndrome, 1-3 hours after a meal, patients suffer hypoglycemia from excessive insulin release following the food bolus entering the GI tract. Symptoms are those typical of hypoglycemia. Nachi: Lastly, let’s talk about complications of lap adjustable gastric band surgery. In the early post op period, you can have esophageal and gastric perforations, which typically occur during balloon placement. Patients present with abd pain, n/v, and peritonitis. These patients often require emergent operative intervention. Jeff: The band can also be overtightened resulting in distention of the proximal gastric pouch. Presenting symptoms include abd pain with food and liquid intolerance and vomiting. Symptoms resolves once the balloon is deflated. The band can also slip, allowing the stomach to move upward and within the band. This occurs in up to 22% of patients and can cause strangulation. Presentation is similar to bowel ischemia. Nachi: Later complications include port site infections due to repeated port access. The infection can spread into connector tubing and the peritoneal cavity causing systemic symptoms. Definitely start antibiotics and touch base with the bariatric surgeon. Jeff: The connector can also dislodge or rupture with time. This can present as an arrest in weight loss. It’s diagnosed by contrast injection into the port. Of note, this complication is less common due to changes in the technique used. Nachi: Much like early band slippage and prolapse, patients can also experience late band slippage and prolapse after weeks or months. In extreme cases, the patients can again have strangulation and symptoms of bowel ischemia. More mild cases will present with arrest in weight loss, reflux, and n/v. Jeff: The band can also erode and migrate into the stomach cavity. If this occurs, it usually happens within 2 years of the initial procedure with an incidence of 4-11%. Presenting symptoms here include epigastric pain, bleeding, and infections. You’ll want to obtain emergent imaging if you are concerned. Nachi: And lastly there are two rare complications worth mentioning from any gastric bypass surgery. These are nephrolithiasis, possibly due to increased urinary oxalate excretion or hypocitraturia, and rhabdomyloysis. Jeff: That was a ton of information but certainly valuable as most EM clinicians, even ones in practice for decades, are unlikely to have that depth of knowledge on bariatric surgery. Nachi: And truthfully these patients are complicated. Aside from the pathologies we just discussed, you also have to still bear in mind other abdominal conditions unrelated to their surgery like appendicitis, diverticulitis, pyelo, colitis, hepatitis, pancreatitis, mesenteric ischemia, and GI bleeds. Jeff: Moving on to my favorite - prehospital care - as always, ABCs first. Consider IV access and early IV fluids in those at risk for dehydration and intra-abdominal infections. In terms of destination, if it’s feasible and the patient is stable consider transport directly to the nearest bariatric center - early efforts up front will really expedite patient care. Nachi: Once in the ED, you will want to continue initial stabilization. Special considerations for the airway include a concern for a difficult airway due to body habitus. Make sure to position appropriately and preoxygenate the patients if time allows. Keep the patient upright for as long as possible as they may desaturate quickly when flat. Jeff: We both routinely raise the head of the bed for all of our intubations. This is ever more important for your obese patients to help maximize your chance of first pass success without significant desaturation. Nachi: And though I’m sure we all remember this from residency, it’s worth repeating: tidal volume settings on the ventilator should be based on ideal body weight, not actual body weight. At 6 to 8 mL/kg. Jeff: Tachycardic patients should make you concerned for hypovolemia 2/2 dehydration, sepsis, leaks, and blood loss. Consider performing a RUSH exam (that is rapid ultrasound for shock and hypotension) to identify the cause. A HR > 120 with abdominal pain should make you concerned enough to discuss urgent ex-lap with the surgeon to evaluate for the post op complications we discussed earlier. Nachi: If possible, obtain a view of the IVC also while doing your ultrasound to assess for volume status. But bear in mind that ultrasound will undoubtedly be more difficult if the patient has a large body habitus, so don’t be disappointed if you’re not getting the best views. Jeff: Resuscitation should be aimed at early fluid replacement with IV crystalloids for hypovolemic patients and packed RBC transfusions for patients presumed to be unstable from hemorrhage. No real surprises there for our listeners. Nachi: Once stabilized, gather a thorough history. In addition to the usual questions, ask about po intolerance, early satiety, hematemesis, and hematochezia. Definitely also gather a thorough surgical history including name of procedure, date, known complications post op, and name of the surgeon. Jeff: You might also run into “medical tourism” or global bariatric care. Patients are traveling overseas to get their bariatric care more and more frequently. Accreditation and oversight is variable in different countries and there isn’t a worldwide standard of care. Just an important phenomenon to be aware of in this population. Nachi: On physical exam, be sure to look directly at the belly, making note of any infections especially near a port-site. Given the reorganized anatomy and extent of soft tissue in obese patients, don’t be reassured by a benign exam. Something awful may be happening deeper. Jeff: This naturally brings us into diagnostic testing. Not surprisingly, labs will be helpful in these patients. Make sure to check abdominal labs and a lipase. Abnormal LFTs or lipase may indicate obstruction of the biliopancreatic limb in bypass patients. Nachi: A lactic acid level will help in suspected cases of hypoperfusion from sepsis or bowel ischemia. Jeff: And as we mentioned earlier, these patients are often at risk for ACS given their comorbidities. Be sure to check a troponin if you suspect cardiac ischemia. Nachi: If concerned for sepsis, draw blood cultures, and if concerned for hemorrhage, be sure to send a type and screen. Urinalysis and urine culture should be considered especially for early post op patients, symptomatic patients, or those with GU complaints. Jeff: And don’t forget the urine pregnancy test for women of childbearing age, especially prior to imaging. Nachi: Check an EKG immediately after arrival for any patient that may be concerning for ACS. A normal ekg of course does not rule out a cardiac cause of their presentation. Jeff: As for imaging, plain radiographs certainly play a role here. For patients with respiratory complaints, check a CXR. In the early postoperative period, there is increased risk for pneumonia. Nachi: Unstable patients with abdominal pain will benefit from an emergent abdominal series, which may show free air under the diaphragm, pneumatosis, air-fluid levels, or even dilated loops of bowel. Jeff: Of course don’t forget that intra abd air may be seen after laparoscopic procedures depending on how recently the operation was performed. Nachi: Plain x-ray can also help diagnose malpositioned or slipped gastric bands. But a negative study doesn’t rule out any of these pathologies definitively, given the generally limited sensitivity and specificity of x-ray. Jeff: You might also consider an upper GI series. Emergent uses include diagnosis of slipped or prolapsed gastric bands as well as gastric or esophageal perforations. Urgent indications include diagnosis of strictures. These can also diagnose gastric band erosions and help identify staple-line or anastomotic leaks in stable patients. Nachi: However, upper GI series might not be easy to obtain in the ED, so it’s often not the first test performed. Jeff: This brings us to the workhorse for diagnostic evaluation. The CT. Depending on suspected pathology, oral and/or IV contrast will be helpful. Oral contrast can help identify gastric band erosions, staple-line leaks, and anastomotic leaks. Leaks can be identified in up 86% of cases with oral contrast. Nachi: CT will also help diagnose internal hernias. You might see the swirl sign on CT, which represents swirling of the mesenteric vessels. This is highly predictive of an internal hernia, with a sensitivity of 78-100% and specificity of 80-90% according to at least two studies. Jeff: While CT is extremely helpful in making this diagnosis, note that it may be falsely negative for internal hernias. A retrospective review showed a sensitivity of 76% and a specificity of 60%. It also showed that 22% of patients with an internal hernia on surgical exploration had a negative CT in the ED. Another study found a false negative rate of 32%. What does all this mean? It likely means that a negative study may still necessitate diagnostic laparoscopy to rule out an internal hernia. Nachi: While talking about CT, we should definitely mention CTA for concern of pulmonary embolism. In order to limit contrast exposure, you might consider doing a CTA chest and CT of the abdomen simultaneously. Jeff: Next up is ultrasound. Ultrasound is still the first-line imaging modality for assessing the gallbladder and for biliary tract disease. And as we mentioned previously, ultrasound should be considered for your RUSH exam and for assessing the IVC. Nachi: We also should discuss endoscopy, which is the test of choice for diagnosing gastric band erosions. Endoscopy is also useful for evaluating marginal ulcers, strictures, leaks, and GI bleeds. Endoscopy additionally can be therapeutic for patients. Jeff: When treating these patients, attempt to contact the bariatric surgeon for guidance as needed. This shouldn’t delay imaging however. Nachi: For septic patients, make sure your choice of antibiotics covers intra-abdominal gram-negative and anaerobic organisms. Port-site infections require gram-positive coverage to cover skin flora. Additionally, give IV fluids, blood products, and antiemetics as appropriate. Jeff: Alright, so this month, we also have 2 special populations to discuss. First up, the kids. Nachi: Recent estimates from 2015-2016 put the prevalence of obesity of those 2 years old to 19 years old at about 19%. As obese children are at higher risk for comorbidities later in life and bariatric surgery remains one of the best modalities for sustained weight loss, these surgical procedures are also being done in children. Jeff: Criteria for bariatric surgery in the adolescent population is similar to that of adults and includes a BMI of 35 and major comorbidities (like diabetes or moderate to severe sleep apnea) or patients with a BMI 40 with other comorbidities associated with long term risks like hypertension, dyslipidemia, insulin resistance and impaired quality of life. Nachi: Despite many adolescents meeting criteria, they should be referred with caution as the long term effects are unclear and the adolescent experience is still in its infancy with few pediatric specific programs. Jeff: Still, the complication rate is low - about 2.3% with generally good clinical outcomes including improved quality of life and reducing or staving off comorbidities. Nachi: Women of childbearing age are the next special population. They are at particular risk because of the unique caloric and nutrient needs of a pregnant mother. Jeff: Pregnant women who have had bariatric surgery have an increased risk of perinatal complications including prematurity, small for gestational age status, NICU admission and low Apgar scores. However, these risks come with benefits as other studies have shown reduced incidence of pre-eclampsia, large for gestational age neonates, and gestational diabetes. Nachi: 2013 guidelines from various organizations recommend avoiding becoming pregnant for at least 12-18 months postoperatively, with ACOG recommending a minimum of 2 years. Bariatric surgery patients who do become pregnant require serial monitoring for fetal growth and higher doses of supplemental folate. Jeff: We also have 2 pretty cool cutting edge techniques to mention this month before getting to disposition. Nachi: Though these are certainly not going to be done in the ED, you should be aware of two new techniques. Recently, the FDA approved 3 new endoscopic gastric balloon procedures in which a balloon is inflated in the stomach as a means of simulating a restrictive procedure. Complications include perforation, ulceration, GI bleeding, and migration with obstruction. As of now, they are only approved as a temporary modality for up to 6 months. Jeff: And we also have the AspireAssist siphon, which was approved in 2016. With the siphon, a g tube is placed in the stomach, and then ⅓ of the stomach contents is drained 20 minutes after meals, thus limiting overall digested intake. Nachi: Pretty cool stuff... Jeff: Yup - In terms of disposition, decisions should often be made in conjunction with the bariatric surgical team. Urgent and occasionally emergent surgery is required for those with hemodynamic instability, anastomotic or staple line leaks, SBO, acute band slippage with dilatation of the gastric pouch, tight gastric bands, and infected port sites with concurrent intra abdominal infections. Nachi: And while general surgeons should be well-versed in these complications should the patient require an emergent surgery, it is often best to stabilize and consider transfer to your local bariatric specialty facility. Jeff: In addition to the need for admission for surgical procedures, admission should also be considered in those with dehydration and electrolyte disturbances, those with persistent vomiting, those with GI bleeding requiring transfusions, those with acute cholecystitis or choledococholithiasis, and those with malnutrition. Nachi: Finally, patients with chronic strictures, marginal ulcers, asymptomatic trocar or ventral hernias, and stable gastric band erosions can usually be safely discharged after an appropriate conversation with the patient’s bariatric surgeon. Jeff: Definitely a great time to do some joint decision making with the patient and their surgeon. Nachi: Exactly. Let’s close out with some Key points and clinical pearls. Jeff: Bariatric surgeries are being performed more frequently due to both their success in sustained weight loss and improvements in associated comorbidities. Nachi: There is an increased risk of postoperative myocardial infarction and pulmonary embolism after bariatric surgery. There is also an increased risk of self-harm emergencies after bariatric surgery, mostly in patients with known psychiatric co-morbidities. Jeff: Nutritional deficiencies can occur following bariatric surgery, with thiamine deficiency being one of the most common. Look for signs of beriberi or even Wernicke encephalopathy. Nachi: Staple-line leaks are an important cause of postoperative morbidity. Patients often present with abdominal pain, vomiting, sepsis, and peritonitis. Jeff: Strictures can also present postoperatively and cause reflux, epigastric discomfort, and vomiting. Nachi: Intraperitoneal or intraluminal hemorrhage is a known complication of bariatric surgery and may present as peritonitis or with hematemesis and melena. Jeff: After significant weight loss, internal hernias with our without features of strangulation are a late complication. Nachi: Late dumping syndrome is a rare complication following Roux-en-Y bypass occurring months to years postoperatively. It presents with hypoglycemia due to excessive insulin release. Jeff: Esophageal or gastric perforation are early complications of adjustable gastric band surgery. These patients require emergent surgical intervention. Nachi: Overtightening of the gastric band results in food and liquid intolerance. This resolves once the balloon is deflated. Jeff: Late complications of gastric band surgery include port-site infections, connector tubing dislodgement or rupture, band slippage or prolapse, and band erosion with intragastric migration. Nachi: Given the myriad of possible bariatric surgeries, emergency clinicians should be cognizant of procedure-specific complications. Jeff: Consider obtaining a lactic acid level for cases of suspected bowel ischemia or sepsis. Nachi: Endoscopy is the best method for diagnosing and treating gastric band erosions. Jeff: Septic patients should be treated with antibiotics that cover gram-negative and anaerobic organisms. Suspected port site or wound infections require gram positive coverage. Nachi: Pregnant patients who previously had bariatric surgery are at risk for complications from their prior surgery as well as pregnancy-related pathology. Jeff: A plain radiograph may be useful in unstable patients to evaluate for free air under the diaphragm, pneumatosis, air-fluid levels, or dilated loops of bowel. Nachi: CT of the abdomen and pelvis is the mainstay for evaluation. Oral and/or IV contrast should be considered depending on the suspected pathology. Jeff: Have a low threshold for emergent surgical consultation for ill-appearing, unstable, or peritonitic patients. Nachi: So that wraps up Episode 30! Jeff: As always, additional materials are available on our website for Emergency Medicine Practice subscribers. If you’re not a subscriber, consider joining today. You can find out more at ebmedicine.net/subscribe. Subscribers get in-depth articles on hundreds of emergency medicine topics, concise summaries of the articles, calculators and risk scores, and CME credit. You’ll also get enhanced access to the podcast, including any images and tables mentioned. PA’s and NP’s - make sure to use the code APP4 at checkout to save 50%. Nachi: And the address for this month’s cme credit is ebmedicine.net/E0719, so head over there to get your CME credit. As always, the [DING SOUND] you heard throughout the episode corresponds to the answers to the CME questions. Lastly, be sure to find us on iTunes and rate us or leave comments there. You can also email us directly at [email protected] with any comments or suggestions. Talk to you next month! Most Important References Altieri MS, Wright B, Peredo A, et al. Common weight loss procedures and their complications. Am J Emerg Med. 2018;36(3):475-479. (Review article) Colquitt JL, Pickett K, Loveman E, et al. Surgery for weight loss in adults. Cochrane Database Syst Rev. 2014(8):CD003641. (Cochrane review; 22 trials) Mechanick JI, Youdim A, Jones DB, et al. Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient—2013 update: cosponsored by American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery. Obesity (Silver Spring). 2013;21 Suppl 1:S1-S27. (Society practice guidelines) Phillips BT, Shikora SA. The history of metabolic and bariatric surgery: development of standards for patient safety and efficacy. Metabolism. 2018;79:97-107. (Review article) Contival N, Menahem B, Gautier T, et al. Guiding the nonbariatric surgeon through complications of bariatric surgery. J Visc Surg. 2018;155(1):27-40. (Review article) Parrott J, Frank L, Rabena R, et al. American Society for Metabolic and Bariatric Surgery integrated health nutritional guidelines for the surgical weight loss patient, 2016 update: micronutrients. Surg Obes Relat Dis. 2017;13(5):727-741. (Society practice guidelines) Chousleb E, Chousleb A. Management of post-bariatric surgery emergencies. J Gastrointest Surg. 2017;21(11):1946-1953. (Review article) Goudsmedt F, Deylgat B, Coenegrachts K, et al. Internal hernia after laparoscopic Roux-en-Y gastric bypass: a correlation between radiological and operative findings. Obes Surg. 2015;25(4):622-627. (Retrospective review; 7328 patients) Michalsky M, Reichard K, Inge T, et al. ASMBS pediatric committee best practice guidelines. Surg Obes Relat Dis. 2012;8(1):1-7. (Society practice guidelines)

Show Notes Jeff: Welcome back to EMplify the podcast corollary to EB Medicine’s Emergency medicine Practice. I’m Jeff Nusbaum and I’m back with Nachi Gupta for your regularly scheduled monthly dose of evidence based medicine. This month, we are tackling an incredibly important topic – Assessing abdominal pain in adults, a rational, cost effective, and evidence-based strategy. Nachi: This incredibly important topic was chosen to mark the 20th anniversary of Emergency Medicine Practice. It is actually a revision of the first issue of Emergency Medicine Practice in 1999, now with updated evidence and recommendations. Thanks Robert Williford and Dr. Colucciello for getting this all started 2 decades ago! Jeff: Wow – 20 years – that’s amazing considering Emergency Medicine as a specialty hadn’t even been around all that long at the time and as Dr. Jagoda writes in his intro “evidence based education was still finding its footing.” Nachi: As a tribute to the man who started it all, EB Medicine again turned to Dr. Colucciello, who is no longer wearing his editor in chief hat, but instead is a professor at the University of North Carolina School of Medicine, to update his original article with the latest evidence. Jeff: Before we dive into the meat and potatoes of this month’s issue, let me also recognize Drs. Taylor and Shaukat of Emory and Coney Island Hospital respectively for their efforts in peer reviewing this huge topic. Show More v Nachi: For a number of reasons, this month is going to be a little different. You will notice that we will focus more on safe disposition instead of on diagnosis. Which is reasonable, as that is the crux of our job as emergency physicians. Jeff: Indeed. So for those of you who can’t wait, here’s a quick spoiler, The CBC isn’t all that useful. CT is good but you really should learn ultrasound, and lastly, sick patients need prompt consultation and resuscitation, not rapid trips to radiology. Nachi: All valid points, but let’s dive in too some actual detail. Jeff: Abdominal pain is the one of most frequent complaint in US emergency departments, representing 8% of all adult ED visits, with admission rates for all patients with abdominal pain ranging between 18-42% and reaching as high as 60% for the elderly. Nachi: With respect to the elderly, statistically speaking, 20% presenting with abdominal pain will undergo surgery, and 5% will die. Jeff: Often the etiology of the abdominal pain is never determined. This happens up to 40% of the time by the end of the ED visit. Nachi: I feel like that needs to be restated for emphasis – nearly half of patients who present to the ED with abdominal pain will have no determined etiology for their pain. Clearly, that doesn’t mean you are a bad ED physician – it’s just the way it goes. Jeff: Definitely still a win to be told you aren’t having an intra-abdominal catastrophe at the end of your visit! Nachi: Moving on to pathophysiology. Visceral pain results from distention or inflammation of the hollow organs or from ischemia from any internal organ, while the more localized, somatic pain is typically from irritation of the adjacent peritoneum. Jeff: And don’t forget about referred pain. Due to the movement of organs and stretching of nerve pathways during fetal development, pain may be referred to distant sites, like diaphragmatic irritation presenting as shoulder pain. Nachi: Let’s talk differential diagnosis. The differential for abdominal pain is tremendously broad and includes both intra-abdominal and extra abdominal pathologies. Check out table 2 for a very thorough list. Jeff: Table 1 is also worth reviewing while you’re on page 3 as it lists a few of the common dangerous mimics that often lead to misdiagnosis on initial presentation. To highlight a few – a AAA can masquerade as renal colic, diverticulitis, or a lumbar strain; an ectopic may present similar to PID, a UTI, or a corpus luteum cyst, and mesenteric ischemia may present shockingly similar to gastroenteritis, constipation, ileus, or an SBO. Nachi: Though misdiagnosis is certainly possible at any age, one must be particularly cautious with the elderly. Abdominal pain in the elderly is complicated by a number of factors, they often have no fever, no leukocytosis, or no localized tenderness despite surgical disease, surgical problems progress more rapidly, and lastly, they are at risk for vascular catastrophes, which don’t typically afflict the younger population Jeff: Dr. Colucciello closes the section on the elderly with a really thought-provoking point – we routinely admit 75 year old with chest pain and benign exams, yet we readily discharge a 75 year old with abdominal pain and a benign exam even though the morbidity and mortality of abdominal pain in this group exceeds that of the chest pain group. Nachi: That’s an interesting perspective, but we still have to think about this in the context of what an admission would offer in either of these cases. Most of the testing for abdominal pain can be done in the ED, CT being the workhorse. This point certainly merits more thought though. Jeff: Most clinicians have a low threshold to scan their elderly patients with abdominal pain, and the data behind this practice is quite compelling. In one study, CT altered the admission decision in 26%, need for surgery in 12%, the need for antibiotics in 21%, and changed the suspected diagnosis in 45%. Nachi: That latter figure, 45% change in suspected diagnosis, that was also confirmed in another study in which CT revealed a clinically unsuspected diagnosis in 43% of the elderly. Jeff: And it’s worth mentioning, that even though CT may be the go-to-tool - biliary tract disease, which we know is best visualized on ultrasound, is actually the most common cause of abdominal pain, especially sudden onset abdominal pain in the elderly. Nachi: The next higher risk group to discuss are patients with HIV. While anti retroviral therapy has certainly decreased the burden of opportunistic infections, don’t forget to keep a broader differential in this group including bacterial enterocolitis, drug-induced pancreatitis, or AIDS related cholangiopathy Jeff: Definitely make sure to check to see if the patient has a recent CD4 count to give you a sense of their disease and what they may be at risk for. At less than 200, cryptosporidium, isospora, cyclospora, and microsporidium all make their way onto the differential in addition to the standard players. Nachi: For more information on HIV and its management, check out the February 2016 issue of Emergency Medicine Practice, which covered this and more in depth. Jeff: The next high risk population we are going to discuss are women of childbearing age. Step one is always the same - diagnose pregnancy! Always get a pregnancy test for women between menarche and menopause. Nachi: The pregnancy test is important not only for diagnosing an intrauterine pregnancy, but it’s also a reminder, that we need to consider and rule out an ectopic. Jeff: Along similar lines, you also need to consider torsion, especially in your pregnant population, as 20% of cases of ovarian torsion occur during pregnancy. Nachi: Unfortunately, you cannot rely on the physical exam alone in this age group, as the pelvic exam may be misleading. Up to a quarter of women with appendicitis can exhibit cervical motion tenderness -- a finding typically associated with PID. Sadly, errors are common and ⅓ of women of childbearing age who ultimately were found to have appendicitis were initially misdiagnosed. Jeff: To help reduce your risk in the pregnant population, consider imaging, particularly with radiation reduction strategies, including using ultrasound and MRI, which is gaining favor in the diagnosis of appendicitis in pregnancy. Nachi: Diagnosis of appendicitis, in a pregnant patient, ultrasound vs. mri. Sounds familiar. Didn’t we just talk about this in Episode 24 back in January? Jeff: We sure did! Take another listen if that doesn’t ring a bell. Nachi: That was focused on first trimester only, but while we’re talking about appendicitis in pregnancy - keep in mind that during the second half of pregnancy, the appendix has moved out of the RLQ and is more likely to be found in the RUQ. Jeff: As yes, the classic RUQ appendix. As if our jobs weren’t hard enough, now anatomy is changing… Anyway, the last high risk group we are going to discuss here are those patients with prior abdominal surgery. Make sure to ALWAYS examine the patient's exposed skin to look for scars. Adhesions are the leading cause of SBOs in the industrialized world, followed by malignancy, IBS, and internal or external hernias. Nachi: Also keep a high index of suspicion for patients who have undergone bariatric surgery. They are especially prone to surgical causes of abdominal pain including skin infections and surgical leaks. Jeff: For this reason, CT imaging should be done with IV and oral contrast, with those having undergone a Roux-en-Y receiving oral contrast on the CT table. Nachi: Perfect. Let’s move on to evaluation once in the ED! Jeff: As we mentioned a few times already - diagnosis is difficult, a comparison of initial and final diagnosis only has about 50-65% accuracy. For this reason, Dr. C suggests taking a ‘worst first’ approach to forming your differential and guiding your workup. Nachi: And as a brief aside, before we continue… Missed appendicitis is one of the three most common causes of emergency medicine malpractice lawsuits - with MI and fractures being the other two. That being said, you, as a clinician, have either missed appendicitis or likely will in the future. In a study of cases of misdiagnosed appendicitis brought to litigation, several themes recurred. For example, patients with misdiagnosed disease has less RLQ pain and tenderness as well as diminished anorexia, nausea, and vomiting. Jeff: Well that’s scary - I know I’ve already missed a case, but luckily, he returned thanks to good return precautions, which we’ll get to in a few minutes. Also, note that in addition to imaging and the physical exam, history is often the key to uncovering the cause of abdominal pain. Nachi: Not to harp on litigation, but in malpractice cases brought up for failure to diagnose abdominal conditions, deficiencies in data gathering and charting were often to blame rather than misinterpretation of data. Jeff: As no shocker here, getting a complete history remains tremendously important in your practice as an emergency clinician. A recurring theme of EMplify for sure. Nachi: In order to really nail this down, consider using a standardized history form -- or memorizing one. An example is shown in Table 1. Standardized forms have been shown to improve patient satisfaction and diagnostic accuracy. Jeff: An interesting question for your abdominal pain patient is to ask about the ride to the hospital. Experiencing pain going over a speed bump has been shown to be about 97% sensitive and 30% specific for appendicitis. So fairly sensitive, but not too specific. Nachi: That’s interesting and may help guide you, but it’s certainly no replacement for CT. And remember that you can have stump appendicitis. This can occur in the appendiceal remnant after an appendectomy and is found in about 0.15% of all appendectomies. Jeff: Alright, so on to the physical exam. Like always, let’s start with vital signs. An elevated temp can be associated with intra abdominal infection, but sensitivity and specificity vary greatly here. Always consider a rectal temp, as these are generally more reliable. Nachi: And remember that hypothermic patients who are septic have worse outcomes than those who are hyperthermic and septic. Jeff: Elevated respiratory rate can be due to pain or subdiaphragmatic irritation. However, it can also be due to hypoxia, sepsis, anemia, PE, or metabolic acidosis, so consider all of those also in your differential. Nachi: Moving on to blood pressure: frank hypotension should make you immediately think of a ruptured AAA or septic shock 2/2 an intra abd infection. You can also use the shock index, which as a reminder is simply the HR/SBP. In one study, a SI > 0.7 was sensitive for 28-day mortality in sepsis. Jeff: Speaking of HR, tachycardia can be a response to pain, anxiety, fever, blood loss, or sepsis. An irregularly irregular rhythm -- or a fib -- is an important risk factor for mesenteric ischemia in elderly patients. This is important to consider in your differential early as it may guide your imaging modality. Nachi: With vitals done, we can move on to the abdominal exam - it is rare that a serious abdominal condition will present without tenderness in a young adult patient, but remember that the elderly patient may not present with much tenderness at all due decreased peritoneal sensitivity. Abdominal tenderness that is greatest when the abdominal muscles are contracted is likely due to abdominal wall pain. This can be elicited by having the patient lift their head or let their legs off the bed. This finding is known as Carnett sign and is about 95% accurate for distinguishing abdominal wall pain from visceral abdominal pain. Jeff: Though tenderness itself is helpful, the location of tenderness can be misleading. Note that while 80% of patients with appendicitis have RLQ tenderness, 20% don’t. The old 80-20 rule! So definitely don’t let RLQ tenderness be your sole guide! Nachi: Voluntary guarding is due to fear, anxiety, or even a reaction to a clinician’s cold hands. Involuntary guarding (also called rigidity) is more likely to occur with surgical disease. Remember that rigidity may be a less common finding in the elderly despite surgical disease. Jeff: Peritoneal signs are the true hallmark of surgical disease. These include rebound pain, pain with coughing, pain with shaking the stretcher or pain with striking the patient’s heel. Rebound historically has been thought to be pathognomonic for surgical disease, but recent literature hasn’t found it to be all that useful, with one study claiming it has no predictive value. Nachi: As an alternative, consider the “cough test”. Look for evidence of posttussive abd pain (like grimacing, flinching, or grabbing the belly). Studies have found the cough sign to be 80-95% sensitive for peritonitis. Jeff: In terms of other sings elicited during the abdominal exam: The murphy sign, ruq palpation that causes the patient to stop a deep inspiration -- in one study had a sensitivity of 97%, but a specificity of just under 50%. The psoas sign, pain elicited by extending the RLE towards the back while the patient lies on their left side -- in one study had a specificity of 95%, but only had a sensitivity of 16%. Nachi: Neither the obturator sign (pain with internal rotation of the flexed hip) nor the rosving sign (pain in the RLQ by palpating the LLQ) have been rigorously studied. Jeff: Moving a bit further south, from the abdomen to the pelvis - let’s talk about the pelvic exam. Most EM training programs certainly emphasize the importance of the the pelvic exam for women with lower abdominal pain, but some recent papers have questioned its role. A 2018 study involving 288 women 14-20 years old found that the pelvic didn’t increase sensitivity or specificity of diagnosis of chlamydia, gonorrhea, or trichomoniasis when compared with history alone. Another study questioned whether the pelvic exam can be omitted in these patients with an early intrauterine pregnancy confirmed on ultrasound, but it was unable to reach a conclusion, possibly due to insufficient power. Nachi: While Jeff and I do find it valuable to elicit as much as information from the history as possible and take value in the possibility of omitting the pelvic in certain cases in the future, given the current evidence based medicine, we both agree with the author here. Don’t abandon the pelvic for these patients just yet! Jeff: While on this topic, we should also briefly mention a reminder about fitz-hugh-curtis syndrome, perihepatic inflammation associated with PID. Nachi: As for the digital rectal exam, this can certainly be of use when considering and diagnosing prostatitis, perirectal disease, stool impactions, rectal foreign bodies, and gi bleeds. Jeff: And let’s not forget the often overlooked scrotal and testicular exam. In men with abdominal or flank pain, this should always be considered. Testicular torsion often presents with isolated abdominal or flank pain. The scrotal exam will help diagnose inguinal and scrotal hernias. Nachi: Getting back to malpractice case reviews for a minute --- in a 2018 review involving testicular torsion, almost ⅓ of the patients with missed torsion had presented with abdominal pain --- not scrotal pain! In ⅕ of the cases, no testicular exam was performed at all. Also, most cases of missed torsion occured in patients under 25 years old. Jeff: Speaking of torsion, about 6% occur over the age of 31, so have an increased concern for this in the young. Of course, if concerned for torsion, consult urology immediately and consider manual detorsion. Nachi: And if you, like me, were taught to manually detorse by rotating in the lateral or open book direction, keep in mind that in a study of 200 males with torsion, ⅓ had rotated laterally, not medially. Jeff: Great point. And one last quick point here. Especially if you are unsure about the diagnosis, make sure to perform serial exams both in the ED and also in the next few days at their PCP’s office. In one study, a 30 hour later repeat exam for patients discharged with nonspecific abdominal pain resulted in a clinically relevant change in diagnosis and therapy in almost 25% of patients. Nachi: So that wraps up the physical. Let’s get into diagnostic studies, starting with lab work and everybody’s favorite topic... the cbc. Jeff: Yup, just the other day I was asked by a consultant “what’s the white count.” in a patient with CT proven appendicitis. Man, a small part of my soul dies every time this happens. Nachi: It appears you must have an evidenced based soul then. According to a few studies, anywhere from 10-60% of patients with surgically proven appendicitis have an initially normal WBC. So in some studies, it’s even worse than a coin flip. Jeff: Even worse, in children the CBC is less helpful. In children, an elevated WBC detects a mere 53% of severe abdominal pathology - so again not all that helpful. Nachi: That being said, at the other end of the spectrum, in the elderly, an elevated WBC may imply serious disease. Jeff: So let’s make this perfectly clear. A normal WBC should not be reassuring, but an elevated WBC, especially in the elderly, should be very concerning. Nachi: The CRP is up next. Though not used frequently, it’s still worth mentioning, as there is a host of data on it in the setting of abdominal pain. In one meta analysis, CRP was approximately 62% sensitive and 66% specific for appendicitis. Jeff: And while lower levels of CRP do not rule out positive findings, increasing levels of CRP do predict, with increasing likelihood, the chances of positive findings. Nachi: Next we have lipase and amylase. The serum lipase is the best test for suspected pancreatitis. The amylase adds limited value and should not be routinely ordered. Jeff: As for the lactate. The greatest value of a lactate level is to detect occult shock and sepsis. It is also useful to screen for visceral ischemia. Nachi: And the last lab test we’ll discuss is the UA. The urinalysis is a potentially misleading test. In two studies, 20-30% of patients with appendicitis also had hematuria with leukocytes and bacteria on their UA. In a separate study of those with a AAA, there was an 87% incidence of hematuria. Jeff: That’s pretty troubling. Definitely not great to diagnosis someone with hematuria and a primary GU problem, when their aorta is actually exploding. Nachi: And that’s a great reminder to always avoid premature diagnostic closure. Jeff: Also worth mentioning is that not all ureteral stones present with hematuria. At least 6% have no hematuria on microscopy. Nachi: Alright, so that brings us to imaging. First up: plain films. I’m going to quote this directly from the article since I think it's so important, ‘never rely on plain films to exclude surgical disease.” Jeff: This statement is certainly evidence based as in one study 40% of x-ray findings were inconsistent with the final diagnosis. In another study, 43% of patients with major surgical disorders had either normal or misleading plain film results. So again, the take home here is that XR cannot rule out surgical disease, and should not be routinely ordered except for in specific settings. Nachi: And perhaps the most important of all those settings is in the setting of possible free air under the diaphragm. In this case, an upright chest visualizing the area under the diaphragm would be the test of choice. But again, even this doesn’t rule out surgical disease as free air may be absent on plain films in ⅓ to ½ of patients who have already perfed. Jeff: Next we have everybody’s favorite, the ultrasound. Because of it’s low cost and ease of use, bedside ultrasound is gaining traction. And we’ve cited this and other similar studies in other issues, this is a skill emergency medicine physicians must have in this day and age and it’s a skill they can learn quickly. Nachi: Ultrasound can visualize most solid organs, but it is best suited for the Right upper quadrant and pelvis. In the RUQ, we are looking for wall thickening, pericholecystic fluid, ductal dilatation, and sonographic murphys sign. Jeff: In the pelvis, there is a role for both transabdominal and transvaginal to rule out ectopic and potentially rule in intrauterine pregnancy. I know the thought of performing your own transvaginal ultrasound may sound crazy to some, but we both trained in places where ED TVUS was the norm and certainly wasn’t that hard to learn. Nachi: Ah, the good old days of residency. I’m certainly grateful for the US tech where I am now though! Next up we have CT. CT scans are ordered in just under 30% of patients with abdominal pain. Jeff: It’s worth noting, that while many used to scan with triple contrast - oral, rectal and IV, recent literature has shown that IV contrast alone is adequate for the diagnosis of most surgical conditions, including appendicitis. Nachi: If you’re still working in a shop that scans for RLQ pain with oral or rectal contrast, definitely check out the 2018 american college of radiology appropriateness criteria that states that IV contrast is generally appropriate for assessing the RL. Jeff: And while we are on the topic of contrast, let’s dive a bit deeper into the, perhaps myth, that contrast leads to contrast induced nephropathy. Nachi: This is another really important point. Current data show that being ill enough to be admitted to the hospital is a risk factor for acute kidney injury and that IV contrast for CT does not add to that risk. In 2015, the american college of radiology noted in their manual on contrast media that the concern for the development of contrast induced nephropathy is not an absolute contraindication for using IV contrast. IV contrast may be necessary regardless of the risk of nephrotoxicity in certain clinical situations. Jeff: Ok, so contrast induced nephropathy may be real, but more studies and a definitive statement are still needed. Regardless, if the patient is sick and they need the scan with contrast, don’t hold back. Nachi: I think that’s a fair take home. As another note about the elderly, CT should be almost routine in the elderly patient with acute abdominal pain as it improves accuracy, optimizes appropriate hospitalization, and boosts ED management decision making confidence for this patient group. Jeff: If they are over 65, make sure you chart very carefully why they don’t need a scan. Nachi: Speaking of not needing a scan, two quick caveats on CT before moving to MRI. Unstable patients do not belong in a radiology suite - they belong in the ED resus bay to be resuscitated first. Prompt surgical consultation and bedside ultrasound if indicated are both a must in unstable patients. Jeff: The second caveat is on the other end of the spectrum - not all CT scanning is created equally - the interpretation depends on the scanner, the quality of the scan, and the experience and training of the reading radiologist. In one study, nearly 13% of abdominal CT scans may initially be misread. Nachi: So if you’re concerned, consider consultation or an extended ED observation to monitor for any changes in the patient’s status. Jeff: Next up is MRI - MRI has an ever expanding role in the ED. The accuracy of MRI to diagnose appendicitis is very similar to CT, so consider it in all pregnant patients, though ultrasound is still considered first line. Nachi: And finally let’s touch upon the ekg and ACS. In patients over 40 with upper abdominal pain, an EKG and troponin should always be considered. Jeff: Don’t be reassured by a response to a GI cocktail either - this does not exclude myocardial ischemia. Nachi: Next, let’s talk the role of analgesia in treating the undifferentiated abdominal pain patient. Jeff: While there was formerly a concern of ‘masking the pain’ with opiates, the evidence says otherwise. Pain medicine may even aid in the diagnosis, so definitely don’t withhold it in the setting of acute abdominal pain. Nachi: Wait I get that masking the pain is no longer considered a concern, but how would it aid in the diagnosis? Jeff: Good question. Analgesics might facilitate the gathering of history and allow a more complete physical exam by relaxing the abdominal musculature. Nachi: Ahh that makes sense. So certainly treat pain! Both morphine at 0.1 mg/kg and fentanyl at 1 mic/kg are appropriate analgesics for acute abdominal pain. In those that are a difficult stick, a recent study showed that 2 micrograms/kg of fentanyl via a nebulizer was a safe alternative. Remember, fentanyl is quick on, quick off, which may make it desirable in certain situations. It actually has the shortest time of onset of any opioid. It’s also safer in patients with a “marginal” blood pressure. Jeff: And just like the GI cocktail - response to opiate analgesics does not exclude serious pathology. These patients need serial exams and likely labs and imaging if their pain is so severe. Nachi: Few things are more important prior to discharge of an abdominal pain patient than documenting repeat exams and a PO trial. Jeff: True. You should also consider haloperidol for patients with gastroparesis and cannabinoid hyperemesis as a growing body of literature supports its use in such settings. Check out the August 2018 EMP or EMplify for more details if you’re curious. Nachi: The last analgesic to discuss is our good friend ketamine. Low dose ketamine at 0.3 mg/kg over 15 minutes is gaining traction as the analgesic of choice in many ED’s. Jeff: The key there, is that it must be given over 15 minutes. Ketamine has a great safety profile, but you make it so much safer and a much better experience if you give it slowly. Nachi: Before we get to disposition, let’s talk controversies and cutting edge - and there is just one this month - and that’s the use of the Alvarado score. Jeff: In the Alvarado score, you get two points for RLQ tenderness and 2 points for a leukocytosis over 10,000. You get an additional point for all of the following; rebound, temp over 99.1, migration of pain to the RLQ, anorexia, n/v, and a left shift. The max score is therefore 10. A score of 3 or less make appendicitis unlikely, 4-6 warrants CT imaging, and 7 or more a surgical consultation. Nachi: A 2007 study suggests that using the Alvarado score along with bedside ultrasound might allow for rapid and inexpensive diagnosis of appendicitis. Jeff: I don’t think we should change practice based on this just yet, but more ultrasound diagnosis may be on the horizon. If you want to start using the Alvarado score in your practice, MDcalc has a great easy to use calculator. Nachi: Let’s get to the final section. Disposition! Jeff: As we mentioned at the beginning of this episode, the diagnosis is less important than proper disposition. For patients with suspected ruptured AAA, torsion, or mesenteric ischemia - the disposition is easy - they need immediate surgical consultation and likely operative intervention. Nachi: For others, use the tools we outlined above - ct, us, labs, etc, to help support your decision. Keep in mind, that serial exams are a great tool and of little expense - so make sure to lay your hands on the patient's abdomen frequently, especially when the diagnosis is unclear. Jeff: For those that look well after a work up, with no clear diagnosis, it may be reasonable to discharge them home with prompt follow up, assuming prompt follow up is plausible. The key here is that these patients need good discharge instructions. Check out figure 2 on page 20 for a sample discharge template. Nachi: But if the patient is still uncomfortable, even after a thorough workup, there may be a role for ED observation units. In one study of 220 patients admitted for to ED obs units for serial exams, 39% eventually underwent surgery with only 5% having negative laparotomies. Jeff: This month’s issue wraps up with some super important time and cost effective strategies, so let’s see if we can quickly breeze through some of the most important points before closing out this episode. Nachi: First - limit your abdominal x-rays as they offer limited value and are rarely helpful except in the setting of perforation, when an early upright chest film should be used liberally. Jeff: Next - limit electrolyte testing especially in young adults with nausea, vomiting and diarrhea. In those 18 to 60, clinically significant electrolyte abnormalities occur in only 1% of those with gastro. Nachi: With respect to urine testing, urine cultures are rarely indicated for uncomplicated cystitis in young women. Along similar lines, don’t anchor on the diagnosis of UTI as other lower abdominal conditions often lead to abnomal urine studies. Jeff: In your alcoholic patients, although all should be approached with an abundance of caution, limit testing to repeat abdominal exams in your non-toxic appearing patient who is already tolerating PO. Nachi: For those with suspected renal colic, especially those with a history of renal colic, limit CT use and instead consider ultrasound to look for hydro. This approach is endorsed by ACEPs choosing wisely campaign. Jeff: But as a reminder, this is for low risk patients only. Anyone with signs of infection should also undergo CT imaging. Nachi: And lastly - consider incorporating bedside US into your routine. The US is fast and accurate and compares similarly to radiology, especially in the context of detecting acute cholecystitis. Jeff: Alright, so that wraps up the new material for this episode, let’s close out with some key points and clinical pearls. The peritoneum becomes less sensitive with aging, and peritonitis can be a late or absent finding. Be wary of early diagnostic closure and misdiagnosis with a mimic of a more severe and dangerous pathology. The elderly, immunocompromised, women of childbearing age, and patients with prior abdominal surgeries are all at a higher risk for misdiagnosis. Elderly patients can present without fever, leukocytosis, or abdominal tenderness, but still have surgical abdominal pathology. Consider diagnostic imaging in all geriatric patients presenting with abdominal pain. Consider plain film if you suspect a viscus perforation or for certain foreign body ingestions. Do not forget the pelvic exam, testicular exam, and rectal exam as part of your physical, when appropriate. Testicular torsion can present with abdominal pain only. If suspected, consult urology and consider manual detorsion. A normal white blood cell count does not rule out appendicitis or other intra-abdominal pathology. Serum amylase should not be used in your assessment of the abdominal pain patient. Lack of microscopic hematuria does not rule out renal colic. CT of the abdomen with IV contrast alone is enough for most surgical conditions including appendicitis. Oral and rectal contrast does not need to be routinely administered. The 2018 American College of Radiology (ACR) Appropriateness Criteria discuss concern for delay in diagnosis associated with oral contrast use and an increased rate of perforation. There is recent literature to support that IV contrast does not cause nephropathy. The ACR 2015 Manual on Contrast Media states that concern for contrast induced nephropathy is not an absolute contraindication, and IV contrast may be necessary in many situations. Ultrasound can be used to evaluate the aorta, gallbladder, kidneys, appendix, bowel, spleen, pancreas, uterus, and ovaries. Consider bedside ultrasound and emergency surgical consult for all unstable patients with abdominal pain. For stable pregnant patients with concern for appendicitis, start with an ultrasound. If inconclusive, order an MRI. Epigastric pain in an elderly patient should raise concern for ACS. An EKG and troponin should be considered. For analgesia in patients with gastroparesis or cannabinoid hyperemesis syndrome, haloperidol is considered first-line. Low-dose ketamine (0.3mg/kg over 15 minutes) may be a better choice than opiate analgesia for abdominal pain. Nachi: So that wraps up Episode 29! Jeff: As always, additional materials are available on our website for Emergency Medicine Practice subscribers. If you’re not a subscriber, consider joining today. You can find out more at ebmedicine.net/subscribe. Subscribers get in-depth articles on hundreds of emergency medicine topics, concise summaries of the articles, calculators and risk scores, and CME credit. You’ll also get enhanced access to the podcast, including any images and tables mentioned. PA’s and NP’s - make sure to use the code APP4 at checkout to save 50%. Nachi: And last reminder here -The clinical Decision Making in Emergency Medicine Conference is just around the corner and spots are quickly filling up. Don’t miss out on this great opportunity and register today. Jeff: And the address for this month’s cme credit is ebmedicine.net/E0619, so head over there to get your CME credit. As always, the [DING SOUND] you heard throughout the episode corresponds to the answers to the CME questions. Lastly, be sure to find us on iTunes and rate us or leave comments there. You can also email us directly at [email protected] with any comments or suggestions. Talk to you next month!   Most Important References 18. Gardner CS, Jaffe TA, Nelson RC. Impact of CT in elderly patients presenting to the emergency department with acute abdominal pain. Abdom Imaging. 2015;40(7):2877-2882. (Retrospective study; 464 patients aged ≥ 80 years) 38. Kereshi B, Lee KS, Siewert B, et al. Clinical utility of magnetic resonance imaging in the evaluation of pregnant females with suspected acute appendicitis. Abdom Radiol (NY). 2018;43(6):1446-1455. (Retrospective study; 212 MRI examinations) 41. Lewis KD, Takenaka KY, Luber SD. Acute abdominal pain in the bariatric surgery patient. Emerg Med Clin North Am. 2016;34(2):387-407. (Review) 57. Wagner JM, McKinney WP, Carpenter JL. Does this patient have appendicitis? JAMA. 1996;276(19):1589-1594. (Review) 67. Magidson PD, Martinez JP. Abdominal pain in the geriatric patient. Emerg Med Clin North Am. 2016;34(3):559-574. (Review) 83. Macaluso CR, McNamara RM. Evaluation and management of acute abdominal pain in the emergency department. Int J Gen Med. 2012;5:789-797. (Review) 94. Bass JB, Couperus KS, Pfaff JL, et al. A pair of testicular torsion medicolegal cases with caveats: the ball’s in your court. Clin Pract Cases Emerg Med. 2018;2(4):283-285. (Case studies; 2 patients) 106. Kestler A, Kendall J. Emergency ultrasound in first-trimester pregnancy. In: Connolly J, Dean A, Hoffman B, et al, eds. Emergency Point-of-Care Ultrasound. 2nd edition. Oxford UK: John Wiley and Sons; 2017. (Textbook)

Show Notes Jeff: Welcome back to EMplify, the podcast corollary to EB Medicine’s Emergency Medicine Practice. I’m Jeff Nusbaum, and I’m back with my co-host, Nachi Gupta. This month, we’re moving into uncharted territories for the podcast… we’re talking psychiatry Nachi: Specifically, we’ll be discussing Depressed and Suicidal Patients in the emergency department. Jeff: As a quick survey of our audience before we begin, how many of you routinely encounter co-morbid psychiatric conditions in your ED patients, especially depression? Nachi: That would certainly be all of our listeners! Jeff: And how many of you struggle to admit or transfer patients for a formal psychiatric eval? Show More v Nachi: Again, just about all of our listeners I’m sure! Jeff: And finally, how many of you wish there was a clearly outlined evidence-based approach to managing such patients to improve care and outcomes? Nachi: That would certainly be helpful. So now that we are all in agreement with just how necessary this episode is, let’s dive in. Jeff: This month’s issue was authored by Dr. Bernard Chang, Katherine Tezanos, Ilana Gratch and Dr. Christine Cha, who are all at Columbia University. Nachi: In addition, it was peer reviewed by Dr. Nicholas Schwartz of Mount Sinai School of Medicine in New York and Dr. Scott Zeller of the university of California-Riverside. Jeff: Quite the team, from a variety of backgrounds. Nachi: And just to put this topic into perspective - annually, there are more than 12 million ED visits for substance abuse and mental health crises. This represents nearly 12.5% of all ED visits. Of note, among these visits, nearly 650,000 individuals are evaluated for suicide attempt. Jeff: Looking more in depth, of the mental health complaints we see daily, mood disorders are the most common, representing 43%, followed by anxiety disorders, 26%, and then alcohol related conditions at 23% Nachi: And as is often the case, these numbers are likely underestimates, as many psychiatric complaints, especially depression, often go unnoticed by the patients and providers alike. In one study of patients who presented with unexplained chest and somatic complaints, 23% met the criteria for a major depressive episode. Jeff: Sad, but terrifying, though I suppose it all makes this issue so much more valuable. Nachi: Before we get to the evidence and an evidence-based approach, let’s start with some definitions. Jeff: Certainly a good place to start, but let me preface this with an important point - arriving at a specific psychiatric diagnosis in the ED is likely neither feasible nor realistic due to the obvious limitations, most namely, time - instead, you should focus on assessing and collecting information on the presenting symptoms and taking a comprehensive psychiatric and medical history. Nachi: According to DSM-5, to diagnose a major depressive disorder you must have 5 or more of the following: depressed mood, decreased interest or pleasure in most activities, body weight change, insomnia or hypersomnia, restlessness or slowing, fatigue, feelings of worthlessness or guilt, diminished ability to think or concentrate or indecisiveness, or finally recurrent thoughts of death and or suicide. In addition, at least 1 of the symptoms must be either a depressed mood or loss of interest. Jeff: These symptoms must last most of the day, nearly every day, for 2 weeks. Nachi: And these symptoms must cause clinically significant distress or impairment across multiple areas of functioning. Jeff: So those were criterion A and B. Criterion C, D, and E state that a MDD does not include factors from substance use or medical conditions, psychotic disorders, or manic episodes. Nachi: Once you’ve had the symptoms for 2 years with little interruption, you likely qualify for a persistent depressive disorder rather than a MDD. Jeff: And if your symptoms repeatedly co-occur around menses, this is more likely premenstrual dysphoric disorder. Nachi: Moving on to suicide and suicide related concepts. Suicidal ideation is the consideration or desire to kill oneself. Jeff: These can be active or passive thoughts, for example, “I don’t want to be alive” vs “I want to kill myself.” Nachi: Other important terms include, the suicide plan, suicide attempt, suicide gesture and nonsuicidal self-injury. The plan typically includes the how, where, and when a person will carry out their attempt. Jeff: A suicide gesture is an action or statement that makes others believe that a person wants to kill him or herself, regardless of the actual plan. Nachi: I think that’s good for definitions, let’s discuss some more epidemiology. Based on 2005 data, the prevalence of 1 month MDD was 5% with a lifetime prevalence of major depression of 13%. Jeff: If those figures seem a bit high, another CDC study found that in a general population survey of a quarter million people between 2006-2008, 9% met the criteria for major depression. Pretty big numbers... Nachi: Sadly, though outpatient visits for depression and suicide related complaints have decreased over the years, while ED visits remain stable, implying that the ED is a critical entry point for depressed and suicidal patients. Jeff: It’s important to also recognize at risk populations. In several studies, the prevalence of MDD is reported as being nearly twice as high in women as it is in men. Nachi: MDD is also much more common in younger adults, with a prevalence of about 20% in those under 65 and a prevalence of just 10% in those 65 and older. Jeff: Additionally, being never-married / widowed / or divorced, being black or hispanic, having poor social support, major life events, and have a history of substance abuse are all serious risk factors for depression. Nachi: In terms of suicidality, nearly half of depressed adults in one study felt that they wanted to die, with ⅓ having thought about suicide. Taking it one step further, somewhere between 14-31% of depressed adults have attempted suicide, and roughly 1 in 10 depressed adults ultimately die by suicide. Jeff: And while it seems crass to even mention the financial impact, the number is shocking - suicide has an estimated economic burden of $5.4 billion per year in the US. Nachi: That’s an incredible amount and much more than I would have guessed. Jeff: In terms specific risk factors for suicide and suicide related complaints - white men over 80 have the highest rate of suicide death in the US, with 51.6 deaths per year per 100,000 individuals. Nachi: You snuck in an important word there - suicide DEATH. While old people die the most from suicide, younger adults attempt suicide more often. Jeff: Along similar lines, while women attempt suicide nearly 4 times more frequently than men, men are 3 times more likely to die by suicide, likely related to their respective choice of suicide methods. Nachi: Lesbian, gay, and bisexual men or women are another at risk population, with rates of suicidal ideations being nearly twice that of their heterosexual counterparts Jeff: Despite the litany of risk factors we just ran through, the strongest single predictor for suicide related outcomes is a prior history of suicidal ideation or attempt, with individuals who have made a previous attempt being nearly 6 times more likely to make another. Nachi: And lastly, those who have had symptoms severe enough to warrant psychiatric admission have an increased lifetime risk of suicide also at 8.6% vs 0.5% for the general population, in one study. Jeff: Alright, so that wraps up the background, let’s move on to the actual evaluation. Nachi: When forming your differential, a crucial aspect is identifying potential secondary causes of depressive symptoms, as many depressive symptoms are driven by etiologies that require different management strategies and treatment. Be on the lookout for toxic-metabolic, infectious, neurologic disturbances, medication side effects, and recent medical events as the etiology for depressive episodes and suicidality. Jeff: Excellent point, which we’ll reiterate a few times throughout the episode - always be on the lookout for medical causes of new psychiatric symptoms. Next, we have my favorite, prehospital care - when doing your scene assessment, look out for possible signs of overdose such as empty pill bottles lying around. It’s also important to assess for the presence of firearms. Of course, this should not be done at the expense of acute medical stabilization. Nachi: And don’t forget to consider transport directly to institutions with full psychiatric services, especially for those with active suicidal ideations. Jeff: Once in the ED - start by maximizing the patient's privacy. Always use a nonjudgmental approach and use open-ended questions. Nachi: If feasible, map the chronology of depressive symptoms and their impact on the patient’s functional status. It’s also important to elicit any psychiatric history, including prior hospitalizations. Jeff: Screening for suicidality is critical in all patients with depressive symptoms given the elevated risk in this population. Though not broadly adopted in many EDs, there are a number of screening tools to assist you in this process, including the PHQ-9, ED SAFE PSS-3, and C-SSRS, which all asses for severity of suicide risk. These have been developed primarily for the outpatient and primary care settings. Nachi: And not surprisingly, MDCalc has online tools to help you use these risk assessments, so you can easily pull up a scoring tool on your phone should the appropriate clinical scenario arise. Jeff: The PHQ-9 was validated in various outpatient settings, including the ED. This is a self-administered depression questionnaire that has been found to be reliable across genders and different cultures. Interestingly, the PHQ-9 questionnaire contains one question about suicidality - how often is the patient bothered by thoughts that you would be better off dead or hurting yourself. Responding “nearly every day” increases your odds from 1 in 250 to 1 in 25 of attempting suicide. Nachi: The next tool to discuss is the ED-Safe PSS-3. The PSS-3 assesses for depression/hopelessness and suicidal ideations in the past 2 weeks as well as lifetime history of suicide attempt. Jeff: In one study, using this tool doubled the number of suicide-risk cases detected. Nachi: Once someone has screened positive for recent suicidal ideations, further screening must be done via a secondary screener. Jeff: In one study, following this approach decreased the total number of suicide attempts by 30% following an ED visit. Nachi: And what would you advise to clinicians that are concerned that questioning a patient about suicidal ideation may actually encourage or introduce the idea of suicide in those who hadn’t already considered it? Jeff: Great question - It has been found that there has been no associated introduction of negative effect when a patient is asked about suicidal ideations. Concerns about iatrogenic effects should not prevent such evaluations. Nachi: Definitely reassuring that this has been looked into. Let’s move on to the physical. Jeff: The physical exam should include a cognitive assessment that focuses on identifying medical conditions, as well as a behavioral mental health status exam that focuses on identifying the presence and degree of depression. Nachi: And as you said, we would mention it a few times -- In the ED, you always want to make sure you aren’t missing an underlying medical condition that manifests as depression. Jeff: So important. Alright, let’s move on to diagnostic studies. And thanks to a systematic review of 60 studies on this topic, there is actually reasonably good data here. Nachi: According to this review, in patients with a known psychiatric disease presenting with exacerbating psychiatric complaints, routine serum and urine tox screening is not recommended. Additional screening tests should be considered in those with new psychiatric symptoms who are 65 years or older, those who are immunosuppressed, and those with concomitant medical disease. Jeff: a 2017 ACEP clinical policy also recommends against routine lab testing in those with acute psychiatric complaints. They too call for a focused history and physical to guide testing. Nachi: It’s also worth highlighting one other incredibly important point from that ACEP policy - urine tox screens for drugs of abuse should not delay patient evaluation for transfer to a psychiatric facility. Jeff: Definitely a great policy to check out if you find yourself in all too frequent disagreements with your local psychiatric receiving facility. Nachi: You should also consider serum testing in those taking psychotropic medications with known toxic effects, such as lithium, as toxicity would change management. Jeff: Ok, last point about the work up, imaging studies of the brain should not be routinely ordered unless you have a high degree of suspicion. Nachi: That wraps up testing. Let’s move on to treatment. Jeff: First and foremost, you must maintain a safe environment. Effective precautions include alerts to staff about the potential safety risk in addition to searches of the patient and his / her belongings if applicable. Nachi: With the staff notified and the patient searched, the patient should be placed in a room without potentially dangerous items, like tubing or needles. Those who are at a very high risk may warrant continuous observation. Jeff: Speaking of safety, you will definitely want to engage in safety planning with the patient. Safety planning can be completed by any emergency clinician and should take about 20-45 minutes. Nachi: And while this is typically done by a psychologist or psychiatrist, this is something any emergency clinician can also easily do. Jeff: Safety planning beings with a brief interview. Next you establish a list of personalized and prioritized steps to help the patient through his or her next crisis. In a full plan, you should identify: warning signs, internal coping strategies, people and social settings that provide distraction, people whom the patient can ask for help, professionals or agencies whom the patient can contact during a crisis, and lastly how to make the environment safe (for example, lethal means counseling). Nachi: Of course, while the plan is meant to be a step by step approach for the patient, you should encourage the patient to seek professional help at any time if it is necessary. Jeff: Great point. And while safety planning typically is most effective when combined with other interventions, research suggests that it does enhance outpatient treatment engagement after an ED visit and in one study, reduce subsequent suicide attempts by 30% vs usual care. That’s a huge win for something that’s not that hard to do. Nachi: Similar to safety planning, let’s discuss no-suicide contracts. No-suicide contracts or no-harm contracts are verbal or written agreements between the patient and the clinician to articulate that he or she will not attempt to hurt him or herself. Though there isn’t a ton of evidence, at least one RCT showed that safety planning was superior to contracts. Jeff: Lethal-means counseling on the other hand is a potentially helpful prevention strategy. In lethal means counseling, you merely have to address the patient’s access to lethal means. By slowing their access to their lethal means, it is thought that the relatively short-lived suicidal crises may pass before they could access said means. Nachi: For example, you could provide options for restricting access to lethal means, such as disposal, locking up and giving the key to someone else, or temporarily giving the means to a friend. Jeff: And this may be a good time to involve friends and or family, especially when dealing with suicidal youths. Nachi: This is such an important and simple intervention that has actually been shown to reduce suicide attempts and deaths. Unfortunately, few ED clinicians address lethal means. Jeff: Pro tip: since most ED clinicians chart with templates, add something to your standard suicidality / psychiatric template about lethal means. This will serve as an important reminder to address it in real time. Nachi: That is a really great idea to ensure you don’t skip over this underutilized counseling. Jeff: The next aspect of treatment to discuss is follow up. Follow up is critical for both depressed and suicidal patients. Follow up can come in many forms and at a minimum should include the national suicide prevention lifeline. Nachi: The authors even simplify this for us a bit, providing 5 easy steps to help make sure patients follow through with ED discharge recommendations. Jeff: First, provide a standard handout that includes a list of outpatient providers. Next provide the patient the 24 hours crisis line number. After that, ask the patient to identify the most viable resources and address any barriers the patient may have in getting there. Next, schedule a follow up appointment, ideally within a week of discharge, and lastly, document the patient’s preferred follow up resources and steps taken to get them there. Nachi: And if this seems too burdensome for a single provider, think about identifying a staff member who may help the patient with follow up - perhaps a social worker or case manager. Follow up is so important, it’s critical that the ball not be dropped after you’ve put in so much hard work to make the plan. Jeff: As always, the team approach is preferred. Alright so the last treatment to discuss is actual pharmacotherapy. Since commonly prescribed antidepressants take up to 6-8 weeks to have a clinical effect, the administration of psychotropic medications is not routinely initiated in the ED. Interestingly, there may be a role for ketamine, yes, ketamine, in conjunction with oral meds. More on that in a few minutes though... Nachi: Let’s talk first about special populations - the only one we will discuss this month is military veterans. Jeff: Recent evidence has demonstrated an association between exposure to blast and concussive injuries and subsequent depressive and anxiety symptoms. Nachi: In part, because of this, among veterans presenting for emergency psychiatric services, approximately 52% reported suicidal ideations in the prior week and 70% reported current depressive symptoms. Clearly this is a major problem in this population. Jeff: But to bring it back to ED care, in one study, among depressed veterans with death by suicide, 10% had visited a VA ED in the 30 days prior to their death. Nachi: And this is in no way meant to be a knock-on VA ED docs - they are dealing with a very at risk population. But it is worth highlighting the importance of the ED visit as an excellent opportunity to begin to engage the patient in long term care. Jeff: Exactly, every ED visit is an opportunity that shouldn’t be missed. Nachi: Let’s talk controversies and cutting-edge topics from this issue. Jeff: First, let’s start by returning to ketamine and the treatment-resistant depression and suicidality. Nachi: Recent trials, including RCTs have found that low doses of ketamine administered via a variety of routes, may have a significant therapeutic effect towards reducing suicidality in patients in the acute setting. Jeff: To this end, Esketamine, an intranasal version of ketamine has already been FDA approved for treatment resistant depression. Nachi: This has huge implications for some of the psychiatrically sickest patients, so be on the lookout for more in the future. Jeff: Next we have the zero-suicide model. This is a program of the national action alliance for suicide prevention that involves a multi pronged approach to reducing suicide based on the premise that suicide is preventable. This model involves educating clinicians on best practices, identifying screening and assessment tools for engagement, treatment, and disposition. Nachi: Though not yet implemented in the ED setting, this may offer a novel approach to ED patients with psychiatric emergencies in the ED. Jeff: The next controversy is a big one - alcohol intoxication and suicide risk. There is a bidirectional relationship between depression and alcohol abuse and dependency. Not only is alcohol abuse a lifetime risk factor for completed suicide, those who make suicide attempts or present with suicidal ideations are more likely to be intoxicated. Nachi: In addition, formerly intoxicated patients may deny their previous thoughts and intentions when sober. Interestingly, though such patients have an increased lifetime risk of death by suicide. Jeff: Given this paradox and the evidence that exists, the authors recommend observing the patient until they have reached a reasonable level of sobriety. This effective level of sobriety should be based on clinical assessment and not blood alcohol levels. If the patient unfortunately has reached a place where they are at risk of withdrawal, this should be treated while in the ED. Nachi: It’s worth noting that ACEP guidelines and guidelines from the american association for emergency psychiatry have both supported a personalized approach that emphasize evaluating the patient’s cognitive abilities rather than a specific blood alcohol level to determine when to pursue a formal psychiatric assessment. Jeff: Very important point - in this high-risk population, you are targeting a clinical endpoint, not a laboratory end point and this is backed by several national guidelines. Nachi: Moving on to the next topic - let’s discuss post discharge patient contact. Jeff: Though not something many ED clinicians routinely do, this may be something to consider implementing in your department. And this doesn’t even have to be something as time consuming as a phone call. In one study, sending a brief postcard 9 times a year with a quick “hope things are well” type message to patients discharged after deliberate self-harm reduced self-poisonings by 50%. Nachi: Though other studies including other methods of follow up have not shown as drastic results, generally the results have shown a positive impact. Jeff: Next we have to discuss the various screening tools. Though we previously mentioned screening tools in a positive light, using such decision-making tools is still of limited utility due to the fact that they rely on self-reporting and suicidal thoughts and behaviors are complex and may require the consideration of hundreds of risk factors. Nachi: And while implicit association tests are being developed to predict suicidal thoughts and behaviors, and computer models and machine learning are being used to enhance our screening tools, there is still a long way to go before such tools perform more independently with acceptable performance. Jeff: The last cutting-edge topic to discuss is telepsychiatry. Nachi: Just as telestroke has changed stroke care forever, as technology advances, telepsychiatry may provide a solution to easily expand access to outpatient services and consultation in a cost effective manner - offering quick psychiatric care to those that never had access. Jeff: Let’s move on to the final section of the article. Disposition, which can be a bit complicated. Nachi: The decision for discharge, observation, or admission depends on clinical judgment and local protocols. Appropriate disposition is often fraught with legal, ethical, and psychological considerations. Jeff: It’s also worth noting that patients with suicidal ideations tend to have overall longer lengths of stay when compared to other patients on involuntary mental health hold. Nachi: There are however some suicide risk assessment tools that can help in the disposition decision planning such as C-SSRS, SAFE-T, and ICARE2. C-SSRS is a series of questions that assess the quality of suicidal ideation. SAFE-T is 5 step evaluation and triage tool that assesses various qualities and makes treatment recommendations. ICARE2 is provided by the American College of Emergency Physicians as a result of an iterative literature review and expert consensus panel. It also integrates many risk factors and treatment approaches. Jeff: It goes without saying that none of these tools are perfect. They should be used to assist in your clinical decision making. Nachi: For depressed but not actively suicidal patients, ensure close follow up with a mental health clinician. These patients typically do not require inpatient hospitalization. Jeff: Let’s also touch upon involuntary confinement here. Patients who are at imminent risk of self harm who refuse to stay for evaluation may need to be held involuntarily until a complete psychiatric and safety evaluation is performed. Nachi: Before holding a patient involuntarily, it is important to fully familiarize yourself with the state and county laws as there is wide variation. The period of involuntary confinement should be as short as possible. Jeff: With that, let’s close out this month’s episode with some high yield points and clinical pearls. Risk factors for major depression include female gender, young or old age, being divorced or widowed, black or Hispanic ethnicity, poor social support, and substance abuse. The strongest predictor for suicide-related outcomes is history of prior suicidal ideation or suicide attempt. When evaluating a patient with depressive symptoms, try to identify potential secondary causes, as this may influence your management strategy. When assessing for depression, perform a complete history and consider underlying medical causes that may be contributing to their presentation. Consider serum testing for the patient’s psychiatric medications if the medications have known toxic effects. 1. Routine serum testing and urine toxicology testing are not recommended for psychiatric patients presenting to the emergency department. Imaging of the brain should not be ordered routinely in depressed or suicidal patients. Depression places patients at a significantly increased risk for alcohol abuse and dependence. In addition to providing appropriate follow up resources to your depressed patients, emergency clinicians should consider making a brief follow up telephone call to the patient. Telepsychiatry may improve access to mental health providers and allow remote assessment and care from the ED. Suicide risk assessment tools such as C-SSRS, SAFE-T, and ICARE2 can help when deciding on disposition from the ER. It may be necessary to hold a patient against their will if they are at immediate risk of self-harm. Though not routinely administered in the ED for this purpose, psychotropic medications, such as ketamine, have proven helpful in acute depressive episodes. Patients who are actively suicidal should be admitted to a psychiatric observation unit or inpatient psychiatric unit. Nachi: So that wraps up Episode 28! Jeff: As always, additional materials are available on our website for Emergency Medicine Practice subscribers. If you’re not a subscriber, consider joining today. You can find out more at ebmedicine.net/subscribe. Subscribers get in-depth articles on hundreds of emergency medicine topics, concise summaries of the articles, calculators and risk scores, and CME credit. You’ll also get enhanced access to the podcast, including any images and tables mentioned. PA’s and NP’s - make sure to use the code APP4 at checkout to save 50%. Nachi: And don’t forget to check out the lineup for the upcoming Clinical Decision Making in Emergency Medicine conference hosted by EB Medicine, which will take place June 27th-30th. Great speakers, great location, what more could you ask. Jeff: And the address for this month’s cme credit is ebmedicine.net/E0519, so head over there to get your CME credit. As always, the [DING SOUND] you heard throughout the episode corresponds to the answers to the CME questions. Lastly, be sure to find us on iTunes and rate us or leave comments there. You can also email us directly at [email protected] with any comments or suggestions. Talk to you next month! Most Important References 1. Owens PL, Mutter R, Stocks C. Mental health and substance abuse-related emergency department visits among adults, 2007: statistical brief #92. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. Rockville (MD): Agency for Healthcare Research and Quality (US); 2006. (US government report) 12. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-5). 5th ed. Washington DC: American Psychiatric Association; 2013. (Reference book) 15. Grant BF, Stinson FS, Dawson DA, et al. Prevalence and co-occurrence of substance use disorders and independent mood and anxiety disorders: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry. 2004;61(8):807-816. (Survey data; 49,093 patients) 16. Centers for Disease Control and Prevention. Current depression among adults---United States, 2006 and 2008. MMWR Morb Mortal Wkly Rep. 2010;59(38):1229-1235. (Government survey data analysis; 235,067 subjects) 97. Murrough J, Soleimani L, DeWilde K, et al. Ketamine for rapid reduction of suicidal ideation: a randomized controlled trial. Psychol Med. 2015;45(16):3571-3580. (Randomized controlled trial; 24 participants) 100. Griffiths JJ, Zarate CA, Rasimas J. Existing and novel biological therapeutics in suicide prevention. Am J Prev Med. 2014;47(3):S195-S203. (Review article)

Show Notes Jeff: Welcome back to EMplify, the podcast corollary to EB Medicine’s Emergency Medicine Practice. I’m Jeff Nusbaum, and I’m back with my co-host, Nachi Gupta. This month, we’re moving from the trauma bay back to a more private setting, to discuss Emergency Department Diagnosis and Treatment of Sexually Transmitted Diseases. Nachi: And for those of you who follow along with the print issue and might be reading in a public place, this issue has a few images that might not be ideal for wandering eyes. Jeff: I’d say we need a “not safe for work” label on this episode, though I think we are one of the unique workplaces where this is actually quite safe. Nachi: And we’re obviously pushing for “safe” practices this month. The article was authored by Dr. Pfenning-Bass and Dr. Bridges from the University of South Carolina School of medicine. It was edited by Dr. Borhart of Georgetown University and Dr. Castellone of Eastern Connecticut Health Network. Jeff: Thanks, team for this deep dive. Nachi: STDs or STIs are incredibly common and often under recognized by both the public and health care providers. Jeff: In addition, the rates of STDs in the US continue to rise, partly due to the fact that many patients have minimal to no symptoms, leading to unknowing rapid spread and an estimated 20 million new STDs diagnosed each year. Treating these 20 million cases amounts to a whopping $16 billion dollars worth of care annually. Nachi: 20 million! Kinda scary if you step back and think about it. Jeff: Definitely, perhaps even more scary, undiagnosed and untreated STDs can lead to infertility, ectopic pregnancies, spontaneous abortions, chronic pelvic pain and chronic infections. On top of this, there is also growing antibiotic resistance, making treatment more difficult. Nachi: All the more reason we need evidence based guidelines, which our team from South Carolina has nicely laid out after reviewing 107 references dating back to 1990, as well as guidelines from the CDC and the national guideline clearinghouse. Jeff: Alright, so let’s start with some basics: pathophysiology, prehospital care, and the H&P. STDs are caused by bacteria, viruses, or parasites that are transmitted vaginally, anally, or orally during sexual contact, or passed from a mother to her baby during delivery and breastfeeding. Nachi: In terms of prehospital care, first, make sure you are practicing proper precautions and don appropriate personal protective equipment to eliminate or reduce the chance of bloodborne and infectious disease exposure. In those with concern for possible sexual assault, consider transport to facilities capable of performing these sensitive exams. Jeff: As in many of the prehospital sections we have covered -- a destination consult could be very appropriate here if you’re unsure of the assault capabilities at your closest ER. Nachi: And in such circumstances, though patient care comes first, make sure to balance medical stabilization with the need to protect evidence. Jeff: Exactly. Moving on to the ED… The history and physical should be conducted in a private setting. For the exam, have a chaperone present, whose name you can document. The “5 Ps” are a helpful starting point for your history: partners, practices, prevention of pregnancy, protection from STDs, and past STDs. Nachi: 5 p’s, I actually haven’t heard this mnemonic before, but I like it and will certainly incorporate it into my practice. Again, the 5 p’s stand for: partners, practices, prevention of pregnancy, protection from STDs, and past STDs. After you have gathered all of your information, make sure to end with an open ended question like “Is there anything else about your sexual practices that I need to know?” Jeff: Though some of the information and even the history gathering may make you or the patient somewhat uncomfortable, it’s essential. Multiple partners, anonymous partners, and no condom use all increase the risk of multiple infections.

Show Notes Jeff: Welcome back to EMplify, the podcast corollary to EB Medicine’s Emergency Medicine Practice. I’m Jeff Nusbaum, and I’m back with my co-host, Nachi Gupta. This month, after a few months of primarily medical topics, we’re talking trauma, specifically Blunt Cardiac Injury: Emergency Department Diagnosis and Management. Nachi: With no gold standard diagnostic test and with complications ranging from simple ectopic beats to fulminant cardiac failure and death, this isn’t an episode you’ll want to miss. Jeff: Before we begin, let me give a quick shout out to our incredible group of authors from New York -- Dr. Eric Morley, Dr. Bryan English, and Dr. David Cohen of Stony Brook Medicine and Dr. William Paolo, residency program director at SUNY Upstate. I should also mention their peer reviewers Drs. Jennifer Maccagnano and Ashley Norse of the NY institute of technology college of osteopathic medicine and UF Health Jacksonville, respectively. Nachi: This month’s team parsed through roughly 1200 articles as well as guidelines from the eastern association for surgery in trauma also known as EAST. Jeff: Clearly a large undertaking for a difficult topic to come up with solid evidence based recommendations. Nachi: For sure. Let’s begin with some epidemiology, which is admittedly quite difficult without universally accepted diagnostic criteria. Jeff: As you likely know, despite advances in motor vehicle safety, trauma remains a leading cause of death for young adults. In the US alone, each year, there are about 900,000 cases of cardiac injury secondary to trauma. Most of these occur in the setting of vehicular trauma. Nachi: And keep in mind, that those injuries don’t occur in isolation as 70-80% of patients with blunt cardiac injury sustain other injuries. This idea of concomitant trauma will be a major theme in today’s episode. Jeff: It certainly will. But before we get there, we have some more definitions to review - cardiac concussion and contusion, both of which were defined in a 1989 study. In this study, cardiac concussion was defined as an elevated CKMB with a normal echo, while a cardiac contusion was defined as an elevated CKMB and abnormal echo. Nachi: Much to my surprise, though, abnormal echo and elevated ck-mb have not been shown to be predictive of adverse outcomes, but conduction abnormalities on ekgs have been predictive of development of serious dysrhythmia Jeff: More on complications in a bit, but first, returning to the idea of concomitant injuries, in one autopsy study of nearly 1600 patients with blunt trauma - cardiac injuries were reported in 11.9% of cases and contributed to the death of 45.2% of those patients. Nachi: Looking more broadly at the data, according to one retrospective review, blunt cardiac injury may carry a mortality of up to 44%. Jeff: That’s scary high, though I guess not terribly surprising, given that we are discussing heart injuries due to major trauma... Nachi: The force may be direct or indirect, involve rapid deceleration, be bidirectional, compressive, concussive, or even involve a combination of these. In general, the right ventricle is the most frequently injured area due to the proximity to the chest wall. Jeff: Perfect, so that's enough background, let’s talk differential. As you likely expected, the differential is broad and includes cardiovascular injuries, pulmonary injuries, and other mediastinal injuries like pneumomediastinum and esophageal injuries. Nachi: Among the most devastating injuries on the differential is cardiac wall rupture, which not surprisingly has an extremely high mortality rate. In terms of location of rupture, both ventricles are far more likely to rupture than the atria with the right atria being more likely to rupture than the left atria. Atrial ruptures are more survivable, whereas complete free wall rupture is nearly universally fatal. Jeff: Septal injuries are also on the ddx. Septal injuries occur immediately, either from direct impact or when the heart becomes compressed between the sternum and the spine. Delayed rupture can occur secondary to an inflammatory reaction. This is more likely in patients with a prior healed or repaired septal defects. Nachi: Valvular injuries, like septal injuries, are rare. Left sided valvular damage is more common and carries a higher mortality risk. In order, the aortic valve is more commonly injured followed by the mitral valve then tricuspid valve, and finally the pulmonic valve. Remember that valvular damage can be due to papillary muscle rupture or damage to the chordae tendineae. Consider valvular injury in any patient who appears to be in cardiogenic shock, has hypotension without obvious hemorrhage, or has pulmonary edema. Jeff: Next on the ddx are coronary artery injuries, which include lacerations, dissections, aneurysms, thrombosis, and even MI secondary to increased sympathetic activity and platelet activity after trauma. In one review, dissection was the most commonly uncovered pathology, occurring 71% of the time, followed by thrombosis, which occured only 7% of the time. The LAD is the most commonly injured artery followed by the RCA. Nachi: Pericardial injury, including pericarditis, effusion, tamponade, and rarely rupture, is also certainly on the differential. Jeff: In terms of dysrhythmias, sinus tachycardia is the most common dysrhythmia, with other rhythms, including PVC / PAC / and afib being found only 1-6% of the time. Nachi: And while conduction blocks are rare, a RBBB is the most commonly noted, followed by a 1st degree AVB. Jeff: Though also rare, commotio cordis deserves it’s own section as its the second most common cause of death in athletes < 18 who are victims of blunt trauma. Though only studied in swine models, it’s hypothesized that the impact to the chest wall during T-wave upstroke can precipitate v-fib. Nachi: Aortic root injuries usually occur at the insertion of the ligamentum arteriosum and isthmus. Such injuries typically result in aortic insufficiency. Jeff: And the last pathology on the differential requiring special attention is a myocardial contusion. Again, no standard definition exists, with some diagnostic criteria including simply chest pain and increasing cardiac enzymes, and others including cardiac dysfunction, ecg abnormalities, wall motion abnormalities, and an elevation of cardiac enzymes. Nachi: Certainly a pretty broad differential… before moving on to the work up, Jeff why don’t you get us started with prehospital care? Jeff: Prehospital management should focus on rapid identification and stabilization of life threatening injuries with expeditious transport as longer prehospital times have been associated with increased mortality in trauma. Immediate transport to a Level I trauma center should be the highest priority for those with suspected blunt cardiac injury. Nachi: In terms of who specifically should be transporting the patient, a Cochrane review evaluated the utility of ALS vs BLS transport in trauma. There is reasonably good data to support BLS over ALS, even when controlling for trauma severity. Moreover, when airway management is needed, advanced airway techniques by ALS crews were associated with decreased odds of survival. Regardless of who is there, the message is the same: focus not on interventions, but instead on rapid transport. Jeff: And if it does happen to be an ALS transport crew, without delaying transport, pain management with fentanyl is both safe and reasonable and preferred over morphine. Post opiate hypotension in prehospital trauma patients is a rare but documented complication. Nachi: And if the prehospital team is lucky enough, or maybe unlucky enough, i don’t know, to have a credentialed provider who can perform ultrasound for those suspected of having a blunt cardiac injury, the general prehospital data on ultrasound is sparse. As of now, it’s difficult to conclude if prehospital US improves care for trauma patients. Jeff: Interestingly, the system I work in has prehospital physicians, who do carry US, but I can’t think of a major trauma where ultrasound changed any of the decisions we made. Nachi: Right, and I think that just reinforces the main point here: there may be a role, we just don’t have the data to support it at this time. Jeff: Great, let’s move onto ED care, beginning with the H&P. Nachi: On history, make sure to elucidate if there is any chest pain, and if it’s onset was before or after the traumatic event. In addition, make sure to ask about dyspnea, fatigue, palpitations, and lightheadedness. Jeff: And don’t forget to get the crash details from the EMS crew before they depart! As a side note, for anyone taking oral boards in a few months, don’t forget to ask the EMS crew for the details!!! Nachi: A definite must for oral boards and for your clinical practice. Jeff: In terms of the physical, tachycardia is the most common abnormality in blunt cardiac injury. In those with severe injury, you may note refractory hypotension secondary to cardiogenic shock. But don’t be reassured by normal vitals, especially in the young, who may be compensating well despite being quite ill. Nachi: Fully undress the patient to appropriately inspect and percuss the chest wall - looking for signs of previous cardiac surgeries or pacemaker placement, as well as to auscultate for new murmurs which may be a sign of valvular injury. Jeff: Similarly, as concomitant injuries are common, inspect the abdomen, looking for ecchymosis patterns, which often accompany blunt cardiac injury. Nachi: Pretty standard stuff. Let’s move on to diagnostic testing. Jeff: Lab testing should include a CBC, BMP, coags, troponin, lactate, and T&S. In one retrospective analysis, an elevated troponin and a lactate over 2.5 were predictors of mortality. Nachi: Additionally, in patients with chest trauma, a troponin > 1.05 was associated with a greater risk for dysrhythmias and LV dysfunction. Jeff: And it likely goes without saying, but an EKG is a must on all trauma patients with suspicion for blunt cardiac injury in accordance with the EAST guidelines. New EKG findings requires admission for monitoring. Unfortunately, on the flip side, an ECG cannot be used to rule out blunt cardiac injury. Nachi: Diving a bit deeper into the data, in a prospective study of 333 patients with blunt thoracic trauma, serial EKG and troponins at 0, 4, and 8 hours post injury had a sensitivity and specificity of 100% and 71%, respectively. However, of those with abnormal findings, all but one had them on initial testing, leading to a negative predictive value of 98%. Jeff: Well that’s an impressive NPV and has huge implications, especially in the era of heavily monitored lengths of stay... Nachi: Definitely. In terms of radiography, a chest x-ray should be obtained as rib fractures, hemopneumothorax, and mediastinal free air are all things you wouldn't want to miss and are also associated with blunt cardiac injury. Jeff: Keep in mind, however, that the chest x-ray should not be seen as a test for pericardial fluid as up to 200 mL of fluid can be contained in the pericardial space and remain undetectable by chest radiograph. Nachi: Which is why you’ll have to turn to our good friend the ultrasound, for more useful data. The data is strong that in the hands of trained Emergency Clinicians, when parasternal, apical, and subcostal views are obtained, US has an accuracy of 97.5% for pericardial effusion. Jeff: Not only is US accurate, it’s also quick. In one RCT, the FAST exam reduced the time from arrival in the ED to operative care by 64% in the setting of trauma. Nachi: That’s impressive -- for expediting patient care and for managing ED flow. Jeff: Exactly. The authors do note however that hemopericardium is a rare finding, so, while not the focus of this article, the real utility of the FAST exam may be in its expanded form, the eFAST, in which a rapid bedside ultrasonographic lung exam for pneumothorax is included, as this can lead to immediate changes in management. Nachi: And assuming you do your FAST or eFAST and have no management changing findings, CT will often be your next test. Jeff: Yeah, EKG-gated multidetector CT can easily diagnose myocardial rupture, pneumopericardium, pericardial rupture, hemopericardium, coronary artery insult, ventricular septal defects and even valvular dysfunction. Unfortunately, CT does not perform well for the evaluation of myocardial contusions. Nachi: This is all well and good, and certainly accurate, but let’s not forget that hemodynamically unstable trauma patients, like those with myocardial rupture, need to be in the operating room, not the CT scanner. Jeff: An important point that should not be understated. Nachi: And the last major testing modality to discuss is the echocardiogram. Jeff: The echo is a fantastic test for detecting focal cardiac dysfunction often see with cardiac contusions, hemopericardium, and valve disruption. Nachi: And it’s worth noting that transthoracic is enough, as transesophageal, despite the better images, hasn’t been shown to change management. TEE should be saved for those in whom a optimal TTE study isn’t feasible. Jeff: Great point. And one last quick note on echo: in terms of guidelines, the EAST guidelines from 2012 specifically recommend an echo in hemodynamically unstable patients or those with a persistent new dysrhythmia without other sources of ongoing hemorrhage or neurologic etiology of instability. Nachi: Perfect, so that wraps up testing and imaging for our blunt cardiac injury patient. Let’s move on to treatment. Jeff: In terms of initial resuscitation, there is an ever increasing body of literature to support blood transfusion over crystalloid in patients requiring volume expansion in trauma. There are no specific guidelines for transfusion in the setting of blunt cardiac injury, so stick to your standard trauma protocols. Nachi: It is worth noting, though, that there is literature outside of trauma for those with pericardial effusions, suggesting that those with a SBP < 100 have substantial benefit from volume expansion. So keep this in mind if your clinical suspicion is high and your trauma patient has a soft but not truly shocky blood pressure. Jeff: Operative management, specifically ED thoracotomy is a heavily debated topic, and it’s next on our list to discuss. Nachi: The 2015 EAST guidelines conditionally recommend ED thoracotomy for moribund patients with signs of life. The Western Trauma Association broadens the ED thoracotomy window a bit to include anyone with no signs of life but less than 10 minutes of CPR. The latter also recommend ED thoracotomy in those with refractory shock. Jeff: Though few studies exist on the topic, in one study of 187 patients, cardiac motion on US was 100% sensitive for predicting survivors. Nachi: Not great data, but it does support one's decision to stop any further work up should there be no cardiac activity, which is important, because the decision to pursue an ED thoracotomy is not an easy one. Jeff: And lastly, emergent pericardiocentesis may be another option in an unstable patient when definitive operative management is not possible. But do note that pericardiocentesis is only a temporizing measure, and not definitive for cardiac tamponade. Nachi: Treatment for dysrhythmias is standard, treat in accordance with standard ACLS protocols, as formal randomized trials on prophylaxis and treatment in the setting of blunt cardiac injury do not exist. Jeff: Seems reasonable enough. And in the very rare setting of an MI after blunt cardiac injury, you should involve cardiology, cardiothoracic surgery, and trauma to help make important management decisions. Data is, again, lacking, but the patient likely needs percutaneous angiography for appropriate diagnosis and potentially further intervention. Definitely hold off on ASA and likely nitroglycerin, at least until significant bleeding has been ruled out. Nachi: Yup, no style points for giving aspirin to a bleeding trauma patient. Speaking of medications, the last treatment modality to discuss here is pain control. Pain management is essential with chest injuries, as appropriate pain management has been shown to reduce mortality in pulmonary related complications. Jeff: And in line with every acute pain consult note I’ve ever come across, a multimodal approach utilizing opioids and nonopioids is recommended. Nachi: Perfect, so that sums up treatment, next we have one special circumstance to discuss: sternal fractures. Cardiac contusions are found in 1.8-2.4% of patients with sternal fractures, almost all of which were seen on CT and not XR according to the NEXUS chest CT study. Of these patients, only 2 deaths occured, both due to cardiac causes.  Thus, in patients with isolated sternal fractures, negative trops, ekg, and negative cxr - the patient can likely be discharged from the ED, as long as their pain is well-controlled. Jeff: And let’s talk controversies for this issue. We only have one to discuss: MRI. Nachi: The fact that MRI produces awesome images is not controversial, see figure 3. It’s role, however, is. In accordance with EAST guidelines, MRI may be most useful in differentiating acute ischemia from blunt cardiac injury in those with abnormal ECGs, elevated enzymes, or abnormal echos. It’s use in the hyperacute evaluation, however, is limited, in large part owing to the length of time required to complete an MRI Jeff: What a time to be alive that we even have to say that MRIs may not have a hyperacute role in trauma - absolutely crazy... Nachi: Moving on to disposition: any patient with aortic, pericardial, or myocardial injury and hemodynamic instability needs operative evaluation and likely intervention, so do not hesitate to get the consults coming or the helicopter in the air should such a patient arrive at your non-trauma center. Jeff: And in those that are hemodynamically stable, with either a positive ECG or a positive trop, they should be monitored on telemetry. There is no clear answer as to how long, but numerous studies suggest a 24 hour period of observation is sufficient. For those with persistent ekg abnormalities or rising trops - this is precisely when you will want to pursue echocardiography. Nachi: And if there are positive EKG findings AND a rising trop, they should be admitted to a step down unit or ICU as well -- as ⅔ of them will develop myocardial dysfunction. Similarly, those with hemodynamic instability but no active traumatic bleeding source - they too should be admitted to the ICU for a STAT echo and serial enzymes. Jeff: But in the vast majority of patients, those that are hemodynamically stable with negative serial EKGs and serial tropinins, they can effectively be ruled out for significant BCI after an 8 hour ED observation period, as we mentioned earlier with a sensitivity approaching 100%! Nachi: Though there are, of course, exceptions to this rule, like those with low physiologic reserve, mobility or functional issues, or complex social situations, which may need to be assessed on a more case-by-case basis. Jeff: Let’s wrap up this episode with some key points and clinical pearls. Cardiac wall rupture is the most devastating form of Blunt Cardiac Injury. The sealing of a ruptured wall may lead to a pseudoaneurysm and delayed tamponade. Trauma to the coronary arteries may lead to a myocardial infarction. The left anterior descending artery is most commonly affected. The most common arrhythmia associated with blunt cardiac injury is sinus tachycardia. RBBB is the most commonly associated conduction block. Commotio cordis is the second most common cause of death in athletes under the age of 18. Early defibrillation is linked to better outcomes. Antiplatelet agents like aspirin should be avoided in blunt cardiac injury until significant hemorrhage has been ruled out. An EKG should be obtained in all patients with suspected blunt cardiac injury. However, an EKG alone does not rule out blunt cardiac injury. Serial EKG and serial troponin testing at hours 0, 4, and 8 have a sensitivity approaching 100% for blunt cardiac injury. An elevated lactate level or troponin is associated with increased mortality in blunt cardiac injury. Perform a FAST exam to assess for pericardial effusions. FAST exams are associated with a significant reduction in transfer time to an operating room. Obtain a chest X-ray in all patients in whom you have concern for blunt cardiac injury. Note that the pericardium is poorly compliant and pericardial fluid might not be detected on chest X-ray. Transesophageal echocardiogram should be considered when an optimal transthoracic study cannot be achieved. CT is used routinely in evaluating blunt chest trauma but know that it does not evaluate cardiac contusions well. In acute evaluation, MRI is generally a less useful imaging modality given the long imaging time. There is evidence to suggest that a patient with an isolated sternal fracture and negative biomarkers and negative EKG findings can be safely discharged from the ED if pain is well-controlled. Trauma to the aorta, pericardium, or myocardium is associated with severe hemodynamic instability. These patients need surgical evaluation emergently. Hemodynamically stable patients with a positive troponin test or with new EKG abnormalities should be observed for cardiac monitoring. Nachi: So that wraps up Episode 26 on Blunt Cardiac Injury! Jeff: Additional materials are available on our website for Emergency Medicine Practice subscribers. If you’re not a subscriber, consider joining today. You can find out more at ebmedicine.net/subscribe. Subscribers get in-depth articles on hundreds of emergency medicine topics, concise summaries of the articles, calculators and risk scores, and CME credit. You’ll also get enhanced access to the podcast, including any images and tables mentioned. You can find everything you need to know at ebmedicine.net/subscribe. Nachi: It’s also worth mentioning for current subscribers that the website has recently undergone a major rehaul and update. The new site is easier to use on mobile browsers, has better search functionality, mobile-friendly CME testing, and quick access to the digest and podcast. Jeff: And as those of us in the north east say goodbye to the snow for the year, it’s time to start thinking about the summer and maybe start planning for the Clinical Decision Making conference in sunny Ponta Vedra Beach, Fl. The conference will run from June 27th to June 30th this year with a pre-conference workshop on June 26th. Nachi: And the address for this month’s credit is ebmedicine.net/E0319, so head over there to get your CME credit. As always, the [DING SOUND] you heard throughout the episode corresponds to the answers to the CME questions. Lastly, be sure to find us on iTunes and rate us or leave comments there. You can also email us directly at [email protected] with any comments or suggestions. Talk to you next month! Most Important References 7.* Clancy K, Velopulos C, Bilaniuk JW, et al. Screening for blunt cardiac injury: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2012;73(5 Suppl 4):S301-S306. (Guideline) 22.* Schultz JM, Trunkey DD. Blunt cardiac injury. Crit Care Clin. 2004;20(1):57-70. (Review article) 23.* El-Chami MF, Nicholson W, Helmy T. Blunt cardiac trauma. J Emerg Med. 2008;35(2):127-133. (Review article) 27.* Bock JS, Benitez RM. Blunt cardiac injury. Cardiol Clin. 2012;30(4):545-555. (Review article) 34.* Berk WA. ECG findings in nonpenetrating chest trauma: a review. J Emerg Med. 1987;5(3):209-215. (Review article) 64.* Velmahos GC, Karaiskakis M, Salim A, et al. Normal electrocardiography and serum troponin I levels preclude the presence of clinically significant blunt cardiac injury. J Trauma. 2003;54(1):45-50. (Prospective; 333 patients) 73.* Melniker LA, Leibner E, McKenney MG, et al. Randomized controlled clinical trial of point-of-care, limited ultrasonography for trauma in the emergency department: the first sonography outcomes assessment program trial. Ann Emerg Med. 2006;48(3):227-235. (Randomized controlled trial; 262 patients)

Shownotes Jeff: Welcome back to EMplify, the podcast corollary to EB Medicine’s Emergency Medicine Practice. I’m Jeff Nusbaum, and I’m back with my co-host, Nachi Gupta. This month, we’re tackling an incredibly important topic - evaluation and management of life threatening headaches in the Emergency Department. Nachi: Fear not, this will not simply be “who needs a head CT episode”; we’ll cover much more than that. Listen closely as this is an important topic, with huge consequences for mismanagement. Jeff: Absolutely. As some quick background - headaches account for 3% of all ED visits in the US, with 90% being benign primary headaches and less than 10% being secondary to other causes like vascular, infectious, or traumatic etiologies. It’s within these later 10% that we are looking for the red flag signs to identify the potentially life-threatening headaches. Nachi: And to do so, Dr. David Zodda and Dr. Amit Gupta, PD and APD at Hackensack University Medical and Trauma Center, and their colleague Dr. Gabrielle Procopio, a PharmD, have done a fantastic job parsing through the literature, which included over 500 abstracts, 89 full text articles, guidelines from ACEP and the American Academy of Neurology, as well as canadian and european neurology guidelines, to summarize the best evidence based recommendations for you all. Jeff: We would be remiss to not also mention Dr. Mert Erogul of Maimonides Medical Center and Dr. Steven Godwin, Chair of Emergency Medicine at the University of Florida College of Medicine. Nachi: Alright, so let’s get started with some definitions and pathophysiology. The international classification of headache disorders 3, or ICHD-3, classifies headaches into primary, secondary, and cranial neuropathies. Jeff: Primary headache disorders include migraine, tension, and cluster headaches. Secondary headaches include those secondary to vascular disorders, traumatic disorders, and disorders in hemostasis. These are the potentially life threatening headaches that can have a mortality has high as 50%. Nachi: And the final category includes cranial neuropathies, such as trigeminal neuralgia. Jeff: And I think we can safely say that that wraps up our discussion in this episode on cranial neuropathies, moving on…. Nachi: Headaches result from traction to or irritation of the meninges and blood vessels, which are the only innervated central nervous system structures. Activation of specific nerve ganglion complexes by neuropeptides like -- substance P and calcitonin gene-related peptide -- are thought to contribute to head pain. Jeff: It is important to note that all headache pain shares common pain pathways, thus response to pain medications does not exclude potential life threatening secondary causes of headache. This led to the ACEP guideline which states just that.. Nachi: I feel like that deserves ding sound as it's a critically important point. To repeat, just because a pain medication relieves a headache, that does not exclude dangerous secondary causes! Jeff: And what are the life threatening headaches? Life-threatening headaches include subarachnoid hemorrhage, cervical Artery Dissection, which includes both vertebral Artery Dissection and carotid artery dissection, cerebral Venous Thrombosis, idiopathic intracranial hypertension, giant cell arteritis, and posterior reversible encephalopathy syndrome, or PRES. Nachi: Slow down for a second and let’s not skip over your favorite section.. Let’s talk pre hospital care for headache patients. Jeff: Good call! Pre-hospital care is fairly straightforward and includes a primary survey, conducting a focused neurologic exam, and assessing for red flag signs, which include focal neurologic deficits, sudden onset headache, new headache in those over 50, neck pain or stiffness, changes in visual Acuity, fever or immunocompromised State, history of malignancy, pregnancy or postpartum status, syncope, and seizure. That’s quite a list. For a visual reference, see Table 3 in the print issue. Nachi: And patients with neurologic deficits or severe sudden-onset headaches, should be transported immediately to the nearest available stroke center. Tylenol should be offered for pain management. Avoid opioids and nsaids. Jeff: Upon arrival to the emergency department, history and physical should include your standard vitals, testing neurologic function, cranial nerve testing, head and neck exam, as well as a fundoscopic exam. As was the case for your pre-hospital colleagues, you should also assess for red flag signs for life-threatening headaches. Check out tables 2, 3, and 4 for more details here. Nachi: With respect to Vital Signs, in the setting of an acute headache, severe hypertension should prompt a search for signs of end-organ damage such as hypertensive encephalopathy, intracranial Hemorrhage, PRES, and preeclampsia in pregnant women. Additionally, fever, and especially fever and neck stiffness, should raise concern for CNS infection. Jeff: For your neurologic examination, make sure to include assessments of motor strength, coordination, reflexes, sensory function, and gait. Don't forget that lesions involving the anterior circulation, such as dysarthria, cognitive impairment, and Horner syndrome may be indicative of a carotid artery dissection, whereas dizziness, vision changes, and limb weakness may be due to a vertebral Artery Dissection. Nachi: And for cranial nerve testing - pay particular attention to cranial nerves 2, 3 and 6. For cranial nerve 2 - look out for an afferent pupillary defect, or a marcus-gunn pupil, which is seen in optic neuritis, giant cell artertitis, and central retinal artery occlusion. For CN3, oculomotor nerve palsies raise concern for a posterior communicating aneurysm and SAH. And lastly, CN6 palsies, which often presents with diplopia on lateral gaze , are often seen with intracranial idiopathic hypertension and cerebral venous thrombosis, in addition to impaired visual acuity, visual field defects, and tunnel vision. Jeff: For the head and neck exam, remember that a partial horner syndrome, with miosis and ptosis without anhidrosis, may be indicative of a cervical artery dissection. Unfortunately, if the patient presents acutely, their only complaint may be pain, as the neurologic sequelae may take days to develop. Nachi: Additionally, with respect to the head and neck exam, evaluate the patient for tenderness and beading along the temporal artery. Jeff: One review noted that temporal artery beading actually had the highest likelihood ratio for GCA, 4.6, whereas temporal artery tenderness only had a LR of 2.6 Nachi: And the last physical exam maneuver you should ideally perform is a fundoscopic exam for papilledema, which is often seen in IIH, malignant hypertension, and CVT. Jeff: Perfect so that rounds out the physical, next we have diagnostic studies. Most importantly, routine lab testing is typically of low utility in aiding in the diagnosis of headache. Nachi: Even ESR and CRP in the setting of possible giant cell arteritis have poor sensitivity and specificity to diagnose it. So even if the ESR and CRP are negative, if the suspicion for GCA is high enough, it should be treated and you should get a biopsy. Jeff: Do consider adding on a venous or arterial carboxyhemoglobin in the right clinical scenario, as CO poisoning represents an important cause of headache you wouldn’t want to miss. This is especially important at this time of year when heating systems are working overtime here in the states. Nachi: And hopefully you have a co-oximeter, so you can even check this non-invasively. Jeff: Interestingly, there may be a unique role for a d-dimer here as well. Several small studies have used the d-dimer to risk stratify patients with possible CVT. In one study a d-dimer level < 500 mcg/L had a 97% sensitivity and a negative predictive value of 99% - not bad! Nachi: Pretty impressive performance characteristics. I think that about wraps up lab work. Let’s talk radiology. Jeff: Though low yield, CT utilization is estimated at 2.5-10% of non-traumatic headaches. A non-con CT should be reserved for those with suspicion for an intracranial hemorrhage, while a contrast CT would be required in those in whom there is concern for an infectious process or space occupying lesion. Nachi: CT angio or MRI should be used in cases of possible cervical artery dissection. MRI also is the neuroimaging of choice for PRES, which is more sensitive for cerebral edema than CT. Jeff: Similarly, MRV is recommended in those with a concerning story for CVT. Nachi: To help guide your emergent neuroimaging utilization, ACEP suggests imaging in those with headache and an abnormal finding on neuro exam, those with new and sudden-onset severe headache, HIV positive patients with new headache, and those over 50 with a new headache. Jeff: With that in mind, let’s dive a bit deeper into the use of CT for SAH, a topic which doesn’t get a ding sound, but is certainly critically important. Recent literature have found that a CT within 6 hours of symptom onset has a sensitivity and specificity and negative predictive value of 100%. In addition, one 2016 study demonstrated a LR of 0.01 in those with a negative HCT within 6 hours. These are really important results because that means SAH is essentially ruled out with a negative study. Nachi: Unfortunately, the 2008 ACEP guideline and 2012 AHA guidelines still recommend a lumbar puncture in those being worked up for SAH. Luckily the ACEP guideline is currently being revised so your decision to forego the LP with a negative HCT in the first 6 hours will likely also be backed by ACEP in the near future. Jeff: That’s a nice transition into our next test - the LP. Since LP carries a risk of herniation, in those with signs of increased ICP, make sure to get appropriate neuroimaging before attempting the puncture. In those without signs of increased ICP, no imaging is necessary. Nachi: While the position in which the LP is performed doesn’t matter as much when ruling out infection or SAH, in those with suspected IIH, make sure to obtain an opening pressure with the patient lying in the lateral decubitus position. An opening pressure of greater than 25 is often seen in IIH. Jeff: And the LP in the setting of IIH is not only diagnostic but also potentially therapeutic, as the removal of 1 ml of CSF can lower the pressure by 1 cm of H20 and potentially relieve the patient’s symptoms. Nachi: Always rewarding to diagnose and treat simultaneously... Jeff: Absolutely. But back to the LP for SAH for a second or two. When evaluating for a subarachnoid hemorrhage, you’ll often note an opening pressure of greater than 20 with persistent RBC in all tubes. Nachi: While there are no RBC cutoffs, one study found no patients with a SAH with less than 100 RBC in the final tube. In contrast, greater than 10,000 RBC increased the odds by a factor of 6. In addition, one 2015 study found that patients without xanthrochromia and less than 2000 RBC were effectively ruled out of having a SAH with a combined sensitivity of 100% Jeff: Lots of 100% sensitivities and specificities being thrown around today, which is definitely not the norm. No complaints here, I’ll take it. Anyway, the last test to discuss is our good friend the ultrasound, specifically the ocular ultrasound. Nachi: Examining the optic nerve sheath 3 mm posterior to the globe, an optic nerve sheath diameter of 5 mm or greater is predictive of an ICP greater than 20. Jeff: Keep in mind that this may expedite the work up, though a normal diameter does not rule out increased ICP, so a head CT may still be indicated. Nachi: Alright, so we’ve talked a lot about testing, both lab and imaging, and we’ve mentioned a bunch of pathologies, but let’s spend a few minutes going over the specifics of each. Jeff: Let’s start with SAH. SAH account for 1% of all headache visits to the ED. Most nontraumatic SAH are caused by aneurysm rupture. A missed diagnosis of SAH can have a case-fatality rate as high as 50% Nachi: Although 75% of SAH patients report an abrupt onset, objective neck stiffness has the highest likelihood ratio of 6.6. Other important features include LOC, neurologic deficit, subjective neck stiffness, photophobia, and onset during exertion or intercourse. Jeff: Additionally, approximately 20% of patients with a SAH have warning signs of a sentinel bleed including headaches, cranial nerve palsies, neck pain, or nausea and vomiting. Nachi: In order to aid you in diagnosing a SAH, you should consider the ottawa SAH Rule which has a 100% sensitivity and a 15% specificity. To use this rule you must be between 15 and 40 with a GCS of 15 and present with a headache with maximal intensity within 1 hour of onset. If you meet those inclusion criteria, and you have no neurologic deficits, no neck pain or stiffness, no witnessed LOC, no onset during exertion, no limitation of neck flexion, and no thunderclap onset, you can essentially rule out a SAH. Jeff: While the ottawa SAH rule has been prospectively validated, know that this study has been challenged for its interobserver variability, but in any case it still provides helpful red flags to consider. If your patient is found to have a SAH, a CT angiogram and neurosurgical consultation should be considered immediately. Nachi: In addition to monitoring ABCs, early care involves the administration of analgesics and anti-emetics. Also consider elevating the head of the bed to 30 deg, which may also improve venous drainage and decrease ICP. Jeff: In terms of BP management, guidelines from the american stroke association recommend targeting a SBP of 160 with a titratable agent like nicardipine or clevidipine. Nachi: In addition, nimodipine, 60 mg q4h, should be given to those with aneurysmal SAH to improve outcomes. Jeff: and any role for anti-epileptics? Nachi: That’s controversial and the authors state it may be considered in the immediate post-hemorrhagic period and should be limited to a 3-7 day course with longer courses required in special populations. Jeff: The next pathology to discuss is cervical artery dissections, which account for 2% of all strokes and nearly 20% of strokes in those 50 and under. cervical artery dissections are most commonly due to trauma, but can occur spontaneously. Nachi: Risk factors include Ehlers-Danlos syndrome, osteogenesis imperfecta, and Marfan syndrome. Jeff: Regardless of the etiology, the management of cervical artery dissections is primarily medical with IV heparin followed by warfarin or a direct oral anticoagulant in those with extracranial dissections, and antiplatelet therapy like aspirin or clopidogrel in those with intracranial dissections. Nachi: Thanks to the CADISP study, we know there is no difference in mortality or neurologic outcome when choosing between antiplatelet therapy and anticoagulation. Jeff: Next we have cerebral venous thrombosis. This typically presents with a gradual onset headache. Though it can happen to anybody, cerebral venous thrombosis typically results from thrombotic disease. Nachi: Important risk factors include oral contraceptive use, pregnancy and postpartum states, Factor V Leiden deficiency, and lupus. Jeff: Treatment for CVT is controversial due to a high risk of hemorrhage and hemorrhagic transformation. According to the best available evidence, anticoagulation is the standard therapy with full dose anticoagulation of low-molecular weight heparin or heparin as a bridge to warfarin. Nachi: Yeah, it’s really a tough spot to be in as one third end up having some form of hemorrhage too…. Jeff: Perhaps yet another good place for shared decision making? Nachi: Honestly, it’s a good thought, but anticoagulation is the guideline recommendation, so I think that is likely the best route in this case. Jeff: Great point. Next we have idiopathic intracranial hypertension. This is typically associated with obese women of childbearing age. It may also be due to hypervitaminosis A from excessive dietary intake and even drugs like the retinoids used in treating dermatologic conditions and cancers. Nachi: idiopathic intracranial hypertension can be diagnosed by the modified dandy criteria which are found in table 8 on page 11. Let’s just run through the criteria. Jeff: The modified Dandy criteria for idiopathic intracranial hypertension include: signs and symptoms of increased ICP, no other neurologic abnormalities or altered level of consciousness, ICP > 20 on LP with normal CSF composition, neuroimaging without another etiology for intracranial hypertension, and lastly no other identified cause of intracranial hypertension. Nachi: And as we mentioned a few minutes ago, an LP can be both diagnostic and therapeutic, though the relief is likely temporary Jeff: For more permanent treatment, weight loss is the key. Acetazolamide, 250 mg to 500 BID is the first line pharmacotherapy. Combined with weight loss, acetazolamide and a low sodium diet has been shown to improve visual field function. Nachi: And if this fails, topiramate, furosemide, and in the worst case surgical options like CSF shunting, venous sinus stenting, and optic sheath fenestration are all options. Jeff: I imagine taking a diuretic for a headache could be a real hindrance on quality of life, though I suppose it’s better than risking vision loss or having a significant neurosurgery. Nachi: Agreed. Next we have giant cell arteritis. GCA is rare, with a prevalence of <1%. It is 3x more likely in women and is really a disease of those older than 50. Jeff: Common features include fever, fatigue, myalgias, headache, jaw claudication, and visual symptoms like diplopia and amaurosis fugax. Treatment should be started in anyone in whom you are highly suspicious. Nachi: And the treatment of choice is high-dose methylprednisolone 15 mg/kg/day for 1-3 days followed by prednisone 40 mg/day. Of course, don’t wait the biopsy to begin treatment if concerned. Jeff: That’s quite a bit of steroids…. Nachi: It is! But again, better than the alternatives. Next up we have PRES. PRES is a form of hypertensive emergency in which severe hypertension leads to cerebral autoregulatory failure, vasodilation, interstitial extravasation of fluid, and brain vasogenic edema. Jeff: PRES is commonly associated with hypertensive encephalopathy, eclampsia, and using immunosuppressive agents. Nachi: PRES usually manifests with an acute onset headache in the setting of elevated BP and altered level of consciousness. Seizures are very common as well. Jeff: PRES should be treated with blood pressure control with your agent of choice, though nicardipine is often preferred, with the goal of reducing the MAP by 25% within the first hour. If it were caused by a medication such as an immunosuppressive, medication cessation will also be imperative. Nachi: While we’re on the topic of BP control, I should also mention two trials, INTERACT-2 and ATACH-2. Results from these trials showed that BP control didn’t appear to impact rates of death or disability, but it was associated with improved functional outcomes. Therefore, current guidelines recommend lowering SBP to 140 in the setting of an ICH. Jeff: We’ve mentioned quite a few BP goals here, but if you can’t remember, start nicardipine to begin lowering the MAP in a controlled and titratable manner. Nachi: The next pathology we haven’t talked about yet, but it certainly is worth discussing - acute angle closure glaucoma. Jeff: Most commonly found in the elderly or hyperoptic patients, acute angle closure glaucoma presents with headache, pain, redness, tearing, photophobia, nausea and vomiting, blurred vision, and seeing halos in the setting of a rapid rise in intraocular pressure above the normal 10-21. Nachi: If untreated, this can lead to fairly rapid vision loss, so initiating treatment with timolol, pilocarpine, and apraclonidine is imperative.. Jeff: And the last pathology to discuss is pre-eclampsia. Nachi: Preeclampsia is defined as hypertension with a systolic bp greater than 140 or a diastolic greater than 90 for 2 readings 4 hours apart, or a systolic greater than 160 or a diastolic greater than 110 for one reading with either proteinuria, thrombocytopenia, liver impairment, renal insufficiency, pulmonary edema and a new-onset headache in a woman who is greater than 20 weeks gestation to 4 weeks postpartum. Jeff: Treat severe preeclampsia, that is preeclampsia with thrombocytopenia, liver impairment, renal insufficiency, pulmonary edema, or new headache with IV magnesium, a 4-6 grams load over 15-20 minutes followed by an infusion of 1-2 g/h. If the patient simply has hypertension and proteinuria, you may skip the magnesium and only use anti-hypertensives, such has labetalol, hydralazine, or nifedipine. And with that, I think we’ve covered all the big secondary causes of headache. Let’s talk disposition. Nachi: Pretty straight forward. Nearly all patients diagnosed with a severe, life-threatening headache will require admission or transfer to a facility with access to a 24-hour neurology critical care team. Jeff: Often such patients will end up in the ICU, so make sure to get the ball rolling early as delays have been shown to increase rates of morbidity and mortality. Nachi: Let’s wrap up this episode with a quick review of key points and clinical pearls. 1. Headaches account for 3% of all ED visits, with 90% being benign primary headaches. 2. The most common life-threatening causes of headaches are subarachnoid hemorrhage (SAH), cervical artery dissection (CAD), cerebral venous thrombosis (CVT), idiopathic intracranial hypertension (IIH), giant cell arteritis (GCA), and posterior reversible encephalopathy syndrome (PRES). 3. SAH accounts for 1% of all headaches and is commonly caused by aneurysm rupture. 75% present with abrupt onset. Nimodipine should be administered to those with aneurysmal SAH to improve outcomes. The use of prophylactic antiepileptic drugs is controversial. 4. CAD accounts for 2% of all strokes and is commonly associated with trauma and connective tissue disorders. Treat with IV heparin followed by warfarin or a direct oral anticoagulant in those with extracranial dissections, and treat with aspirin or clopidogrel in those with intracranial dissections 5. CVT presents as a gradual-onset headache which is often the result of thrombotic disease and spreading facial infections. Current recommendations for the treatment of CVT include low-molecular weight heparin or heparin as a bridge to warfarin. Consider broad-spectrum antibiotics if an infectious etiology is suspected. 6. IIH is associated with obese women of childbearing age as well as hypervitaminosis A. Lumbar puncture is both diagnostic and therapeutic for IIH. The LP should be performed in the lateral decubitus position to measure opening pressures, which will be greater than or equal to 25. Acetazolamide is a first-line pharmacotherapy. 7. GCA is more common in woman and is almost exclusively found in patients older than 50. Common features include fever, fatigue, myalgias, jaw claudication, and visual symptoms. Polymyalgia rheumatica is present in more than half of all cases. Treat with steroids. 8. PRES is a form of hypertensive emergency due to cerebral autoregulatory failure, vasodilatation, interstitial extravasation of fluid, and vasogenic brain edema. PRES is treated with blood pressure control, typically with nicardipine or labetalol. 9. When treating hypertensive emergencies, aim for a 25% reduction in MAP in the first hour. 10. Based on data from the INTERACT-2 and ATACH-2 trials, for patients with ICH, lowering SBP to <140 is safe. This, however, does not impact death or disability, but it is associated with improved functional outcomes. 11. For patients with an aneurysmal SAH, target an SBP of 160 using nicardipine or clevidipine. 12. Pre-eclampsia is defined as elevated blood pressure with proteinuria or other severe symptoms after 20 weeks’ gestation. Treat with 4-6 g of magnesium as a loading dose, followed by 1-2g/h as maintenance in addition to antihypertensives. 13. Acute angle closure glaucoma is found most commonly in the elderly. It presents with headache, pain, redness, tearing, photophobia, nausea, blurred vision, and vision loss. Treat with timolol, pilocarpine, and apraclonidine while awaiting an ophthalmology consult. 1. Routine laboratory testing in the setting of a headache is generally of low utility. ESR and CRP are poor screening tests for GCA. Biopsies should be obtained in those with high suspicion for GCA after treatment has already begun. 2. Consider a d-dimer in low risk patients to exclude CVT. 3. Non-contrast and contrast head CT should be reserved for those suspected of having acute intracranial hemorrhage and space occupying lesions. MRV is the test of choice for concern of CVT. 4. A non-contrast head CT performed within 6 hours of onset of headache is adequate to rule out SAH. A lumbar puncture looking at RBC and xanthochromia will be required if outside of this window. Utilize shared decision making to determine an appropriate testing and treatment plan. 5. Ocular ultrasound can expedite the diagnosis and management of ocular emergencies and rapidly diagnose ICP by measuring optic sheath diameter. Optic nerve sheath diameter greater than 5 mm is predictive of an intracranial pressure > 20. Jeff: So that wraps up episode 25 - Evaluation and Management of Life-Threatening Headaches in the Emergency Department . Nachi: Additional materials are available on our website for Emergency Medicine Practice subscribers. If you’re not a subscriber, consider joining today. You can find out more at www.ebmedicine.net/subscribe. Subscribers get in-depth articles on hundreds of emergency medicine topics, concise summaries of the articles, calculators and risk scores, and CME credit. You’ll also get enhanced access to the podcast, including the images and tables mentioned. You can find everything you need to know at ebmedicine.net/subscribe. Jeff: It’s also worth mentioning for current subscribers that the website has just undergone a major rehaul and update. The new site is easier to use on mobile browsers, has better search functionality, mobile-friendly CME testing, and quick access to the digest and podcast. Nachi: And the address for this month’s credit is ebmedicine.net/E0219, so head over there to get your CME credit. As always, the you heard throughout the episode corresponds to the answers to the CME questions. Lastly, be sure to find us on iTunes and rate us or leave comments there. You can also email us directly at [email protected] with any comments or suggestions. Talk to you next month! Most Important References 1.* Headache Classification Subcommittee of the International Headache Society. The International Classification of Headache Disorders, 3rd edition. Cephalalgia. 2018;38(1):1- 211. (Clinical guideline) 7.* Edlow JA, Panagos PD, Godwin SA, et al. Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with acute headache. Ann Emerg Med. 2008;52(4):407-436. (Clinical policy) 15.* Carpenter CR, Hussain AM, Ward MJ, et al. Spontaneous subarachnoid hemorrhage: a systematic review and meta-analysis describing the diagnostic accuracy of history, physical examination, imaging, and lumbar puncture with an exploration of test thresholds. Acad Emerg Med. 2016;23(9):963-1003. (Meta-analysis; 22 studies) 54.* Perry JJ, Stiell IG, Sivilotti ML, et al. Sensitivity of computed tomography performed within six hours of onset of headache for diagnosis of subarachnoid hemorrhage: prospective cohort study. BMJ. 2011;343:d4277. (Prospective; 3132 patients) 65.* Anderson CS, Heeley E, Huang Y, et al. Rapid blood-pressure lowering in patients with acute intracerebral hemorrhage. N Engl J Med. 2013;368(25):2355-2365. (Prospective; 2794 patients) 87.* ACOG Task Force on Hypertension and Pregnancy. Hypertension in pregnancy. American College of Obstetricians and Gynecologists. Available at:www.acog.org/~/media/Task%20Force%20and%20Work%20Group%20Reports/public/HypertensioninPregnancy.pdf. Accessed January 10, 2019. (Expert/guideline recommendations)

  Jeff: Welcome back to Emplify, the podcast corollary to EB Medicine’s Emergency Medicine Practice. I’m Jeff Nusbaum, and I’m back with my co-host, Nachi Gupta. This month, we’re talking about a topic… Nachi: … woah wait, slow down for a minute, before we begin this month’s episode – we should take a quick pause to wish all of our listeners a happy new year! Thanks for your regular listenership and feedback. Jeff: And we’re actually hitting the two year mark since we started this podcast. At 25 episodes now, this is sort of our silver anniversary. Nachi: We have covered a ton of topics in emergency medicine so far, and we are looking forward to reviewing a lot more evidence based medicine with you all going forward. Jeff: With that, let’s get into the first episode of 2019 – the topic this month is first trimester pregnancy emergencies: recognition and management. Nachi: This month’s issue was authored by Dr. Ryan Pedigo, you may remember him from the June 2017 episode on dental emergencies, though he is perhaps better known as the director of undergraduate medical education at Harbor-UCLA Medical center. In addition, this issue was peer reviewed by Dr. Jennifer Beck-Esmay, assistant residency director at Mount Sinai St. Luke’s, and Dr. Taku Taira, the associate director of undergraduate medical education and associate clerkship director at LA County and USC department of Emergency Medicine. Jeff: For this review, Dr. Pedigo had to review a large body of literature, including thousands of articles, guidelines from the American college of obstetricians and gynecologists or ACOG, evidence based Practice bulletins, ACOG committee opinions, guidelines from the American college of radiology, the infectious diseases society of America, clinical policies from the American college of emergency physicians, and finally a series of reviews in the Cochrane database. Nachi: There is a wealth of literature on this topic and Dr. Pedigo comments that the relevant literature is overall “very good.” This may be the first article in many months for which there is an overall very good quality of literature. Jeff: It’s great to know that there is good literature on this topic. It’s incredibly important as we are not dealing with a single life here, as we usually do... we are quite literally dealing with potentially two lives as the fetus moves towards viability. With opportunities to improve outcomes for both the fetus and the mother, I’m confident that this episode will be worth your time. Nachi: Oh, and speaking of being worth your time…. Don’t forget that if you’re listening to this episode, you can claim your CME credit. Remember, the indicates an answer to one of the CME questions so make sure to keep the issue handy. Jeff: Let’s get started with some background. First trimester emergencies are not terribly uncommon in pregnancy. One study reported 85% experience nausea and vomiting. Luckily only 3% of these progressed to hyperemesis gravidarum. In addition, somewhere between 7-27% experience vaginal bleeding or miscarriage. Only 2% of these will be afflicted with an ectopic pregnancy. Overall, the maternal death rate is about 17 per 100,000 with huge racial-ethnic disparities. Nachi: And vaginal bleeding in pregnancy occurs in nearly 25% of patients. Weeks 4-8 represent the peak time for this. The heavier the bleeding, the higher the risk of miscarriage. Jeff: Miscarriage rates vary widely based on age, with an overall rate of 7-27%. This rises to nearly 40% risk in those over 40. And nearly half of miscarriages are due to fetal chromosomal abnormalities. Nachi: For patient who have a threatened miscarriage in the first trimester, there is a 2-fold increased risk of subsequent maternal and fetal adverse outcomes. Jeff: So key points here, since I think the wording and information you choose to share with often scared and worried women is important – nearly 25% of women experience bleeding in their first trimester. Not all of these will go on to miscarriages, though the risk does increase with maternal age. And of those that miscarry, nearly 50% were due to fetal chromosomal abnormalities. Nachi: So can we prevent a miscarriage, once the patient is bleeding…? Jeff: Short answer, no, longer answer, we’ll get to treatment in a few minutes. For now, let’s continue outlining the various first trimester emergencies. Next up, ectopic pregnancy… Nachi: An ectopic pregnancy is implantation of a fertilized ovum outside of the endometrial cavity. This occurs in up to 2% of pregnancies. About 98% occur in the fallopian tube. Risk factors for an ectopic pregnancy include salpingitis, history of STDs, history of PID, a prior ectopic, and smoking. Jeff: Interestingly, with respect to smoking, there is a dose-relationship between smoking and ectopic pregnancies. Simple advice here: don’t smoke if you are pregnant or trying to get pregnant. Nachi: Pretty sound advice. In addition, though an IUD is not a risk factor for an ectopic pregnancy, if you do become pregnant while you have in IUD in place, over half of these may end up being ectopic. Jeff: It’s also worth mentioning a more obscure related disease pathology here – the heterotopic pregnancy -- one in which there is an IUP and an ectopic pregnancy simultaneously. Nachi: Nausea and vomiting, though not as scary as miscarriages or an ectopic pregnancy, represent a fairly common pathophysiologic response in the first trimester -- with the vast majority of women experiencing nausea and vomiting. And as we mentioned earlier, only 3% of these progress to hyperemesis gravidarum. Jeff: And while nausea and vomiting clearly sucks, they seem to actually be protective of pregnancy loss, with a hazard ratio of 0.2. Nachi: Although this may be protective of pregnancy loss, nausea and vomiting can really decrease the quality of life in pregnancy -- with one study showing that about 25% of women with severe nausea and vomiting had actually considered pregnancy termination. 75% of those women also stated they would not want to get pregnant again because of these symptoms. Jeff: So certainly a big issue.. Two other common first trimester emergency are asymptomatic bacteriuria and UTIs. In pregnant patients, due to anatomical and physiologic changes in the GU tract – such as hydroureteronephrosis that occurs by the 7th week and urinary stasis due to bladder displacement – asymptomatic bacteriuria is a risk factor for developing pyelonephritis. Nachi: And pregnant women are, of course, still susceptible to the normal ailments of young adult women like acute appendicitis, which is the most common surgical problem in pregnancy. Jeff: Interestingly, based on epidemiologic data, pregnant women are less likely to have appendicitis than age-matched non-pregnant woman. I’d like to think that there is a good pathophysiologic explanation there, but I don’t have a clue as to why that might be. Nachi: Additionally, the RLQ is the the most common location of pain from appendicitis in pregnancies of all gestational ages. Peritonitis is actually slightly more common in pregnant patients, with an odds ratio of 1.3. Jeff: Alright, so I think we can put that intro behind us and move on to the differential. Nachi: When considering the differential for abdominal pain or vaginal bleeding in the first trimester, you have to think broadly. Among gynecologic causes, you should consider miscarriage, septic abortion, ectopic pregnancy, corpus luteum cyst, ovarian torsion, vaginal or cervical lacerations, and PID. For non-gynecologic causes, you should also consider appendicitis, cholecystitis, hepatitis, and pyelonephritis. Jeff: In the middle of that laundry list you mentioned there is one pathology which I think merits special attention - ovarian torsion. Don’t forget that patients undergoing ovarian stimulation as part of assisted reproductive technology are at a particularly increased risk due to the larger size of the ovaries. Nachi: Great point. Up next we have prehospital care... Jeff: Always a great section. First, prehospital providers should attempt to elicit an ob history. Including the number of weeks’ gestation, LMP, whether an IUP has already been confirmed, prior hx of ectopic, and amount of vaginal bleeding. In addition, providers should consider an early destination consult both to select the correct destination and to begin the process of mobilizing resources early in those patients who really need them, such as those with hemodynamic instability. Nachi: As with most pathologies, the more time you give the receiving facility to prepare, the better the care will be, especially the early care, which is critical. Jeff: Now that the patient has arrived in the ED we can begin our H&P. Nachi: When eliciting the patient’s obstetrical history, it’s common to use the G’s and Ps. This can be further annotated using the 4-digit TPAL method, that’s term-preterm-abortus-living. Jeff: With respect to vaginal bleeding, make sure to ask about the number of pads and how this relates to the woman’s normal number of pads. In addition, make sure to ask about vaginal discharge or even about the passage of tissue. Nachi: You will also need to elicit whether or not the patient has a history of a prior ectopic pregnancies as this is a major risk for future ectopics. And ask about previous sexually transmitted infections also. Jeff: And, of course, make sure to elicit a history of assisted reproductive technology, as this increases the risk of a heterotopic pregnancy. Nachi: Let’s move on to the physical. While you are certainly going to perform your standard focused physical exam, just as you would for any non-pregnant woman - what does the evidence say about the pelvic exam? I know this is a HOTLY debated topic among EM Docs. Jeff: Oh it certainly is. Dr. Pedigo takes a safe, but fair approach, noting, “A pelvic exam should always be performed if the emergency clinician suspects that it would change management, such as identifying the source of bleeding, or identifying an STD or PID.” However, it is noteworthy that the only real study he cites on this topic, an RCT of pelvic vs no pelvic in those with a confirmed IUP and first trimester bleeding, found no difference between the two groups. Obviously, the pelvic group reported more discomfort. Nachi: You did leave out one important fact about the study enrollment - they only enrolled about 200 of 700 intended patients. Jeff: Oh true, so a possibly underpowered study, but it’s all we’ve got on the topic. I think I’m still going to do pelvic exams, but it’s something to think about. Nachi: Moving on, all unstable patients with vaginal bleeding and no IUP should be assumed to have an ectopic until proven otherwise. Ruptured ectopics can manifest with a number of physical exam findings including abdominal tenderness, with peritoneal signs, or even with bradycardia due to vagal stimulation in the peritoneum. Jeff: Perhaps most importantly, no history or physical alone can rule in or out an ectopic pregnancy, for that you’ll need testing and imaging or operative findings. Nachi: And that’s a perfect segue into our next section - diagnostic studies. Jeff: Up first is the urine pregnancy test. A UPT should be obtained in all women of reproductive age with abdominal pain or vaginal bleeding, and likely other complaints too, though we’re not focusing on them now. Nachi: The UPT is a great test, with nearly 100% sensitivity, even in the setting of very dilute urine. False positives are certainly plausible, with likely culprits being recent pregnancy loss, exogenous HCG, or malignancy. Jeff: And not only is the sensitivity great, but it’s usually positive just 6-8 days after fertilization. Nachi: While the UPT is fairly straight forward, let’s talk about the next few tests in the context of specific disease entities, as I think that may make things a bit simpler -- starting with bHCG in the context of miscarriage and ectopic pregnancy. Jeff: Great starting point since there is certainly a lot of debate about the discriminatory zone. So to get us all on the same page, the discriminatory zone is the b-HCG at which an IUP is expected to be seen on ultrasound. Generally 1500 is used as the cutoff. This corresponds nicely to a 2013 retrospective study demonstrating a bHCG threshold for the fetal pole to be just below 1400. Nachi: However, to actually catch 99% of gestational sacs, yolk sacs, and fetal poles, one would need cutoffs of around 3500, 18000, and 48,000 respectively -- much higher. Jeff: For this reason, if you want to use a discriminatory zone, ACOG recommends a conservatively high 3,500, as a cutoff. Nachi: I think that’s an understated point in this article, the classic teaching of a 1500 discriminatory zone cutoff is likely too low. Jeff: Right, which is why I think many ED physicians practice under the mantra that it’s an ectopic until proven otherwise. Nachi: Certainly a safe approach. Jeff: Along those lines, lack of an IUP with a bHCG above whatever discriminatory zone you are using does not diagnose an ectopic, it merely suggests a non-viable pregnancy of undetermined location. Nachi: And if you don’t identify an IUP, serial bHCGs can be really helpful. As a rule of thumb -- in cases of a viable IUP -- b-HCG typically doubles within 48 hours and at a minimum should rise 53%. Jeff: In perhaps one of the most concerning things I’ve read in awhile, one study showed that ⅓ of patients with an ectopic had a bCHG rise of 53% in 48h and 20% of patients with ectopics had a rate of decline typical to that of a miscarriage. Nachi: Definitely concerning, but this is all the more reason you need to employ our favorite imaging modality… the ultrasound. Jeff: All patients with a positive pregnancy test and vaginal bleeding should receive an ultrasound performed by either an emergency physician or by radiology. Combined with a pelvic exam, this can give you almost all the data necessary to make the diagnosis, even if you don’t find an IUP. Nachi: And yes, there is good data to support ED ultrasound for this indication, both transabdominal and transvaginal, assuming the emergency physician is credentialed to do so. A 2010 Meta-Analysis found a NPV of 99.96% when an er doc identified an IUP on bedside ultrasound. So keep doing your bedside scans with confidence. Jeff: Before we move on to other diagnostic tests, let’s discuss table 2 on page 7 to refresh on key findings of each of the different types of miscarriage. For a threatened abortion, the os would be closed with an IUP seen on ultrasound. For a completed abortion, you would expect a closed OS with no IUP on ultrasound with a previously documented IUP. Patients may or may not note the passage of products of conception. Nachi: A missed abortion presents with a closed os and a nonviable fetus on ultrasound. Findings such as a crown-rump length of 7 mm or greater without cardiac motion is one of several criteria to support this diagnosis. Jeff: An inevitable abortion presents with an open OS and an IUP on ultrasound. Along similar lines, an incomplete abortion presents with an open OS and partially expelled products on ultrasound. Nachi: And lastly, we have the septic abortion, which is sort of in a category of its own. A septic abortion presents with either an open or closed OS with essentially any finding on ultrasound in the setting of an intrauterine infection and a fever. Jeff: I’ve only seen this two times, and both women were incredibly sick upon presentation. Such a sad situation. Nachi: For sure. Before we move on to other tests, one quick note on the topic of heterotopic pregnancies: because the risk in the general population is so incredibly low, the finding of an IUP essentially rules out an ectopic pregnancy assuming the patient hasn’t been using assisted reproductive technology. In those that are using assisted reproductive technology, the risk rises to 1 in 100, so finding an IUP, in this case, doesn’t necessarily rule out a heterotopic pregnancy. Jeff: Let’s move on to diagnostic studies for patients with nausea and vomiting. Typically, no studies are indicated beyond whatever you would order to rule out other serious pathology. Checking electrolytes and repleting them should be considered in those with severe symptoms. Nachi: For those with symptoms suggestive of a UTI, a urinalysis and culture should be sent. Even if the urinalysis is negative, the culture may still have growth. Treat asymptomatic bacteriuria and allow the culture growth to guide changes in antibiotic selection. Jeff: It’s worth noting, however, that a 2016 systematic review found no reliable evidence supporting routine screening for asymptomatic bacteriuria, so send a urinalysis and culture only if there is suspicion for a UTI. Nachi: For those with concern for appendicitis, while ultrasound is a viable imaging modality, MRI is gaining favor. Both are specific tests, however one study found US to visualize the appendix only 7% of the time in pregnant patients. Jeff: Even more convincingly, one 2016 meta analysis found MRI to have a sensitivity and specificity of 94 and 97% respectively suggesting that a noncontrast MRI should be the first line imaging modality for potential appendicitis. Nachi: You kind of snuck it in there, but this is specifically a non-contrast MRI. Whereas a review of over a million pregnancies found no associated fetal risk with routine non-contrast MRI, gadolinium-enhanced MRI has been associated with increased rates of stillbirth, neonatal death, and rheumatologic and inflammatory skin conditions. Jeff: CT is also worth mentioning since MRI and even ultrasound may not be available to all of our listeners. If you do find yourself in such a predicament, or you have an inconclusive US without MRI available, a CT scan may be warranted as the delay in diagnosis and subsequent peritonitis has been found to increase the risk of preterm birth 4-fold. Nachi: Right, and a single dose of ionizing radiation actually does not exceed the threshold dose for fetal harm. Jeff: Let’s talk about the Rh status and prevention of alloimmunization. While there are no well-designed studies demonstrating benefit to administering anti-D immune globulin to Rh negative patients, ACOG guidelines state “ whether to administer anti-D immune globulin to a patient with threatened pregnancy loss and a live embryo or fetus at or before 12 weeks of gestation is controversial, and no evidence-based recommendation can be made.” Nachi: Unfortunately, that’s not particularly helpful for us. But if you are going to treat an unsensitized Rh negative female with vaginal bleeding while pregnant with Rh-immune globulin, they should receive 50 mcg IM of Rh-immune globulin within 72 hours, or the 300 mcg dose if that is all that is available. It’s also reasonable to administer Rh(d)-immune globulin to any pregnant female with significant abdominal trauma. Jeff: Moving on to the treatment for miscarriages - sadly there isn’t much to offer here. For those with threatened abortions, the vast majority will go on to a normal pregnancy. Bedrest had been recommended in the past, but there is little data to support this practice. Nachi: For incomplete miscarriages, if visible, products should be removed and you should consider sending those products to pathology for analysis, especially if the patient has had recurrent miscarriages. Jeff: For those with a missed abortion or incomplete miscarriages, options include expectant management, medical management or surgical management, all in consultation with an obstetrician. It’s noteworthy that a 2012 Cochrane review failed to find clear superiority for one strategy over another. This result was for the most part re-confirmed in a 2017 cochrane review. The latter study did find, however, that surgical management in the stable patient resulted in lower rates of incomplete miscarriage, bleeding, and need for transfusion. Nachi: For expectant management, 50-80% will complete their miscarriage within 7-10 days. Jeff: For those choosing medical management, typically with 800 mcg of intravaginal misoprostol, one study found this to be 91% effective in 7 days. This approach is preferred in low-resource settings. Nachi: And lastly, remember that all of these options are only options for stable patients. Surgical management is mandatory for patients with significant hemorrhage or hemodynamic instability. Jeff: Since the best evidence we have doesn’t suggest a crystal clear answer, you should rely on the patient’s own preferences and a discussion with their obstetrician. For this reason and due to the inherent difficulty of losing a pregnancy, having good communication is paramount. Nachi: Expert consensus recommends 6 key aspects of appropriate communication in such a setting: 1 assess the meaning of the pregnancy loss, give the news in a culturally competent and supportive manner, inform the family that grief is to be expected and give them permission to grieve in their own way, learn to be comfortable sharing the products of conception should the woman wish to see them, 5. provide support for whatever path she chooses, 6. and provide resources for grief counselors and support groups. Jeff: All great advice. The next treatment to discuss is that for pregnancy of an unknown location and ectopic pregnancies. Nachi: All unstable patients or those with suspected or proven ectopic or heterotopic pregnancies should be immediately resuscitated and taken for surgical intervention. Jeff: For those that are stable, with normal vitals, and no ultrasound evidence of a ruptured ectopic, with no IUP on ultrasound, -- that is, those with a pregnancy of unknown location, they should be discharged with follow up in 48 hours for repeat betaHCG and ultrasound. Nachi: And while many patients only need a single additional beta check, some may need repeat 48 hour exams until a diagnosis is established. Jeff: For those that are stable with a confirmed tubal ectopic, you again have a variety of treatment options, none being clearly superior. Nachi: Treatment options here include IM methotrexate, or a salpingostomy or salpingectomy. Jeff: Do note, however, that a bHCG over 5000, cardiac activity on US, and inability to follow up are all relative contraindications to methotrexate treatment. Absolute contraindications to methotrexate include cytopenia, active pulmonary disease, active peptic ulcer disease, hepatic or renal dysfunction, and breastfeeding. Nachi: Such decisions, should, of course, be made in conjunction with the obstetrician. Jeff: Always good to make a plan with the ob. Moving on to the treatment of nausea and vomiting in pregnancy, ACOG recommends pyridoxine, 10-25 mg orally q8-q6 with or without doxylamine 12.5 mg PO BID or TID. This is a level A recommendation as first-line treatment! Nachi: In addition, ACOG also recommends nonpharmacologic options such as acupressure at the P6 point on the wrist with a wrist band. Ginger is another nonpharmacologic intervention that has been shown to be efficacious - 250 mg by mouth 4 times a day. Jeff: So building an algorithm, step one would be to consider ginger and pressure at the P6 point. Step two would be pyridoxine and doxylamine. If all of these measures fail, step three would be IV medication - with 10 mg IV of metoclopramide being the agent of choice. Nachi: By the way, ondansetron carries a very small risk of fetal cardiac abnormalities, so the other options are of course preferred. Jeff: In terms of fluid choice for the actively vomiting first trimester woman, both D5NS and NS are appropriate choices, with slightly decreased nausea in the group receiving D5NS in one randomized trial of pregnant patients admitted for vomiting to an overnight observation unit. Nachi: Up next for treatment we have asymptomatic bacteriuria. As we stated previously, asymptomatic bacteriuria should be treated. This is due to anatomical and physiologic changes which put these women at higher risk than non-pregnant women. Jeff: And this recommendation comes from the 2005 IDSA guidelines. In one trial, treatment of those with asymptomatic bacteriuria with nitrofurantoin reduced the incidence of developing pyelonephritis from 2.4% to 0.6%. Nachi: And this trial specifically examined the utility of nitrofurantoin. Per a 2010 and 2011 Cochrane review, there is not evidence to recommend one antibiotic over another, so let your local antibiograms guide your treatment. Jeff: In general, amoxicillin or cephalexin for a full 7 day course could also be perfectly appropriate. Nachi: A 2017 ACOG Committee Opinion analyzed nitrofurantoin and sulfonamide antibiotics for association with birth defects. Although safe in the second and third trimester, they recommend use in the first trimester -- only when no other suitable alternatives are available. Jeff: For those, who unfortunately do go on to develop pyelo, 1g IV ceftriaxone should be your drug of choice. Interestingly, groups have examined outpatient care with 2 days of daily IM ceftriaxone vs inpatient IV antibiotic therapy and they found that there may be a higher than acceptable risk in the outpatient setting as several required eventual admission and one developed septic shock in their relatively small trial. Nachi: And the last treatment to discuss is for pregnant patient with acute appendicitis. Despite a potential shift in the standard of care for non pregnant patients towards antibiotics-only as the initial treatment, due to the increased risk of serious complications for pregnant women with an acute appy, the best current evidence supports a surgical pathway. Jeff: Perfect, so that wraps up treatment. We have a few special considerations this month, the first of which revolves around ionizing radiation. Ideally, one should limit the amount of ionizing radiation exposure during pregnancy, however avoiding it all together may lead to missed or delayed diagnoses and subsequently worse outcomes. Nachi: It’s worth noting that the American College of Radiology actually lists several radiographs that are such low exposure that checking a urine pregnancy test isn’t even necessary. These include any imaging of the head and neck, extremity CT, and chest x-ray. Jeff: Of course, an abdomen and pelvis CT carries the greatest potential risk. However, if necessary, it’s certainly appropriate as long as there is a documented discussion of the risk and benefits with the patient. Nachi: And regarding iodinated contrast for CT -- it appears to present no known harm to the fetus, but this is based on limited data. ACOG recommends using contrast only if “absolutely required”. Jeff: Right and that’s for iodinated contrasts. Gadolinium should always be avoided. Let me repeat that Gadolinium should always be avoided Nachi: Let’s also briefly touch on a controversial topic -- that of using qualitative urine point of care tests with blood instead of urine. In short, some devices are fda-approved for serum, but not whole blood. Clinicians really just need to know the equipment and characteristics at their own site. It is worth noting that there have been studies on determining whether time can be saved by using point of care blood testing instead of urine for the patient who is unable to provide a prompt sample. Initial study conclusions are promising. But again, you need to know the characteristics of the test at your ER. Jeff: One more controversy in this issue is that of expectant management for ectopic pregnancy. A 2015 randomized trial found similar outcomes for IM methotrexate compared to placebo for tubal ectopics. Inclusion criteria included hemodynamic stability, initial b hcg < 2000, declining b hcg titers 48 hours prior to treatment, and visible tubal pregnancy on trans vaginal ultrasound. Another 2017 multicenter randomized trial found similar results. Nachi: But of course all of these decisions should be made in conjunction with your obstetrician colleagues. Jeff: Let’s move on to disposition. HDS patients who are well-appearing with a pregnancy of undetermined location should be discharged with a 48h beta hcg recheck and ultrasound. All hemodynamically unstable patients, should of course be admitted and likely taken directly to the OR. Nachi: Also, all pregnant patients with acute pyelonephritis require admission. Outpatient tx could be considered in consultation with ob. Jeff: Patient with hyperemesis gravidarum who do not improve despite treatment in the ED should also be admitted. Nachi: Before we close out the episode, let’s go over some key points and clinical pearls... J Overall, roughly 25% of pregnant women will experience vaginal bleeding and 7-27% of pregnant women will experience a miscarriage 2. Becoming pregnant with an IUD significantly raises the risk of ectopic pregnancy. 3. Ovarian stimulation as part of assisted reproductive technology places pregnant women at increased risk of ovarian torsion. 4. Due to anatomical and physiologic changes in the genitourinary tract, asymptomatic bacteriuria places pregnant women at higher risk for pyelonephritis. As such, treat asymptomatic bacteriuria according to local antibiograms. 5. A pelvic exam in the setting of first trimester bleeding is only warranted if you suspect it might change management. 6. Unstable patients with vaginal bleeding and no IUP should be assumed to have an ectopic pregnancy until proven otherwise. 7. If you are to use a discriminatory zone, ACOG recommends a beta-hCG cutoff of 3500. 8. The beta-hCG typically doubles within 48 hours during the first trimester. It should definitely rise by a minimum of 53%. 9. For patients using assisted reproductive technology, the risk of heterotopic pregnancy becomes much higher. Finding an IUP does not necessarily rule out a heterotopic pregnancy. N. Send a urine culture for patients complaining of UTI symptoms even if the urinalysis is negative. J. The most common surgical problem in pregnancy is appendicitis. N, If MRI is not available and ultrasound was inconclusive, CT may be warranted for assessing appendicitis. The risk of missing or delaying the diagnosis may outweigh the risk of radiation. J. ACOG recommends using iodinated contrast only if absolutely required. N. For stable patients with a pregnancy of unknown location, plan for discharge with follow up in 48 hours for a repeat beta-hCG and ultrasound. J For nausea and vomiting in pregnancy, try nonpharmacologic treatments like acupressure at the P6 point on the wrist or ginger supplementation. First line pharmacologic treatment is pyridoxine. Doxylamine can be added. Ondansetron may increase risk of fetal cardiac abnormalities N So that wraps up episode 24 - First Trimester Pregnancy Emergencies: Recognition and Management. J: Additional materials are available on our website for Emergency Medicine Practice subscribers. If you’re not a subscriber, consider joining today. You can find out more at www.ebmedicine.net/subscribe. Subscribers get in-depth articles on hundreds of emergency medicine topics, concise summaries of the articles, calculators and risk scores, and CME credit. You’ll also get enhanced access to the podcast, including the images and tables mentioned. You can find everything you need to know at ebmedicine.net/subscribe. N: And the address for this month’s credit is ebmedicine.net/E0119, so head over there to get your CME credit. As always, the you heard throughout the episode corresponds to the answers to the CME questions. Lastly, be sure to find us on iTunes and rate us or leave comments there. You can also email us directly at [email protected] with any comments or suggestions. Talk to you next month!  

  Jeff: Welcome back to Emplify, the podcast corollary to EB Medicine’s Emergency Medicine Practice. I’m Jeff Nusbaum, and I’m back with my co-host, Nachi Gupta. This month, we’re talking about a topic that is ripe for review this time of year. We’re talking Influenza… Diagnosis and Management. Nachi: Very appropriate as the cold is settling in here in NYC and we’re already starting to see more cases of influenza. Remember that as you listen through the episode, the means we’re about to cover one of the CME questions for those of you listening at home with the print issue handy. Jeff: This month’s issue was authored by Dr. Al Giwa of the Icahn School of Medicine at Mount Sinai, Dr. Chinwe Ogedegbe of the Seton Hall School of Medicine, and Dr. Charles Murphy of Metrowest Medical Center. Nachi: And this issue was peer reviewed by Dr. Michael Abraham of the University of Maryland School of Medicine and by Dr. Dan Egan, Vice Chair of Education of the Department of Emergency Medicine at Columbia University. Jeff: The information contained in this article comes from articles found on pubmed, the cochrane database, center for disease control, and the world health organization. I’d say that’s a pretty reputable group of sources. Additionally, guidelines were reviewed from the american college of emergency physicians, infectious disease society of america, and the american academy of pediatrics. Nachi: Some brief history here to get us started -- did you know that in 1918/1919, during the influenza pandemic, about one third of the world’s population was infected with influenza? Jeff: That’s wild. How do they even know that? Nachi: Not sure, but also worth noting -- an estimated 50 million people died during that pandemic. Jeff: Clearly a deadly disease. Sadly, that wasn’t the last major outbreak… fifty years later the 1968 hong kong influenza pandemic, H3N2, took between 1 and 4 million lives. Nachi: And just last year we saw the 2017-2018 influenza epidemic with record-breaking ED visits. This was the deadliest season since 1976 with at least 80,000 deaths. Jeff: The reason for this is multifactorial. The combination of particularly mutagenic strains causing low vaccine effectiveness, along with decreased production of IV fluids and antiviral medication because of the hurricane, all played a role in last winter’s disastrous epidemic. Nachi: Overall we’re looking at a rise in influenza related deaths with over 30,000 deaths annually in the US attributed to influenza in recent years. The ED plays a key role in outbreaks, since containment relies on early and rapid identification and treatment. Jeff: In addition to the mortality you just cited, influenza also causes a tremendous strain on society. The CDC estimates that epidemics cost 10 billion dollars per year. They also estimate that an epidemic is responsible for 3 million hospitalized days and 31 million outpatient visits each year. Nachi: It is thought that up to 20% of the US population has been infected with influenza in the winter months, disproportionately hitting the young and elderly. Deaths from influenza have been increasing over the last 20 years, likely in part due to a growing elderly population. Jeff: And naturally, the deaths that we see from influenza also disproportionately affect the elderly, with up to 90% occurring in those 65 or older. Nachi: Though most of our listeners probably know the difference between an influenza epidemic and pandemic, let’s review it anyway. When the number of cases of influenza is higher than what would be expected in a region, an epidemic is declared. When the occurrence of disease is on a worldwide spectrum, the term pandemic is used. Jeff: I think that’s enough epidemiology for now. Let’s get started with the basics of the influenza virus. Influenza is spread primarily through direct person-to-person contact via expelled respiratory secretions. It is most active in the winter months, but can be seen year-round. Nachi: The influenza virus is a spherical RNA-based virus of the orthomyxoviridae family. The RNA core is associated with a nucleoprotein antigen. Variations of this antigen have led to the the 3 primary subgroups -- influenza A, B, and C, with influenza A being the most common. Jeff: Influenza B is less frequent, but is more frequently associated with epidemics. And Influenza C is the form least likely to infect humans -- it is also milder than both influenza A or B. Nachi: But back to Influenza A - it can be further classified based on its transmembrane or surface proteins, hemagglutinin and neuraminidase - or H and N for short. There are actually 16 different H subtypes and 9 different N subtypes, but only H1, H2, H3, and N1 and N2 have caused epidemic disease. Jeff: Two terms worth learning here are antigen drift and anitgen shift. Antigen drift refers to small point mutations to the viral genes that code for H and N. Antigen shift is a much more radical change, with reassortment of viral genes. When cells are infected by 2 or more strains, a new strain can emerge after genetic reassortment. Nachi: With antigen shift, some immunity may be maintained within a population infected by a similar subtype previously. With antigen drift, there is loss of immunity from prior infection. Jeff: The appearance of new strains of influenza typically involves an animal host, like pigs, horses, or birds. This is why you might be hear a strain called “swine flu”, “equine flu”, or “avian flu”. Close proximity with these animals facilitates co-infection and genetic reassortment. Nachi: I think that’s enough basic biology for now, let’s move on to pathophysiology. When inhaled, the influenza virus initially infects the epithelium of the upper respiratory tract and alveolar cells of the lower respiratory tract. Viral replication occurs within 4 to 6 hours. Incubation is 18 to 72 hours. Viral shedding is usually complete roughly 7 days after infection, but can be longer in children and immunocompromised patients. Jeff: As part of the infectious process and response, there can be significant changes to the respiratory tract with inflammation and epithelial cell necrosis. This can lead to viral pneumonia, and occasionally secondary bacterial pneumonia. Nachi: The secondary bacterial pathogens that are most common include Staph aureus, Strep pneumoniae, and H influenzae. Jeff: Despite anything you may read on the internet, vaccines work and luckily influenza happens to be a pathogen which we can vaccinate against. As such, there are 3 methods approved by the FDA for producing influenza vaccines -- egg-based, cell-based, or recombinant influenza vaccine. Once the season’s most likely strains have been determined, the virus is introduced into the medium and allowed to replicate. The antigen is then purified and used to make an injection or nasal spray. Nachi: It isn’t easy to create vaccines for all strains. H3N2, for example, is particularly virulent, volatile, and mutagenic, which leads to poor prophylaxis against this particular subgroup. Jeff: In fact, a meta-analysis on vaccine effectiveness from 2004-2015 found that the pooled effectiveness against influenza B was 54%, against the H1N1 pandemic in 2009 was 61%, and against the H3N2 virus was 33%. Not surprisingly, H3N2 dominant seasons are currently associated with the highest rates of influenza cases, hospitalizations, and death. Nachi: Those are overall some low percentages. So should we still be getting vaccinated? The answer is certainly a resounding YES.. Despite poor protection from certain strains, vaccine effectiveness is still around 50% and prevents severe morbidity and mortality in those patients. Jeff: That’s right. The 2017-2018 vaccine was only 40% effective, but this still translates to 40% less severe cases and a subsequent decrease in hospitalizations and death. Nachi: But before we get into actual hospitalization, treatment, and preventing death, let’s talk about the differential. We’re not just focusing on influenza here, but any influenza like illness, since they can be hard to distinguish. The CDC defines “influenza-like illness” as a temperature > 100 F, plus cough or sore throat, in the absence of a known cause other than influenza. Jeff: Therefore, influenza should really be considered on the differential of any patient who presents to the ED with a fever and URI symptoms. The differential when considering influenza might also include mycoplasma pneumoniae, strep pneumoniae, adenovirus, RSV, rhinovirus, parainfluenza virus, legionella, and community acquired MRSA. Nachi: With the differential in mind, let’s move on to prehospital care. For the prehospital setting, there isn’t much surprising here. Stabilize and manage the respiratory status with all of your standard tools - oxygen for those with mild hypoxia and advanced airway maneuvers for those with respiratory distess. Jeff: Of note, EMS providers should use face masks themselves and place them on patients as well. As community paramedicine and mobile integrated health becomes more common, this is one potential area where EMS can potentially keep patients at home or help them seek treatment in alternate destinations to avoid subjecting crowded ED’s to the highly contagious influenza virus. Nachi: It’s also worth noting, that most communities have strategic plans in the event of a major influenza outbreak. Local, state, and federal protocols have been designed for effective care delivery. Jeff: Alright, so now that the EMS crew, wearing proper PPE of course, has delivered the patient, who is also wearing a mask, to the ED, we can begin our ED H&P. Don’t forget that patients present with a range of symptoms that vary by age. A typical history is 2-5 days of fever, nasal congestion, sore throat, and myalgias. You might see tachycardia, cough, dyspnea, and chills too. Nachi: Van Wormer et al conducted a prospective analysis of subjective symptoms to determine correlation with lab confirmed influenza. They found the most common symptoms were cough in 92%, fatigue in 91%, and nasal congestion in 84%, whereas sneezing was actually a negative predictor for influenza. Jeff: Sneezing, really? Can’t wait to get the Press-Gany results from the sneezing patient I discharge without testing for influenza based on their aggressive sneezes! Nachi: Aggressive sneezes…? I can’t wait to see your scale for that. Jeff: Hopefully I’ll have it in next month’s annals. In all seriousness, I’m not doing away with flu swabs just yet. In another retrospective study, Monto et al found that the best multivariate predictors were cough and fever with a positive predictive value of 79%. Nachi: Yet another study in children found that the predominant symptoms were fever in 95%, cough in 77%, and rhinitis in 78%. This study also suggested that the range of fever was higher in children and that GI symptoms like vomiting and diarrhea were more common in children than adults. Jeff: Aside from symptomatology, there are quite a few diagnostic tests to consider including viral culture, immunofluoresence, rt-pcr, and rapid antigen testing. The reliability of testing varies greatly depending on the type of test, quality of the sample, and the lab. During a true epidemic, formal testing might not be indicated as the decision to treat is based on treatment criteria like age, comorbidities, and severity of illness. Nachi: We’ll get to treatment in a few minutes, but diving a bit deeper into testing - there are 3 major categories of tests. The first detects influenza A only. The second detects either A or B, but cannot distinguish between them; and the third detects both influenza A and B and is subtype specific. The majority of rapid testing kits will distinguish between influenza A and B, but not all can distinguish between them. Fluorescent antibody testing by DFA is relatively rapid and yields results within 2 to 4 hours. Jeff: Viral culture and RT-PCR remain the gold standard, but both require more time and money, as well as a specialized lab. As a result, rapid testing modalities are recommended. Multiple studies have shown significant benefit to the usefulness of positive results on rapid testing. It’s safe to say that at a minimum, rapid testing helps decrease delays in treatment and management. Nachi: Looking a bit further into the testing characteristics, don’t forget that the positive predictive value of testing is affected by the prevalence of influenza. In periods of low influenza activity (as in the summer), a rapid test will have low PPV and high NPV. The test is more likely to yield false positive results -- up to 50% according to one study when prevalence is below 5%. Jeff: And conversely, in periods of high influenza activity, a rapid test will have higher PPV and lower NPV, and it is more likely to produce a false negative result. Nachi: In one prospective study of patients who presented with influenza-like illness during peak season, rapid testing was found to be no better than clinical judgement. During these times, it’s probably better to reserve testing for extremely ill patients in whom diagnostic closure is particularly important. And since the quality of the specimen remains important, empiric treatment of critically ill patients should still be considered. Jeff: Which is a perfect segway into our next topic - treatment, which is certainly the most interesting section of this article. To start off -- for mild to moderate disease and no underlying high risk conditions, supportive therapy is usually sufficient. Nachi: Antiviral therapy is reserved for those with a predicted severe disease course or with high risk conditions like long-standing pulmonary disease, pregnancy, immunocompromise, or even just being elderly. Jeff: Note to self, avoid being elderly. Nachi: Good luck with that. Anyway, early treatment with antivirals has been shown to reduce influenza-related complications in both children and adults. Jeff: Once you’ve decided to treat the patient, there are two primary classes of antivirals -- adamantane derivatives and neuraminidase inhibitors. Oh and then there is a new single dose oral antiviral that was just approved by the FDA… baloxavir marboxil (or xofluza), which is in a class of its own -- a polymerase endonuclease inhibitor. Nachi: The oldest class, the adamantane derivatives, includes amantadine and rimantadine. Then the newer class of neuraminidase inhibitors includes oseltamavir (which is taken by mouth), zanamavir (which is inhaled), and peramivir (which is administered by IV). Jeff: Oseltamavir is currently approved for patients of all ages. A 2015 meta analysis showed that the intention-to-treat infected population had a shorter time to alleviation of all symptoms from 123 hours to 98 hours. That’s over a day less of symptoms, not bad! There were also fewer lower respiratory tract complications requiring antibiotics and fewer admissions for any cause. Really, not bad! Nachi: Zanamavir is approved for patients 7 and older -- or for children 5 or older for disease prevention. Zanamavir has been associated with possible bronchospasm and is contraindicated in patients with reactive airway disease. Jeff: Peramivir, the newest drug in this class, is given as a single IV dose for patients with uncomplicated influenza who have been sick for 2 days or less. Peramavir is approved for patients 2 or older. This is a particularly great choice for a vomiting patient. Nachi: And as you mentioned before, just last month, the FDA approved baloxavir, a single dose antiviral. It’s effective for influenza type A or B. Note that safety and efficacy have not been established for patients less than 12 years old, weighing less than 40 kg, or pregnant or lactating patients. Jeff: Unfortunately, there has been some pretty notable antiviral resistance in the recent past, moreso with the adamantane class, but recently also with the neuraminidase inhibitors. In 2007-2008, an oseltamivir-resistant H1N1 strain emerged globally. Luckily, cross-resistance between baloxavir and the adamantanes or neuraminidase inhibitors isn’t expected, as they target different viral proteins, so this may be an answer this year, and in the future. Nachi: Let’s talk chemoprophylaxis for influenza.. Chemoprophylaxis with oseltamavir or zanamavir can be considered for patients who are at high risk for complications and were exposed to influenza in the first 2 weeks following vaccination, patients who are at high risk for complications and cannot receive the vaccination, and those who are immunocompromised. Jeff: Chemoprophylaxis is also recommended for pregnant women. For postexposure prophylaxis for pregnant women, the current recommendation is to administer oseltamivir. Nachi: We should also discuss the efficacy of treatment with antivirals. This has been a hotly debated topic, especially with regards to cost versus benefit… In a meta-analysis, using time to alleviation of symptoms as the primary endpoint, oseltamavir resulted in an efficacy of 73% (with a wide 95% CI from 33% to 89%). And this was with dose of 150mg/day in a symptomatic influenza patient. Jeff: Similarly zanamavir given at 10mg/day was 62% effective, but again with a wide 95% CI from 15% to 83%. And, of note, other studies have looked into peramivir, but have found no significant benefits other than the route of delivery. Nachi: In another 2014 study by Muthuri et al., neuraminidase inhibitors were associated with a reduction in mortality -- adjusted OR = 0.81 (with a 95% CI 0.70 to 0.93). Also when comparing late treatment with early treatment (that is, within 2 days of symptom onset), there was a reduction in mortality risk with adjusted OR 0.48 (95%CI 0.41-0.56). These associations with reduction in mortality risk were less pronounced and less significant in children. Jeff: Mortality benefit, not bad! They further found an increase in mortality hazard ratio with each day’s delay in initiation of treatment up to 5 days, when compared to treatment initiated within 2 days. Nachi: But back to the children for a second -- another review of neuraminidase inhibitors in children < 12 years old found duration of clinical symptoms was reduced by 36 hours among previously healthy children taking oseltamivir and 30 hours by children taking zanamivir. Jeff: I think that’s worth summarizing - According to this month’s author’s review of the best current evidence, use of neuraminidase inhibitors is recommended, especially if started within 2 days, for elderly patients and those with comorbidities. Nachi: Seems like there is decent data to support that conclusion. But let’s not forget that these medications all have side effects. Jeff: These drugs actually tend to be well tolerated.The most frequently noted side effect of oseltamavir is nausea and vomiting, while zanamavir is associated with diarrhea. Nachi: Amazing. Let’s talk disposition for your influenza patient. Jeff: Disposition will depend on many clinical factors, like age, respiratory status, oxygen saturation, comorbid conditions, and reliability of follow up care. Admission might be needed not only to manage the viral infection, but also expected complications. Nachi: If you’re discharging a patient, be sure to engage in shared decision making regarding risks and benefits of available treatments. Ensure outpatient follow up and discuss return to er precautions. Jeff: Also, the CDC recommends that these patients stay home for at least 24 hours after their fever has broken. Nachi: With that -- Let’s summarize the key points and clinical pearls from this month’s issue J: Even though influenza vaccine effectiveness is typically only 50%, this still translates to a decrease in influenza-related morbidity and mortality. 2. The CDC defines influenza-like illness as a temperature > 100 F with either cough or sore throat, in the absence of a known cause other than influenza. 3. When influenza is suspected in the prehospital setting, patients and providers should wear face masks to avoid spreading the virus. 4. In the emergency department, standard isolation and droplet precautions should be maintained for suspected or confirmed infections. 5. The most common symptoms of influenza in adults are cough, fatigue, nasal congestion, and fever. Sneezing is a negative predictor in adults. 6. In children, the most common presenting symptoms are fever, cough, and rhinitis. Vomiting and diarrhea is also more common in children than adults. 7. Rapid testing and identification results in decreased delays in treatment and management decisions. 8. During peak flu season, clinical judgement may be as good as rapid testing, making rapid testing less necessary. J: Rapid testing may be more beneficial in times of lower disease prevalence. 10. Empiric treatment of critically ill patients should be considered even if rapid testing is negative. J: For mild to moderate disease and no underlying high-risk conditions, supportive therapy is usually sufficient. 12.For more ill patients or those at substantial risk for complications, consider antiviral treatment. 13.Oseltamivir is approved for patients of all ages, and reduces the length of symptoms by one day. 14.When treating influenza, peramivir is an ideal agent for the vomiting patient. 15.Baloxavir is a new single-dose antiviral agent approved by the FDA in October 2018. It works in a novel way and is effective for treatment of influenza A and B. 16.Chemoprophylaxis with oseltamivir or zanamivir should be considered in patients who are immunocompromised or patients who are at elevated risk for complications and cannot receive the vaccination. 17.Consider oseltamivir as post exposure prophylaxis in pregnant women. 18.Neuraminidase inhibitors are associated with decreased duration of symptoms and complications, especially if started within 2 days of symptom onset. J: So that wraps up episode 23 - Influenza: Diagnosis and Management in the Emergency Department. N: Additional materials are available on our website for Emergency Medicine Practice subscribers. For our subscribers: be sure to go online to get your CME credit for this issue, which includes 3 pharmacology CME credits. J: Also, for our NP and PA listeners, we have a special offer this month: You can get a full year of access to Emergency Medicine Practice for just $199--including lots of pharmacology, stroke, and trauma CME--and so much more! To get this special deal, go to www.ebmedicine.net/APP. Again, that’s www.ebmedicine.net/APP. N: If you’re not a subscriber, consider joining today. You can find out more at www.ebmedicine.net/subscribe. Subscribers get in-depth articles on hundreds of emergency medicine topics, concise summaries of the articles, calculators and risk scores, and CME credits. You’ll also get enhanced access to the podcast, including the images and tables mentioned. You can find everything you need to know at ebmedicine.net/subscribe. J: And the address for this month’s credit is ebmedicine.net/E1218. As always, the you heard throughout the episode corresponds to the answers to the CME questions. Lastly, be sure to find us on iTunes and rate us or leave comments there. You can also email us directly at [email protected] with any comments or suggestions. Talk to you next month!    

Jeff: Welcome back to Emplify, the podcast corollary to EB Medicine’s Emergency Medicine Practice. I’m Jeff Nusbaum, and I’m back with my co-host, Nachi Gupta. This month, we’re back with our old routine – no special guests. Nachi: Don’t sound so sad about it! Jeremy was great last month, and he’s definitely paved the way for more special guests in upcoming episodes. Jeff: You’re right. But this month’s episode is special in its own way - we’ll be tackling Electrical Injuries in the emergency department - from low and high voltage injuries to the more extreme and rare lightning related injuries. Nachi: And this is obviously not something we see that often, so listen up for some easy to remember high yield points to help you when you get an electrical injury in the ED. And pay particular attention to the , which, as always, signals the answer to one of our CME questions. Jeff: I hate to digress so early and drop a cliché, “let’s start with a case…” but we, just a month ago, had a lightning strike induced cardiac arrest in Pittsburgh, so this hits really close to home. Thankfully, that gentleman was successfully resuscitated despite no bystander CPR, and if you listen carefully, we hope to arm you with the tools to do so similarly. Nachi: This month’s print issue was authored by Dr. Gentges and Dr. Schieche from the Oklahoma University School of Community Medicine. It was peer reviewed by Dr. O’Keefe and Dr. Silverberg from Florida State University College of Medicine and Kings County Hospital, respectively. Jeff: And unlike past issues covering more common pathologies, like, say, sepsis, this month’s team reviewed much more literature than just the past 10 years. In total, they pulled references from 1966 until 2018. Their search yielded 477 articles, which was narrowed to 88 after initial review. Nachi: Each year, in the US, approximately 10,000 patients present with electrical burns or shocks. Thankfully, fatalities are declining, with just 565 in 2015. On average, between 25 and 50 of the yearly fatalities can be attributed to lightning strikes. Jeff: Interestingly, most of the decrease in fatalities is due to improvements in occupational protections and not due so much to changes in healthcare. Nachi: That is interesting and great to hear for workers. Also, worth noting is the trimodal distribution of patients with electrical injuries: with young children being affected by household currents, adolescent males engaging in high risk behaviors, and adult males with occupational exposures and hazards. Jeff: Electrical injuries and snake bites – leave it to us men to excel at all the wrong things… Anyway, before we get into the medicine, we unfortunately need to cover some basic physics. I know, it might seem painful, but it’s necessary. There are a couple of terms we need to define to help us understand the pathologies we’ll be discussing. Those terms are: current, amperes, voltage, and resistance. Nachi: So, the current is the total amount of electrons moving down a gradient over time, and it’s measured in amperes. Jeff: Voltage, on the other hand, is the potential difference between the top and bottom of a gradient. The current is directly proportional to the voltage. It can be alternating, AC, or direct, DC. Nachi: Resistance is the obstruction of electrical flow and it is inversely proportional to the current. Think of Ohm’s Law here. Voltage = current x resistance. Jeff: Damage to the tissues from electricity is largely due to thermal injury, which depends on the tissue resistance, voltage, amperage, type of circuit, and the duration of contact. Nachi: That brings us to an interesting concept – the let-go threshold. Since electrical injuries are often due to grasping an electric source, this can induce tetanic muscle contractions and therefore the inability to let go, thus increasing the duration of contact and extent of injury. Jeff: Definitely adding insult to injury right there. With respect to the tissue resistance, that amount varies widely depending on the type of tissue. Dry skin has high resistance, far greater than wet or lacerated skin. And the skin’s resistance breaks down as it absorbs more energy. Nerve tissue has the least resistance and can be damaged by even low voltage without cutaneous manifestations. Bone and fat have the highest resistance. In between nerve and bone or fat, we have blood and vascular tissue, which have low resistance, and muscle and the viscera which have a slightly higher resistance. Nachi: Understanding the resistances will help you anticipate the types of injuries you are treating, since current will tend to follow the path of least resistance. In high resistance tissues, most of the energy is lost as heat, causing coagulation necrosis. These concepts also explain why you may have deeper injuries beyond what can be visualized on the surface. Jeff: And not only does the resistance play a role, but so too does the amount and type of current. AC, which is often found in standard home and office settings, but can also be found in high voltage transmission lines, usually affects the electrically sensitive tissues like nerve and muscle. DC has a higher let-go threshold and does not cause as much sensation. It also requires more amperage to cause v-fib. DC is often found in batteries, car and computer electrical systems, some high voltage transmission lines, and capacitors. Nachi: Voltage has a twofold effect on tissues. The first mechanism is through electroporation, which is direct damage to cell membranes by high voltage. The second is by overcoming the resistance of body tissues and intervening objects such as clothes or water. You’re probably familiar with this concept when you see high voltages arcing through the air without direct contact with the actual electrical source, leading to diffuse burns. Jeff: As voltage increases, the resistance of dry skin is -- not surprisingly -- reduced, leading to worse injuries. Nachi: And for this reason, the US Department of Energy has set 600 Volts as the cutoff for low vs high voltage electrical exposure. Jeff: It is absolutely critical that we also mention and then re-mention throughout this episode, that those with electrical injuries often have multisystem injuries due to not only the thermal injury, electrical damage to electrically sensitive tissue, but also mechanical trauma. Injuries are not uncommon both from forceful pulling away from the source or a subsequent fall if one occurs. Nachi: That’s a great point which we’ll return to soon, as it plays an important role in destination selection. But before we get there, let’s review the common clinical manifestations of electrical injuries. Jeff: First up is – the cutaneous injuries. Most electrical injuries present with burns to the skin. Low voltage exposures typically cause superficial burns at the entry and exit sites, whereas high voltage exposures cause larger, deeper burns that may require skin grafting, debridement, and even amputation. Nachi: High voltage injuries can also travel through the sub-q tissue leading to extensive burns to deep structures despite what appears to be relatively uninjured skin. In addition, high voltage injuries can also result in superficial burns to large areas secondary to flash injury. Jeff: Electrical injuries can also lead to musculoskeletal injuries via either thermal or mechanical means. Thermal injury can lead to muscle breakdown, rhabdo, myonecrosis, edema, and in worse cases, compartment syndrome. In the bones, it can lead to osteonecrosis and periosteal burns. Nachi: In terms of mechanical injury – electrical injury often leads to forceful muscular contraction and falls. In 2 retrospective studies, 11% of patients with high voltage exposures also had traumatic injuries. Jeff: While not nearly as common, the rarer cardiovascular injuries are certainly up there as the most feared. Pay attention to the entry and exit sites, as the pathway of the shock is predictive of the potential for myocardial injury and arrhythmia. Common arrhythmias include AV block, bundle branch blocks, a fib, QT prolongation and even ventricular arrhythmias, including both v-fib and v-tach, both of which typically occur immediately after the injury. Nachi: There is a school of thought out there that victims of electrical injury can have delayed onset arrhythmias and require prolonged cardiac monitoring – however several well-designed observational studies, including 1000s of patients, have demonstrated no such evidence. Jeff: It’s also worth noting that ST elevation MIs have also been reported, however this is usually due to coronary artery vasospasm rather than acute arterial occlusion. Nachi: Respiratory injuries are somewhat less common. Acute respiratory failure usually occurs secondary to electrical injury-induced cardiac arrest. Thoracic tetany can cause paralysis of respiratory muscles. Late findings of respiratory injury including pulmonary effusions, pneumonitis, pneumonia, and even PE. The electrical resistance of lung tissue is relatively high, which may account for why pulmonary injury is less common. Jeff: Vascular injuries include coagulation necrosis as well as thrombosis. In addition, those with severe burns are at increased risk of DVT, especially in those who are immobilized. In at least one study, the incidence of DVT in hospitalized burn patients was as high as 23%. That’s -- high. Nachi: Neurologic complaints are far more common as nerve tissue is highly conductive. While the most common injury from an electric shock is loss of consciousness, other common neurologic insults include weakness, paresthesias, and difficulty concentrating. Jeff: And if the entry and exit sites traverse the spinal cord – this also puts the patient at risk for spinal cord lesions. Specifically with respect to high voltage injuries – these victims are at risk for posterior cord syndrome. In addition, depression, pain, anxiety, mood swings, and cognitive difficulties have all been commonly described. Nachi: Rounding out our discussion of electrical injuries, visceral injuries are rather rare, with bowel perforation being the most common. High voltage injuries have also been associated with cataracts, macular injury, retinal detachment, hearing loss, tinnitus, and vertigo. Jeff: Perfect. I think that more or less rounds out an overview of organ specific electrical injuries. Let’s talk about prehospital care for these patients -- a broad topic in this case. As always, the first, and most important step in prehospital care is protecting oneself from the electrical exposure if the electrical source is still live. Nachi: In cases of high voltage injuries from power lines or transformers or whatever oddity the patient has come across, it may even be necessary to wait for word from the local electrical authority prior to initiating care. Remember, the last thing you want to do is become a victim yourself. Jeff: For those whose electrical injury resulted in cardiac arrest, follow your standard ACLS guidelines. These aren’t your standard arrest patients though, they typically have many fewer comorbidities – so CPR tends to be more successful. Nachi: Intubation should also be considered especially early in those with facial or neck burns, as risk of airway loss is high. Jeff: And as we mentioned previously, concurrent trauma and therefore traumatic injuries is very common, especially with high voltage injuries, so patients with electrical injuries require a complete survey and not just a brief examination of their obvious injuries. Nachi: When determining destination, trauma takes priority over burn, so patients with significant trauma or those who are obtunded or unconscious should be transported to an appropriate trauma center rather than a burn center if those sites are different. Jeff: Let’s move on to evaluation in the emergency department. As always, it’s ABC and IV, O2, monitor first with early airway management in those with head and neck burns being a top priority. After that, complete your primary and secondary surveys per ATLS guidelines. Nachi: During your survey, make sure the patient is entirely undressed and all constricting items, like jewelry is removed. Jeff: Next, make sure that all patients with high voltage injuries have an EKG and continuous cardiac monitoring. Those with low voltage injuries and a normal EKG do not require monitoring. Nachi: Additionally, for those with severe electrical injuries, an IV should be placed and fluid resuscitation should begin. Fluid requirements will likely be higher than those predicted by the parkland formula, and you should aim for a goal of maintaining urine output of 1-1.5 ml/kg/h. Jeff: With your initial stabilization underway, you can begin to gather a more thorough history either from bystanders or EMS if they are still present. Try to ascertain whether the current was AC or DC, and whether it was high or low voltage. Don’t forget to ask about the setting of the injury as this may point to other concurrent traumatic injuries, that may in fact take precedence during your work up. Nachi: Moving on to the physical exam. As mentioned previously, disrobe the patient and complete a primary and secondary survey. Jeff: If the patient has clear entry and exit wounds, the path through the body may become apparent and offer clues about what injuries to expect. Nachi: A single exam will not suffice for electrical injury patients. All patients with serious electrical injuries will require serial exams to evaluate for vascular compromise and compartment syndrome. Jeff: So that wraps up the physical, let’s move onto diagnostic studies. Nachi: First off -- I know we’ve said it, but it’s definitely worth reiterating. All patients presenting with a history of an electric shock require an EKG Jeff: In those with a low voltage injury without syncope and a normal EKG, you don’t routinely need cardiac monitoring. However, in the setting of high voltage injuries, the data is less clear. Based on current literature, the authors recommend overnight monitoring for at least 8 hours for all high voltage injuries. Nachi: While no routine labs work is required for minor injuries, those with more serious injuries require a cbc, cmp, CK, CK-MB, and urinalysis. Jeff: The CK is clearly for rhabdo, but interestingly, a CK-MB greater than 80 ng/mL is actually predictive of limb amputation. Oh and don’t forget that urine pregnancy test when appropriate. Nachi: In terms of imaging, you’ll have to let your history guide your diagnostic studies. Perform a FAST exam to screen for intra-abdominal pathology for anyone with concern for concurrent trauma. Keep a low threshold to XR or CT any potentially injured body region. Jeff: Real quick – in case you missed it – ultrasound sneaks in again. Maybe I should reconsider and do an US fellowship – seems like that’s where the money is at - well maybe not money but still. Let’s move on to treatment. Nachi: In those with minor injuries like small burns and a low voltage exposure – if they have a normal EKG and no other symptoms, these patients require analgesia only. Give return precautions and have them follow up with their PCP or a burn center. Jeff: In those with more severe injuries, as we mentioned before, but we’ll stress again, protect the patient’s airway early especially if you are considering transfer and have any concerns. In one study, delays in intubation was associated with a high risk of a difficult airway. Always make sure you have not only your tool of choice but also all of your backup airway devices ready as all deeper airway injuries may not be apparent externally. Nachi: Fluid resuscitation with isotonic fluids is the standard -- again -- with a goal urine output of 1-1.5 ml/kg/h. Jeff: Address pain with analgesia – likely in the form of opiates – and don’t be surprised if large doses are needed. Nachi: Dress burned areas with an antibiotic dressing and update the patient’s tetanus if needed. While there is ongoing debate about the role of prophylactic antibiotics, best evidence at this point recommends against them. We talked about thermal burns in Epsiode 13 also, so go back and listen there for more... Jeff: There is also a range of practice variation with respect to early surgical exploration of the burned limb with severe injuries. At this time, however, the best current evidence supports a conservative approach. Nachi: Serial exams and watch and wait it is. . We have some interesting special populations to discuss this month. First up, as is often the case, the kids. Jeff: Young children are sadly more likely to present with orofacial burns due to, well, everything ending up in their mouth. And since many of our listeners are likely in boards study mode – why don’t you fill us in on the latest evidence with respect to labial artery bleeding. Nachi: Sure – . There is up to a 24% risk of labial artery bleeding and primary tooth damage with oral electrical injuries. Although there isn’t a clear consensus, current evidence supports early ENT consultation and a strong consideration for admission and observation for delayed bleeding. Jeff: Keep in mind though, that labial artery bleeding is often delayed and has been reported as far as 2 weeks out from the initial insult. Nachi: Moral of the story: don’t put electrical cords in or anywhere near your mouth. Next, we have pregnant patients. Case reports of pregnant patients suffering electrical injuries have described fetal arrhythmias, ischemic brain injury, and fetal demise. For this reason, those that are past the age of fetal viability should have fetal monitoring after experiencing an electric shock. Jeff: If not already done, an ultrasound should be obtained as well and a two week follow up ultrasound will be needed. Nachi: We’re switching gears a bit with this next special population – those injured by an electrical control device or taser. Jeff: Tasers typically deliver an initial 50,000 volt shock, with a variable number of additional shocks following that. Nachi: Most taser injuries are thankfully direct traumatic effects of the darts or indirect trauma from subsequent falls. Jeff: While there are case reports of taser induced v fib, the validity of taser induced arrhythmias remains questionable due to confounders such as underlying disease and previously agitated states like excited delirium Nachi: Basically, [DING SOUND} those with taser injuries should be approached as any standard trauma patient would be, with the addition of an EKG for all of these patients. Jeff: The next special population --- the one I’m sure you’ve all been waiting patiently for -- is lightning strike victims. Lightening carries a voltage in the millions with amperage in the thousands, but with an incredibly short exposure time. Because of this, lightening causes injuries in a number of different ways. Nachi: First, because it’s often raining when lightning strikes, wet skin may cause the energy to stay on the skin in what is known as a flashover effect. Jeff: Similarly and not surprisingly, burns are common after a lightning strike. Lichtenberg figures are superficial skin changes that resemble bare tree branches and are pathognomonic for lightning injury. Thankfully, these usually disappear within a few weeks without intervention. Nachi: Next, the rapid expansion of the air around the strike can lead to a concussive blast and a variety of traumatic injuries including ocular and otologic injury like TM rupture which occurs in up to two thirds of cases. Jeff: An ophthalmologic consult should be obtained in most, if not all of these cases. Nachi: Making matters worse, lightning can also travel through electric wiring and plumbing to cause a shock to a person indoors nearby the strike! Jeff: And like we mentioned earlier, just as was the case with my fellow Pittsburgher or ‘Yinzer. Nachi: Yinzer? Jeff: Forget about it, it’s just what Pittsburghers call themselves for some reason or another - but we’re still talking lightning. Cardiac complications including death, contusion and vasospasm have all been reported secondary to lightning injury. But don’t lose hope – in fact – you should gain hope as these patients have a much higher than typical survival rates. Nachi: From the neurologic standpoint – it’s a bit more complicated. CNS dysfunction may be immediate or delayed and can range from strokes to spinal cord injuries. Cerebral salt wasting syndrome, peripheral nerve lesions, spinal cord fracture, and cerebral hemorrhages have all been described. An MRI may be required to elucidate the true diagnosis. Jeff: Clearly victims of lighting strikes are complex and, for that reason, among many others, the American College of Surgeons recommends that victims of lightning strikes be transferred to a burn center for a comprehensive eval. Nachi: Let’s touch upon any other details regarding disposition. Jeff: Those with low voltage exposures, a normal EKG and minimal injury may be discharged home with PCP follow up and strict return precautions. Nachi: High voltage injuries on the other hand require admission to a burn center and the involvement of a burn surgeon, even if it involves transferring the patient. Jeff: And remember, trauma takes precedence over burn and those with traumatic injuries or the possibility of traumatic injuries should be evaluated at a trauma center. Don’t forget to take the airway early if there is any concern, and consider transporting via air as the services of a critical care transport team may be required. Nachi: That wraps up Episode 22, but let’s go over some key points and clinical pearls. During evaluation, consider multisystem injuries due to not only the thermal injury and electrical damage to electrically sensitive tissue, but also mechanical trauma. Thermal injury can lead to muscle breakdown, rhabdomyolysis, myonecrosis, edema, compartment syndrome, osteonecrosis, and even periosteal burns. Mechanical injury can be a result of forceful muscular contractions, and trauma can manifest as fractures, dislocations, and significant muscular injuries. Electrical injuries due to grasping an electric source can induce tetanic muscle contractions and therefore the inability to let go, increasing the duration of contact and extent of injury. Current tends to follow the path of least resistance, which explains why you might have deeper injuries beyond what can be visualized in the surface. Nerve tissue has the least resistance and can be damaged by even low voltage without cutaneous manifestations. Bone and fat, on the other hand, have the highest resistance to electrical injury. High voltage injuries place patients at risk for spinal injuries, most notably posterior cord syndrome. High voltage injuries have also been associated with cataracts, macular injury, retinal detachment, hearing loss, tinnitus, and vertigo. All patients with electrical injury require an EKG. Low voltage injuries with a normal presenting EKG do not always require cardiac monitoring. High voltage injuries require cardiac monitoring for at least 8 hours. Intubation should be considered early in patients with facial or neck burns, as risk of airway loss is high. Make sure to have airway adjuncts and back up equipment at bedside, as deeper airway injuries may not be obvious upon external exam. For severe injuries, target a urine output rate of 1-1.5 mL/kg/hr. All patients with serious electrical injuries require serial exams to evaluate for vascular compromise and compartment syndrome. Address pain with analgesia. Larger than expected doses may be needed. Dress burned areas with an antibiotic dressing and update the patient’s tetanus if required. For pediatric patients with oral electric injuries from biting on a cord, consult ENT early and consider admission for observation of delayed arterial bleeding. Pregnant patients who are past the age of fetal viability should have fetal monitoring and ultrasound after experiencing an electric shock. Tympanic membrane rupture is a commonly noted blast injury after a lightning strike. Cardiac resuscitation should follow ACLS guidelines and is more likely to be successful than your tyipcal cardiac arrest patient as the patient population is typically younger and without significant comorbidities. When determining destination, trauma centers take priority over burn centers if those sites are different. So that wraps up episode 22 - managing electrical injury in the emergency department. Additional materials are available on our website for Emergency Medicine Practice subscribers. If you’re not a subscriber, consider joining today. You can find out more at www.ebmedicine.net/subscribe. Subscribers get in-depth articles on hundreds of emergency medicine topics, concise summaries of the articles, calculators and risk scores, and CME credits. You’ll also get enhanced access to the podcast, including the images and tables mentioned. You can find everything you need to know at ebmedicine.net/subscribe. And the address for this month’s credit is ebmedicine.net/E1118, so head over there to get your CME credit. As always, the you heard throughout the episode corresponds to the answers to the CME questions. Lastly, be sure to find us on iTunes and rate us or leave comments there. You can also email us directly at [email protected] with any comments or suggestions. Talk to you next month!

Disclaimer: This is the unedited transcript of the podcast. Please excuse any typos. Jeff:  Welcome back to Emplify, the podcast corollary to EB Medicine’s Emergency Medicine Practice. I’m Jeff Nusbaum, and I’m back with my co-host, Nachi Gupta. This month, we’ll be talking Updates and Controversies in the Early Management of Sepsis and Septic Shock. We have a special  episode for you this month… We’ve brought Dr. Jeremy Rose, one of the peer reviewers, and a sepsis expert, on with us to talk through the content this month. Jeremy: Dr. Jeremy Rose here. Thanks for having me in on this conversation.  I’m always happy to talk about this topic because it’s clearly important.  There’s a great deal of confusion around sepsis and I hope that in the next couple minutes we can clarify things in a way that really help your average front line doc trying to get it right. Nachi: So Dr. Rose, before we get started, tell us a bit about your background and your interest in sepsis… Jeremy: I’m the Assistant Medical Director and Sepsis Chair at Mount Sinai Beth Israel in Manhattan.  For those listening, my hospital probably looks a little bit like yours.  We’re busy, interesting, and just a little rough around the edges.  We like it that way.  More importantly, though, we mirror the national averages regarding sepsis.  Roughly half of in-hospital mortality is associated with septic  in some fashion.  Pretty incredible when you think about it.  Half. Jeff:  Sepsis chair... clearly this is an important topic if it warrants it’s own chair at a major hospital in NYC. But getting back to the article this month. This month’s issue was authored by Faheem Guirgis, Laurent Page Black, and Elizabeth DeVos of the University of Florida, Department of Emergency Medicine. Nachi: And it was peer reviewed by Michael Allison, Assistant Director of the Adult ICU at Saint Agnes Hospital, and Jeremy Rose and Eric Steinberg of Mount Sinai Beth Israel. Jeff: So as well all know Sepsis is bread and butter emergency medicine, but, what is sepsis?  It seems that every month or so we have a new guideline, bundle, definition, or whatever… I think it’s best to start with the basics -  At its core, sepsis is a dysregulated response to infection that can be life-threatening. Nachi: Right and it’s the combined inflammatory with immunosuppressive features of sepsis that lead to the devastating organ dysfunction and even death. Optimal management of septic patients has been a source of intense research, stemming from the landmark study by Rivers in 2001. Jeremy, can you give us a little historical context there? Jeremy: Rivers was a real pioneer.  He found a 16% mortality reduction with randomization to an early aggressive care bundle.  Amazing work.  That being said, many components of that bundle have since been disregarded.  For example, Manny Rivers would measure CVP in all of his patients, something we rarely do. Nachi: Not to cut you off and steal your thunder there, but we’ll get to the most recent updates in management shortly. Let’s first talk definitions and terminology, and specifically, diagnosis, which is definitely a big elephant in the room. As Jeff mentioned a few minutes ago, diagnostic criteria have undergone so so so many changes. Jeff: Yes it has! 1991 marked the first standardized definition.  Then in 2001, sepsis-2 was introduced.  In 2014, the Society of Critical Care Medicine and the European Society of Intensive Care Medicine started a task force, and by 2016, updated definitions were out again! Sepsis-3!! A lot of this came after the realization that SIRS was just too broad and was overly sensitive and non-specific. Jeremy, why don’t you take us through Sepsis 3. Jeremy: So just to back up a little and frame this: Here’s the fundamental problem:  As we likes to say, “there’s no troponin for sepsis.”  And if you look at our patients, we tend not to miss the hypotensive, tachycardic, febrile patient.  We know they’re septic.  But how do we find the ones who don’t look as sick.  Frequently elderly, possibly with normal-ish vitals and no fever.  Those can be a lot harder to spot, but they may indeed be septic.  Also, for research purposes we have to have a common definition, so Sepsis 3 came up with something called the SOFA score. The problem with the SOFA score is that its difficult to perform in the ED.  It has parameters like bilirubin that often aren’t available when we want to screen out very sick patients.  Fortunately there is the abridged version qSOFA, which identifies non-icu patients who are at high risk of inpatient mortality. So here it is, and if you get one thing from this episode, this is it: There are ONLY 3 criteria to the qSOFA.  3 Criteria. RR > 22; AMS; SBP <= 100. That’s it. If you have two of these criteria, you are up to 14 times more likely to die of sepsis during a hospital admission. That’s pretty profound; these patients are very sick.  This is meant to replace SIRS.  It also captures  a much sicker population than the patients included in the Medicare definition. Jeff: So why do you think these parameters turn out to be so useful? Jeremy:  Drilling down into these criteria you can see the pathophysiology at work. Obviously, SBP < 100 means sick.  Interestingly, an elevated RR also turns out to be prognostic, because you’re seeing the compensation for an underlying acidosis.  WHen you see a patient breathing quickly, it’s either from a primary respiratory problem or them trying to relieve an underlying acidosis. The caveat here is that you have to check it. At our hospital in southern Manhattan, patients tend to breathe around 16.  At our hospital in northern Manhattan they like to breath around 18. It’s probably because the air is thinner.  Seriously though, you have to actually measure RR for this to work. Temp is not in QSOFA but we should be checking that too. And I mean checking it by putting something that measures temperature inside the patient. We’ve looked at the forehead and tympanic thermometers and in real world conditions, they tend to underestimate by a degree or more. Think about that. A patient with a headache and a temperature of 99.5 is a very different patient than one with a temp of 100.5.  Make sure you measure temperature. Nachi: Very true and these two patients can definitely go down very different management pathways! Rounding out our discussion on sepsis-3. We should note that severe sepsis is now a term of the past under Sepsis-3. And sepsis-3 redefined septic shock as “hypotension not responsive to fluid resuscitation” with the added requirement of vasopressors to maintain a MAP greater than or equal to 65 and with a lactate > 2. So quite a few changes! Jeff: And Jeremy, sticky topic coming up here. Center for Medicare and Medicaid Services (or CMS) quality measures - They haven’t really caught on to and adapted to Sepsis-3 yet, have they? Jeremy:  The CMS mandate is based on the presence of SIRS criteria. Sepsis 3 is based on SOFA.  This is definitely confusing.  Part of the challenge in discussing this topic is separating out the QI guidelines from what is actually relevant to patient care based on the latest evidence-based medicine. Nachi: That seems fair.  We’re really going to put you in an uncomfortable spot for a second and push you here Jeremy. Do you have any insight into why CMS isn’t interested in following the mountains of research that have led to sepsis-3? Is there a reason they are sticking to their current criteria? Jeremy:  I think some of it is the slow pace of bureaucracy and the time that it takes to develop a consensus on management.  Even if we can agree on who is septic, it’s really hard, if not impossible to link the care to a pay-for-performance metric which is what CMS ultimately would like to see.  That’s not how Sepsis-3, or for that matter, SIRS, was designed to be used.  You’re trying to take a tool which was originally designed for research and mold them into a tool used for pay for performance. Nachi: What a struggle. The CMS metrics are slightly different from the 2001 sepsis guidelines also. Take a look at Table 2 of the article for a quick comparison of sepsis-3, 2001 sepsis, and cms side-by-side. And for those on twitter, we’ll be sure to tweet this table out too for your review. Jeff: With so many different scores and definitions, I think that adequately sets the stage for the challenge this month’s authors faced coming up with real evidenced based guidelines. Nachi: Oh absolutely.  And to make matters worse - this is a HUGE problem. We’re talking up to 850,000 ED visits annually in the US, and 19 million cases worldwide. Compounding this, sepsis results in death in approximately 1 out of 4 cases. Not only is it lethal, it is also very costly -- 17 billion dollars per year in the US alone! Jeff: And don’t forget importantly the 30-day hospital readmission rate. Sepsis is coming in at a higher readmission rate and cost per admission than acute MI, CHF, COPD, and PNA. Nachi: Let’s speak briefly on the etiology and pathophysiology of sepsis: we all know that sepsis is due to local infections that then become systemic. Previously, it was believed that the bacterial infection itself was the cause of the clinical syndrome of sepsis. However, we now know now that the syndrome of sepsis is due to the inflammatory and immunosuppressive mediators that were triggered by the infection. Normal immune regulatory safeguards fail and this leads to the syndrome. And interestingly, several studies have shown that critically ill septic patients experience reactivations of specific viruses that were previously limited to patients with severe immunosuppression. Jeff: Definitely something to look out for in your critically ill septic patients.  We should talk  briefly about the most common inciting infections that lead to sepsis. In order, these are: pneumonia, intra-abdominal infections, and urinary tract infections. No surprises there! Nachi: Yeah, that basically parallels my own experience, so that’s reassuring!  That takes us to our next potentially controversial topic - blood cultures.  Jeremy - we’re going to punt this one back to you Jeremy: This is another interesting topic that has received plenty of attention.   CMS loves blood cultures.  It’s an easy metric to track.  That doesn’t mean they’re always helpful.  We looked at our patients with lactates between 2.1 and 4.0 which had “severe sepsis.”  These patients were normotensive though, In other words, the ones that aren’t that sick.  We found that blood cultures are useful about 20% of the time.  That’s not bad.  So what do we do? We draw cultures before pushing antibiotics.  Is that helpful? Sometimes yes, does it waste money?  Debatable.  Does it help us meet our metrics, yes. Jeff: And I think that gets at the crux of the problem here: we don’t want to delay antibiotics on anybody, but we must balance this with the potential harm of further increasing the drug resistant bacterial population via sound antibiotic stewardship.  Remember also that there is a broad differential for sepsis, with several “sepsis mimics”. To name a few, we have PE, MI, CHF, acute pulmonary edema, DKA, thyroid storm, GI bleeds, drug intoxications, and withdrawal syndromes, just to name a few.  In case that wasn’t enough check out Table 3 of the article. Nachi:  And we already mentioned the leading causes of sepsis, that’s pneumonia, intra abdominal infections, and uti’s. But remember the source can be anywhere. Be sure to also think of pyelonephritis, central line associated bloodstream infections, prosthetics, endocarditis, necrotizing fasciitis, and meningitis. Jeff:  I don’t think we need to dwell on this much longer - basically the differential is huge.  Let’s move on to my favorite section - prehospital care. Jeremy: 20 pages of evidenced based recommendations and your favorite is the prehospital section, what’s up with that? Jeff: I’m an EMS fellow, what can I say… Anyway, on to my favorite section -- prehospital care.  This is always a hot topic because the prehospital period is a special opportunity to get early interventions in for septic patients  as 40 - 70% of all severe sepsis hospitalizations arrive via EMS. Nachi: And in one study taking place in a large metropolitan area, prehospital care time was over 45 minutes, and less than  37% arrived with IV access. Of course, these numbers would vary significantly based on where you practice. Jeff: So get this -- one study showed that out-of-hospital shock index and respiratory rate were highly predictive of ICU admission. So clearly early recognition and therapy may play a role here. Another study, however, showed knowledge gaps by advanced EMS providers in diagnosis and management of sepsis. And yet another study showed that only 18 to 21% of confirmed septic patients were suspected of having sepsis by EMS. Out of hospital fluids were started in only half of patients with severe sepsis. In essence, there is likely a strong role here for pre hospital protocols for identifying and treating sepsis. Nachi: In terms of pre hospital treatments though, prehospital IV fluids haven’t been shown to improve mortality, but have been associated with shorter hospital stays. Prehospital sepsis protocols have been described, but in general more research is needed in this area. Jeff: While prehospital care hasn’t yet been shown to improve the prognosis of septic patients, those presenting via EMS do have shorter delays to initiation of antibiotics, IV fluids, and early care bundles. EMS should focus primarily on stabilizing vital signs and providing efficient transport. If it’s possible to establish an IV and initiate fluids without delaying transport, EMS should do that as well. Nachi: And of course, oxygen for the hypoxic patients! Moving on to history and physical for your presumed septic patient. Jeremy, what are the big hitting things here that you always ask and check for, and that you make sure your residents are doing? Jeremy:  After ABC’s and glucose, AMS is really important, it’s in the QSOFA SCORE.  Unfortunately, this can be hard in many septic patients where they’re baseline mental status is less than perfect.  The other thing is to try and find the source.  Finding the source lets you make wise choices about therapy. Jeff:  Great point about the mental status - so many of our older population have an altered baseline, but recognizing changes from that baseline is key. Nachi:  Absolutely, with that in mind, let’s talk diagnostic studies, especially lactate.  Where I trained, basically everybody was getting a lactate, even tired looking residents seemed to be having their lactates checked, and trust me, they weren’t looking that good... Jeremy:  Brace yourself: lactate is really important in septic patients.  That being said, not every cause of elevated lactate is sepsis.  There is this animal called Type B lactic acidosis can come from numerous drugs like albuterol. Just because you see elevated lactate doesn’t mean you can forget about the other causes.  That being said, we know that patients with sepsis do better when they clear lactate. Jeff: Seems like the evidence is definitely in favor of serial lactate testing… Jeremy: For sure.  At least until you have a reasonable trend towards improvement.  We know lactate clearers do better.  We’ve looked at our own lactate numbers.  Interestingly, the takeoff point for sepsis seems to be around 2.5.  Meaning that patients with altered vitals and lactates above 2.5 tend to do worse.  But, there is a broad ddx to elevated lactate.   What is true, though, is that lactate is a marker for badness.  If your patient’s lactate is rising, yours should be too. Nachi: I bet I’m a “lactate clearer”. I may add “lactate clearer to my CV,” sounds impressive.  But I digress…  Next up we have Procalcitonin.   Since procalcitonin becomes elevated in those with bacterial infections, intuitively, this should be a valuable marker to assess in potentially septic patients.  Unfortunately procalcitonin lacks negative predictive value so most literature supports its use in diagnosing pulmonary infections and for antibiotic de-escalation. Jeff: Good to know, I’ve seen it being used a lot more recently and wondered how evidence based this test was. Jeremy:  Honestly, I don’t see Procalcitonin changing ED management at the moment.  If you’re   waiting for Procalcitonin to start antibiotics or fluids, you’re waiting too long. Nachi: Moving on, let’s talk imaging.  Based on current studies, the authors recommend focused imaging only.  In addition, they also note that our good friend, the point of care ultrasound, likely plays a role, as in one study, POCUS demonstrated a 25% improvement in sensitivity from clinical impression alone. Jeremy:  I think there are two ways POCUS comes in.  One, lung ultrasound can be really useful to find that occult pneumonia or differentiating pneumonia from CHF.   Two, your ultrasound is your best tool for assessing volume status.  I try to look at the IVC of all my septic patients and echo them when possible. Nachi: Right.  So now we’ve examined, drawn labs and cultures, checked a lactate, may be obtained imaging… next up we should probably start treating the patient. Whether you like it or not, we have to discuss CMS. Jeremy: Just to clarify before we start.  CMS defines “severe sepsis” as SIRS + infection with a lactate of 2.1-4.0. Septic shock is SIRS + infection with hypotension or a lactate > 4.0. That’s where we’re at. Jeff:  Good point.  Back to treatment: within the first 3 hours, for any patient with sepsis and septic shock, you must measure a lactate, obtain 2 sets of blood cultures, administer antibiotics, and give an isotonic fluid challenge with 30 cc/kg to patients with hypotension or a lactate greater than 4.   Then, within the first 6 hours, you must apply vasopressors to achieve a MAP of at least 65, re-assess volume status and perfusion, and remeasure a lactate. Nachi: This begs the question - are these recommendations evidenced based? Jeremy…. Jeremy: I’m so glad you asked that . Let’s start with fluids. Patient’s need adequate fluid resuscitation.  Interestingly there are 3 large RCT’s, PROMISE, PROCESS and ARISE,  that compared a Rivers type bundle to usual care.  Surprisingly, they showed no difference.  But when your drill down into these 3 trials, you see that “the usual care,” now generally includes at least 2 liters of fluid. Jeff: Ok, so it seems that there is some pretty good data to support a rapid fluid challenge of at least 30 cc/kg.  But how do we determine who needs more fluids and how much more they need.  There must be an endpoint to all of this? Jeremy: Another million dollar question. 30cc/kg is probably a good place to start.  How much is too much?  I think we need to be smart about our fluids.  Some patients will need less and some will need much more.  So, I remind my resident’s to be smart about fluids.  Sono an IVC, trend a lactate, follow a urine output, do a passive leg raise, even check JVP.  I mean just because you haven’t seen a unicorn doesns’t mean they’re not real.  Do something to monitor volume status. Nachi: Very important. Put your ultrasound skills to work here. They’ll only improve as you practice more.  Jeff, let’s get started on the ever important topic of antibiotics. Jeff: Sounds good.  Current guidelines recommend that broad spectrum antibiotics be administered within the first hour of presentation for those with sepsis or septic shock, ideally with blood cultures being drawn beforehand. In one study, every hour of delayed abx administration was associated with an 8% increase in mortality.  Since this 2006 study, other studies have had mixed results - with studies showing increased odds of death with delays in abx administration and others showing only a benefit in those with septic shock with or without hypotension with no benefit to those without shock. Nachi:  In terms of antibiotic coverage - you need to consider the site of infection, local resistance patterns, the presence of immunosuppression, and the patient’s age and comorbidities.  Table 5 of the article is very thorough and should be kept as a quick reference. Jeremy do you have any specific recommendations for our listeners on how we should approach antibiotic usage in the septic patient? Jeremy: I like to think about antibiotics a little more simply than referencing a table.  I ask a couple questions.  Does my patient need MRSA coverage ?  Does my patient need Pseudomonal coverage?  If the answer is no and no, then narrow your coverage.  You don’t necessarily have to use a bunch of Vanco, or a big gun antipseudomonal like Pip/tazo.  Also, have a look at your local antibiogram.  I can’t tell you how many times this changes prescribing habits for even things like simple UTIs.  I’m going to stray into some controversial territory here. The benefits of sepsis protocols are measured one patient at a time, but the harms are only measured in the aggregate.  What does that mean?  CMS metrics have caused us to  use to use more broad spectrum antibiotics.  As a result, we’re seeing more resistance.  My resident’s tell me to make it easy, give em VZ (that’s vanco/zosyn) and it kills me.   Every time you put a Z-pack into the world a pneumococcus gets it’s wings. So think more about your antibiotics, and know your local biograms. Jeff: That’s a great way to think about it, I fear I’ve given a lot of pneumococci wings during my training…  Next we’re on to vasopressors.  The data is pretty clear on this one - norepinephrine is the recommended first line vasopressor for septic shock.  In numerous trials comparing Norepi to dopamine, NE was far superior, with dopamine increasing arrhythmias in one trial and associated with an increased risk of death as compared to NE in another trial. Jeremy:  So here’s a question I get all the time: How can I give Norepi without a central line.  Let’s use Dopamine, its safe peripherally.  Ok, so follow that through.  We’re going to give a drug to increase blood pressure by constricting blood vessels, but don’t worry, it’s safe peripherally.  What does that mean?  It means it doesn’t work!!  It doesn’t give much blood pressaure.  Dopamine is a lousy pressor.  It causes a lot of tachycardia, which is not what you want in failing septic hearts.  So what do we do if we don’t have a central line?   We start norepi peripherally into a large bore IV for the time it takes us to get a central line.  That’s where the evidence is.  There’s a mortality benefit to NE over dopaine in septic shock. Jeff:  Right, this month’s authors note peripheral pressors may be safe for brief periods in settings with close monitoring.  While this is commonplace in some hospitals, others haven’t yet jumped on that bandwagon. I think it’s important to mention that this is becoming more and more commonplace, even in the prehospital realm.  With the service I fly for, we routinely start peripheral vasopressors without hesitation.  But this isn’t limited to the air.  Many ground 911 services have also adopted peripheral vasopressors in a variety of settings. Nachi: I’m sure there are many trials to come in the future documenting their safety profile, but moving on to the next pressor to discuss... vasopressin. This should be your second line vasopressor for septic shock.  In the VASST trial, low-dose vasopressin was found to be noninferior to NE.  In other trials, vasopressin also appeared to show a potential benefit in those with AKI and sepsis, although the subsequent VANISH trial (perhaps the best name for a clinical trial so far) failed to demonstrate a benefit to vasopressin titration with regard to renal outcomes in septic shock. Vasopressin has also been shown to reduce NE dosing when administered at a fixed dose of 0.03-0.04 units/min. Jeff: Next we have epinephrine.  In one study epinephrine and NE were equivalent in achieving MAP goals in ICU patients with shock, however several of those receiving epi developed marked tachycardia, lactic acidosis, or an increased insulin requirement.  The increasing lactic acidosis could confound the trending of lactates, so in those requiring inotropy in addition to some peripheral squeeze - the authors recommend adding dobutamine to norepinephrine instead of starting epinephrine. Although, keep in mind, this can lead to some hypotension so remember to start at low doses. Nachi: Phenylephrine, a pure alpha adrenergic agent, is next and should be considered neither first nor second line, but it may have a role as a push dose agent while preparing other vasoactive agents. Jeff: And lastly, we have angiotensin 2.  One recent 2017 study examining the role of angiotensin 2 in those with septic shock already on 0.2 mcg/kg/min of NE found that those receiving AT2 had significant improvements in MAPs as well as cardiovascular SOFA score at 48h with no difference in mortality.  Unfortunately, these benefits do not come without risk as AT2 may increase risk of arterial and venous thrombosis and potentially thromboembolism.  Clearly, one study isn’t enough to change practice, but it’s certainly food for thought. Nachi: So that wraps up vasopressors. Jeremy, we’re on to corticosteroids -- another hotly debated topic. When do you give steroids in sepsis? Jeremy:  Hmmm steroids, this is an age old question.  No study has clearly supported the blanket use of steroids in septic shock. Several like CORTICUS and ADRENAL showed no difference.  I will use hydrocortisone for pressor refractory shock. Meaning, you’ve tried everything else, so you might as well try.  Also, I do tend to avoid Etomidate, given the possibility of adrenal suppression and that there are several other induction agents, notably Ketamine  that don’t have this problem. Jeff: Those trials are certainly important, thanks for bringing them up - Especially with all the FOAM content out there, it’s incredibly important to look back at the data to understand where certain recommendations are coming from.   Anyway… one quick note on blood transfusions before we move on to special populations - Although part of the original early goal directed therapy, thanks to data from the TRISS trial which showed no difference in outcomes with a transfusion goal of 7 vs 9, transfusions are reserved for those with a hbg of less than 7. Jeremy:  One population we should make sure to mention and be careful with is end stage liver disease.  In the ER, we tend to miss SBP alot.  Mostly because these patients have lots of reasons to be sick and they already have elevated lactate because of their deceased clearance.  My practice is to give a dose of Ceftriaxone and sent a diagnostic tap to patients who are sick and have ascites. Nachi: Alright Jeremy, let’s talk controversies in sepsis. We’re giving you all the big questions this month! Jeremy:  We’ve already talked about fluids and how much to give.  Just a reminder that a history of CHF doesn’t preclude proper fluid resuscitation.  I think broad spectrum antibiotics for relatively well patients is a big controversy.  Our national rates of antibiotic resistance are terrible, and yet we’re using more antibiotics all the time.  There are very few if any antibiotics coming down the pharma pipeline and we’re going to have to face the music eventually.  Finally, we need national metrics that mirror clinical evidnece.  Protocols should be a tool and not a crutch.  You know what’s best for the patient in front of you, so don’t let metrics or protocols make you do things you think are not in your patient’s best interest. Nachi: So how do you escape the hospital protocols and CMS and do what’s best for your patient without “getting in trouble”? Jeremy: Here’s how I deal with it as the one who reads and QI’s all of our sepsis charts. I tell my colleagues to do what’s right, and if you need to deviate from the protocol tell me why.  As long as you can explain your decision, I’ll support it.  Explaining your thinking is good clinical practice and is good medico-legal practice. CMS has been unable to link these metric  to payment, simply because no hospital can meet them with any regularity.  It’s important that we advocate for our patients or nothing will change. Make them respect you for the highly educated professional that you are, and your patients will ultimately benefit. Jeff: Preach!! And before we close out with disposition, there are a few new therapies and trials on the horizon to keep a lookout for. The RACE trail examined the role of L-carinitine.  The VICTAS trial is looking at vitamin C, thiamine, and steroids in sepsis.  The CLOVERS trial is looking at early vasopressors vs a crystalloid liberal strategy.  And lastly, IL-7 is also being investigated.  All really cool stuff that could change how we manage sepsis in the future.. Nachi  A few quick notes on disposition before we close this episode out.  Certainly not all patients meeting SIRS require admission, but many do.  Those with qSOFA of 2 or higher represent a sick population and an ICU admission should be considered.   Even for those with a qSOFA of 1 but a lacate over 2 -- they have a mortality approaching that of patients with a qSOFA of 2.  Be careful just sending a patient who is on the fence to the floor because several studies have demonstrated that patients who are later upgraded have worse outcomes. Jeff: That’s in line with the general themes we’ve laid out today - definitely better to start early with aggressive care rather than play catch up later.  Jeremy - in 30 seconds or less, what are the most salient points in the management of sepsis that you would like our listeners to take with them from this episode. Jeremy:  Here are my take aways: qSOFA, RR, AMS SBP < 100 Norepi, not Dopamine - it doesn’t work! Be smart about fluids!! Be smarter about antibiotic use! You are the best advocate for your patient, despite what anyone else says! Jeff: Excellent, so that wraps up the October 2018 episode of Emplify. A big thanks to Jeremy Rose for joining us. Jeremy: Thank you for having me!!! It was great talking with you. Nachi: For our listeners -- additional materials are available on our website for Emergency Medicine Practice subscribers. If you’re not a subscriber, consider joining today. You can find out more at www.ebmedicine.net/subscribe. Subscribers get in-depth articles on hundreds of emergency medicine topics, concise summaries of the articles, calculators and risk scores, and CME credits. You’ll also get enhanced access to the podcast, including the images and tables mentioned. You can find everything you need to know at ebmedicine.net/subscribe. Jeff: And the address for this month’s credit is ebmedicine.net/E1018, so head over there to get your CME credit.  As always, the ding sound  you heard throughout the episode corresponds to the answers to the CME questions. Nachi: Lastly, be sure to find us on iTunes and rate us or leave comments there. You can also email us directly at [email protected] with any comments or suggestions. Talk to you next month!

Jeff:  Welcome back to Emplify, the podcast corollary to EB Medicine’s Emergency Medicine Practice. I’m Jeff Nusbaum, and I’m back with my co-host, Nachi Gupta and we’ll be taking you through the September 2018 issue of Emergency Medicine Practice - Emergency Department Management of North American Snake envenomations. Nachi: Although this isn’t something we encountered too frequently – it does seem like I’ve been hearing more about snake bites in the recent months. Jeff: I actually flew someone just the other day because the local ED ran out of CroFab after an envenomation in Western PA. Nachi: Yeah, this is definitely more than “just a boards topic,” and it’s really important to know about in those rare circumstances. In terms of incidence, there are actually about 10,000 ED visits in the US for snake bites each year, and 1/3 of these involve venomous species. Jeff:  That’s a good teaser, so let’s start by recognizing this month’s team – the two authors, Dr. Sheikh, a medical toxicologist, and Patrick Leffers, a pharmD, and emergency medicine and clinical toxicology fellow. Both are at the University of Florida Jacksonville, and they reviewed a total of 120 articles from 2006-2017, in addition to reviews from both Cochrane and Dare. Nachi: And don’t forget our peer reviewers this month, Dr. Daniel Sessions, a medical toxicologist working at the South Texas Poison Center, and our very own editor-in-chief, Dr. Andy Jagoda, who is also Chair of the Department of Emergency Medicine at Mount Sinai in New York City. Jeff: What a team! But, let’s get back to the snakes. As some background, from 2006-2015 there were almost 66,000 reported snake exposures and 31 deaths from snake envenomation in the US.  Of course, this number likely underestimates the true total. Nachi: And there are two key subfamilies of venomous snakes to be aware of – the Crotalinae – or pit vipers – which includes rattlesnakes, copperheads, and water moccasins; and the Elapidae – of which you really only need to know about the coral snake. Jeff:  And while those are the only two NATIVE snake subfamilies to be acutely aware of, don’t forget that exotic snakes, which are shockingly popular pets -- they can also cause significant morbidity and mortality. Nachi:  Oh, and one other quick note before we get into the epidemiology – most of the recommendations this month come from expert opinion, as high quality RCTs are obviously difficult.  In addition, many of the studies were based in other countries, where the snakes, the anti-venoms and their availability, and the general healthcare systems are different from those that most of us work in. Jeff:  Unless we have listeners abroad? Do we have listeners in other countries? Nachi: Oh we definitely do... but we are going to be a bit biased towards US envenomation today. In any case, venomous snake bites occur most frequently in men aged 18 to 49 during warmer months with provoked bites occurring more frequently in the upper extremities and unprovoked bites in the lower extremities. Jeff:  In one study of poison center data from the last decade, nearly half of all victims of snake bites were victims of unknown type snakes.  However, of those that were known, copperheads were the most common, while rattlesnakes caused the most fatalities – 19 of 31 in this dataset. Nachi:  In a separate study of snake bites in the early 2000s, 32% of exposures were from venomous snakes and 59% of those resulted in admission. That’s remarkably high. Jeff:  Snake bite severity depends on several key factors: the amount of venom, the composition of the venom, the body size of the bite victim, the victim's clothing, the size of the bite, comorbid conditions, and the timing and quality of medical care the victim receives. Nachi:  To be a bit more specific - First, the amount of venom will depend on the species of snake, with variations even occurring within the same species.  Secondly, while there is a correlation between rattlesnake size and bite severity, there is much more at play.  Some snakes can even vary the amount of venom based on threat risk – with defensive bites having different profiles than bites to strike prey. Jeff: I found it pretty interesting that  an estimated 10-25% of pit viper bites are considered dry bites, that is, ones in which no venom is released. Nachi:  Right, this is just one reason why all victims shouldn’t immediately get anti-venom, but we’ll get there. Jeff:  We definitely will.  As we already stated – venom composition varies greatly.  Pit vipers produce a predominantly hemotoxic venom.  Systemic effects include tachycardia, tachypnea, hypotension, nausea, vomiting, weakness, and diaphoresis.  Neurotoxicity is rare and is usually due to inter-breeding between species. Nachi:  While rattlesnake bites are associated with higher morbidity and mortality, the more common copperhead bites typically only cause local tissue effects.  More serious systemic findings such as coagulopathy and respiratory failure have been reported though. Jeff:  So that’s a solid background to get us started.  Let’s talk about the individual snakes.  Why don’t you start with the crotalinae family – aka the pit vipers. Nachi:  Sure – the crotalinae includes rattlesnakes, cottonmouths (also known as water moccasins), and copperheads.  These make up the vast majority of reports to the poison centers.  They can be identified by their heat sensing pits located behind their nostrils (hence pit vipers).  As a general rule, you can also identify the venomous snakes by their triangular or spade-like head, elliptical pupils, and hollow retractable fangs. Jeff:  wait, so you want me to walk up to the snake and ask to see if their fangs retract… yea, no thanks. Nachi: Haha, of course not, I’m just giving you some of the general principles here. In contrast, non-venomous pit vipers have rounded heads, round pupils, a double row of vertical scales, and they lack fangs. Jeff: In terms of location, rattlesnakes are found in all states but Hawaii, and cottonmouths and copperheads are distributed mostly throughout the southern and southeastern states, with copperheads also extending further north, even into Massachusetts. Nachi: Moving on to the Elapidae –  there are 3 species of coral snakes, only two of which you need to know about, Micrurus fulvius fulvius or the eastern coral snake and Micrurus tener or the Texas coral snake.  Of the two, the eastern or Micrurus fulvius fulvius produces more potent venom. Jeff:  As you may have guessed by their names, the eastern coral snake is found in the southeastern united states, specifically, east of the Mississippi -- whereas the Texas coral snake lives west of the Mississippi. Nachi:  Venomous North American coral snakes can be recognized by the red and yellow bands around their bodies whereas their nonvenomous counterparts can be recognized by their characteristic black band between the red and yellow bands. I’m sure you’ve heard the popular mnemonic for this… Red touch yellow kill a fellow, red touch black, venom lack. Jeff:  I have heard that one, and it’s not a bad mnemonic. Just remember that this is more of a guideline than a rule, as it doesn’t always hold true. Nachi: Coral snakes also tend to chew rather than bite thanks to their short, fixed, hollow fangs.  Locally, bites can lead to muscle destruction thanks to a certain myotoxin.  Systemic signs of infection include nausea, vomiting, abdominal pain, and dizziness.  Jeff: The venom also contains a neurotoxin which can lead to diplopia, difficulty swallowing and speaking and generalized weakness. Nachi: Complicating matters even further, the onset of these symptoms may be delayed for many hours. Jeff:  Alright, so I think that about wraps up the background.  Let’s move on to the meat and potatoes of this article, starting with the differential. Nachi:  For differential this month, we are really focusing on differentiating a venomous snake from a non-venomous one. Jeff: Oh yeah, this is where you want us to ask the snake if it can retract its fangs, right? Nachi: Ha very funny – Although the type of snake may be obvious if the patient owns the snake, for most cases you see in the ED, the type of snake won’t be clear. Try to get a description of the snake and consider your local geography. Some patients may even bring the snake in with them. Jeff: yea, no thanks. As for prehospital care, it’s actually pretty interesting stuff as recommendations have changed many times.  You may have heard of the recommendations for incision / excision, use of venom extraction devices, tourniquets, chill methods and even electroshock therapy – well these methods are all OUT. Nachi:  Not only are they out, they actually worsen outcomes, so definitely don’t pursue any of them.  Instead,  since no treatment has been shown to improve outcome, you should prioritize prompt transport. Jeff: And while we definitely don’t want to encourage ill-advised attempts at capturing the snake, taking pictures at a distance may be helpful in identifying it.  Oh and the authors do note- pretty terrifying stuff coming up here so brace yourself - even if the snake is dead the bite reflex is still intact… Nachi: And that’s why I work in city hospitals… Jeff:  There’s also a bit of controversy here with regards to pressure immobilization, which is definitely something I thought we were supposed to do in the prehospital setting. Apparently in other countries, like Australia, prehospital providers frequently employ pressure immobilization – that is, wrapping bandages proximally up a splinted limb to impede lymphatic toxin spread. Nachi:  Right, but in Australia, not only are the snakes more venomous but the hospital transport distances are much longer, so, basically they sacrifice the limb to potentially save a life.  In the US, with our current indigenous snake population and the relatively short transport distances, this isn’t justified at all! Jeff:  Take home: based on the current literature, the American College of Medical Toxicology, other experts, and Drs. Sheikh and Leffers recommend against pressure immobilization in lieu of prompt patient transport to definitive treatment. Nachi:  Good to know – alright so now we have the patient in the emergency department, let’s begin ED care.  As always – IV, O2, Monitor including end tidal CO2 if you suspect a neurotoxic or exotic snake bite.  Of course, avoid using the affected limbs for vitals… Jeff: If not done already, remove any constrictive clothing or jewelry and mark the leading edge of pain, edema, and erythema both above and below the bite.  If EMS has placed bandages, leave them in place until antivenom and resuscitative equipment is ready. Nachi:  And definitely involve the poison control center or a medical toxicology service early as they are an amazing resource. It’s an easy number to remember.. 1-800-222-1222. If you just type “poison control center” into google, that number will come up immediately. Jeff: Hypotension should be treated with isotonic fluids and, as usual, anaphylaxis should be treated with the usual cocktail of antihistamines and epinephrine at first IM and then via infusion if refractory. Note that antivenom will NOT reverse anaphylaxis on its own. Nachi:  When eliciting a history, there are a number of important factors to look out for, including – time and location of the bite, description of the snake, tetanus status, comorbid conditions, medications and allergies, any systemic or neurologic symptoms, muscle cramps, perioral tingling or numbness, metallic taste, history of previous snakebites and any reactions to previous envenomation or antivenom treatment. Jeff: Moving on to the physical exam, when examining the wound, look specifically for local tissue effects which occur in over 90% of patients after pit viper envenomations.  In such cases, you would expect pain, erythema, swelling, tenderness, and myonecrosis beginning at the wound site and then spreading via the lymphatic system. Nachi:  In addition, specifically with pit viper envenomations, monitor the patient for possible compartment syndrome as the venom can lead to local tissue destruction, increased cell permeability, third spacing of fluids, and bleeding.  And remember that while the local compartment may be hypertensive, the patient may also have systemic hypotension. Jeff: Just to reiterate what I said before – hypotension may indicate severe anaphylaxis and its not necessarily just due to third spacing.  Regardless, the treatment is the same – epinephrine. Nachi:  Good point, but let’s focus on compartment syndrome for a minute.  True compartment syndrome is actually quite rare --- its really subcutaneous hypertension with preservation of otherwise normal compartment pressures that you’re most likely to see.  Compartment syndrome should therefore only be diagnosed by actual compartment measurements and not just the exam.  However, if you are dealing with compartments that can’t be measured, like in the fingers, you’re only choice is to be guided by the exam… Jeff:  Risk factors for compartment syndrome in the setting of a snake bite include envenomations in small children, involvement of digits, application of ice or cold packs, and delayed or inadequate antivenom administration. Nachi: In terms of respiratory effects of envenomations – they aren’t common.  Both bites to the head or neck and neurotoxin containing venom are potential causes. In the setting of respiratory failure, be prepared with advanced airway maneuvers like nasotracheal intubation or cricothyroidotomy. Antivenom will not reverse respiratory failure. Jeff: Neurologic effects may be present upon arrival but may also be delayed up to 12 hours in the case of eastern coral snake bites. Nachi: It’s noteworthy that in one study of almost 400 eastern coral snake exposures, the onset of systemic symptoms occurred on average 5.6 hours after the bite.  So definitely remember that repeat exams and observation will be tremendously important. Jeff:  The actual neurologic symptoms to look for depend on the snake.  Coral snake venom can produce a descending flaccid paralysis characterized by motor weakness, especially of the cranial nerves.  Similarly pit vipers, especially the Mojave rattlesnake, have also been associated with muscular weakness of the cranial nerves and even respiratory insufficiency. Nachi:  Pit viper envenomation can also lead to myokymia which is repetitive small muscle fasciculations.  Unfortunately, this myokymia may not respond to antivenom administration and myokymia of the chest well and torso can necessitate intubation in extreme cases.  Both myokymia and myonecrosis may lead to rhabdo in the case of significant envenomations. Jeff:  Pit viper envenomation can also cause hematologic effects.  Fibrinolysis and platelet consumption at the bit site can lead to decreased fibrinogen and thrombocytopenia.  In severe cases this can lead to systemic bleeding and even hemorrhagic shock.  Those on anticoagulants and anti-platelet agents are at increased risk. Nachi:  Dermal effects such as edema, ecchymosis, bullae, and bleeding are not uncommon, but up to 50% of coral snake bite victims may have none of these. Jeff:  And to round out this section – just be aware that rare effects such as osteonecrosis, ischemic stroke, massive PE, and septic shock have all been reported. Nachi: Let’s move on to diagnostic studies.  Most patients require a CBC, coags, and a fibrinogen concentration.  Those with systemic toxicity should also have their electroyltes, CPK, creatinine, glucose, and urine tested. Jeff:  And while the data is somewhat mixed, one study suggests that all patients with pit viper envenomations need their coags checked, not just those with severe symptoms as in one series nearly 90% of patients had missed coagulation abnormalities.  The clinical consequences of this aren’t clearly explained, so the authors don’t make a specific recommendation. Nachi:  In terms of imaging, a chest x-ray should be obtained in those with respiratory symptoms and ultrasound may even have an expanding role here for tracking edema, looking for fluid collections, and assessing deep muscle compartments and vascular flow. Jeff: I feel like we should get some entry music for every ultrasound reference because it seems to make its way into just about every episode. Nachi: What would it sound like? You bring this up every month. I’ll look into something for a future episode. If any of our listeners have a suggestion, shoot us an e-mail at [email protected]. In terms of monitoring and observation, this is important, ALL patients with suspected pit viper envenomations should be observed for 8-12 hours with the leading edge marked every 15-30 minutes. Jeff:  In addition, serial diagnostic testing may also be needed as such changes will be used to guide treatment.  In those with systemic symptoms, lab testing will be required every 4-6 hours prior to discharge. Nachi:  Before we move onto treatment – let me quickly mention grading.  There is no universal grading system.  The snakebite severity score, the minimum-moderate-severe score, and grade 1-4 score which consider symptoms, exam findings, and lab abnormalities have all been studied.  None have been validated and none track changes, so the authors recommend relying on severity of symptoms and progression of symptoms to guide treatment. Jeff:  The crux of treatment for pit viper envenomations is with supportive care and anti-venom. Nachi:  FabAV or CroFab is the antivenom of choice for pit viper envenomations.  This antivenom is made from extracting the Fab portion of anti-venom antibodies from envenomated sheep and processing them with papain. Jeff:  Since the sheep are injected with venom from the western diamondback, eastern diamondback and Mojave rattlesnake as well as the cottonmouth, the FabAV is most effective against venom from these snakes, however it does have cross reactivity to other immunologically similar venoms. Nachi:  Indications for FabAV include a more than minimal local swelling, rapid progression of swelling, swelling crossing a major joint, evidence of hemotoxicity, signs of systemic toxicity including hemodynamic compromise, neuromuscular toxicity, and late or recurrent new-onset coagulopathy. Jeff:  Initially, dose FabAV as a bolus of 4-6 vials, IV.  With life threatening envenomations or those with cardiovascular collapse, double the starting dose to 8-12 vials.  The goal is arresting progression, improvement in coagulation abnormalities, and resolution of systemic symptoms. Nachi: Although FabAV will reduce the duration and severity of symptoms and lab abnormalities, it will not reverse tissue necrosis and may not reverse neurologic effects. Jeff:  Once the symptoms have been controlled after the bolus dose or a second bolus dose, maintenance dosing of 2 vials every 6 hours for 3 doses is recommended to prevent recurrence. Nachi:  So to reiterate.  4-6 vial bolus to start, doubled in severe cases and then 2 vials every 6 hours for 18 hours after that. Jeff:  You got it. Nachi:  And like most, maybe all medicines, there are side effects and contraindications to be aware of.  Hypersensitivity reactions and serum sickness to FabAV have been reported as 8% and 13% respectively.   Most are mild and can be treated with your standard bundle of steroids, antihistamines, fluids and epi. Jeff:  Risk factors for developing allergic reactions to FabAV include  a known allergy to papaya, papain, chymopapin, pineapple enzyme bromelain, and previous allergic reaction to FabAV. Nachi:  Although FabAV isn’t produced using copperhead venom, it may be effective in severe envenomations and in one study, FabAV reduced limb disability compared to placebo. Jeff:  Therefore, the authors very reasonably advise that you should use the patient’s clinical picture and individual factors rather than the snake species to guide your treatment. Nachi:  Interestingly, compartment syndrome should be treated with the initial 4-6 vial dose of antivenom and not necessarily a fasciotomy.  Fasciotomies have not been shown to improve outcomes and are reserved only for those failing anti-venom treatment. Jeff:  The reason for this is that antivenom may reduce tissue pressures obviating the need for fasciotomy.  In addition, fasciotomy wouldn’t affect muscle necrosis that is occurring so fascia removal really doesn’t solve anything. Nachi:  And just as anti-venom can be used to treat elevated compartment pressures, it can also be used to treat coagulopathy. Jeff:  Blood products should be used for those who are actively bleeding or severely anemic as venom does not discriminate and will destroy whatever blood it comes across. Nachi:  Recurrent and late onset coagulopathy after FabAV treatment has also been well described.   Although not exactly clear why, some speculate that it occurs for one of 4 reasons. 1) because the half life of FabAV is shorter than that of the venom, or 2) because the venom is initially stored in the soft tissues and then slowly released over time or 3) because the venom has a late onset component, or lastly, 4) there is delayed dissociation of the venom-antivenom complexes.  Regardless of the mechanism, late onset coagulopathy can be treated with FabAV. Jeff:  Luckily, bleeding associated with coagulopathy and bleeding associated with late onset coagulopathy are both extremely rare.   Nachi:  Moving on to coral snakes.  Coral snake bites should be treated with NACSA or North American Coral Snake anti-venom.  This antivenom halts or at least limits the progression of muscle paralysis and shortens the clinical course. Jeff:  Most experts recommend NACSA treatment with the first signs of systemic toxicity and not for all comers.  This recommendation is backed by the literature as in one observational study those treated with prophylactic NACSA did less favorably as compared to those who got it only after symptoms onset.  This is probably because NACSA doesn’t reverse neuromuscular weakness and only limits progression. Nachi:  And it’s not like you are just sitting by and watching while doing nothing – focus your initial treatment on wound care, pain control, and then observation for the development of systemic symptoms.  The exact length of observation will depend on the snake, but should be somewhere between 8 and 24h. Jeff:  As for dosing – the initial NACSA dose is 3-5 vials IV for both peds and adults with a repeat dose if the initial symptoms don’t improve. Nachi: Side effects and adverse reactions occur somewhere between 8-11% of the time with dermal reactions being most common and anaphylaxis being the most severe. Jeff: There is also one last anti-venom to be aware of – Coralmyn, for coral snake envenomations.  Coralmyn is a polyclonal antivenom F(ab’)2 coral snake antivenom, developed because the current lot of NACSA has technically expired although the date has been extended numerous times.  It’s currently in a phase 3 trial, so keep your eyes out. Nachi:  Other non-antivenom treatments that have been tested include acetylcholinesterase inhibitors and trypsin at the bite site – both should be considered experimental at this point. Jeff:  To wrap up the treatment section, let’s talk exotic snakes.  You may recall from the intro that these have a higher morbidity and mortality compared to native species. Nachi:  You will have to rely on your local poison control center or toxicologist for advice and you may even need to turn to the zoo or aquarium for antivenom, if it exists at all.  Patients with bites from exotic snakes should be monitored, likely in the ICU, for up to 24 hours as toxicity from some venom may have a delayed onset of up to 20 hours. Jeff:  Scary stuff, hopefully the patient knows which type of exotic snake they own and you don’t have to sort through a million google images to try to get to the bottom of this.  Anyway, there are 3 special populations to discuss.  First are pregnant patients. Nachi:  The authors cite a 1.4% incidence of snake bites in pregnant patients.  They note that this is low, but from my perspective, this seems shockingly high – why would a pregnant person ever get anywhere near a snake, seems just ill advised… Jeff:  haha, true.   But regardless, treatment is the same with antivenom as needed for all the same indications.  With fetal demise rates as high as 30%, in addition to maternal monitoring, the fetus should also be monitored. Nachi:  That number may seem high, but keep in mind that that’s from studies in other countries with more venomous snakes, so it’s likely to be lower in the US.  But the point remains, that antivenom is generally recommended to be given if the mother has indications for treatment, as poor fetal outcome is tied directly to the severity of envenomation in the mother. Jeff: Continuing right along, the next special population to discuss are pediatric patients.  Because dosing is based on the amount of venom delivered and not on patient specific factors, dosing is the same for peds and adults. Nachi:  How rare – so few meds seem to be the same for peds and adults.  The last population to discuss are anticoagulated patients.  Patients on antiplatelet or anti-coagulants are at increased risk of bleeding after pit viper envenomations and therefore should have their coags checked every 2 days following the last dose of FabAV. Jeff:  I think we’ve at least mentioned most of this months controversies, but it’s probably worth quickly reviewing them since they mostly dispel common myths. Nachi:  Good idea.  Incision and suction of snake bites is nearly universally not recommended. Jeff:  In the absence of ischemia, fasciotomy for snake bites is not recommended, even with elevated compartment pressures.  Instead treat compartment syndrome with anti-venom and save the fasciotomy for true cases of ischemia refractory to antivenom. Nachi:  With a known or suspected coral snake envenomation, due to shortages of NACSA, wait until the patient develops symptoms instead of empirically treating all bite victims. Jeff:  Maintenance dosing of FabAV continues to be debated.  The manufacturer recommends 2 doses every 6 hours for 3 doses while some experts recommend only maintenance dosing as needed.  It’s therefore probably safest to punt this to whatever poison control center or toxicologist you speak with. Nachi:  I feel like we are plugging the poison center a lot, but it’s such a good free, and usually very nice consult to have on your team. Jeff: Nice consultant – what a win!  Moving on to the cutting edge.  There is a new Crotalidae antivenom called Crotalidae Immune F(ab’)2 or, more simply, Anavip.  It should be available in the next few months.  The dosing will be 10 vials up front over 60 minutes followed by an additional 10 vials if the symptoms having been controlled.  4 more vials may be given for symptom recurrence.  Patients must be observed for a minimum of 18 hours after initial control of symptoms. Nachi: This would be a really nice development as Anavip has a longer half life and therefore should reduce the rates of late coagulopathy and decrease the need for maintenance dosing, follow up, and repeating coags. Jeff:  And finally, like we mentioned before, injection of the trypsin has been tried as a bridge to antivenom, as has carbon monoxide, which may mediate degradation of fibrinogen dependent coagulation. Nachi:  Alright, so let’s talk about the disposition next. Victims of pit viper envenomations should be monitored for 8-12 hours from the time of the bite.  They will need baseline labs and repeat testing ever 4-6 hours.  IF there is no progression of the symptoms and repeat testing is normal, the patient can be discharged. Jeff: Victims of coral snake bites should be admitted and observed for 12-24 hours regardless of symptoms. Nachi: Victims of rattle snake envenomations who initially develop hematologic abnormalities and are treated with FabAV should have repeat testing done in 2-4 days and 5-7 days. Jeff:  Wounds should also be closely followed to avoid complications and long term disfigurement and disability.  PT/OT may be necessary as well. Nachi:  Perfect, let’s round this episodes out with a review of the key points and clinical pearls from this month’s issue. There are about 10,000 ED visits in the US for snake bites each year, and 1/3 of these involve venomous species. Pit vipers produce a predominantly hemotoxic venom. Both local and systemic effects can occur. Systemic effects include tachycardia, tachypnea, hypotension, nausea, vomiting, weakness, and diaphoresis. In general, venomous snakes have a triangular or spade-like head, elliptical pupils, and hollow retractable fangs. In contrast, non-venomous snakes have a rounded head, round pupils, lack fangs, and can have a double row of vertical scales on the tail. Venomous North American coral snakes often have adjacent red and yellow bands, whereas their nonvenomous counterparts usually have a characteristic black band between the red and yellow bands. For prehospital care in the US, the following strategies are not recommended: incision or excision, use of venom extraction devices, tourniquets, chill methods, and electroshock therapy -- and they can all actually worsen outcomes.  Prehospital providers should focus on rapid transport. Be cognizant of compartment syndrome, but measure compartments when possible, as some envenomations present similarly but have only subcutaneous hypertension. Neurologic effects can be delayed up to 12 hours after coral snake envenomations. Symptoms can include a descending paralysis. For diagnostic testing, consider a CBC, coags, fibrinogen level, electrolytes, cpk, creatine, glucose, and urine studies.  All patients with envenomation should be observed for at least 8 hours. Mark the site of envenomation circumferentially to monitor for changes. Management of patients with snake bites should be treated with supportive care, pain control, and specific antivenom when indicated. FabAV or CroFab is the antivenom of choice for pit viper envenomations. Although FabAV will reduce the duration and severity of symptoms and lab abnormalities, it will not reverse tissue necrosis and may not reverse neurologic effects. Be aware of the possibility for a hypersensitivity reaction or serum sickness to FabAV. Treat with steroids, antihistamine, IV fluids, and epinephrine as appropriate. Coral snake envenomations can be treated with NACSA, which halts or at least limits the progression of muscle paralysis and shortens the clinical course.  Side effects to NACSA include dermal reaction as the most common -- and anaphylaxis as the most severe. Patients with bites from exotic snakes should be monitored, likely in the ICU, for up to 24 hours as toxicity from some venom may have a delayed onset of up to 20 hours. You may have to turn to your local zoo for help with anti-venoms here. Management of pregnant patient\s is the same as nonpregnant patients with regards to snake envenomations. Dosing of antivenom is based on the amount of venom. Dosing is the same regardless of the age of the patient. All patients requiring antivenom or with suspected envenomation should be admitted.  Seek consultation with your regional poison center and local toxicologist Jeff: So that wraps up the September 2018 episode of Emplify. Nachi: As always - the address for this month’s credit is ebmedicine.net/E0918, so head over there right away to get your credit.  Remember that the  you heard throughout the episode corresponds to the answers to the CME questions. Jeff: And don’t forget to grab your free issue of Synthetic Drug Intoxication in Children at ebmedicine.net/drugs specifically for emplify listeners. Feel free to share the link with your colleagues or through social media too. Next month we are talking sepsis and the ever frequently changing guidelines so it’s not something you want to miss.  Talk to you soon   Most Important References 4. *Lavonas EJ, Ruha AM, Banner W, et al. Unified treatment algorithm for the management of crotaline snakebite in the United States: results of an evidence-informed consensus workshop. BMC Emerg Med. 2011;11:2-227X-11-2. (Consensus panel) 6. *Bush SP, Ruha AM, Seifert SA, et al. Comparison of F(ab’)2 versus Fab antivenom for pit viper envenomation: a prospec­tive, blinded, multicenter, randomized clinical trial. Clin Toxicol (Phila). 2015;53(1):37-45. (Randomized controlled trial; 121 patients) 7. *Gerardo CJ, Vissoci JR, Brown MW, et al. Coagulation parameters in copperhead compared to other Crotalinae envenomation: secondary analysis of the F(ab’)2 versus Fab antivenom trial. Clin Toxicol (Phila). 2017;55(2):109-114. (Ran­domized controlled trial; 121 patients) 8. *American College of Medical Toxicology, American Acad­emy of Clinical Toxicology, American Association of Poison Control Centers, European Association of Poison Control Centres and Clinical Toxicologists, International Society on Toxinology, Asia Pacific Association of Medical Toxicology. Pressure immobilization after North American Crotalinae snake envenomation. Clin Toxicol (Phila). 2011;49(10):881-882. (Position statement) 10. *Wood A, Schauben J, Thundiyil J, et al. Review of eastern coral snake (Micrurus fulvius fulvius) exposures managed by the Florida Poison Information Center Network: 1998-2010. Clin Toxicol (Phila). 2013;51(8):783-788. (Retrospective; 387 patients) 48. *Cumpston KL. Is there a role for fasciotomy in Crotalinae envenomations in North America? Clin Toxicol (Phila). 2011;49(5):351-365. (Review) 75. *Walker JP, Morrison RL. Current management of copper­head snakebite. J Am Coll Surg. 2011;212(4):470-474. (Retro­spective; 142 patients) 81. *Kitchens C, Eskin T. Fatality in a case of envenomation by Crotalus adamanteus initially successfully treated with polyvalent ovine antivenom followed by recurrence of defibrinogenation syndrome. J Med Toxicol. 2008;4(3):180-183. (Case report) 118. *Hwang CW, Flach FE. Recurrent coagulopathy after rattle­snake bite requiring continuous intravenous dosing of anti­venom. Case Rep Emerg Med. 2015;2015:719302. (Case report)

Show Notes Disclaimer: This is the unedited transcript of the podcast. Please excuse any typos. Jeff:  Welcome back to Emplify, the podcast corollary to EB Medicine’s Emergency Medicine Practice. I’m Jeff Nusbaum, and I’m back with my co-host, Nachi Gupta and we’ll be taking you through the August 2018 issue of Emergency Medicine Practice. Nachi: This month’s topic is one that Jeff has significant personal experience with from his college days. We’re reviewing Cannabinoids -- and emerging evidence in their use and abuse. Jeff: Um… that is definitely not true. I was actually a varsity rower in college... Are we still reviewing talking points together before we start recording these episodes? Nachi: Sometimes… Jeff: This month’s issue was authored by Mollie Williams, who is the EM residency program director at the Brooklyn Hospital Center. It was peer-reviewed by Joseph Habboushe, assistant professor at NYU and Nadia Maria Shaukat, director of the emergency and critical care ultrasound at Coney Island Hospital in Brooklyn, New York. Nachi: We’re going to be talking about the pathophysiology of cannabinoids, clinical findings in abuse, best practice management, differences between natural and synthetic cannabinoids, and treatment for cannabinoid hyperemesis syndrome. So buckle up and get ready. Jeff: As you’re listening through this episode, remember that the means that we are about to answer one of the CME questions from the end of the print issue. If you’re not driving while listening, be sure to jot down these answers and get your CME credit when we’re going through this issue.. Nachi: As of June 2018, there are 31 states, the District of Columbia, and 2 US territories that possess state and local-level laws allowing the use of cannabis medicinally or in recreational formulations. Marijuana actually maintains the highest lifetime use of an illicit drug used within the US. Jeff: There are a shocking 22 million past-month users of marijuana in the US, followed by pain relievers at 3.8 million, and cocaine at 1.9 million. Clearly, an important topic worth discussion, especially as synthetic products have become more widely available. Nachi: And worth noting -- Colorado, where medicinal and recreational marijuana use has been decriminalized and later legalized, has shown a nearly 2-fold increase in the prevalence of ED visits, which may be related to marijuana exposure. Jeff: Medicinally, cannabinoids are currently used in the treatment of chronic pain syndromes, complications of multiple sclerosis and paraplegia, weight loss due to appetite suppression in HIV/aids, chemotherapy-induced nausea and vomiting, seizures, and many other neuropsychiatric disorders. In fact, cannabis use has been documented for medical use dating as far back as 600 BC in West and Central Asia. Nachi: All of that being said though, there is an absence of high-quality reviews and evidence to support the use of cannabinoids for any of the indications you just mentioned. And the US DEA maintains cannabis as a Schedule I substance. Jeff: This DEA designation limits the ability to do research and obtain federal funding for such research. General lack of federal regulations on chemical content also leads to product variation, which may be a cause of increased incidences of accidental overdoses. Nachi: To attain the most up to date information for this article, Dr. Williams searched the PubMed and Cochrane Databases from 1950 to 2018. This produced predominantly case reports and retrospective studies. There were just a few randomized prospective studies -- not surprising. Jeff: Let’s get started with the pathophysiology. There are 3 cannabis species to be aware of: Cannabis sativa, cannabis indica, and cannabis ruderalis. Within these species, over 545 active cannabis-derived components have been described. Nachi: There are ten main constituents of cannabis sativa. Of these, 9-tetrahydrocannabinol (delta-9-THC) and cannabidiol (CBD) are found in the greatest quantities. The neuropsychiatric and addictive properties of cannabis are due primarily to the delta-9-THC. Jeff: THC and other cannabis derivatives work through the endocannabinoid system and other neuroregulators. The endogenous cannabinoid system has 4 components: (1) endogenous endocannabinoids, (2) receptors, (3) degradation enzymes, and (4) transport mechanisms. Nachi: There are two endogenous endocannabinoids to know about: anandamide (AEA) and 2-arachidonoyl-glycerol. Jeff: Cannabinoid receptors are broadly dispersed through the central nervous system, and to a lesser degree, also to other organ systems. Nachi: Because CB receptors are concentrated within the central nervous system, they exert the majority of their effects on the neuropsychiatric systems. And   -- yes that’s a double ding -- the cannabinoid 1 (or CB1) receptor is most responsible for cannabis-induced neuropsychiatric effects. Jeff: Interestingly, the anti-emetic effects and possible palliative properties of cannabis derivatives are thought to be secondary to the inhibitory effects on serotonin receptors and the excitatory effects on the transient receptor potential vanilloid 1 (or TRPV1).  More on TRPV1 later... Nachi: So far we have been talking about cannabinoids from the cannabis plant, but with cannabis being illegal in many states, there has been a growing emergence of synthetic cannabinoids. Synthetics were initially developed in the 1980s largely for research purposes. Jeff: Because the current DEA controlled substances schedule designations are based on original chemical names, synthetics have gained popularity as manufacturers are able to produce newer compounds and circumvent DEA designation as well as routine urine drug screening tests. Nachi: You may be familiar with some of the street names for synthetics -- like spice, K2, scooby snacks, black mamba, kush, and kronic. These can often be purchased over the internet or through specialty smoke shops. Jeff: Scooby Snacks, what a fantastic name, mooovingggg on… Synthetic cannabinoids often have greater affinity for the CB1 receptor than naturally occurring cannabinoids -- and synthetics can produce 100 times the effect. As a result, the presenting symptoms with synthetic intoxication can be difficult to differentiate from crystal meth or bath salt abuse. Nachi: Manufacturers sometimes use solvents and other contaminants. Clusters of toxic ingestions and deaths have occurred. Emergency clinicians need to be aware of this and should report suspicious events immediately. Jeff: For more on synthetic intoxications in the ED, be sure to take a look at the recent May 2018 issue of Pediatric Emergency Medicine Practice on Synthetic Drug Intoxication in Children if you haven’t already read it. Also, just a quick FYI - If you’re not a current subscriber to Pediatric Emergency Medicine Practice, we’re giving away a free copy of the issue specifically for our listeners. Just head over to ebmedicine.net/drugs for the PDF of the issue. Nachi: A free issue for our listeners, that’s nice! Let’s move on to a discussion about current indications for cannabinoids. So, there is no clear consensus on these indications, but there is some research of varying quality that supports the treatment of some chronically debilitating diseases with cannabinoids. Jeff: A systematic review and meta-analysis from 2015 found low-quality evidence to support cannabis therapy for appetite suppression in HIV and aids patients; moderate-quality evidence for treatment of chronic pain and spasticity; and also moderate quality evidence for some chronic debilitating diseases. Nachi: While talking about evidence-based medicine here, another review by the National Academies of Science, Engineering, and Medicine on possible associations between cannabis and cancers arising in the lungs, head, and neck, or testicles -- showed no statistically significant associations exist. Jeff: So in case that wasn’t clear - the overall evidence to support cannabis therapy, in general, is weak. Also, be aware that there are various formulations of cannabis that allow for different routes of administration. We’re talking oils, tinctures, teas, extracts, edibles like candies and baked goods, parenteral formulations, eye solutions, intranasal, sublingual, transmucosal, tablets, sprays, skin patches, topical creams, rectal suppositories, and capsules -- just to name, a few. Nachi: A few! That seems pretty complete to me. Basically, any way you can imagine, it seems like a route of administration has been explored. But of importance, these formulations have different absorption times -- as you might expect. The shortest duration to peak plasma levels of delta-9-THC is through the inhalation route, which can produce effects within 3 minutes. On the longer end, rectal cannabis administration can take up to 8 hours to reach peak plasma concentrations. Jeff: Let’s talk about some of the clinical findings and systemic effects associated with cannabis use. First up is the link between cannabis use and stroke or TIA. Cannabis users who smoked at least once weekly had a 3.3 times higher risk of stroke or TIA. Nachi: And there is moderate quality evidence that this link may be dose-dependent. Larger amounts of cannabis use lead to cerebral vasospasm and a reduction in cerebral blood flow. Jeff: In terms of psychiatric effects, several low-to-moderate quality studies have shown statistically significant associations between psychosis and self-reported cannabis use. Some association between high potency cannabis or synthetic cannabinoid use with new-onset psychosis or relapse in previous psychiatric disorders has also been found. Lastly, there is weak data supporting a correlation between cannabis use and depression. Nachi: From a cardiovascular standpoint, cannabis use is associated with increased resting heart rate, hypertension, and decreases in the anginal threshold for patients with chronic stable angina. A 2001 study described an augmented risk of myocardial infarction within the first hour of cannabis use and found an almost 5-fold increase in those who reported smoking cannabis at least weekly when compared to those who smoked monthly or less. Jeff: Dysrhythmias, qt prolongation, av blocks, myocarditis, and sudden death have all been reported with cannabinoids. Nachi: In terms of pulmonary effects, these are not really related to cannabis use directly, but rather the smoke inhalation and combustion materials of synthetic cannabinoids. Effects from chronic use can be seen. Jeff: Renally speaking, acute kidney injury and rhabdomyolysis are associated with synthetic cannabinoids and have been observed in several case reports. The rhabdo is believed to be due, in part, to associated seizures, muscle tremors, and agitation. Nachi: Among metabolic abnormalities, patients can present with hyperthermia, hypoglycemia, hypokalemia, hyponatremia, and metabolic acidosis. Jeff: Orally and dentally, dry mouth is the most common finding in acute cannabis toxicity. Chronic use has also been linked to severe periodontitis. Nachi: And ophthalmologically, there is, of course, the commonly seen conjunctival injection. Cannabis has also been found to decrease intraocular pressure when used topically -- and of note, there have also been rare reports of acute angle closure glaucoma and central retinal vein occlusion. Jeff: While talking about clinical findings and systemic effects of cannabis use, we certainly need to go over cannabinoid hyperemesis syndrome (or CHS), which is -- quite simply put -- associated with frequent visits to the ED in chronic users. It presents with nausea, vomiting, and abdominal pain. Nachi: CHS is commonly misdiagnosed as cyclical vomiting syndrome. After the legalization of marijuana in Colorado, it was reported that nearly twice as many patients had presented for what was thought to be cyclical vomiting syndrome. And ironically, though cannabis has been used as an anti-emetic, chronic use can cause the opposite reaction, leading to CHS, which is typically refractory to traditional anti-emetics. Jeff: And the etiology of CHS is not well understood. Similarly, the exact criteria for CHS are poorly defined. It presents as a recurrent and relapsing disorder that can be divided into 3 phases: prodromal, hyperemetic, and recovery. Nachi: In the prodromal phase, patients complain of early morning nausea without vomiting, and they can have mild abdominal discomfort. This can last from months to years. In the hyperemetic phase, patients complain of severe, unremitting abdominal pain with repeated episodes of vomiting and retching. This is often associated with an inability to tolerate po. Jeff: The hyperemetic phase lasts 24-48 hours and can lead to dehydration, electrolyte abnormalities, and weight loss. Patients may learn to relieve symptoms by compulsively bathing in hot water. Nachi: Resolution of symptoms is seen when the patient stops using cannabis. This is during the recovery phase, which can last from days to months. But this can be short-lived if the patients begin using cannabis again. Jeff: On that note, we should also touch on cannabis withdrawal. Termination of heavy and habitual use can lead to withdrawal syndromes within 48 hours. Symptoms here include irritability, anxiety, restlessness, sleep difficulty, seizures, and aggression. Medications that can be helpful include benzodiazepines, neuroleptic agents, and quetiapine in refractory cases. Nachi: Moving on to the next sections in the article, let’s talk about differential diagnosis and prehospital care. The differential for acute cannabinoid intoxication, as you might suspect, is broad, and it includes some life-threatening processes. We won’t list them here, but be sure to think broadly before deciding on cannabis as the cause of your patient’s symptoms. Jeff: For the prehospital providers -- care here is mainly supportive. Provide airway protection as needed - gather information from the patient’s environment, looking for empty pill bottles or another empty packaging. Nachi: Let’s move on to care once in the ED. All patients who are in distress and suspected of drug ingestion should be disrobed completely and placed on a cardiac monitor. Fully assess for trauma and place an IV in the patient. Search the patient’s clothing for drugs and paraphernalia, which may help in making the diagnosis. Jeff: When getting a complete history from the patient, it may also be worthwhile to talk with any persons accompanying the patient to the ER for more information. In your history, be sure to ask about a pattern of use and possible co-ingestions. Nachi: When considering cannabis hyperemesis syndrome, a detailed history and physical exam are crucial for making the diagnosis. To differentiate between other etiologies of abdominal pain and vomiting, be sure to ask about the use of hot baths for relief, resolution of symptoms after stopping cannabis use, and the predominance of symptoms in the morning hours. Jeff: On physical exam, for cannabis intoxication, there isn’t a particular toxidrome to look for. Monitor vital signs closely, looking out for alterations in blood pressure and heart rate. A complete neurologic and mental status examination will be the key here. Nachi: Decisions for lab testing should be dependent on the patient’s presentation. Possible tests include CBC, BMP, LFT’s, lipase, cpk, ckmb, troponin, urinalysis, urine drug screening, serum tox screens (for alcohol, aspirin, and acetaminophen), and any other drug levels for medications that the patient is taking for medicinal purposes, like phenytoin or lithium levels. Jeff: One study supported point of care urine drug testing in the ED. However, know that acute cannabis intoxication can be difficult in the chronic user, as delta-9-THC will be present in urine for up to 24 days. Testing for synthetically derived cannabinoids is difficult due to changes in synthetic compounds. Nachi: Interestingly, there are a number of medications that are associated with false positive cannabinoid screenings. These include ibuprofen, pantoprazole, efavirenz, and lamotrigine. Jeff: For any patient arriving with suspected cannabis or synthetic abuse, consider checking an EKG. You’re looking for signs of ischemia, arrhythmia, and interval abnormalities. Serum and urine tox tests are not particularly helpful in the acute chest pain patient who is using synthetic marijuana. Nachi: Not surprisingly, there are no specific diagnostic imaging modalities to help diagnose cannabis or synthetic cannabinoid intoxication. But imaging may help with assessing other disease states on a patient’s differential, so stay mindful of that. Jeff: Now that we’ve talked about history, physical exam, and useful testing modalities, let’s talk about treatment for cannabis and synthetic cannabinoid toxicity… therapy is primarily focused on supportive care. Most ED visits only require a short stay. Nachi: That’s right, there are no antidotes to give for treatment here. Be sure to look for and treat dehydration, acute renal failure, and rhabdo though. In severe cases of neuropsychotropic effect, give benzodiazepines, like lorazepam, to help with control. Jeff: For GI effects, first-line treatment is traditional anti-emetics like ondansetron or metoclopramide. Recent literature and case reports have shown significant improvement with butyrophenones like haloperidol as a second-line treatment. Nachi: While talking about treating the gastrointestinal effects of cannabis toxicity, let’s also discuss methods to control cannabinoid hyperemesis syndrome. The mainstays for treatment here are actually supportive therapy and cessation of cannabis use. Jeff: And can you tell us more about why these patients crave hot showers and improve after? Is there a pathophysiology or mechanism to know about there? Nachi: There is a well-studied theory here and it relates to the TRPV1 receptor that we talked about earlier. Temperatures in excess of 109 degrees Fahrenheit, acidic conditions, and compounds found in certain foods and plants (like cannabis) activate this receptor. It’s believed that intermittent and repetitive exposure to agonists of the TRPV1 receptor leads to a persistent state of nausea and vomiting. Desensitization of the receptor happens after repeated stimulation, and repetitive topical capsaicin or hot water is believed to function as an exogenous agonist. Jeff: In any case of repetitive emesis, be sure to consider electrolyte replacement if needed. In many cases, hydration or repletion will need to happen through an IV. Proton pump inhibitors can also help in some cases where GI symptoms are a dominating complaint of the patient. Nachi: Recent literature supporting the use of haloperidol for nausea and vomiting has found that symptoms improve approx 1hr after administration. This can decrease the need for observation or admission. Jeff: Haloperidol works via dopamine 2 receptor antagonism. D2 receptors are found in high concentrations throughout the nervous system and bind with high affinity to haloperidol. The suggested starting dose is 2.5mg IV with a repeat dose of 5mg IV if needed. An RCT is underway in Canada on the use of ondansetron versus haloperidol with an estimated completion of July 2019. Nachi: Capsaicin has similarly shown promise in cannabis hyperemesis syndrome through the TRPV1 receptor as we discussed already. Currently, there are no dosing recommendations or application instructions for capsaicin. There is some evidence supporting relief within 30 to 45 minutes, and capsaicin can be applied topically to any nonmucosal surface like the abdomen, chest, or back. Jeff: So to recap -for cannabis hyperemesis syndrome, treat with anti-emetics, PPI’s, electrolyte repletion, and IV hydration as needed. As a second line treatment, consider haloperidol and topical capsaicin applied to the chest, abdomen, or back. Nachi: Let’s talk about some special populations next -- starting with Pediatrics. According to data from 2012, of the 130 million people reporting illicit drug use within their lifetime, 25% were children between 12 and 17 years of age. Jeff: And according to the national poison data system, states with marijuana use laws have seen a 30% increase in calls related to marijuana use by children. From 2010 to 2011, the number of ED visits by children aged 12 to 17 years old due to synthetic cannabinoid use also has doubled. Nachi: Many children and adults believe that synthetic cannabinoids don’t pose serious health risks, as these are not illegal to purchase. And this class of drugs is particularly attractive to adolescents since it will not readily test positive on urine drug tests. All of this is very concerning for emergency clinicians. Jeff: There have been several recent reports of myocarditis in association with marijuana use. One case resulted in death due to myocyte necrosis after an unknown amount of edible marijuana was consumed by a toddler. Nachi: Horrific! Jeff: And the exact mechanism through which the myocardial necrosis happens isn’t known. Nachi: For all children and adolescents who present to the ED with alteration in mental status, psychosis, or chest pain -- be sure to screen for cannabis or synthetic cannabinoid use.  There are case reports in the pediatric literature of STEMIs seen in patients without pre-existing cardiac disease or risk factors. Jeff: Keep in mind that urine drug screens can be falsely positive from certain proton pump inhibitors, so if possible, assess a urine drug screen prior to starting a PPI in these patients. Nachi: Moving on to our next special population… pregnant women. Know that it can be difficult to the differential between hyperemesis gravidarum and cannabis hyperemesis syndrome in pregnant patients. Ask specific questions regarding marijuana use before and during the pregnancy. Jeff: It’s also worth noting that cannabis is known to cause adverse outcomes on babies such as low birth weight and more frequent perinatal ICU placement. Nachi: Let’s move on to the final major section of the article, which is on the legal status of cannabis and cannabinoids. Much of the controversy surrounding cannabis for medicinal use relates to the absence of quality evidence. More research is needed to evaluate potential public health risks posed by variations in quality and potency, potential impact to our healthcare system, and ability to legislate for synthetic cannabinoids. Jeff: Though marijuana and all whole-plant derivatives are schedules I controlled substances, there are a few cannabinoid-based drugs approved by the FDA for medicinal purposes -- with lower schedule designations. Dronabinol is a schedule III drug derived synthetically from delta-9-THC. It’s used in chemotherapy-induced nausea/vomiting, as well as anorexia and weight loss from AIDS/cancer. Nachi: Nabilone, a schedule II synthetic variant of THC, has been approved in the treatment of aids-related anorexia and chemotherapy-induced nausea also. Jeff: Nabiximols, a plant-derived cannabinoid, has been approved in Europe and Canada for multiple sclerosis induced spasticity and cancer-related pain. Nabiximols are not yet approved in the US. Nachi: And lastly, we should mention cannabidiol, which is a schedule I controlled substance approved for treatment of seizures with 2 rare diseases -- Lennox-gastaut syndrome and dravet syndrome. Compared with placebo alone cannabidiol and other medications have shown efficacy in lowering the rate of seizures for these diseases. Jeff:  Lots of interesting stuff to look out for there in cannabinoid-related medications. Alright, on to disposition - Nachi: Most patients who present with uncomplicated acute cannabis or synthetic cannabinoid intoxication can be observed until clinically sober. Discharge home should be in the care of a sober family member or friend. Make sure that the patient knows not to operate vehicles or heavy machinery under the influence of drugs. Counsel them on drug abuse also. Jeff:   In more rare situations, patients will require admission. Consider this particularly for patients who have end-organ damage, rhabdomyolysis, acute renal failure -- evidence of cardiovascular, cerebrovascular, or ophthalmologic insults -- intractable vomiting, or acute psychosis. Nachi: And for cannabinoid hyperemesis syndrome, patients may require admission for IV hydration and electrolyte correction. Once the patient is tolerating PO and lab derangements have been corrected, they can be discharged. Jeff: Let’s wrap up the episode with key points and clinical pearls… N: Marijuana is the most commonly used illicit substance in the US. States that have legalized marijuana for medical and recreational purposes are showing increased rates of marijuana abuse and dependence. J: When concerned with drug intoxication, search your patient’s clothing for drugs and paraphernalia on arrival. N: The neuropsychiatric and addictive properties of cannabis are due primarily to delta-9-THC. J: Synthetic cannabinoids have gained popularity as manufacturers are able to produce newer compounds and circumvent DEA designations as well as routine urine drug screening tests. N: Manufacturers of synthetic cannabinoids sometimes use solvents and other contaminants, which have caused clusters of toxic ingestions and death. J: The shortest duration to peak plasma levels of delta-9-THC is through the inhalational route. Effects can be seen within 3 minutes. N: Cannabis users who smoke at least once weekly can have a 3.3 times higher risk of stroke or TIA. J: The risk of myocardial infarction is increased within the first hour of use, and there is an almost 5-fold increase for individuals who smoke at least once per week. N: Acute kidney injury and rhabdomyolysis have been noted with synthetic cannabinoid use in several case reports. J: Cannabis intoxication is associated with many metabolic abnormalities like hyperthermia, hypoglycemia, hypokalemia, hyponatremia, and metabolic acidosis. N: Cannabis hyperemesis syndrome, which presents with abdominal pain and vomiting, is associated with frequent visits to the ED in chronic users. J: The mainstay for treatment of cannabis hyperemesis syndrome is supportive therapies and cessation of cannabis use. N: Patients with cannabis hyperemesis syndrome crave hot showers because of activation of the TRPV1 receptor. J: Topical capsaicin may also help in the treatment of cannabis hyperemesis syndrome through activation of the TRPV1 receptors. N: Haloperidol at 2.5mg IV may help in refractory vomiting associated with cannabis hyperemesis syndrome. J: Many children and adults do not believe synthetic cannabinoids pose serious health issues as the they are not illegal to purchase. This is incorrect. N: Most patients with acute uncomplicated cannabis intoxication can be observed and discharged. Admit if there are any signs of end organ damage, intractable vomiting, or acute psychosis. Jeff: So that wraps up the August 2018 episode of Emplify. Nachi: For those of you looking for CME - the address for this months credit is ebmedicine.net/E0818, so head over there right away to get the credit you deserve.  Remember that the you heard throughout the episode corresponds to the answers to the CME questions. Jeff: And don’t forget to grab your free issue of Synthetic Drug Intoxication in Children at ebmedicine.net/drugs specifically for emplify listeners. Feel free to share the link with your colleagues or through social media too. See you next time! Most Important References 5. * Kim HS, Monte AA. Colorado cannabis legalization and its effect on emergency care. Ann Emerg Med. 2016;68(1):71-75. (Literature review; 21 studies)7. * Baron EP. Comprehensive review of medicinal marijuana, cannabinoids, and therapeutic implications in medicine and headache: What a long strange trip it’s been …. Headache. 2015;55(6):885-916. (Review)9. * Whiting PF, Wolff RF, Deshpande S, et al. Cannabinoids for medical use: a systematic review and meta-analysis. JAMA. 2015;313(24):2456-2473. (Retrospective chart review; 4 cases)64. * Tournebize J, Gibaja V, Kahn JP. Acute effects of synthetic cannabinoids: update 2015. Subst Abus. 2016:1-23. (Systematic review; 46 articles, 114 patients)83. * Wallace EA, Andrews SE, Garmany CL, et al. Cannabinoid hyperemesis syndrome: literature review and proposed diagnosis and treatment algorithm. South Med J. 2011;104(9):659-664. (Review)

Join Jeff, a former firefighter, and Nachi, a former mathematician, as they take you through the July 2018 issue of Emergency Medicine Practice: Emergency department management of dyspnea in the dying patient Most Important References 17. Reuben DB, Mor V. Dyspnea in terminally ill cancer patients. Chest. 1986;89(2):234-236. (Prospective; 1754 patients)34. Lunney JR, Lynn J, Foley DJ, et al. Patterns of functional decline at the end of life. JAMA. 2003;289(18):2387-2392. (Prospective cohort; 4190 patients)40. Steinhauser KE, Christakis NA, Clipp EC, et al. Factors considered important at the end of life by patients, family, physicians, and other care providers. JAMA. 2000;284(19):2476-2482. (Cross-sectional survey; 1122 patients/families/providers)41. Quill TE, Arnold R, Back AL. Discussing treatment preferences with patients who want “everything.” Ann Intern Med. 2009;151(5):345-349. (Review)63. Clemens KE, Quednau I, Klaschik E. Use of oxygen and opioids in the palliation of dyspnoea in hypoxic and non-hypoxic palliative care patients: a prospective study. Support Care Cancer. 2009;17(4):367-377. (Nonrandomized trial; 46 patients)66. Abernethy AP, McDonald CF, Frith PA, et al. Effect of palliative oxygen versus room air in relief of breathlessness in patients with refractory dyspnoea: a double-blind, randomised controlled trial. Lancet. 2010;376(9743):784-793. (Double-blind randomized controlled trial; 239 patients)68. Galbraith S, Fagan P, Perkins P, et al. Does the use of a handheld fan improve chronic dyspnea? A randomized, controlled, crossover trial. J Pain Symptom Manage. 2010;39(5):831-838. (Randomized controlled crossover trial; 50 patients)

Join hosts Jeff Nusbaum, MD, and Nachi Gupta, MD on this episode of EMplify as they take you through the June 2018 issue of Emergency Medicine Practice: Managing Shoulder Injuries in the Emergency Department Fracture, Dislocation, and Overuse. This month, Richard Pescatore, director of clinical research at Crozer-Keystone Health System and clinical assistant professor at the Rowan University School of Osteopathic Medicine, along with Andrew Nyce, vice chairman and associate professor at cooper medical school of Rowan University reviewed just over 100 articles to come up with their evidence-based recommendations. Their recommendations were then edited by John Munyak of Maimonides and Mark Silverberg of SUNY Downstate and Kings County Hospital. Most Important References * Ponce BA, Kundukulam JA, Pflugner R, et al. Sternoclavicular joint surgery: how far does danger lurk below? J Shoulder Elbow Surg. 2013;22(7):993-999. (Prospective cohort; 49 patients) * Slaven EJ, Mathers J. Differential diagnosis of shoulder and cervical pain: a case report. J Man Manip Ther. 2010;18(4):191-196. (Case report) * Helfen T, Ockert B, Pozder P, et al. Management of prehospital shoulder dislocation: feasibility and need of reduction. Eur J Trauma Emerg Surg. 2016;42(3):357-362. (Retrospective review; 70 patients) * Lenza M, Belloti JC, Andriolo RB, et al. Conservative interventions for treating middle third clavicle fractures in adolescents and adults. Cochrane Database Syst Rev. 2014(5):CD007121. (Systematic review; 3 trials, 354 patients) * Neer CS, 2nd. Displaced proximal humeral fractures: part I. Classification and evaluation. 1970. Clin Orthop Relat Res. 2006;442:77-82. (Review article) * Sholsberg J, Jackson R. Best evidence topic report. Intra-articular corticosteroid injections in acute rheumatoid monoarthritides. Emerg Med J. 2004;21(2):204. (Systematic review; 1 study, 137 patients)

Join hosts Jeff Nusbaum, MD, and Nachi Gupta, MD on this episode of EMplify as they take you through the  May  2018  issue  of  Emergency  Medicine  Practice:  Recognizing  and  Managing  Emerging  Infectious  Diseases  in  the  Emergency  Department. This month’s issue was authored by Drs. Millan,  Thomas-Paulose, and Egan from Mount Sinai St  Luke’s and Mount Sinai West in New York city.

Jaundice is a manifestation of elevated serum bilirubin, and can have many causes, some of which can be life-threatening. Join hosts Jeff Nusbaum, MD, and Nachi Gupta, MD on this episode of EMplify as they take you through the April 2018 issue of Emergency Medicine Practice: Jaundice in the Emergency Department: Meeting the Challenges of Diagnosis and Treatment. This month’s issue was authored by Dr. Taylor and Dr. Wheatley both of the Emory School of Medicine.  It was peer reviewed by Dr. Chung of the Icahn School of Medicine at Mount Sinai, and Dr. Horan of Our Lady of Lourdes Medical Center.

When treating patients who have suffered injury in a fire, managing their airway is as critical as treating their burns. Join hosts Jeff Nusbaum, MD, and Nachi Gupta, MD on this episode of EMplify as they take you through the March 2018 issue of Emergency Medicine Practice: Emergency Department Management of Smoke Inhalation Injuries in Adults. This month’s issue was authored by Dr. Otterness and Dr. Ahn of the Stony Brook School of Medicine. It was also reviewed by a toxicology duo of Dr. Manini of The Icahn School of Medicine at Mount Sinai and Dr. Nelson of Rutgers New Jersey Medical School.

Welcome back to Emplify, the podcast corollary to EB Medicine’s Emergency Medicine Practice. We’ll be taking you through the February 2018 issue of Emergency Medicine Practice: Emergency Department Management of Patients with Thermal Burns.

As the prevalence of cancer continues to increase in the general population and improvements in cancer treatment prolong survival, the incidence of patients presenting to the emergency department with oncologic complications will, similarly, continue to rise. This episode reviews 3 of the more common presentations of oncology patients to the emergency department: metastatic spinal cord compression, tumor lysis syndrome, and febrile neutropenia. Signs and symptoms of these conditions can be varied and nonspecific, and may be related to the malignancy itself or to an adverse effect of the cancer treatment. Timely evidence-based decisions in the emergency department regarding diagnostic testing, medications, and arrangement of disposition and oncology follow-up can significantly improve a cancer patient's quality of life. This episode of EB Medicine's EMplify podcast is hosted by Nachi Gupta, MD, PhD, and Jeff Nusbaum, MD. This month's corresponding full-length journal issue of Emergency Medicine Practice was authored by David Wacker, MD, and Michael McCurdy, MD. It was peer reviewed by Kevin Chase, MD, and Natalie Kreitzer, MD. Link to article: http://www.ebmedicine.net/topics.php?paction=showTopic&topic_id=564

Lower-extremity dislocations are less common in the emergency department (ED) than shoulder and elbow dislocations, and emergency clinicians’ experience with evaluation and reduction techniques is often limited. Nonetheless, these dislocations can be serious because of their association with vascular injury. This episode discusses the mechanism of injury, diagnostic approach, treatment plans, and potential complications of dislocations of the hip, knee, and ankle. This episode of EB Medicine's EMplify podcast is hosted by Jeff Nusbaum, MD, and Nachi Gupta, MD, PhD. This month's corresponding full-length journal issue of Emergency Medicine Practice was authored by Dr. Caylyne Arnold, Dr. Zane Fayos, Dr. David Bruner, and Dr. Dylan Arnold. It was peer reviewed by Dr. Melissa Leber and Dr. Christopher Tainter. Link to article: http://www.ebmedicine.net/topics.php?paction=showTopic&topic_id=559

Because of the chronic relapsing nature of inflammatory bowel disease (IBD), emergency clinicians frequently manage patients with acute flares and complications. IBD patients present with an often-broad range of nonspecific signs and symptoms, and it is essential to differentiate a mild flare from a life-threatening intra-abdominal process. Recognizing extraintestinal manifestations and the presence of infection are critical. This episode reviews the literature on management of IBD flares in the emergency department, including laboratory testing, imaging, and identification of surgical emergencies, emphasizing the importance of coordination of care with specialists on treatment plans and offering patients resources for ongoing support This episode of EB Medicine’s EMplify podcast is hosted by Jeff Nusbaum, MD, and Nachi Gupta, MD, PhD. This month’s corresponding full-length journal issue of Emergency Medicine Practice was authored by Dr. Michael Burg and Dr. Steven Riccoboni. It was peer reviewed by Dr. Andrew Lee and Dr. Chad Roline. Links and Resouces: http://www.ebmedicine.net/topics.php?paction=showTopic&topic_id=559 - Management of Inflammatory Bowel Disease Flares in the Emergency

COPD has huge economic and human burdens in the US. In fact, in 2010, two studies estimated that COPD exacted a direct and indirect cost of somewhere between $36 and $50 billion dollars in the US. With respect to the ED – in 2011, there were more than 1.7 million ED visits for COPD-related problems, with nearly 1/5th requiring hospitalization.   This episode of EB Medicine’s EMplify podcast is hosted by Jeff Nusbaum, MD, and Nachi Gupta, MD. This month’s corresponding full-length journal issue of Emergency Medicine Practice was authored by a strong team from the University of Maryland: Drs. Van Holden, Donald Slack, Michael McCurdy, and Nirav Shah. It was peer reviewed by Dr. Gabriel Wardi of the University of California San Diego and Dr. Geralda Xavier of Kings County Hospital in New York City. Links and Resouces: http://www.ebmedicine.net/topics.php?paction=showTopic&topic_id=557 - Diagnosis and Management of Acute Exacerbation of Chronic Obstructive Pulmonary Disease

Primary and secondary adrenal insufficiency are underrecognized conditions among emergency department patients, affecting an estimated 10% to 20% of critically ill patients. The signs and symptoms of cortisol deficit can be nonspecific and wide-ranging, and identification and swift treatment with stress-dosing of hydrocortisone is vital to avoid life-threatening adrenal crisis. This episode offers a review of the literature regarding adrenal disorders, from diagnosis to management to disposition. This episode is hosted by Jeff Nusbaum, MD, and Nachi Gupta, MD. This month’s issue was authored by Drs. Cutright, Ducey, and Barthold of the University of Nebraska Medical Center, and it was edited by Dr. Knight of the University of Cincinnati and Dr. Zammit of the University of Rochester. Thank you, team, for your efforts putting this together. Links and resources: EB Medicine - www.ebmedicine.net Recognizing and Managing Adrenal Disorders in the Emergency Department - http://www.ebmedicine.net/topics.php?paction=showTopic&topic_id=550

For trauma patients in the ED, life- and limb-threatening injuries take priority, but renal and genitourinary injury can have long-term consequences for patients, including chronic kidney disease, erectile dysfunction, incontinence, and other serious problems. This episode offers a review of the literature regarding treatment of renal and GU injuries, from diagnosis to management to disposition. This episode is hosted by Jeff Nusbaum, MD, and Nachi Gupta, MD. This month’s issue was authored by Drs. Bryant and Shewakramani of the University of Cincinnati College of medicine and it was edited by Dr. Bryce of Vanderbilt University Medical Center and Dr. Shaukat of Coney Island Hospital. Thank you, team, for your efforts putting this together. Links and resources: EB Medicine - www.ebmedicine.net Emergency Management of Renal and Genitourinary Trauma: Best Practices Update - http://www.ebmedicine.net/topics.php?paction=showTopic&topic_id=547

Though a minority of patients presenting to the emergency department with chest pain have acute coronary syndromes, identifying the patients who may be safely discharged and determining whether further testing is needed remains challenging. This topic is of massive importance to emergency physicians and there is a wealth of literature exploring it. Every year, in the US, there are roughly 8 million ED visits for chest pain, and of those, only 13-25% lead to the diagnosis of acute coronary syndromes or ACS. This episode is hosted by Jeff Nusbaum, MD, and Nachi Gupta, MD. This month’s issue was authored by Dr. David Markel, of Tacoma Emergency Care Physicians and was reviewed by Dr. Keith Marill from Mass General and Dr. Andrew Schmidt of the University of Florida College of Medicine. Links and resources: EB Medicine - www.ebmedicine.net Identifying Emergency Department Patients With Chest Pain who are at Low Risk for Acute Coronary Syndromes - https://tinyurl.com/y848wacl MDCalc - www.mdcalc.com

This month's episode of EMplify, a podcast corollary to the Emergency Medicine Practice journal, focuses on management strategies that improve dental emergency outcomes. Hosts Jeff Nusbaum, MD, and Nachi Gupta, MD, cover all aspects of the diagnosis and management of this condition, from initial diagnosis and treatment in the emergency department to controversies and cutting-edge strategies. This podcast is based on the full-length review published in the June 2017 issue of Emergency Medicine Practice. In it, author Ryan Pedigo, MD, Director of Undergraduate Medical Education at Harbor-UCLA Medical Center and Assistant Professor of Emergency Medicine at the David Geffen School of Medicine, cover evidence published in more than 700 articles and reviewed recommendations from the International Association for Dental Traumatology and the Cochrane Database. Topics covered in this episode of EMplify include: Case Presentations Dental Anatomy Pathophysiology Traumatic Dental Emergencies Concussion Subluxation Luxation Avulsion Fracture Ellis classification system Atraumatic dental emergencies Dental Infections Dental Disease Prehospital Care Imaging Nerve blocks Antibiotics Management of tooth trauma Treatment for dental fractures Summary of key points Links and resources: Tables referenced in this podcast episode - http://www.ebmedicine.net/topics.php?paction=showTopicSeg&topic_id=543&seg_id=9020 Dental Emergencies: Management Strategies That Improve Outcomes - https://www.ebmedicine.net/topics.php?paction=showTopic&topic_id=532 Clinical Decision Making in Emergency Medicine - http://www.clinicaldecisionmaking.com/

This month's episode of EMplify, the podcast corollary to the Emergency Medicine Practice journal, focuses on acute decompensated heart failure. Hosts Jeff Nusbaum, MD, and Nachi Gupta, MD, cover all aspects of the acute management of this condition, from initial diagnosis and treatment in the emergency department to novel biomarkers and new and controversial therapies. The podcast is based on the full-length review published in the May 2017 issue of Emergency Medicine Practice. In it, co-authors Emily Singer Fisher, MD, and Boyd Burns, DO, FACEP, FAAEM, both of the University of Oklahoma School of Community Medicine, cover evidence published in 190 articles, and 10 reviews from the Cochrane database, as well as current guidelines issued by the American Heart Association and the American College of Cardiology Foundation. Topics covered in this episode of EMplify include Basics of acute decompensated heart failure Key differences in the pathophysiology of heart failure with reduced ejection fraction and heart failure with preserved ejection fraction Prehospital Care Initial ED Evaluation of acute decompensated heart failure Narrowing down the differential Physical exam best practices Diagnostic Studies Pulmonary ultrasound Cardiac ultrasound Treatment Lab markers Management of acute decompensated heart failure Role of early revascularization New and novel therapies Disposition Summary of the key points Links and resources: Tables referenced in this podcast episode - https://www.ebmedicine.net/topics.php?paction=showTopicSeg&topic_id=541&seg_id=8977 Noninvasive Ventilation For Patients In Acute Respiratory Distress: An Update - https://www.ebmedicine.net/topics.php?paction=showTopic&topic_id=532 Clinical Decision Making in Emergency Medicine - http://www.clinicaldecisionmaking.com/

Welcome back to another episode of EMplify, the podcast corollary to EB Medicine’s Emergency Medicine Practice. This month, we’ll be talking “Maxillofacial Trauma in the Emergency Department.” This episode’s content was curated by Drs. Devjani Das, MD, RDMS, FACEP, and Lea Salazar, MD. Both of Hofstra Northwell School of Medicine, Northwell Health-Staten Island University Hospital, Staten Island, NY. Don’t miss it! Topics: Overview on Maxillofacial Trauma Epidemiology of Maxillofacial Trauma Fracture Types: Nasal bone fractures Mandibular fractures Orbital fractures Zygomatic fractures Maxillary fractures or Le Fort fractures Le Fort 1 fractures or horizontal fractures Le fort 2 fractures or pyramidal fractures Le Fort 3 fractures or transverse fractures Frontal bone fractures Prehospital Care Initial ED Evaluation and Management 10 Steps of the Physical Exam Diagnostic Testing, Treatment, and Disposition Imaging Specific to Each Injury Management of Each Injury Special Populations Controversies and Cutting-Edge A Disposition Quick Rundown of the Key Take-Home Points Links and Resources: Maxillofacial Trauma: Managing Potentially Dangerous and Disfiguring Complex Injuries - https://www.ebmedicine.net/topics.php?paction=showTopic&topic_id=538 Hofstra Northwell School of Medicine - http://medicine.hofstra.edu/ Northwell Health-Staten Island University - https://www.northwell.edu/find-care/locations/staten-island-university-hospital Clinical Decision Making in Emergency Medicine - http://www.clinicaldecisionmaking.com/ EMplify Twitter Account - @ebmedicine Email: [email protected]

Welcome back to another episode of EMplify, the podcast corollary to EB Medicine’s Emergency Medicine Practice. This month, we’ll be talking about sedative-hypnotics. Specifically, we’ll be talking about sedative-hypnotic drug withdrawal syndromes, both the recognition of such syndromes and their appropriate treatment. This episode’s content was curated by Cynthia Santos, MD, of Emory University Hospital and Ruben Olmedo, MD, who is director of the division of toxicology at Mount Sinai Hospital. Don’t miss it! Topics: Why EB Medicine chose this topic Pathophysiology of sedative-hypnotic drug withdrawal syndromes Specific sedative hypnotic classes Toxicologic syndromes’ differential subcategories Prehospital care Initial ED management Emergency department diagnostic studies Treatment Different classes of medications Controversies Quick rundown of the key take-home points Bonus: Interview with Dr. Cynthia Santos Links and Resources: Sedative-Hypnotic Drug Withdrawal Syndrome: Recognition And Treatment - http://bit.ly/2mp4mAR Alcohol Withdrawal Syndrome: Improving Outcomes Through Early Identification And Aggressive Treatment Strategies (Critical Care Issue) - http://bit.ly/2mWN8hp Current Guidelines For The Management Of Acute Alcohol Withdrawal In The Emergency Department - http://bit.ly/2nkBM7H Emory University Hospital - https://www.emoryhealthcare.org/locations/hospitals/emory-university-hospital/ Mount Sinai Hospital - http://www.mountsinai.org/locations/mount-sinai Twitter Account - @ebmedicine 16th Annual Clinical Decision Making in Emergency Medicine - http://clinicaldecisionmaking.com/ Email: [email protected]

Welcome to the inaugural episode of EMplify, the podcast corollary to EB Medicine’s Emergency Medicine Practice journal. For the first episode, we are going to focus on one of the most popular articles from last year, the October 2016 issue, entitled “Optimizing Survival Outcomes For Adult Patients With Nontraumatic Cardiac Arrest.” We have one huge disclosure about this episode, as we will have for them all. The content was not originally created by us. This issue was authored by Dr. Julianna Jung, MD, FACEP at Johns Hopkins University. Here’s what we will cover: Topics: Facts about cardiac arrest A quick review of the latest iteration of the AHA guidelines The pathophysiology The differential The common underlying causes Prehospital care Diagnostic imaging Chest compressions and shock Ventilation Medications Post-arrest cooling Tools used to prognosticate When to stop resuscitating Special circumstances Recent controversies and cutting-edge advances Links and Resources: Link to the post - http://www.ebmedicine.net/topics.php?paction=showTopic&topic_id=521 The New England Journal of Medicine - http://www.nejm.org/ Johns Hopkins University - https://www.jhu.edu/ AHA - http://www.heart.org/HEARTORG/ Email: [email protected]

Brought to you by EB Medicine, this new emergency medicine podcast will refresh your knowledge on each monthly topic from Emergency Medicine Practice while you're on the go.