Author: EMMadmin

Podcast # 425: Oseltamivir Efficacy in Children

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Author: Aaron Lessen, MD

Educational Pearls:

  • Recent meta-analysis reviewed efficacy oseltamivir (Tamiflu) in pediatric populations treated for influenza, showing an 18 hour reduction in duration of illness for those with laboratory confirmed influenza
  • Those with suspected influenza unsurprisingly had less effect
  • Subgroup analysis showed most benefit in those treated within the first 24 hours of symptom onset
  • Patients with confirmed influenza treated with oseltamivir had a 34% reduction in risk of otitis media

Editor’s note:  Vomiting was higher in the treatment groups; There were no significantly different outcomes in regards to other endpoints, such as lower respiratory tract infections and hospitalizations

References:

Malosh RE, Martin ET, Heikkinen T, Brooks WA, Whitley RJ, Monto AS. Efficacy and Safety of Oseltamivir in Children: Systematic Review and Individual Patient Data Meta-analysis of Randomized Controlled Trials. Clin Infect Dis. 2018 May 2;66(10):1492-1500. doi: 10.1093/cid/cix1040. PubMed PMID: 29186364.

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

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Podcast # 424: Hunting for Measles

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Author: Mike Hunt, MD

Educational Pearls:

  • Measles is highly contagious and successfully infects 90% of those at risk exposed to the virus.
  • 10 day prodrome where patients are asymptomatic.
  • 3 day period of characteristic cough, coryza, conjunctivitis, fever and Koplick spots with a maculopapular rash that moves from head through trunk
  • Infection risk extends three to four days after the onset of rash but also three to four days prior to onset.  Have fun with that.
  • A potential exposure, say in an emergency department waiting room, needs review of any exposed patient’s immunization history to contain spread

References:

Moss WJ. Measles. Lancet. 2017 Dec 2;390(10111):2490-2502. doi: 10.1016/S0140-6736(17)31463-0. Epub 2017 Jun 30. Review. PubMed PMID: 28673424.

Bester JC. Measles and Measles Vaccination: A Review. JAMA Pediatr. 2016 Dec 1;170(12):1209-1215. doi: 10.1001/jamapediatrics.2016.1787. Review. PubMed PMID: 27695849.

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

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Podcast # 423: Blunt Cardiac Injuries

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Author: Mike Hunt, MD

Educational Pearls:

 

  • Blunt cardiac injuries most commonly occur in motor vehicle collisions, auto-pedestrian collisions, and from sports injuries
  • The more anterior right ventricle is the most commonly injured structure
  • Look for new EKG changes such as bundle branch blocks, ST changes, or other arrhythmias
  • New EKG abnormalities should prompt consideration of further workup and admission for telemetry
  • Patients may have an elevated troponin – but it is unclear when exactly this should be drawn after the injury

 

References:

Bellister SA, Dennis BM, Guillamondegui OD. Blunt and Penetrating Cardiac Trauma. Surg Clin North Am. 2017 Oct;97(5):1065-1076. doi: 10.1016/j.suc.2017.06.012. Review. PubMed PMID: 28958358.

Marcolini EG, Keegan J. Blunt Cardiac Injury. Emerg Med Clin North Am. 2015 Aug;33(3):519-27. doi: 10.1016/j.emc.2015.04.003. Epub 2015 Jun 10. Review. PubMed PMID: 26226863.

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

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Podcast # 422: ED Opioid Prescription Trends

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Author: Jared Scott, MD

Educational Pearls:

 

  • From 1996 to 2012, the total quantity of opioids prescribed increased 647% for non-cancer pain
  • Office based prescriptions accounted for 84% of the total opioid prescriptions, up from 64%
  • The total share of opioids prescribed from the emergency department declined from 10% to 3.9% but
  • Total opioids prescribed from the ED still increased 219% over this same time frame

 

References:

Axeen S, Seabury SA, Menchine M. Emergency Department Contribution to the Prescription Opioid Epidemic. Ann Emerg Med. 2018 Jun;71(6):659-667.e3. doi: 10.1016/j.annemergmed.2017.12.007. Epub 2018 Jan 16. PubMed PMID: 29373155

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

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Podcast # 421: Sweet DKA Pearls

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Author: Gretchen Hinson, MD

Educational Pearls:

 

  • Diabetic ketoacidosis patients are subject to electrolyte derangements
  • Potassium should be monitored closely:
    • K < 3.3 = Do not give insulin and replete K first
    • 3.3 < K < 5.3 = give 20-30mEq K for each L of IVF 
    • K > 5.3 = delay potassium replacement
  • Adult patients are typically severely volume depleted and can require 50 cc/kg bolus or more
  • Insulin typically given in bolus of 0.1 units/kg followed by drip at 0.1 units/kg/hr

 

References:

Fayfman M, Pasquel FJ, Umpierrez GE. Management of Hyperglycemic Crises: Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar State. Med Clin North Am. 2017 May;101(3):587-606. doi: 10.1016/j.mcna.2016.12.011. Review. PubMed PMID: 28372715.

Nyenwe EA, Kitabchi AE. The evolution of diabetic ketoacidosis: An update of its etiology, pathogenesis and management.Metabolism. 2016 Apr;65(4):507-21. doi: 10.1016/j.metabol.2015.12.007. Epub 2015 Dec 19. Review. PubMed PMID: 26975543.

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

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Podcast # 420: CT Contrast and the Kidneys

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Author: Don Stader, MD

Educational Pearls:

 

  • Recent meta-analysis has demonstrated that there is no significant risk for kidney injury from CT contrast
  • Most kidney injury  seen after contrast CTs were due to other underlying illnesses (sepsis, hypovolemia, etc.)
  • Older contrast agents likely did have nephrotoxic effects but this appears to be a thing of the past

 

References:

Aycock RD, Westafer LM, Boxen JL, Majlesi N, Schoenfeld EM, Bannuru RR. Acute Kidney Injury After Computed Tomography: A Meta-analysis. Ann Emerg Med. 2018 Jan;71(1):44-53.e4. doi: 10.1016/j.annemergmed.2017.06.041. Epub 2017 Aug 12. Review. PubMed PMID: 28811122.

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

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Podcast # 419: Etripamil

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Author: Don Stader, MD

Educational Pearls:

 

  • Etripamil is an intranasal calcium channel blocker in development for use in SVT
  • A recent study showed that etripamil has an SVT conversion rate of around 80%
  • Etripamil does not have the same feeling of “impending doom” that can occur with adenosine

Editor’s note: Etripamil is still in development and these results are from a phase II clinical trial.

 

References:

Stambler BS, Dorian P, Sager PT, Wight D, Douville P, Potvin D, Shamszad P, Haberman RJ, Kuk RS, Lakkireddy DR, Teixeira JM, Bilchick KC, Damle RS, Bernstein RC, Lam WW, O’Neill G, Noseworthy PA, Venkatachalam KL, Coutu B, Mondésert B, Plat F. Etripamil Nasal Spray for Rapid Conversion of Supraventricular Tachycardia to Sinus Rhythm. J Am Coll Cardiol. 2018 Jul 31;72(5):489-497. doi: 10.1016/j.jacc.2018.04.082. PubMed PMID: 30049309.

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

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Podcast # 418: Vertebral Artery Dissection

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Author: Don Stader, MD

Educational Pearls:

  • Vertebral artery dissection (VAD) contributes to just 2% of strokes overall but ~25% of strokes for patients < 30
  • VAD is associated with minor trauma (chiropractic manipulation, yoga), typically with neck extension and rotation.
  • VAD can cause posterior stroke symptoms (vertigo, diplopia, Horner’s Syndrome, Wallenberg Syndrome)
  • Overall a good prognosis with around 50% of patients recovering without lasting neurologic deficits.

References:

Debette S, Leys D. Cervical-artery dissections: predisposing factors, diagnosis, and outcome. Lancet Neurol. 2009 Jul;8(7):668-78. doi: 10.1016/S1474-4422(09)70084-5. Review. PubMed PMID: 19539238.

Gottesman RF, Sharma P, Robinson KA, et al. Clinical characteristics of symptomatic vertebral artery dissection: a systematic review. Neurologist. 2012;18(5):245-54.

Schievink WI. Spontaneous dissection of the carotid and vertebral arteries. N Engl J Med. 2001 Mar 22;344(12):898-906. Review. PubMed PMID: 11259724.

 

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

 

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Podcast # 417: Water Balance

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Author: Katie Sprinkle, MD

Educational Pearls:

  • Hyponatremia results when patients over hydrate and dilute their sodium with too much free water
  • Symptoms of hyponatremia can mimic symptoms of dehydration (dizziness,  lightheadedness, general malaise)
  • With severe hyponatremia patients can progress to seizure, coma, and death
  • Hypernatremia results from dehydration and is more common

References:

Bennett BL, Hew-Butler T, Hoffman MD, Rogers IR, Rosner MH; Wilderness Medical Society.. Wilderness Medical Society practice guidelines for treatment of exercise-associated hyponatremia: 2014 update. Wilderness Environ Med. 2014 Dec;25(4 Suppl):S30-42. doi: 10.1016/j.wem.2014.08.009. PubMed PMID: 25498260.

Braun MM, Barstow CH, Pyzocha NJ. Diagnosis and management of sodium disorders: hyponatremia and hypernatremia. Am Fam Physician. 2015 Mar 1;91(5):299-307. PubMed PMID: 25822386.

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

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Podcast # 416: Wide Complex Tachycardia

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Author: Aaron Lessen, MD

Educational Pearls:

  • Defined as QRS over 120 ms and rate over 120
  • Two major rhythms = Vetricular tachycardia (VT) or SVT with aberrancy
  • Safest approach is to assume it is VT
  • Synchronized Cardioversion is preferred even for stable VT for multiple reasons including safety and efficacy
  • Procainamide is preferred pharmacologic option
  • Amiodarone is less preferred third option
  • Calcium channel blockers (i.e. diltiazem) can worsen certain rhythms and should be avoided

References:

Long B, Koyfman A. Best Clinical Practice: Emergency Medicine Management of Stable Monomorphic Ventricular Tachycardia. J Emerg Med. 2017 Apr;52(4):484-492. doi: 10.1016/j.jemermed.2016.09.010. Epub 2016 Oct 15. Review. PubMed PMID: 27751700.

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

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