Contributor: Aaron Lessen MD

Educational Pearls:

• Induction agent selection during rapid sequence intubation involves accounting for hemodynamic stability in the post-intubation setting

• Many emergency departments use ketamine or etomidate

• A recent study sought to explore the rates of post-induction hypotension of ketamine compared with propofol

  • Single center retrospective cohort study of patients between 2018-2021

• Ketamine and propofol were both significantly associated with post-induction hypotension

  • Ketamine adjusted odds ratio = 4.50

  • Propofol adjusted odds ratio = 4.88

  • 50% of patients became hypotensive after induction with either propofol or ketamine

• These findings suggest post-induction hypotension is mainly due to sympatholysis rather than the choice of agent itself

References

1. Tamsett Z, Douglas N, King C, et al. Does the choice of induction agent in rapid sequence intubation in the emergency department influence the incidence of post-induction hypotension?. Emerg Med Australas. 2024;36(3):340-347. doi:10.1111/1742-6723.14355

Summarized & Edited by Jorge Chalit, OMS3

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Contributor: Aaron Lessen MD

Educational Pearls:

Can opioids cause cardiac arrest?

• Opioids can cause respiratory suppression and the subsequent low oxygen levels can lead to arrhythmias and eventually cardiac arrest.

• In 2023, 17% of out-of-hospital cardiac arrests (OHCA) were attributable to opioids.

Given that this is a rising cause of cardiac arrest, should we just treat all cardiac arrest with naloxone (Narcan)?

• Naloxone is correlated with an increased chance of return of spontaneous circulation (ROSC)

• Additionally, a wide variety of individuals can be exposed to opioids and therefore opioid overdose should be considered in all cases of OHCA

But does naloxone improve neurologic outcomes?

• Yes, naloxone, especially when given early on in the resuscitation can improve neuro outcomes

What is the dose?

• 2-4 mg IN/IV depending on access.

• High suspicion for opioid overdose consider going with an even higher dose such as 4-8 mg IN/IV

References

1. Orkin, A. M., & Dezfulian, C. (2024). Recognizing the fastest growing cause of out-of-hospital cardiac arrest. Resuscitation, 198, 110206. https://doi.org/10.1016/j.resuscitation.2024.110206

2. Quinn, E., & Du Pont, D. (2024). Naloxone administration in out-of-hospital cardiac arrest: What's next?. Resuscitation, 201, 110307. https://doi.org/10.1016/j.resuscitation.2024.110307

3. Saybolt, M. D., Alter, S. M., Dos Santos, F., Calello, D. P., Rynn, K. O., Nelson, D. A., & Merlin, M. A. (2010). Naloxone in cardiac arrest with suspected opioid overdoses. Resuscitation, 81(1), 42–46. https://doi.org/10.1016/j.resuscitation.2009.09.016

4. Wampler D. A. (2024). Naloxone in Out-of-Hospital Cardiac Arrest-More Than Just Opioid Reversal. JAMA network open, 7(8), e2429131. https://doi.org/10.1001/jamanetworkopen.2024.29131

Summarized by Jeffrey Olson, MS3 | Edited by Meg Joyce MS1 & Jorge Chalit, OMS3

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Contributor: Aaron Lessen MD

Educational Pearls:

• A study evaluated the patient-care impact and financial costs of holding patients in the ED, a nationwide issue

• • Prospective, observational study of acute stroke management

  • Conducted at a large urban, comprehensive stroke center

• The study evaluated patients in multiple categories:

1. admitted to med/surg

2. admitted to med/surg but held in the ED

3. admitted to the ICU

4. Admitted to ICU but held in the ED

• Examined the amount of time nurses and providers spent with each patient

• • This was analyzed in conjunction with the knowledge of each providers’ salaries and the overhead costs of the med/surg unit, ICU, and ED

• Conclusions:

• • Patients who required med/surg inpatient care but who were held in the ED resulted in a doubled daily cost

  • • $1856 for med/surg inpatient boarding vs $993 for med/surg inpatient care

  • Patients who required ICU care but who were held in the ED also resulted in an increased daily cost, but this difference was not as large

  • • $2267 for ICU inpatient boarding vs $2165 for ICU care

• Holding in the ED negatively impacts patients since they receive less time from providers

• Holding also results in increased financial costs

References

1. Canellas MM, Jewell M, Edwards JL, Olivier D, Jun-O’Connell AH, Reznek MA. Measurement of Cost of Boarding in the Emergency Department Using Time-Driven Activity-Based Costing. Annals of emergency medicine. Published online May 1, 2024. doi:https://doi.org/10.1016/j.annemergmed.2024.04.012

Summarized by Meg Joyce, MS1 | Edited by Meg Joyce & Jorge Chalit, OMS3

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Contributor: Aaron Lessen MD

Educational Pearls:

• Aortic injury occurs in 1.5-2% of patients who sustain blunt thoracic trauma

• • Majority are caused by automobile collisions or motorcycle accidents

  • Due to sudden deceleration mechanism accidents

• Clinical manifestations

• • Signs of hypovolemic shock including tachycardia and hypotension, though not always present

  • Patients may have altered mental status

• Imaging

• • Widened mediastinum on chest x-ray, though not highly sensitive

  • CT is more sensitive and specific, and signs of thoracic injury include an intimal flap, aortic wall outpouching, and aortic contour abnormalities

  • In hemodynamically unstable or otherwise unfit for CT patients, transesophageal echocardiogram may be used

• Four types of aortic injury (in order of ascending severity)

• • I: Intimal tear or flap

  • II: Intramural hematoma

  • III: Pseudoaneurysm

  • IV: Rupture

• Management

• • Hemodynamically unstable: immediate OR for exploratory laparotomy and repair

  • Hemodynamically stable: heart rate and blood pressure control with beta-blockers

  • Minor injuries are treated with observation and hemodynamic control

  • Severe injuries may receive surgical management

  • • Some patients benefit from delayed repair

    • An endovascular aortic graft is a surgical option

• Mortality

• • 80-85% of patients die before hospital arrival

  • 50% of patients that make it to the hospital do not survive

References

1. Fox N, Schwartz D, Salazar JH, et al. Evaluation and management of blunt traumatic aortic injury: a practice management guideline from the Eastern Association for the Surgery of Trauma [published correction appears in J Trauma Acute Care Surg. 2015 Feb;78(2):447]. J Trauma Acute Care Surg. 2015;78(1):136-146. doi:10.1097/TA.0000000000000470

2. Lee WA, Matsumura JS, Mitchell RS, et al. Endovascular repair of traumatic thoracic aortic injury: clinical practice guidelines of the Society for Vascular Surgery. J Vasc Surg. 2011;53(1):187-192. doi:10.1016/j.jvs.2010.08.027

3. Osgood MJ, Heck JM, Rellinger EJ, et al. Natural history of grade I-II blunt traumatic aortic injury. J Vasc Surg. 2014;59(2):334-341. doi:10.1016/j.jvs.2013.09.007

4. Osman A, Fong CP, Wahab SFA, Panebianco N, Teran F. Transesophageal Echocardiography at the Golden Hour: Identification of Blunt Traumatic Aortic Injuries in the Emergency Department. J Emerg Med. 2020;59(3):418-423. doi:10.1016/j.jemermed.2020.05.003

5. Steenburg SD, Ravenel JG, Ikonomidis JS, Schönholz C, Reeves S. Acute traumatic aortic injury: imaging evaluation and management. Radiology. 2008;248(3):748-762. doi:10.1148/radiol.2483071416

Summarized by Jorge Chalit, OMS3 | Edited by Meg Joyce & Jorge Chalit

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Laboring Under Pressure Episode 4: Obstetric Emergency in South Africa with Dr. Meghan Hurley

Contributors: Meghan Hurley MD, Travis Barlock MD, Jeffrey Olson MS3

Show Pearls

Map of South Africa Referenced

South Africa Geography Lesson

• There is a big disparity between Cape Town and its neighbor Khayelitsha.

• Cape Town is the legislative capital and economic hub of South Africa, known for its infrastructure, tourist attractions, and developed urban areas.

• Khayelitsha Township is a large informal settlement on the outskirts of Cape Town, with limited infrastructure and services compared to the city center. Many residents live in informal housing.

• This disparity is the lasting effect of how land was divided up and populations were moved around during Apartheid.

• Apartheid was a policy of segregation that lasted from 1948 to 1994.

How does medical education work in South Africa?

• Medical education in South Africa typically follows a 6-year undergraduate program directly after high school

• Registrars our the equivalent of Resident in America. They are graduated doctors who work in hospitals under the supervision of senior doctors as they progress toward becoming specialists.

Pearls from the case and the discussion afterward

• Whole blood from a draw can be used instead of urine on a POC pregnancy test. Wait a little bit longer before making a determination because blood is more viscous. Although the casettes are not approved for whole blood several studies have shown this to be efficacious.

• Free fluid in the abdomen and a pregnancy of unknown location is a rupture ectopic until proven otherwise.

• Appendicitis can present on the left side. Most commonly from an extra appendix, but can also result from situs inversus or mid-gut malrotation. This presentation can also be the result of an atypically large appendix.

• Fever is common in appendicitis (~40%) and becomes less common with older patients.

• Don’t be falsely reassured by a normal hemoglobin in acute bleeding because patients bleed whole blood and the hemoglobin concentration is not affected. These patients should be resuscitated with whole blood.

• Give rhesus factor negative blood to female patients of childbearing age to prevent them from developing antibodies to the rhesus factor which can lead to Rh disease in future pregnancies.

• Rhogam can be given in cases of ruptured ectopic pregnancies to lower the risk of alloimmunization.

• Blood transfusions carry the risk of lung and heart injury from the extra volume. The treatment for this condition is to diurese the patient.

Other topics discussed include the complications of working in a South African township hospital at night, the epidemiology of burns, and the importance of global health.

References

1. Akbulut S, Ulku A, Senol A, Tas M, Yagmur Y. Left-sided appendicitis: review of 95 published cases and a case report. World J Gastroenterol. 2010 Nov 28;16(44):5598-602. doi: 10.3748/wjg.v16.i44.5598. PMID: 21105193; PMCID: PMC2992678.

2. Barash, J. H., Buchanan, E. M., & Hillson, C. (2014). Diagnosis and management of ectopic pregnancy. American family physician, 90(1), 34–40.

3. Fromm C, Likourezos A, Haines L, Khan AN, Williams J, Berezow J. Substituting whole blood for urine in a bedside pregnancy test. J Emerg Med. 2012 Sep;43(3):478-82. doi: 10.1016/j.jemermed.2011.05.028. Epub 2011 Aug 27. PMID: 21875776.

4. Moris, D., Paulson, E. K., & Pappas, T. N. (2021). Diagnosis and Management of Acute Appendicitis in Adults: A Review. JAMA, 326(22), 2299–2311. https://doi.org/10.1001/jama.2021.20502

5. Sowder AM, Yarbrough ML, Nerenz RD, Mitsios JV, Mortensen R, Gronowski AM, Grenache DG. Analytical performance evaluation of the i-STAT Total β-human chorionic gonadotropin immunoassay. Clin Chim Acta. 2015 Jun 15;446:165-70. doi: 10.1016/j.cca.2015.04.025. Epub 2015 Apr 25. PMID: 25916696.

Produced by Jeffrey Olson, MS3 | Edited by Jeffrey Olson and Jorge Chalit, OMSIII

Contributor: Taylor Lynch, MD

Educational Pearls:

What is neutropenic fever?

• Specific type of fever that is seen in cancer patients and other patients with impaired immune systems

• These patients are highly susceptible to infection

• Typically occurs 7-10 days after the last chemotherapy dose, this is when the immune system is the weakest

• It is useful to know the specific type of malignancy. For example, heme malignancies (ALL, AML, etc.) have more intense chemo and are at higher risk of neutropenic fever

• To qualify as a neutropenic fever, a patient must have one recorded temperature greater than 38.3 degrees C or be over 38 degrees C for one hour.

• The severity of the neutropenic fever is established by the absolute neutrophil count. Abs neutrophil count under 1500 is mild, less than 1000 is moderate, less than 500 is severe.

• Also look at monocytes (cell that becomes a macrophage). Less than 200 is very concerning

What is the workup and treatment?

• Obtain a panculture (culture blood from both arms and all indwelling lines), obtain urine culture, and get a chest x-ray.

• Do not preform a rectal exam or obtain a rectal core temperature. This could cause bacteremia.

• Treat with Cefepime (broad range and includes pseudomonas but not MRSA). If there is concern for MRSA add vancomycin.

• Admit with Neutropenic precautions (gowns, gloves, mask, positive pressure room)

References

1. Peseski, A. M., McClean, M., Green, S. D., Beeler, C., & Konig, H. (2021). Management of fever and neutropenia in the adult patient with acute myeloid leukemia. Expert review of anti-infective therapy, 19(3), 359–378. https://doi.org/10.1080/14787210.2020.1820863

2. Zimmer, A. J., & Freifeld, A. G. (2019). Optimal Management of Neutropenic Fever in Patients With Cancer. Journal of oncology practice, 15(1), 19–24. https://doi.org/10.1200/JOP.18.00269

Summarized by Jeffrey Olson, MS3 | Edited by Meg Joyce & Jorge Chalit, OMS3

Contributor: Jorge Chalit-Hernandez, OMS3

• Typically presents with biliary colic

• • Right upper quadrant abdominal pain lasting more than 30 minutes and subsiding over several hours

  • Often associated with fatty meals but not always

• Must rule out other causes of pain

• • Peptic ulcer disease - typically presents with epigastric pain

  • Pancreatitis - pain that radiates to the back or family history of pancreatitis

• Laboratory workup

• • LFTs including ALT, AST, and alkaline phosphatase are within the reference range

  • Lipase and amylase within the reference range

• Imaging workup

• • RUQ ultrasound is unremarkable

  • Upper endoscopy with ultrasound can help rule out peptic ulcer disease and small stones

  • HIDA scan may show a reduced gallbladder ejection fraction below 30-35% or it may be normal

  • • Opiates may give false-positive results

• Opiates can sometimes make biliary colic worse due to their contractile effect on the sphincter of Oddi

• Some patients may benefit from surgical intervention i.e. cholecystectomy

• • Classic biliary-type pain (best predictor of response to cholecystectomy)

  • Pain for > 3 months duration

  • Positive HIDA scan

References

1. Alhayo S, Eslick GD, Cox MR. Cholescintigraphy may have a role in selecting patients with biliary dyskinesia for cholecystectomy: a systematic review. ANZ J Surg. 2020;90(9):1647-1652. doi:10.1111/ans.16003

2. Arshi J, Layfield LJ, Esebua M. Mast cell infiltration and activation in the gallbladder wall: Implications for the pathogenesis of functional gallbladder disorder in adult patients. Ann Diagn Pathol. 2021;54:151798. doi:10.1016/j.anndiagpath.2021.151798

3. Carr JA, Walls J, Bryan LJ, Snider DL. The treatment of gallbladder dyskinesia based upon symptoms: results of a 2-year, prospective, nonrandomized, concurrent cohort study. Surg Laparosc Endosc Percutan Tech. 2009;19(3):222-226. doi:10.1097/SLE.0b013e3181a74690

4. Joehl RJ, Koch KL, Nahrwold DL. Opioid drugs cause bile duct obstruction during hepatobiliary scans. Am J Surg. 1984;147(1):134-138. doi:10.1016/0002-9610(84)90047-3

5. Mahid SS, Jafri NS, Brangers BC, Minor KS, Hornung CA, Galandiuk S. Meta-analysis of cholecystectomy in symptomatic patients with positive hepatobiliary iminodiacetic acid scan results without gallstones. Arch Surg. 2009;144(2):180-187. doi:10.1001/archsurg.2008.543

Summarized & Edited by Jorge Chalit, OMS3

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Contributor: Taylor Lynch MD

• Supraventricular tachycardias (SVTs) arise above the bundle of His

• • The term SVT includes AV nodal reentrant tachycardia (AVNRT), atrioventricular reentrant tachycardia (AVRT), atrial tachycardia, atrial fibrillation, atrial flutter, and multifocal atrial tachycardia

• AVNRT is the most common form of SVT

• • Paroxysmal

  • Spontaneous or provoked by exertion, coffee, alcohol, or thyroid disease

  • More common in women (3:1 women:men ratio)

  • HR 160-240

  • Narrow complex with a normal QRS

• Unstable patients receive synchronized cardioversion at 0.5-1 J/kg

• Valsalva maneuver is attempted before pharmaceutical interventions

• • Increases vagal tone at the AV node to slow conduction and prolongs its refractory period to normalize the conduction

  • Traditionally, patients are asked to bear down, but this only works in 17% of patients

  • REVERT trial assessed a modified valsalva that worked in 43% of patients

• Adenosine

• • Slows conduction at the AV node by activating potassium channels and inhibiting calcium influx

  • Extremely uncomfortable for most patients

  • Not commonly used anymore

• Nondihydropyridine calcium-channel blockers are preferred

• • A 2009 RCT investigated low-infusion CCBs compared with adenosine bolus

  • The study found a conversion rate of 98% in the CCB group vs. adenosine group at 86.5%

  • The main adverse effect of CCB is hypotension, which a slow infusion rate can mitigate

  • Diltiazem dose is 0.25 mg/kg/2min and repeat at 0.35 mg/kg/15 minutes or slow infusion at 2.5 mg/min up to a conversion or 50 mg total

References

1. 1. Appelboam A, Reuben A, Mann C, et al. Postural modification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): A randomised controlled trial. Lancet. 2015;386(10005):1747-1753. doi:10.1016/S0140-6736(15)61485-4

2. Belz MK, Stambler BS, Wood MA, Pherson C, Ellenbogen KA. Effects of enhanced parasympathetic tone on atrioventricular nodal conduction during atrioventricular nodal reentrant tachycardia. Am J Cardiol. 1997;80(7):878-882. doi:10.1016/s0002-9149(97)00539-0

3. Lim SH, Anantharaman V, Teo WS, Chan YH. Slow infusion of calcium channel blockers compared with intravenous adenosine in the emergency treatment of supraventricular tachycardia. Resuscitation. 2009;80(5):523-528. doi:10.1016/j.resuscitation.2009.01.017

4. Page RL, Joglar JA, Caldwell MA, et al. 2015 ACC/AHA/HRS Guideline for the Management of Adult Patients With Supraventricular Tachycardia: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society [published correction appears in Circulation. 2016 Sep 13;134(11):e234-5. doi: 10.1161/CIR.0000000000000448]. Circulation. 2016;133(14):e506-e574. doi:10.1161/CIR.0000000000000311

Summarized & Edited by Jorge Chalit, OMS3

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