Managing Envenomations

ResidentOfficial Publication of the Emergency Medicine Residents’ Association June/July 2021 VOL 48 / ISSUE 3 Managing Envenomations

How to Sustain a Career: Peer Support Guide to ABEM Certi ication We Help Healers

SCP Reach New Heights Health

Meet Your Medical Career Dream Team SCP Health

Step Right Up, Residents! As you’re transitioning from residency to begin your career, our team is here to create a tailored environment for you that fosters growth and delivers rewarding daily work experiences.

Explore clinical careers at scp-health.com/explore

TOGETHER, WE HEAL Welcome to a New Academic Year!

uly marks a turning point each year, as new interns arrive in programs throughout Jthe country, newly graduated residents launch the next phase of their careers, and medical students take the next steps in their journey to residency. DO YOU KNOW HOW EMRA CAN HELP? Resources for Interns Resources for PGY2+ Resources for Students All EM programs will receive EMRA residents members receive the EMRA shows up for medical students Intern Kits this summer with nearly 10-pound EMRA Resident Kit upon interested in this specialty. From resources that offer immediate first joining EMRA. It is packed with clinical new advising content every month to backup for those first nerve-wracking resources for every rotation — some you’ll opportunities for leadership and growth, shifts. The high-yield EMRA Intern need only rarely (but prove to be clutch), and EMRA student membership is high-yield. Kit is sent for free to all EM interns some you’ll use every single shift (EMRA Plus, our online resources are unparalleled: (membership not required) and Antibiotic Guide, anyone?). Plus, check out: • EMRA Match for Clerkships: https:// includes: • EMRA Match for Fellowship: https:// webapps.emra.org/utils/spa/match#/ • Basics of Emergency Medicine, webapps.emra.org/utils/spa/match#/ search/map (click C for clerkships in the 4th ed. (newly updated this year!) search/map (click F for fellowships in the upper left corner) upper left corner) • EMRA Match for Residency: https:// • Basics of EM: Pediatrics, 3rd ed. • EMRA Fellowship Guide: https://www.emra. webapps.emra.org/utils/spa/match#/ (newly updated this year!) org/books/fellowship-guide-book/i-title search/map • EMRA Trauma Guide • PGY2 resources: https://www.emra.org/ • EMRA and CORD Student Advising Plus, log in at emra.org to resident/pgy2 Guide: https://www.emra.org/books/ find resources specific for interns: • PGY3+ resources: https://www.emra.org/ msadvisingguide/msag https://www.emra.org/resident/pgy1 resident/pgy3 • EMRA resources for every year of your medical school journey: https:// Resources for Fellows and Alumni www.emra.org/student/msi (log in as a You remain one of our #EMRAFamily, long after you’ve surpassed your member to view) residency years. Fellows and alumni receive their own tailored EMRA Member kits upon joining after residency. Resources for All Check www.emra.org often, as we Plus, check out: constantly add new content (podcasts, • EMRA Match for Jobs: https://webapps.emra.org/utils/spa/match#/search/map vlogs, Hangouts, free publications, open- (click J for Jobs in the upper left corner) access EM Resident online, and more). • EMRA Career Resources: https://www.emra.org/residents-fellows/career-planning Plus, refer often to these critical resources: From EMRA Match for Jobs to podcast content to contract negotiation tips and • EMRA Wellness Guide: https://www.emra. CV prep, we’ve got you covered. org/books/emra-wellness-guide/cover • Log in to get your Fellow-specific content here:https://www.emra.org/emra- • Emergency Medicine Advocacy fellow Handbook: https://www.emra.org/books/ • Alumni, log in and visit: https://www.emra.org/alumni advocacy-handbook/advhbook

Welcome to this new stage of your career! We’re glad you’re here, and it’s our privilege to journey with you. ¬

June/July 2021 | EM Resident 1 TABLE OF CONTENTS

Looking Beyond Patient Outcomes in EDITORIAL STAFF 4 the Uncertainty 36 ED Observation Units LEADERSHIP for Syncope EDITOR-IN-CHIEF Priyanka Lauber, DO Micro-Communities ADMIN & OPS Lehigh Valley Health Network 6 of Practice to Maintain EMRA as the MVP EDITORS 38 HEALTH POLICY, OP-ED Resilience During Times Erich Burton, DO of Uncertainty Why EM Physicians Should Greenville Health System CAREER DEVELOPMENT, 39 Care About Health Literacy Marc Cassone, DO WELLNESS, COVID-19 SOCIAL EM Shiprock, NM Residents’ Guide 25 Under 45 Brian Sumner, MD 8 to ABEM Certification 41 AWARDS Mount Sinai Morningside-West BOARD CERTIFICATION EMRA at ACEP21 Devan Pandya, MD Managing Envenomation UC Riverside 42 EMRA EVENTS 10 TOXICOLOGY EMRA 20-in-6; Gabrielle Ransford, MD Pericardial Effusion East Virginia Medical School 43 Case-Con 15 TOXICOLOGY EMRA EVENTS Sarah Ring, MD An Unexpected Icahn SOM at Mount Sinai EMRA MedWAR; 18 Electrical Injury Samuel Southgate, MD, MA 44 EMRA Resident SIMWars TRAUMA Regions Hospital EMRA EVENTS A Case of Excipient EMRA Job & MSC Editor Luke Wohlford 20 Lung Disease 45 Fellowship Fair TOXICOLOGY University of Arizona EMRA EVENTS College of Medicine–Phoenix Shockingly Dangerous EMRA Residency Fair; 22 Hypokalemia ECG Faculty Editor 46 Virtual Medical Jeremy Berberian, MD CARDIOLOGY Student Forum ChristianaCare Juvenile Ovarian Cancer EMRA EVENTS 24 and the Importance PEM Fellowship Editor News & Notes Emine Tunc, MD of POCUS in the ED 47 EMRA RELEASE 6 NEW PUBS; University of Washington US, PEDIATRICS ABEM VIRTUAL EXAM DATES Complications Seen Toxicology Faculty Editor The Hidden Curriculum David J. Vearrier, MD, MPH, FACMT, 25 in Pediatric Sickle Cell 48 HEART OF EM FAACT, FAAEM Disease Patients University of Mississippi PEDIATRICS, HEMATOLOGY, Lessons in Vulnerability PAIN MANAGEMENT 49 HEART OF EM Be Wary of the Bruise Regarding “Failure 50 of Follow-Up: Scrotal EM Resident (ISSN 2377-438X) is the bi-monthly 28 PEDIATRICS magazine of the Emergency Medicine Residents’ Hernia Case Illustrates Association (EMRA). The opinions herein are One Bad Hand of Poker Healthcare Disparities” 30 TRAUMA those of the authors and not of EMRA or any LETTER TO EDITOR institutions, organizations, or federal agencies. A Case of Overwhelming ECG Challenge EMRA encourages readers to inform themselves 32 fully about all issues presented. Post-splenectomy Infection 51 CARDIOLOGY EM Resident INFECTIOUS DISEASE reserves the right to edit all material and does Board Review Questions not guarantee publication. EM Use of Sphenopalatine 53 PEER ASSISTANCE 34 Ganglion Block for © Copyright 2021 Migraine Headaches Emergency Medicine Residents’ Association PAIN MANAGEMENT WHY I’M AN OWNER

At Vituity, I get to be a part of something bigger “ than myself. As an academic leader, I teach new physicians and aspiring leaders how to make a difference in healthcare.”

Lori Winston, MD, FACEP Vituity Partner & Director of Academic Affairs | Visalia, CA

Vituity has always been 100% owned by its physicians, and you join as a Partner from Day 1.

Learn more about Vituity’s Fellowships in Administration, Clinical Education & Simulation, EMS, and Ultrasound.

vituity.com/fellowships

Now hiring in: Arizona, California, Illinois, Indiana, Kansas, Missouri, Minnesota, Nevada, New Jersey, Oregon, South Carolina, Texas, Washington, and Wisconsin. June/July 2021 | EM Resident 3 Vituity® is a registered trademark of CEP America, LLC. © CEP America, LLC, All Rights Reserved. LEADERSHIP

Looking Beyond the Uncertainty

RJ Sontag, MD I called a stroke alert and spoke to a workforce (acep.org/workforce). I see the EMRA President neurologist. I looked her in the eyes as impact of this when I look in the eyes of Mid Ohio Emergency Services I described the patient’s presentation, EMRA members who have already felt @RJSontagMD and she agreed the presentation made the pressures of these changing workforce he first thing I notice about a patient diagnosis difficult. I breathed a sigh of trends. We have the opportunity to look Tare their eyes. Are they open or shut? relief, realizing I was not alone in my this challenge in the eyes and make a Are they bloodshot? Are they avoiding eye uncertainty. I was beginning to build decision: We can sit back and wait contact? When we look in someone’s eyes, what would become strong relationships to see how it unfolds, or we can emergency physicians get an immediate with our consultants. lean in to our uncertainty and sense of what we will encounter as our Later in the year, as the winter look for solutions. Now is the time to time together unfolds. Not only do we set in and the pandemic worsened, a have difficult conversations, including begin to gather pertinent information nurse pulled me into a room. He looked conversations about our own residency for our physical exam, but we also see concerned and explained that his patient training models and about the impact of the emotions underlying their chief arrived in respiratory distress, and she business interests and other providers on complaints. As I reflect on my time as was not responding to the BiPAP EMS our training and practice. EMRA’s recent EMRA president and on my first year as a had provided. I called for respiratory Workforce Town Hall showed that our brand-new attending, I also wonder what therapy to join us, and I looked in my members are ready to have these difficult people saw when they looked in my eyes. patient’s eyes. I saw fatigue, and I knew conversations. Did my very first patient see any she needed immediate help. Between Whether I am with patients as their uncertainty? His chief complaint was shallow breaths and coughing fits, she doctor, with consultants as their partner, dizziness, and his symptoms were shared that her partner recently died or with you as EMRA’s president, I see vague. I looked in his eyes, searching from COVID-19, and she wondered if she it as my job to look a person in the eyes for nystagmus or any other clues I could would survive. I maintained eye contact and share what I know and what I am use. As I examined him, differentials and did my best to comfort her as we uncertain about. I am uncertain about swirled in my head, and I tried to decide discussed intubation. The pandemic has the future, but I know it looks different. I if I should call a stroke alert. That shown all of us how little certainty we can know that we have more power when we uncertainty left me with a sinking feeling have in these situations, and balancing band together to make change. I know in my stomach, and imposter syndrome the desire to be both honest and we have the power to design our future, began to set in. reassuring is never easy. As the sedative a future where our generation leads, We all have that feeling at was pushed, her eyes became glassy, and with new solutions for safe and effective these times of transition. These then they slowly shut. I wondered if they patient care. transitions tend to happen in summer, would ever open again. After intubating As we embrace the uncertainty that as one academic year moves into the her, I looked up at the staff around me; summer and its associated transitions next. As we adapt to starting medical the patient was not the only one with inevitably bring, keep in touch. I hope to school or clerkships or residency, we fatigue in her eyes. be able to look you in the eye in person at know our training and preparation are Navigating uncertainty through a conference very soon. In the meantime, designed to propel us to success, but challenging times has been a hallmark of email me at [email protected] to share we also appreciate the magnitude of the past year, and it became even more your ideas for the future. Let’s find ways what we cannot know. I leaned in to my apparent in the spring with the release to support each other and work together uncertainty and decided to ask for help. of the report about the changing EM for a better future. ¬

4 EMRA | emra.org • emresident.org B:8.75" T:8.5" S:8" B:11.25" S:10.5" T:11"

FOR SOME OF OUR MOST ELITE SOLDIERS, THIS IS THE FRONT LINES.

As an ofﬁcer working in Emergency Medicine for the U.S. Army health care team, you’ll be on the front lines of medical innovation, practicing in world-renowned hospitals, clinics and health care facilities with access to the most sophisticated medical equipment in the ﬁeld. With over 90 medical career specialties to choose from, you’ll have the opportunity to participate in humanitarian efforts, learn innovative techniques and make a real difference in the lives of Soldiers and their families.

To see the benefits of being at the forefront of Army medicine call 800-431-6717 or visit healthcare.goarmy.com/aqsb

For artwork inquiries, contact [email protected] | For print inquiries, contact [email protected]

US_Army Mechanical Size Final Output Size Team US Army Corp C. Nieto, M. Holzman, Y. Doud Scale 1" = 1" Bleed 8.75" w x 11.25" h Ad # ARMCOR_P7281_Front_Lines_F_051121 Trim 8.5" w x 11" h Project # P00007281 WO# 17 Final Output 100% Safety 8" w x 10.5" h Destination(s) Studio PO# 28231 Bleed 8.75" w x 11.25" h EM Resident - June/July 2021 Issue Print_Magazine, "For some of our most elite soldiers, this is the front lines", Full Page, Trim 8.5" w x 11" h 4/C, Bleed Safety 8" w x 10.5" h

File Name ARMCOR_P7281_Front_Lines_F_051121.indd Document Path Macintosh HD:Users:matt.holzman:Documents:Army:ads:5-11-21:ARMCOR_P7281_Front_Lines_F_051121.indd Revision # 0 Links Fonts Inks Creative Date Created 5-11-2021 4:15 PM CNY_MCE-ARMY-HI-2355_V2.tif (CMYK; 377 ppi; 106.05%), ARMYAlrv4cwoTag_Patch_.ai (16.48%) Slug Font Myriad Pro Family Cyan Account Group Saved 5-11-2021 5:27 PM Minion Pro (Regular; OpenType), Magenta Print Producer [email protected] Printed 5-11-2021 5:27 PM Interstate (Regular, Light; OpenType) Yellow Lead Digital Artist matt holzman Print Scale None Black Digital Artist matt holzman InDesign 2020 Retoucher _ Notes MATS Due: 05/11/21 Proofreader Email ad to: [email protected] CAREER DEVELOPMENT, WELLNESS, COVID-19

Micro-Communities of Practice to Maintain Resilience During Times of Uncertainty A Sustainable Means to Draw Strength When Depleted Dimitrios Papanagnou, MD he impact COVID-19 has had on our connectedness while adhering to social Associate Professor and Vice Chair for Education Tpersonal and professional livelihood distancing requirements. How then can Department of Emergency Medicine cannot be taken lightly. Since the we practically and sustainably maintain Associate Dean for Faculty Development Sidney Kimmel Medical College beginning of the pandemic, we have our sanity during times of uncertainty? at Thomas Jefferson University focused our efforts on protecting our In this commentary, we describe Merle Carter, MD patients, our loved ones, and ourselves. lessons learned for maintaining Executive Vice Chair We relinquished the connectedness personal vitality and professional Previous EM Program Director & Assistant Vice that had once rejuvenated our ethos for connectedness. By creating our very President for Graduate Medical Education (DIO) emergency medicine. Social creatures by own micro-community of practice, Einstein Healthcare Network nature, emergency physicians (EP) crave we have been able to create a shared Brian Levine, MD opportunities to share narratives and space to provide peer-to-peer Associate Chief Academic Officer and DIO ChristianaCare Health System create meaning from work collectively. mentorship and process the ripples Clinical Associate Professor of Emergency Medicine Some of us have successfully navigated of the pandemic to create meaning Sidney Kimmel Medical College separation from family and friends by from chaos — meaning that has been at Thomas Jefferson University identifying creative ways to maintain essential to guide us as leaders.

6 EMRA | emra.org • emresident.org We are three emergency physicians as yours. Share your stories and most. Don’t be afraid to inject who hold a variety of academic leadership listen to others’ — in them, you will supportive messages during the day positions at three institutions within find common ground. or week. You never know what the the same geographic region. While our 3. Raise your glass. What’s better than person might be dealing with on kinship began long before the pandemic, sharing a meal with friends? (Sharing the other end. You very well may be the last year strengthened our resolve a BIG meal with friends!) We made helping them through. to maintain regular interactions to a commitment to make time for 7. Offer support through transitions. support one another — personally and this at every regional or national When making life- or career-altering professionally. It did not matter that we conference, and in between. Strive for decisions, call on those you trust and represented three very unique health connectedness as often as possible. who have had to make the same or systems; we had one same goal in mind: Unfortunately, COVID put the kibosh similar decisions. These are people Keeping ourselves and our respective on getting together at restaurants, who understand what you are going teams moving forward through the but we did this electronically during through, understand the context and isolation and frustration of COVID-19. the pandemic. As restrictions lifted, potential roadblocks or pitfalls. And We have learned that to maintain sanity and we were all vaccinated, we who better to air your dirty laundry and nurture resilience during a pandemic hopped back on the food-train and and get advice! requires intentional action. And over the shared some great meals, provided 8. Venture off your island. When last year, we have identified critical tips lots of laughter, and generating things are tough, it’s easy to remain that have helped us sustainably navigate great ideas we could take with us to isolated. Sometimes it’s just easier to uncertainty. develop for ourselves or with each turn inward. Periodically check-in on As you travel the many roads and other. This winter was intimidating; others who might be doing the same. detours over your evolving careers, but we eventually decided to have an Find ways to leave what’s comfortable remember that the relationships you outdoor dinner thanks to a heated for you, and find comfort in new build along the way will be critical to igloo (see pic). There is nothing more or alternate ways of connecting or your success. You may need to rely on memorable than an Arctic dinner enjoying life. Purposely choose to these relationships during darker days to with great company! meet up somewhere distant from come. Our overarching message is simple: 4. Embrace laughter. There are few your home or workplace. Physical Expand your relationship circles, both things as cathartic and nurturing separation from these places can be professional and personal, and nurture for the soul as a good belly-laugh. refreshing and invigorating. You will them with intention. It’s worth it. There Find ways to see things for what leave with a new sense of energy and will come a day when you will need they are, even the humor in them. purpose. support through difficult work situations, Create spaces for others to rant and 9. Inspire one another. Brainstorm career-altering decisions, or perhaps complain, and try to find humor or create opportunities that were another pandemic. Start building your in the ridiculous. Find others who not obvious to you as an individual. micro-communities of practice. allow the same for you. Laughing Sometimes you need peers to see Tips to Maintain Thriving got us through some difficult times, areas of growth required in yourself Professional Relationships kept our sanity and further bonded that you do not see. Offer ideas for During Times of Uncertainty our relationship. It was a safe space; growth or change and accept that 1. Share resources with one another. what was discussed between us stays from others. Life can be tough at One benefit of networking is between us. times, but through it all, three peer utilizing the expertise and resources 5. Watch the forecast. Tough times lie mentors found a way to empower one of that colleague to aid in your ahead of any career. Identify triggers another. daily responsibilities and career for burnout and create sustainable 10. Do Steps #1 through #9 over again. development. Through the years plans to mitigate them. Plan ahead Do not underestimate the impact a we continue to share our resources during stable times when waters are consistent routine can have on your to help one another. Policies, calm for those times you’ll need a well-being. A consistent routine spreadsheet templates, curricula, you rudder for stability. built into how you connect with your name it, we’ve sent to each other as 6. Commit to communicate. Keep community of peer mentors can satisfy samples; and it really helps to reduce in touch and check-in with your the innate craving for belonging and work. Why recreate the wheel for group – no matter how silly the boost brain dopamine levels. some things when a colleague has communication may seem. The What’s our message? Leave your self- already done it? random, occasional funny text or imposed islands and develop your micro- 2. Connect with like-minded meme within our group text sets off communities to sustainably maintain individuals, regardless of where a flurry of return texts, likes, dislikes, your sanity and resilience during times of they’re from. Join a local or regional laughs, and further conversation. crisis and uncertainty. Basically, screw group with similar interests or roles It may also arrive when it’s needed COVID! ¬

June/July 2021 | EM Resident 7 BOARD CERTIFICATION Residents’ Guide to ABEM Certification

WRITTEN BY THE ABEM RESIDENT AMBASSADOR PANEL Haig K. Aintablian, MD Alaa M. Aldalati, MD William Spinosi, DO AAEM/RSA President Chief Resident 2021-2022 Lehigh Valley Health Chief Resident Mayo Clinic EM Residency Network Ronald Reagan/Olive View UCLA Medical Center

Editor’s note: ABEM Resident Ambassador Panel members serve 2-year terms during residency training and provide a resident perspective to ABEM activities. Working with ABEM over the past year, the 2020-2022 ABEM Resident Ambassador Panel has gained insights into the process of becoming ABEM-certified, and they have outlined those steps from their perspective in an effort to streamline your preparation for the certification process.

ecoming board certified in Emergency Board eligible means that a resident before the start of the exam. Please BMedicine by the American Board of graduated from an ACGME or RCPSC arrive 30 minutes before your exam time Emergency Medicine is a simple process accredited emergency medicine program and make sure to bring a valid form of requiring three steps for residents who or an ABEM-approved combined identification. This process is similar to are in their final years of training. program. Additionally, you must fulfill many of the other examinations you have all medical licensure per ABEM policy. taken to get to this point in your career STEP 1. Applying If you are applying directly out of as a physician! residency, you do not need to hold a The exam appointment is a total for Certification 1 state medical license. This starts on the of 8 hours long, divided into 3 testing day you graduate from residency and sections, each about 3 hours and 10 During the last year of a resident’s extends to Dec. 31, 5 years after your minutes long with a 1-hour break in emergency medicine training, graduating graduation date. between. The question topics are based residents destined to finish residency by Oct. 31 can access application on the EM Model, similar in makeup to information by signing into the ABEM STEP 2. Passing the in-training exams, which you have initial certification page. ABEM will the Qualifying Exam likely already experienced during your 2 residency training. also send application information to the program director of the residency The second step in becoming ABEM Once you have completed this program, usually in April. Anyone board certified is to pass the qualifying qualifying examination, you can expect graduating later than Oct. 31 will examination, a computerized test with your score within 90 days of completion. apply in the next application cycle. For 305 multiple choice questions (with EM residents who graduate between only single best answer choices). The STEP 3. Passing Nov. 1 and the following Oct. 31, it’s qualifying exam is offered in about 200 the Oral Board Exam important to apply in the current Pearson testing centers across the U.S., 3 application period. If you delay, you making it easy to take the exam in the The third and final step in may need additional certification state you graduated from or plan on completing board certification is to requirements, including a state practicing in. The exam itself is offered pass the oral board examination. To medical license, if you do not have one during one 6-day period, typically in the be eligible, you must have passed the already. fall. In order to take the exam during qualifying examination and have a state The entire application and fee this time, you must schedule one 8-hour medical license. Once you pass your payment process is online. Applications block in this 5-day period. qualifying examination, you must take are processed as soon as they are Should you be unable to attend the the oral board exam the next calendar completed. exam, you can cancel up to 24 hours year.

8 EMRA | emra.org • emresident.org It’s important to note that given with 1 being very unacceptable to 8 being then sent to the ABEM Board to determine the COVID-19 pandemic, there very acceptable. performance expectations for a pass or fail have been some changes to the In addition to the 6 single patient cases, score. ABEM does not allow for rescoring implementation of this section a discussion on your approach to patient or second scoring any examinations. of board certification. Notably, the care will evaluate your thought processes. Success examination has been offered on a virtual Structured interviews are scored as 25 Once you have passed the Oral Board platform, as opposed to in-person, for the points spread across 8 stages of a typical Examination, congratulations! You are safety of test takers and testing staff. patient interaction. These include: now an ABEM board-certified emergency The oral board examination ü History physician! comprises 6 single patient cases, each 15 ü Physical exam ABEM-certified physicians serve a minutes long. The examiner will provide ü Differential diagnosis pertinent history and offer answers to ü Testing valuable and irreplaceable clinical role in the examinee’s questions. The examiner ü Treatment the care of the critically ill and injured. The will track 8 specific markers during these ü Final diagnosis delivery of emergency care is best led by patient cases. These markers include: ü Disposition physicians with EM training, experience, - Data acquisition ü Transitions of care and ABEM certification. ABEM will - Problem solving ABEM typically releases oral board support you throughout your career in - Patient management exam results within 45-60 days, and continuing certification activities and - Resource utilization definitely within 90 days. ABEM does not promoting the important and valuable - Healthcare provided or outcome use quotas or percentages to determine role ABEM-certified physicians bring to - Interpersonal relations and a passing score. Instead, after each emergency care in the ED. communication skills examination, ABEM testers meet to Do you have questions about the - Comprehension of pathophysiology determine the standard of care for each certification process? Reach out to your - Clinical competence case and then determine whether testers program director or contact ABEM at Examiners assign a score from 1-8, passed or failed. The final passing score is [email protected]. ¬ Because someone always takes it one step too far. You’re there for them, we’re here for you.

ACEP AND EMRA’S OFFICIAL ONLINE CAREER CENTER

June/July 2021 | EM Resident 9 TOXICOLOGY

Managing Envenomation Luke He, MD John Michael Sherman Geoffrey B. Comp, DO, FAWM Maricopa Medical Center University of Arizona College of Medicine Faculty- Creighton University School of Medicine/Maricopa Medical Class of 2023 Center (Phoenix) Emergency Medicine Residency Christopher Rajan, DO Assistant Professor, University of Arizona College of Medicine Phoenix Maricopa Medical Center Assistant Professor Health Sciences Associated Faculty, Creighton University School of Medicine

RATTLESNAKE In the wilderness setting, local care and evacuation must A 50-year-old female is celebrating Labor Day weekend be initiated. Jewelry should be removed from the entirety of with you and your friends in New Mexico. She is swimming the affected limb. If erythema is present, it may be helpful at a lake, and upon walking out of the water feels a sharp to mark the leading edge and notice of the time for tracking pain around her ankle. You notice a snake under a rock of progression. If possible, immobilize the limb in a neutral near her foot and take a photo with your phone as shown. position. Though some may have heard to do the following, You see 2 small dots around her ankle, and you’re 3 miles you should refrain from catching the snake, drinking alcohol, from your car and another 1-hour drive from the nearest cutting a wound to suck out the venom, applying tourniquets, 6 hospital. She is neurovascularly intact with a normal exam or attempting to use an electric shock. Assessment at a except for subjective pain. medical facility with labs and monitoring is warranted, and typically will consist of labs to assess coagulopathy as well as consideration of antivenom.3,4 SCORPION A 4-year-old girl is brought to an ED in Phoenix, Arizona, with agitation and foot pain. She is tachypneic, restless, and drooling, and on exam you note tongue fasciculations, multidirectional nystagmus, and a small area of erythema on her right foot. What animal is likely responsible for her symptoms?

This woman has sustained a bite from a rattlesnake and possible envenomation. Rattlesnakes are classified as crotalinae, also known as pit vipers.1 The name pit comes from a heat sensing pit behind the nostril used to find prey. When venom is released, local damage is done by metalloproteinases, phospholipase A2, serine proteases, and hyaluronidase which lead to local tissue edema and swelling from capillary damage.2-4 Approximately 25% of bites are “dry bites,” with no venom released. Crotalus scutulatus, also known as Mohave rattlesnakes, are indigenous to the deserts of the western United States and Mexico. They contain a neurotoxic- This child has likely suffered a bark scorpion hemolytic venom, which may lead to vision abnormalities, envenomation. Centruroides sculpturatus is endemic to the difficulty with swallowing, and even respiratory failure.5 American southwest, especially Arizona, Texas, Nevada,

10 EMRA | emra.org • emresident.org California, Oklahoma, and New Mexico.7 Scorpion venom is When bit, it may be difficult to remove. Submersion in a complex mix of many substances, but the most clinically water or prying open the mouth may be necessary.15 There important is a heat-stable and protease-resistant neurotoxin.8 have been historical reports of using gasoline in the mouth, This neurotoxin targets axonal sodium channels, increasing flame on the chin or underbelly, and pulling on the tail but the firing of axons by widening and prolonging the action these should not be done.16,17 Irrigation and medical attention potential and leading to increased release of catecholamines.8 is recommended immediately. There is no antivenom available There is a wide spectrum of symptoms including local pain/ and treatment is supportive. The affected area should be paresthesia as well as: elevated to heart level. Suction or compression for treatment • Neuromuscular abnormalities — agitation, skeletal muscle is unproved, and cryotherapy, tourniquet, and excision can be fasciculation, motor hyperactivity (flailing movements, dangerous.15 tetanus-like spasms), rhabdomyolysis • Autonomic dysfunction — tachycardia, hypertension, BLACK WIDOW SPIDER A 27-year-old woman presents to the ED with muscle vomiting, hypersalivation pain. She was gathering firewood near her campsite • Cranial nerve abnormalities — opsoclonus (roving, in eastern Texas when she suddenly felt a mild pain on multidirectional eye movements), blurred vision, tongue her left arm. About one hour later she developed left fasciculations, dysarthria, stridor, pharyngeal spasm, arm muscle pain and paresthesia, diffuse abdominal dysphagia, hyposmia, and dysgeusia.8-11 pain, and nausea. On exam she has a tender and rigid While adults are stung more often, children are more likely abdomen, and you note a small area of erythema with a to have more severe symptoms.8,12 The mainstay of treatment blanched center and small central punctum on her left is supportive care, analgesia, and possible benzodiazepines volar forearm. What is responsible for her symptoms? if needed to reduce neuromuscular hyperactivity.8 In severe cases, an FDA-approved antivenom is available for use after consulting with a regional poison control center.13 GILA MONSTER A distraught mother and friend of yours video calls to show you her son with an animal latched onto his arm from the backyard. They recently bought a home with a pool in the Southwest United States. You immediately recognize the color pattern is consistent with a Gila Monster. What do you do next?

This patient was likely bitten by a black widow spider. Spiders in the Latrodectus species are found in warm climates worldwide, with the most common in the United States being the southern black widow (L. mactans) and the western black widow (L. hesperus). These spiders collectively range throughout the southern and western United States and are easily recognizable by their black bodies with red, hourglass-shaped abdominal markings.18 Black widow venom contains excitatory neurotoxins which stimulate massive exocytosis of multiple neurotransmitters from presynaptic nerve terminals.19 Symptoms can include muscle pain and intermittent rigidity, abdominal pain, paresthesias, and autonomic dysfunction. The typical appearance of the bite is a blanched circular patch with surrounding red perimeter and central punctum. Local diaphoresis and lymphadenopathy This is a Gila monster (Heloderma suspectum), is a may also be present. Treatment is generally supportive, sluggish lizard commonly found in Southwest United States consisting of oral analgesia, benzodiazepines, antiemetics, and Northwest Mexico. Typically biting when agitated, they local wound care, and tetanus prophylaxis if indicated. will latch on and chew onto tissue activating the release venom Antivenoms are available and may be used in moderate to and can be difficult to remove. This may lead to pain, edema, severe envenomations after consulting with a regional poison hypotension, nausea, vomiting, weakness, and diaphoresis.14 control center.20

June/July 2021 | EM Resident 11 TOXICOLOGY

ASIAN GIANT HORNET CORAL SNAKE A 38-year-old man presents to the ED after 3 days of “Red on yellow? Red on black? Jack?” Your friend progressively decreased urination. He was in Northern sustained a bite from a snake yesterday while visiting India 3 days ago when he was attacked by a group of a friend in Florida. He couldn’t remember the riddle but insects, and since returning to the US yesterday has also started feeling paraesthesias, nausea, and vomiting after developed ankle swelling, fatigue, nausea, and vomiting. 12 hours. He sends you this picture and asks if he should He has approximately 8-10 small, tender areas of erythema anticipate staying in the hospital. and edema on his trunk and upper extremities. What animal is responsible for his symptoms?

This patient was likely stung multiple times by the Asian giant hornet, colloquially called the “murder hornet.” Vespa mandarinia is native to China, India, Japan, Russia, Vietnam, Thailand, Malaysia, Nepal, and other South and East Asian countries, but there have been a number of reports of these wasps in British Columbia and Washington State in 2019 and 2020.21-23 Wasp venom contains several active The Eastern coral snake (Micrurus fulvius fulvius) as components and can result in conditions ranging from local described here with red adjacent to yellow, commonly confused type I hypersensitivity reactions to anaphylaxis.24,25 Systemic with the Scarlet King Snake or the Milk Snake, which has red reactions such as shock, rhabdomyolysis, coagulopathies, adjacent to black. The “Red on Yellow, Kill a Fellow, Red on respiratory distress, hepatitis, and acute kidney injury are Black, Friend to Jack” rhyme is generally true but there are possible especially with multiple stings.24,26,27 Treatment is morphology variants of coral snakes that do not follow this symptomatic and supportive (often including glucocorticoids, pattern. They possess small, fixed front fangs and may chew antihistamines, and IV fluids), as there is no anti-venom to envenomate. Coral snakes have a venom that binds to available.24,26,27 acetylcholine receptors and is neurotoxic. Around 20-25% of 28,29 Diagnosing snake envenomation is the time, the bite may be a dry bite. Typically after envenomation, there are minimal local a crucial step in determining which symptoms, and symptoms may develop up to 12 after the antivenom is to be applied. Each year exposure.30 Symptoms can include swelling, paresthesias, there are around 2 million cases of nausea, vomiting, euphoria, weakness, dizziness, diaphoresis, muscle tenderness, fasciculations, confusion. In worst case snake envenomation and up to 100,000 scenarios, bulbar paralytic symptoms, extremity paralysis, and deaths worldwide. Various anti-venom possible respiratory failure.28 treatments exist, typically consisting Treatment involves immobilizing the extremity, marking the erythema, and removing any jewelry. Do not to suck the of antibodies or antibody fragments, venom, submerge in warm water, use tourniquets, take NSAIDs, which neutralize the venom. Anti- or splint the affected extremity. Some suggest that all need to venom therapy is designed to treat the be admitted to the hospital due to delayed symptoms, and some may need antivenom.31 Some may advocate for a 8-12 hour hemorrhaging and coagulation effects monitoring period in the ED with assessments for compartment that venom has on humans. syndrome and coagulopathies, and if discharged, with strict return precautions.32

12 EMRA | emra.org • emresident.org AIRWAY

FIRE ANT STINGRAY A 72-year-old man with a history of dementia presents You are walking along the beach and you see a couple to an ED in Mississippi with painful, pruritic lesions on taking wedding photos with their feet in the water at a his feet. He was found 20 minutes prior to arrival sitting Louisiana beach. The bride shouts and looks down and on a bench outside his assisted living facility. On both sees a stingray next to her leg. The photographer catches of his feet there are numerous wheals with surrounding this photo before it swims away. erythema, which developed into pustules the next day. What animal is responsible for these findings?

Stingrays are found in coastal tropical and subtropical marine waters around the world, with 24 different species found in the US.35,36 When envenomated, the stinger punctures This patient was bitten by fire ants. The red imported fire the skin and introduces a heat labile venom. This commonly ant (Solenopsis invicta), black imported fire ant (Solenopsis occurs when stingrays are stepped on in shallow water and richteri), and a hybrid species are found in many states in the shuffling your feet may decrease your likelihood of getting southern and southeast US, and as far west as California.33 stung. Effects are typically limited to just local effects including They are generally aggressive, swarming and stinging even pain, irritation, erythema out of proportion to the wound without provocation. Ant bites are more common in children, but vary by species. Maximal pain is usually experienced at but less mobile patients are at higher risk; there have been 30-90 minutes.37 If systemic effects occur, they may include several recent reports of attacks on nursing home residents.34 nausea, vomiting, diarrhea, diaphoresis, weakness, headache, The venom is 95% water-insoluble alkaloid which is vertigo, abdominal pain, syncope, cramping, and in worst cytotoxic and hemolytic, and 5% allergenic aqueous protein case scenarios, seizures, respiratory distress, hypotension, solution. The immediate response (IgE-mediated) is a dermal convulsions, paralysis, cardiac arrest.38,39 flare and wheal, with papules forming within 2 hours, vesicles Management should start with rinsing in tap water, or if within 4 hours, and pustules within 24 hours. There can be unavailable, salt water. Warm and hot soaks, ideally as hot as large local reactions of pain, erythema, and edema, and they tolerated should be applied. Oral narcotics or local anesthesia can also cause systemic anaphylaxis. Interestingly, anaphylaxis may be used. The affected individual be evaluated by a medical more commonly occurs in those with prior ant or yellow jacket professional to ensure their tetanus is up to date, evaluated for stings due to venom cross-reactivity. retained foreign bodies, and supportive care.37 Prophylactic Fire ant stings can rarely cause serum sickness, nephrotic antibiotics are controversial. Since the venom is heat labile, syndrome, seizures, and exacerbation of pre-existing the wound should be immersed in hot water as soon after the cardiopulmonary disease. Treatment is firstly to remove injury as possible, be careful as to not cause further injury by any remaining ants, as they can sting repeatedly. Topical scalding: 45° for 30-90 minutes is recommended. Removal of antihistamines and corticosteroid creams are sufficient the barb may be attempted and tetanus should be updated.40,41 for local reactions, and anaphylaxis should be treated Urine, as well as other historically suggested treatments such as appropriately. The sterile pustules should be left alone but application of numerous substances: macerated cockroaches, should be cleaned with soap, water, and an antibiotic cream if fish liver, tobacco juice, cactus juice, gasoline, wine, and broken.33 cryotherapy are not recommended.40,41

Envenomation is the process by which venom is injected by the bite or sting of a venomous animal. Many kinds of animals, including mammals, reptiles, spiders, insects, and fish employ venom for hunting and for self-defense.

June/July 2021 | EM Resident 13 TOXICOLOGY

BOX JELLYFISH FIRE CORAL You and your friends walk across the street to the beach A 16-year-old boy just got a job at a fish aquarium and in Florida after eating at a seafood restaurant. Your friend comes in with intense forearm pain after cleaning a fish walks out of the water with a jellyfish wrapped around his tank with coral. Other than local pain, he has no other leg. You immediately run over to provide aid, and you’re symptoms and has normal vital signs. being asked what can be done to aid the victim, and if urine can be used to “neutralize” the venom.

Fire coral (Millepora alcicornis) has a white to yellow or green exoskeleton and exists around the world. It contains dactylozooids, which are small tentacles, in the exoskeleton. Envenomation occurs via nematocysts, similar to jellyfish. The venom has hemolytic, dermonecrotic, and cytotoxic effects. Since they are rigid, many injuries occur after abrading the Classically, jellyfish stings cause local pain up to 8 hours structure.52,53 The envenomation is immediate and painful, and with linear welts which can progress to blistering and necrotic also is associated with pruritus, urticaria, blistering.54 In severe areas. The specific venom components and mechanisms are cases, pulmonary edema, hypotension, fever, and renal failure unclear, but it’s thought to affect sodium, potassium, and may occur.55,56 calcium channels at cell membranes. Classically, it causes Pain and sensitivity may last months but systemic local pain up to 8 hours with linear welts that can progress symptoms are rare. Treatment is mostly extrapolated from to blistering and necrotic areas. Sometimes, if involving nematocysts of other Cnidarians such as jellyfish. Like jellyfish, > 10% body surface area, systemic effects may take place, both hot and cold water are beneficial, as are oral agents, including cardiac arrhythmia, hypotension, shock, tachycardia, topical lidocaine, and steroids.52 Lacerations are common, respiratory dysfunction, death. These usually manifest within and should be irrigated and closed loosely. Antibiotics are 5 minutes of the sting.42 recommended to cover skin and aquatic flora and tetanus There are many different species of box jellyfish should be updated. If no systemic symptoms present, patients depending on location so following local guidelines are may be discharged. ¬ recommended. The American Heart Association-American Red Cross International Consensus on First Aid Science currently advocates vinegar or baking soda slurry followed by From catfish to Irukandji jellyfish, marine the application of heat (or an ice pack if heat is not available) envenomations present a wide and for all jellyfish stings in North America and Hawaii.43 Be wary of using vinegar because some studies suggests it may varied picture, in terms of pain, systemic 44 worsen symptoms. Try to control the pain with oral agents severity, and treatment. While the most if available, and hot or cold packs or water may help.43,45 Topical lidocaine and how water has shown to help in lethal and complex envenomations multiple studies.46 Pressure bandages should not be used.47 occur in more tropical waters, it pays Other potential options with unclear benefit for treating symptoms include commercial products with aluminum to be ready to handle any marine sulfate,48 papain,49 lidocaine hydrochloride,44 baking soda,50 envenomation — more than 50% of all 48 deionized water, seawater, meat tenderizer. In some venomous vertebrates are fish. hospital settings, antivenom has been administered, which is a bovine IgG Fab.51

14 EMRA | emra.org • emresident.org References available online TOXICOLOGY PERICARDIAL EFFUSION A Rare Case of a Potentially Dangerous Manifestation of Lyme Disease Amanda dos Santos, MD “bull’s eye rash” (Figure 1), unilateral later she developed a unilateral right 6th Summa Health, Bell’s Palsy, and Lyme carditis which and 7th nerve palsy. Extensive workup PGY1 Emergency Medicine Resident often causes an AV node conduction was non-contributory until a spinal tap Nicholas Jouriles, MD, FACEP abnormality.1,2,3,8 This case report demonstrated elevated cerebrospinal Northeast Ohio Medical University, Professor and Chair of Emergency Medicine describes a less common cardiac fluid protein and lymphocytes, when led Acute Care Solutions, manifestation of Lyme disease: her PCP to suspect Lyme disease. Chair of Faculty Development pericarditis with pericardial effusion. In the ED, her heart rate was yme disease is one of the most Case 121 bpm, BP 155/65 mmHg, RR 20 breaths/min, and oxygen saturation Lcommon vector-borne diseases in the A 61-year-old female was sent 100% on room air. Her physical exam United States, affecting over 300,000 to the ED after an incidental finding was significant for a comfortable people annually between June and of pericardial effusion on outpatient appearing woman with an elevated BMI, December and most prominent in the echocardiogram. Her medical history tachycardia, and moderate bilateral northeastern, mid-Atlantic, and north- was significant for well controlled central regions.1 The culprit, Borrelia lower extremity pitting edema. Blood type 2 diabetes, hypertension, and Burgdorferi, is a spirochete transmitted work was significant for a WBC 10.9, hyperlipidemia. Upon presentation to through deer tick (Ixodes Scapularis) Hgb 10.5, CRP 33.5, ESR 45. ECG the ED, the patient endorsed two weeks in the Eastern U.S. and the Western showed atrial flutter with variable block of intermittent palpitations, worsening blacklegged tick (Ixodes Pacificus) in the (figure 2), and a bedside echo showed a dyspnea that was exacerbated by West, that gets transmitted to the human moderate pericardial effusion without laying down, and weight gain. She host when the tick is attached to the hemodynamic compromise, which was denied chest pain, cough, recent fevers human host for over 36 hours.1 confirmed by formal echocardiography or illnesses, any surgeries or long Lyme disease affects every organ (figure 3). The patient was admitted to periods of immobilization. Recent system and is described in three cardiology for pericardiocentesis and travel history was only significant progressive stages of disease: early further work-up. for spending summers at her cabin in localized, early disseminated, and late Pericardiocentesis was performed disseminated or chronic. Stereotypical Pennsylvania. She denied any family by interventional cardiology and yielded manifestations include the cutaneous history of cardiovascular disease as 500 cc of blood so her anticoagulant was well as tobacco, alcohol, or recreational discontinued. There was no cytologic drug use. On the previous week the evidence of malignancy, viral, bacterial patient visited her primary care or fungal growth in the pericardial fluid, physician (PCP) with these concerns. At but have findings consistent with an that time, atrial flutter was identified exudative process with LDH 234 (fluid/ on electrocardiogram (ECG). She serum LDH > 0.6) and fluid protein 76.2 was started on a beta blocker, an (fluid/serum protein >0.5). Meningitis anticoagulant, and referred for the and respiratory panels, tuberculosis, echocardiogram. syphilis, SARS Cov2, and West Nile virus Upon further questioning, patient tests were negative. Her Lyme ELISA reported she was in her usual state of test resulted 11 days post-admission and health until last summer (4 months prior was unequivocally positive. to presentation) when she had developed Given her history and presentation, a single erythematous lesion on the disseminated Lyme disease was thought left upper extremity, which eventually to have been the cause of her pericarditis spread over her entire body. A skin complicated by pericardial effusion, and biopsy was significant for urticaria and she was presumptively treated for Lyme she completed a treatment of steroids. with 4 weeks of intravenous ceftriaxone. FIGURE 1. Bull’s eye rash indicative of She subsequently developed fatigue, then The acute pericarditis was managed with Lyme disease mild positional dyspnea, and 2 months intra-pericardial steroids, ibuprofen,

June/July 2021 | EM Resident 15 PEDIATRICS, ORTHOPEDICS

FIGURE 2. are dyspnea, pleuritic chest pain ECG at that is relieved by leaning forward presentation and exacerbated by lying down and demonstrates swallowing, nausea, abdominal pain, atrial and malaise.2,7 fibrillation Pericardial tamponade is a dangerous complication of the rapid development of a pericardial effusion leading to increased pressure in the pericardial space, decreased ventricular filling and cardiac output leading to hemodynamic collapse. Signs of tamponade can be remembered by the “Beck’s triad:” hypotension, muffled 1 and colchicine. Diuresis was initiated, mono-arthralgias (often the knee). heart sounds and jugular venous leading to a 7.7 kg weight loss during her Evidently, we met this patient on distention.7 hospitalization and another 10 kg in the the second stage. “Lyme carditis” most The essential workup for pericarditis subsequent 2 weeks. Her hospitalization frequently manifests as conduction in the ED includes a physical exam, was complicated by refractory atrial abnormalities (eg, AV nodal blocks) chest x-ray or bedside ultrasound, ECG, flutter and decreased cardiac function due to direct toxic and immune- and basic labs. An auscultated high- evidenced by a left ventricular ejection mediated mechanisms. Less commonly, pitched scratchy “friction rub” is 100% fraction (LVEF) of 30% (from 65% on Lyme carditis has been implicated in specific for pericarditis.3 While chest admission) with global dysfunction. She coronary aneurysms, congestive heart x-ray may detect effusions larger than was discharged on digoxin on hospital failure, valve disease, ischemic events, 250 cc, a bedside echocardiogram can day 7 and felt better for a month at endocarditis, myocarditis, and rarely detect as little as 20–50 cc of pericardial which time her symptoms started to pericarditis (2-5% of Lyme carditis cases fluid3 and up to 60% of pericardial return. An echocardiogram at that in the U.S. and 23% in Europe4,5). effusions.7 ECG with PR depression or time revealed interval improvement The pericardium consists of thin ST changes that do not match anatomic of cardiac function (LVEF 48%) but visceral and parietal layers between regions, low voltage, and electrical a moderate pericardial effusion re- which a potential space usually alternans suggests a large pericardial accumulation, managed conservatively holds 15–35 cc of fluid, but when effusion and should prompt evaluation with high dose prednisone. the pericardium becomes acutely for tamponade physiology. Classically, Discussion inflamed, a pericardial effusion can the ECG findings seen with pericarditis Lyme disease is often classified into ensue and hold up to liters of fluid. evolve through 4 stages: 3 stages: Infectious organisms are often the 1. Diffuse concave upward ST- First — Early Localized Disease precursor to pericarditis in world, but elevations (typically 2-4 mm) and PR Within days of exposure patients in north America up to 90% of cases segment depressions diffusely in all 7 present in the spring or summer with are idiopathic. The most common leads other than aVR and V1 which flu-like illness, fever, and a typical rash symptoms of pericarditis with effusion will show PR segment elevations and (erythematous patch with a central scab and blurred margins) (figure 1). FIGURE 3. Pericardial effusion. Transthoracic The erythema migrans “bull’s eye rash” echocardiogram appears within 48 hours and is most demonstrates a large apparent 7-14 days after tick is detached.1 pericardial effusion Second — Early Disseminated (+) a: Parasternal long axis view Disease demonstrates typical Neurologic manifestations such as interposition of the Bell’s palsy (unilateral or bilateral) or pericardial effusion aseptic meningitis may develop. Cardiac (+) between the heart manifestations occur in 1-10 % of and the descending 1,2,8 thoracic aorta. b: cases. Parasternal short axis Third — Late Disseminated at the level of the or Chronic papillary muscles. c: In the apical 4-chamber Encephalopathy, radiculopathy, view, note that the severe fatigue, psychologic disturbances, pericardial effusion surrounds the cardiac apex. d: Subcostal view.

16 EMRA | emra.org • emresident.org ST-segment depressions arthritis, joint effusion cryoglobulin Acute pericarditis treatment with 2. Normalization of ST and PR may be increased 5-fold compared with non-steroidal anti-inflammatories segments plus T-wave flattening serum.3,8 and colchicine should be started 3. Diffuse T-wave inversions, typically If the most common cardiac in the ED. Refractory pericarditis in the leads that previously had ST- manifestation of Lyme is observed treatment include low to moderate segment elevation (first- degree heart block), admission doses of corticosteroids with taper and 4. ECG normalizes or may have some may be warranted as patients may colchicine for at least 6 months.2,3,8 2 persistent T-wave inversions rapidly decompensate into second and Patients who are stable, afebrile, Bloodwork is non-specific or third-degree atrioventricular block, without large pericardial effusions and sensitive, but may show leukocytosis, and some patients require a temporary reliable follow-up may be managed 2,7 elevated ESR and CRP, while positive pacemaker. outpatient as most patients tend to cardiac enzymes would indicate Treatments recover within 3 weeks.7 2,3,5,7 myocardial involvement. Treating the early manifestations of Cases of pericarditis that are There is no specific work-up for Lyme disease is important to prevent resistant to NSAIDs, colchicine and Lyme disease in the ED. The Infectious development of complications. Oral corticosteroids are extremely difficult to Diseases Society of America (IDSA) antibiotics (doxycycline, cefuroxime treat and may require pericardiectomy.7 supports a clinical diagnosis and or amoxicillin) may be used for early Unless the patient presents with cardiac subsequent treatment of erythema localized disease or mild cardiac tamponade, ED pericardiocentesis is not migrans.8 Serologic tests should only be involvement, while intravenous antibiotics recommended and should be performed performed 6-8 weeks into the suspected (ceftriaxone or penicillin G) are suggested by interventional cardiology.2,3 disease after antibodies have developed. for disseminated and more severe cardiac The CDC recommends a 2-tier testing manifestations.1,2,3,7,8 Prophylactic use of TABLE 2. Pericarditis Medications for Lyme Disease, which includes an antibiotics after a tick bite is controversial, Medication Oral Adult dose Duration initial enzyme immunoassay (EIA) such but a one-time dose of 100 mg oral Aspirin 1200-1800 mg daily 1-2 weeks as enzyme-linked immunosorbent assay doxycycline for children and 200 mg for Ibuprofen 600-800 mg every 1-2 weeks (ELISA) or immunofluorescence assay adults may be administered.8 8 hours (IFA) followed by a Western blot. If the Indomethacin 75–150 mg daily 1-2 weeks TABLE 1. Lyme Disease Antibiotics immunoassay is negative, the diagnosis Colchicine 0.5-1.2 mg twice 3-6 of early disseminated or late Lyme Medication Adult dose Duration daily months disease is unlikely. If the immunoassay Ceftriaxone 2 g IV daily 14 days Prednisone 0.2–0.5 mg/kg/day 1 month is positive, the Western blot should be Penicillin G 20 million units IV daily 14 days performed and interpreted accordingly:8 Doxycycline 100 mg PO 2x daily 14-21 days Summary Effective management of Lyme Early Disseminated Lyme Disease Cefuroxime 500 mg PO 2x daily 14-21 days disease and its related complications Detectable IgM and IgG antibodies Amoxicillin 500 mg PO 3x daily 14-21 days ¬ to B. burgdorferi. An isolated positive begins with recognition and diagnosis. IgM Western blot may represent a false positive test. If there’s evidence of TAKE-HOME POINTS erythema migrans, the recommendation l As with all undifferentiated patients in the ED, taking a good history is of utmost is to treat empirically and repeat testing importance to diagnose both Lyme disease and pericarditis. in 3 weeks. l Although there are no signs or symptoms specific for pericarditis, the diagnosis Late Lyme Disease can be made if the patient has a constellation of symptoms including preceding illness, low grade fever, dyspnea exacerbated by laying down, and pleuritic chest IgG should be positive. IgM may pain. ECG is helpful but unreliable and lab tests are not specific. An auscultated or may not be positive and should not friction rub is very specific for pericarditis, yet it comes with environmental be used for diagnosis. Serology might challenges in a busy ED. be positive for months to years after l To diagnose a pericardial effusion, the single best tool we have in the ED is the infection.6,8 ultrasound. Although non-diagnostic, bloodwork l Although not every patient with Lyme carditis requires hospital admission, even may show leukocytosis, anemia, first-degree heart blocks can quickly decompensate into third-degree and the thrombocytopenia, ESR>30 mm/ decision about disposition should be made with our consulting cardiologists. hr, elevated liver enzymes (notably l Treatment with NSAID and colchicine should not be delayed for suspected γ-glutamyl transferase). In Lyme pericarditis. meningitis, CSF analysis will reveal l The same holds true for initiating antibiotic treatment for Lyme disease since pleocytosis and elevated protein, but delayed treatment can lead to progression of disease and confirmatory tests CSF spirochete antibodies are not might take days to weeks to result. recommended.3,8 In Lyme mono-

References available online June/July 2021 | EM Resident 17 TRAUMA An Unexpected Electrical Injury A Case Report Vahini Koka, DO palpable pulses, cool extremities to but no further chemical or electrical Beaumont Health touch, fixed and dilated pupils, and interventions were required. Peter Nemes, DO disconjugate gaze, with the right eye Beaumont Health Discussion deviating laterally. Resuscitation Benjamin D. Goodman, MS-3 There are 2 types of electrical current: was continued adhering to Advanced Michigan State University direct current (DC) found in batteries and College of Osteopathic Medicine Cardiovascular Life Support guidelines. lightning, and alternating current (AC) Angel Chudler, DO After the first round of CPR, VF was used in electrical wires. AC and DC can Beaumont Health again detected, he was defibrillated, and be further categorized into low-voltage lectrical injuries range in severity ROSC was achieved with conversion (<1,000 volts) or high-voltage (>1,000 Efrom minor cutaneous burns to to normal sinus rhythm. He was volts). When traveling through the human life-threatening internal organ damage subsequently intubated. Vital signs body, the current follows the path of least and death. These injuries account for were BP 164/80, HR 86, RR 16, T resistance. This resistance is variable

at least 30,000 non-fatal incidents and 35.6C (96.3°F), spO2 97%, on 35% FiO2. based on the type of organ or tissue it is 1,000 fatalities in the U.S. every year.1 Secondary exam demonstrated erythema going through with the highest to lowest The mechanism of an electrical injury of the palmar aspect of the right hand, resistance being bone, fat, tendon, skin, varies with age, with younger children ecchymosis of the left popliteal fossa, muscle, blood vessel, and nerve.3 The accounting for household electrical and bilateral great toe linear “exit severity of the injury due to low-voltage injuries via cords and outlets, older wound” burns with necrotic centers. His AC can be increased by tetany causing children via high-voltage power lines, and EKG showed wide QRS complexes with prolonged contact, which is seen more adults via work-related accidents. Two- nonspecific ST-T changes. Chest x-ray in low voltages, as compared to higher thirds of all electrical injuries occur in and chest CT showed right upper and voltage DC that may cause one large single 2 electrical and construction workers. middle lobe pulmonary contusions. muscle contraction. Many different organ Case Upon returning from imaging, he systems are affected by an electrical injury, but we are going to limit the discussion to A 20-year-old male was brought to was noted to have equal and reactive those injured in our patient. the ED by EMS in cardiac arrest after pupils with aligned gaze. During the an electrical injury while working as remainder of his ED stay, telemetry Cardiovascular a residential construction worker. The showed fluctuations from atrial The heart is the internal organ most patient was carrying an aluminum ladder fibrillation to sinus tachycardia, commonly affected by electrical injury as that contacted overhead wires it is located along many paths running to a house (240 volts). between entrance and exit of The homeowner had started the electrical current.4 Cardiac CPR approximately 3 minutes injuries can occur due to direct after initial downtime. Upon damage from the electrical EMS arrival, the patient was in current to the myocardium, ventricular fibrillation (VF). They extensive catecholamine delivered 4 rounds of defibrillation release, myocardial infarction, and 2 rounds of epinephrine en severe hypotension leading to route to the ED, but attempts hypoperfusion, and myocardial failed to achieve return of contusion due to prolonged CPR. spontaneous circulation (ROSC). EKG findings may demonstrate The estimated downtime prior to arrhythmias, myocardial damage, ED arrival was 25 minutes. and conduction abnormalities. On arrival to the ED, the Typically, high-voltage DC patient was in asystole with causes ventricular asystole and agonal respirations. He had a AC causes death via VF. Delayed Glasgow Coma Scale of 3, no arrhythmias after an initial

18 EMRA | emra.org • emresident.org presentation of NSR have been seen up to disorders.7 Dysfunction of cranial nerves Integumentary 5 12 hours later. associated with the eye as seen in our The severity of skin manifestations It is important to note that normal patient can occur due to reversible after an electrical injury can vary, but it cardiac markers cannot rule out heart autonomic deficits and should not be used is important to recognize that the level of damage, as shown in our patient who had as indication of poor prognosis.10 cutaneous involvement is a poor predictor normal CK and troponin levels despite Respiratory of the extent of internal injury. When clear signs of myocardial injury. There Pulmonary injuries rarely present present, burn marks are more commonly should be high suspicion that the electrical after a low or high voltage contact and are seen at the point of contact and where the pathway may have cardiac involvement electrical current exited the individual.1 more often seen after a lightning strike. in cases with loss of consciousness or Our patient was noted to have an entrance Our patient showed multiple pulmonary entrance wounds on the hands. The most wound on his right palm and bilateral exit contusions on chest CT in his right upper significant clinical predictor of cardiac wounds on his big toes. Kissing burns may and middle lobes. As he had no previous injury is evidence of a vertical pathway of also be seen in individuals as a result of pulmonary disease, no signs of thoracic electricity, mapped by a line between the limb flexion and the electricity arcing from 6 or abdominal wall trauma, or concern entrance and exit wounds. Our patient one surface to another.17 An electrical burn for respiratory infection, we suspect the was found to have a vertical pathway can be treated similarly to a thermal injury. between his right hand and feet. pulmonary contusions were most likely caused by electrical injury, specifically the Case Resolution Nervous flow of electricity from his right hand to After being stabilized in our community Neurological deficits can be present his lungs. In addition, prolonged tetany ED, the patient was transferred to a burn throughout the central (CNS) and of the diaphragm and intercostal muscles center. Prior to transfer, he began to peripheral (PNS) nervous systems, may have contributed to his respiratory have spontaneous movements requiring often due to cerebral hemorrhage and sedation. Upon arrival at the burn center, arrest. The pathology is consistent with infarction. The etiologies of these injuries the patient was subsequently cooled two other cases describing low-voltage may include but are not limited to secondary to VF arrest. By the end of pulmonary contusions, making this the direct damage, thermal damage, tissue hospital day one, he was more alert and was separation whether due to electrostatic third case reported in English literature 11,12 extubated without issue. His hospital course 7 worldwide. These injuries can be measures or force, and ischemic changes. was complicated by elevated troponin levels, a result of either non-thermal effects Acute-onset neurological deficits have but he was ultimately cleared by cardiology (electricity causing cellular changes) or a more favorable outcome than those and discharged from the hospital four days 8 due to thermal effects (electricity heating which are delayed. Immediate injuries later with full neurologic recovery. ¬ are typically seen in the CNS with loss surrounding air causing a blast). of consciousness as well as respiratory Other low-voltage pulmonary TAKE-HOME POINTS and motor paralysis. Delayed injuries are injuries have included cardiogenic and ü Limited external injuries should not more often documented in high-voltage neurogenic induced pulmonary edema limit a thorough evaluation for internal injuries with spinal cord injuries taking as well as ground-glass opacities with injuries.1 as little as a few hours and up to a few thickening of interlobular septa and ü Ocular dysfunction should not be used years to present.9 Albeit rare, these long- bronchial walls. With high-voltage as an indicator of poor patient outcome.10 term effects have included amyotrophic electrical injuries, pulmonary embolism ü Cardiac insults should be considered lateral sclerosis and other demyelinating and infiltrates have been described.12-16 with low voltage electrical injuries.5

References available online June/July 2021 | EM Resident 19 TOXICOLOGY A Case of Excipient Lung Disease Pulmonary Manifestations Following IV Injection of Crushed Suboxone

Anthony Halupa, DO Geisinger Medical Center Case 38-year-old male presented A to the emergency department via ambulance with a 4-day history of worsening agitation, confusion, altered mental status, fever and cough. The patient’s wife reported seeing a text on the patient’s phone about possible recent intravenous injection of buprenorphine with naloxone. Upon arrival to the ED, the patient was afebrile (37.5°C) but extremely agitated. Initial vitals were notable for marked hypoxia (SpO2 74%) and tachycardia (140 bpm) with stable blood pressure (146/74 mmHg). On physical exam, the patient appeared to be a young, uncooperative man with diaphoresis, increased work of FIGURE 1. Axial cuts of computed tomography (CT) scan of patient’s chest breathing, and accessory muscle use. suggesting excipient lung disease. Dashed circles indicate centrilobular Track marks were noted on his bilateral periarteriolar micronodules that create a tree-in-bud pattern. Solid arrows show upper extremities. Due to worsening centrilobular micronodules in the lungs corresponding to perivascular granulomas, respiratory failure and agitation, the also often seen in excipient lung disease. patient was emergently intubated. A CT angiogram showed a distinct tree-in- well as shape/lubricate the tablet for altered mental status. Advanced cases bud pattern with findings of pulmonary easy swallowing. Common excipients may present as acute respiratory hypertension (Figure 1). The patient include talc, microcrystalline cellulose, disease syndrome (ARDS), panlobular received vancomycin, piperacillin/ crospovidone, and starch.2 When these emphysema, cor pulmonale, or tazobactam, and was admitted to the oral tablets are injected intravenously, acute pulmonary hypertension due intensive care unit. these excipients may cause varying to pulmonary arterial occlusion.4 In Discussion presentations of ELD. Patients with mild cases, the physical exam may Excipient lung disease (ELD) occurs ELD are at increased risk of acute and reveal only bibasilar end-inspiratory when foreign substance particles are chronic pulmonary complications such crackles. Patients presenting with more lodged into pulmonary arterioles and as pneumonia (10-fold increased risk), advanced disease may show evidence capillaries and trigger a potentially septic embolization, noncardiogenic of acute pulmonary hypertension, fatal reaction referred to as pulmonary pulmonary edema, foreign body including augmentation of the second foreign body granulomatosis.1,2 The exact granulomatosis, emphysema, interstitial heart sound, a right ventricular heave, pathophysiology of this lung disease is lung disease, pulmonary vascular and/or peripheral edema.4 Physicians based on the type of pulverized agent disease, pneumothorax, and increased should also look for secondary signs injected. Oral tablets contain excipients, incidence of fatal asthma exacerbation.3 of injection drug use such as needle which are insoluble particulate filler Patients with ELD may initially marks, cutaneous abscesses, and materials that bind and protect the present with nonspecific complaints hyperpigmented scars at the sites of active drug during production as such as dyspnea, cough, hypoxia with previous injections.5

20 EMRA | emra.org • emresident.org The initial evaluation of a patient be considered for further estimation positive for Streptococcus pneumonia with a history concerning for ELD of the pulmonary artery pressures and and MSSA bacteremia. Respiratory should include chest radiograph, to rule out concomitant endocarditis.8 PCR analysis was positive for Influenza continuous pulse oximetry and If a diagnosis is still unclear following A. A transthoracic echocardiogram arterial blood gas analysis. The CT imaging, a transbronchial biopsy was negative for valvular vegetations chest radiograph in ELD typically may be performed, with the specimens concerning for endocarditis but did shows widespread, small (2-3 mm) being sent for microbiologic culture and reveal biventricular heart failure. well-defined micronodules, often histopathologic examination.10 The patient was treated with 6 occurring in the midlung zones. Management of ELD oseltamivir for severe influenza and The typical CT findings include a prolonged course of antibiotics for The treatment of ELD is largely numerous centrilobular micronodules sepsis secondary to bacterial pneumonia. individualized and based on the severity in the lungs (Figure 1: solid arrows), The patient was eventually extubated of symptoms and degree of respiratory corresponding to perivascular on hospital day 10 without further impairment. In patients who do not granulomas. Although centrilobular complications. Repeat transthoracic present with acute respiratory distress, nodules typically reflect bronchiolar echocardiogram showed normalization supportive care measures may be disease, in the setting of excipient lung of biventricular function, and sufficient to improve symptoms that disease, they reflect embolic arteriolar subsequent thoracic CT showed interval can last from days to weeks. Following disease.7 Centrilobular periarteriolar improvement of the tree-in-bud pattern. resolution of the acute episode, periodic micronodules can also appear as a tree- The patient was discharged to his home reassessment with repeat chest imaging in-bud pattern (Figure 1: dashed circles), on hospital day 25 with outpatient and echocardiography is recommended further mimicking bronchiolar disease.7 referral for polysubstance abuse as secondary lung fibrosis and The “tree-in-bud pattern” described in rehabilitation. pulmonary hypertension may develop the case refers to small centrilobular Excipient lung disease can over months to years.8 nodules of soft tissue attenuation manifest from many different injected The use of systemic steroids in connected to multiple branching substances and can present with patients who develop granulomatosis linear structures of similar caliber clinical manifestations ranging from has limited supporting data and is that originate from a single stalk. (See asymptomatic to acute respiratory generally not recommended.11 Patients Table 1 for differential diagnosis of failure. Knowing and recognizing with intravenous drug use should also “tree-in-bud” pattern on CT imaging.) radiologic patterns, in conjunction be counselled on their habits, treated In addition to centrilobular nodules, with the patient’s history and physical for associated illnesses, and referred other CT findings such as enlargement of exam, will help emergency physicians the pulmonary arteries from pulmonary for outpatient counselling when and radiologists narrow the differential hypertension and other secondary appropriate. diagnosis and provide appropriate signs of right heart strain should raise The foreign body granulomatosis treatment. ¬ concern for excipient lung disease associated with ELD can lead to once pulmonary embolism and chronic increased long-term morbidity TAKE-HOME POINTS pulmonary hypertension have been because of the complications of • Include excipient lung disease (ELD) excluded.8,9 Echocardiography should angiothrombosis, pulmonary in the differential diagnosis when hypertension, severe emphysema, evaluating and treating a patient with TABLE 1. Differential Diagnosis of chronic hypoxia, and progressive a history of intravenous drug use Tree-In-Bud Pattern on CT Imaging3 interstitial lung disease.8 It is also presenting with respiratory failure and typical findings on chest imaging. Differential Diagnosis for “Tree-in-bud suggested that individuals who have • Patients with acute presentations of pattern” on CT imaging injected a higher number of crushed pills may have a worse prognosis.4 Lung ELD may also have superimposed Bronchioalveolar Infection transplantation has been performed bronchoalveolar infections, endocarditis, and acute pulmonary Congenital disorders (cystic fibrosis, in patients with advanced pulmonary hypertension; ED clinicians should Kartagener’s syndrome) hypertension secondary to foreign body keep these in mind when evaluating Idiopathic disorders (obliterative 12 granulomatosis. these patients. bronchiolitis, panbronchiolitis) Case Conclusion • Treatment for acute presentations ELD Aspiration pneumonitis Given the initial CT findings, the include airway/respiratory support Inhalation of foreign substances patient underwent an extensive work- as indicated and supportive care. Data on the use of steroids or other Immunologic disorders (allergic up for possible infectious causes. A interventions is limited. bronchopulmonary aspergillosis) bronchoscopy with bronchoalveolar • Physicians should consider a wide lavage was notable for Methicillin- Connective tissue disorders differential for patients with tree-in- sensitive Staphylococcus aureus Neoplasms bud pattern on CT. (Table 1) (MSSA) and blood cultures were

References available online June/July 2021 | EM Resident 21 CARDIOLOGY Shockingly Dangerous Hypokalemia Christopher Cardillo, DO a shock, leading to resolution of the TABLE 2. Potassium Repletion Plan2 PGY-3, Emergency Medicine ventricular tachycardia, and the patient KCI Dose, Geisinger Medical Center immediately became alert and oriented. maximum Fluids Route Ross Ellison, MD Ventricular tachycardia with subsequent 60 mEQ IL normal saline Peripheral Residency Core Faculty, Emergency Medicine ICD activation occurred several more 10 mEQ 100-200 cc Peripheral Geisinger Medical Center times over the next 30 minutes. normal saline Case 40 mEQ 100-200 cc Central Serial ECGs (Figures 1-3) showed in- normal saline 65-year-old female presented to the verted T-waves, wide QRS complexes, and A ED for evaluation of generalized prominent U-waves with frequent prema furosemide, several days of poor oral weakness and hyperglycemia following ture ventricular contractions. Point of care intake, diarrhea, and vomiting. The a syncopal episode. The patient was laboratory testing revealed: K 1.9 mmol/L, inpatient team discharged the patient 6 seated in a chair while visiting another Mg 2.4 mg/dL, glucose 440 mg/dL. days after admission with discontinuation patient in the hospital when she suddenly Intravenous potassium was started of hydrochlorothiazide and the addition of had a syncopal episode without reported immediately; she received 70 mEq total amlodipine for hypertension control. trauma. She denied experiencing any in the ED. An amiodarone bolus followed Clinical Manifestations associated chest pain or shortness of by infusion was also provided. The of Severe Hypokalemia breath. She reported nausea and vomiting patient continued to experience several Hypokalemia can be precipitated following the event, as well as malaise more episodes of unstable ventricular by a number of factors (Table 1). Severe and diarrhea in the days prior to the tachycardia and resolution with ICD hypokalemia can present similarly to event. She said her blood glucose had been activation. Emergent central access was hyperkalemia; therefore, a thorough history poorly controlled in the past week. She obtained via femoral central venous is paramount. When serum potassium denied any recent fevers or chills. catheter, and the patient was intubated levels fall below 2.5 mEq/L, patients may Her extensive medical history included without complications to ensure experience severe muscle weakness, muscle coronary artery disease, congestive heart airway protection during recurrent cramping, and even rhabdomyolysis failure with depressed ejection fraction defibrillation. Serial laboratory tests and myoglobinuria.1 If rhabdomyolysis and bi-ventricular implantable cardiac showed incremental improvement is present, intracellular potassium is defibrillator, diabetes, chronic kidney of hypokalemia, with appropriate released and may mask the severity of the disease, depression, and tobacco abuse. stabilization of the patient’s myocardial underlying overall hypokalemia. She had multiple prescribed medications, irritability and normalization of her ECG. Additionally, patients may experience notably including hydrochlorothiazide and This patient was admitted to the ICU and respiratory muscle weakness that may lead furosemide. extubated the next day. to respiratory failure, as well as vomiting Vitals on initial presentation were Cardiac electrophysiology was and diarrhea that will potentiate further unremarkable, and the patient was consulted for ICD interrogation and found potassium losses.2 afebrile. Other than appearing generally that the patient had 14 defibrillation As seen in this case, severe hypokalemia ill with intermittent non-bloody vomiting, events in total in the ED; 7 were triggered can result in life threatening cardiac the patient’s physical examination was by ventricular tachycardia and 7 were arrhythmias. Consider hypokalemia if unremarkable. ventricular fibrillation. Additionally, EKG findings include premature atrial During the initial evaluation, the electrophysiology noted the patient had an contractions, premature ventricular patient began having rigid, convulsive ICD discharge on each of the 2 days prior contractions, sinus bradycardia, body movements and became to her ED episode. atrioventricular blocks, ventricular unresponsive with snoring respirations. It was determined that the patient’s tachycardia, or ventricular fibrillation.3 Cardiac telemetry monitoring showed severe hypokalemia was likely There are several EKG manifestations ventricular tachycardia. The patient’s precipitated by a combination of factors: that are characteristic of hypokalemia. implanted cardiac defibrillator delivered the use of hydrochlorothiazide and Early EKG changes may include increased amplitude and width of P-waves, PR 1 TABLE 1. Common Hypokalemia Precipitants segment prolongation, T-wave flattening Renal Losses Nonrenal Losses Decreased Intake Intracellular Shift Endrocrine and inversion, ST segment depression, Diureitcs (hydrochloro Sweating Ethanol abuse Hyperventilation Cushing's prominent U waves in the lateral precordial thiazide, furosemide) disease leads. There may also be an “apparent” Steroids Diarrhea Malnutrition 60%-94% Insulin use long QT resulting from the fusion of the Metabolic acidosis Vomtitng T and U waves, termed “long QU”.3 Be Renal tubular acidosis Laxaitve use alert for concomitant hypomagnesemia in Diabetic ketoacidosis patients with hypokalemia. Patients with

22 EMRA | emra.org • emresident.org FIGURE 1. EKG on arrival. Note PVCs (pink arrows), wide QRS, long QT, and both hypokalemia and hypomagnesemia have developing U waves in the precordial leads (red arrows). Potassium 1.9 mmol/L. an increased risk of developing polymorphic ventricular tachycardia.2 Severe Hypokalemia Treatment The treatment of hypokalemia consists of several strategies that may be utilized depending on the chronicity and severity of the disturbance. The following treatments are intended for acute life-threatening hypokalemia when serum levels fall below 2.5mEq/L or if patients are symptomatic. In the setting of severe, life-threatening hypokalemia, IV potassium repletion should be initiated. Oral repletion may be considered as an adjunct if the patient can tolerate oral medications, however systemic absorption is slower. Potassium chloride (KCl) is the preferred FIGURE 2. EKG after beginning infusion of IV potassium chloride. Note choice for IV repletion as it has faster onset prominence of inverted T waves (blue arrows), long QT (green lines), U waves than potassium bicarbonate. KCl should be (red arrows) and resolution of PVCs. Potassium 2.9 mmol/L. administered in an isotonic saline solution without dextrose. The use of dextrose-containing fluids will prompt an insulin release, driving potassium into the cells resulting in further reduction of serum potassium levels.2 Patients with life-threatening hypokalemia secondary to GI losses, as in this case, should have potassium repleted between 10-40 mEq/hr.1 This can be accomplished in several ways (Table 2). It is important to be mindful of potential complications and risks associated with potassium infusions. Pain at the site of infusion and phlebitis occurs typically at rates > 10 mEq/ hr when run peripherally. When faster rates or higher doses are needed, central vascular access should be obtained. Infusing large amounts of potassium can FIGURE 3. Third EKG after infusing potassium chloride with amiodarone. Again inadvertently result in severe hyperkalemia. demonstrating a wide QRS, long QT, prominent but improving U waves (red Caution should be taken, especially in patients arrows). Potassium 3.0 mmol/L. with acute or chronic renal dysfunction. Normal serum potassium in the extracellular space is 50-70 mEq; rapid infusions of 40-60 mEq can result in serum concentrations that exceed safe levels. Therefore, close cardiac monitoring as well as serum potassium level checks every 2-4 hours are recommended. Repletion should be continued until serum potassium concentrations are consistently above 3-3.5 mEq/L and symptoms related to hypokalemia have resolved. At that time, dosing may be reduced, typically after the patient has already been admitted. Depending on the severity of hypokalemia, admission to a critical care service should be considered, especially if there is any indication of hemodynamic instability or if the patient will need close cardiac monitoring. ¬

References available online June/July 2021 | EM Resident 23 US, PEDIATRICS A Case Study of Juvenile Ovarian Cancer and the Importance of POCUS in the ED Joseph C. Smith, MD 190. Labs and vitals were otherwise prolonged hospital course and increased University of Tennessee Health Science Center unremarkable. Abdominal exam was time in the PICU. Also, an x-ray might not Author’s note: Author is father of the documented as “soft, no organomegaly, be sufficient imaging to implement in a patient. No other disclaimers. abdominal distention, bowel sounds case of abdominal distention, as it proved his case study describes the absent. Moderated diffuse tenderness to be ineffective in this case. Abdominal Tpresentation of an 8-month-old throughout.” A formal ultrasound was x-ray has sensitivity/specificity of 82/83% female who had been misdiagnosed with ordered to rule out intussusception. for small bowel obstruction3 and 84/72% constipation twice in the previous 36 This revealed a mass measuring 9.2 % for constipation.4 hours before being correctly diagnosed 7.5 % 6.3cm in the lower abdomen, It is a well-established practice to use with ovarian torsion and a tumor, likely arising from the left ovary, as well abdominal x-ray as an initial diagnostic identified as a Juvenile Granulosa Cell as a large amount of ascites (seen in test, but if this proves to be insufficient tumor. The overall incidence of granulosa Figure 1). This was confirmed with CT in providing a diagnosis, an ultrasound cell tumors varies from 0.4 to 1.7 cases (seen in Figure 2). The CT also suggested is a reasonable next step in workup. per 100,000 women.1 The juvenile form ovarian torsion. Ultimately, POCUS is fast and cheap of this tumor is even rarer, being only 5% and should be integrated into pediatric Management and Outcome of these cases. The incidence of ovarian emergency medicine training just as it has The patient was brought to torsion among females ages 1-20 years is in general EM training. Using POCUS in the operating room for diagnostic estimated to be 4.9 of 100,000.2 cases of abdominal distention could help laparoscopy and ovarian detorsion. The purpose of this case report is to prevent misdiagnosis. ¬ 400cc of bloody ascites show the importance of using appropriate were also drained. imaging before settling on a diagnosis. FIGURE 1. US of the ovarian mass during 2nd ED visit Three days later, an Case Presentation additional 800cc of An 8-month-old female with no bloody ascites were past medical history presents to the drained, and removal pediatrician with abdominal distention of the mass and ovary (noticed by parents as having tighter was performed. The clothes/diaper and visually large mass was identified as abdomen), fever up to 103°F, decreased a juvenile granulosa urinary output, and decreased activity. cell tumor, and the This physician diagnosed the patient patient was referred with constipation after ordering an to the local pediatric abdominal x-ray to look for stool burden. oncological hospital. This was read as normal. A few hours later, the symptoms worsened, so the Discussion patient was brought to a pediatric ED. No This case imaging was obtained. The patient was demonstrates the FIGURE 2. CT of the ovarian mass during the 2nd ED visit again diagnosed with constipation and importance of point discharged. The following day, the patient of care ultrasound in developed increased work of breathing, the ED. Because no livedo reticularis, and increased imaging was obtained abdominal distention. There had been during the first ED no urinary output for 24 hours. She visit, the patient had was brought to a different pediatrician to experience an who observed lack of bowel sounds. The additional 24 hours patient was then referred to a different of discomfort caused pediatric ED than the day before. by ovarian torsion At the ED, triage showed a secondary to the temperature of 39.9°C and RR 44. Initial mass. The delayed labs showed a WBC of 23.8, hemoglobin diagnosis could also of 9.4, platelet of 720, and CRP of have contributed to a

24 EMRA | emra.org • emresident.org PEDIATRICS, HEMATOLOGY, PAIN MANAGEMENT World Sickle Cell Day, June 19 Sickle Cell Disease Overview of Complications Seen in Pediatric Sickle Cell Disease Patients and How to Manage Them in the Emergency Department Heather Jones, DO the patient’s transfusion history and IV opioid is considered first line for APC Prisma Health Upstate baseline hemoglobin level will help guide pain management. NSAIDs should be Pediatric Resident clinical decision making.2 used in conjunction with opioid therapy. Zachary Burroughs, MD The use of APC patient-management Prisma Health Upstate Of note, patients with SCD PEARL. protocols are recommended to give a Pediatric Emergency Medicine Physician (hemoglobin SS disease much standardized approach for providers in less common HbSβ0-thalassemia) Epidemiology and the same hospital system.2 Studies show typically present earlier and with FIGURE 1. US of the ovarian mass during 2nd ED visit Pathophysiology the protocols decrease time to delivery of more severe symptoms.1 It is estimated there are around pain medication, decrease frequency of ED 100,000 individuals living in the United Clinical Cases to Highlight visits, result in fewer hospital days, and States with sickle cell disease (SCD). The Complications of SCD Pain increase utilization of patients’ primary majority are of African ancestry with a 4 A 16-year-old male presents to the provider for follow-up services. minority being Hispanic, Middle Eastern, ED for acute pain crisis. He has a Pain management strategies or Asian Indian descent. In addition, there history of Hemoglobin SS disease. that need further investigation are estimated to be 3.5 million people in He is on hydroxyurea for suppression Akinsola et al. found that use of the U.S. who are heterozygous carriers.1 therapy. He reports his current home intranasal fentanyl decreased the time to Patients with SCD predominantly pain regimen of first line ibuprofen first parenteral opioid in the emergency have sickle hemoglobin present in their and second line oxycodone have not department, but overall did not show red blood cells because of the amino acid controlled his current pain episode. significant decrease in overall pain scores substitution of valine for glutamic acid at He typically has severe bilateral lower or admission rates. The investigators th the 6 position on the beta-globin chain. extremity pain with his previous crises. concluded intranasal fentanyl may be This substitution causes the red blood Today he is presenting for similar a useful temporizing measure for pain FIGURE 2. CT of the ovarian mass during the 2nd ED visit cells to develop a sickle shape and become symptoms. control until IV access can be established.5 inflexible in deoxygenated conditions, Acute pain crisis (APC) is pain caused Things to avoid: The use of leading to increased blood viscosity as by vaso-occlusion and can involve any supplemental oxygen is not recommended well as abnormal interactions with other body system. Fever and leukocytosis unless oxygen saturations are less than cells in systemic circulation. Patients with frequently occur with APC and warrant 92%.2 Euvolemia should be maintained. sickle cell disease are predisposed to a an infectious investigation if present, The use of normal saline boluses has 1 variety of complications. given SCD patients’ high susceptibility to not been shown to reduce pain scores or Things to ask every patient pathogens. admission rates.6 Excessive hydration with sickle cell disease Established pain protocols can lead to atelectasis, hyperchloremic Any patient with a history of SCD The National Heart, Lung and Blood metabolic acidosis and pulmonary edema.2 should be asked what their typical pain Institute (NHLBI) have established Ketamine infusions are currently being crisis looks like and how their current guidelines for the management of APC. utilized and investigated as a pain control pain varies. When obtaining a review They recommend initiation of analgesia option. Hagedorn et al performed a of systems, it is important to ask if the within 60 minutes of registration or 30 literature review which showed ketamine patient has recently had a fever. Knowing minutes of triage to the ED.4 The use of was useful in reducing pain scores, but

June/July 2021 | EM Resident 25 PEDIATRICS, HEMATOLOGY, PAIN MANAGEMENT

not enough data is currently available for PEARL. Urine culture should be NEUROLOGIC 7 specific clinical recommendations. obtained in any febrile pediatric A 16-year-old female with history of Discharge can be considered if pain is patient with SCD complaining of hemoglobin SS disease presents with adequately controlled. Patients should be urinary symptoms.3 new onset slurred speech and right sided discharged home with an oral equivalent weakness. She was in her normal state Fever in children over 5 years: of the IV pain regimen provided while of health until she started experiencing in the ED. If adequate pain control Any child presenting with a fever of 101.3 these symptoms at school earlier today. cannot be achieved the patient should be ⁰ F warrants prompt evaluation to include EMS was called and she was transported admitted for further management.2 history and physical, CBC and blood to your department. She has no recent culture. If urinary symptoms are present history of head trauma and is non-toxic FEVER a urine culture should also be obtained. A 2-year-old female with history of on exam. Vital signs are within normal Most patients with SCD who lack high risk limits. Physical exam exhibits an aphasic hemoglobin SS disease presents with criteria can be managed as an outpatient teenager who is cooperative but anxious fever of 102⁰F at home. Family has after administration of IV ceftriaxone. on exam. She has 3/5 strength in her been intermittently compliant with home Patients are considered high risk if: white upper and lower right extremities. Normal penicillin prophylaxis. Family reports blood cell could greater than 30,000 or strength on the left. Cranial nerves are no recent cough, congestion, or other less than 5,000, fever is greater than or grossly intact, she has no ataxia or URI symptoms, and no sick contacts. equal to103.1⁰ F or they are ill-appearing.3 abnormal cerebellar testing. Her blood Toddler is non-toxic on exam with no glucose is 70 by POC glucometer. focal findings. Any SCD patient presenting PEARL. Stroke: Stroke and silent cerebral Fever in infants < 60 days: with a fever ≥ 103.1⁰ F who are infarcts are the most common permanent Proceed to complete full work-up per ill-appearing warrant hospital sequelae of SCD in children and adults. institutional guidelines. Use of Rochester 1 admission with IV antibiotics. Acute stroke evaluation should be criteria or home institution algorithm can PULMONARY considered in any SCD patient presenting help guide limited workup with discharge with severe headache, altered level of versus full workup with antibiotics and A 6-year-old male with history of SCD presents with fever, cough and consciousness, seizures, speech problems, admission. All infants under 29 days of and/or paralysis. A neurology consult age warrant a CBC, CMP, CRP (or other difficulty breathing. He is tachypneic with course breath sounds on exam. should be obtained as well as head CT and inflammatory marker), blood culture, UA MRI as well as MRA when available.3 ASH with urine culture and lumbar puncture. Acute chest syndrome (ACS) has a classic triad of fever, hypoxia, and a guidelines recommend blood transfusion to Providers should consider viral testing new infiltrate on chest x-ray. Any SCD achieve a hemoglobin of 10 g/dL or exchange (to include HSV) and CXR on a case-by- patient presenting with respiratory transfusion in any child with SCD presenting 8 case basis. symptoms accompanied by chest pain with acute neurological deficits including PEARL. The NHLBI recommend and are hypoxic should alert the provider TIA. The decision to transfuse should not oral penicillin prophylaxis until 5 to consider ACS in the differential solely rely on MRI results but the entire diagnosis. Children with SCD can also 11 years of age in all children with clinical picture. have pulmonary acute pain crisis. In hemoglobin SS disease.3 Subarachnoid hemorrhage: pulmonary APC children present with Children with SCD are at increased risk a constellation of chest pain, fever, and Fever in infants > 60 days for cerebral aneurysms which can rupture shortness of breath like that seen in ACS through 5 years: Children under and result in subarachnoid hemorrhage. but do not have an infiltrate on CXR age 5 with SCD should be on daily Aneurysms are more commonly found in prophylactic penicillin. Compliance and are not hypoxic. Pain should be managed aggressively in these patients posterior or vestibular circulation when with this regimen should be since splitting can lead to atelectasis and compared to the general population. This elicited during the H&P to help risk pneumonia. Patients diagnosed with ACS diagnosis should be considered in any stratify these children. Vaccination should be admitted for close monitoring patient presenting with sudden severe history is also an important and symptom management. Antibiotics headache, nausea, vomiting, symptoms of component since these children for community acquired pneumonia meningeal irritation, photophobia or other are at increased risk for bacterial should be started and aggressive visual changes, behavior changes or loss of 10 infections. Given their increased pulmonary toilet should be utilized.2 consciousness. If neurosurgical intervention risk for Streptococcus pneumoniae is required, it is recommended to give a PEARL. SCD patients presenting infections along with Haemophilus blood transfusion to prevent anesthesia with chest pain, hypoxia and influenzae, Neisseria meningitides, complications.10 and Salmonellae infections, all children respiratory distress who lack fever under 5 with hemoglobin SS disease or specific chest x-ray findings PEARL. Consider cerebral venous should receive antibiotics that cover should warrant consideration of sinus thrombosis in symptomatic pneumococcus such as ceftriaxone obtaining a CT to evaluate for patient with SCD and negative 10 12 (50-75 mg/kg/dose every 24 hours).9,13 pulmonary embolism. neuroimaging.

26 EMRA | emra.org • emresident.org OPHTHALMOLOGIC also at increased risk of pica which in Urology consultation is recommended for 2 A 15-year-old male presents with rare instance can lead to ingestion of providers unfamiliar with this procedure. decreased vision in his right eye. Exam nonfood items that accumulate and cause Sickle cell nephropathy and renal 14 reveals fluid in the anterior chamber; the a bezoar. In addition to a thorough infarct: Presentation depends on the right eye is injected and actively tearing. history and physical exam initial studies part of the kidney affected. If the renal He reports significant pain and says he should include a CBC, liver function medulla is involved the patient will present was in a fight at school. test, coagulation studies. Further with flank pain and costovertebral angle 2 Acute glaucoma after eye injury: evaluation with imaging should include tenderness on exam. If there is papillary 2 Patients who sustain direct or blunt an ultrasound or CT. Children with SCD necrosis the patient will present with 14 force trauma to the eye orbit are at are at increased risk of gallbladder and painful gross or microscopic hematuria. risk of hyphema. The accumulation of hepatic pathologies due to the increased Either presentation can result in renal blood in the anterior chamber allows for hemolysis leading to the formation dysfunction which should be managed with sickling and the blockage of trabecular of pigmented gallstones and hepatic IVF hydration. Serial examination of renal 2 meshwork, which can lead to acute closed congestion. Complications: function is recommended. angle glaucoma. Patients present with a Acute intrahepatic cholestasis: HEMATOLOGIC painful red eye and blood may be seen on Sickled red blood cells can cause vascular A 3-year-old female with history of inspection or with slit lamp exam. Consult stasis in the hepatic sinusoids. Patients can hemoglobin SS disease presents Ophthalmology immediately. present with isolated hyperbilirubinemia, for pallor, difficulty breathing, and Central Retinal artery occlusion: RUQ pain with or without other liver fatigue. Per family, the patient had not Presents with sudden painless vision loss function derangements. Renal failure and appeared ill but woke up looking pale, in one or both eyes. No specific therapy coagulopathies can be present. Consider uninterested in playing, and wanting to has been characterized for management, consulting Hematology for possible rest while appearing to breathe harder 2 but goal should be to optimize oxygen exchange transfusion. than usual. Exam reveals palpable delivery and blood flow to prevent Acute sickle hepatic crisis: spleen 5 cm below the costal margin; further ischemia while obtaining an Patients present like cholecystitis to she is tachycardic and tachypneic. ophthalmology consult. Most individuals include RUQ pain, fever, leukocytosis Splenic sequestration: A drop affected by this will only have partial if and transaminitis in addition to in hemoglobin ≥ 2g/dL below baseline any vision recovery.10 hepatomegaly. Management is and acute increase in spleen size with Orbital wall infarct: Typically, a conservative with pain control and elevated reticulocyte count. Patients 2 younger patient, due to increased marrow possible blood transfusion. report abdominal pain and/or fullness, space in facial bones, will present with eye Acute hepatic sequestration can occur pallor, and lethargy. Exam can show pain, periorbital edema, proptosis, visual with acute sickle hepatic crisis. Includes splenomegaly, tachycardia, and other signs acuity changes, fever and/or headache. the symptomatology mentioned as well of hypovolemic shock.. Treatment is with Symptoms overlap with periorbital or as an acute drop in hemoglobin and blood transfusion.14 orbital cellulitis and orbital abscess. hematocrit with a reticulocytotic. Consult Aplastic crisis: Infection with Imaging includes CT or MRI. Treatment Hematology for simple versus exchange parvovirus B19 can induce transient red is supportive with IV hydration and pain transfusion.2 cell aplasia. Due to the shortened lifespan control and ophthalmology consultation.10 GENITOURINARY of red blood cells in SCD patients they are GASTROINTESTINAL An 8-year-old male with history of SCD at increased risk for significant drops in A 10-year-old male with SCD presents presents for an erection lasting greater hemoglobin. Patients can present with a with new onset RUQ pain. He has had than 4 hours. viral syndrome of gradual onset of pallor, nausea and non-bilious, non-bloody Priapism: Ischemic priapism is fatigue, and headache. In extreme cases emesis but no diarrhea or urinary the most common form of priapism patients may present in hypovolemic symptoms. He is tender to palpation in encountered in SCD patients. It is due shock. This clinical presentation can be RUQ without rebound or guarding. to the low flow or venous occlusion. differentiated from splenic sequestration Children with SCD can have any of Patients present with rigid, painful corpus with normal spleen size and low the common etiologies of abdominal cavernosa. Ischemic priapism is a medical reticulocyte count. Treatment is slow 10 pain such as constipation, reflux, or emergency and can be distinguished blood transfusion. acute gastroenteritis but they also are from non-ischemic priapism with a Summary at risk for multiple other abdominal corpus cavernosum venous blood gas. Patients with SCD presenting to the pathologies. In the setting of new onset The blood gas typical shows an acidosis ED are at risk for unique complications but abdominal pain, the clinician must with pH < 7.25, PO2 < 30 and PCO2 can also have garden-variety diagnoses. It consider: cholelithiasis, cholecystitis, of > 60. Treatment involves needle is important for the clinician to take into acute intrahepatic cholestasis, acute aspiration of blood from the cavernosa consideration the entire clinical picture sickle hepatic crisis and acute hepatic followed by intercavernosal injection of a and obtain appropriate diagnostics based sequestration.2 Children with SCD are sympathomimetic such as phenylephrine. on recommended practice guidelines. ¬

References available online June/July 2021 | EM Resident 27 PEDIATRICS BE WARY OF THE BRUISE

Don’t Forget the Full-Body Exam

Justin Hanson, DO circumferentially around the left arm, to investigate each week. In the same PGY-2, Emergency Medicine and an abrasion to the inferior gum line. period this year, that number fell to 672, Grand Strand Medical Center Her lungs were clear to auscultation a decline of 51 percent.”1 With the added Myrtle Beach, South Carolina bilaterally with no tachypnea or physical and mental stress of a pandemic ou are in the emergency department retractions. What would you do if this affecting parents all over the U.S., it is Yand a 1-month old female presents patient presented to your ED? interesting to note that we have not seen with her father for dyspnea. According Between the overflow of patients an increase in reported abuse and neglect. to the father, she was being removed recently, the ED has been in chaos Has abuse really diminished? Or does the from the bath the night before when she recently. The combination of social decrease in pediatric presentations mean slipped out of his hands, hitting her face distancing, abundant precaution, and fewer children are receiving medical care on the nearby counter. He was able to fear of Covid-19 have contributed to and appropriately indicated work-ups? grab her by the arm before she hit the a drop in our pediatric census. In a Before the pandemic it was estimated that ground. When asked why he did not recent New York Times article, author between 2-10% of children visiting the ED seek medical care, he stated “I thought Nikita Stewart reported, “In the first were victims of child abuse or neglect.2 In she was fine.” Physical exam showed an eight weeks of spring 2019, New York the coming months and year we must be abrasion to the bridge of the nose with City’s child welfare agency received an on the lookout for these patients and have underlying ecchymosis, ecchymosis average of 1,374 cases of abuse or neglect a high index of suspicion for child abuse.

28 EMRA | emra.org • emresident.org As emergency medicine resident Patient Age Your judgement alone is not a reliable physicians, we must be vigilant for these Those that don’t cruise rarely enough way to determine whether a patients. A study of 44 children who died bruise.5 One study on prevalence of bruise is younger than 24 hours old. of child abuse showed that 20% of them bruising in infants in the pediatric Is non-accidental trauma the were evaluated by a physician within ED found a significant difference in only cause of bruising? Of course not. a month prior to their death. It was bruise rates for infants younger than Patients with concerning bruising determined that 71% of those evaluations 5 months old compared to those older should be admitted to the hospital for were in an ED.2 At times we are the only than 5 months old. The prevalence a full workup, including further testing medical care these high-risk patients of bruising for infants 5 months and for other causes of bruising such as receive and possibly their only chance bleeding diatheses, coagulopathy, for intervention. How, then, do we get younger, in comparison to those older than 5 months, was 1.3% to 6.4%.6 infection, thrombocytopenia, and better? other etiologies. We must not be The most important part of these Infants younger than 5 months old afraid to advocate for children and evaluations is the physical exam. should not present to your ED with report possible child abuse. A bruising Although the caretaker can be dishonest, bruising. As soon as the child starts prevalence study conducted in three your physical exam is an objective to crawl or walk, bruising will become pediatric EDs found that only 23% of measure of truth. In a study with 200 more common. These bruises should pediatric patients found with bruising infants who had experienced confirmed not be located in the aforementioned (88/2344) had an abuse evaluation. severe abuse, 55 (27.5%) had a sentinel locations. According to the injury before the author this was episode of severe TEN 4 FACES P decision rule:4 any bruises present in any of abuse. Of the 55, 80% far fewer than the following locations should be concerning for child abuse. 6 had bruising and 11% expected. Although had intraoral injury, a bruise increased T Torso including genitals often bruising to their the threshold for E Ears frenulum.3 All children evaluation, it was N Neck under one year of age, not enough. Most Any bruising in regardless of chief 4 children with a child less than 4 complaint, should suspicious bruising months of age be placed in a gown should be reported to F Frenulum to facilitate a full- the proper authorities (bruising from forcing body exam. This is an and evaluated for a bottle into a further injury. It is easy way to facilitate child’s mouth) more thorough A Angle of the mandible more acceptable to examinations in a C Cheek report child abuse chaotic emergency E Eyelid and be wrong than it department. Bruising S Subconjunctival hemorrhage is to not report and should be used as a risk a child dying or screening tool for child P Patterned bruising sustaining serious abuse, and careful injuries from child attention should be abuse. paid to location of the In the case bruise, age of the child, and distribution Patterned Bruising mentioned at the beginning of this of ecchymosis. The TEN 4 FACES P Patterned bruising should always be article, the patient was admitted for decision rule can be a useful clinical aide concerning. Hand imprints are common, further evaluation and found to have when suspecting abuse. as are the imprints of objects like belts, multiple new and healing rib fractures, 7 Location cords, shoes, and kitchen utensils. Look retinal hemorrhages, and a subdural for bruising that is consistent with the Bruises that were predictive of abuse hemorrhage. All findings were consistent items mentioned above. were located on the torso, ear, or neck with non-accidental trauma. Although of a child younger than 4 years of age. Bruise Age with younger children illness and injury Bruising in any region on an infant What if the bruise looks old? In a is not always obvious, we must stay younger than 4 months of age was also study of fifty children with accidental vigilant of the bruise, and keep non- predictive. The sensitivity of this decision bruises, EM pediatricians accurately accidental trauma on our minds and in rule was 97% and the specificity was 84% estimated bruise age (within 24 hours our differential. If you do not look for it, for predicting abuse.4 of the actual age) 47.6% of the time.8 you will never find it. ¬

References available online June/July 2021 | EM Resident 29 TRAUMA ONE BAD HAND OF POKER Shawn Tuttle, MD repair have phonation difficulties post-op. Hospital of the University of Pennsylvania Nonsurgical management options Joshua Glick, MD include elevation of the head of the bed Hospital of the University of Pennsylvania @JoshGlickMD to reduce edema and manage secretions, 77-year-old man presented to the voice rest, cool humidified air to improve Aemergency department after being ciliary management of secretions, steroids punched in the throat over a dispute for reduction of edema, and proton involving a card game. He reported pump inhibitors to reduce laryngeal immediate odynophagia, abnormal inflammation from acid reflux. Antibiotics phonation, and small volume hemoptysis, may also be used as prophylaxis. but had no difficulty breathing. The most common cause of blunt neck Physical exam was notable for trauma is motor vehicle accidents. Many anterior neck pain over the thyroid of these accidents involve collision of the cartilage with palpable crepitus. Bedside FIGURE 1. Iberoptic NPL demonstra patient’s neck against the steering wheel nasopharyngolaryngoscopy (NPL) was ting significant supraglottic edema or windshield. Other possibilities include performed (Figure 1), followed by a and hooding of the false vocal cords sports accidents such as clothesline (black arrow). computed tomography (CT) of the neck tackles. History and physical exam will typically reveal the symptoms seen in our with intravenous contrast (Figure 2), airway. Blind intubation should never be patient, but can also involve respiratory confirming the diagnosis. attempted due to the high risk of creating distress, an expanding hematoma, edema, a false passage. Diagnosis ecchymosis, or distorted anatomical Tracheal cartilage fracture with Surgical consultation should be landmarks. Adult thyroid and cricoid airway edema obtained if the injury is severe enough to cartilages will typically fracture in multiple Discussion cause disruption of basic functions such places due to ossification, whereas in Tracheobronchial injury (TBI) is a as swallowing or phonation. Surgical children, they tend to fracture in one place. rare, but potentially life-threatening, options include observation, plating In children younger than age 3, the cricoid complication of neck trauma. It represents of fractures, or stenting of the airway. cartilage sits higher at C4, versus at C7 in 1 in 30,000 ED visits per year. Fracture of Displaced fractures will typically require most adults. the tracheal cartilage is most commonly open reduction in the operating room; The neck is divided into 3 anatomic the result of direct anterior blunt trauma, 21% of patients who undergo surgical zones, with zone 1 being sternal notch and can result in significant airway edema, tracheal laceration, hemoptysis, Schaefer Classification System of Laryngeal Injury pneumothorax, and disruption of adjacent Group Injury Treatment Comments vascular structures. Cricoid cartilage 0 Normal None fracture is associated with recurrent 1 Mild hematoma or laceration Observation, laryngeal nerve damage. NPL may without fracture humidified air, medical demonstrate airway edema or bleeding. management If the patient is stable, CT with contrast 2 Moderate edema, hematoma, Tracheostomy, Serial examinations due should be obtained to evaluate for mucosal disruption without direct laryngoscopy, to frequent worsening significant tracheobronchial and vascular exposed cartilage, non- esophagoscopy over time. Usually do not injuries in symptomatic patients following displaced fractures require tracheostomy anterior neck trauma. Patients with 3 Major edema or lacerations, Tracheostomy, Usually requires surgical tracheobronchial trauma have a high risk of exposed cartilage, displaced exploration/repair repair. other injury, especially with motor vehicle fractures, or vocal cord immobility accidents, so imaging for C-spine injury and 4 Group 3 and disruption of Tracheostomy, Require tracheostomy skull fractures should be obtained. anterior larynx, unstable exploration/repair, and stenting to maintain Early intubation with a fiberoptic fractures, two or more fracture stent required larynx. scope, to ensure placement of the cuff lines, or severe mucosal injuries distal to the site of injury, should be 5 Complete laryngotracheal Surgical repair Require an airway considered given the risk of progressive separation emergently placed airway edema. An emergency directly into the trachea cricothyroidotomy may also be necessary through the neck below depending on the degree of trauma to the the injury

30 EMRA | emra.org • emresident.org to cricoid cartilage, zone 2 being cricoid cartilage to the angle of the mandible, and zone 3 being above the angle of the mandible. Hard signs of vascular injury, including expanding hematoma, bruit or thrill, or cerebral ischemia require immediate surgical consultation. In a stable patient such as ours with soft signs of injury (hemoptysis, dysphagia, dysphonia, subcutaneous air, and crepitus) a computed tomography angiogram is indicated. Aerodigestive injuries can be very difficult to identify on initial presentation but should be pursued if clinically indicated (dysphagia, blood in gastric contents, or crepitus). These patients will typically require endoscopy or barium swallow to identify injuries. Antibiotics FIGURE 2. CT of the neck demonstrating tracheal cartilage fracture (white arrow) might also be indicated if suspected due and mild anterior subcutaneous emphysema (white star). to gastric contents. Case Conclusion emphysema indicating an injury to uneventful follow-up. He regained normal In our patient, bedside NPL the trachea. The patient was given phonation and swallowing function demonstrated significant supraglottic dexamethasone and admitted to an ICU several weeks after discharge. It is edema and hooding of the false vocal for airway monitoring and serial NPL unclear if he ever played cards again with cords. CT confirmed tracheal cartilage examinations. His swelling improved the same group that caused him to spend fracture, with evidence of subcutaneous after 2 days, and he was discharged with a night in the intensive care unit. ¬

The best prep for ITE and certification exam success

NEW PEERprep For Physicians is what you need when it’s time to get serious about your boards. Challenging, high-quality questions—more added continually Closer to the actual boards than any other prep product today Sign up at acep.org/peerprep

Approved for AMA PRA Category 1 Credits™

References available online June/July 2021 | EM Resident 31 INFECTIOUS DISEASE Sick as a Dog A Case of Overwhelming Post-splenectomy Infection

Ashley Rider, MD confused about the date but had no focal cause of severe sepsis. Arterial vasculature Clinical Instructor, Simulation Fellow neurologic deficits and was answering was patent, portal vein and SMV showed Stanford Department of Emergency Medicine questions. Her extremity exam showed no chronic thrombus seen on imaging 10 Tsuyoshi Mitarai, MD peripheral edema. Her skin was noted to years prior. Non-contrast CT of the head Clinical Associate Professor was unremarkable. The patient developed Stanford Department of Emergency Medicine be pale with delayed capillary refill of >3 seconds. Petechia and early purpura were worsening respiratory distress and Jennifer Wilson, MD, MS Clinical Associate Professor noted on her back. confusion, ultimately requiring intubation Stanford Department of Emergency Medicine What is your working differential while still boarding in the emergency Case diagnosis? How would you treat department. Within 6 hours of arrival, aerobic 57-year-old woman with a history this patient? blood cultures grew Capnocytophaga of antiphospholipid syndrome, ITP, Workup A canimorsus. emphysema, and recurrent mesenteric An initial point-of-care blood glucose vein thrombosis status-post bowel demonstrated critical hypoglycemia to 25 Case Discussion resections and splenectomy presented mg/dL. iSTAT lactate was elevated at 10.8 Background to the emergency department with mmol/L. Venous blood gas showed a pH The patient described in this case fever, chills, and vomiting for 1 day. 7.25, pCO2 31.7 mmHg, PO2 12 mmHg, developed overwhelming post-splenec- The patient reported multiple episodes HCO3 14 mmol/L, and Base Excess of tomy infection (OPSI) with septic shock of non-bilious non-bloody emesis over -13. Laboratory studies returned with an and multi-organ failure due to Capno- the prior 24 hours without abdominal abnormal CBC including WBC 3.1 K/uL, cytophaga canimorsus bacteremia. This pain. She had several loose stools, but Hb 12.1 g/dL, platelets 28 K/uL, which gram-negative bacterium is commonly no melena or hematochezia. She denied also showed Howell-Jolly bodies and isolated from the oral microbiota of dogs cough, shortness of breath, chest pain, many intracellular bacteria. Chemistry and less commonly in cats.1 There are 7 sore throat, neck pain, or headache. Over resulted with a sodium of 138 mmol/L, species of Capnocytophaga, all of which the day prior to presentation, she had potassium 6.4 mmol/L, chloride 98 can be found in the oral cavity of both hu- become increasingly weak and confused, mmol/L, CO2 10 mmol/L, urea nitrogen mans and domestic animals. It is estimat- prompting her partner to bring her in 56 mg/dL, creatinine 2.87 mg/dL, anion ed that somewhere between 8% and 41% 1,2 to the ED for evaluation. She reported gap of 30, calcium of 9.8 mg/dL, bilirubin of canines have a colonized oropharynx. no recent travel or sick contacts, no 0.6 mg/dL, AST 116 U/L, ALT 56 U/L, alk Capnocytophaga canimorsus infections toxic ingestions or substance abuse, and phos 66 U/L, albumin 4.0 g/dL, protein in humans are most commonly associat- multiple pets in her home. 7.0 g/dL. Prothrombin time was 25.4 ed with dog and cat bites, and to a lesser 3 Her triage vital signs were BP seconds, INR 2.3, partial thromboplastin extent, scratches and licking. The first 123/100, HR 136, RR 24, temperature time 201.2 seconds, D-dimer was 7,695 human infection was described in 1976, 97.5°F, and oxygen saturation 100% ng/mL FEU, and fibrinogen 400mg/dL. and there are very few documented cases 4,5 on room air. On physical exam she Influenza PCR was negative. each year. was ill-appearing. HEENT exam was With dextrose administration glucose Clinical Presentation unremarkable. Cardiovascular exam improved to 236. Blood gas in the A patient with a remote splenectomy was significant for tachycardia with a subsequent 2 hours worsened to 7.20/ may not recognize initial symptoms of regular rhythm. She was tachypneic but CO2 35/O2 17, HCO3 13.9/ BE -14, with a infection, and may be unaware of how had an otherwise normal pulmonary mild improvement in lactate to 9.03 after quickly infections can become fulminant. exam. Abdominal exam was non-tender volume resuscitation and antibiotics. Chest In addition, they may not associate a throughout, but did reveal multiple healed x-ray did not reveal a source of infection. canine bite or other common exposures scars from prior surgeries. She was CT of the abdomen did not show any acute with symptoms of infection, so a careful

32 EMRA | emra.org • emresident.org history is essential in all ill-appearing careful history, asking the patient about erythromycin, doxycycline, and splenectomy patients. In the case of C. any exposure to animals or recent bite metronidazole.1,15 It is unlikely that a canimorsus infection, symptom onset wounds. diagnosis will be confirmed during the typically occurs within 5 days of bite, and The spleen is responsible for phago- ED stay, and thus for severe infections hospitalization occurs on average at 7 cytosis of bacteria and production of broad-spectrum antibiotics should be days after exposure.1,6 The infection may antibodies. Asplenic patients are at administered while the differential present in a variety of ways, from local- risk for serious infection from not only remains open. Non-severe infections may ized skin and soft tissue infection to sys- encapsulated bacteria, but also other instead by treated with oral amoxicillin- temic symptoms of septicemia.1 In those pathogens like C. canimorsus.10 Patients clavulanate or clindamycin. For who develop sepsis, the most common may develop OPSI which is characterized confirmed cases, duration of treatment symptoms are fever (78%), chills (46%), by initial vague symptoms (fever, malaise, ranges from 14-21 days.6 vomiting (31%), diarrhea (26%), abdomi- headache, vomiting, diarrhea) followed Finally, in order to prevent life-threat- nal pain (26%), dyspnea (23%), confusion by septic shock with disseminated intra- ening infection from C. canimorsus and (23%) and headache (18%).7 vascular coagulation and mortality of 50 other bacteria, prophylactic antibiotics Sepsis due to C. canimorsus can be to 80%, even with appropriate antibiotics. (usually amoxicillin-clavulanate) should devastating, with mortality rates estimat- Mortality can be reduced by if patients be given to asplenic individuals who have ed to be 30%.5 It is essential that bacte- seek medical care and are treated imme- been bitten by a dog, even in the absence remia is considered early and antibiotics diately, which is why early recognition in of infectious symptoms.1,5 Currently that treat C. canimorsus are administered the ED is essential.11 there is not clear utility on the testing of promptly. The rapid progression of dis- The ED work up should include a canines, since it does not guarantee that ease suggests that the organism may be complete blood count, chemistry, lactate, particular dog will stay infection-free. able to evade the immune system.1 While and blood cultures. Peripheral blood Furthermore, isolation from canine saliva it is possible for severe sepsis to occur in smear examination may demonstrate or bite wounds is challenging.1 immunocompetent individuals, in 33% extracellular and phagocytosed bacilli.12 Case Conclusion of cases there is a history of splenectomy, Blood cultures often confirm the diag- Patient was admitted to the MICU 13 which is also associated with a higher risk nosis of C. canimorsus (88% of cases). for septic shock due to Capnocytophaga 1,8,9 of death. Besides splenectomy, other However, because blood cultures may not canimorsus bacteremia. Her course risk factors for severe disease include become positive during the ED stay, it is was complicated by anuric renal failure 5 immunosuppression and alcohol abuse. essential for the EM physician to have a with severe metabolic acidosis requiring In the case of this patient, fever, high index of suspicion for bacteremia in initiation of CRRT. Hemodynamics vomiting, and confusion were the primary a patient presenting with sepsis. If there continued to worsen, and within hours symptoms, although she was afebrile is a concern for meningitis, a lumbar the patient progressed to PEA arrests upon presentation. She had three SIRS puncture should be performed to obtain and ultimately passed away despite criteria and a qSOFA score of 2, which cerebrospinal fluid (CSF). The cerebro- maximal support. ¬ initiated work up and treatment for sep- spinal fluid culture may take an extend- sis. Her confusion, tachypnea, purpura, ed period of time to become positive TAKE-HOME POINTS and extremely high lactic acid were (median of 5 days, with a range of 1-19) • All post-splenectomy patients who present all ominous signs of a life-threatening so it is important to continue culture with fever or other signs of sepsis should infection. On review of the patient’s chart, growth beyond five days.14 Antibiotics be treated with broad-spectrum antibiotics she had a remote history of splenectomy should be given based on clinical concern while work-up is pending, as infections may which predisposed her to infection with and the physician should not wait for a become rapidly fulminate (overwhelming post-splenectomy infection). encapsulated bacteria, intraerythrocytic clear source of infection to be identified in • Although it is rare, it is important to parasites, and gram-negative bacteremia laboratory work up, cultures or CSF. recognize C. canimorsus sepsis, as it is 10 such as C. canimorsus. While there was The patient should be given a associated with high mortality rate and the no specific history of animal bite, her broad-spectrum antibiotic that covers C. patient can deteriorate rapidly. exposure to pets may have put her at risk canimorsus while awaiting susceptibility • C. canimorsus bacteremia results from for this infection. testing. For the initial treatment of severe bites, scratches, and licking by dogs and cats among patients at risk, such as those infections, empiric antibiotics should ED Management with splenectomy, history of alcohol abuse, The first step in ED management is include a carbapenem or a beta-lactam or immunosuppression. consideration of life-threatening infection beta lactamase combination such as • Gram negative rods may be seen in and atypical pathogens in a patient with pipercillin-tazobactam, though the the blood smear for patients with C. a history of splenectomy who presents bacterium may end up being susceptible canimorsus bacteremia. with sepsis or septic shock.1 C. cani- to a variety of other antimicrobials • For severe cases, preferred antibiotics to morsus is one of the pathogens which such as penicillin G, linezolid, treat C. canimorsus include carbapenems or a beta-lactam beta lactamase may be considered in such patients, and chloramphenicol, third generation combination. the emergency physician should take a cephalosporins, fluoroquinolones,

References available online June/July 2021 | EM Resident 33 PAIN MANAGEMENT EM Use of Sphenopalatine Ganglion Block for Migraine Headaches Tickle Your Brain to Numb the Pain Luke Wohlford, MS4 medications. However, triptans and receptors transmit impulses through the University of Arizona College of Medicine – NSAIDs are the mainstay of abortive SPG to autonomic nerves. Phoenix treatment, which must be delivered at SPG involvement results in EMRA Medical Student Council Editor the onset of symptoms.1 This article lacrimation and nasal discharge @retinueofblue intends to discuss the procedure, noted in migraines and other primary Chiamara Anokwute, MS4 Indiana University School of Medicine use, and relevance of Sphenopalatine headaches. In the midst of a migraine, EMRA Medical Student Council Chair Ganglion (SPG) blockade in the parasympathetic outflow from the @ChiamaraAnokwu1 abortive treatment of migraines and SPG results in cranial vasodilation. he most prevalent medical problems other noteworthy primary headaches Inflammatory mediators are able to Taround the globe are in the sphere not due to trauma. The research behind activate meningeal pain receptors of headache disorders. Between 50% SPG blocks and the application to ED leading to migraine pain.3 and 75% of adults between ages 18-65 use will also be discussed. The SPG relays sensory, will have headaches. Worldwide, the Research Behind SPG Blocks sympathetic, and parasympathetic pathways.4,5 Sensory pathways for disability and loss of productivity due to The culprit behind headache pterygopalatine branches with the headache disorders being ranked third disorders are largely the nerves 1 maxillary nerve to terminate at the in the number of years lost to disability. that converge at the sphenopalatine trigeminal ganglion, innervating parts However, primary headache disorders, of ganglion (SPG), an extracranial of the head and neck. Sympathetic which migraines are the most prevalent, parasympathetic ganglion.3 The pathways arise from the superior only account for up to 4% of chief SPG is located behind the nasal cervical ganglion to converge at the SPG complaints for emergency department bony structures, giving rise to the 1,2 to innervate vasoconstriction in the (ED) admissions. Migraine therapies superior, inferior and posterior lateral nasal cavity, upper pharynx and palate. revolve around preventive measures in nasal branches, nasopalatine nerve, The parasympathetic pathways arise anticipation of migraines and adjuvant greater and lesser palatine nerves, the from the superior salivatory nucleus to treatments for associated symptoms of pharyngeal branch of the maxillary join the SPG, innervating the lacrimal, migraines such as nausea and emesis. nerve, and orbital branches that nasal, and other oropharyngeal Another key therapy for migraines innervate the lacrimal gland.3,4 During glands.4,5 As such, blockade at the SPG is abortive treatment. Preventative a headache meninges become inflamed, theoretically should propagate relief of treatments include antidepressants, leading to activated pain receptors symptoms associated with a headache antihypertensive, ant antiseizure per the trigeminal nerve. These pain state: meningeal vessel inflammation, lacrimation, rhinorrhea. SPG blocks have been shown to be effective in the reduction of headaches, including but not limited to cluster headaches, chronic migraine, refractory trigeminal neuralgia, and postoperative analgesia for endoscopic sinus surgery.5 Approaches within the studies considered in the literature do not all use the procedures noted in the SPG Procedures and Steps section of this article. Variable approaches included intranasal, intraoral, transcutaneous as well as the use of radiologically guided needles to achieve the desired a SPG block.5 Image obtained from Wikimedia Commons; picture is public domain. All other images were Immediately following the taken with a volunteer in a non-clinical setting. procedure, the patient may already be

34 EMRA | emra.org • emresident.org feeling relief! If they have numbness in of the studies supporting SPG blocks are however, is that it has been shown to the posterior pharynx, advise them not to based in outpatient settings such as pain work relatively quickly. As much as eat or drink until full feeling returns. clinics. Anecdotally, these blocks’ efficacy 70% of migraines improved after 15 Note: There are several proprietary can be externalized to the EM setting, minutes in one case series, although applicators for blocking the SPG, with but more research will need to be done to bilateral blocks were utilized in this 7 the SphenoCath® being the most prove this. study. Other treatment remedies may studied. It can still be performed with an Even if you are sold on the SPG block have similar times to treatment success inexpensive simple cotton tip applicator as an effective treatment for migraine but would be more sedating and could but studies will need to be performed to headaches, it will not likely be your require longer ED stays. Besides the determine any difference in efficacy. first approach to every patient with a time involved in the procedure, another migraine. Ordering prochlorperazine downside of the SPG block is proposing Verdict: Is this realistic for use and diphenhydramine will remain an to a patient that a cotton tip applicator in EM? effective and relatively easy treatment be placed several inches into their Research behind SPG blocks is for most migraines, and the medications nostril. However, given how prevalent consistent in demonstrating efficacy take less time to order than it does to placing nasal swabs in nostrils has in reducing or even resolving migraine perform the SPG block procedure. become over the past year, this just may headaches. It should be noted that many One strength of the SPG block, be time for the SPG block to shine. ¬

SPG BLOCK DESCRIPTION & STEPS

Step 1. Gather the following materials: • Cotton tipped applicator, ≥ 6 inches Step 2 • Anesthetic of choice – Lidocaine, 1-4% – Bupivicaine, 0.25-0.50% – No difference in efficacy between the two anesthetics6 • Small cup or container for anesthetic • 5 mL syringe with needle to draw up anesthetic

Step 2: Position patient in the supine position with the neck extended.

Step 3. Soak cotton tipped applicator in the anesthetic solution, and draw up anesthetic into the syringe. Steps 4-5 Step 4. Place cotton tipped applicator in the nostril of the affected side, advancing through the middle turbinate until resistance is met.

Step 5. Use the needleless syringe to drip 1-2 mL of anesthetic solution down the shaft of the cotton tipped applicator. Note: some providers’ preference is to only use the anesthetic on the cotton tip and not drip any into the turbinate.

Step 6. If this procedure is used for a bilateral headache such as a known cluster headache, repeat steps 3-5 on the other side. However, take care to not administer SPG blocks on bilateral headaches of unknown cause so as to miss new life-threatening pathology.

Step 7. Allow the patient to rest supine for 10-15 minutes. Keep patient on cardiac monitor due to the nature of the procedure.

Step 8. Remove the cotton tipped applicator(s). Monitor for side effects, most commonly epistaxis.

References available online June/July 2021 | EM Resident 35 ADMIN & OPS

Editor’s note: The literature is full of studies that can impact the operations of a health care system. This series from the Admin & Ops Committee examines recent papers and the potential implications for emergency medicine. Find additional literature reviews on their committee page at emra.org.

Patient Outcomes in ED Observation Units for Syncope Wes Spiro, MD management costs the US healthcare abnormal ECG. In phase 1, patients were Mount Sinai Morningside – West system an annual 2.4 billion dollars3. The randomized to standard care in the ED Jared Ditkowsky, MD development of ED Observation Units, versus syncope unit — which was equipped Admin & Ops Committee Past-Chair or EDOUs, have allowed patients and with 24-hr telemetry monitoring, TTE, Mount Sinai School of Medicine hospitals alike to seek specialized care orthostatic BP qhr, and tilt-table testing. Vineet Kumar Sharma, MD, MS that is less costly and, in some instances, The latter group had a higher diagnosis New York Presbyterian Hospital just as efficient at diagnostics as a full rate (meaning diagnosis for the etiology of Nicholas Cozzi, MD, MBA hospitalization. The literature review EMRA Board of Directors syncope). At two years, nearly all metrics Spectrum Health/MSU College of Medicine below will focus on patient-centered measured between the two groups were Nicholas Stark, MD, MBA outcomes in EDOUs for syncope. equal — namely, probability of survival Admin & Ops Committee Chair Review of Literature at 2 years, recurrent syncope at 2 years, UCSF-San Francisco General Hospital 1) Syncope Evaluation in the and probability of being free of a syncopal yncope is a complex presenting Emergency Department Study event. The authors conclude that a Schief complaint spanning several (SEEDS): a multidisciplinary dedicated syncope observation unit leads physiologic systems. Its differential approach to syncope management. to decreased hospital and patient costs and includes several “can’t miss” etiologies, (Circulation, 2004) shortened stays, while not affecting all- making diagnosis and disposition This prospective, single-center cause mortality or recurrent syncope. sometimes difficult for the emergency study randomized patients in an 2) Randomized clinical trial of an provider. Per The Framingham Study, intermediate-risk group for syncope (met emergency department observation the estimated incidence of syncope is by pre-determined clinical features) into syncope protocol versus routine approximately 6.2 per 1000 person admission versus EDOU for syncope. inpatient admission. (Ann of Emerg years, accounting for approximately 1% Notably, the intermediate group contained Med, 2014) of all ED visits in the United States.1,2 It patients with high-risk features — 43% This randomized control trial of is estimated that syncope workup and had a history of CAD, and 57% had an 124 patients across 5 EDs compared an

36 EMRA | emra.org • emresident.org ED observation protocol to inpatient comment favorably on the SEEDS trial, individual studies analyzed, little weight admission for adults over 50 presenting included in their analysis and outlined is placed on patient-centered metrics with syncope. The observation unit above, for this trial demonstrated that such as patient satisfaction. led to shorter hospital stays (29 versus a dedicated syncope workup unit in the Summary of Literature 47 hours) and serious outcomes were ED led to a higher diagnosis rate than There have been limited high-quality equivalent at both 3 month and 6 hospitalization. The authors comment papers investigating the role of EDOUs months. Zooming in on patient-centered on two of the main drawbacks to current for syncope, but the evidence suggests outcomes, there was no significant literature on this subject that require a that they lead to lower healthcare costs difference found in patient satisfaction closer look — namely, who qualifies as and shorter hospital stays. In addition, between the two groups. Notably, this ‘intermediate risk’ syncope and would long-term serious outcomes do not paper estimates an average cost for thus benefit from an observational stay appear significantly different between syncope hospitalization at approximately as opposed to a full hospitalization, and those admitted to hospital versus $2420, compared to a mean cost of what qualifies a syncope observational observation units. EDOU observation status of $1400. unit (as tilt-table testing is not practical Looking Forward/What’s Next 3) Comparison of 1-Day Emergency nor cost effective for most hospital It is unclear whether observation Department Observation and systems). Similar to most of the units have as much diagnostic value as a Inpatient Ward for 1-Day full hospitalization in the differentiation Admissions in Syncope Patients Procedures List in Syncope of syncope, and this is likely based, in (J Emerg Med, 2016) Observation Study large part, on the degree of complex Several texts presented above APC APC testing available to the observation provide evidence for the benefits of Procedure code cost unit. There is little evidence in the EDOU admissions for syncope — Insertion of heart 00089 7811.77 literature evaluating patient satisfaction notably cost savings and equivalent pacemaker in observation stays versus full hospital patient centered outcomes. This study, Echocardiogram 00269 402.39 stays. Further research should emphasize however, sheds light on a metric that 00107 23404.61 may correlate with patient satisfaction, Implantable defibrillator bounce-backs, or repeat visits, between placement presuming that patient satisfaction those admitted to a full hospitalization 00104 5655.53 correlates with having a formal Intracoronary stent versus syncope observation unit. placement diagnosis at time of discharge. Nevertheless, this review demonstrates 00080 2726.85 This retrospective cohort study Coronary angiography the utility of observation units, for analyzed 351 ED patients admitted to Carotid artery duplex/ 00267 152.99 syncope but also much more broadly either the hospital or the EDOU for ultrasound a diverse array of chief complaints, in syncope workup. Importantly, none Troponin 84484 18.72 reducing both patient and hospital cost and achieving shorter length of stays. of the EDOU patients had serious Chest x-ray 00260 45.04 Looking ahead, syncope risk etiologies of syncope compared to 38% Holter monitor 00097 66.25 of admitted inpatients (who tended to be stratification tools may further aid Tilt-table evaluation 00101 293.90 older with more comorbidities, and thus emergency providers in determining Cardiovascular stress test 00100 178.42 more likely to have serious etiologies of disposition for patients who present syncope.) Additionally, EDOU patients Perfusion-ventilated chest 00378 319.92 with syncope. A recent systematic review scan were much more likely to be discharged of nine syncope risk stratification tools without a diagnosis. In this regard, CT of brain/cervical spine/ 00332 193.85 found the Canadian Syncope Risk Score this study points to a potential flaw of face/pelvis to have statistically significant high EDOU observation workups for syncope, MRI of brain 70551 342.93 likelihood ratios. See references for this in that patients may be less likely to Electroencephalogram 00213 166.64 paper to check out the Canadian Syncope Risk Score. receive a formal etiology of their syncope Lower extremity venous 00266 96.28 compared to their admitted counterparts. ultrasound EMRA Administration & 4) Role of emergency department Electrocardiogram 00099 27.26 Operations Committee Links, observation units in the Venipuncture 36415 3.00 Guides and Opportunities management of patients with Complete blood count test 85025 14.79 • Check out what’s happening with unexplained syncope: a critical our group at the EMRA A&O Metabolic panel 80053 20.10 review and meta-analysis (Clin Exp landing page. Emerg Med, 2017) Cardioversion 00679 371.97 • Looking to gain a mastery of this This systematic review of EDOU Chest CT angiogram 00662 338.53 and other relevant operational for syncope analyzed a total of six Observation unit visit 08002 714.33 knowledge? Consider applying for studies — four observational and two From supplemental material for Study 2: various EMRA’s ED Directors Academy RCTs. The authors make a point to costs of syncope work up related procedures. scholarship. ¬

References available online June/July 2021 | EM Resident 37 HEALTH POLICY, OP-ED EMRA as the MVP The regulatory acronym soup can be difficult to grasp; EMRA opportunities can help it make sense.

Cameron Gettel, MD When in residency, I was fortunate Fellow, National Clinician Scholars Program, enough to be selected for the EMRA Yale University Emergency Medicine Basic Research Instructor, Department of Emergency Medicine, Skills (EMBRS) Scholarship as well Yale University @CameronGettel as the EMRA/ACEP Resident-Fellow Health Policy Award in Washington, imes are changing for EM health D.C. Respectively, these opportunities policy and reimbursement with the T provided me a fundamental recent shift toward value-based care understanding of research techniques and away from fee-for-service models. as well as a “learning of the language” Currently, the Centers for Medicare & needed. Medicaid Services (CMS) uses the Merit- Recently, as a fellow, I was based Incentive Payment System (MIPS) nominated and selected to lead the as the program to evaluate clinicians on ACEP MVP Task Force, assembled to quality, cost, improvement activities, develop an EM-specific MVP that would and promoting interoperability. include meaningful quality measures Dependent on performance, these that EM clinicians should be judged and evaluations and scoring on quality reimbursed on. measures are used to alter Medicare have applied for and not been selected Using those developed skills, the Part B reimbursements to clinicians for significantly more, including EMRA Task Force rapidly gathered feedback by up to 9%. Stakeholders, including Health Policy Director. That’s OK, other from a wide range of clinicians within physician groups, have noted significant doors will open as a result. ACEP and implemented findings into limitations in the MIPS due to the a candidate MVP. While still under Second: Say yes to opportunities quality measures not being particularly review with CMS, the goal of the MVP early in your training. meaningful to individual specialties. As You might have a bit of impostor is to focus on the “bread and butter” a result, CMS has developed the MIPS syndrome, but you likely have more time complaints we see daily — those Value Pathway (MVP) framework to be to sink your teeth in and drive a project being the high-risk undifferentiated implemented in performance year 2022 forward in comparison to several other complaints of chest pain, abdominal with aims to:1 uber-busy folks. pain, headache, and back pain. Including • Develop connected meaningful available quality measures around those Third: Do your homework and be measures for clinicians complaints will allow EM clinicians to prepared. • Include measures that are valuable to report on measures that are meaningful, You only get one first impression. patients and caregivers while also offering opportunities to Understand what has been written on • Include the patient voice the topic at hand and by whom. identify areas of practice variation ready • Reduce barriers to alternative for improvement. Finally, and potentially most payment model (APM) participation Lessons Learned important: Don’t reinvent the • Support the transition to digital wheel. From these unique experiences quality measures. Be strategic and identify those people I’ve learned a few lessons that I think This acronym soup can quickly you respect, and look at their path are translatable to many EM residents become dizzying and difficult to follow, through CVs, leadership, publications, trying to find their way and identify their but opportunities through EMRA and service to see how that journey helped form the foundation of my subject niche. might be adapted to meet your goals. To understanding on these topics and other First: If you don’t shoot, you can’t have impact, don’t just think 1 year in programs that will inevitably impact score. advance, but instead think about where our specialty significantly in the coming While I was fortunate to be selected you want to be in 10-15 years, and be years. for the opportunities listed above, I also intentional about your actions today. ¬

38 EMRA | emra.org • emresident.org SOCIAL EM Speaking Up for Speaking Plainly Why EM Physicians Should Care About Health Literacy Dominique Gelmann, BS and vaccines, improper medication use, surrounding the pandemic resulted University of Maryland School of Medicine and greater morbidity and mortality.3-6 from a lack of adequate information, Class of 2021 It is important to note that low health but other qualms were deeply rooted in @DGelmann_EM literacy disproportionately affects well-founded mistrust of the healthcare ou’re in the middle of a busy ED shift individuals of minority, low-income, system. Building public trust is essential Ywhen a new patient arrives in bed 7. and low-education groups.2 These in mounting an effective response to Her breathing is labored and her lungs groups, often impacted by other social this global crisis. Likewise, our patients are riddled with crackles. She tells you she determinants of health, are at further risk may be more willing to share their lack was diagnosed with “a heart problem” a of health inequities when additionally of understanding and ask questions few months ago. She recently ran out of affected by low health literacy. when the patient-physician relationship her medications and did not refill them While health lit eracy was is founded on trust. It is well worth because she “wasn’t sure what they were traditionally thought of as an individual our while to dedicate a few minutes to doing anyway.” You ask if she sees a trait, the definition has evolved over listening to patients, addressing any cardiologist. “A what?” she responds. recent years to incorporate the role of gaps in understanding, and engaging in As emergency clinicians, we clinicians and healthcare systems. Health patient-centered communication. encounter scenarios like this one more literacy is now described as occurring Best Practices for often than we might hope. At times it is when society and its healthcare system easy to label patients as “noncompliant” “provide accurate health information Communication and assign them blame for their and services that people can easily find, Quality communication is important conditions, but providing compassionate understand, and use to inform their for both patient care decisions in the and equitable care requires us to analyze decisions and actions.”7 Emergency ED and patient self-care after discharge. the underlying cause. We must consider physicians are equipped to play an Emergency physicians are often pressed what circumstances precipitated important role in addressing and for time, and may not have the ability this presentation. What can be done promoting health literacy. We often to engage in lengthy conversations with differently this time to help prevent take care of patients who struggle with patients or review discharge instructions a repeat scenario? Many underlying proper medication use, demonstrate in great detail. But practicing simple issues stem from flaws in the healthcare limited understanding of their conditions, communication skills that promote system that we cannot individually fix, or are unable to access appropriate health health literacy is an efficient and effective but optimizing communication and services. We have the ability to provide way to demonstrate empathy, increase promoting health literacy is something clear and helpful information in order patient understanding, and improve that we can easily do. to enhance patient understanding and patient outcomes. Best practices for Health literacy is defined by the increase health potential — or we can communication include avoiding medical U.S. Department of Health and Human deepen a patient’s confusion. jargon, demonstrating concepts when Services as the ability to access and The COVID-19 pandemic possible, distilling information into key understand basic health information illuminated the detrimental power of points, writing clear instructions, utilizing and services needed to make appropriate misunderstanding health information. the teach-back method, and inviting health decisions.1 A national survey As the virus swept through society, so too patient questions. performed in 2003 revealed that over one did misinformation, disinformation, and Plain language is terminology that third of US adults have basic or below- confusion. Uncertainty regarding how anyone can understand upon first use, basic health literacy.2 Health literacy and when to wear masks, the importance which requires avoidance of medical has gained recognition in recent decades of social distancing, and vaccine safety jargon. Even terms that seem simple, for its association with a multitude of overwhelmed communities and social such as “contraceptives,” can be confusing health outcomes. In the US, low health media. One thing was plainly evident: for patients and should be replaced with literacy is associated with higher rates of clear and effective communication plays clearer alternatives like “birth control.” hospitalization and emergency care use, a critical part in societal health literacy. Discussion of self-care measures can greater healthcare costs, less frequent use Equally important to quality information also be simplified through the use of of preventive services such as screenings is trust. Much of the confusion demonstration. Instead of using words or

June/July 2021 | EM Resident 39 SOCIAL EM

from patients in an open-ended and judgement-free manner. Instead of HEALTH LITERACY the potentially intimidating “Do you COMMUNICATION PRACTICES have any questions?”, try “I know that you’ve been through a lot today; what questions do you have for me?” USE PLAIN DISTILL This demonstrates the expectation for LANGUAGE INFORMATION questions and makes patients feel more comfortable asking them. Plain language is Emphasize the top 1-3 We can now apply some of these communication all things your patient communication principles to our patient patients can understand should know about his/ in bed 7. When talking with her, we can avoid jargon and explain her condition in the first time they hear it. her condition and its simple terms. Instead of asking about her Avoid technical jargon! management. cardiologist, we can use the term “heart doctor.” We can end the encounter with emphasizing the key 3 things she needs GET VISUAL WRITE CLEAR to do to manage her condition, and use Demonstrate how teach-back to ensure her understanding. INSTRUCTIONS Our discharge instructions should provide to use a medication Ensure that discharge easily digestible information, as well or draw a picture to instructions are easy to as resources when available. Questions explain a concept — should be elicited in an inviting manner read and clear. Explicitly and fully addressed. Our patient will leave simpler is better! highlight any follow-up the ED with a better understanding of her measures. disease and how to manage it thanks to our patient-centered communication that promoted health literacy. ¬

USE TEACH-BACK INVITE TAKE-HOME POINTS Check that you QUESTIONS Care that does not prioritize patient have communicated understanding is suboptimal care. We Ask “What questions cannot place the onus solely on our patients clearly by asking do you have?” to understand everything we spent years your patient to repeat in school learning. It is our responsibility instead of to communicate clearly in a manner that back what he/she “Do you have promotes comprehension and addresses understands. patient questions and needs. We do our any questions?” patients a disservice when we do not take the time to properly explain a diagnosis or written instructions to describe how to use back model is a means of ensuring patient appropriate management strategies. an inhaler, demonstrate proper technique. understanding. It employs a cycle of relaying On the flip side, we have the ability to use Another method of maximizing the information to the patient, asking her to simple communication techniques to make amount of information patients walk away repeat back what she understood, and a real impact on patient understanding. Use some proven practices: with is distilling material into a limited clarifying any missed points until mutual — Avoid jargon number of high-importance points. The understanding is achieved. It should be — Distill information sheer volume of new information often emphasized that teach-back is used to — Use teach-back relayed to patients during a hospital visit ensure clear communication by the provider, — Invite questions can be overwhelming beyond the point not to measure patient intelligence. This can Promoting health literacy not only reduces of comprehension. Focusing on 3-5 key be illustrated to the patient by introducing healthcare costs and otherwise avoidable concepts and next steps increases the the concept with an opening along the overutilization of the ED, but also empowers patients and improves health outcomes. likelihood of retention. It is helpful to lines of, “To make sure that I have done Knowledge is power, and health literacy highlight these in discharge instructions as a good job explaining everything to you, is a vehicle for patient empowerment that well, which should be written in clear and can you tell me what you understand allows individuals to play a more active role concise language. about…” Nursing staff typically receive more in their own health. Ensuring understanding Use of the teach-back method and education on teach-back than physicians, is one simple way emergency physicians an invitation for questions are ideal ways and may be able to assist with this. can work toward quality care and health to close a patient encounter. The teach- Finally, questions should be elicited equity for all.

40 EMRA | emra.org • emresident.org UNDER 45 INFL U E NCE RS IN EMER G ENC Y ME DICINE

Our 25 Under 45 campaign recognizes 25 young emergency physicians who are making big changes in the world. We are excited to continue celebrating young influencers who shape the future of their communities, hospitals, and our specialty. For full details and nomination instructions, visit us online. Nominations due July 15.

EMRA 25 Under 45

EMRA Awards

Faculty Teaching LAC Travel Scholarship Excellence Award EMRA / ACEP Steve Tantama, MD EDDA Travel Scholarship Do you have the pleasure Military Excellence Award EMRA / EDPMA Scholarship of working with a rock star Faculty Mentor of the Year Award peer in the emergency EMRA / EDPMA Fellowship Joseph F. Waeckerle, MD, FACEP department? Know someone Alumni of the Year Award Be the Change Project Grant who has demonstrated Augustine D’Orta EMRA Simulation Research Grant exceptional leadership skills? Humanism Award

Nominate them for an EMRA EMRA / ACEP Resident Clinical Excellence Award Award! Several opportunities Fellow Health Policy Elective in Washington, DC are available to recognize FOAM(er) of the Year outstanding individuals, and EMRA / ACEP CORD Academic Assembly Medical Student Elective self-nominations are Travel Scholarship in Health Policy encouraged, too! Nominations due July 1 5. https://www.emra.org/be-involved/awards

June/July 2021 | EM Resident 41 EMRA at ACEP21 EMRA programming will be held at the Omni Seaport, across the street from the Boston Convention & Exhibition Center. Registration opens in early Summer 2021; registration for ACEP21 is not required to attend EMRA programming, but it is encouraged.

Sunday, October 24 11:00 am – 12:30 pm EMRA Resolution Review & Public Hearing 5:00 pm – 7:30 pm EMRA/ACEP Leadership Academy (by invitation only) 7:30 pm – 8:30 pm EMRA Awards Ceremony (virtual)

Monday, October 25 1:30 pm – 6:30 pm Case-Con Residents 1:30 pm – 6:30 pm Case-Con Medical Students 1:30 pm – 3:00 pm EMRA Committee Programming 3:15 pm – 4:45 pm EMRA Committee Programming 5:00 pm – 6:30 pm EMRA Committee Programming 6:00 pm – 8:00 pm EMRA Job & Fellowship Fair (Boston Convention & Exhibition Center)

Tuesday, October 26 8:00 am – 9:00 am EMRA Rep Council Registration 8:00 am – 9:00 am EMRA Rep Council Welcome Breakfast & Candidate’s Forum 9:00 am – 2:30 pm EMRA Rep Council and Town Hall Meeting 10:00 am – 4:00 pm EMRA Resident SIMWars Competition 6:00 pm – 7:30 pm EMRA 25u45, VIP & Board Alumni Reception

Wednesday, October 27 2:00 pm – 4:00 pm EMRA 20 in 6 Resident Lecture Competition 6:00 pm – 8:00 pm EMRA Airway Stories

Thursday, October 28 8:00 am – 6:00 pm EMRA MedWAR (site to be announced)

Visit https://www.emra.org/be-involved/events--activities/acep for registration updates. All times listed are Eastern. 42 EMRA | emra.org • emresident.org We seek out the best resident speakers in the country to compete for the title “Best Resident Lecturer.” Residents are given up to 6 minutes and exactly 20 slides to lecture on any topic relevant to emergency in medicine. It’s designed to be 66 a fast-paced, intellectually stimulating event in a fun, EMRA- 22 style atmosphere. RESIDENTRESIDENT LECTURELECTURE#EMRA20in6 COMPETITIONCOMPETITION #EMRAatACEP21 Entries are now being accepted at emra.org/20in6. Proposal Deadline Selection Notice July 31, 2021 Aug. 1, 2021

WEDNESDAY, OCT. 27 @ ACEP21 LIVE FROM BOSTON, MA

MONDAY, OCT. 25 @ ACEP21 | BOSTON, MA

Entries are now being accepted at emra.org/case-con.

Abstract Submission Deadline Case-c n July 5, 2021 Medical Student and Resident Case Study Contest Selection Notice Aug. 3, 2021

EMRA Case-Con is a poster presentation contest Poster Design Deadline featuring fascinating emergency medicine cases. Oct. 4, 2021 The event includes a 5-minute presentation followed by 2 minutes of group discussion. Presentations will be judged by a panel of EM residents and faculty. Students and residents are invited to compete! 3 winners will be selected from each category. #EMRAcasecon #EMRAatACEP21

June/July 2021 | EM Resident 43 THURSDAY, OCT. 28 @ ACEP21 LIVE FROM BOSTON, MA | SITE TBA

Get details and deadlines at emra.org/medwar. #EMRAmedwar #EMRAatACEP21

TUESDAY, OCT.. 26 @ ACEP21 LIVE FROM BOSTON, MA

Team entries are now being accepted at emra.org/simwars.

Team Submission Deadline July 9, 2021

Selection Notice July 15, 2021

#EMRAsimwars #EMRAatACEP21 SAVE THE DATE! EMRA’s Job & Fellowship Fair will be held in-person at ACEP21 on Monday, Oct. 25. Meet with recruiters and programs from across the country, and get ready to network with leading emergency medicine employers.

EMRA JOB & FELLOWSHIP FAIR Monday, Oct. 25 at ACEP21 | 6:00 - 8:00 pm Eastern Boston Convention & Exhibition Center

https://www.emra.org/be-involved/events--activities/acep/ June/July 2021 | EM Resident 45 EMRA RESIDENCY FAIR Aug. 14 — 19 | VIRTUAL We are excited to provide you with a virtual experience that personally connects you to 160+ emergency medicine residency programs across the country.

To take care of members preparing for the 2022 cycle, MSIVs will have ﬁrst access. As space allows, we will open registration to all medical student members.

Our virtual platform provides: • Customizable virtual proﬁle • Residency program booths organized in geographical regions • Ability to chat with up to 5 program representatives from each program • Opportunity to schedule appointments

VIRTUAL MEDICAL STUDENT FORUM Saturday, Aug . 14 | 9:30 am - 12:30 pm Central The EMRA Medical Student Forum brings together program directors and faculty to answer questions speciﬁc to transitioning to residency. General sessions answered big-picture topics, and breakout sessions per year to target exactly where you are in your training.

EMRA Virtual EMRA Medical Residency Fair Student Forum NEWS & NOTES EMRA RESIDENCY FAIR Aug. 14 — 19 | VIRTUAL Note: EMRA Special Thanks ABEM Sets Virtual We are excited to provide you with Releases to the Editors Oral Exam Dates a virtual experience that personally connects 6 New of these for Fall 2021 you to 160+ emergency medicine residency Publications The American Board of Emergency Medicine has programs across the country. New EMRA Guides announced the 2021 oral exam dates, which will MRA has released a bevy of Emergency ECGs: Jeremy Berberian, be held virtually: updated clinical guides and MD; William J. Brady, MD; and Amal Fall 2021 Exam Dates* To take care of members preparing for the brand-new publications, all Mattu, MD September 10-13, 2021 designed to help you become Basics of EM, 4th ed.: Joseph Habboushe, October 5-10, 2021 December 8-11, 2021 2022 cycle, MSIVs will have ﬁrst access. the best doctor you can be. MD, MBA, and Eric Steinberg, DO, MEHP *Exam dates are tentative and subject to change Candidates who were scheduled for the As space allows, we will open registration These new publications Basics of EM: Pediatrics, 3rd ed: postponed 2020 exams will be the first assigned will be incorporated into the Joseph Habboushe, MD, MBA, and to all medical student members. to the 2021 administrations. ABEM is working to appropriate EMRA member kits Eric Steinberg, DO, MEHP, with C. confirm logistics for these exams. this summer, with app versions to Anthoney Lim, MD, MS, and Jeranil ABEM values the Oral Exam as part of the Our virtual platform provides: follow in MobilEM later this year. Nunez, MD process to become ABEM certified and has invested None of these valuable EM Fundamentals, 2nd ed: Laura Welsh, • Customizable virtual proﬁle in pivoting our delivery to meet physician needs. guides would be possible MD, and the Boston Medical Center We recognize the frustration that EM physicians are • Residency program booths organized without the care and attention EM Residency experiencing due to COVID-19. Please know we in geographical regions of the content teams. Hundreds PEM Fundamentals: Cindy D. Chang, are focused on providing all eligible physicians the of emergency physicians have • Ability to chat with up to 5 program Patricia Padlipsky, MD, and Kelly D. opportunity to become certified as soon as possible. dedicated countless hours representatives from each program Young, MD, MS, with Los Angeles The ABEM Board is committed to providing the to produce evidence-based County Harbor-UCLA Medical Center opportunity to take the Oral Certification Exam in • Opportunity to schedule appointments guidance you can count on at Urgent Care Guide: Brian J. Levine, MD, 2021 to all who were affected by the postponed the bedside. ¬ FACEP, and Lori Felker, DHSc, PA-C. ¬ exams in 2020. ¬

Resident Editorial Board VIRTUAL MEDICAL STUDENT FORUM Fellowship Appointment Saturday, Aug . 14 | 9:30 am - 12:30 pm Central Description The EMRA Medical Student Forum brings together program directors The Resident Fellow appointment to the Editorial Board of Annals of Emergency Medicine is designed to introduce the Fellow to the peer and faculty to answer questions speciﬁc to transitioning to residency. review, editing, and publishing of medical research manuscripts. Its General sessions answered big-picture topics, and breakout sessions purpose is not only to give the Fellow experience that will enhance his/her career in academic emergency medicine and in scientific per year to target exactly where you are in your training. publication, but to develop skills that could lead to later participation as a peer reviewer or editor at a scientific journal. It also provides a strong resident voice at Annals to reflect the concerns of the next generation of emergency physicians.

Application Deadline: July 26, 2021 EMRA Virtual EMRA Medical Residency Fair Student Forum Learn More at: www.annemergmed.com

June/July 2021 | EM Resident 47 HEART OF EM

The Hidden Curriculum

Joy McLaughlin Florida Atlantic University Charles E. Schmidt College of Medicine Class of 2022

The school talks to us about “the hidden curriculum;” The only subject they can’t teach and only act as adminiculum. When some of us realize that the shiny apple we have bitten is rotting at the core And what we learn about ourselves is more than we’ve bargained for. A patient with a still born (still waiting to be born) Tests COVID positive and I’m not permitted to scrub and see this rare case through I’m not the same person that I thought I knew I’m more concerned with the opportunity cost Than the whole new life that this patient has lost. Another patient, much younger than me Comes in with a tender, swollen knee She’s a champion athlete Finally able to compete After nearly a year since her MCL repair, But we both worry it’s another tear. While I’m evaluated, I palpate patella, Tendons, pulses, and lamella, She’s gracious as I fumble through But that was hours before she knew— “A thorough history, a pertinent exam” Writes my attending, but I feel a sham, Imaging reveals a shattered bone The next time she’ll compete is now unknown We give her time to process this result And lamely wait for the ortho consult. And yet I’m determined to find a way To more often be the person that I was that day, And twice a day ‘till she was d/c’d Every shift I’d check, every note I’d read She wasn’t my patient after her admission I’m an EM student; she was in stable condition. But I know what it’s like to want something so much And how tightly to our dreams we clutch. We are all heroes but occasionally villains Armed with our penems and penicillins But exhausted by the journey that it took to get here And tackling our own doubt, debt, and fear. The hidden curriculum reveals the chiasm between What is ideal and real in the medical machine But I was told “the more urgent the condition, the slower you should go” Leave room for the human among everything you try to know. ¬

48 EMRA | emra.org • emresident.org HEART OF EM Lessons in Vulnerability Diana Halloran, MD I hear my neighbors having another party. Northwestern University During my commute to the hospital one t is hard enough to be an intern, let day I catch faint snippets of a stranger’s Ialone an intern in the middle of a global conversation about how “we sure did pandemic. In addition to learning how overreact to this COVID business, didn’t to diagnose, treat, perform procedures, we?” A flash of anger stops me in my and identify critically ill patients, we tracks. I think of our full ICUs and my learned how to cope with constantly COVID patient mere hours earlier who witnessing the most brutal and honest needed a ventilator. I think about all of human experiences: emotional trauma, the death I have seen, of the families I sadness, pain. And while I might have have called to tell them their loved one has anticipated this emotional burden, what I died. Of the many death exams I have now didn’t anticipate — or train for — was the performed. For another moment I wonder resultant feelings of futility. if what I am doing matters. I was an intern resident physician in But I get to the hospital, put on my Chicago in 2020. My last few months of N95, and I am reminded of the difference medical school were full of uncertainty we do make. Of the connections that we — my canceled ICU rotation, weekly Along with seeing so much sadness forge with patients and their families, university-wide coronavirus updates, these past months, every day I wonder not only during times of their greatest watching the numbers of available — did I matter? Did I make a difference? struggles but also in the quiet moments. hospital beds dwindle nationwide. Like Did my work help this patient and their It is easy for me to overlook the small thousands of 2020 graduates, I celebrated family? differences we make day to day and of the 4 years of medical training over Zoom. I spend my days providing care, impact we have. Every time I start to lose Everything changed on July 1, 2020, helping where I can, listening to fears sight of this meaning, another patient when I walked into the emergency and concerns. I become more confident brings it back up to the foreground. An department for the first time as a with procedures I never thought I could older woman comes to the emergency physician and immediately entered the be as a medical student. I learn so much department for abdominal pain. Our fray: My very first patient was COVID every day yet still feel that I will never imaging reveals a high likelihood of positive. The nurse and I donned our know enough to be competent and cancer, so I discuss the findings with her. yellow disposable gowns, goggles, gloves, confident. During my intensive care unit As we sit together in her room, a small orange N95s, and we entered the room. night shifts I have to pronounce a death moment of stillness in an otherwise busy I stumbled through introducing myself for the first time for my patient who had emergency department, she tells me — saying “My name is Dr. Halloran listed her code status as DNR. Her nurse about her faith, her husband, and the and I’ll be one of the people taking care sat with her and held her hand while inner strength that she has. of you today” for the first time, barely she died alone in her room as my senior These moments show me how I feel convincing myself or the patient. resident and I attended a code across the the most connected to my patients during Every day since then I have seen the unit. The nurse and my senior resident times of quiet and emotional honesty. heart-wrenching emotional cost of this help me go through the steps, listening to I had been trying to block the ever- pandemic and medicine as a whole. A her now silent heart and lungs, shining growing internal wave of sadness from patient with COVID having difficulty a light into her open, unseeing eyes, tragedies witnessed, to bury my feelings getting enough oxygen into her body, until it is time to pronounce. We leave in an effort to protect myself, but that listening to her husband tell her he loves her room, and my senior asks how I effort to protect nearly imprisoned — it her right before I insert a tube into her am doing as I swallow back tears. I go left me alone behind an impenetrable lungs to help her breathe. The wife of down to the emergency department to wall. How can I connect with patients, another patient with COVID pulls me see my co-residents, who tell me their empathize with them and their struggles, aside outside her husband’s room – he stories of their first death exams. I feel if I have effectively numbed myself and has a weak immune system, and she understood — they know exactly how my emotions? is devastated that her work as a home I’m feeling, they’ve been here before. I Through my patients I have learned health nurse might have exposed him to cry in the elevator, then tamp down my how to be more open, more empathetic, the virus. There are stories of hospital sadness and go back to the ICU to call the more understanding. Through these staff treating their own critically ill co- patient’s husband. moments of vulnerability, I am reminded workers. These were daily occurrences, Months later, after work I continue to that our actions do matter, we do make a and they have taken their toll on us. see people walking outside without masks, difference, and we do not go unnoticed. ¬

June/July 2021 | EM Resident 49 LETTER TO EDITOR Regarding “Failure of Follow-Up: Scrotal Hernia Case Illustrates Healthcare Disparities” Gabriela M. Doyle, MD and plastics/reconstructive teams; repair is widely accepted as superior Surgery Resident additionally, postoperative care may to tissue repair in large hernias as the University of Nevada, require an experienced ICU.3 The surgical recurrence rate decreases by 50%-75%.6 Las Vegas School of Medicine @surgeon_and_tonic resources for complex mesh repairs are In comparison to elective surgery, the not available at all hospitals. option of using mesh is less likely in Taylor Fontenot, MD Surgery Resident Potential complications are emergency surgery. Bowel resections are University of Nevada, significant. Our colleagues rightfully significantly more common in emergency Las Vegas School of Medicine bring up the well-known complications hernia operations compared to elective @tfontenotmd of general hernia intervention, including repair.7,8 This patient’s hernia was Dear Editor, poor wound healing and hernia widely patent, and he had no clinical or e read with interest the article by Dr. recurrence. With complex LOD hernias laboratory abnormalities to suggest bowel WJason David et al. in the November requiring abdominal wall reconstruction, compromise or systemic signs of sepsis. edition, titled “Failure of Follow-Up: the adverse sequalae can be substantially Given this patient had no indication for Scrotal Hernia Case Illustrates Healthcare life-threatening. Reduction of hernia emergent surgery and the aforementioned Disparities.” We commend the authors contents into the peritoneal cavity factors made him a poor surgical for highlighting this unusual case and can lead to an abrupt increase in candidate, the safest course of action was emphasizing the need for interdisciplinary intra-abdominal pressure, reduction treatment of medical comorbidities and management in patients who face of venous return, and decreased repair of his hernia in the elective setting. healthcare disparities. We would like to diaphragmatic excursion. Reduction in The overall predicted costs for address the proposed surgical treatment tidal volume, postoperative ileus, and surgical intervention for hernias with and estimated costs, with insight from the abdominal compartment syndrome are LOD range between $24,000-$64,000. surgeon’s perspective. potential postoperative complications. Increased hospital length of stay, ICU A large hernia (>10 cm width) with Intensive management is essential, admission, preoperative testing, and loss of domain (LOD) is categorically a including bladder pressure monitoring, treatment of any complications with “complex abdominal hernia.” Treatment serial abdominal examinations, and possible need for reoperation can add considerations differ substantially when consideration of elective mechanical $54,000-$100,000+.8,9 Postoperative comparing a simple hernia to those with ventilation to monitor peak airway reconditioning must also be factored, extensive LOD. LOD can generally be pressure.1 The overall morbidity and as frail patients may require physical understood to describe the significantly mortality of an elective CAWR can range rehabilitation services to maximize abnormal relationship between a hernia as high as 66% and 6.7% respectively.4 mobility after a CAWR. These expenses sac and the existing abdominopelvic These complications become more represent a major barrier to a patient who volume.1 Different sources have expressed prominent with underlying comorbidities. is uninsured or underinsured. the concept of LOD as a ratio of hernia This patient had several conditions that Our EM colleagues rightfully bring up sac volume to abdominal cavity volume or compromised his ability to heal and concerns that extend beyond this case; total peritoneal volume. Some surgeons served as a positive predictor of morbidity namely, the growing use of the ED as the use a cutoff value of 20%, while other and mortality for CAWR:5 untreated sole source of primary care. The social authors use up to 30%. It serves as a Hepatitis C, HIV, poor nutrition, IVDU, determinants of health often play a major predictor of operative difficulty and and untreated psychiatric illness. role in precluding patients from obtaining success.2 This case was a large, though Arguably, the most important outpatient surgical evaluation. Delay in patent, hernia containing several loops of preoperative consideration for patients management can progress disease from bowel with significant LOD. who present for urgent evaluation of a elective to urgent or emergent in nature Treatment is not simple. In returning hernia is the delineation of elective vs - while emergency hernia repair typically the hernia contents to the abdominopelvic emergent/urgent categorization. It is leads to higher costs and worse outcomes. cavity and restoring the integrity of the imperative that complicated hernias be We agree that a continuous series abdominal wall, surgical treatment must repaired in the elective setting if feasible, of ED visits for chronic, non-emergent be highly individualized and carefully as the morbidity and mortality rise with surgical illness is not productive for planned. A complex abdominal wall emergent interventions. Prospective the patient. It is only through the reconstruction (CAWR), consisting often studies have shown that the risk interdisciplinary effort of surgery, of an abdominal component separation for 30-day mortality, reoperation, social work, primary care, and patients combined with placement of mesh, is and readmission increased up to themselves that barriers can be overcome, typically warranted. This often requires 15-fold after emergency repairs and meaningful progress made in collaboration between general surgery rather than elective repairs. Mesh delivering elective surgery. ¬

50 EMRA | emra.org • emresident.org References available online CARDIOLOGY ECG Challenge Sahar Khan, MD Jeremy Berberian, MD Emergency Medicine PGY-2 Associate Director of Emergency Medicine Resident Education ChristianaCare Dept. of Emergency Medicine ChristianaCare @jgberberian

CASE. A 55-year-old female presents from home due to a brief episode of unresponsiveness and AMS. What is your interpretation of her ECG? (Bonus points if you identify the less obvious abnormality.).

See the ANSWER on page 52

YOUR EMF DONATION SUPPORTS COVID-19 RESEARCH

Amyna Husain, DO (Pictured) and Daniel Hindman, MD, MPH Janice Blanchard, MD, PhD Johns Hopkins University School of Medicine George Washington University Pediatric Patient Characteristics and Their An Evaluation of Stressors related to Associations with Screening, Receipt of COVID-19 COVID-19 In Emergency Medicine Physicians Testing and Management within the Johns Hopkins Health System Enterprise

John Purakal, MD, MS Felipe Teran, MD, FACEP Duke University University of Pennsylvania Social Determinants of Health and COVID-19 Prognostic Value of Point of Care Cardiac and Infection in North Carolina: A Geospatial and Lung Ultrasound in COVID-19–CLUSCO Study Qualitative Analysis

JOIN THE EMF RESIDENT VIP CLUB

A $120 tax-deductible gift will place you in the prestigious Resident VIP Club

emfoundation.org 469-499-0296

June/July 2021 | EM Resident 51 CARDIOLOGY ECG Challenge

This ECG shows normal sinus rhythm with a PVC (the 3rd to last beat) at a rate of 89 beats per minute, normal PR interval, normal QRS complex duration, prolonged QTc interval, and deep, wide, symmetric T-wave inversions in leads I, II, aVF and V2-V6. The less obvious abnormality is the presence of left arm-left leg (LA-LL) lead reversal. Discussion and deep TWI as seen in this ECG, so it is This ECG shows LA-LL (left arm-left leg) The T-wave represents ventricular valuable to review the other possible causes, lead reversal. A notable finding in this ECG repolarization. In the limb leads, the T-waves even if they don’t fit the clinical picture. that should prompt concern for LA-LL lead should always be upright in leads I and II, • Takotsubo cardiomyopathy can cause reversal is the prominent P-wave in lead I and inverted in lead aVR. The T-waves in deep TWI and QTc prolongation. It when compared to lead II. In general, the leads III and aVL can be inverted or upright, can also present with STE that mimic P-wave should be more prominent in lead and lead aVF will usually have an upright a STEMI, and it can be difficult to II than lead I in normal sinus rhythm with T-wave but may be flat or slightly inverted. differentiate the two clinically. correct lead placement. In the precordial leads, the T-waves should • Hypertrophic cardiomyopathy (HCM), ECG findings seen with LA-LL lead always be upright in leads V5-V6 and usually more often the apical variant, can cause reversal include (see Figure 1): upright in leads V1-V4. Inverted T-waves deep TWI with large R-waves in the 1. Leads I and II “switch places,” meaning in lead V1 can be a normal variant, as are precordial leads. that the normal findings in lead I are biphasic T-waves (upright then inverted) in • Wellens’ type B will show deep TWI, noted in lead II and vice versa the right precordial leads. In general, the typically in leads V2-V3, suggestive of 2. Leads aVL and aVF “switch places,” so T-wave amplitude is < 6 mm in the limb leads a critical stenosis/lesion of the proximal the normal findings in lead aVL are noted and < 10 mm in the precordial leads. LAD. in lead aVF and vice versa The differential diagnosis for inverted • Pulmonary embolism can cause deep TWI 3. Lead III is inverted T-waves includes: in the inferior and right precordial leads. 4. Lead aVR is unchanged • Acute ischemia (early reciprocal changes) • Bundle branch blocks FIGURE 1. Comparison of the limb leads from the case ECG (with LA-RA lead reversal) with • Cardiomyopathies a repeat ECG (with correct lead placement) • CNS injury LA-LL lead reversal Correct lead placement • Digitalis effect (from case ECG) (from a repeat ECG) • Intra-abdominal disorders • Juvenile T-wave pattern • LVH • Metabolic abnormalities • Pericarditis • Pre-excitation syndromes • Pulmonary embolism • Toxicologic abnormalities • Ventricular paced rhythms • Wellens’ type B Given this patient’s history, it would be reasonable to assume that these T-waves are cerebral T-waves. This term is used to describe the T-WAVE LEARNING Case Conclusion broad, deep TWI seen with a variety of The patient underwent a broad work up which was neurologic pathologies, including stroke, POINTS notable for a slightly elevated troponin and a normal • Always upright in leads I, II, and TIA, intracranial hemorrhage, and seizures. head CT. A non-emergent cardiac catherization V5-V6 and inverted in lead aVR Cerebral T-waves are typically seen in the showed clean coronaries and an echocardiogram • TWI can be a normal variant in precordial leads and will often have an showed apical hypokinesis diagnostic of Takotsubo leads III, V1, and aVL (aVF may outward bulge in in the descending limb cardiomyopathy. It was later discovered that the be slightly inverted) making them asymmetric. Other common patient had been undergoing significant emotional • The differential diagnosis for ECG findings seen with CNS etiologies stress at home, consistent with her diagnosis TWI is broad and the workup include QTc prolongation, seen in this ECG, of Takotsubo. Note that this was a very atypical should be based on clinical and bradycardia. presentation for Takotsubo which commonly picture Not many things cause such broad presents with chest pain. ¬

52 EMRA | emra.org • emresident.org References available online Board Review Questions PEERprep for Physicians is ACEP's gold standard in PEERprep self-assessment and educational review. on sale For complete answers and explanations, visit the Board Review Questions page at emresident.org, under "Test Your Knowledge" NOW! Order PEERprep at acep.org/peerprep

1. A 22-year-old man presents with watery, non-bloody diarrhea of 2 days’ duration that is associated with cramping, abdominal pain, and nausea. He just returned from a 2-week service project in Mexico. What is the most appropriate management? A. Give a single dose of ciprofloxacin 750 mg PO B. Prescribe metronidazole 500 mg three times daily for 7 days C. Provide reassurance and advice on symptomatic therapy D. Send stool for examination for WBCs, ova and parasites, and culture

2. A mother brings in her 30-day-old daughter for difficulty breathing. The baby was born at home at 37 weeks' gestation. The mother received normal prenatal care, and there were no complications during the pregnancy or delivery. The baby only recently returned to her birth weight of 6 pounds. She is formula fed 3 ounces every 2 to 3 hours and is noted to fall asleep during most feeds. The baby is awake and responsive on examination, with a palpable liver edge 2 cm below the costal margin. Her hands and feet are cool and slightly mottled. A 3/4 harsh, holosystolic murmur is noted at the left lower sternal border. Upper and lower extremity blood pressures are symmetric. What is the likely underlying cause of her symptoms? A. Coarctation of the aorta B. Total anomalous pulmonary venous return C. Transposition of the great arteries D. Ventricular septal defect

3. Which symptom is reliably found in patients who develop clinical signs of pneumoconiosis? A. Acute wheezing B. Chest pain C. Gradual onset dyspnea D. Sputum production

4. Which treatment is contraindicated in the management of an agricultural worker who presents with diaphoresis, fasciculations, hypersalivation, miosis, respiratory distress, and vomiting? A. Atropine B. Diazepam C. Physostigmine D. Pralidoxime

5. Which physical examination finding is reassuring when trying to rule out a mandibular fracture in a patient with facial trauma? A. The interdental incisor distance at maximal opening is less than 4 cm B. The patient can bite down on and break a tongue blade while the examiner twists it C. The patient has a sublingual hematoma on the affected side

D. The patient’s chin is deviated toward the affected side ¬

1. B; 2. D; 3. C; 4. C; 5. B 5. C; 4. C; 3. D; 2. B; 1. ANSWERS

June/July 2021 | EM Resident 53

PEERprep_physicians_QUESTION_AD_EMRA.indd 1 5/5/21 3:13 PM Exciting opportunities at our growing organization

• Adult and Pediatric Emergency Medicine Faculty positions • Medical Director • Vice Chair, Clinical Operations P E R KS • Vice Chair, Research • Medical Student Clerkship Director for our #EMRAfamily You know about our chock-full EMRA Member Kit boxes. But how about better mortgage and student loan rates? Penn State Health, Hershey PA, is expanding our health system. We What the Area Offers: offer multiple new positions for exceptional physicians eager to join our We welcome you to a community that Or special pricing for exam prep? Plug in to all the valuable dynamic team of EM and PEM faculty treating patients at the only Level I emulates the values Milton Hershey discounts, access, and information you get through EMRA. Adult and Level I Pediatrics Trauma Center in Central Pennsylvania. instilled in a town that holds his name. Located in a safe family-friendly setting, What We’re Offering: Hershey, PA, our local neighborhoods boast • Salaries commensurate with qualiﬁ cations a reasonable cost of living whether you • Sign-on Bonus prefer a more suburban setting or thriving • Relocation Assistance city rich in theater, arts, and culture. Known Board Prep Education Financial • Retirement options, Penn State University Tuition Discount, and so as the home of the Hershey chocolate much more! PEER EM:RAP Laurel Road bar, Hershey’s community is rich in history What We’re Seeking: and offers an abundant range of outdoor Rosh Review Annals of EM Doctors Without • Emergency Medicine trained physicians with additional training in any activities, arts, and diverse experiences. Hippo Education Critical Decisions Quarters of the following: Toxicology, Ultrasound, Geriatric Medicine, Pediatric We’re conveniently located within a Integrated WealthCare Emergency Medicine, Research short distance to major cities such as EB Medicine • Completion of an accredited Residency Program. Philadelphia, Pittsburgh, NYC, Baltimore, • BE/BC by ABEM or ABOEM and Washington DC. EMedHome Pepid Visit emra.org/beneﬁts and get the most from your membership

FOR MORE INFORMATION PLEASE CONTACT: Heather Peffl ey, PHR FASPR at: hpeffl [email protected] Medical Students | Residents | Fellows | Alumni Oldest & Largest EM Resident Association Penn State Health is committed to affi rmative action, equal opportunity and the diversity of its workforce. Equal Opportunity Employer – Minorities/Women/Protected Veterans/Disabled.

54 EMRA | emra.org • emresident.org Exciting opportunities at our growing organization

• Adult and Pediatric Emergency Medicine Faculty positions • Medical Director • Vice Chair, Clinical Operations • Vice Chair, Research • Medical Student Clerkship Director

Penn State Health, Hershey PA, is expanding our health system. We What the Area Offers: offer multiple new positions for exceptional physicians eager to join our We welcome you to a community that dynamic team of EM and PEM faculty treating patients at the only Level I emulates the values Milton Hershey Adult and Level I Pediatrics Trauma Center in Central Pennsylvania. instilled in a town that holds his name. Located in a safe family-friendly setting, What We’re Offering: Hershey, PA, our local neighborhoods boast • Salaries commensurate with qualiﬁ cations a reasonable cost of living whether you • Sign-on Bonus prefer a more suburban setting or thriving • Relocation Assistance city rich in theater, arts, and culture. Known • Retirement options, Penn State University Tuition Discount, and so as the home of the Hershey chocolate much more! bar, Hershey’s community is rich in history What We’re Seeking: and offers an abundant range of outdoor • Emergency Medicine trained physicians with additional training in any activities, arts, and diverse experiences. of the following: Toxicology, Ultrasound, Geriatric Medicine, Pediatric We’re conveniently located within a Emergency Medicine, Research short distance to major cities such as • Completion of an accredited Residency Program. Philadelphia, Pittsburgh, NYC, Baltimore, • BE/BC by ABEM or ABOEM and Washington DC.

FOR MORE INFORMATION PLEASE CONTACT: Heather Pefﬂ ey, PHR FASPR at: hpefﬂ [email protected]

Penn State Health is committed to afﬁ rmative action, equal opportunity and the diversity of its workforce. Equal Opportunity Employer – Minorities/Women/Protected Veterans/Disabled.

June/July 2021 | EM Resident 55 New Fellowship in Medical Toxicology

We are excited to announce a new ACGME-accredited fellowship in Medical Toxicology sponsored by the Medical College of Wisconsin and Children’s Wisconsin.

• Located in Milwaukee, WI – high quality of life, lower cost of living. • FULLY FUNDED • 7 Medical Toxicology faculty, 2 Pharmacy Toxicology faculty all in one department and including national leaders in the field • Inpatient and outpatient consultation service to three hospitals • Open to graduates of ACGME approved residencies in Emergency Medicine and Pediatrics. Not EM or Peds but interested? Let us know and we can find a way. • Be a member of one of the only expanding Departments of Emergency Medicine with a mix of academic and community practice moonlighting opportunities • Work with a stable and well-established poison center

Send inquiries to:

Mark Kostic, MD Janice Hinze Fellowship Director Fellowship Coordinator [email protected] [email protected]

Talking about the issues that matter. Listen today!

Supported by emracast.org

56 EMRA | emra.org • emresident.org NEW GRAD EMERGENCY MEDICINE JOBS

At TeamHealth, we go the extra mile to create a supportive environment for our post-residency physicians. Grow in experience, learn from highly-respected leaders and benefit from the resources and connections of our nationwide clinical network.

Join our team teamhealth.com/join or call 877.709.4638 EMERGENCY MEDICINE • ANESTHESIOLOGY • HOSPITALIST SERVICES GENERAL SURGERY • ORTHOPEDIC SURGERY • OB/GYN HOSPITALIST CRITICAL CARE • POST-ACUTE CARE • BEHAVIORAL HEALTH AMBULATORY CARE • ACUTE BEHAVIORAL HEALTH Say it louder for those in the back.

We bought back our group!

At USACS, our fans know the power of physician ownership. They’re the ones we kiss goodnight and cheer on at games. They’re the colleagues we work with, and love hang- ing out with. So yes, we’ll say it louder for those in the back. We bought out our private equity partner just like we said we would.

Physician Ownership Wins … AGAIN!

OWN YOUR FUTURE JOIN USACS Learn more at USACS.com