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New recommendations for concussion evaluation in the emergency department from the writers of the ACEP clinical policies.

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Vaping associated lung injury (VALI) has become a frequent topic in the news in the United States (US). The Centers for Disease Control and Prevention (CDC) has released new guidance for clinicians that we review in this episode. We also discuss problems with widespread concern (potential over-screening and radiation exposure) as well as the available evidence on diagnosis and treatment of VALI.

References:

1. Morbidity and Mortality Weekly Report (MMWR). 2019; 68(40)
2. Layden JE, Ghinai I, Pray I, et al. Pulmonary Illness Related to E-Cigarette Use in Illinois and Wisconsin – Preliminary Report. N Engl J Med. 2019; Sept 6.
3. Maddock SD, Cirulis MM, Callahan SJ, et al. Pulmonary Lipid-Laden Macrophages and Vaping. N Engl J Med. 2019;381:1488-1489.

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Insulin is a mainstay in the emergent treatment of hyperkalemia but comes at the cost of increased risk of hypoglycemia, which is quite common.

References:

1. Scott NL, Klein LR, Cales E, Driver BE. Hypoglycemia as a complication of intravenous insulin to treat hyperkalemia in the emergency department. Am J Emerg Med. 2019;37(2):209-213.
2. Apel J, Reutrakul S, Baldwin D. Hypoglycemia in the treatment of hyperkalemia with insulin in patients with end-stage renal disease. Clin Kidney J. 2014;7(3):248-50.
3. Coca A, Valencia AL, Bustamante J, Mendiluce A, Floege J. Hypoglycemia following intravenous insulin plus glucose for hyperkalemia in patients with impaired renal function. PLoS ONE. 2017;12(2):e0172961.
4. Larue HA, Peksa GD, Shah SC. A Comparison of Insulin Doses for the Treatment of Hyperkalemia in Patients with Renal Insufficiency. Pharmacotherapy. 2017;37(12):1516-1522.
5. Jacob BC, Peasah SK, Chan HL, Niculas D, Shogbonnwaesei A. Hypoglycemia Associated With Insulin Use During Treatment of Hyperkalemia Among Emergency Department Patients. Hosp Pharm. 2019;54(3):197-202.
6. Harel Z, Kamel KS. Optimal Dose and Method of Administration of Intravenous Insulin in the Management of Emergency Hyperkalemia: A Systematic Review. PLoS ONE. 2016;11(5):e0154963.
7. Pierce DA, Russell G, Pirkle JL. Incidence of Hypoglycemia in Patients With Low eGFR Treated With Insulin and Dextrose for Hyperkalemia. Ann Pharmacother. 2015;49(12):1322-6.

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Droperidol received a black box warning from the US Food & Drug Administration (FDA) in 2001.

 

More on droperidol
Taming the SRU
The Short Coat

References:

1. Khokhar MA, Rathbone J. Droperidol for psychosis-induced aggression or agitation. Cochrane Database Syst Rev. 2016;12:CD002830.
2. Calver L, Drinkwater V, Gupta R, Page CB, Isbister GK. Droperidol v. haloperidol for sedation of aggressive behaviour in acute mental health: randomised controlled trial. Br J Psychiatry. 2015;206(3):223-8.
3. Isbister GK, Calver LA, Page CB, Stokes B, Bryant JL, Downes MA. Randomized controlled trial of intramuscular droperidol versus midazolam for violence and acute behavioral disturbance: the DORM study. Ann Emerg Med. 2010;56(4):392-401.e1.
4. Braude D, Soliz T, Crandall C, Hendey G, Andrews J, Weichenthal L. Antiemetics in the ED: a randomized controlled trial comparing 3 common agents. Am J Emerg Med. 2006;24(2):177-82.
5. Meek R, Mee MJ, Egerton-warburton D, et al. Randomized Placebo-controlled Trial of Droperidol and Ondansetron for Adult Emergency Department Patients With Nausea. Acad Emerg Med. 2019;26(8):867-877.
6. Honkaniemi J, Liimatainen S, Rainesalo S, Sulavuori S. Haloperidol in the acute treatment of migraine: a randomized, double-blind, placebo-controlled study. Headache. 2006;46(5):781-7.
7. Gaffigan ME, Bruner DI, Wason C, Pritchard A, Frumkin K. A Randomized Controlled Trial of Intravenous Haloperidol vs. Intravenous Metoclopramide for Acute Migraine Therapy in the Emergency Department. J Emerg Med. 2015;49(3):326-34.
8. Leong LB, Kelly AM. Are butyrophenones effective for the treatment of primary headache in the emergency department?. CJEM. 2011;13(2):96-104.
9. Calver L, Page CB, Downes MA, et al. The Safety and Effectiveness of Droperidol for Sedation of Acute Behavioral Disturbance in the Emergency Department. Ann Emerg Med. 2015;66(3):230-238.e1.
10. Jackson CW, Sheehan AH, Reddan JG. Evidence-based review of the black-box warning for droperidol. Am J Health Syst Pharm. 2007;64(11):1174-86.
11. Habib AS, Gan TJ. Pro: The Food and Drug Administration Black box warning on droperidol is not justified. Anesth Analg. 2008;106(5):1414-7.
12. Rappaport BA. FDA response to droperidol black box warning editorials. Anesth Analg. 2008;106(5):1585.
13. Perkins J, Ho JD, Vilke GM, DeMers G. American Academy of Emergency Medicine Position Statement: Safety of Droperidol Use in the Emergency Department. J Emerg Med. 2015;49(1):91–7.

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The Free Open Access Medical Education (FOAM) world is often obsessed with magnesium. There are two situations that get unequivocal, high recommendations to give intravenous (IV) magnesium – eclampsia and polymorphic ventricular tachycardia. In this show we address the use of magnesium for various applications.

Magnesium for Acute Atrial Fibrillation with Rapid Ventricular Response (RVR)

1. Bouida et al. LOw dose MAGnesium sulfate versus HIgh dose in the early management of rapid atrial fibrillation: randomised controlled double blind study. Acad Emerg Med. 2018 Jul 19.
2. Ho KM, Sheridan DJ, Paterson T. Use of intravenous magnesium to treat acute onset atrial fibrillation: a meta-analysis. Heart. 2007;93(11):1433-40.
3. Davey MJ, Teubner D. A randomized controlled trial of magnesium sulfate, in addition to usual care, for rate control in atrial fibrillation. Ann Emerg Med. 2005;45(4):347-53.

Magnesium for Migraine

1. Corbo J, Esses D, Bijur PE, Iannaccone R, Gallagher EJ. Randomized clinical trial of intravenous magnesium sulfate as an adjunctive medication for emergency department treatment of migraine headache. Ann Emerg Med. 2001;38(6):621–7.
2. Bigal ME, Bordini CA, Tepper SJ, Speciali JG. Intravenous magnesium sulphate in the acute treatment of migraine without aura and migraine with aura. A randomized, double-blind, placebo-controlled study. Cephalalgia. 2002;22(5):345-53.
3. 1Cete Y, Dora B, Ertan C, Ozdemir C, Oktay C. A randomized prospective placebo-controlled study of intravenous magnesium sulphate vs. metoclopramide in the management of acute migraine attacks in the Emergency Department. Cephalalgia. 2005;25(3):199–204.
4. Shahrami A, Assarzadegan F, Hatamabadi HR, Asgarzadeh M, Sarehbandi B, Asgarzadeh S. Comparison of therapeutic effects of magnesium sulfate vs. dexamethasone/metoclopramide on alleviating acute migraine headache. J Emerg Med. 2015;48(1):69–76.
5. Orr SL, Friedman BW, Christie S, Minen MT, Bamford C, Kelley NE, et al. Management of Adults with Acute Migraine in the Emergency Department: The American Headache Society Evidence Assessment of Parenteral Pharmacotherapies. Headache. 2016;56(6):911–40.

Magnesium for Acute Asthma Exacerbation

Griffiths B, Kew KM. Intravenous magnesium sulfate for treating children with acute asthma in the emergency department. Cochrane Database Syst Rev. 2016;4:CD011050.
Kew KM, Kirtchuk L, Michell CI. Intravenous magnesium sulfate for treating adults with acute asthma in the emergency department. Cochrane Database Syst Rev. 2014;(5):CD010909.

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In this episode we highlight key articles in Emergency Medicine that came out, thus far, in 2018.

D’souza et al. Effects of prophylactic anticholinergic medications to decrease extrapyramidal side effects in patients taking acute antiemetic drugs: a systematic review and meta-analysis Emerg Med J. 2018;35(5):325-331.

Driver et al. Effect of Use of a Bougie vs Endotracheal Tube and Stylet on First-Attempt Intubation Success Among Patients With Difficult Airways Undergoing Emergency Intubation: A Randomized Clinical Trial. JAMA. 2018;319(21):2179-2189.Atkinson PR, Milne J, Diegelmann L, et al. Does Point-of-Care Ultrasonography Improve Clinical Outcomes in Emergency Department Patients With Undifferentiated Hypotension? An International Randomized Controlled Trial From the SHoC-ED Investigators. Ann Emerg Med. 2018; In press.

Perkins GD et al. A Randomized Trial of Epinephrine in Out-of-Hospital Cardiac Arrest. N Engl J Med 2018; 379:711-721

Meltzer et al. Effect of Tamsulosin on Passage of Symptomatic Ureteral Stones: A Randomized Clinical Trial. JAMA Intern Med. 2018 Aug 1;178(8):1051-1057

Kabrhel et al Multicenter Evaluation of the YEARS Criteria in Emergency Department Patients Evaluated for Pulmonary Embolism. Acad Emerg Med. 2018;25(9):987-994

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We are in San Diego for the American College of Emergency Physicians (ACEP) Scientific Assembly and are bringing you daily pearls from the lectures.

References

1. Chen F, Shen YH, Zhu XQ, Zheng J, Wu FJ. Comparison between CT and MRI in the assessment of pulmonary embolism: A meta-analysis. Medicine. 2017;96(52):e8935.
2. Akhter M et al. Ruling out Pulmonary Embolism in Patients with High Pretest Probability. Western Journal of Emergency Medicine. 2018; (18)3.
3. Hogg K, Brown G, Dunning J, et al. Diagnosis of pulmonary embolism with CT pulmonary angiography: a systematic review. Emerg Med J. 2006;23(3):172-8.
4. Mccrindle BW, Rowley AH, Newburger JW, et al. Diagnosis, Treatment, and Long-Term Management of Kawasaki Disease: A Scientific Statement for Health Professionals From the American Heart Association. Circulation. 2017;135(17):e927-e999.
5. Schwartz RH, Kim D, Martin M, Pichichero ME. A Reappraisal of the Minimum Duration of Antibiotic Treatment Before Approval of Return to School for Children With Streptococcal Pharyngitis. Pediatr Infect Dis J. 2015;34(12):1302-4.

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We are in San Diego for the American College of Emergency Physicians (ACEP) Scientific Assembly and are bringing you daily pearls from the lectures.

We cover a lecture by Nathan Schlicher on problems with CYA medicine including admissions (which can be harmful), imaging (also can be harmful), and polypharmacy.

We also cover a lecture by Haney Mallemat on the utility of common biomarkers.

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We are in San Diego for the American College of Emergency Physicians (ACEP) Scientific Assembly and are bringing you daily pearls from the lectures.

Nazerian P, Mueller C, Dematosoeiro A, et al. Diagnostic Accuracy of the Aortic Dissection Detection Risk Score Plus D-Dimer for Acute Aortic Syndromes: The ADvISED Prospective Multicenter Study. Circulation. 2018 Jan 16;137(3):250-258

Check out this post from Highland on regional anesthesia for rib fractures

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We review the American Urological Association guidelines on penile fracture and priapism. We supplement this with core content from Tintinalli and Rosen’s.

Rosh Review Emergency Board Review Questions

A 16-year-old boy with sickle cell disease presents to the emergency department having intermittent but frequent short and painful erections. He denies current pain but reports having had four unwanted painful erections beginning this morning, each becoming progressively longer with the most recent lasting one hour. On exam he is well appearing and in no distress with a flaccid non-tender penis on genitourinary exam. Which of the following is the most appropriate next step?

A. Corporal aspiration

B. Oxygen

C. Pseudoephedrine

D. Warm penile compress

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C. Priapism is a painful erection unrelated to sexual stimulation. It is most common in sickle cell patients and is usually an ischemic, low–flow process resulting in venous stasis and sickling of cells. Irreversible tissue damage begins at six hours, so patients with a painful erection are taught to seek medical attention with erections lasting more than four hours. Optimal management is not well defined and local expert opinion may vary. Brief episodes can often be managed at home with oral analgesics, brief exercise, warm/cold compresses, or showering. Recurrent episodes of priapism such as seen in our patient are referred to as stuttering priapism which may herald a longer event. The first-line treatment for stuttering priapism is with an oral alpha-adrenergic agent such as pseudoephedrine. Patients with priapism lasting more than four hours are treated with a combination of intravenous fluids, intravenous analgesia, and emergent urology consult for corporal aspiration. Conscious sedation may be indicated depending on patient age and anxiety. Once low-flow priapism is confirmed, intracavernosal injection of an alpha-adrenergic receptor agent such as phenylephrine can help to achieve detumescence. If multiple attempts at corporal aspiration fail, a surgical shunt may be indicated.

Corporal aspiration (A) is not recommended in patients with current detumescence as in our patient. Oxygen (B) is recommended if hypoxic but has not been shown to assist in achieving detumescence. Warm penile compresses (D) are a recommended home therapy to achieve detumescence early in a painful erection but will not help between recurrent stuttering priapism.

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A 21-year-old man presents to the Emergency Department with sudden onset penile pain that occurred while having intercourse with his wife. Physical examination reveals an angulated circumcised penis with fusiform swelling and ecchymosis. Which of the following is the next best step in management?

A. Analgesic therapy and outpatient urology follow up

B. Foley catheter placement

C. Intracavernosal phenylephrine injection

D. Urologic consultation for surgical repair

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D. A urologic consultation for surgical repair is required to optimize functional outcome in the case of penile fracture. Penile fractures occur during direct penile trauma and involves rupture of Buck’s fascia, tunica albuginea, or corpora cavernosa. Symptoms include acute pain and swelling, angulation of the penis, and loss of erection. The penis may take on a characteristic “eggplant deformity” due to swelling and ecchymosis from extravasated blood that collects within Buck’s fascia. Complications include deep dorsal vein injury and partial or complete urethral rupture. Sexual intercourse is the most common cause, but other causes include animal bites, ballistic injuries, stab wounds, and vigorous masterbation. Management involves early surgical repair of the tunica albuginea (within 24-36 hours after the injury) to improve functionality.

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