Emergency Medical Minute Emergency Medical Minute

Contributor: Aaron Lessen MD
Educational Pearls:
The case:
A gentleman came in from a nursing home with symptoms concerning for sepsis. He was hypotensive, hypoxic, febrile, and mentally altered.
His past medical history included previous strokes which had left him with deficits for which he required a feeding tube.
Initial workup included some point of care labs which revealed a sodium of 165 mEq/L (normal range 135-145)
Hypernatremia
What causes it?
Dehydration, from insufficient fluid intake. This might happen in individuals who cannot drink water independently, such as infants, elderly, or disabled people, as was the case for this patient.
Other causes of dehydration/hypernatremia include excessive sweating; diabetes insipidus; diuretic use; kidney dysfunction; and severe burns which can lead to fluid loss through the damaged skin.
How do you correct it?
Need to correct slowly, not more than 10 to 12 meq/L in 24 hours
Can do normal saline (0.9%) or half saline (0.45%) and D5, at 150-200 mL per hour.
Check the sodium frequently (every 2-3 hours)
Will likely need ICU-level monitoring
What happens if you correct it too quickly?
Cerebral edema
Seizures
Bonus fact: Correction of hyponatremia too quickly causes osmotic demyelination syndrome (ODS).
References
Chauhan, K., Pattharanitima, P., Patel, N., Duffy, A., Saha, A., Chaudhary, K., Debnath, N., Van Vleck, T., Chan, L., Nadkarni, G. N., & Coca, S. G. (2019). Rate of Correction of Hypernatremia and Health Outcomes in Critically Ill Patients. Clinical journal of the American Society of Nephrology : CJASN, 14(5), 656–663. https://doi.org/10.2215/CJN.10640918
Lindner, G., & Funk, G. C. (2013). Hypernatremia in critically ill patients. Journal of critical care, 28(2), 216.e11–216.e2.16E20. https://doi.org/10.1016/j.jcrc.2012.05.001
Muhsin, S. A., & Mount, D. B. (2016). Diagnosis and treatment of hypernatremia. Best practice & research. Clinical endocrinology & metabolism, 30(2), 189–203. https://doi.org/10.1016/j.beem.2016.02.014
Summarized by Jeffrey Olson MS2 | Edited by Meg Joyce & Jorge Chalit, OMSIII

Contributor: Aaron Lessem MD
Educational Pearls: 
Oseltamivir (Tamiflu) is an antiviral medication used commonly to treat influenza
Trials show that the medication reduces the duration of illness by less than 1 day (~16 hours in one systematic review)
Benefit only occurs if taken within 48 hours of symptom onset
Must be taken for 5 days
A 2024 meta-analysis reviewed 15 randomized-controlled trials for the risk of hospitalization
No reduction in hospitalizations with oseltamivir in patients over the age of 12
No difference in high-risk patients over the age of 65 or those with comorbidities
The authors note that the confidence interval in these populations is wide, indicating a need for subsequent studies in high-risk populations
Oseltamivir is associated with adverse effects including nausea, vomiting, and neurologic symptoms
The risk of adverse effects may outweigh the benefits of a small reduction in the duration of illness
References
1. Hanula R, Bortolussi-Courval É, Mendel A, Ward BJ, Lee TC, McDonald EG. Evaluation of Oseltamivir Used to Prevent Hospitalization in Outpatients with Influenza: A Systematic Review and Meta-Analysis. JAMA Intern Med. 2024;184(1):18-27. doi:10.1001/jamainternmed.2023.0699
2. Jefferson T, Jones M, Doshi P, Spencer EA, Onakpoya I, Heneghan CJ. Oseltamivir for influenza in adults and children: Systematic review of clinical study reports and summary of regulatory comments. BMJ. 2014;348(April):1-18. doi:10.1136/bmj.g2545
Summarized by Jorge Chalit, OMSII | Edited by Meg Joyce & Jorge Chalit
 

Contributor: Aaron Lessen MD
Educational Pearls:
Epinephrine is essential in the treatment of anaphylaxis, but is epinephrine dangerous from a cardiovascular perspective?
A 2024 study in the Journal of the American College of Emergency Physicians Open sought to answer this question.
Methods:
Retrospective observational study at a Tennessee quaternary care academic ED that analyzed ED visits from 2017 to 2021 involving anaphylaxis treated with IM epinephrine.
The primary outcome was cardiotoxicity
Results:
Out of 338 patients, 16 (4.7%) experienced cardiotoxicity. Events included ischemic EKG changes (2.4%), elevated troponin (1.8%), atrial arrhythmias (1.5%), ventricular arrhythmia (0.3%), and depressed ejection fraction (0.3%).
Affected patients were older, had more comorbidities, and often received multiple epinephrine doses.
Bottom line:
All adults presenting with anaphylaxis should be rapidly treated with epinephrine but monitored closely for cardiotoxicity, especially in patients with a history of hypertension and those who receive multiple doses.
These results are supported by a 2017 study that found that 9% (4/44) of older patients who received epinephrine for anaphylaxis had cardiovascular complications.
References
Kawano, T., Scheuermeyer, F. X., Stenstrom, R., Rowe, B. H., Grafstein, E., & Grunau, B. (2017). Epinephrine use in older patients with anaphylaxis: Clinical outcomes and cardiovascular complications. Resuscitation, 112, 53–58. https://doi.org/10.1016/j.resuscitation.2016.12.020
Pauw, E. K., Stubblefield, W. B., Wrenn, J. O., Brown, S. K., Cosse, M. S., Curry, Z. S., Darcy, T. P., James, T. E., Koetter, P. E., Nicholson, C. E., Parisi, F. N., Shepherd, L. G., Soppet, S. L., Stocker, M. D., Walston, B. M., Self, W. H., Han, J. H., & Ward, M. J. (2024). Frequency of cardiotoxicity following intramuscular administration of epinephrine in emergency department patients with anaphylaxis. Journal of the American College of Emergency Physicians open, 5(1), e13095. https://doi.org/10.1002/emp2.13095
Summarized by Jeffrey Olson MS2 | Edited by Meg Joyce & Jorge Chalit OMS II

Contributor: Aaron Lessen MD
Educational Pearls:
Opioid overdoses that are reversed with naloxone (Narcan), a mu-opioid antagonist, can precipitate acute withdrawal in some patients
Treatment of opioid use disorder with buprenorphine can also precipitate withdrawal
Opioid withdrawal symptoms include nausea, vomiting, diarrhea, and agitation
Buprenorphine works as a partial agonist at mu-opioid receptors, which may alleviate withdrawal symptoms
The preferred dose of buprenorphine is 16 mg
Treatment of buprenorphine-induced opioid withdrawal is additional buprenorphine
Adjunctive treatments may be used for other opioid withdrawal symptoms
Nausea with ondansetron
Diarrhea with loperamide
Agitation with hydroxyzine
References
1. Quattlebaum THN, Kiyokawa M, Murata KA. A case of buprenorphine-precipitated withdrawal managed with high-dose buprenorphine. Fam Pract. 2022;39(2):292-294. doi:10.1093/fampra/cmab073
2. Spadaro A, Long B, Koyfman A, Perrone J. Buprenorphine precipitated opioid withdrawal: Prevention and management in the ED setting. Am J Emerg Med. 2022;58:22-26. doi:10.1016/j.ajem.2022.05.013
Summarized by Jorge Chalit, OMSII | Edited by Meg Joyce & Jorge Chalit
 

Contributor: Travis Barlock MD
Educational Pearls:
How do you differentiate between compensated and decompensated cirrhosis?
Use the acronym VIBE to look for signs of being decompensated.
V-Volume
Cirrhosis can cause volume overload through a variety of mechanisms such as by increasing pressure in the portal vein system and the decreased production of albumin.
Look for pulmonary edema (dyspnea, orthopnea, wheezing/crackles, coughing up frothy pink sputum, etc.) or a tense abdomen.
I-Infection
The ascitic fluid can become infected with bacteria, a complication called Spontaneous Bacterial Peritonitis (SBP).
Look for abdominal pain, fever, hypotension, and tachycardia. Diagnosis is made with ascitic fluid cell analyses (polymorphonuclear neutrophils >250/mm3)
B-Bleeding
Another consequence of increased portal pressure is that blood backs up into smaller blood vessels, including those in the esophagus.
Over time, this increased pressure can result in the development of dilated, fragile veins called esophageal varices, which are prone to bleeding.
Look for hematemesis, melena, lightheadedness, and pale skin.
E-Encephalopathy
A failing liver also does not clear toxins which can affect the brain.
Look for asterixis (flapping motion of the hands when you tell the patient to hold their hands up like they are going to stop a bus)
Other complications to look out for.
Hepatorenal syndrome
Hepatopulmonary syndrome
References
Engelmann, C., Clària, J., Szabo, G., Bosch, J., & Bernardi, M. (2021). Pathophysiology of decompensated cirrhosis: Portal hypertension, circulatory dysfunction, inflammation, metabolism and mitochondrial dysfunction. Journal of hepatology, 75 Suppl 1(Suppl 1), S49–S66. https://doi.org/10.1016/j.jhep.2021.01.002
Enomoto, H., Inoue, S., Matsuhisa, A., & Nishiguchi, S. (2014). Diagnosis of spontaneous bacterial peritonitis and an in situ hybridization approach to detect an "unidentified" pathogen. International journal of hepatology, 2014, 634617. https://doi.org/10.1155/2014/634617
Mansour, D., & McPherson, S. (2018). Management of decompensated cirrhosis. Clinical medicine (London, England), 18(Suppl 2), s60–s65. https://doi.org/10.7861/clinmedicine.18-2-s60
Summarized by Jeffrey Olson MS2 | Edited by Meg Joyce & Jorge Chalit, OMS II
 

Contributor: Aaron Lessen MD
Educational Pearls:
Lorazepam (Ativan) is dosed at 0.1 mg/kg up to a maximum of 4 mg in status epilepticus
Some ED protocols only give 2 mg initially
The maximum recommended dose of levetiracetam (Keppra) is 60 mg/kg or 4.5 g
In one retrospective study, only 50% of patients received the correct dose of lorazepam
For levetiracetam, it was only 35% of patients
Underdosing leads to complications
Higher rates of intubations
More likely to progress to refractory status epilepticus
References
1. Cetnarowski A, Cunningham B, Mullen C, Fowler M. Evaluation of intravenous lorazepam dosing strategies and the incidence of refractory status epilepticus. Epilepsy Res. 2023;190(November 2022):107067. doi:10.1016/j.eplepsyres.2022.107067
2. Sathe AG, Tillman H, Coles LD, et al. Underdosing of Benzodiazepines in Patients With Status Epilepticus Enrolled in Established Status Epilepticus Treatment Trial. Acad Emerg Med. 2019;26(8):940-943. doi:10.1111/acem.13811
Summarized by Jorge Chalit, OMSII | Edited by Meg Joyce & Jorge Chalit