Contributor: Aaron Lessen, MD Educational Pearls:

How do we take care of kids in severe pain?

• There are many non-pharmacologic options for pain (i.e. ice, elevation) as well as more conventional medication options (i.e. acetaminophen, NSAIDS) but in severe pain stronger medications might be indicated.
• These stronger medications include options such as IV morphine, a subdissociative dose of ketamine, as well as intranasal fentanyl.
• Intranasal fentanyl has many advantages:
  • Studies have shown it might be more effective early on in controlling pain, as in the first 15-20 minutes after administration, and then becomes equivalent to other pain control options
  • Total adverse effects were also lower with IN fentanyl, including low rates of nausea and vomiting
  • To administer, use the IV formulation with an atomizer and spray into the nose; therefore, you do not need an IV line
  • Dose is 1-2 micrograms per kilogram, can be redosed once at 10 minutes. 
• Don’t forget about gabapentinoids for neuropathic pain, muscle relaxants for muscle spasms, and nerve blocks when appropriate. (Disclaimer: muscle relaxers have not been well studied in children)

References

1. Alsabri M, Hafez AH, Singer E, Elhady MM, Waqar M, Gill P. Efficacy and Safety of Intranasal Fentanyl in Pediatric Emergencies: A Systematic Review and Meta-analysis. Pediatr Emerg Care. 2024 Oct 1;40(10):748-752. doi: 10.1097/PEC.0000000000003187. Epub 2024 Apr 11. PMID: 38713846.
2. Bailey B, Trottier ED. Managing Pediatric Pain in the Emergency Department. Paediatr Drugs. 2016 Aug;18(4):287-301. doi: 10.1007/s40272-016-0181-5. PMID: 27260499.
3. Hadland SE, Agarwal R, Raman SR, Smith MJ, Bryl A, Michel J, Kelley-Quon LI, Raval MV, Renny MH, Larson-Steckler B, Wexelblatt S, Wilder RT, Flinn SK. Opioid Prescribing for Acute Pain Management in Children and Adolescents in Outpatient Settings: Clinical Practice Guideline. Pediatrics. 2024 Sep 30:e2024068752. doi: 10.1542/peds.2024-068752. Epub ahead of print. PMID: 39344439.

Summarized by Jeffrey Olson, MS4 | Edited by Jorge Chalit, OMS4

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Contributor: Travis Barlock, MD Educational Pearls:

• Wheezing is classically heard in asthma and COPD, but it can be the result of a wide range of processes that cause airflow limitation
  • Narrowed bronchioles lead to turbulent airflow → creates the wheezing
• Crackles (rales) suggest pulmonary edema which is often due to heart failure
• Approximately 35% of heart failure patients have bronchial edema, which can also produce wheezing
• COPD and heart failure can coexist in a patient, and both of these diseases can cause wheezing
  • It’s vital to differentiate whether the wheezing is due to the patient’s COPD or their heart failure because the treatment differs
• Diagnosing wheezing due to heart failure (cardiac asthma):
  • Symptoms: orthopnea, paroxysmal nocturnal dyspnea
  • Diagnostic tools: bedside ultrasound
  • Treatment: diuresis and BiPAP for respiratory support
• Not all wheezing is asthma
  • Consider heart failure in the differential and tailor treatment accordingly

References 1. Buckner K. Cardiac asthma. Immunol Allergy Clin North Am. 2013 Feb;33(1):35-44. doi: 10.1016/j.iac.2012.10.012. Epub 2012 Dec 23. PMID: 23337063.

2. Hollingsworth HM. Wheezing and stridor. Clin Chest Med. 1987 Jun;8(2):231-40. PMID: 3304813.

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

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Contributor: Jorge Chalit-Hernandez, OMS3 Educational Pearls:

• Psychedelics are being studied for their therapeutic effects in mental illnesses, including major depressive disorder, post-traumatic stress disorder, anxiety, and many others
• Classic psychedelics include compounds like psilocybin, LSD, and ayahuasca
  • MDMA and ketamine are often included in psychedelic research, but have a different mechanism of action than the others
  • Their mechanism of action involves agonism of the 5HT2A receptor, among others
  • Given their resurgence, there is an increase in recreational use of these substances
• A recent study assessed the risks of recreational users developing subsequent psychotic disorders
  • Individuals who visited the ED for hallucinogen use had a greater risk of being diagnosed with a schizophrenia spectrum disorder in the following 3 years
  • Hazard ratio (HR) of 21.32
  • After adjustment for comorbid substance use and other mental illness, the hazard ratio was 3.53 - still a significant increase compared with the general population
  • They also found an elevated risk for psychedelics when compared to alcohol (HR 4.66) and cannabis (HR 1.47)
• The study did not assess whether patients received antipsychotics or other treatments in the ED

References

1. Lieberman JA. Back to the Future - The Therapeutic Potential of Psychedelic Drugs. N Engl J Med. 2021;384(15):1460-1461. doi:10.1056/NEJMe2102835
2. Livne O, Shmulewitz D, Walsh C, Hasin DS. Adolescent and adult time trends in US hallucinogen use, 2002-19: any use, and use of ecstasy, LSD and PCP. Addiction. 2022;117(12):3099-3109. doi:10.1111/add.15987
3. Myran DT, Pugliese M, Xiao J, et al. Emergency Department Visits Involving Hallucinogen Use and Risk of Schizophrenia Spectrum Disorder. JAMA Psychiatry. 2025;82(2):142-150. doi:10.1001/jamapsychiatry.2024.3532

Summarized & Edited by Jorge Chalit, OMS3 Donate: https://emergencymedicalminute.org/donate/

Contributor: Ricky Dhaliwal, MD Educational Pearls:

What factors are considered in a COVID-19 infection?

• The viral load: Understood as the impact of SARS-CoV-2 viral particles infecting host cell tissue itself (utilizing ACE-2 receptors).
• Pro-Inflammatory Response: Post-infection, the body's downstream systemic cytokine release (can be both normal or hyperactive, aka “cytokine storm”).

What cardiac impacts have been observed with COVID-19?

• Arrhythmias: The mechanism of COVID-19 infection and arrhythmias is believed to be multifactorial. However, evidence suggests T-cell-mediated toxicity and cytokine storm may contribute to cardiac myocyte damage, precipitating proarrhythmias instead of direct viral entry.
  • Bradycardia: Increased prevalence in patients with severe COVID-19 infection, but not associated with increased adverse outcomes.
  • Atrial Fibrillation: Most common cardiac complication and risk factor for worsened outcomes in patients with COVID-19. Biggest associated risk is strokes, and may require heightened monitoring and anticoagulation therapy to mitigate stroke risk.
• Fibrosis of Cardiac Tissue: Similar to arrhythmias, believed to be inflammation-mediated in COVID-19. Fibrosis of cardiac tissue increases the risk that any arrhythmias that develop during infection may persist after the infection has resolved.
• Ventricular damage: Also inflammation mediated by an active infection and contributes to myocarditis.
  • No evidence suggests that COVID-19 vaccination contributes to myocarditis. 
• Sinus node dysfunction induced by inflammation that may lead to or be similar to Postural Orthostatic Tachycardia Syndrome (POTS). 

Big takeaway?

• Patients who have had or currently have COVID-19 are at an increased risk of developing arrhythmias and sustaining them post-infection. However, a majority of patients will recover.
• Due to atrial fibrillation being the most prevalent arrhythmia associated with COVID-19 infection, increased monitoring and potential anticoagulation therapy are required. 

References

1. Gopinathannair R, Olshansky B, Chung MK, Gordon S, Joglar JA, Marcus GM, et al. Cardiac Arrhythmias and Autonomic Dysfunction Associated With COVID-19: A Scientific Statement From the American Heart Association. Circulation. 2024 Nov 19;150(21):e449–65.
2. Khan Z, Pabani UK, Gul A, Muhammad SA, Yousif Y, Abumedian M, et al. COVID-19 Vaccine-Induced Myocarditis: A Systemic Review and Literature Search. Cureus. 14(7):e27408.

Summarized by Dan Orbidan, OMS1 | Edited by Dan Orbidan & Jorge Chalit, OMS3

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Contributor: Aaron Lessen, MD

Educational Pearls:

What is a Rescue Inhaler?

• A rescue inhaler is a medication for people with asthma to quickly reverse the symptoms of an asthma attack. 

• Historically albuterol (Short Acting Beta Agonist (SABA)) monotherapy has been the mainstay rescue inhaler. This is because albuterol works fast and is relatively cheap. \n\n

What are Combination Rescue Inhalers?

• Combination rescue inhalers contain a fast-acting bronchodilator as well as an inhaled corticosteroid (ICS)

• The steroid helps to reduce some of the chronic airway inflammation that is worsening the asthma attack and can help to prevent future attacks

• Examples include budesonide-formoterol and albuterol-budesonide

• Global Initiative for Asthma (GINA), states that combination therapy is now the preferred reliever for adults and adolescents with mild asthma

What are the drawbacks of Combination Rescue Inhalers? 

• These inhalers are generally more expensive than just using a SABA inhaler which can be a barrier for some people \n\n

• Improper use can also lead to conditions like thrush due to the addition of the steroid 

References 

1. Krings JG, Beasley R. The Role of ICS-Containing Rescue Therapy Versus SABA Alone in Asthma Management Today. J Allergy Clin Immunol Pract. 2024 Apr;12(4):870-879. doi: 10.1016/j.jaip.2024.01.011. Epub 2024 Jan 17. PMID: 38237858; PMCID: PMC10999356. 

2. Papi A, Chipps BE, Beasley R, Panettieri RA Jr, Israel E, Cooper M, Dunsire L, Jeynes-Ellis A, Johnsson E, Rees R, Cappelletti C, Albers FC. Albuterol-Budesonide Fixed-Dose Combination Rescue Inhaler for Asthma. N Engl J Med. 2022 Jun 2;386(22):2071-2083. doi: 10.1056/NEJMoa2203163. Epub 2022 May 15. PMID: 35569035. 

Summarized by Jeffrey Olson, MS3 | Edited by Jorge Chalit, OMS3 \n\n

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Contributor: Geoff Hogan MD

Educational Pearls:

• Penicillin allergies are relatively uncommon despite their frequent reports

• 10% of the population reports a penicillin allergy but only 5% of these cases are clinically significant

• 90-95% of patients may tolerate a rechallenge after appropriate allergy evaluation

• Penicillin Allergy Decision Rule (PEN-FAST) on MD Calc

• Useful tool to assess patients for penicillin allergies

• Five years or less since reaction = 2 points (even if unknown)

• Anaphylaxis or angioedema OR Severe cutaneous reaction = 2 points 

• Treatment required for reaction (e.g. epinephrine) = 1 point (even if unknown)

• A score of 0 on PEN-FAST indicates a less than 1% risk of a positive penicillin allergy test

• A score of 1 or 2 indicates a 5% risk of a positive penicillin allergy test

• A low score on PEN-FAST should prompt clinicians to proceed with the best empiric antibiotic for the patient’s infection

References

1. Broyles AD, Banerji A, Barmettler S, et al. Practical Guidance for the Evaluation and Management of Drug Hypersensitivity: Specific Drugs [published correction appears in J Allergy Clin Immunol Pract. 2021 Jan;9(1):603. doi: 10.1016/j.jaip.2020.10.025.] [published correction appears in J Allergy Clin Immunol Pract. 2021 Jan;9(1):605. doi: 10.1016/j.jaip.2020.11.036.]. J Allergy Clin Immunol Pract. 2020;8(9S):S16-S116. doi:10.1016/j.jaip.2020.08.006

2. Piotin A, Godet J, Trubiano JA, et al. Predictive factors of amoxicillin immediate hypersensitivity and validation of PEN-FAST clinical decision rule [published correction appears in Ann Allergy Asthma Immunol. 2022 Jun;128(6):740. doi: 10.1016/j.anai.2022.04.005.]. Ann Allergy Asthma Immunol. 2022;128(1):27-32. doi:10.1016/j.anai.2021.07.005

3. Shenoy ES, Macy E, Rowe T, Blumenthal KG. Evaluation and Management of Penicillin Allergy: A Review. JAMA. 2019;321(2):188-199. doi:10.1001/jama.2018.19283

4. Trubiano JA, Vogrin S, Chua KYL, et al. Development and Validation of a Penicillin Allergy Clinical Decision Rule. JAMA Intern Med. 2020;180(5):745-752. doi:10.1001/jamainternmed.2020.0403

Summarized & edited by Jorge Chalit, OMS3

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Contributor: Travis Barlock, MD

Educational Pearls:

• Key clinical considerations when managing heart transplant patients due to their unique pathophysiology

• 1. Arrhythmias

• A transplanted heart is denervated, meaning it lacks autonomic nervous system innervation

• The lack of vagal tone results in an increased resting heart rate

• Adenosine can be used since it primarily slows conduction through the AV node 

• Atropine is ineffective in treating transplant bradyarrhythmia because its mechanism is to inhibit the vagus nerve - but the heart lacks vagal tone

• Allograft rejection can also cause tachycardia

• Consult transplant surgery - treatment is usually 500 mg methylprednisolone

• 2. Rejection

• Transplant patients are administered immunosuppressants

• Clinical presentation of acute rejection looks similar to heart failure with increased BNP, increased troponin, and pulmonary edema 

• Cardiac allograft vasculopathy is a form of chronic rejection

• Patients will not report chest pain due to denervated heart

• Symptoms are usually weakness and fatigue

• 3. High risk of infection due to immunosuppression

• Increased risk of infections which includes CMV, legionella, tuberculosis, etc

• Immunosuppressants have side effects such as acute kidney injury or pancytopenia

• 4. Radiographic Cardiomegaly

• A study found that radiographic cardiomegaly does not connote heart failure

• They hypothesized it is instead the result of a mismatch between the size of the transplanted heart and the space in the thoracic cavity 

References

1. Murphy JD, Mergo PJ, Taylor HM, Fields R, Mills RM Jr. Significance of radiographic cardiomegaly in orthotopic heart transplant recipients. AJR Am J Roentgenol. 1998 Aug;171(2):371-4. doi: 10.2214/ajr.171.2.9694454. PMID: 9694454.

2. Park MH, Starling RC, Ratliff NB, McCarthy PM, Smedira NS, Pelegrin D, Young JB. Oral steroid pulse without taper for the treatment of asymptomatic moderate cardiac allograft rejection. J Heart Lung Transplant. 1999 Dec;18(12):1224-7. doi: 10.1016/s1053-2498(99)00098-4. PMID: 10612382.

3. Pethig K, Heublein B, Wahlers T, Dannenberg O, Oppelt P, Haverich A. Mycophenolate mofetil for secondary prevention of cardiac allograft vasculopathy: influence on inflammation and progression of intimal hyperplasia. J Heart Lung Transplant. 2004 Jan;23(1):61-6. doi: 10.1016/s1053-2498(03)00097-4. PMID: 14734128.

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

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Contributor: Taylor Lynch, MD

Educational Pearls:

• Pediatric febrile seizures are defined as seizures that occur between the ages of six months to five years in the presence of a fever greater than or equal to 38.0 ºC (100.4 ºF). It is the most common pediatric convulsive disorder, with an incidence between 2-5%

• What are the types of seizures?

• Simple: Tonic-clonic seizure, duration 15 minutes, requires medication to stop the seizing, multiple occurrences in a 24-hour period, PRESENCE of focal features, PRESENCE of Todd’s paralysis

• What are the causes?

• Caused by infectious agents leading to fever. Seen with common childhood infections. 

• It is debated whether the absolute temperature of the fever or the rate of change of temperature incites the seizure, but current evidence points to the rate of change of the temperature being the primary catalyst

• What are the treatment considerations?

• For simple febrile seizures, work-up is similar to any pediatric patient presenting with a fever between the ages of six months and five years

• Thorough physical exam to rule out any potential of meningeal or intracranial infections

• Prophylactic antipyretics are not believed to prevent the occurrence of febrile seizures

• Disposition? 

• If the patient has returned to normal baseline behavior following a simple febrile seizure, and the physical exam is reassuring, the patient can be discharged home. 

• Additional labs, electroencephalogram, or lumbar punctures are not indicated in simple febrile seizures as long as the physical exam is completely normal

• Any evidence of a complex seizure requires further workup

• Fast Facts: 

• Patients with a familial history of febrile seizures and developmental delays have a higher risk of developing febrile seizures

• If a child has one febrile seizure, there is a 30-40% chance of another febrile seizure by age 5

• Only 2-7% of children with febrile seizures go on to develop epilepsy

References: 

1. Berg AT, Shinnar S, Hauser WA, Alemany M, Shapiro ED, Salomon ME, et al. A prospective study of recurrent febrile seizures. N Engl J Med. 1992 Oct 15;327(16):1122–7. 

2. Schuchmann S, Vanhatalo S, Kaila K. Neurobiological and physiological mechanisms of fever-related epileptiform syndromes. Brain Dev. 2009 May;31(5):378–82. 

3. Nilsson G, Westerlund J, Fernell E, Billstedt E, Miniscalco C, Arvidsson T, et al. Neurodevelopmental problems should be considered in children with febrile seizures. Acta Paediatr. 2019 Aug;108(8):1507–14. 

4. Subcommittee on Febrile Seizures, American Academy of Pediatrics. Neurodiagnostic evaluation of the child with a simple febrile seizure. Pediatrics. 2011 Feb;127(2):389–94. 

5. Pavlidou E, Panteliadis C. Prognostic factors for subsequent epilepsy in children with febrile seizures. Epilepsia. 2013 Dec;54(12):2101–7. 

6. Huang CC, Wang ST, Chang YC, Huang MC, Chi YC, Tsai JJ. Risk factors for a first febrile convulsion in children: a population study in southern Taiwan. Epilepsia. 1999 Jun;40(6):719–25. 

7. Hashimoto R, Suto M, Tsuji M, Sasaki H, Takehara K, Ishiguro A, et al. Use of antipyretics for preventing febrile seizure recurrence in children: a systematic review and meta-analysis. Eur J Pediatr. 2021 Apr;180(4):987–97. 

Summarized by Dan Orbidan, OMS1 | Edited by Dan Orbidan & Jorge Chalit, OMS3

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Contributor: Aaron Lessen, MD

Educational Pearls:

• Point-of-care ultrasound (POCUS) is used to assess cardiac activity during cardiac arrest and can identify potential reversible causes such as pericardial tamponade

• Ultrasound could be beneficial in another way during cardiac arrest as well: pulse checks

• Manual palpation for detecting pulses is imperfect, with false positives and negatives

• Doppler ultrasound can be used as an adjunct or replacement to manual palpation for improved accuracy

• Options for Doppler ultrasound of carotid or femoral pulses during cardiac arrest:

• Visualize arterial pulsation

• Use color doppler

• Numerically quantify the flow and correlate this to a BP reading - slightly more complex

• Doppler ultrasound is much faster than manual palpation for pulse check

• Can provide information almost instantaneously without waiting the full 10 seconds for a manual pulse check

• The main priority during cardiac arrest resuscitation is to maintain quality compressions

• If pulses are unable to be obtained through Doppler within the 10-second window, resume compressions and try again during the next pulse check

References

1. Cohen AL, Li T, Becker LB, Owens C, Singh N, Gold A, Nelson MJ, Jafari D, Haddad G, Nello AV, Rolston DM; Northwell Health Biostatistics Unit. Femoral artery Doppler ultrasound is more accurate than manual palpation for pulse detection in cardiac arrest. Resuscitation. 2022 Apr;173:156-165. doi: 10.1016/j.resuscitation.2022.01.030. Epub 2022 Feb 4. PMID: 35131404.

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

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Contributor: Travis Barlock, MD

Educational Pearls:

What is Hoover’s sign used to identify?

• This physical exam maneuver differentiates between organic vs. functional (previously known as psychogenic) leg weakness.

• Organic causes include disease processes such as stroke, MS, spinal cord compression, guillain-barre, ALS, and sciatica, among others

• In Functional Neurologic Disorder, the dysfunction is in brain signaling, and treatment relies on more of a psychiatric approach

How is Hoover's Sign performed?

• Place your hand under the heel of the unaffected leg and ask the patient to attempt to lift the paralyzed leg.

• If the paralysis is due to an organic cause, then you should feel the unaffected leg push down.

• This is due to the crossed-extensor reflex mechanism, an unconscious motor control function mediated by the corticospinal tract.

• If you don’t feel the opposite heel push down, that is a positive Hoover’s Sign.

How sensitive/specific is it?

• An unblinded cohort study in patients with suspected stroke found a sensitivity of 63% and a specificity of 100%

Fun Fact

• There’s also a pulmonary Hoover’s sign, named after the same doctor, Charles Franklin Hoover, which refers to paradoxical inward movement of the lower ribs during inspiration due to diaphragmatic flattening in COPD.

References

1. McWhirter L, Stone J, Sandercock P, Whiteley W. Hoover's sign for the diagnosis of functional weakness: a prospective unblinded cohort study in patients with suspected stroke. J Psychosom Res. 2011 Dec;71(6):384-6. doi: 10.1016/j.jpsychores.2011.09.003. Epub 2011 Oct 6. PMID: 22118379.

2. Stone J, Aybek S. Functional limb weakness and paralysis. Handb Clin Neurol. 2016;139:213-228. doi: 10.1016/B978-0-12-801772-2.00018-7. PMID: 27719840.

Summarized by Jeffrey Olson, MS3 | Edited by Jorge Chalit, OMS3

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