Contributor: Megan Hurley, MD

Educational Pearls:

Fevers

• Tylenol

• Up until 20 weeks NSAIDs are ok but after 20 weeks they are contraindicated

• Can limit the amount of amniotic fluid produced

• Can lead to growth restriction

• Can cause premature closure of the ductus arteriosus

Cough

• Cough drops

• Humidifier

• Guafenesine and dextromethorphan (Mucinex) is not well studied but is probably ok with caution in certain circumstances such as post-tussive emesis causing poor PO intake and weight loss

Congestion

• Flonase (Fluticasone nasal spray)

• Nasal rinses

• Humidifier

• 1st generation anti-histamines (Diphenhydramine, Doxylamine, etc.)

• However, these tend to have more side effects such as fatigue, drowsiness, and dizziness

• Concider switching to a 2nd generation (Cetirizine, Loratidine, etc.) during the day

Disease specific treatments

• Flu (A and B) gets tamiflu (Oseltamivir)

• Covid gets paxlovid (Nirmatrelvir/ritonavir)

• Antibiotics for suspected pneumonia

Additional recommendations

• Elevating the head of bed

• Nasal strips

• Stay well hydrated

• Tea

• Ice chips

• Echinacea

• Zinc

• Rest

Avoid

• NSAIDs

• Pseudophedrine

• Afrin (Oxymetazoline)

• Combined meds in general

References

1. Antonucci, R., Zaffanello, M., Puxeddu, E., Porcella, A., Cuzzolin, L., Pilloni, M. D., & Fanos, V. (2012). Use of non-steroidal anti-inflammatory drugs in pregnancy: impact on the fetus and newborn. Current drug metabolism, 13(4), 474–490. https://doi.org/10.2174/138920012800166607

2. Black, E., Khor, K. E., Kennedy, D., Chutatape, A., Sharma, S., Vancaillie, T., & Demirkol, A. (2019). Medication Use and Pain Management in Pregnancy: A Critical Review. Pain practice : the official journal of World Institute of Pain, 19(8), 875–899. https://doi.org/10.1111/papr.12814

3. D'Ambrosio, V., Vena, F., Scopelliti, A., D'Aniello, D., Savastano, G., Brunelli, R., & Giancotti, A. (2023). Use of non-steroidal anti-inflammatory drugs in pregnancy and oligohydramnios: a review. The journal of maternal-fetal & neonatal medicine : the official journal of the European Association of Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International Society of Perinatal Obstetricians, 36(2), 2253956. https://doi.org/10.1080/14767058.2023.2253956

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

Contributor: Travis Barlock MD

Educational Pearls:

• Assessment of head and neck vascular injury due to blunt trauma

• Symptomatic patients require screening head and neck CT angiography

• EAST guidelines include the following criteria for a screening CT angiography in blunt head trauma:

• Unexplained neurological deficits

• Arterial nosebleed

• GCS

• Petrous bone fracture

• Cervical spine fracture

• Any size fracture through the transverse foramen

• LeFort fractures type II or type III

• EAST guidelines include a grading scale for vascular injury:

• Grade I: Luminal irregularity or dissection with

• Grade II: Dissection or intramural hematoma with >25% luminal narrowing, intraluminal thrombus, or raised intimal flap

• Grade III: Pseudoaneurysm

• Grade IV: Occlusion

• Grade V: Transection with free extravasation

References

1. Bensch FV, Varjonen EA, Pyhältö TT, Koskinen SK. Augmenting Denver criteria yields increased BCVI detection, with screening showing markedly increased risk for subsequent ischemic stroke. Emerg Radiol. 2019;26(4):365-372. doi:10.1007/s10140-019-01677-0

2. Biffl WL, Moore EE, Offner PJ, et al. Optimizing screening for blunt cerebrovascular injuries. Am J Surg. 1999;178(6):517-522. doi:10.1016/s0002-9610(99)00245-7

3. Kim DY, Biffl W, Bokhari F, et al. Evaluation and management of blunt cerebrovascular injury: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2020;88(6):875-887. doi:10.1097/TA.0000000000002668

Summarized & Edited by Jorge Chalit, OMS3

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Contributor: Aaron Lessen, MD

Educational Pearls:

• Hemothorax: blood in the pleural cavity, most commonly due to chest trauma

• Treatment: thoracostomy tube for blood drainage

• helps to avoid clotting, scarring, and infection

• A recent study looked at patients with hemothorax who either received or did not receive thoracic irrigation with saline

• Evaluated incidence of secondary intervention, such as video-assisted thoracoscopic surgery (VATS), for persistent hemothorax

• Patients who received irrigation had a slight decrease in secondary intervention frequency

• Multi-center study - all patients who had the irrigation procedure were at two centers

• Study limitation: variability in approaches at each location could be a confounder

• Technique that could potentially prevent future complications

References

1. Carver TW, Berndtson AE, McNickle AG, et al. Thoracic irrigation for prevention of secondary intervention after thoracostomy tube drainage for hemothorax: A Western Trauma Association multi-center study. J Trauma Acute Care Surg. Published online May 20, 2024. doi:10.1097/TA.0000000000004364

2. Yi JH, Liu HB, Zhang M, et al. Management of traumatic hemothorax by closed thoracic drainage using a central venous catheter. J Zhejiang Univ Sci B. 2012;13(1):43-48. doi:10.1631/jzus.B1100161

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

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Contributor: Taylor Lynch, MD

Educational Pearls:

When it comes to hypoglycemia, the age dictates possible causes

• Neonate:

• Hormonal deficiency

• Congenital Adrenal Hyperplasia (21-hydroxylase deficiency, 11β-hydroxylase deficiency)

• Primary or Secondary Adrenal Insufficiency leading to cortisol deficiency

• Hypopituitarism

• Inborn errors of metabolism

• Systemic infection (Under 30 days old should trigger a full infectious workup)

• Toddler

• Accidental ingestions

• Sulfonylureas such as glipizide or glyburide

• Older children

• Addison's Disease (Hypocortisolism)

• Accidential or intentional ingestions

• Exogenous insulin

How is it diagnosed?

• Child or infant

• Glucose

• Newborn

• Glucose

Treatment

• Awake: oral glucose

• Altered: IV glucose

• Rule of 50's. The dose you give times the concentration should equal 50

• Neonate to 2 months get 5 mg/kg of D10W (5*10=50)

• 2 months to 8 years old get 2 mg/kg of D25W (2*25=50)

• Over 8 gets 1 mg/kg of D50W (1*50=50)

• Bonus fact: Rough estimate of weight for a child is 2*patients age plus 8

• Recheck sugar every 15 minutes

• If they stay hypoglycemic give another bolus and consider starting a drip at 1.5 maintenance dose of D10NS.

• If you don't have an IV you can consider glucagon at 0.03 mg/kg IM, although you might be better off trying glucose gel buccally.

• If standard therapy still fails you can give hydrocortisone

• 25 mg IV for neonates and infants

• 50 mg IV for toddlers and smaller school aged children

• 100 mg for anyone older than that

How do you test for exogenous insulin?

• Check a c-peptide which would be low if a patient is taking exogenous insulin

References

1. Lang, T. F., & Hussain, K. (2014). Pediatric hypoglycemia. Advances in clinical chemistry, 63, 211–245. https://doi.org/10.1016/b978-0-12-800094-6.00006-6

2. Lee, S. C., Baranowski, E. S., Sakremath, R., Saraff, V., & Mohamed, Z. (2023). Hypoglycaemia in adrenal insufficiency. Frontiers in endocrinology, 14, 1198519. https://doi.org/10.3389/fendo.2023.1198519

3. Thompson-Branch, A., & Havranek, T. (2017). Neonatal Hypoglycemia. Pediatrics in review, 38(4), 147–157. https://doi.org/10.1542/pir.2016-0063

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

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Contributor: Kiersten Williams MD, Travis Barlock MD, Jeffrey Olson MS3

Show Pearls

• Hypertensive disorders of pregnancy are one of the leading causes of maternal mortality worldwide.

• Hypertension (HTN) complicates 2-8% of pregnancies

• The definition of HTN in pregnancy is a systolic >140 or diastolic >90, measured 4 hours apart

• There is a range of HTN disorders

• Chronic HTN which could have superimposed preeclampsia (preE) on top

• Gestational HTN in which there are no lab abnormalities

• PreE w/o severe features

• Protein in urine

• Urine protein >300 mg in 24 hours

• Urine Protein to Creatinine ratio of .3

• +2 Protein on urine dipstick

• PreE w/ severe features

• Systolics above 160 mmHg

• Diastolics above 110 mmHg

• Headache, especially not going away with meds, or different than previous headaches

• Visual changes, anything that lasts more than a few minutes

• RUQ pain, which could present as heartburn

• Pulmonary edema

• Low platelets, if

• Renal insufficiency, creatinine 1.1 or higher or doubling of baseline

• Impaired liver function

• Note: Hemoconcentration and LDH >600 are not diagnostic but worth paying attention to

• Treatment

• Labetalol, IV

• Avoid in bradycardia, asthma, or myocardial disease

• Quick up titrate, with dosing regimens such as 20-20-40 or 20-40-80 (mg)

• Hydralazine, IV

• 5 mg starting, then another 5 mg then 10 mg if not working

• Nifedipine, Oral

• Can cause a headache

• Goal is not to normalize BP but bring it down slowly

• How to give magnesium

• Start with 6 g or 4 g over 20 minutes if the patient is small or has bad kidney function

• Follow with 2 g per hour or 1 g per hour

• Don't give in myasthenia gravis

• What should you do if the patient progresses to eclampsia (seizures)

• Magnesium is the best drug

• Can use phenytoin or benzos IV as an alternate

• Diazepam is available PR which is a good option if you don't have IV access

• IM magnesium is doable but painful, mix with lidocaine and split dose between the butt cheeks

• Facts about post-partum PreE

• 20% of women will have HTN post-partum

• Most resolve by 6 weeks

• If it lingers past 6 months this is chronic HTN

• If the patient has severe features (see above) they desevere 24 hours on magnesium while being monitored on the L&D floor

• Post-partum is the most common time for strokes

• Providers can be much more aggressive with HTN treatment because the fetus is no longer being exposed

• Enalapril is safe in breast feeding

• Some patients might need to give up breast feeding to be on even more aggressive HTN therapy

• Are NSAIDs safe while breastfeeding?

• Motrin is pretty safe

• Pulm edema is a risk, be careful with fluids

• Last pearl: Put pregnant patients in left or right lateral decubitus while in ER or put a folded towel under their hip to help with venous return which can also help with nausea

References

1. Metoki, H., Iwama, N., Hamada, H., Satoh, M., Murakami, T., Ishikuro, M., & Obara, T. (2022). Hypertensive disorders of pregnancy: definition, management, and out-of-office blood pressure measurement. Hypertension research : official journal of the Japanese Society of Hypertension, 45(8), 1298–1309. https://doi.org/10.1038/s41440-022-00965-6

2. Rana, S., Lemoine, E., Granger, J. P., & Karumanchi, S. A. (2019). Preeclampsia: Pathophysiology, Challenges, and Perspectives. Circulation research, 124(7), 1094–1112. https://doi.org/10.1161/CIRCRESAHA.118.313276

3. Reed, B. (2020, May 2). 'They didn't listen to me': Amber Rose Isaac tweeted about her death before dying in childbirth. The Guardian. https://www.theguardian.com/us-news/2020/may/02/amber-rose-isaac-new-york-childbirth-death

4. Reisner, S. H., Eisenberg, N. H., Stahl, B., & Hauser, G. J. (1983). Maternal medications and breast-feeding. Developmental pharmacology and therapeutics, 6(5), 285–304. https://doi.org/10.1159/000457330

5. Wilkerson, R. G., & Ogunbodede, A. C. (2019). Hypertensive Disorders of Pregnancy. Emergency medicine clinics of North America, 37(2), 301–316. https://doi.org/10.1016/j.emc.2019.01.008

6. Wu, P., Green, M., & Myers, J. E. (2023). Hypertensive disorders of pregnancy. BMJ (Clinical research ed.), 381, e071653. https://doi.org/10.1136/bmj-2022-071653

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

Contributor: Sean Fox, MD

Educational Pearls:

• Newborns may lose up to 10% of their birth weight in the first week of life

• Weight loss is greatest in exclusively breastfed infants

• Should regain birth weight by age 2 weeks

• Newborns should gain an average of 30g (1 oz) per day in the first 3 months of life

• Some will gain more and some will gain less

• Infants double their birth weight by 6 months of life and triple their weight by 12 months

• A 1-year-old should weigh on average 10 kg (22 lbs)

• A 3-year-old should weigh on average 15 kg (33 lbs)

• 2-year-olds are between 10-15 kg on average

• Weight assessment can help determine causes of forceful vomiting

• Not all "projectile" vomiting is due to pyloric stenosis

• Some infants may experience vigorous vomiting from overfeeding

• Weight estimates can also provide information for quick decisions on medical management for children coming via EMS

• Helps to prepare medications and dosages based on predicted average weight

References

1. Crossland DS, Richmond S, Hudson M, Smith K, Abu-Harb M. Weight change in the term baby in the first 2 weeks of life. Acta Paediatr. 2008;97(4):425-429. doi:10.1111/j.1651-2227.2008.00685.x

2. Grummer-Strawn LM, Reinold C, Krebs NF; Centers for Disease Control and Prevention (CDC). Use of World Health Organization and CDC growth charts for children aged 0-59 months in the United States [published correction appears in MMWR Recomm Rep. 2010 Sep 17;59(36):1184]. MMWR Recomm Rep. 2010;59(RR-9):1-15.

3. Macdonald PD, Ross SR, Grant L, Young D. Neonatal weight loss in breast and formula fed infants. Arch Dis Child Fetal Neonatal Ed. 2003;88(6):F472-F476. doi:10.1136/fn.88.6.f472

4. Paul IM, Schaefer EW, Miller JR, et al. Weight Change Nomograms for the First Month After Birth. Pediatrics. 2016;138(6):e20162625. doi:10.1542/peds.2016-2625

Summarized & Edited by Jorge Chalit, OMS3

Special thanks to the Carolinas Medical Center for their contribution to this episode

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Contributor: Travis Barlock, MD

Educational Pearls:

• SVT: supraventricular tachycardia

• Pharmacotherapy for SVT includes drugs that block the AV node, such as adenosine

• EKG criteria before adenosine administration in SVT

1. Regular rhythm

2. Monomorphic: ​​all QRS complexes are identical

• If the EKG is polymorphic, with QRS complexes displaying changing morphologies, it is unsafe to administer adenosine

• Adenosine can worsen polymorphic VTach and lead to VFib

References

1. Ganz, Leonard I., and Peter L. Friedman. "Supraventricular Tachycardia." New England Journal of Medicine, vol. 332, no. 3, 19 Jan. 1995, pp. 162–173, https://doi.org/10.1056/nejm199501193320307.

2. Smith JR, Goldberger JJ, Kadish AH. Adenosine induced polymorphic ventricular tachycardia in adults without structural heart disease. Pacing Clin Electrophysiol. 1997;20(3 Pt 1):743-745. doi:10.1111/j.1540-8159.1997.tb03897.x

3. Viskin, Sami, et al. "Polymorphic Ventricular Tachycardia: Terminology, Mechanism, Diagnosis, and Emergency Therapy." Circulation, vol. 144, no. 10, 7 Sept. 2021, pp. 823–839, https://doi.org/10.1161/circulationaha.121.055783.

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

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Contributor: Aaron Lessen, MD

Educational Pearls:

How does an automated blood pressure cuff work?

• Automated blood pressure cuffs work differently than taking a manual blood pressure.

• While taking a manual blood pressure, one typically listens for Korotkoff sounds (turbulent flow) while slowly deflating the cuff.

• An automatic blood pressure cuff only senses the pressure in the cuff itself and specifically pays attention to oscillations in the pressure caused by when the pressure of the cuff is between the systolic (heart squeezing) and diastolic (heart relaxed) pressures.

• These oscillations are at a maximum when the pressure in the cuff matches the mean arterial pressure (MAP) and therefore the machines are most accurate at reporting the MAP.

• The machines then use the MAP and other information about the oscillations to estimate the systolic and diastolic pressures, which are less accurate.

What should you do if you need more accurate systolic and diastolic blood pressures?

• Take a manual blood pressure.

• Get an arterial-line (a-line), which provides continuous data for the blood pressure at the end of a catheter.

What happens if the cuff is too big or too small for the patient?

• If the cuff is too small it will overestimate the pressure.

• If the cuff is too large it will underestimate the pressure.

What should you do if the cuff cycles a bunch of times before reporting a blood pressure?

• It probably isn't very accurate so consider another method.

Bonus fact!

• The MAP is not directly in the middle of the systolic and diastolic pressures but is weighted towards the diastolic pressure. The MAP can be calculated by adding two-thirds of the diastolic pressure to one third of the systolic pressure. For example if the BP is 120/90 the MAP is 100 mmHg.

References

1. Benmira, A., Perez-Martin, A., Schuster, I., Aichoun, I., Coudray, S., Bereksi-Reguig, F., & Dauzat, M. (2016). From Korotkoff and Marey to automatic non-invasive oscillometric blood pressure measurement: does easiness come with reliability?. Expert review of medical devices, 13(2), 179–189. https://doi.org/10.1586/17434440.2016.1128821

2. Liu, J., Li, Y., Li, J., Zheng, D., & Liu, C. (2022). Sources of automatic office blood pressure measurement error: a systematic review. Physiological measurement, 43(9), 10.1088/1361-6579/ac890e. https://doi.org/10.1088/1361-6579/ac890e

3. Vilaplana J. M. (2006). Blood pressure measurement. Journal of renal care, 32(4), 210–213. https://doi.org/10.1111/j.1755-6686.2006.tb00025.x

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

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Contributor: Megan Hurley, MD

Educational Pearls:

• Heat cramps

• Occur due to electrolyte disturbances

• Most common electrolyte abnormalities are hyponatremia and hypokalemia

• Heat edema

• Caused by vasodilation with pooling of interstitial fluid in the extremities

• Heat rash (miliaria)

• Common in newborns and elderly

• Due to accumulation of sweat beneath eccrine ducts

• Heat syncope

• Lightheadedness, hypotension, and/or syncope in patients with peripheral vasodilation due to heat exposure

• Treatment is removal from the heat source and rehydration (IV fluids or Gatorade)

• Heat exhaustion

• Patients have elevated body temperature (greater than 38º C but less than 40º C)

• Symptoms include nausea, tachycardia, headache, sweating, and others

• Normal mental status or mild confusion that improves with cooling

• Treatment is removal from the heat source and hydration

• Classic heat stroke

• From prolonged exposure to heat

• Defined as a core body temperature > 40.5º C, though not required for diagnosis or treatment

• Presentation is similar to heat exhaustion with the addition of neurological deficits including ataxia

• Patients present "dry"

• Exertional heat stroke

• Prolonged exposure to heat during exercise

• Similar to classic heat stroke but the patients present "wet" due to antecedent treatment in ice baths or other field treatments

• Management of heat-related illnesses includes:

• Cooling

• Rehydration

• Evaluation of electrolytes

• Antipyretics are not helpful because heat-induced illnesses are not due to hypothalamic dysregulation

References

1. Casa DJ, McDermott BP, Lee EC, et al. Cold water immersion: the gold standard for exertional heatstroke treatment. Exerc Sport Sci Rev 2007; 35:141.

2. Ebi KL, Capon A, Berry P, et al. Hot weather and heat extremes: health risks. Lancet 2021; 398:698.

3. Epstein Y, Yanovich R. Heatstroke. N Engl J Med 2019; 380:2449.

4. Gardner JW, JA K. Clinical diagnosis, management, and surveillance of exertional heat illness. In: Textbook of Military Medicine, Zajitchuk R (Ed), Army Medical Center Borden Institute, Washington, DC 2001.

5. Khosla R, Guntupalli KK. Heat-related illnesses. Crit Care Clin 1999; 15:251.

6. Lipman GS, Gaudio FG, Eifling KP, et al. Wilderness Medical Society Clinical Practice Guidelines for the Prevention and Treatment of Heat Illness: 2019 Update. Wilderness Environ Med 2019; 30:S33.

Summarized by Jorge Chalit, OMSIII | Edited by Meg Joyce, MS1

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Contributor: Taylor Lynch, MD

Educational Pearls:

What is Central Cord Syndrome (CCS)?

• Incomplete spinal cord injury caused by trauma that compresses the center of the cord

• More common in hyperextension injuries like falling and hitting the chin

• Usually happens only in individuals with preexisting neck and spinal cord conditions like cervical spondylosis (age-related wear and tear of the cervical spine)

Anatomy of spinal cord

• Motor tracts

• The signals the brain sends for the muscles to move travel in the corticospinal tracts of the spinal cord

• The tracts that control the upper limbs are more central than the ones that control the lower limbs

• The tracts that control the hands are more central than the ones that control the upper arm/shoulder

• Fine touch, vibration, and proprioception (body position) tracts

• These sensations travel in separate tracts in the spinal cord than the sensation of pain and temperature

• Their pathway is called the dorsal column-medial lemniscus (DCML) pathway

• This information travels in the most posterior aspect of the spinal cord

• Pain, crude touch, pressure, and temperature tracts

• These sensations travel in the spinothalamic tract, which is more centrally located

• These signals also cross one side of the body to the other within the spinal cord near the level that they enter

How does this anatomy affect the presentation of CCS?

• Patients typically experience more pronounced weakness or paralysis in their upper extremities as compared to their lower extremities with their hands being weaker than more proximal muscle groups

• Sensation of pain, crude touch, pressure, and temperature are much morelikely to be diminished while the sensation of fine touch, vibration, and proprioception are spared

What happens with reflexes?

• Deep tendon reflexes become exaggerated in CCS

• This is because the disruption in the corticospinal tract removes inhibitory control over reflex arcs

What happens to bladder control?

• The neural signals that coordinate bladder emptying are disrupted, therefore patients can present with urinary retention and/or urge incontinence

What is a Babinski's Sign?

• When the sole of the foot is stimulated a normal response in adults is for the toes to flex downward (plantar flexion)

• If there is an upper motor neuron injury like in CCS, the toes will flex upwards (dorsiflexion)

How is CCS diagnosed?

• CCS is mostly a clinical diagnosis

• These patient also need an MRI to see the extent of the damage which will show increased signal intensity within the central part of the spinal cord on T2-weighted images

How is CCS treated?

• Strict c-spine precautions

• Neurogenic shock precautions. Maintain a mean arterial pressure (MAP) of 85-90 to ensure profusion of the spinal cord

• Levophed (norepinephrine bitartrate) and/or phenylephrine can be used to support their blood pressure to support spinal perfusion

• Consider intubation for injuries above C5 (C3, 4, and 5 keep the diaphragm alive)

• Consult neurosurgery for possible decompression surgery

• Physical Therapy

References

1. Avila, M. J., & Hurlbert, R. J. (2021). Central Cord Syndrome Redefined. Neurosurgery clinics of North America, 32(3), 353–363. https://doi.org/10.1016/j.nec.2021.03.007

2. Brooks N. P. (2017). Central Cord Syndrome. Neurosurgery clinics of North America, 28(1), 41–47. https://doi.org/10.1016/j.nec.2016.08.002

3. Engel-Haber, E., Snider, B., & Kirshblum, S. (2023). Central cord syndrome definitions, variations and limitations. Spinal cord, 61(11), 579–586. https://doi.org/10.1038/s41393-023-00894-2

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

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