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Mental Health Monthly #7: Urine Toxicology in the ED

Emergency Medical Minute

Release Date: 02/10/2021

Podcast 659: Racial Bias in Pulse Oximetry show art Podcast 659: Racial Bias in Pulse Oximetry

Emergency Medical Minute

Contributor:  Aaron Lessen, MD Educational Pearls: Study in NEJM looked at occult hypoxemia, when oxygen saturation reads at >92% when the actual saturation is <88% Rate of occult hypoxemia was 3 times higher in those who identified as black (12% vs 4%) Keep this disparity in mind when providing care to patients of all backgrounds and incorporate into clinical decision-making References Sjoding MW, Dickson RP, Iwashyna TJ, Gay SE, Valley TS. Racial Bias in Pulse Oximetry Measurement. N Engl J Med. 2020;383(25):2477-2478. doi:10.1056/NEJMc2029240 Summarized by John Spartz, MS3 |...

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Podcast 658: Febrile Seizures show art Podcast 658: Febrile Seizures

Emergency Medical Minute

Contributor:  Peter Bakes, MD Educational Pearls: Febrile Seizure clinical criteria 6 months - 5 years of age Rapid rise in temp No preexisting seizure disorder No other explanation for the seizure Nonfocal seizure lasting less than 15 minutes If the seizure does not meet the above criteria, a full workup needs to be completed Regardless of cause, treat the seizure with IV/IO benzodiazepines or IN versed if unable to obtain access Risk of developing epilepsy after a simple febrile seizure roughly doubles References Leung AK, Hon KL, Leung TN. Febrile seizures: an overview. Drugs...

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Podcast 657: Caustic Ingestion show art Podcast 657: Caustic Ingestion

Emergency Medical Minute

Contributor:  Aaron Lessen, MD Educational Pearls: Acid and alkali ingestions have differing prognosis and immediate concerns Immediate issues can include superficial irritation, severe burns, esophageal perforation, and even airway compromise from edem Long term morbidity can include strictures Supportive care is typically all that can be provided in the emergency department Diagnostics may include imaging and endoscopy For more severe ingestions without immediate issues,, patients may be monitored for up to 24 hours References Hoffman RS, Burns MM, Gosselin S. Ingestion of Caustic...

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Podcast 656: Rashes show art Podcast 656: Rashes

Emergency Medical Minute

Contributor:  Peter Bakes, MD Educational Pearls: Lyme disease gives a single expanding target lesion with central clearing called erythema chronicum migrans Erythema multiforme is another targetoid rash that presents with multiple target lesions Characterized into erythema minor and major based on severity but typically resolves More severe hypersensitivity reactions include Stevens-Johnson Syndrome (<10% skin involvement), or Toxic Epidermal Necrolysis (>30% skin involvement) SJS and TEN is associated with NSAIDS including aspirin, antiemetics like phenergan, anticonvulsants like...

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Podcast 655: Hypothermia in Sepsis show art Podcast 655: Hypothermia in Sepsis

Emergency Medical Minute

Contributor: Adam Barkin, MD Educational Pearls: Fever is an adaptive response to infection, but elderly and immunocompromised patients may not be able to mount a hyperthermic response in sepsis Patients with fever in sepsis end up receiving treatment earlier and have better outcomes Hypothermic patients with severe sepsis admitted to the ICU had a 32% mortality versus 21% mortality in those who had a fever on presentation 3-hour sepsis bundle compliance was less frequent in hypothermic patients than in febrile patients (56% versus 71%) Early broad spectrum antibiotics were administered less...

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 Podcast 654: Depression in COVID show art Podcast 654: Depression in COVID

Emergency Medical Minute

Contributor:  Aaron Lessen, MD Educational Pearls: Survey study compared depression symptom prevalence in the United States at the beginning of COVID compared to data acquired by a similar survey for 2017-2018 and found it was three-fold higher Mild symptoms: 25% during pandemic; 16% before Moderate: 15% during pandemic; 6% before Moderately Severe symptoms: 8% during pandemic; 2% before Severe symptoms: ~5% during pandemic; 1% before Those with lower income, less savings, and exposure to more stressors were at greater risk for developing depression symptoms References Ettman CK,...

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Podcast 653: Nitroglycerin Disimpaction show art Podcast 653: Nitroglycerin Disimpaction

Emergency Medical Minute

Contributor:  Ricky Dhaliwal, MD, JD Educational Pearls: Glucagon administered intravenously has a high rate of adverse events (nausea/vomiting) with very weak evidence NItroglycerin too has very limited evidence but a much better adverse event profile Mix 0.4 mg (1 sublingual tablet) nitro in 10 mL of water and administer orally Nothing beats upper endoscopy for effectiveness but in settings where GI is not immediately available, nitroglycerin may be worth an attempt given its better safety profile to other medications References  Arora S, Galich P. Myth: glucagon is an...

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Podcast 652: Prosthetic Hip Dislocation show art Podcast 652: Prosthetic Hip Dislocation

Emergency Medical Minute

Contributor:  Jared Scott, MD Educational Pearls: While it is rare to have a native hip dislocation, it is relatively common to dislocate a prosthetic hip The mechanism for dislocation is usually adduction, flexion, and internal rotation the hip which can occur when walking Arthroplasty in the setting of trauma or fracture, posterior approach during surgery, and using a small femoral head increase the likelihood of later dislocation If a patient with a total hip arthroplasty says they were walking and then developed hip pain, do not discount a potential dislocation References Zahar A,...

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Dr. Don Stader Shares Personal Experience of Losing his Mother to COVID-19 and Ruminates on the Culture of Death in Medicine (UnfilterED #12 Excerpt) show art Dr. Don Stader Shares Personal Experience of Losing his Mother to COVID-19 and Ruminates on the Culture of Death in Medicine (UnfilterED #12 Excerpt)

Emergency Medical Minute

A heartfelt excerpt from with Dr. Don Stader.

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Podcast 651: Hereditary Angioedema show art Podcast 651: Hereditary Angioedema

Emergency Medical Minute

Contributor:  Katie Sprinkel, MD Educational Pearls: Hereditary angioedema (HA) is an autosomal dominant bradykinin-mediated disease affecting the airway, skin or gastrointestinal tract and typically presents with swelling in the absence of pruritus HA episodes last 3-5 days, typically occur first in childhood or adolescence, and decrease in frequency with aging Airway angioedema is the most dangerous but least common Skin angioedema is usually uncomfortable and should be monitored if involving the face GI angioedema involves nausea, vomiting, and severe abdominal pain No definitive...

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More Episodes

This episode of Mental Health Monthly we will be discussing drugs screens in the Emergency Department with Dr. Justin Romano and Eddie Carillo. Dr. Justin Romano is a current psychiatry resident and Eddie Carillo is a licensed mental health therapist. Check out their podcast Millennial Mental Health Channel on all major podcast platforms. Shout out to Dr. Dave Marshall whose grand round presentation this was based on. 

Key Points: 

  • Try not to judge your patient based on the results of their drug screen 
  • Drug screens are used a lot; they are not always accurate 
  • Based on one study there was no significant change in outcome, treatment, disposition or psychiatric course when a drug screen was obtained 
  • Specific good uses for drug screens include new onset of psychiatric symptoms 

Educational Pearls: 

  • 1 in 8 ED visits are due to psychiatric complaints which is up 44% since mid 2000’s 
  • 63% of new psychiatric complaints had a medical cause 
  • Physicians use drug screens commonly in the Emergency Department, but often do not understand their limitations and are often not using them in the most clinically effective manner 
  • Urine is by far the most commonly used in the Emergency Department 
  • UA drug screens are notorious for having false positives and false negatives 
  • Length of clearance from the urine: 
    • Alcohol 12 hours 
    • Methamphetamines/Amphetamines 48 hours 
    • Benzodiazepines 3 days 
    • Opiates 2-3 days 
    • Cocaine 2-4 days 
    • Marijuana dependent on use: 3- 15 days 
    • Phencyclidine (PCP) 8 days 
  • Urine drug screens have a false positive rate of 5-10 % and a false negative rate of 10-15% 
  • False Positive; urine drug screen positive, but drug is not in their body 
    • False positives for amphetamines: bupropion, trazodone, metformin, promethazine, pseudoephedrine, phentermine and atomoxetine 
    • False positives for benzodiazepines: sertraline
    • False positives for cannabis: ibuprofen, naproxen, proton pump inhibitors 
    • False positives for opiates: poppy seeds, antibiotics, Benadryl 
    • False positives for PCP: venlafaxine, ibuprofen and Ambien 
    • False positives for cocaine: amoxicillin 
  • False Negative; urine drug screen negative, but drug is in the body 
    • Benzodiazepines: such as alprazolam, clonazepam, lorazepam or triazolam
    • Cannabinoids: CBD, synthetic marijuana such as K2
    • Opiates: oxycodone, fentanyl, methadone and tramadol 
  • If you get a test that you don’t think is accurate you can always send off for a confirmatory test

References

Summarized by Emily Mack OMSIII | Edited by Mason Tuttle

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