Podcast appearances and mentions of jeff great

更多英语知识，请关注微信公众号: VOA英语每日一听Jeff: So, Tim, you live in a nice natural spot.Tim: Yeah, that's true.Jeff: Lots of nature around where you live?Tim: Yeah, I'm from Oregon. There's lots of nature. There's not a lot of towns really.Jeff: And do you take advantage of it by doing any outdoor sports or activities or anything?Tim: Yeah, I try to, like me and my friends, we go hiking. We camp. We backpack. Snow camp. Snowshoe. All kinds of stuff.Jeff: Really. You snow camp?Tim: Yeah, we snow camped before, yeah.Jeff: So do you stay out or do you stay in a cabin or?Tim: No, usually we go out. A lot of times it's snowshoeing and cross-country skiing. We go out and we build a little hut basically by digging down and go underneath and stay there for the night and come out. It's really cold.Jeff: So, do you pull a sled behind you or do you carry your stuff?Tim: Usually, we just put a pack on your back. Yeah.Jeff: I want to try that.Tim: Yeah, it's a lot of fun, but it's cold and usually, you don't enjoy a lot of it until you done, and when you're done you think, "Ah, that was a great experience."Jeff: Yeah, yeah. I think it would be good but, so is it very different from summer camping?Tim: I think that the biggest thing is that when you go out there it's really, really silent. You don't see a lot of things out and about because it's cold. So it's just really quiet and it's really, really peaceful.Jeff: Is it safe? Can you die?Tim: Yeah, it is relatively safe. People do die doing it. For the most part, it's really safe. One time we were caught in a pretty bad storm and we were coming back. The biggest thing is we came out and our car was covered in snow and we couldn't get out so that was a pretty big deal. Luckily the cellphone worked through and we were able to eventually get out but we had to dig the car out and call some people to come out and help us.Jeff: So do you follow a trail?Tim: Sometimes. It just depends. Sometimes we just use navigation systems and just go out and go and pick points and go for it and sometimes we follow like ski trails that have like little diamonds on trees and you can point towards them and look for them and find them.Jeff: So do you recommend winter camping to people?Tim: Not unless you've had some outdoor experience. Not somebody who's just gonna go out there because you really got to look at the weather. You gotta have the right gear. If you don't have the right gear you'll freeze to death.Jeff: So city people, don't winter camp.Tim: Mostly yeah. I'd say city people better not winter camp unless you've got somebody who's really experienced with you. I've taken my girlfriend out there and so you can do it as long as you're with somebody that knows what they are doing and you have the right gear cause if you don't have something that's waterproof and things that are going to keep water out you can't do it.Jeff: Great.

Show Notes Jeff: Welcome back to EMplify the podcast corollary to EB Medicine’s Emergency medicine Practice. I’m Jeff Nusbaum and I’m back with Nachi Gupta for your regularly scheduled monthly dose of evidence based medicine. This month, we are tackling an incredibly important topic – Assessing abdominal pain in adults, a rational, cost effective, and evidence-based strategy. Nachi: This incredibly important topic was chosen to mark the 20th anniversary of Emergency Medicine Practice. It is actually a revision of the first issue of Emergency Medicine Practice in 1999, now with updated evidence and recommendations. Thanks Robert Williford and Dr. Colucciello for getting this all started 2 decades ago! Jeff: Wow – 20 years – that’s amazing considering Emergency Medicine as a specialty hadn’t even been around all that long at the time and as Dr. Jagoda writes in his intro “evidence based education was still finding its footing.” Nachi: As a tribute to the man who started it all, EB Medicine again turned to Dr. Colucciello, who is no longer wearing his editor in chief hat, but instead is a professor at the University of North Carolina School of Medicine, to update his original article with the latest evidence. Jeff: Before we dive into the meat and potatoes of this month’s issue, let me also recognize Drs. Taylor and Shaukat of Emory and Coney Island Hospital respectively for their efforts in peer reviewing this huge topic. Show More v Nachi: For a number of reasons, this month is going to be a little different. You will notice that we will focus more on safe disposition instead of on diagnosis. Which is reasonable, as that is the crux of our job as emergency physicians. Jeff: Indeed. So for those of you who can’t wait, here’s a quick spoiler, The CBC isn’t all that useful. CT is good but you really should learn ultrasound, and lastly, sick patients need prompt consultation and resuscitation, not rapid trips to radiology. Nachi: All valid points, but let’s dive in too some actual detail. Jeff: Abdominal pain is the one of most frequent complaint in US emergency departments, representing 8% of all adult ED visits, with admission rates for all patients with abdominal pain ranging between 18-42% and reaching as high as 60% for the elderly. Nachi: With respect to the elderly, statistically speaking, 20% presenting with abdominal pain will undergo surgery, and 5% will die. Jeff: Often the etiology of the abdominal pain is never determined. This happens up to 40% of the time by the end of the ED visit. Nachi: I feel like that needs to be restated for emphasis – nearly half of patients who present to the ED with abdominal pain will have no determined etiology for their pain. Clearly, that doesn’t mean you are a bad ED physician – it’s just the way it goes. Jeff: Definitely still a win to be told you aren’t having an intra-abdominal catastrophe at the end of your visit! Nachi: Moving on to pathophysiology. Visceral pain results from distention or inflammation of the hollow organs or from ischemia from any internal organ, while the more localized, somatic pain is typically from irritation of the adjacent peritoneum. Jeff: And don’t forget about referred pain. Due to the movement of organs and stretching of nerve pathways during fetal development, pain may be referred to distant sites, like diaphragmatic irritation presenting as shoulder pain. Nachi: Let’s talk differential diagnosis. The differential for abdominal pain is tremendously broad and includes both intra-abdominal and extra abdominal pathologies. Check out table 2 for a very thorough list. Jeff: Table 1 is also worth reviewing while you’re on page 3 as it lists a few of the common dangerous mimics that often lead to misdiagnosis on initial presentation. To highlight a few – a AAA can masquerade as renal colic, diverticulitis, or a lumbar strain; an ectopic may present similar to PID, a UTI, or a corpus luteum cyst, and mesenteric ischemia may present shockingly similar to gastroenteritis, constipation, ileus, or an SBO. Nachi: Though misdiagnosis is certainly possible at any age, one must be particularly cautious with the elderly. Abdominal pain in the elderly is complicated by a number of factors, they often have no fever, no leukocytosis, or no localized tenderness despite surgical disease, surgical problems progress more rapidly, and lastly, they are at risk for vascular catastrophes, which don’t typically afflict the younger population Jeff: Dr. Colucciello closes the section on the elderly with a really thought-provoking point – we routinely admit 75 year old with chest pain and benign exams, yet we readily discharge a 75 year old with abdominal pain and a benign exam even though the morbidity and mortality of abdominal pain in this group exceeds that of the chest pain group. Nachi: That’s an interesting perspective, but we still have to think about this in the context of what an admission would offer in either of these cases. Most of the testing for abdominal pain can be done in the ED, CT being the workhorse. This point certainly merits more thought though. Jeff: Most clinicians have a low threshold to scan their elderly patients with abdominal pain, and the data behind this practice is quite compelling. In one study, CT altered the admission decision in 26%, need for surgery in 12%, the need for antibiotics in 21%, and changed the suspected diagnosis in 45%. Nachi: That latter figure, 45% change in suspected diagnosis, that was also confirmed in another study in which CT revealed a clinically unsuspected diagnosis in 43% of the elderly. Jeff: And it’s worth mentioning, that even though CT may be the go-to-tool - biliary tract disease, which we know is best visualized on ultrasound, is actually the most common cause of abdominal pain, especially sudden onset abdominal pain in the elderly. Nachi: The next higher risk group to discuss are patients with HIV. While anti retroviral therapy has certainly decreased the burden of opportunistic infections, don’t forget to keep a broader differential in this group including bacterial enterocolitis, drug-induced pancreatitis, or AIDS related cholangiopathy Jeff: Definitely make sure to check to see if the patient has a recent CD4 count to give you a sense of their disease and what they may be at risk for. At less than 200, cryptosporidium, isospora, cyclospora, and microsporidium all make their way onto the differential in addition to the standard players. Nachi: For more information on HIV and its management, check out the February 2016 issue of Emergency Medicine Practice, which covered this and more in depth. Jeff: The next high risk population we are going to discuss are women of childbearing age. Step one is always the same - diagnose pregnancy! Always get a pregnancy test for women between menarche and menopause. Nachi: The pregnancy test is important not only for diagnosing an intrauterine pregnancy, but it’s also a reminder, that we need to consider and rule out an ectopic. Jeff: Along similar lines, you also need to consider torsion, especially in your pregnant population, as 20% of cases of ovarian torsion occur during pregnancy. Nachi: Unfortunately, you cannot rely on the physical exam alone in this age group, as the pelvic exam may be misleading. Up to a quarter of women with appendicitis can exhibit cervical motion tenderness -- a finding typically associated with PID. Sadly, errors are common and ⅓ of women of childbearing age who ultimately were found to have appendicitis were initially misdiagnosed. Jeff: To help reduce your risk in the pregnant population, consider imaging, particularly with radiation reduction strategies, including using ultrasound and MRI, which is gaining favor in the diagnosis of appendicitis in pregnancy. Nachi: Diagnosis of appendicitis, in a pregnant patient, ultrasound vs. mri. Sounds familiar. Didn’t we just talk about this in Episode 24 back in January? Jeff: We sure did! Take another listen if that doesn’t ring a bell. Nachi: That was focused on first trimester only, but while we’re talking about appendicitis in pregnancy - keep in mind that during the second half of pregnancy, the appendix has moved out of the RLQ and is more likely to be found in the RUQ. Jeff: As yes, the classic RUQ appendix. As if our jobs weren’t hard enough, now anatomy is changing… Anyway, the last high risk group we are going to discuss here are those patients with prior abdominal surgery. Make sure to ALWAYS examine the patient's exposed skin to look for scars. Adhesions are the leading cause of SBOs in the industrialized world, followed by malignancy, IBS, and internal or external hernias. Nachi: Also keep a high index of suspicion for patients who have undergone bariatric surgery. They are especially prone to surgical causes of abdominal pain including skin infections and surgical leaks. Jeff: For this reason, CT imaging should be done with IV and oral contrast, with those having undergone a Roux-en-Y receiving oral contrast on the CT table. Nachi: Perfect. Let’s move on to evaluation once in the ED! Jeff: As we mentioned a few times already - diagnosis is difficult, a comparison of initial and final diagnosis only has about 50-65% accuracy. For this reason, Dr. C suggests taking a ‘worst first’ approach to forming your differential and guiding your workup. Nachi: And as a brief aside, before we continue… Missed appendicitis is one of the three most common causes of emergency medicine malpractice lawsuits - with MI and fractures being the other two. That being said, you, as a clinician, have either missed appendicitis or likely will in the future. In a study of cases of misdiagnosed appendicitis brought to litigation, several themes recurred. For example, patients with misdiagnosed disease has less RLQ pain and tenderness as well as diminished anorexia, nausea, and vomiting. Jeff: Well that’s scary - I know I’ve already missed a case, but luckily, he returned thanks to good return precautions, which we’ll get to in a few minutes. Also, note that in addition to imaging and the physical exam, history is often the key to uncovering the cause of abdominal pain. Nachi: Not to harp on litigation, but in malpractice cases brought up for failure to diagnose abdominal conditions, deficiencies in data gathering and charting were often to blame rather than misinterpretation of data. Jeff: As no shocker here, getting a complete history remains tremendously important in your practice as an emergency clinician. A recurring theme of EMplify for sure. Nachi: In order to really nail this down, consider using a standardized history form -- or memorizing one. An example is shown in Table 1. Standardized forms have been shown to improve patient satisfaction and diagnostic accuracy. Jeff: An interesting question for your abdominal pain patient is to ask about the ride to the hospital. Experiencing pain going over a speed bump has been shown to be about 97% sensitive and 30% specific for appendicitis. So fairly sensitive, but not too specific. Nachi: That’s interesting and may help guide you, but it’s certainly no replacement for CT. And remember that you can have stump appendicitis. This can occur in the appendiceal remnant after an appendectomy and is found in about 0.15% of all appendectomies. Jeff: Alright, so on to the physical exam. Like always, let’s start with vital signs. An elevated temp can be associated with intra abdominal infection, but sensitivity and specificity vary greatly here. Always consider a rectal temp, as these are generally more reliable. Nachi: And remember that hypothermic patients who are septic have worse outcomes than those who are hyperthermic and septic. Jeff: Elevated respiratory rate can be due to pain or subdiaphragmatic irritation. However, it can also be due to hypoxia, sepsis, anemia, PE, or metabolic acidosis, so consider all of those also in your differential. Nachi: Moving on to blood pressure: frank hypotension should make you immediately think of a ruptured AAA or septic shock 2/2 an intra abd infection. You can also use the shock index, which as a reminder is simply the HR/SBP. In one study, a SI > 0.7 was sensitive for 28-day mortality in sepsis. Jeff: Speaking of HR, tachycardia can be a response to pain, anxiety, fever, blood loss, or sepsis. An irregularly irregular rhythm -- or a fib -- is an important risk factor for mesenteric ischemia in elderly patients. This is important to consider in your differential early as it may guide your imaging modality. Nachi: With vitals done, we can move on to the abdominal exam - it is rare that a serious abdominal condition will present without tenderness in a young adult patient, but remember that the elderly patient may not present with much tenderness at all due decreased peritoneal sensitivity. Abdominal tenderness that is greatest when the abdominal muscles are contracted is likely due to abdominal wall pain. This can be elicited by having the patient lift their head or let their legs off the bed. This finding is known as Carnett sign and is about 95% accurate for distinguishing abdominal wall pain from visceral abdominal pain. Jeff: Though tenderness itself is helpful, the location of tenderness can be misleading. Note that while 80% of patients with appendicitis have RLQ tenderness, 20% don’t. The old 80-20 rule! So definitely don’t let RLQ tenderness be your sole guide! Nachi: Voluntary guarding is due to fear, anxiety, or even a reaction to a clinician’s cold hands. Involuntary guarding (also called rigidity) is more likely to occur with surgical disease. Remember that rigidity may be a less common finding in the elderly despite surgical disease. Jeff: Peritoneal signs are the true hallmark of surgical disease. These include rebound pain, pain with coughing, pain with shaking the stretcher or pain with striking the patient’s heel. Rebound historically has been thought to be pathognomonic for surgical disease, but recent literature hasn’t found it to be all that useful, with one study claiming it has no predictive value. Nachi: As an alternative, consider the “cough test”. Look for evidence of posttussive abd pain (like grimacing, flinching, or grabbing the belly). Studies have found the cough sign to be 80-95% sensitive for peritonitis. Jeff: In terms of other sings elicited during the abdominal exam: The murphy sign, ruq palpation that causes the patient to stop a deep inspiration -- in one study had a sensitivity of 97%, but a specificity of just under 50%. The psoas sign, pain elicited by extending the RLE towards the back while the patient lies on their left side -- in one study had a specificity of 95%, but only had a sensitivity of 16%. Nachi: Neither the obturator sign (pain with internal rotation of the flexed hip) nor the rosving sign (pain in the RLQ by palpating the LLQ) have been rigorously studied. Jeff: Moving a bit further south, from the abdomen to the pelvis - let’s talk about the pelvic exam. Most EM training programs certainly emphasize the importance of the the pelvic exam for women with lower abdominal pain, but some recent papers have questioned its role. A 2018 study involving 288 women 14-20 years old found that the pelvic didn’t increase sensitivity or specificity of diagnosis of chlamydia, gonorrhea, or trichomoniasis when compared with history alone. Another study questioned whether the pelvic exam can be omitted in these patients with an early intrauterine pregnancy confirmed on ultrasound, but it was unable to reach a conclusion, possibly due to insufficient power. Nachi: While Jeff and I do find it valuable to elicit as much as information from the history as possible and take value in the possibility of omitting the pelvic in certain cases in the future, given the current evidence based medicine, we both agree with the author here. Don’t abandon the pelvic for these patients just yet! Jeff: While on this topic, we should also briefly mention a reminder about fitz-hugh-curtis syndrome, perihepatic inflammation associated with PID. Nachi: As for the digital rectal exam, this can certainly be of use when considering and diagnosing prostatitis, perirectal disease, stool impactions, rectal foreign bodies, and gi bleeds. Jeff: And let’s not forget the often overlooked scrotal and testicular exam. In men with abdominal or flank pain, this should always be considered. Testicular torsion often presents with isolated abdominal or flank pain. The scrotal exam will help diagnose inguinal and scrotal hernias. Nachi: Getting back to malpractice case reviews for a minute --- in a 2018 review involving testicular torsion, almost ⅓ of the patients with missed torsion had presented with abdominal pain --- not scrotal pain! In ⅕ of the cases, no testicular exam was performed at all. Also, most cases of missed torsion occured in patients under 25 years old. Jeff: Speaking of torsion, about 6% occur over the age of 31, so have an increased concern for this in the young. Of course, if concerned for torsion, consult urology immediately and consider manual detorsion. Nachi: And if you, like me, were taught to manually detorse by rotating in the lateral or open book direction, keep in mind that in a study of 200 males with torsion, ⅓ had rotated laterally, not medially. Jeff: Great point. And one last quick point here. Especially if you are unsure about the diagnosis, make sure to perform serial exams both in the ED and also in the next few days at their PCP’s office. In one study, a 30 hour later repeat exam for patients discharged with nonspecific abdominal pain resulted in a clinically relevant change in diagnosis and therapy in almost 25% of patients. Nachi: So that wraps up the physical. Let’s get into diagnostic studies, starting with lab work and everybody’s favorite topic... the cbc. Jeff: Yup, just the other day I was asked by a consultant “what’s the white count.” in a patient with CT proven appendicitis. Man, a small part of my soul dies every time this happens. Nachi: It appears you must have an evidenced based soul then. According to a few studies, anywhere from 10-60% of patients with surgically proven appendicitis have an initially normal WBC. So in some studies, it’s even worse than a coin flip. Jeff: Even worse, in children the CBC is less helpful. In children, an elevated WBC detects a mere 53% of severe abdominal pathology - so again not all that helpful. Nachi: That being said, at the other end of the spectrum, in the elderly, an elevated WBC may imply serious disease. Jeff: So let’s make this perfectly clear. A normal WBC should not be reassuring, but an elevated WBC, especially in the elderly, should be very concerning. Nachi: The CRP is up next. Though not used frequently, it’s still worth mentioning, as there is a host of data on it in the setting of abdominal pain. In one meta analysis, CRP was approximately 62% sensitive and 66% specific for appendicitis. Jeff: And while lower levels of CRP do not rule out positive findings, increasing levels of CRP do predict, with increasing likelihood, the chances of positive findings. Nachi: Next we have lipase and amylase. The serum lipase is the best test for suspected pancreatitis. The amylase adds limited value and should not be routinely ordered. Jeff: As for the lactate. The greatest value of a lactate level is to detect occult shock and sepsis. It is also useful to screen for visceral ischemia. Nachi: And the last lab test we’ll discuss is the UA. The urinalysis is a potentially misleading test. In two studies, 20-30% of patients with appendicitis also had hematuria with leukocytes and bacteria on their UA. In a separate study of those with a AAA, there was an 87% incidence of hematuria. Jeff: That’s pretty troubling. Definitely not great to diagnosis someone with hematuria and a primary GU problem, when their aorta is actually exploding. Nachi: And that’s a great reminder to always avoid premature diagnostic closure. Jeff: Also worth mentioning is that not all ureteral stones present with hematuria. At least 6% have no hematuria on microscopy. Nachi: Alright, so that brings us to imaging. First up: plain films. I’m going to quote this directly from the article since I think it's so important, ‘never rely on plain films to exclude surgical disease.” Jeff: This statement is certainly evidence based as in one study 40% of x-ray findings were inconsistent with the final diagnosis. In another study, 43% of patients with major surgical disorders had either normal or misleading plain film results. So again, the take home here is that XR cannot rule out surgical disease, and should not be routinely ordered except for in specific settings. Nachi: And perhaps the most important of all those settings is in the setting of possible free air under the diaphragm. In this case, an upright chest visualizing the area under the diaphragm would be the test of choice. But again, even this doesn’t rule out surgical disease as free air may be absent on plain films in ⅓ to ½ of patients who have already perfed. Jeff: Next we have everybody’s favorite, the ultrasound. Because of it’s low cost and ease of use, bedside ultrasound is gaining traction. And we’ve cited this and other similar studies in other issues, this is a skill emergency medicine physicians must have in this day and age and it’s a skill they can learn quickly. Nachi: Ultrasound can visualize most solid organs, but it is best suited for the Right upper quadrant and pelvis. In the RUQ, we are looking for wall thickening, pericholecystic fluid, ductal dilatation, and sonographic murphys sign. Jeff: In the pelvis, there is a role for both transabdominal and transvaginal to rule out ectopic and potentially rule in intrauterine pregnancy. I know the thought of performing your own transvaginal ultrasound may sound crazy to some, but we both trained in places where ED TVUS was the norm and certainly wasn’t that hard to learn. Nachi: Ah, the good old days of residency. I’m certainly grateful for the US tech where I am now though! Next up we have CT. CT scans are ordered in just under 30% of patients with abdominal pain. Jeff: It’s worth noting, that while many used to scan with triple contrast - oral, rectal and IV, recent literature has shown that IV contrast alone is adequate for the diagnosis of most surgical conditions, including appendicitis. Nachi: If you’re still working in a shop that scans for RLQ pain with oral or rectal contrast, definitely check out the 2018 american college of radiology appropriateness criteria that states that IV contrast is generally appropriate for assessing the RL. Jeff: And while we are on the topic of contrast, let’s dive a bit deeper into the, perhaps myth, that contrast leads to contrast induced nephropathy. Nachi: This is another really important point. Current data show that being ill enough to be admitted to the hospital is a risk factor for acute kidney injury and that IV contrast for CT does not add to that risk. In 2015, the american college of radiology noted in their manual on contrast media that the concern for the development of contrast induced nephropathy is not an absolute contraindication for using IV contrast. IV contrast may be necessary regardless of the risk of nephrotoxicity in certain clinical situations. Jeff: Ok, so contrast induced nephropathy may be real, but more studies and a definitive statement are still needed. Regardless, if the patient is sick and they need the scan with contrast, don’t hold back. Nachi: I think that’s a fair take home. As another note about the elderly, CT should be almost routine in the elderly patient with acute abdominal pain as it improves accuracy, optimizes appropriate hospitalization, and boosts ED management decision making confidence for this patient group. Jeff: If they are over 65, make sure you chart very carefully why they don’t need a scan. Nachi: Speaking of not needing a scan, two quick caveats on CT before moving to MRI. Unstable patients do not belong in a radiology suite - they belong in the ED resus bay to be resuscitated first. Prompt surgical consultation and bedside ultrasound if indicated are both a must in unstable patients. Jeff: The second caveat is on the other end of the spectrum - not all CT scanning is created equally - the interpretation depends on the scanner, the quality of the scan, and the experience and training of the reading radiologist. In one study, nearly 13% of abdominal CT scans may initially be misread. Nachi: So if you’re concerned, consider consultation or an extended ED observation to monitor for any changes in the patient’s status. Jeff: Next up is MRI - MRI has an ever expanding role in the ED. The accuracy of MRI to diagnose appendicitis is very similar to CT, so consider it in all pregnant patients, though ultrasound is still considered first line. Nachi: And finally let’s touch upon the ekg and ACS. In patients over 40 with upper abdominal pain, an EKG and troponin should always be considered. Jeff: Don’t be reassured by a response to a GI cocktail either - this does not exclude myocardial ischemia. Nachi: Next, let’s talk the role of analgesia in treating the undifferentiated abdominal pain patient. Jeff: While there was formerly a concern of ‘masking the pain’ with opiates, the evidence says otherwise. Pain medicine may even aid in the diagnosis, so definitely don’t withhold it in the setting of acute abdominal pain. Nachi: Wait I get that masking the pain is no longer considered a concern, but how would it aid in the diagnosis? Jeff: Good question. Analgesics might facilitate the gathering of history and allow a more complete physical exam by relaxing the abdominal musculature. Nachi: Ahh that makes sense. So certainly treat pain! Both morphine at 0.1 mg/kg and fentanyl at 1 mic/kg are appropriate analgesics for acute abdominal pain. In those that are a difficult stick, a recent study showed that 2 micrograms/kg of fentanyl via a nebulizer was a safe alternative. Remember, fentanyl is quick on, quick off, which may make it desirable in certain situations. It actually has the shortest time of onset of any opioid. It’s also safer in patients with a “marginal” blood pressure. Jeff: And just like the GI cocktail - response to opiate analgesics does not exclude serious pathology. These patients need serial exams and likely labs and imaging if their pain is so severe. Nachi: Few things are more important prior to discharge of an abdominal pain patient than documenting repeat exams and a PO trial. Jeff: True. You should also consider haloperidol for patients with gastroparesis and cannabinoid hyperemesis as a growing body of literature supports its use in such settings. Check out the August 2018 EMP or EMplify for more details if you’re curious. Nachi: The last analgesic to discuss is our good friend ketamine. Low dose ketamine at 0.3 mg/kg over 15 minutes is gaining traction as the analgesic of choice in many ED’s. Jeff: The key there, is that it must be given over 15 minutes. Ketamine has a great safety profile, but you make it so much safer and a much better experience if you give it slowly. Nachi: Before we get to disposition, let’s talk controversies and cutting edge - and there is just one this month - and that’s the use of the Alvarado score. Jeff: In the Alvarado score, you get two points for RLQ tenderness and 2 points for a leukocytosis over 10,000. You get an additional point for all of the following; rebound, temp over 99.1, migration of pain to the RLQ, anorexia, n/v, and a left shift. The max score is therefore 10. A score of 3 or less make appendicitis unlikely, 4-6 warrants CT imaging, and 7 or more a surgical consultation. Nachi: A 2007 study suggests that using the Alvarado score along with bedside ultrasound might allow for rapid and inexpensive diagnosis of appendicitis. Jeff: I don’t think we should change practice based on this just yet, but more ultrasound diagnosis may be on the horizon. If you want to start using the Alvarado score in your practice, MDcalc has a great easy to use calculator. Nachi: Let’s get to the final section. Disposition! Jeff: As we mentioned at the beginning of this episode, the diagnosis is less important than proper disposition. For patients with suspected ruptured AAA, torsion, or mesenteric ischemia - the disposition is easy - they need immediate surgical consultation and likely operative intervention. Nachi: For others, use the tools we outlined above - ct, us, labs, etc, to help support your decision. Keep in mind, that serial exams are a great tool and of little expense - so make sure to lay your hands on the patient's abdomen frequently, especially when the diagnosis is unclear. Jeff: For those that look well after a work up, with no clear diagnosis, it may be reasonable to discharge them home with prompt follow up, assuming prompt follow up is plausible. The key here is that these patients need good discharge instructions. Check out figure 2 on page 20 for a sample discharge template. Nachi: But if the patient is still uncomfortable, even after a thorough workup, there may be a role for ED observation units. In one study of 220 patients admitted for to ED obs units for serial exams, 39% eventually underwent surgery with only 5% having negative laparotomies. Jeff: This month’s issue wraps up with some super important time and cost effective strategies, so let’s see if we can quickly breeze through some of the most important points before closing out this episode. Nachi: First - limit your abdominal x-rays as they offer limited value and are rarely helpful except in the setting of perforation, when an early upright chest film should be used liberally. Jeff: Next - limit electrolyte testing especially in young adults with nausea, vomiting and diarrhea. In those 18 to 60, clinically significant electrolyte abnormalities occur in only 1% of those with gastro. Nachi: With respect to urine testing, urine cultures are rarely indicated for uncomplicated cystitis in young women. Along similar lines, don’t anchor on the diagnosis of UTI as other lower abdominal conditions often lead to abnomal urine studies. Jeff: In your alcoholic patients, although all should be approached with an abundance of caution, limit testing to repeat abdominal exams in your non-toxic appearing patient who is already tolerating PO. Nachi: For those with suspected renal colic, especially those with a history of renal colic, limit CT use and instead consider ultrasound to look for hydro. This approach is endorsed by ACEPs choosing wisely campaign. Jeff: But as a reminder, this is for low risk patients only. Anyone with signs of infection should also undergo CT imaging. Nachi: And lastly - consider incorporating bedside US into your routine. The US is fast and accurate and compares similarly to radiology, especially in the context of detecting acute cholecystitis. Jeff: Alright, so that wraps up the new material for this episode, let’s close out with some key points and clinical pearls. The peritoneum becomes less sensitive with aging, and peritonitis can be a late or absent finding. Be wary of early diagnostic closure and misdiagnosis with a mimic of a more severe and dangerous pathology. The elderly, immunocompromised, women of childbearing age, and patients with prior abdominal surgeries are all at a higher risk for misdiagnosis. Elderly patients can present without fever, leukocytosis, or abdominal tenderness, but still have surgical abdominal pathology. Consider diagnostic imaging in all geriatric patients presenting with abdominal pain. Consider plain film if you suspect a viscus perforation or for certain foreign body ingestions. Do not forget the pelvic exam, testicular exam, and rectal exam as part of your physical, when appropriate. Testicular torsion can present with abdominal pain only. If suspected, consult urology and consider manual detorsion. A normal white blood cell count does not rule out appendicitis or other intra-abdominal pathology. Serum amylase should not be used in your assessment of the abdominal pain patient. Lack of microscopic hematuria does not rule out renal colic. CT of the abdomen with IV contrast alone is enough for most surgical conditions including appendicitis. Oral and rectal contrast does not need to be routinely administered. The 2018 American College of Radiology (ACR) Appropriateness Criteria discuss concern for delay in diagnosis associated with oral contrast use and an increased rate of perforation. There is recent literature to support that IV contrast does not cause nephropathy. The ACR 2015 Manual on Contrast Media states that concern for contrast induced nephropathy is not an absolute contraindication, and IV contrast may be necessary in many situations. Ultrasound can be used to evaluate the aorta, gallbladder, kidneys, appendix, bowel, spleen, pancreas, uterus, and ovaries. Consider bedside ultrasound and emergency surgical consult for all unstable patients with abdominal pain. For stable pregnant patients with concern for appendicitis, start with an ultrasound. If inconclusive, order an MRI. Epigastric pain in an elderly patient should raise concern for ACS. An EKG and troponin should be considered. For analgesia in patients with gastroparesis or cannabinoid hyperemesis syndrome, haloperidol is considered first-line. Low-dose ketamine (0.3mg/kg over 15 minutes) may be a better choice than opiate analgesia for abdominal pain. Nachi: So that wraps up Episode 29! Jeff: As always, additional materials are available on our website for Emergency Medicine Practice subscribers. If you’re not a subscriber, consider joining today. You can find out more at ebmedicine.net/subscribe. Subscribers get in-depth articles on hundreds of emergency medicine topics, concise summaries of the articles, calculators and risk scores, and CME credit. You’ll also get enhanced access to the podcast, including any images and tables mentioned. PA’s and NP’s - make sure to use the code APP4 at checkout to save 50%. Nachi: And last reminder here -The clinical Decision Making in Emergency Medicine Conference is just around the corner and spots are quickly filling up. Don’t miss out on this great opportunity and register today. Jeff: And the address for this month’s cme credit is ebmedicine.net/E0619, so head over there to get your CME credit. As always, the [DING SOUND] you heard throughout the episode corresponds to the answers to the CME questions. Lastly, be sure to find us on iTunes and rate us or leave comments there. You can also email us directly at emplify@ebmedicine.net with any comments or suggestions. Talk to you next month!   Most Important References 18. Gardner CS, Jaffe TA, Nelson RC. Impact of CT in elderly patients presenting to the emergency department with acute abdominal pain. Abdom Imaging. 2015;40(7):2877-2882. (Retrospective study; 464 patients aged ≥ 80 years) 38. Kereshi B, Lee KS, Siewert B, et al. Clinical utility of magnetic resonance imaging in the evaluation of pregnant females with suspected acute appendicitis. Abdom Radiol (NY). 2018;43(6):1446-1455. (Retrospective study; 212 MRI examinations) 41. Lewis KD, Takenaka KY, Luber SD. Acute abdominal pain in the bariatric surgery patient. Emerg Med Clin North Am. 2016;34(2):387-407. (Review) 57. Wagner JM, McKinney WP, Carpenter JL. Does this patient have appendicitis? JAMA. 1996;276(19):1589-1594. (Review) 67. Magidson PD, Martinez JP. Abdominal pain in the geriatric patient. Emerg Med Clin North Am. 2016;34(3):559-574. (Review) 83. Macaluso CR, McNamara RM. Evaluation and management of acute abdominal pain in the emergency department. Int J Gen Med. 2012;5:789-797. (Review) 94. Bass JB, Couperus KS, Pfaff JL, et al. A pair of testicular torsion medicolegal cases with caveats: the ball’s in your court. Clin Pract Cases Emerg Med. 2018;2(4):283-285. (Case studies; 2 patients) 106. Kestler A, Kendall J. Emergency ultrasound in first-trimester pregnancy. In: Connolly J, Dean A, Hoffman B, et al, eds. Emergency Point-of-Care Ultrasound. 2nd edition. Oxford UK: John Wiley and Sons; 2017. (Textbook)

Show Notes Jeff: Welcome back to EMplify, the podcast corollary to EB Medicine’s Emergency Medicine Practice. I’m Jeff Nusbaum, and I’m back with my co-host, Nachi Gupta. This month, we’re moving into uncharted territories for the podcast… we’re talking psychiatry Nachi: Specifically, we’ll be discussing Depressed and Suicidal Patients in the emergency department. Jeff: As a quick survey of our audience before we begin, how many of you routinely encounter co-morbid psychiatric conditions in your ED patients, especially depression? Nachi: That would certainly be all of our listeners! Jeff: And how many of you struggle to admit or transfer patients for a formal psychiatric eval? Show More v Nachi: Again, just about all of our listeners I’m sure! Jeff: And finally, how many of you wish there was a clearly outlined evidence-based approach to managing such patients to improve care and outcomes? Nachi: That would certainly be helpful. So now that we are all in agreement with just how necessary this episode is, let’s dive in. Jeff: This month’s issue was authored by Dr. Bernard Chang, Katherine Tezanos, Ilana Gratch and Dr. Christine Cha, who are all at Columbia University. Nachi: In addition, it was peer reviewed by Dr. Nicholas Schwartz of Mount Sinai School of Medicine in New York and Dr. Scott Zeller of the university of California-Riverside. Jeff: Quite the team, from a variety of backgrounds. Nachi: And just to put this topic into perspective - annually, there are more than 12 million ED visits for substance abuse and mental health crises. This represents nearly 12.5% of all ED visits. Of note, among these visits, nearly 650,000 individuals are evaluated for suicide attempt. Jeff: Looking more in depth, of the mental health complaints we see daily, mood disorders are the most common, representing 43%, followed by anxiety disorders, 26%, and then alcohol related conditions at 23% Nachi: And as is often the case, these numbers are likely underestimates, as many psychiatric complaints, especially depression, often go unnoticed by the patients and providers alike. In one study of patients who presented with unexplained chest and somatic complaints, 23% met the criteria for a major depressive episode. Jeff: Sad, but terrifying, though I suppose it all makes this issue so much more valuable. Nachi: Before we get to the evidence and an evidence-based approach, let’s start with some definitions. Jeff: Certainly a good place to start, but let me preface this with an important point - arriving at a specific psychiatric diagnosis in the ED is likely neither feasible nor realistic due to the obvious limitations, most namely, time - instead, you should focus on assessing and collecting information on the presenting symptoms and taking a comprehensive psychiatric and medical history. Nachi: According to DSM-5, to diagnose a major depressive disorder you must have 5 or more of the following: depressed mood, decreased interest or pleasure in most activities, body weight change, insomnia or hypersomnia, restlessness or slowing, fatigue, feelings of worthlessness or guilt, diminished ability to think or concentrate or indecisiveness, or finally recurrent thoughts of death and or suicide. In addition, at least 1 of the symptoms must be either a depressed mood or loss of interest. Jeff: These symptoms must last most of the day, nearly every day, for 2 weeks. Nachi: And these symptoms must cause clinically significant distress or impairment across multiple areas of functioning. Jeff: So those were criterion A and B. Criterion C, D, and E state that a MDD does not include factors from substance use or medical conditions, psychotic disorders, or manic episodes. Nachi: Once you’ve had the symptoms for 2 years with little interruption, you likely qualify for a persistent depressive disorder rather than a MDD. Jeff: And if your symptoms repeatedly co-occur around menses, this is more likely premenstrual dysphoric disorder. Nachi: Moving on to suicide and suicide related concepts. Suicidal ideation is the consideration or desire to kill oneself. Jeff: These can be active or passive thoughts, for example, “I don’t want to be alive” vs “I want to kill myself.” Nachi: Other important terms include, the suicide plan, suicide attempt, suicide gesture and nonsuicidal self-injury. The plan typically includes the how, where, and when a person will carry out their attempt. Jeff: A suicide gesture is an action or statement that makes others believe that a person wants to kill him or herself, regardless of the actual plan. Nachi: I think that’s good for definitions, let’s discuss some more epidemiology. Based on 2005 data, the prevalence of 1 month MDD was 5% with a lifetime prevalence of major depression of 13%. Jeff: If those figures seem a bit high, another CDC study found that in a general population survey of a quarter million people between 2006-2008, 9% met the criteria for major depression. Pretty big numbers... Nachi: Sadly, though outpatient visits for depression and suicide related complaints have decreased over the years, while ED visits remain stable, implying that the ED is a critical entry point for depressed and suicidal patients. Jeff: It’s important to also recognize at risk populations. In several studies, the prevalence of MDD is reported as being nearly twice as high in women as it is in men. Nachi: MDD is also much more common in younger adults, with a prevalence of about 20% in those under 65 and a prevalence of just 10% in those 65 and older. Jeff: Additionally, being never-married / widowed / or divorced, being black or hispanic, having poor social support, major life events, and have a history of substance abuse are all serious risk factors for depression. Nachi: In terms of suicidality, nearly half of depressed adults in one study felt that they wanted to die, with ⅓ having thought about suicide. Taking it one step further, somewhere between 14-31% of depressed adults have attempted suicide, and roughly 1 in 10 depressed adults ultimately die by suicide. Jeff: And while it seems crass to even mention the financial impact, the number is shocking - suicide has an estimated economic burden of $5.4 billion per year in the US. Nachi: That’s an incredible amount and much more than I would have guessed. Jeff: In terms specific risk factors for suicide and suicide related complaints - white men over 80 have the highest rate of suicide death in the US, with 51.6 deaths per year per 100,000 individuals. Nachi: You snuck in an important word there - suicide DEATH. While old people die the most from suicide, younger adults attempt suicide more often. Jeff: Along similar lines, while women attempt suicide nearly 4 times more frequently than men, men are 3 times more likely to die by suicide, likely related to their respective choice of suicide methods. Nachi: Lesbian, gay, and bisexual men or women are another at risk population, with rates of suicidal ideations being nearly twice that of their heterosexual counterparts Jeff: Despite the litany of risk factors we just ran through, the strongest single predictor for suicide related outcomes is a prior history of suicidal ideation or attempt, with individuals who have made a previous attempt being nearly 6 times more likely to make another. Nachi: And lastly, those who have had symptoms severe enough to warrant psychiatric admission have an increased lifetime risk of suicide also at 8.6% vs 0.5% for the general population, in one study. Jeff: Alright, so that wraps up the background, let’s move on to the actual evaluation. Nachi: When forming your differential, a crucial aspect is identifying potential secondary causes of depressive symptoms, as many depressive symptoms are driven by etiologies that require different management strategies and treatment. Be on the lookout for toxic-metabolic, infectious, neurologic disturbances, medication side effects, and recent medical events as the etiology for depressive episodes and suicidality. Jeff: Excellent point, which we’ll reiterate a few times throughout the episode - always be on the lookout for medical causes of new psychiatric symptoms. Next, we have my favorite, prehospital care - when doing your scene assessment, look out for possible signs of overdose such as empty pill bottles lying around. It’s also important to assess for the presence of firearms. Of course, this should not be done at the expense of acute medical stabilization. Nachi: And don’t forget to consider transport directly to institutions with full psychiatric services, especially for those with active suicidal ideations. Jeff: Once in the ED - start by maximizing the patient's privacy. Always use a nonjudgmental approach and use open-ended questions. Nachi: If feasible, map the chronology of depressive symptoms and their impact on the patient’s functional status. It’s also important to elicit any psychiatric history, including prior hospitalizations. Jeff: Screening for suicidality is critical in all patients with depressive symptoms given the elevated risk in this population. Though not broadly adopted in many EDs, there are a number of screening tools to assist you in this process, including the PHQ-9, ED SAFE PSS-3, and C-SSRS, which all asses for severity of suicide risk. These have been developed primarily for the outpatient and primary care settings. Nachi: And not surprisingly, MDCalc has online tools to help you use these risk assessments, so you can easily pull up a scoring tool on your phone should the appropriate clinical scenario arise. Jeff: The PHQ-9 was validated in various outpatient settings, including the ED. This is a self-administered depression questionnaire that has been found to be reliable across genders and different cultures. Interestingly, the PHQ-9 questionnaire contains one question about suicidality - how often is the patient bothered by thoughts that you would be better off dead or hurting yourself. Responding “nearly every day” increases your odds from 1 in 250 to 1 in 25 of attempting suicide. Nachi: The next tool to discuss is the ED-Safe PSS-3. The PSS-3 assesses for depression/hopelessness and suicidal ideations in the past 2 weeks as well as lifetime history of suicide attempt. Jeff: In one study, using this tool doubled the number of suicide-risk cases detected. Nachi: Once someone has screened positive for recent suicidal ideations, further screening must be done via a secondary screener. Jeff: In one study, following this approach decreased the total number of suicide attempts by 30% following an ED visit. Nachi: And what would you advise to clinicians that are concerned that questioning a patient about suicidal ideation may actually encourage or introduce the idea of suicide in those who hadn’t already considered it? Jeff: Great question - It has been found that there has been no associated introduction of negative effect when a patient is asked about suicidal ideations. Concerns about iatrogenic effects should not prevent such evaluations. Nachi: Definitely reassuring that this has been looked into. Let’s move on to the physical. Jeff: The physical exam should include a cognitive assessment that focuses on identifying medical conditions, as well as a behavioral mental health status exam that focuses on identifying the presence and degree of depression. Nachi: And as you said, we would mention it a few times -- In the ED, you always want to make sure you aren’t missing an underlying medical condition that manifests as depression. Jeff: So important. Alright, let’s move on to diagnostic studies. And thanks to a systematic review of 60 studies on this topic, there is actually reasonably good data here. Nachi: According to this review, in patients with a known psychiatric disease presenting with exacerbating psychiatric complaints, routine serum and urine tox screening is not recommended. Additional screening tests should be considered in those with new psychiatric symptoms who are 65 years or older, those who are immunosuppressed, and those with concomitant medical disease. Jeff: a 2017 ACEP clinical policy also recommends against routine lab testing in those with acute psychiatric complaints. They too call for a focused history and physical to guide testing. Nachi: It’s also worth highlighting one other incredibly important point from that ACEP policy - urine tox screens for drugs of abuse should not delay patient evaluation for transfer to a psychiatric facility. Jeff: Definitely a great policy to check out if you find yourself in all too frequent disagreements with your local psychiatric receiving facility. Nachi: You should also consider serum testing in those taking psychotropic medications with known toxic effects, such as lithium, as toxicity would change management. Jeff: Ok, last point about the work up, imaging studies of the brain should not be routinely ordered unless you have a high degree of suspicion. Nachi: That wraps up testing. Let’s move on to treatment. Jeff: First and foremost, you must maintain a safe environment. Effective precautions include alerts to staff about the potential safety risk in addition to searches of the patient and his / her belongings if applicable. Nachi: With the staff notified and the patient searched, the patient should be placed in a room without potentially dangerous items, like tubing or needles. Those who are at a very high risk may warrant continuous observation. Jeff: Speaking of safety, you will definitely want to engage in safety planning with the patient. Safety planning can be completed by any emergency clinician and should take about 20-45 minutes. Nachi: And while this is typically done by a psychologist or psychiatrist, this is something any emergency clinician can also easily do. Jeff: Safety planning beings with a brief interview. Next you establish a list of personalized and prioritized steps to help the patient through his or her next crisis. In a full plan, you should identify: warning signs, internal coping strategies, people and social settings that provide distraction, people whom the patient can ask for help, professionals or agencies whom the patient can contact during a crisis, and lastly how to make the environment safe (for example, lethal means counseling). Nachi: Of course, while the plan is meant to be a step by step approach for the patient, you should encourage the patient to seek professional help at any time if it is necessary. Jeff: Great point. And while safety planning typically is most effective when combined with other interventions, research suggests that it does enhance outpatient treatment engagement after an ED visit and in one study, reduce subsequent suicide attempts by 30% vs usual care. That’s a huge win for something that’s not that hard to do. Nachi: Similar to safety planning, let’s discuss no-suicide contracts. No-suicide contracts or no-harm contracts are verbal or written agreements between the patient and the clinician to articulate that he or she will not attempt to hurt him or herself. Though there isn’t a ton of evidence, at least one RCT showed that safety planning was superior to contracts. Jeff: Lethal-means counseling on the other hand is a potentially helpful prevention strategy. In lethal means counseling, you merely have to address the patient’s access to lethal means. By slowing their access to their lethal means, it is thought that the relatively short-lived suicidal crises may pass before they could access said means. Nachi: For example, you could provide options for restricting access to lethal means, such as disposal, locking up and giving the key to someone else, or temporarily giving the means to a friend. Jeff: And this may be a good time to involve friends and or family, especially when dealing with suicidal youths. Nachi: This is such an important and simple intervention that has actually been shown to reduce suicide attempts and deaths. Unfortunately, few ED clinicians address lethal means. Jeff: Pro tip: since most ED clinicians chart with templates, add something to your standard suicidality / psychiatric template about lethal means. This will serve as an important reminder to address it in real time. Nachi: That is a really great idea to ensure you don’t skip over this underutilized counseling. Jeff: The next aspect of treatment to discuss is follow up. Follow up is critical for both depressed and suicidal patients. Follow up can come in many forms and at a minimum should include the national suicide prevention lifeline. Nachi: The authors even simplify this for us a bit, providing 5 easy steps to help make sure patients follow through with ED discharge recommendations. Jeff: First, provide a standard handout that includes a list of outpatient providers. Next provide the patient the 24 hours crisis line number. After that, ask the patient to identify the most viable resources and address any barriers the patient may have in getting there. Next, schedule a follow up appointment, ideally within a week of discharge, and lastly, document the patient’s preferred follow up resources and steps taken to get them there. Nachi: And if this seems too burdensome for a single provider, think about identifying a staff member who may help the patient with follow up - perhaps a social worker or case manager. Follow up is so important, it’s critical that the ball not be dropped after you’ve put in so much hard work to make the plan. Jeff: As always, the team approach is preferred. Alright so the last treatment to discuss is actual pharmacotherapy. Since commonly prescribed antidepressants take up to 6-8 weeks to have a clinical effect, the administration of psychotropic medications is not routinely initiated in the ED. Interestingly, there may be a role for ketamine, yes, ketamine, in conjunction with oral meds. More on that in a few minutes though... Nachi: Let’s talk first about special populations - the only one we will discuss this month is military veterans. Jeff: Recent evidence has demonstrated an association between exposure to blast and concussive injuries and subsequent depressive and anxiety symptoms. Nachi: In part, because of this, among veterans presenting for emergency psychiatric services, approximately 52% reported suicidal ideations in the prior week and 70% reported current depressive symptoms. Clearly this is a major problem in this population. Jeff: But to bring it back to ED care, in one study, among depressed veterans with death by suicide, 10% had visited a VA ED in the 30 days prior to their death. Nachi: And this is in no way meant to be a knock-on VA ED docs - they are dealing with a very at risk population. But it is worth highlighting the importance of the ED visit as an excellent opportunity to begin to engage the patient in long term care. Jeff: Exactly, every ED visit is an opportunity that shouldn’t be missed. Nachi: Let’s talk controversies and cutting-edge topics from this issue. Jeff: First, let’s start by returning to ketamine and the treatment-resistant depression and suicidality. Nachi: Recent trials, including RCTs have found that low doses of ketamine administered via a variety of routes, may have a significant therapeutic effect towards reducing suicidality in patients in the acute setting. Jeff: To this end, Esketamine, an intranasal version of ketamine has already been FDA approved for treatment resistant depression. Nachi: This has huge implications for some of the psychiatrically sickest patients, so be on the lookout for more in the future. Jeff: Next we have the zero-suicide model. This is a program of the national action alliance for suicide prevention that involves a multi pronged approach to reducing suicide based on the premise that suicide is preventable. This model involves educating clinicians on best practices, identifying screening and assessment tools for engagement, treatment, and disposition. Nachi: Though not yet implemented in the ED setting, this may offer a novel approach to ED patients with psychiatric emergencies in the ED. Jeff: The next controversy is a big one - alcohol intoxication and suicide risk. There is a bidirectional relationship between depression and alcohol abuse and dependency. Not only is alcohol abuse a lifetime risk factor for completed suicide, those who make suicide attempts or present with suicidal ideations are more likely to be intoxicated. Nachi: In addition, formerly intoxicated patients may deny their previous thoughts and intentions when sober. Interestingly, though such patients have an increased lifetime risk of death by suicide. Jeff: Given this paradox and the evidence that exists, the authors recommend observing the patient until they have reached a reasonable level of sobriety. This effective level of sobriety should be based on clinical assessment and not blood alcohol levels. If the patient unfortunately has reached a place where they are at risk of withdrawal, this should be treated while in the ED. Nachi: It’s worth noting that ACEP guidelines and guidelines from the american association for emergency psychiatry have both supported a personalized approach that emphasize evaluating the patient’s cognitive abilities rather than a specific blood alcohol level to determine when to pursue a formal psychiatric assessment. Jeff: Very important point - in this high-risk population, you are targeting a clinical endpoint, not a laboratory end point and this is backed by several national guidelines. Nachi: Moving on to the next topic - let’s discuss post discharge patient contact. Jeff: Though not something many ED clinicians routinely do, this may be something to consider implementing in your department. And this doesn’t even have to be something as time consuming as a phone call. In one study, sending a brief postcard 9 times a year with a quick “hope things are well” type message to patients discharged after deliberate self-harm reduced self-poisonings by 50%. Nachi: Though other studies including other methods of follow up have not shown as drastic results, generally the results have shown a positive impact. Jeff: Next we have to discuss the various screening tools. Though we previously mentioned screening tools in a positive light, using such decision-making tools is still of limited utility due to the fact that they rely on self-reporting and suicidal thoughts and behaviors are complex and may require the consideration of hundreds of risk factors. Nachi: And while implicit association tests are being developed to predict suicidal thoughts and behaviors, and computer models and machine learning are being used to enhance our screening tools, there is still a long way to go before such tools perform more independently with acceptable performance. Jeff: The last cutting-edge topic to discuss is telepsychiatry. Nachi: Just as telestroke has changed stroke care forever, as technology advances, telepsychiatry may provide a solution to easily expand access to outpatient services and consultation in a cost effective manner - offering quick psychiatric care to those that never had access. Jeff: Let’s move on to the final section of the article. Disposition, which can be a bit complicated. Nachi: The decision for discharge, observation, or admission depends on clinical judgment and local protocols. Appropriate disposition is often fraught with legal, ethical, and psychological considerations. Jeff: It’s also worth noting that patients with suicidal ideations tend to have overall longer lengths of stay when compared to other patients on involuntary mental health hold. Nachi: There are however some suicide risk assessment tools that can help in the disposition decision planning such as C-SSRS, SAFE-T, and ICARE2. C-SSRS is a series of questions that assess the quality of suicidal ideation. SAFE-T is 5 step evaluation and triage tool that assesses various qualities and makes treatment recommendations. ICARE2 is provided by the American College of Emergency Physicians as a result of an iterative literature review and expert consensus panel. It also integrates many risk factors and treatment approaches. Jeff: It goes without saying that none of these tools are perfect. They should be used to assist in your clinical decision making. Nachi: For depressed but not actively suicidal patients, ensure close follow up with a mental health clinician. These patients typically do not require inpatient hospitalization. Jeff: Let’s also touch upon involuntary confinement here. Patients who are at imminent risk of self harm who refuse to stay for evaluation may need to be held involuntarily until a complete psychiatric and safety evaluation is performed. Nachi: Before holding a patient involuntarily, it is important to fully familiarize yourself with the state and county laws as there is wide variation. The period of involuntary confinement should be as short as possible. Jeff: With that, let’s close out this month’s episode with some high yield points and clinical pearls. Risk factors for major depression include female gender, young or old age, being divorced or widowed, black or Hispanic ethnicity, poor social support, and substance abuse. The strongest predictor for suicide-related outcomes is history of prior suicidal ideation or suicide attempt. When evaluating a patient with depressive symptoms, try to identify potential secondary causes, as this may influence your management strategy. When assessing for depression, perform a complete history and consider underlying medical causes that may be contributing to their presentation. Consider serum testing for the patient’s psychiatric medications if the medications have known toxic effects. 1. Routine serum testing and urine toxicology testing are not recommended for psychiatric patients presenting to the emergency department. Imaging of the brain should not be ordered routinely in depressed or suicidal patients. Depression places patients at a significantly increased risk for alcohol abuse and dependence. In addition to providing appropriate follow up resources to your depressed patients, emergency clinicians should consider making a brief follow up telephone call to the patient. Telepsychiatry may improve access to mental health providers and allow remote assessment and care from the ED. Suicide risk assessment tools such as C-SSRS, SAFE-T, and ICARE2 can help when deciding on disposition from the ER. It may be necessary to hold a patient against their will if they are at immediate risk of self-harm. Though not routinely administered in the ED for this purpose, psychotropic medications, such as ketamine, have proven helpful in acute depressive episodes. Patients who are actively suicidal should be admitted to a psychiatric observation unit or inpatient psychiatric unit. Nachi: So that wraps up Episode 28! Jeff: As always, additional materials are available on our website for Emergency Medicine Practice subscribers. If you’re not a subscriber, consider joining today. You can find out more at ebmedicine.net/subscribe. Subscribers get in-depth articles on hundreds of emergency medicine topics, concise summaries of the articles, calculators and risk scores, and CME credit. You’ll also get enhanced access to the podcast, including any images and tables mentioned. PA’s and NP’s - make sure to use the code APP4 at checkout to save 50%. Nachi: And don’t forget to check out the lineup for the upcoming Clinical Decision Making in Emergency Medicine conference hosted by EB Medicine, which will take place June 27th-30th. Great speakers, great location, what more could you ask. Jeff: And the address for this month’s cme credit is ebmedicine.net/E0519, so head over there to get your CME credit. As always, the [DING SOUND] you heard throughout the episode corresponds to the answers to the CME questions. Lastly, be sure to find us on iTunes and rate us or leave comments there. You can also email us directly at emplify@ebmedicine.net with any comments or suggestions. Talk to you next month! Most Important References 1. Owens PL, Mutter R, Stocks C. Mental health and substance abuse-related emergency department visits among adults, 2007: statistical brief #92. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. Rockville (MD): Agency for Healthcare Research and Quality (US); 2006. (US government report) 12. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-5). 5th ed. Washington DC: American Psychiatric Association; 2013. (Reference book) 15. Grant BF, Stinson FS, Dawson DA, et al. Prevalence and co-occurrence of substance use disorders and independent mood and anxiety disorders: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry. 2004;61(8):807-816. (Survey data; 49,093 patients) 16. Centers for Disease Control and Prevention. Current depression among adults---United States, 2006 and 2008. MMWR Morb Mortal Wkly Rep. 2010;59(38):1229-1235. (Government survey data analysis; 235,067 subjects) 97. Murrough J, Soleimani L, DeWilde K, et al. Ketamine for rapid reduction of suicidal ideation: a randomized controlled trial. Psychol Med. 2015;45(16):3571-3580. (Randomized controlled trial; 24 participants) 100. Griffiths JJ, Zarate CA, Rasimas J. Existing and novel biological therapeutics in suicide prevention. Am J Prev Med. 2014;47(3):S195-S203. (Review article)

Show Notes Jeff: Welcome back to EMplify, the podcast corollary to EB Medicine’s Emergency Medicine Practice. I’m Jeff Nusbaum, and I’m back with my co-host, Nachi Gupta. This month, after a few months of primarily medical topics, we’re talking trauma, specifically Blunt Cardiac Injury: Emergency Department Diagnosis and Management. Nachi: With no gold standard diagnostic test and with complications ranging from simple ectopic beats to fulminant cardiac failure and death, this isn’t an episode you’ll want to miss. Jeff: Before we begin, let me give a quick shout out to our incredible group of authors from New York -- Dr. Eric Morley, Dr. Bryan English, and Dr. David Cohen of Stony Brook Medicine and Dr. William Paolo, residency program director at SUNY Upstate. I should also mention their peer reviewers Drs. Jennifer Maccagnano and Ashley Norse of the NY institute of technology college of osteopathic medicine and UF Health Jacksonville, respectively. Nachi: This month’s team parsed through roughly 1200 articles as well as guidelines from the eastern association for surgery in trauma also known as EAST. Jeff: Clearly a large undertaking for a difficult topic to come up with solid evidence based recommendations. Nachi: For sure. Let’s begin with some epidemiology, which is admittedly quite difficult without universally accepted diagnostic criteria. Jeff: As you likely know, despite advances in motor vehicle safety, trauma remains a leading cause of death for young adults. In the US alone, each year, there are about 900,000 cases of cardiac injury secondary to trauma. Most of these occur in the setting of vehicular trauma. Nachi: And keep in mind, that those injuries don’t occur in isolation as 70-80% of patients with blunt cardiac injury sustain other injuries. This idea of concomitant trauma will be a major theme in today’s episode. Jeff: It certainly will. But before we get there, we have some more definitions to review - cardiac concussion and contusion, both of which were defined in a 1989 study. In this study, cardiac concussion was defined as an elevated CKMB with a normal echo, while a cardiac contusion was defined as an elevated CKMB and abnormal echo. Nachi: Much to my surprise, though, abnormal echo and elevated ck-mb have not been shown to be predictive of adverse outcomes, but conduction abnormalities on ekgs have been predictive of development of serious dysrhythmia Jeff: More on complications in a bit, but first, returning to the idea of concomitant injuries, in one autopsy study of nearly 1600 patients with blunt trauma - cardiac injuries were reported in 11.9% of cases and contributed to the death of 45.2% of those patients. Nachi: Looking more broadly at the data, according to one retrospective review, blunt cardiac injury may carry a mortality of up to 44%. Jeff: That’s scary high, though I guess not terribly surprising, given that we are discussing heart injuries due to major trauma... Nachi: The force may be direct or indirect, involve rapid deceleration, be bidirectional, compressive, concussive, or even involve a combination of these. In general, the right ventricle is the most frequently injured area due to the proximity to the chest wall. Jeff: Perfect, so that's enough background, let’s talk differential. As you likely expected, the differential is broad and includes cardiovascular injuries, pulmonary injuries, and other mediastinal injuries like pneumomediastinum and esophageal injuries. Nachi: Among the most devastating injuries on the differential is cardiac wall rupture, which not surprisingly has an extremely high mortality rate. In terms of location of rupture, both ventricles are far more likely to rupture than the atria with the right atria being more likely to rupture than the left atria. Atrial ruptures are more survivable, whereas complete free wall rupture is nearly universally fatal. Jeff: Septal injuries are also on the ddx. Septal injuries occur immediately, either from direct impact or when the heart becomes compressed between the sternum and the spine. Delayed rupture can occur secondary to an inflammatory reaction. This is more likely in patients with a prior healed or repaired septal defects. Nachi: Valvular injuries, like septal injuries, are rare. Left sided valvular damage is more common and carries a higher mortality risk. In order, the aortic valve is more commonly injured followed by the mitral valve then tricuspid valve, and finally the pulmonic valve. Remember that valvular damage can be due to papillary muscle rupture or damage to the chordae tendineae. Consider valvular injury in any patient who appears to be in cardiogenic shock, has hypotension without obvious hemorrhage, or has pulmonary edema. Jeff: Next on the ddx are coronary artery injuries, which include lacerations, dissections, aneurysms, thrombosis, and even MI secondary to increased sympathetic activity and platelet activity after trauma. In one review, dissection was the most commonly uncovered pathology, occurring 71% of the time, followed by thrombosis, which occured only 7% of the time. The LAD is the most commonly injured artery followed by the RCA. Nachi: Pericardial injury, including pericarditis, effusion, tamponade, and rarely rupture, is also certainly on the differential. Jeff: In terms of dysrhythmias, sinus tachycardia is the most common dysrhythmia, with other rhythms, including PVC / PAC / and afib being found only 1-6% of the time. Nachi: And while conduction blocks are rare, a RBBB is the most commonly noted, followed by a 1st degree AVB. Jeff: Though also rare, commotio cordis deserves it’s own section as its the second most common cause of death in athletes < 18 who are victims of blunt trauma. Though only studied in swine models, it’s hypothesized that the impact to the chest wall during T-wave upstroke can precipitate v-fib. Nachi: Aortic root injuries usually occur at the insertion of the ligamentum arteriosum and isthmus. Such injuries typically result in aortic insufficiency. Jeff: And the last pathology on the differential requiring special attention is a myocardial contusion. Again, no standard definition exists, with some diagnostic criteria including simply chest pain and increasing cardiac enzymes, and others including cardiac dysfunction, ecg abnormalities, wall motion abnormalities, and an elevation of cardiac enzymes. Nachi: Certainly a pretty broad differential… before moving on to the work up, Jeff why don’t you get us started with prehospital care? Jeff: Prehospital management should focus on rapid identification and stabilization of life threatening injuries with expeditious transport as longer prehospital times have been associated with increased mortality in trauma. Immediate transport to a Level I trauma center should be the highest priority for those with suspected blunt cardiac injury. Nachi: In terms of who specifically should be transporting the patient, a Cochrane review evaluated the utility of ALS vs BLS transport in trauma. There is reasonably good data to support BLS over ALS, even when controlling for trauma severity. Moreover, when airway management is needed, advanced airway techniques by ALS crews were associated with decreased odds of survival. Regardless of who is there, the message is the same: focus not on interventions, but instead on rapid transport. Jeff: And if it does happen to be an ALS transport crew, without delaying transport, pain management with fentanyl is both safe and reasonable and preferred over morphine. Post opiate hypotension in prehospital trauma patients is a rare but documented complication. Nachi: And if the prehospital team is lucky enough, or maybe unlucky enough, i don’t know, to have a credentialed provider who can perform ultrasound for those suspected of having a blunt cardiac injury, the general prehospital data on ultrasound is sparse. As of now, it’s difficult to conclude if prehospital US improves care for trauma patients. Jeff: Interestingly, the system I work in has prehospital physicians, who do carry US, but I can’t think of a major trauma where ultrasound changed any of the decisions we made. Nachi: Right, and I think that just reinforces the main point here: there may be a role, we just don’t have the data to support it at this time. Jeff: Great, let’s move onto ED care, beginning with the H&P. Nachi: On history, make sure to elucidate if there is any chest pain, and if it’s onset was before or after the traumatic event. In addition, make sure to ask about dyspnea, fatigue, palpitations, and lightheadedness. Jeff: And don’t forget to get the crash details from the EMS crew before they depart! As a side note, for anyone taking oral boards in a few months, don’t forget to ask the EMS crew for the details!!! Nachi: A definite must for oral boards and for your clinical practice. Jeff: In terms of the physical, tachycardia is the most common abnormality in blunt cardiac injury. In those with severe injury, you may note refractory hypotension secondary to cardiogenic shock. But don’t be reassured by normal vitals, especially in the young, who may be compensating well despite being quite ill. Nachi: Fully undress the patient to appropriately inspect and percuss the chest wall - looking for signs of previous cardiac surgeries or pacemaker placement, as well as to auscultate for new murmurs which may be a sign of valvular injury. Jeff: Similarly, as concomitant injuries are common, inspect the abdomen, looking for ecchymosis patterns, which often accompany blunt cardiac injury. Nachi: Pretty standard stuff. Let’s move on to diagnostic testing. Jeff: Lab testing should include a CBC, BMP, coags, troponin, lactate, and T&S. In one retrospective analysis, an elevated troponin and a lactate over 2.5 were predictors of mortality. Nachi: Additionally, in patients with chest trauma, a troponin > 1.05 was associated with a greater risk for dysrhythmias and LV dysfunction. Jeff: And it likely goes without saying, but an EKG is a must on all trauma patients with suspicion for blunt cardiac injury in accordance with the EAST guidelines. New EKG findings requires admission for monitoring. Unfortunately, on the flip side, an ECG cannot be used to rule out blunt cardiac injury. Nachi: Diving a bit deeper into the data, in a prospective study of 333 patients with blunt thoracic trauma, serial EKG and troponins at 0, 4, and 8 hours post injury had a sensitivity and specificity of 100% and 71%, respectively. However, of those with abnormal findings, all but one had them on initial testing, leading to a negative predictive value of 98%. Jeff: Well that’s an impressive NPV and has huge implications, especially in the era of heavily monitored lengths of stay... Nachi: Definitely. In terms of radiography, a chest x-ray should be obtained as rib fractures, hemopneumothorax, and mediastinal free air are all things you wouldn't want to miss and are also associated with blunt cardiac injury. Jeff: Keep in mind, however, that the chest x-ray should not be seen as a test for pericardial fluid as up to 200 mL of fluid can be contained in the pericardial space and remain undetectable by chest radiograph. Nachi: Which is why you’ll have to turn to our good friend the ultrasound, for more useful data. The data is strong that in the hands of trained Emergency Clinicians, when parasternal, apical, and subcostal views are obtained, US has an accuracy of 97.5% for pericardial effusion. Jeff: Not only is US accurate, it’s also quick. In one RCT, the FAST exam reduced the time from arrival in the ED to operative care by 64% in the setting of trauma. Nachi: That’s impressive -- for expediting patient care and for managing ED flow. Jeff: Exactly. The authors do note however that hemopericardium is a rare finding, so, while not the focus of this article, the real utility of the FAST exam may be in its expanded form, the eFAST, in which a rapid bedside ultrasonographic lung exam for pneumothorax is included, as this can lead to immediate changes in management. Nachi: And assuming you do your FAST or eFAST and have no management changing findings, CT will often be your next test. Jeff: Yeah, EKG-gated multidetector CT can easily diagnose myocardial rupture, pneumopericardium, pericardial rupture, hemopericardium, coronary artery insult, ventricular septal defects and even valvular dysfunction. Unfortunately, CT does not perform well for the evaluation of myocardial contusions. Nachi: This is all well and good, and certainly accurate, but let’s not forget that hemodynamically unstable trauma patients, like those with myocardial rupture, need to be in the operating room, not the CT scanner. Jeff: An important point that should not be understated. Nachi: And the last major testing modality to discuss is the echocardiogram. Jeff: The echo is a fantastic test for detecting focal cardiac dysfunction often see with cardiac contusions, hemopericardium, and valve disruption. Nachi: And it’s worth noting that transthoracic is enough, as transesophageal, despite the better images, hasn’t been shown to change management. TEE should be saved for those in whom a optimal TTE study isn’t feasible. Jeff: Great point. And one last quick note on echo: in terms of guidelines, the EAST guidelines from 2012 specifically recommend an echo in hemodynamically unstable patients or those with a persistent new dysrhythmia without other sources of ongoing hemorrhage or neurologic etiology of instability. Nachi: Perfect, so that wraps up testing and imaging for our blunt cardiac injury patient. Let’s move on to treatment. Jeff: In terms of initial resuscitation, there is an ever increasing body of literature to support blood transfusion over crystalloid in patients requiring volume expansion in trauma. There are no specific guidelines for transfusion in the setting of blunt cardiac injury, so stick to your standard trauma protocols. Nachi: It is worth noting, though, that there is literature outside of trauma for those with pericardial effusions, suggesting that those with a SBP < 100 have substantial benefit from volume expansion. So keep this in mind if your clinical suspicion is high and your trauma patient has a soft but not truly shocky blood pressure. Jeff: Operative management, specifically ED thoracotomy is a heavily debated topic, and it’s next on our list to discuss. Nachi: The 2015 EAST guidelines conditionally recommend ED thoracotomy for moribund patients with signs of life. The Western Trauma Association broadens the ED thoracotomy window a bit to include anyone with no signs of life but less than 10 minutes of CPR. The latter also recommend ED thoracotomy in those with refractory shock. Jeff: Though few studies exist on the topic, in one study of 187 patients, cardiac motion on US was 100% sensitive for predicting survivors. Nachi: Not great data, but it does support one's decision to stop any further work up should there be no cardiac activity, which is important, because the decision to pursue an ED thoracotomy is not an easy one. Jeff: And lastly, emergent pericardiocentesis may be another option in an unstable patient when definitive operative management is not possible. But do note that pericardiocentesis is only a temporizing measure, and not definitive for cardiac tamponade. Nachi: Treatment for dysrhythmias is standard, treat in accordance with standard ACLS protocols, as formal randomized trials on prophylaxis and treatment in the setting of blunt cardiac injury do not exist. Jeff: Seems reasonable enough. And in the very rare setting of an MI after blunt cardiac injury, you should involve cardiology, cardiothoracic surgery, and trauma to help make important management decisions. Data is, again, lacking, but the patient likely needs percutaneous angiography for appropriate diagnosis and potentially further intervention. Definitely hold off on ASA and likely nitroglycerin, at least until significant bleeding has been ruled out. Nachi: Yup, no style points for giving aspirin to a bleeding trauma patient. Speaking of medications, the last treatment modality to discuss here is pain control. Pain management is essential with chest injuries, as appropriate pain management has been shown to reduce mortality in pulmonary related complications. Jeff: And in line with every acute pain consult note I’ve ever come across, a multimodal approach utilizing opioids and nonopioids is recommended. Nachi: Perfect, so that sums up treatment, next we have one special circumstance to discuss: sternal fractures. Cardiac contusions are found in 1.8-2.4% of patients with sternal fractures, almost all of which were seen on CT and not XR according to the NEXUS chest CT study. Of these patients, only 2 deaths occured, both due to cardiac causes.  Thus, in patients with isolated sternal fractures, negative trops, ekg, and negative cxr - the patient can likely be discharged from the ED, as long as their pain is well-controlled. Jeff: And let’s talk controversies for this issue. We only have one to discuss: MRI. Nachi: The fact that MRI produces awesome images is not controversial, see figure 3. It’s role, however, is. In accordance with EAST guidelines, MRI may be most useful in differentiating acute ischemia from blunt cardiac injury in those with abnormal ECGs, elevated enzymes, or abnormal echos. It’s use in the hyperacute evaluation, however, is limited, in large part owing to the length of time required to complete an MRI Jeff: What a time to be alive that we even have to say that MRIs may not have a hyperacute role in trauma - absolutely crazy... Nachi: Moving on to disposition: any patient with aortic, pericardial, or myocardial injury and hemodynamic instability needs operative evaluation and likely intervention, so do not hesitate to get the consults coming or the helicopter in the air should such a patient arrive at your non-trauma center. Jeff: And in those that are hemodynamically stable, with either a positive ECG or a positive trop, they should be monitored on telemetry. There is no clear answer as to how long, but numerous studies suggest a 24 hour period of observation is sufficient. For those with persistent ekg abnormalities or rising trops - this is precisely when you will want to pursue echocardiography. Nachi: And if there are positive EKG findings AND a rising trop, they should be admitted to a step down unit or ICU as well -- as ⅔ of them will develop myocardial dysfunction. Similarly, those with hemodynamic instability but no active traumatic bleeding source - they too should be admitted to the ICU for a STAT echo and serial enzymes. Jeff: But in the vast majority of patients, those that are hemodynamically stable with negative serial EKGs and serial tropinins, they can effectively be ruled out for significant BCI after an 8 hour ED observation period, as we mentioned earlier with a sensitivity approaching 100%! Nachi: Though there are, of course, exceptions to this rule, like those with low physiologic reserve, mobility or functional issues, or complex social situations, which may need to be assessed on a more case-by-case basis. Jeff: Let’s wrap up this episode with some key points and clinical pearls. Cardiac wall rupture is the most devastating form of Blunt Cardiac Injury. The sealing of a ruptured wall may lead to a pseudoaneurysm and delayed tamponade. Trauma to the coronary arteries may lead to a myocardial infarction. The left anterior descending artery is most commonly affected. The most common arrhythmia associated with blunt cardiac injury is sinus tachycardia. RBBB is the most commonly associated conduction block. Commotio cordis is the second most common cause of death in athletes under the age of 18. Early defibrillation is linked to better outcomes. Antiplatelet agents like aspirin should be avoided in blunt cardiac injury until significant hemorrhage has been ruled out. An EKG should be obtained in all patients with suspected blunt cardiac injury. However, an EKG alone does not rule out blunt cardiac injury. Serial EKG and serial troponin testing at hours 0, 4, and 8 have a sensitivity approaching 100% for blunt cardiac injury. An elevated lactate level or troponin is associated with increased mortality in blunt cardiac injury. Perform a FAST exam to assess for pericardial effusions. FAST exams are associated with a significant reduction in transfer time to an operating room. Obtain a chest X-ray in all patients in whom you have concern for blunt cardiac injury. Note that the pericardium is poorly compliant and pericardial fluid might not be detected on chest X-ray. Transesophageal echocardiogram should be considered when an optimal transthoracic study cannot be achieved. CT is used routinely in evaluating blunt chest trauma but know that it does not evaluate cardiac contusions well. In acute evaluation, MRI is generally a less useful imaging modality given the long imaging time. There is evidence to suggest that a patient with an isolated sternal fracture and negative biomarkers and negative EKG findings can be safely discharged from the ED if pain is well-controlled. Trauma to the aorta, pericardium, or myocardium is associated with severe hemodynamic instability. These patients need surgical evaluation emergently. Hemodynamically stable patients with a positive troponin test or with new EKG abnormalities should be observed for cardiac monitoring. Nachi: So that wraps up Episode 26 on Blunt Cardiac Injury! Jeff: Additional materials are available on our website for Emergency Medicine Practice subscribers. If you’re not a subscriber, consider joining today. You can find out more at ebmedicine.net/subscribe. Subscribers get in-depth articles on hundreds of emergency medicine topics, concise summaries of the articles, calculators and risk scores, and CME credit. You’ll also get enhanced access to the podcast, including any images and tables mentioned. You can find everything you need to know at ebmedicine.net/subscribe. Nachi: It’s also worth mentioning for current subscribers that the website has recently undergone a major rehaul and update. The new site is easier to use on mobile browsers, has better search functionality, mobile-friendly CME testing, and quick access to the digest and podcast. Jeff: And as those of us in the north east say goodbye to the snow for the year, it’s time to start thinking about the summer and maybe start planning for the Clinical Decision Making conference in sunny Ponta Vedra Beach, Fl. The conference will run from June 27th to June 30th this year with a pre-conference workshop on June 26th. Nachi: And the address for this month’s credit is ebmedicine.net/E0319, so head over there to get your CME credit. As always, the [DING SOUND] you heard throughout the episode corresponds to the answers to the CME questions. Lastly, be sure to find us on iTunes and rate us or leave comments there. You can also email us directly at EMplify@ebmedicine.net with any comments or suggestions. Talk to you next month! Most Important References 7.* Clancy K, Velopulos C, Bilaniuk JW, et al. Screening for blunt cardiac injury: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2012;73(5 Suppl 4):S301-S306. (Guideline) 22.* Schultz JM, Trunkey DD. Blunt cardiac injury. Crit Care Clin. 2004;20(1):57-70. (Review article) 23.* El-Chami MF, Nicholson W, Helmy T. Blunt cardiac trauma. J Emerg Med. 2008;35(2):127-133. (Review article) 27.* Bock JS, Benitez RM. Blunt cardiac injury. Cardiol Clin. 2012;30(4):545-555. (Review article) 34.* Berk WA. ECG findings in nonpenetrating chest trauma: a review. J Emerg Med. 1987;5(3):209-215. (Review article) 64.* Velmahos GC, Karaiskakis M, Salim A, et al. Normal electrocardiography and serum troponin I levels preclude the presence of clinically significant blunt cardiac injury. J Trauma. 2003;54(1):45-50. (Prospective; 333 patients) 73.* Melniker LA, Leibner E, McKenney MG, et al. Randomized controlled clinical trial of point-of-care, limited ultrasonography for trauma in the emergency department: the first sonography outcomes assessment program trial. Ann Emerg Med. 2006;48(3):227-235. (Randomized controlled trial; 262 patients)

Shownotes Jeff: Welcome back to EMplify, the podcast corollary to EB Medicine’s Emergency Medicine Practice. I’m Jeff Nusbaum, and I’m back with my co-host, Nachi Gupta. This month, we’re tackling an incredibly important topic - evaluation and management of life threatening headaches in the Emergency Department. Nachi: Fear not, this will not simply be “who needs a head CT episode”; we’ll cover much more than that. Listen closely as this is an important topic, with huge consequences for mismanagement. Jeff: Absolutely. As some quick background - headaches account for 3% of all ED visits in the US, with 90% being benign primary headaches and less than 10% being secondary to other causes like vascular, infectious, or traumatic etiologies. It’s within these later 10% that we are looking for the red flag signs to identify the potentially life-threatening headaches. Nachi: And to do so, Dr. David Zodda and Dr. Amit Gupta, PD and APD at Hackensack University Medical and Trauma Center, and their colleague Dr. Gabrielle Procopio, a PharmD, have done a fantastic job parsing through the literature, which included over 500 abstracts, 89 full text articles, guidelines from ACEP and the American Academy of Neurology, as well as canadian and european neurology guidelines, to summarize the best evidence based recommendations for you all. Jeff: We would be remiss to not also mention Dr. Mert Erogul of Maimonides Medical Center and Dr. Steven Godwin, Chair of Emergency Medicine at the University of Florida College of Medicine. Nachi: Alright, so let’s get started with some definitions and pathophysiology. The international classification of headache disorders 3, or ICHD-3, classifies headaches into primary, secondary, and cranial neuropathies. Jeff: Primary headache disorders include migraine, tension, and cluster headaches. Secondary headaches include those secondary to vascular disorders, traumatic disorders, and disorders in hemostasis. These are the potentially life threatening headaches that can have a mortality has high as 50%. Nachi: And the final category includes cranial neuropathies, such as trigeminal neuralgia. Jeff: And I think we can safely say that that wraps up our discussion in this episode on cranial neuropathies, moving on…. Nachi: Headaches result from traction to or irritation of the meninges and blood vessels, which are the only innervated central nervous system structures. Activation of specific nerve ganglion complexes by neuropeptides like -- substance P and calcitonin gene-related peptide -- are thought to contribute to head pain. Jeff: It is important to note that all headache pain shares common pain pathways, thus response to pain medications does not exclude potential life threatening secondary causes of headache. This led to the ACEP guideline which states just that.. Nachi: I feel like that deserves ding sound as it's a critically important point. To repeat, just because a pain medication relieves a headache, that does not exclude dangerous secondary causes! Jeff: And what are the life threatening headaches? Life-threatening headaches include subarachnoid hemorrhage, cervical Artery Dissection, which includes both vertebral Artery Dissection and carotid artery dissection, cerebral Venous Thrombosis, idiopathic intracranial hypertension, giant cell arteritis, and posterior reversible encephalopathy syndrome, or PRES. Nachi: Slow down for a second and let’s not skip over your favorite section.. Let’s talk pre hospital care for headache patients. Jeff: Good call! Pre-hospital care is fairly straightforward and includes a primary survey, conducting a focused neurologic exam, and assessing for red flag signs, which include focal neurologic deficits, sudden onset headache, new headache in those over 50, neck pain or stiffness, changes in visual Acuity, fever or immunocompromised State, history of malignancy, pregnancy or postpartum status, syncope, and seizure. That’s quite a list. For a visual reference, see Table 3 in the print issue. Nachi: And patients with neurologic deficits or severe sudden-onset headaches, should be transported immediately to the nearest available stroke center. Tylenol should be offered for pain management. Avoid opioids and nsaids. Jeff: Upon arrival to the emergency department, history and physical should include your standard vitals, testing neurologic function, cranial nerve testing, head and neck exam, as well as a fundoscopic exam. As was the case for your pre-hospital colleagues, you should also assess for red flag signs for life-threatening headaches. Check out tables 2, 3, and 4 for more details here. Nachi: With respect to Vital Signs, in the setting of an acute headache, severe hypertension should prompt a search for signs of end-organ damage such as hypertensive encephalopathy, intracranial Hemorrhage, PRES, and preeclampsia in pregnant women. Additionally, fever, and especially fever and neck stiffness, should raise concern for CNS infection. Jeff: For your neurologic examination, make sure to include assessments of motor strength, coordination, reflexes, sensory function, and gait. Don't forget that lesions involving the anterior circulation, such as dysarthria, cognitive impairment, and Horner syndrome may be indicative of a carotid artery dissection, whereas dizziness, vision changes, and limb weakness may be due to a vertebral Artery Dissection. Nachi: And for cranial nerve testing - pay particular attention to cranial nerves 2, 3 and 6. For cranial nerve 2 - look out for an afferent pupillary defect, or a marcus-gunn pupil, which is seen in optic neuritis, giant cell artertitis, and central retinal artery occlusion. For CN3, oculomotor nerve palsies raise concern for a posterior communicating aneurysm and SAH. And lastly, CN6 palsies, which often presents with diplopia on lateral gaze , are often seen with intracranial idiopathic hypertension and cerebral venous thrombosis, in addition to impaired visual acuity, visual field defects, and tunnel vision. Jeff: For the head and neck exam, remember that a partial horner syndrome, with miosis and ptosis without anhidrosis, may be indicative of a cervical artery dissection. Unfortunately, if the patient presents acutely, their only complaint may be pain, as the neurologic sequelae may take days to develop. Nachi: Additionally, with respect to the head and neck exam, evaluate the patient for tenderness and beading along the temporal artery. Jeff: One review noted that temporal artery beading actually had the highest likelihood ratio for GCA, 4.6, whereas temporal artery tenderness only had a LR of 2.6 Nachi: And the last physical exam maneuver you should ideally perform is a fundoscopic exam for papilledema, which is often seen in IIH, malignant hypertension, and CVT. Jeff: Perfect so that rounds out the physical, next we have diagnostic studies. Most importantly, routine lab testing is typically of low utility in aiding in the diagnosis of headache. Nachi: Even ESR and CRP in the setting of possible giant cell arteritis have poor sensitivity and specificity to diagnose it. So even if the ESR and CRP are negative, if the suspicion for GCA is high enough, it should be treated and you should get a biopsy. Jeff: Do consider adding on a venous or arterial carboxyhemoglobin in the right clinical scenario, as CO poisoning represents an important cause of headache you wouldn’t want to miss. This is especially important at this time of year when heating systems are working overtime here in the states. Nachi: And hopefully you have a co-oximeter, so you can even check this non-invasively. Jeff: Interestingly, there may be a unique role for a d-dimer here as well. Several small studies have used the d-dimer to risk stratify patients with possible CVT. In one study a d-dimer level < 500 mcg/L had a 97% sensitivity and a negative predictive value of 99% - not bad! Nachi: Pretty impressive performance characteristics. I think that about wraps up lab work. Let’s talk radiology. Jeff: Though low yield, CT utilization is estimated at 2.5-10% of non-traumatic headaches. A non-con CT should be reserved for those with suspicion for an intracranial hemorrhage, while a contrast CT would be required in those in whom there is concern for an infectious process or space occupying lesion. Nachi: CT angio or MRI should be used in cases of possible cervical artery dissection. MRI also is the neuroimaging of choice for PRES, which is more sensitive for cerebral edema than CT. Jeff: Similarly, MRV is recommended in those with a concerning story for CVT. Nachi: To help guide your emergent neuroimaging utilization, ACEP suggests imaging in those with headache and an abnormal finding on neuro exam, those with new and sudden-onset severe headache, HIV positive patients with new headache, and those over 50 with a new headache. Jeff: With that in mind, let’s dive a bit deeper into the use of CT for SAH, a topic which doesn’t get a ding sound, but is certainly critically important. Recent literature have found that a CT within 6 hours of symptom onset has a sensitivity and specificity and negative predictive value of 100%. In addition, one 2016 study demonstrated a LR of 0.01 in those with a negative HCT within 6 hours. These are really important results because that means SAH is essentially ruled out with a negative study. Nachi: Unfortunately, the 2008 ACEP guideline and 2012 AHA guidelines still recommend a lumbar puncture in those being worked up for SAH. Luckily the ACEP guideline is currently being revised so your decision to forego the LP with a negative HCT in the first 6 hours will likely also be backed by ACEP in the near future. Jeff: That’s a nice transition into our next test - the LP. Since LP carries a risk of herniation, in those with signs of increased ICP, make sure to get appropriate neuroimaging before attempting the puncture. In those without signs of increased ICP, no imaging is necessary. Nachi: While the position in which the LP is performed doesn’t matter as much when ruling out infection or SAH, in those with suspected IIH, make sure to obtain an opening pressure with the patient lying in the lateral decubitus position. An opening pressure of greater than 25 is often seen in IIH. Jeff: And the LP in the setting of IIH is not only diagnostic but also potentially therapeutic, as the removal of 1 ml of CSF can lower the pressure by 1 cm of H20 and potentially relieve the patient’s symptoms. Nachi: Always rewarding to diagnose and treat simultaneously... Jeff: Absolutely. But back to the LP for SAH for a second or two. When evaluating for a subarachnoid hemorrhage, you’ll often note an opening pressure of greater than 20 with persistent RBC in all tubes. Nachi: While there are no RBC cutoffs, one study found no patients with a SAH with less than 100 RBC in the final tube. In contrast, greater than 10,000 RBC increased the odds by a factor of 6. In addition, one 2015 study found that patients without xanthrochromia and less than 2000 RBC were effectively ruled out of having a SAH with a combined sensitivity of 100% Jeff: Lots of 100% sensitivities and specificities being thrown around today, which is definitely not the norm. No complaints here, I’ll take it. Anyway, the last test to discuss is our good friend the ultrasound, specifically the ocular ultrasound. Nachi: Examining the optic nerve sheath 3 mm posterior to the globe, an optic nerve sheath diameter of 5 mm or greater is predictive of an ICP greater than 20. Jeff: Keep in mind that this may expedite the work up, though a normal diameter does not rule out increased ICP, so a head CT may still be indicated. Nachi: Alright, so we’ve talked a lot about testing, both lab and imaging, and we’ve mentioned a bunch of pathologies, but let’s spend a few minutes going over the specifics of each. Jeff: Let’s start with SAH. SAH account for 1% of all headache visits to the ED. Most nontraumatic SAH are caused by aneurysm rupture. A missed diagnosis of SAH can have a case-fatality rate as high as 50% Nachi: Although 75% of SAH patients report an abrupt onset, objective neck stiffness has the highest likelihood ratio of 6.6. Other important features include LOC, neurologic deficit, subjective neck stiffness, photophobia, and onset during exertion or intercourse. Jeff: Additionally, approximately 20% of patients with a SAH have warning signs of a sentinel bleed including headaches, cranial nerve palsies, neck pain, or nausea and vomiting. Nachi: In order to aid you in diagnosing a SAH, you should consider the ottawa SAH Rule which has a 100% sensitivity and a 15% specificity. To use this rule you must be between 15 and 40 with a GCS of 15 and present with a headache with maximal intensity within 1 hour of onset. If you meet those inclusion criteria, and you have no neurologic deficits, no neck pain or stiffness, no witnessed LOC, no onset during exertion, no limitation of neck flexion, and no thunderclap onset, you can essentially rule out a SAH. Jeff: While the ottawa SAH rule has been prospectively validated, know that this study has been challenged for its interobserver variability, but in any case it still provides helpful red flags to consider. If your patient is found to have a SAH, a CT angiogram and neurosurgical consultation should be considered immediately. Nachi: In addition to monitoring ABCs, early care involves the administration of analgesics and anti-emetics. Also consider elevating the head of the bed to 30 deg, which may also improve venous drainage and decrease ICP. Jeff: In terms of BP management, guidelines from the american stroke association recommend targeting a SBP of 160 with a titratable agent like nicardipine or clevidipine. Nachi: In addition, nimodipine, 60 mg q4h, should be given to those with aneurysmal SAH to improve outcomes. Jeff: and any role for anti-epileptics? Nachi: That’s controversial and the authors state it may be considered in the immediate post-hemorrhagic period and should be limited to a 3-7 day course with longer courses required in special populations. Jeff: The next pathology to discuss is cervical artery dissections, which account for 2% of all strokes and nearly 20% of strokes in those 50 and under. cervical artery dissections are most commonly due to trauma, but can occur spontaneously. Nachi: Risk factors include Ehlers-Danlos syndrome, osteogenesis imperfecta, and Marfan syndrome. Jeff: Regardless of the etiology, the management of cervical artery dissections is primarily medical with IV heparin followed by warfarin or a direct oral anticoagulant in those with extracranial dissections, and antiplatelet therapy like aspirin or clopidogrel in those with intracranial dissections. Nachi: Thanks to the CADISP study, we know there is no difference in mortality or neurologic outcome when choosing between antiplatelet therapy and anticoagulation. Jeff: Next we have cerebral venous thrombosis. This typically presents with a gradual onset headache. Though it can happen to anybody, cerebral venous thrombosis typically results from thrombotic disease. Nachi: Important risk factors include oral contraceptive use, pregnancy and postpartum states, Factor V Leiden deficiency, and lupus. Jeff: Treatment for CVT is controversial due to a high risk of hemorrhage and hemorrhagic transformation. According to the best available evidence, anticoagulation is the standard therapy with full dose anticoagulation of low-molecular weight heparin or heparin as a bridge to warfarin. Nachi: Yeah, it’s really a tough spot to be in as one third end up having some form of hemorrhage too…. Jeff: Perhaps yet another good place for shared decision making? Nachi: Honestly, it’s a good thought, but anticoagulation is the guideline recommendation, so I think that is likely the best route in this case. Jeff: Great point. Next we have idiopathic intracranial hypertension. This is typically associated with obese women of childbearing age. It may also be due to hypervitaminosis A from excessive dietary intake and even drugs like the retinoids used in treating dermatologic conditions and cancers. Nachi: idiopathic intracranial hypertension can be diagnosed by the modified dandy criteria which are found in table 8 on page 11. Let’s just run through the criteria. Jeff: The modified Dandy criteria for idiopathic intracranial hypertension include: signs and symptoms of increased ICP, no other neurologic abnormalities or altered level of consciousness, ICP > 20 on LP with normal CSF composition, neuroimaging without another etiology for intracranial hypertension, and lastly no other identified cause of intracranial hypertension. Nachi: And as we mentioned a few minutes ago, an LP can be both diagnostic and therapeutic, though the relief is likely temporary Jeff: For more permanent treatment, weight loss is the key. Acetazolamide, 250 mg to 500 BID is the first line pharmacotherapy. Combined with weight loss, acetazolamide and a low sodium diet has been shown to improve visual field function. Nachi: And if this fails, topiramate, furosemide, and in the worst case surgical options like CSF shunting, venous sinus stenting, and optic sheath fenestration are all options. Jeff: I imagine taking a diuretic for a headache could be a real hindrance on quality of life, though I suppose it’s better than risking vision loss or having a significant neurosurgery. Nachi: Agreed. Next we have giant cell arteritis. GCA is rare, with a prevalence of

  Jeff: Welcome back to Emplify, the podcast corollary to EB Medicine’s Emergency Medicine Practice. I’m Jeff Nusbaum, and I’m back with my co-host, Nachi Gupta. This month, we’re talking about a topic… Nachi: … woah wait, slow down for a minute, before we begin this month’s episode – we should take a quick pause to wish all of our listeners a happy new year! Thanks for your regular listenership and feedback. Jeff: And we’re actually hitting the two year mark since we started this podcast. At 25 episodes now, this is sort of our silver anniversary. Nachi: We have covered a ton of topics in emergency medicine so far, and we are looking forward to reviewing a lot more evidence based medicine with you all going forward. Jeff: With that, let’s get into the first episode of 2019 – the topic this month is first trimester pregnancy emergencies: recognition and management. Nachi: This month’s issue was authored by Dr. Ryan Pedigo, you may remember him from the June 2017 episode on dental emergencies, though he is perhaps better known as the director of undergraduate medical education at Harbor-UCLA Medical center. In addition, this issue was peer reviewed by Dr. Jennifer Beck-Esmay, assistant residency director at Mount Sinai St. Luke’s, and Dr. Taku Taira, the associate director of undergraduate medical education and associate clerkship director at LA County and USC department of Emergency Medicine. Jeff: For this review, Dr. Pedigo had to review a large body of literature, including thousands of articles, guidelines from the American college of obstetricians and gynecologists or ACOG, evidence based Practice bulletins, ACOG committee opinions, guidelines from the American college of radiology, the infectious diseases society of America, clinical policies from the American college of emergency physicians, and finally a series of reviews in the Cochrane database. Nachi: There is a wealth of literature on this topic and Dr. Pedigo comments that the relevant literature is overall “very good.” This may be the first article in many months for which there is an overall very good quality of literature. Jeff: It’s great to know that there is good literature on this topic. It’s incredibly important as we are not dealing with a single life here, as we usually do... we are quite literally dealing with potentially two lives as the fetus moves towards viability. With opportunities to improve outcomes for both the fetus and the mother, I’m confident that this episode will be worth your time. Nachi: Oh, and speaking of being worth your time…. Don’t forget that if you’re listening to this episode, you can claim your CME credit. Remember, the indicates an answer to one of the CME questions so make sure to keep the issue handy. Jeff: Let’s get started with some background. First trimester emergencies are not terribly uncommon in pregnancy. One study reported 85% experience nausea and vomiting. Luckily only 3% of these progressed to hyperemesis gravidarum. In addition, somewhere between 7-27% experience vaginal bleeding or miscarriage. Only 2% of these will be afflicted with an ectopic pregnancy. Overall, the maternal death rate is about 17 per 100,000 with huge racial-ethnic disparities. Nachi: And vaginal bleeding in pregnancy occurs in nearly 25% of patients. Weeks 4-8 represent the peak time for this. The heavier the bleeding, the higher the risk of miscarriage. Jeff: Miscarriage rates vary widely based on age, with an overall rate of 7-27%. This rises to nearly 40% risk in those over 40. And nearly half of miscarriages are due to fetal chromosomal abnormalities. Nachi: For patient who have a threatened miscarriage in the first trimester, there is a 2-fold increased risk of subsequent maternal and fetal adverse outcomes. Jeff: So key points here, since I think the wording and information you choose to share with often scared and worried women is important – nearly 25% of women experience bleeding in their first trimester. Not all of these will go on to miscarriages, though the risk does increase with maternal age. And of those that miscarry, nearly 50% were due to fetal chromosomal abnormalities. Nachi: So can we prevent a miscarriage, once the patient is bleeding…? Jeff: Short answer, no, longer answer, we’ll get to treatment in a few minutes. For now, let’s continue outlining the various first trimester emergencies. Next up, ectopic pregnancy… Nachi: An ectopic pregnancy is implantation of a fertilized ovum outside of the endometrial cavity. This occurs in up to 2% of pregnancies. About 98% occur in the fallopian tube. Risk factors for an ectopic pregnancy include salpingitis, history of STDs, history of PID, a prior ectopic, and smoking. Jeff: Interestingly, with respect to smoking, there is a dose-relationship between smoking and ectopic pregnancies. Simple advice here: don’t smoke if you are pregnant or trying to get pregnant. Nachi: Pretty sound advice. In addition, though an IUD is not a risk factor for an ectopic pregnancy, if you do become pregnant while you have in IUD in place, over half of these may end up being ectopic. Jeff: It’s also worth mentioning a more obscure related disease pathology here – the heterotopic pregnancy -- one in which there is an IUP and an ectopic pregnancy simultaneously. Nachi: Nausea and vomiting, though not as scary as miscarriages or an ectopic pregnancy, represent a fairly common pathophysiologic response in the first trimester -- with the vast majority of women experiencing nausea and vomiting. And as we mentioned earlier, only 3% of these progress to hyperemesis gravidarum. Jeff: And while nausea and vomiting clearly sucks, they seem to actually be protective of pregnancy loss, with a hazard ratio of 0.2. Nachi: Although this may be protective of pregnancy loss, nausea and vomiting can really decrease the quality of life in pregnancy -- with one study showing that about 25% of women with severe nausea and vomiting had actually considered pregnancy termination. 75% of those women also stated they would not want to get pregnant again because of these symptoms. Jeff: So certainly a big issue.. Two other common first trimester emergency are asymptomatic bacteriuria and UTIs. In pregnant patients, due to anatomical and physiologic changes in the GU tract – such as hydroureteronephrosis that occurs by the 7th week and urinary stasis due to bladder displacement – asymptomatic bacteriuria is a risk factor for developing pyelonephritis. Nachi: And pregnant women are, of course, still susceptible to the normal ailments of young adult women like acute appendicitis, which is the most common surgical problem in pregnancy. Jeff: Interestingly, based on epidemiologic data, pregnant women are less likely to have appendicitis than age-matched non-pregnant woman. I’d like to think that there is a good pathophysiologic explanation there, but I don’t have a clue as to why that might be. Nachi: Additionally, the RLQ is the the most common location of pain from appendicitis in pregnancies of all gestational ages. Peritonitis is actually slightly more common in pregnant patients, with an odds ratio of 1.3. Jeff: Alright, so I think we can put that intro behind us and move on to the differential. Nachi: When considering the differential for abdominal pain or vaginal bleeding in the first trimester, you have to think broadly. Among gynecologic causes, you should consider miscarriage, septic abortion, ectopic pregnancy, corpus luteum cyst, ovarian torsion, vaginal or cervical lacerations, and PID. For non-gynecologic causes, you should also consider appendicitis, cholecystitis, hepatitis, and pyelonephritis. Jeff: In the middle of that laundry list you mentioned there is one pathology which I think merits special attention - ovarian torsion. Don’t forget that patients undergoing ovarian stimulation as part of assisted reproductive technology are at a particularly increased risk due to the larger size of the ovaries. Nachi: Great point. Up next we have prehospital care... Jeff: Always a great section. First, prehospital providers should attempt to elicit an ob history. Including the number of weeks’ gestation, LMP, whether an IUP has already been confirmed, prior hx of ectopic, and amount of vaginal bleeding. In addition, providers should consider an early destination consult both to select the correct destination and to begin the process of mobilizing resources early in those patients who really need them, such as those with hemodynamic instability. Nachi: As with most pathologies, the more time you give the receiving facility to prepare, the better the care will be, especially the early care, which is critical. Jeff: Now that the patient has arrived in the ED we can begin our H&P. Nachi: When eliciting the patient’s obstetrical history, it’s common to use the G’s and Ps. This can be further annotated using the 4-digit TPAL method, that’s term-preterm-abortus-living. Jeff: With respect to vaginal bleeding, make sure to ask about the number of pads and how this relates to the woman’s normal number of pads. In addition, make sure to ask about vaginal discharge or even about the passage of tissue. Nachi: You will also need to elicit whether or not the patient has a history of a prior ectopic pregnancies as this is a major risk for future ectopics. And ask about previous sexually transmitted infections also. Jeff: And, of course, make sure to elicit a history of assisted reproductive technology, as this increases the risk of a heterotopic pregnancy. Nachi: Let’s move on to the physical. While you are certainly going to perform your standard focused physical exam, just as you would for any non-pregnant woman - what does the evidence say about the pelvic exam? I know this is a HOTLY debated topic among EM Docs. Jeff: Oh it certainly is. Dr. Pedigo takes a safe, but fair approach, noting, “A pelvic exam should always be performed if the emergency clinician suspects that it would change management, such as identifying the source of bleeding, or identifying an STD or PID.” However, it is noteworthy that the only real study he cites on this topic, an RCT of pelvic vs no pelvic in those with a confirmed IUP and first trimester bleeding, found no difference between the two groups. Obviously, the pelvic group reported more discomfort. Nachi: You did leave out one important fact about the study enrollment - they only enrolled about 200 of 700 intended patients. Jeff: Oh true, so a possibly underpowered study, but it’s all we’ve got on the topic. I think I’m still going to do pelvic exams, but it’s something to think about. Nachi: Moving on, all unstable patients with vaginal bleeding and no IUP should be assumed to have an ectopic until proven otherwise. Ruptured ectopics can manifest with a number of physical exam findings including abdominal tenderness, with peritoneal signs, or even with bradycardia due to vagal stimulation in the peritoneum. Jeff: Perhaps most importantly, no history or physical alone can rule in or out an ectopic pregnancy, for that you’ll need testing and imaging or operative findings. Nachi: And that’s a perfect segue into our next section - diagnostic studies. Jeff: Up first is the urine pregnancy test. A UPT should be obtained in all women of reproductive age with abdominal pain or vaginal bleeding, and likely other complaints too, though we’re not focusing on them now. Nachi: The UPT is a great test, with nearly 100% sensitivity, even in the setting of very dilute urine. False positives are certainly plausible, with likely culprits being recent pregnancy loss, exogenous HCG, or malignancy. Jeff: And not only is the sensitivity great, but it’s usually positive just 6-8 days after fertilization. Nachi: While the UPT is fairly straight forward, let’s talk about the next few tests in the context of specific disease entities, as I think that may make things a bit simpler -- starting with bHCG in the context of miscarriage and ectopic pregnancy. Jeff: Great starting point since there is certainly a lot of debate about the discriminatory zone. So to get us all on the same page, the discriminatory zone is the b-HCG at which an IUP is expected to be seen on ultrasound. Generally 1500 is used as the cutoff. This corresponds nicely to a 2013 retrospective study demonstrating a bHCG threshold for the fetal pole to be just below 1400. Nachi: However, to actually catch 99% of gestational sacs, yolk sacs, and fetal poles, one would need cutoffs of around 3500, 18000, and 48,000 respectively -- much higher. Jeff: For this reason, if you want to use a discriminatory zone, ACOG recommends a conservatively high 3,500, as a cutoff. Nachi: I think that’s an understated point in this article, the classic teaching of a 1500 discriminatory zone cutoff is likely too low. Jeff: Right, which is why I think many ED physicians practice under the mantra that it’s an ectopic until proven otherwise. Nachi: Certainly a safe approach. Jeff: Along those lines, lack of an IUP with a bHCG above whatever discriminatory zone you are using does not diagnose an ectopic, it merely suggests a non-viable pregnancy of undetermined location. Nachi: And if you don’t identify an IUP, serial bHCGs can be really helpful. As a rule of thumb -- in cases of a viable IUP -- b-HCG typically doubles within 48 hours and at a minimum should rise 53%. Jeff: In perhaps one of the most concerning things I’ve read in awhile, one study showed that ⅓ of patients with an ectopic had a bCHG rise of 53% in 48h and 20% of patients with ectopics had a rate of decline typical to that of a miscarriage. Nachi: Definitely concerning, but this is all the more reason you need to employ our favorite imaging modality… the ultrasound. Jeff: All patients with a positive pregnancy test and vaginal bleeding should receive an ultrasound performed by either an emergency physician or by radiology. Combined with a pelvic exam, this can give you almost all the data necessary to make the diagnosis, even if you don’t find an IUP. Nachi: And yes, there is good data to support ED ultrasound for this indication, both transabdominal and transvaginal, assuming the emergency physician is credentialed to do so. A 2010 Meta-Analysis found a NPV of 99.96% when an er doc identified an IUP on bedside ultrasound. So keep doing your bedside scans with confidence. Jeff: Before we move on to other diagnostic tests, let’s discuss table 2 on page 7 to refresh on key findings of each of the different types of miscarriage. For a threatened abortion, the os would be closed with an IUP seen on ultrasound. For a completed abortion, you would expect a closed OS with no IUP on ultrasound with a previously documented IUP. Patients may or may not note the passage of products of conception. Nachi: A missed abortion presents with a closed os and a nonviable fetus on ultrasound. Findings such as a crown-rump length of 7 mm or greater without cardiac motion is one of several criteria to support this diagnosis. Jeff: An inevitable abortion presents with an open OS and an IUP on ultrasound. Along similar lines, an incomplete abortion presents with an open OS and partially expelled products on ultrasound. Nachi: And lastly, we have the septic abortion, which is sort of in a category of its own. A septic abortion presents with either an open or closed OS with essentially any finding on ultrasound in the setting of an intrauterine infection and a fever. Jeff: I’ve only seen this two times, and both women were incredibly sick upon presentation. Such a sad situation. Nachi: For sure. Before we move on to other tests, one quick note on the topic of heterotopic pregnancies: because the risk in the general population is so incredibly low, the finding of an IUP essentially rules out an ectopic pregnancy assuming the patient hasn’t been using assisted reproductive technology. In those that are using assisted reproductive technology, the risk rises to 1 in 100, so finding an IUP, in this case, doesn’t necessarily rule out a heterotopic pregnancy. Jeff: Let’s move on to diagnostic studies for patients with nausea and vomiting. Typically, no studies are indicated beyond whatever you would order to rule out other serious pathology. Checking electrolytes and repleting them should be considered in those with severe symptoms. Nachi: For those with symptoms suggestive of a UTI, a urinalysis and culture should be sent. Even if the urinalysis is negative, the culture may still have growth. Treat asymptomatic bacteriuria and allow the culture growth to guide changes in antibiotic selection. Jeff: It’s worth noting, however, that a 2016 systematic review found no reliable evidence supporting routine screening for asymptomatic bacteriuria, so send a urinalysis and culture only if there is suspicion for a UTI. Nachi: For those with concern for appendicitis, while ultrasound is a viable imaging modality, MRI is gaining favor. Both are specific tests, however one study found US to visualize the appendix only 7% of the time in pregnant patients. Jeff: Even more convincingly, one 2016 meta analysis found MRI to have a sensitivity and specificity of 94 and 97% respectively suggesting that a noncontrast MRI should be the first line imaging modality for potential appendicitis. Nachi: You kind of snuck it in there, but this is specifically a non-contrast MRI. Whereas a review of over a million pregnancies found no associated fetal risk with routine non-contrast MRI, gadolinium-enhanced MRI has been associated with increased rates of stillbirth, neonatal death, and rheumatologic and inflammatory skin conditions. Jeff: CT is also worth mentioning since MRI and even ultrasound may not be available to all of our listeners. If you do find yourself in such a predicament, or you have an inconclusive US without MRI available, a CT scan may be warranted as the delay in diagnosis and subsequent peritonitis has been found to increase the risk of preterm birth 4-fold. Nachi: Right, and a single dose of ionizing radiation actually does not exceed the threshold dose for fetal harm. Jeff: Let’s talk about the Rh status and prevention of alloimmunization. While there are no well-designed studies demonstrating benefit to administering anti-D immune globulin to Rh negative patients, ACOG guidelines state “ whether to administer anti-D immune globulin to a patient with threatened pregnancy loss and a live embryo or fetus at or before 12 weeks of gestation is controversial, and no evidence-based recommendation can be made.” Nachi: Unfortunately, that’s not particularly helpful for us. But if you are going to treat an unsensitized Rh negative female with vaginal bleeding while pregnant with Rh-immune globulin, they should receive 50 mcg IM of Rh-immune globulin within 72 hours, or the 300 mcg dose if that is all that is available. It’s also reasonable to administer Rh(d)-immune globulin to any pregnant female with significant abdominal trauma. Jeff: Moving on to the treatment for miscarriages - sadly there isn’t much to offer here. For those with threatened abortions, the vast majority will go on to a normal pregnancy. Bedrest had been recommended in the past, but there is little data to support this practice. Nachi: For incomplete miscarriages, if visible, products should be removed and you should consider sending those products to pathology for analysis, especially if the patient has had recurrent miscarriages. Jeff: For those with a missed abortion or incomplete miscarriages, options include expectant management, medical management or surgical management, all in consultation with an obstetrician. It’s noteworthy that a 2012 Cochrane review failed to find clear superiority for one strategy over another. This result was for the most part re-confirmed in a 2017 cochrane review. The latter study did find, however, that surgical management in the stable patient resulted in lower rates of incomplete miscarriage, bleeding, and need for transfusion. Nachi: For expectant management, 50-80% will complete their miscarriage within 7-10 days. Jeff: For those choosing medical management, typically with 800 mcg of intravaginal misoprostol, one study found this to be 91% effective in 7 days. This approach is preferred in low-resource settings. Nachi: And lastly, remember that all of these options are only options for stable patients. Surgical management is mandatory for patients with significant hemorrhage or hemodynamic instability. Jeff: Since the best evidence we have doesn’t suggest a crystal clear answer, you should rely on the patient’s own preferences and a discussion with their obstetrician. For this reason and due to the inherent difficulty of losing a pregnancy, having good communication is paramount. Nachi: Expert consensus recommends 6 key aspects of appropriate communication in such a setting: 1 assess the meaning of the pregnancy loss, give the news in a culturally competent and supportive manner, inform the family that grief is to be expected and give them permission to grieve in their own way, learn to be comfortable sharing the products of conception should the woman wish to see them, 5. provide support for whatever path she chooses, 6. and provide resources for grief counselors and support groups. Jeff: All great advice. The next treatment to discuss is that for pregnancy of an unknown location and ectopic pregnancies. Nachi: All unstable patients or those with suspected or proven ectopic or heterotopic pregnancies should be immediately resuscitated and taken for surgical intervention. Jeff: For those that are stable, with normal vitals, and no ultrasound evidence of a ruptured ectopic, with no IUP on ultrasound, -- that is, those with a pregnancy of unknown location, they should be discharged with follow up in 48 hours for repeat betaHCG and ultrasound. Nachi: And while many patients only need a single additional beta check, some may need repeat 48 hour exams until a diagnosis is established. Jeff: For those that are stable with a confirmed tubal ectopic, you again have a variety of treatment options, none being clearly superior. Nachi: Treatment options here include IM methotrexate, or a salpingostomy or salpingectomy. Jeff: Do note, however, that a bHCG over 5000, cardiac activity on US, and inability to follow up are all relative contraindications to methotrexate treatment. Absolute contraindications to methotrexate include cytopenia, active pulmonary disease, active peptic ulcer disease, hepatic or renal dysfunction, and breastfeeding. Nachi: Such decisions, should, of course, be made in conjunction with the obstetrician. Jeff: Always good to make a plan with the ob. Moving on to the treatment of nausea and vomiting in pregnancy, ACOG recommends pyridoxine, 10-25 mg orally q8-q6 with or without doxylamine 12.5 mg PO BID or TID. This is a level A recommendation as first-line treatment! Nachi: In addition, ACOG also recommends nonpharmacologic options such as acupressure at the P6 point on the wrist with a wrist band. Ginger is another nonpharmacologic intervention that has been shown to be efficacious - 250 mg by mouth 4 times a day. Jeff: So building an algorithm, step one would be to consider ginger and pressure at the P6 point. Step two would be pyridoxine and doxylamine. If all of these measures fail, step three would be IV medication - with 10 mg IV of metoclopramide being the agent of choice. Nachi: By the way, ondansetron carries a very small risk of fetal cardiac abnormalities, so the other options are of course preferred. Jeff: In terms of fluid choice for the actively vomiting first trimester woman, both D5NS and NS are appropriate choices, with slightly decreased nausea in the group receiving D5NS in one randomized trial of pregnant patients admitted for vomiting to an overnight observation unit. Nachi: Up next for treatment we have asymptomatic bacteriuria. As we stated previously, asymptomatic bacteriuria should be treated. This is due to anatomical and physiologic changes which put these women at higher risk than non-pregnant women. Jeff: And this recommendation comes from the 2005 IDSA guidelines. In one trial, treatment of those with asymptomatic bacteriuria with nitrofurantoin reduced the incidence of developing pyelonephritis from 2.4% to 0.6%. Nachi: And this trial specifically examined the utility of nitrofurantoin. Per a 2010 and 2011 Cochrane review, there is not evidence to recommend one antibiotic over another, so let your local antibiograms guide your treatment. Jeff: In general, amoxicillin or cephalexin for a full 7 day course could also be perfectly appropriate. Nachi: A 2017 ACOG Committee Opinion analyzed nitrofurantoin and sulfonamide antibiotics for association with birth defects. Although safe in the second and third trimester, they recommend use in the first trimester -- only when no other suitable alternatives are available. Jeff: For those, who unfortunately do go on to develop pyelo, 1g IV ceftriaxone should be your drug of choice. Interestingly, groups have examined outpatient care with 2 days of daily IM ceftriaxone vs inpatient IV antibiotic therapy and they found that there may be a higher than acceptable risk in the outpatient setting as several required eventual admission and one developed septic shock in their relatively small trial. Nachi: And the last treatment to discuss is for pregnant patient with acute appendicitis. Despite a potential shift in the standard of care for non pregnant patients towards antibiotics-only as the initial treatment, due to the increased risk of serious complications for pregnant women with an acute appy, the best current evidence supports a surgical pathway. Jeff: Perfect, so that wraps up treatment. We have a few special considerations this month, the first of which revolves around ionizing radiation. Ideally, one should limit the amount of ionizing radiation exposure during pregnancy, however avoiding it all together may lead to missed or delayed diagnoses and subsequently worse outcomes. Nachi: It’s worth noting that the American College of Radiology actually lists several radiographs that are such low exposure that checking a urine pregnancy test isn’t even necessary. These include any imaging of the head and neck, extremity CT, and chest x-ray. Jeff: Of course, an abdomen and pelvis CT carries the greatest potential risk. However, if necessary, it’s certainly appropriate as long as there is a documented discussion of the risk and benefits with the patient. Nachi: And regarding iodinated contrast for CT -- it appears to present no known harm to the fetus, but this is based on limited data. ACOG recommends using contrast only if “absolutely required”. Jeff: Right and that’s for iodinated contrasts. Gadolinium should always be avoided. Let me repeat that Gadolinium should always be avoided Nachi: Let’s also briefly touch on a controversial topic -- that of using qualitative urine point of care tests with blood instead of urine. In short, some devices are fda-approved for serum, but not whole blood. Clinicians really just need to know the equipment and characteristics at their own site. It is worth noting that there have been studies on determining whether time can be saved by using point of care blood testing instead of urine for the patient who is unable to provide a prompt sample. Initial study conclusions are promising. But again, you need to know the characteristics of the test at your ER. Jeff: One more controversy in this issue is that of expectant management for ectopic pregnancy. A 2015 randomized trial found similar outcomes for IM methotrexate compared to placebo for tubal ectopics. Inclusion criteria included hemodynamic stability, initial b hcg < 2000, declining b hcg titers 48 hours prior to treatment, and visible tubal pregnancy on trans vaginal ultrasound. Another 2017 multicenter randomized trial found similar results. Nachi: But of course all of these decisions should be made in conjunction with your obstetrician colleagues. Jeff: Let’s move on to disposition. HDS patients who are well-appearing with a pregnancy of undetermined location should be discharged with a 48h beta hcg recheck and ultrasound. All hemodynamically unstable patients, should of course be admitted and likely taken directly to the OR. Nachi: Also, all pregnant patients with acute pyelonephritis require admission. Outpatient tx could be considered in consultation with ob. Jeff: Patient with hyperemesis gravidarum who do not improve despite treatment in the ED should also be admitted. Nachi: Before we close out the episode, let’s go over some key points and clinical pearls... J Overall, roughly 25% of pregnant women will experience vaginal bleeding and 7-27% of pregnant women will experience a miscarriage 2. Becoming pregnant with an IUD significantly raises the risk of ectopic pregnancy. 3. Ovarian stimulation as part of assisted reproductive technology places pregnant women at increased risk of ovarian torsion. 4. Due to anatomical and physiologic changes in the genitourinary tract, asymptomatic bacteriuria places pregnant women at higher risk for pyelonephritis. As such, treat asymptomatic bacteriuria according to local antibiograms. 5. A pelvic exam in the setting of first trimester bleeding is only warranted if you suspect it might change management. 6. Unstable patients with vaginal bleeding and no IUP should be assumed to have an ectopic pregnancy until proven otherwise. 7. If you are to use a discriminatory zone, ACOG recommends a beta-hCG cutoff of 3500. 8. The beta-hCG typically doubles within 48 hours during the first trimester. It should definitely rise by a minimum of 53%. 9. For patients using assisted reproductive technology, the risk of heterotopic pregnancy becomes much higher. Finding an IUP does not necessarily rule out a heterotopic pregnancy. N. Send a urine culture for patients complaining of UTI symptoms even if the urinalysis is negative. J. The most common surgical problem in pregnancy is appendicitis. N, If MRI is not available and ultrasound was inconclusive, CT may be warranted for assessing appendicitis. The risk of missing or delaying the diagnosis may outweigh the risk of radiation. J. ACOG recommends using iodinated contrast only if absolutely required. N. For stable patients with a pregnancy of unknown location, plan for discharge with follow up in 48 hours for a repeat beta-hCG and ultrasound. J For nausea and vomiting in pregnancy, try nonpharmacologic treatments like acupressure at the P6 point on the wrist or ginger supplementation. First line pharmacologic treatment is pyridoxine. Doxylamine can be added. Ondansetron may increase risk of fetal cardiac abnormalities N So that wraps up episode 24 - First Trimester Pregnancy Emergencies: Recognition and Management. J: Additional materials are available on our website for Emergency Medicine Practice subscribers. If you’re not a subscriber, consider joining today. You can find out more at www.ebmedicine.net/subscribe. Subscribers get in-depth articles on hundreds of emergency medicine topics, concise summaries of the articles, calculators and risk scores, and CME credit. You’ll also get enhanced access to the podcast, including the images and tables mentioned. You can find everything you need to know at ebmedicine.net/subscribe. N: And the address for this month’s credit is ebmedicine.net/E0119, so head over there to get your CME credit. As always, the you heard throughout the episode corresponds to the answers to the CME questions. Lastly, be sure to find us on iTunes and rate us or leave comments there. You can also email us directly at emplify@ebmedicine.net with any comments or suggestions. Talk to you next month!  

Toby Mathis and Jeff Webb of Anderson Advisors are here to answer all sorts of tax-related questions that focus on everything from applications to forms and QuickBooks. Do you have a tax question? Submit it to Webinar@andersonadvisors.com. Highlights/Topics: Will income earned by lending money to real estate investors reduce Social Security benefits or increase taxes on them? Income vs. earned income; until full retirement age, benefits are reduced; when full retirement age, it doesn't matter what you make How do I get the 20% deduction from Trump's Tax Plan? The 199A Deduction is a 20% deduction on qualified business income, but you need a pass-through entity; QBI 20% deduction vs. 20% of taxable income are compared, and you get whichever is less When you make a contribution out of your own account to your LLC as a member, are you taxed on contributions? No. It’s a contribution to an entity that becomes your capital and money you can take back out tax-free, if you haven't used it to recognize losses What is the best business structure recommended against asset, structure, and personal protection? With any passive activity, use a passive entity - LLC taxed as a partnership/limited partner; whomever has control of entity decides what's distributed What is the best way to set up QuickBooks when I have a Wyoming Holding LLC and several other LLCs holding real estate in other states? Create one set of books with Wyoming LLC as the primary; do a classified income statement for other states What are the tax forms for 501c3? Use Form 1023 to apply to be an exempt charitable organization; yearly recording forms include 990-N If someone has rentals in their self-directed IRA, how are they impacted as UBIT - does it make a difference on the number/dollar amount? No UBIT, if it's a rental; UBIT is for an active business inside an IRA; passive income is almost always exempt Can I have recourse debt in a 401K or IRA? Can I have non-recourse debt? You can’t have recourse debt, but you can have recourse debt What are my options to re-distribute funds from one LLC in several entities to separate investments? You can always move it from one to another with no tax implication Can I write off costs for rehabbing out of the country? Yes. Worldwide profits; if it's income-producing property, you report it to the United States I lent money to a real estate flipper. She gave me a promissory note, but it wasn’t recorded with the deed of trust. Now, she is in default. Can I foreclose? Document it because you can’t foreclose until you file your secured interest Is there anything I can do to reduce my taxable income? Yes. There are lots of things you can do - make contributions to qualified retirement plans, charities, and C Corp I purchased a new computer that cost less than $2,500. Is that a straight expense in the current tax year or some weird depreciation thing? Section 179 deduction; you can buy up to $1 million and write it all off For all questions/answers discussed, sign up to be a Platinum member to view the replay! Resources U.S. Social Security Administration Trump’s Tax Plan 199A Deduction QuickBooks Tax-Wise Workshop 501c3 Unrelated Business Income Tax (UBIT) 990-T 990-N Section 179 Deduction 1244 Election Kiddie Tax Anderson Advisors Tax and Asset Prevention Event Toby Mathis Anderson Advisors   Full Episode Transcript: Toby: Hey, guys. This is Toby Mathis with Jeff Webb again. Jeff: Good afternoon. Toby: If you don't know, Jeff Webb's a tax manager here, and I am one of the partners. I'm not an accountant but I'm an attorney. Jeff is actually a CPA. This is Tax Tuesdays. If you've never been on Tax Tuesdays before, all we do is answer all sorts of questions. Let me see here whether I've got the right question field up. Look at that. We've got a bunch of people asking questions. Let's see. We'll get to all your questions, making sure you can hear us in the question and answer part. Just say, "Yes, I can hear you loud and clear," to make sure that we're getting through to everybody. If you do that, then we appreciate it. There we go. I'm getting a whole bunch of "loud and clear", "loud and clear", "loud and clear". All right, if you don't know the format if Tax Tuesday, it goes like this. We answer a whole bunch of questions. We answer the questions that people ask via the email that I'll be giving you at the end of the webinar, and we grab a whole bunch of them, and we just start answering them. If we can't answer the question or the question that you ask is too complicated, too specific, too long, then I grab it and kick it off to a staff or we answer it the following week, depending on how cool a question it is. That being kind of the overview, this is where we're at. We're going to go through these and we're going to make sure that we're answering all the questions. Let's see if I can actually make these slides advance. Look at that. That's weird. I didn't even know what that W there is. It's kind of cool. "Will the income I earned by lending my money to my real estate investors reduced my social security benefits or increased my taxes on them?" That's an interesting question. There's, "How do I get a 20% deduction?" I'm picking these literally from people's emails so don't yell at me for the typos. "When you make a contribution funds to your own account to your LLC as a member, are you taxed on contributions that you contribute to an LLC?" "What is the best structure–" and that is the weirdest thing I've ever had. "What is the best structure recommended against asset, structure and personal protection for a Multi-Family Home Investor acquiring and holding rental properties, especially if working–" and I'm going to go through each one of these. "What is the best way to set up QuickBooks when I have a Wyoming Holding LLC and several other LLCs holding real estate in various other states?" Those are our opening questions. We have a few more. We're going to go through a ton of them, and I'm already getting a bunch of questions on the Q&A portion. We will get to those but, first, we're going to knock these ones out. The first question: "Will the income earned by lending money to real estate investors reduce my Social Security benefits or increase my taxes on them?" The first thing is there's the benefit itself. In this particular question, I looked it up and I believe there were 61, so they're receiving Social Security benefits before they reach the full retirement age. Full retirement age varies between 65 and 67. The reason this is important is because, once you reach that age, it doesn't matter what you make. Until you reach that age, you will have your benefits reduced on what you're receiving. When you're pulling out Social Security early, 50 cents on the dollar once you get over $17,080.Of course, it's indexed for inflation, but it's a little bit over $17,000. I think this year it's $17,080 or something like that. What that means is, if you are lending money, then that would be counted as income. However, if you're under the full retirement age, they only count earned income. The question here is, "Until you're at full retirement age, will the income earned by lending money to real estate investors reduce my Social Security benefits or increase my taxes on them?" The answer is a big, resounding, "No." This will not hurt you in any way. Once you hit full retirement age, now we have to be worried about how much of your social security becomes taxable. When they look at your tax ability of the benefit, now we're looking at all sorts of income, everything that you make, and it's going to push it up. That's the one where it's not that you reduce the benefit but it becomes taxable. Jeff: Fairly quickly, additional income starts making your Social Security benefits taxable. They're never going to be more than–85% of your benefits are never going to be taxable. I'm saying this totally backwards. Toby: What it means is that the most they're ever going to tax your benefits is 85% of them. If you're getting $20,000 of benefit, the most you'll ever pay tax on is $17,000. You'll still get $3,000, tax-free. The sad part is you didn't get, really, a deduction when they took it out the first place. That's the old double tax that you hear about with Social Security. Anything else you want jumped into? This is kind of stuff. It makes your brain go numb so you're doing it right. You're actually asking good questions. Jeff: Just the matter of when you should take Social Security is such a huge question. Toby: Because you can start taking it. When is the earliest, is it 64? Jeff: I'm going to say 62, but maybe it's earlier depending on their age. Toby: It does depend on their age. There is a before-a-threshold and after-a-threshold. Now, I forget what the threshold is. What you do is you go to the Social Security Administration and you run your scenarios and they'll give them all to you, or you can contact us. We have folks we could send you out to that have software because it is complicated. Depending on what month you were born in and all that stuff, how many days–all of this gets factored in as to what's the earliest you could start receiving benefits. Once you start receiving the benefit, they let you receive that benefit only so long as your income is low and it's your earned income. If you're trying to get the benefit when you're 62 and you make too much money, you're going to lose a bunch of the benefits. If you start making–if you're 62, start pulling out the benefit and you have passive income, not that big of a deal; it doesn't reduce it so that's really cool. Enough of that. It makes my head hurt, Social Security. Do not rely on Social Security. There, I said it. Yeah, Social Security is one of those things that, when it was set up, the average life expectancy of people on Social Security was two years. It was really there to catch you if you're really old and didn't have any other benefits. Now, we use it almost like it's a retirement plan that's not what it was intended for. That's why it doesn't work to do it. Here's the next one. "How do I get the 20% deduction from Trump's Tax Plan?" First off, it's not Trump's Tax Plan. It's the Tax Cut and Jobs Act and it was passed by our wonderful Congress because, technically–though, they seem to forget this–Presidents don't write laws. Now that we got that out of the way, they did put this thing called a 199A Deduction, which is a 20% deduction on qualified business income from pass-through entities. Follow me here. The first thing we need to have–and I'm going to write these up–is we need to have a pass-through entity, and you can be an LLC taxed as–this is a 1065 that's partnership, a sole proprietor or as an S Corp. Those are your choices. Technically, it could also be a trust. Then, you look at other entities, S Corps and just flat out partnerships, including limited partnerships, all that fun stuff. It's passing through; it doesn't pay its own tax. Then, you need qualified business income. I'm just going to call it QBI, which just means income. Generally speaking, it's active income, but they also include real estate, if you are making money on real estate in which you participate in some fashion. The only type of real estate that's not included as far as we can tell–because they're still giving us regulations on it, but the proposed regulations make clear that real estate, rental real estates included, is if you have a commercial building and triple-net leases that you're giving out where you're not really taking on much of the risk, then they're not going to let you have the qualified business income. Then, they compare that qualified business income 20% deduction versus 20% of your taxable income, whichever is less. Why is this important? Because if I'm a sole proprietor–let's say I have $50,000 that I'm making–that I would get a $10,000-deduction under the QBI. Let's say that I take and contribute into my retirement plan–a husband-and-wife sole proprietor is still the same thing, and they both put in–what's a good number–let's just say $10,000. Then, my taxable income is actually $40,000 because I rode off–I made tax-deductible contributions into my IRA of $10,000 so I would take the lesser of that. Then, they do this wonderful thing, is they then say, "Well, if it's a special service company, we're going to put a cap on how much QBI you can actually make." It's not really QBI; it's actually your taxable income, and they say, "We'll only let you ride off so long as your taxable income is below a threshold." If you're single, that threshold is $157,500, and there's a phase-out for the next $50,000. To make your head spin, it goes from $157,000 to $207,500. That's the easiest way to look at it. If you're married, filing jointly, those numbers are $315,000 to $415,000. Jeff: What's an example of a special service? Toby: Special services are something that it is you and your skill that makes the money, and they use–it's going to be doctors, lawyers, accountants, engineers, real estate agents who are solo, somebody who–it's their skill so like a carpenter who doesn't have a bunch of staff. That's going to be a special service. If you get above those thresholds, you are done. Somebody's asking a question which is pretty interesting. A single-member LLC counts. You have a flow under you so that's when you're sole proprietor or just going under your tax return that's passed through entity so you're fine. The interesting here is that you can control your taxable income. Even on those thresholds–and when we teach this in the class, we actually go through a learning chart where we say, "If this, then this. If this, then this." If you're a special service, we just need to make sure that we can control your income, and the way you control your income is by splitting it with tax-free, tax-exempt or separately-taxable entities. Let me give you an example. If I have a C Corp and it makes a bunch of money, great, that's not income to me. I don't want to pay myself a whole bunch of money and make whatever my other business is that is or where I'm going to meet the threshold taxable because I'm losing that 20% deduction. Let's say I have $200,000 coming in. As an individual, I can get some donations and deductions into a retirement plan and I get myself underneath that $157,000 and I have another $200,000 in C Corp that I pay myself. If I leave the $157,000 as is and I don't take any money out of the C Corp, I'm going to get a 30-something thousand dollar deduction. It's just going to come off the top. It's a 20% deduction so almost like I spent. If I took the money out of the C Corp–and, by the way, that C Corp is a flat 21% tax rate now so it's going to pay 21% so it's not horrific. If I paid myself that money, I push my taxable income over the threshold, now I get 0 deduction on my qualified business income. That's why it's important. If it is not a special service, then those thresholds trigger something else. It takes us to an area where we can write off up to 50% of the W2 income or 25% of the W2 income for the business plus 2.5% of the assets. Jeff: No, you're right. I'm just jumping ahead of you. Toby: Yeah, so what we're looking at, then, is you better have a regular business that actually has salaries. If you, for example, as a sole proprietor, single, are making–what would be a good example–$200,000 and you're over the threshold, you're phasing out, you'd have to go to the second test. You're over the 157 and the second test is now pushing you at 50% of W2 wages, and you have zero so your deduction is going to be zero. You're going to get literally nothing. You might get a few dollars because you're not quite at the 207, which is the top line of the actual phase-out so you'd be phased out about 90% plus of the benefit. Now, let's say you converted that sole proprietorship to an S Corp and, instead, you paid yourself a salary, so same situation, $200,000. Let's say I paid you $75,000 of salary. Then, the QBI or the monies that's flowing through is actually the net income and net profit, so you'd subtract the 75 off. It would be $125,000. You compare 20% of that number, which I should grab the calculator, whatever that number is. Jeff: It'd be 25,000. Toby: Yeah, 25,000, and we would compare it to one-half of the W2 income, which would be 37,500. You'd get the lesser of the two. You'd get a $25,000-deduction just because of the type of entity. That's the one I have to do. Somebody just said, "I have almost 300K in real estate and other income. Is there anything I can do?" A single person? Yeah, there's something you can do because, remember, it depends on whether you're special service and then it depends on the business, and there's one last thing: It always comes down to your taxable income. "What other ways can I use to control my taxable income?" The most obvious is I split it with a C Corp, I give it to charity–and it could be my charity–or I deduct it by putting it into a tax-deferred retirement plan. For example, same situation, I'll use the $200,000 and they do a 401K. They put a husband and wife each–they're under 50. They each contribute 18,500–or, actually, the example I used was a single person so I would have to say I put 18,500 and in, and they get a 25% deduction on the 75,000. They would put in–again, I'm using crazy numbers so what would that be? About $18,750 or whatever that is–around under $19,000. I can put, in essence, about $37,000 right into the 401K, and that reduces my taxable income. The taxable income goes from 200 down to almost the threshold, and now I don't have to worry about it. It makes my life so much easier. I'm just going to get a nice big, fat deduction and I'm happy as a clam. That's how this stuff works, but if you don't do it before the year ends, you're toast. This is going to be my–this is why you need to have some sort of somebody doing tax planning. How do I get the 20% deduction from the new tax act? Very deliberately. You make sure that you have the income flowing under your return and then you make sure that, if there's a disqualifying factor that would cause you to lose it, that you look and say, "What's better? To just walk away from it and not worry about it or would I be better to take a couple of actions to allow myself to take advantage of the deduction?" It's a freebie, guys. If I make $20,000 in real estate, that rental real estate–that's my net after all my depreciation–I get a $4,000-deduction. I'm only recognizing 16,000 under this taxable income so that's a nice little benefit especially if I'm a high-income person so that's what I'd be looking at. Jeff, do you want to do this one because I'm […] barding the answers again? Jeff: No, that's alright. "When you make a contribution out of your own account to your LLC as a member, are you taxed on contributions that you contribute to the LLC?" No, actually, you're not. That is a contribution to an entity that becomes your capital, your owner's equity–we can call it a lot of things–your owner's capital in that company. That's actually money that you can take back out also tax-free assuming that you haven't used it up to recognize losses or maybe other things like that. Toby: We get that a lot. I'll give you a real-life example. Some guys were doing a syndication on apartment buildings and they were telling people, "Hey, we're going to return your capital out of the profits and you're not going to have to pay any tax on the money that you receive up to your investment." I said, "Hey, that's not really the case." Here's how it works: I can always get back my contribution, and it's tax-neutral; it means nothing. If the company makes zero, no profit, it can always give me back my money and I pay no tax, but if the company makes money, I'm taxed on my portion of that gain no matter what even if they're giving me extra. I was like–what they were doing was they were saying, "Here's a little thing. We'll make some profit. We'll just give you your money back. You want to pay tax on it?" I was like, "No, that's not how it works. You actually have to pay tax on the profit in proportion to your ownership, and it's a little bit funky." Jeff: This is a case that, sometimes, we see where a client will tell us, "I had deposits of $100,000 into my business," and what they fail to tell us is that 50,000 of it was their own money. We want to make sure that we're able to differentiate what the owners are putting into the company versus what income they're making in the company. Toby: There's a couple of questions. Somebody says, "My head is spinning." We do record this. If you're platinum, you're going to get a recording of it in your little platinum area. Somebody asks, "Is this pre-recorded?" No, it's not. We're doing it live but I'm answering the questions that people have emailed me first and, yes, we have about 50 questions that are in the queue that we're going to go through here in a second. Jeff: We don't have a three-second delay or anything? Toby: No, I don't think so. I could give you a 10-second delay. All right, "What is the best business structure recommended against asset, structure and personal protection?" I don't know what that means. I'm going to assume they mean to protect the business–for a Multi-Family Home Investor acquiring and holding rental properties, especially if working as a team member with other investors? Here's what I'm going to say: Anytime you have a passive activity–that is, when you buy the property or the cash flow and the appreciation–you're going to want to use a passive entity, meaning an LLC taxed as a partnership or a limited partner. Don't do anything else. That's it. There's maybe some really weird exceptions but I'm going to say, 99% of the time, you're going to end up using an LLC, and it's either going to be disregarded even if you have other people in or it's going to be a partnership. If anybody does anything differently, they're doing some weird stuff. If you have other investors, then it depends on your relationship with those investors. I'm not going to going to get into securities, Reg Ds and all that but, generally speaking, you're going to have it taxed as a partnership, but the most important consideration is always going to be control, who has control of that entity, because that's who decides what's distributed. That partnership agreement or the operating agreement of the LLC is really going to be important. You do not want to do this stuff half-arsed. You want to make sure that you're actually really addressing this stuff. At Anderson, we tend to be very protective of the manager, meaning we want you to have control. If it's your project, we don't want people to force you to do stuff and, on the flip side, if you're investing and you're a client, we're always going to say, "You don't want to be forced to kick in more capital against your will." Those are the things we always look at. Where does that one go? Here we go. "What is the best way to set up QuickBooks when I have a Wyoming–" and this is going to be so you, Jeff, because Jeff loves QuickBooks. "What is the best way to set up QuickBooks when I have a Wyoming Holding LLC with several other LLCs holding real estate in various other states?" I'm going to draw this. There's my Wyoming LLC. It's either going to be a 1065 or disregarded, and it holds all these cute little LLCs in other states. Let's say this is Texas LLC, Washington LLC, Nevada LLC, Georgia LLC, and they're all going to flow up to that Wyoming. I want to keep my books straight because, if you know QuickBooks, they will sell you QuickBooks for this one, this one and this one. You'll end up with four sets of QuickBooks and you'll drive yourself crazy. What do you do, Jeff? Jeff: Here's what we like to do: We like to create one set of books with the Wyoming LLC at the top being the primary set of books. Then, what we do is what we call a classified income statement where each of these four LLCs below the Georgia, Nevada, Washington and Texas where they're all kind of their own set of books within your Wyoming LLC books. All this income is going to flow from those bottom four up to the top one anyway and, while we need to keep the entities separate so we can report them that way, ultimately, what we're reporting is what's coming through the whole kit and caboodle. Toby: Yeah, we only need to worry about setting up QuickBooks for this guy right here, and then we set up these guys as classes. All that means is we have one set of books. Jeff: Yeah. You can still pull an income statement for your Georgia LLC or your Texas LLC to see what's just in that but, all in all, you still have one set of books. It makes it easier and you don't have all these inter-company transfers that you have to track. Toby: Oh my god. I'll tell you, we're horrible on that. He's giving me the look. See, here's the problem, is if you have different companies with different sets of books, you've got to close out the previous sets of books and then open up the new company. It's a process and it takes a few minutes and it's really annoying when you're trying to enter stuff into it. It's going to save you a whole bunch of time to use one set. Jeff: Yeah, then you don't run into things like, "Well, I transferred money from Georgia, the taxes that I did it, I record it in both companies." When you record them on one, you end up re-recording it in both. Toby: Yeah, and there's some fun stuff. Some of them just ask for a basic QuickBooks question, jump in the line. It's hard to set up classes in QuickBooks, not horribly, but if you don’t want to learn–QuickBooks is one of those things where you're going to spend some time with it. You just have a bookkeeper do it. Anderson does that if you want. All right. If you have questions–you guys, I know you do because there's a ton of them already in the little queue here. Here's how it works: If you want to ask a more detailed question, if you have a question that you didn't hear answered on the webinar, you can just email them on in to webinar@andersonadvisors.com, and, that way, we can put it in that queue and we can answer it just like we just did. We're going to break those out. Those will be separate little videos, each one of those, so that you get your answer. Somebody was saying, "My head was spinning about 199A." You can go back and listen to that. Better yet, you can come to some of our other webinars or come, actually, to the Tax-Wise Workshop and we go through this stuff. Spend some time with us. If you invest a little bit of time in taxes, it will pay off in spades. Other questions–some people just answered this stuff. "Can you go over the tax forms for 501c3? Jeff: There's a couple of forms for the 501c3. To apply the BF 5O1c3, there's what's called the Form 1023. It's the application to be an exempt charitable organization. Then, there's several different yearly recording forms. The 990 is the primary one where you report, among other things, what your income was, what your balance sheet looks like, your plan, your purpose, who you've dealt with. What were you going to say? Come on. Toby: Basically, if you're making less than $50,000 in your 501c3, you're doing a 990 post-note card. You're just doing a real basic here. Literally, it looks like a postcard. Jeff: They don't do that anymore. Toby: I thought they're still– Jeff: All these old people still call it postcards, but it's a… Toby: They do that in the 10… Jeff: But it's a 990N and it's filed electronically. Toby: Yeah, I know but it's the same thing. Jeff: It's still close. Okay. Toby: It's a postcard. Oh, my god. Yeah, you do it electronically now but it's really simple. You go above that, then you're going to be filing a little more detail. You get about 250, you're filing very detailed. Never do it yourself. Just hire an accountant to do it, and those guys–we do them. They're not horrifically complicated unless you have a huge void that everybody's taking money. You go American Red Cross, you can go look at the actual tax forms that everybody files because they're all public record. You can go in there and take a look at anybody and see just how complicated it is. What you'll realize is that the more the stuff they're doing, the more complicated it gets, and not doing ton it is pretty simple. We have ones that are $5 million non-profits and it's a few pages. Then, you have ones that are $1 million but they've got everybody and their mother with their hands in the thing, and you're doing a lot of reporting. That one might be more complicated. If you're a church, you don't file anything. If you're religious and you're a religious organization, you don't file anything; you file zero tax forms. Jeff: When you have an accountant do these 990s for you, they're going to ask you a lot of questions because there's a lot of questions on the form that they don't have the answer to, basically about what it is the non-profit does and things like that. Toby: All right. "If someone has rentals in their–" basically, again, if you have those tax forms, this is one other thing, is that's the tax compliance on an annual basis. If you're setting up a 501c3, you are doing–more than likely, 501c3 is an application called a 1023. If you're doing a 501C6 or some of these others, that's a 1024. Jeff: Wow, I'm impressed. Toby: Yeah, sorry. It's stuck in my head. Those are the applications for exempt status. Your business, your non-profit, is in existence and it's considered exempt from Day 1. Even though you haven't gotten your exemption approved, you actually have 28 or 29 months to get approved, and it relates back to the day that you started. You can actually do a 501c3 and be up and running in a matter of weeks if you want to. All right, from Lisa: "If someone has rentals in their self-directed IRA, how is it impacted as far as unrelated business income tax (UBIT) and does it make a difference on the number or dollar amount?" You want to do this one or would you like me to? Jeff: Why don't you do this one? Toby: All right. Self-directed IRA and it has real estate? You have no UBIT if it's just rental. That's not unrelated business income tax. Unrelated business income tax is when you're doing an active business inside an exempt organization, inside an IRA, or church, or something else, and you're running a mini-mart then they tax you on it because it's unrelated business income so not related to your exempt purpose so they tax you on it. Passive income's always going to be–I shouldn't say "always"; it's almost always exempt. I guess there's possible–if you have some royalty stuff, it's possible, if you're advertising, that the exempt organization tax, but for your IRA for rentals, don't worry about it. Here's what you worry about when you're doing an IRA with rentals: It's usually the case–this is what we've seen–is that people will oftentimes want to lever that real estate. In an IRA, you have something called–I'm just going to blank on it–unrelated debt financed income. There we go, UDFI. Unrelated debt financed income means–or just call it debt finance income–the portion of the profits that are coming from the debt. If I have a piece of property, I have a 50% loan on it, then 50% of its income is going to be taxable to the IRA. It's not allowed to have that type of loan and not pay tax on it. A 401K is allowed to have that type of loan, and it doesn't pay tax on it. It's one of those weird things where you're like, "Hey, should I be an IRA or 401K?" More often than not in our world, you're going to want to be the 401K. It has different rules, and one of the big ones is the ability to use debt. Now, here's something for you. I think I had poll questions on this. This is fun. I'm going to send a poll out to see whether you guys are listening. You guys can answer this, and what it is, "Can I have recourse debt in a 401K or IRA?" Let's see about that. Isn't this kind of cool? Jeff: It is cool. Toby: We're going to see whether or not you can have recourse debt in a 401K or IRA. For those of you who don't know what recourse debt, recourse means, "I can go after you. I have recourse, and I can go–" basically, a personal guarantee, personal guarantor. We got a lot of people voting. I will share the results with you once we're there. Jeff: What if Lisa is flipping instead of renting in an IRA? Toby: Then, we don't have any cases on it. Jeff: Great. Toby: What we always say is do five at a max. Here's the thing: If you disqualify an IRA, the whole thing's disqualified. What I want to do is if I'm flipping in a self-directed IRA, I want to make sure only that money is in that IRA so if I have a disqualifying event, it's only for that one little IRA. So, I may have two or three IRAs. Good news: People are listening. That's always good news. We have about–50% of you guys voted. I'm going to go ahead and close this thing in about a few seconds. Let's see. There, I closed it and now I'm going to share it with you. Do you want me to tell you the answer? You cannot have recourse debt. 36% of you guys just disqualified your plans, and you have a 10% penalty plus it's all taxable. Sorry to say that you just destroyed your plan, but you cannot have recourse. This is half the fun. What's the next question I could ask you? I could throw up another poll at you. Let's see. Get out of there. Let me see if I can do this. All right, what's the next one? Here's a better one: Now that you know you can't have recourse debt, I'm going to launch a new poll. "Can I have non-recourse debt in an IRA or 401K?" This is where accountants and tax lawyers have– Jeff: Disagreements? Toby: No, this is where it's so much fun. Are you kidding? Let's see. Somebody's saying, "No." What is non-recourse? Non-recourse means you can't hold the person responsible. There's no personal guarantor. You can only go after the property so the property is truly asset-based lending. There's nobody on the hook for that loan if it goes south. A typical non-recourse loan in a plan–this is kind of cheap because it's going to give you the answer–is they're going to look at the other plan assets and so they're going to secure the other plan assets. They're going to make sure that they're not over-leveraged. In other words, they're not going to give you a 99% loan to value; they're going to give you a 60% loan to value or 50% loan to value. We'll see if you guys still get the answer even though I just basically gave it to you. This is fun. I'm just going to stop this one and I'm going to share it because the numbers are pretty done. It looks like 86% of you said, "Yes." Can I have non-recourse debt? 86% of you are correct. You can have recourse debt. Here's the trick: In an IRA, that non-recourse debt creates debt finance income so you have to pay tax on the portion that you're making but it doesn't disqualify your plan. In a 401K, you do not pay the debt finance income, and some of you guys are not too pleased with me for that, but I'm getting giggles out of it. That's enough with polls. I could have polls all day long and we would have a lot of fun. Last one: "I hold some assets in LLC–"and, by the way, this is the last one from people that have shot it in but it says, "You don't pay tax until withdrawal, correct?" No, if you have debt finance income, you're paying it in the year in which the debt finance income–you actually file a 990 T. You actually have to report it. "I have some assets in an LLC that is a day-trading entity." You're brave. "If this generates sizable profits–" I just love traders. "What options are out there to re-distribute funds from one LLC in several entities to the separate investments?" You can always move–if it's yours, it's like–an LLC is a safe so I can always move it from one safe to another, no tax implication. This is one of the questions we had earlier. I can always put money in, take it out. Somebody was talking about an opportunity zone. The opportunity zone's awesome. It's where you take capital gains and invest them in the opportunity zone. It's actually called the growth opportunity zone, and you defer the tax on that income. The max amount you can defer that tax is until 2025 right now. Then, you get a portion of that as non-taxable. Then, the growth–if you leave it in the opportunity zone for 10 years, all that growth and the gains on the investment itself are tax-free, and that's pretty interesting. Growth opportunities, we'll be talking about that as they give us more information. Somebody says, "Can you take the poll down?" I thought I did. I'll make sure polls, hide. There we go. Sorry about that, guys. Everybody's telling me, "Flip off the poll." I'm flipping it off. I like your opportunity zone discussion, and think about a bank, and loan out funds to other LLCs you use. You could do that. Then, it's interest unless it's all you. In which case, you don't charge yourself interests. "I am told that funds in an LLC are much like funds in a savings account. I pay taxes on the gains my funds make, and funds can be withdrawn at any time." That is true as long as it's disregarded or taxed as a partnership. I want to make sure that we're very clear. LLCs that are partnerships are disregarded. Yes, you can do that. If it's an LLC taxed as a corporation or LLC taxes in S Corp, little bit different. An S Corp probably has a huge difference. Jeff: Yeah. You can even pull securities out–even if it's a partnership–pull securities out and put them somewhere else. Like what Toby's saying, if it's an S Corporation or corporation, if you pull securities out of a corporation, you have to recognize gain immediately. Toby: It sucks. Appreciated assets is considered wages, right? Use an example here. Jeff: We had a client who had a couple of $100,000 of securities in a corporation, wanted to move it somewhere else, and we tried to explain to him that if he pulls securities out that are now worth 250 and he's only got a basis of $100,000, he's going to have capital gains of $125,000 in that corporation. The corporation will pay gains and then, for you to take it out, that's got to come from somewhere else, so either a salary, roan repayments or dividends. It doesn't work out well. Toby: No Bueno. The other one is people that real estate in an S Corp and then they need to take it out to refile it or something. All that appreciation is wages. It's horrific and so we have oftentimes say, "Hey, if you're going to do this S Corp, it's cool." The capital gains still flow down to you; it's just that you can't take it out. You've got to leave it in there. Jeff: Can we  re-running into that more and more where the banks are running to take it out of the LLCs and stuff? Toby: They got horribly hosed during the downturn of people doing weird stuff. What happened is I would do a financing in an entity. Say I'm the owner, and then I would sell Jeff my ownership and the entity and the bank had no idea that I'm no longer the guy that they were dealing with that they gave the loan to in their mind and had sold his interests. They had no idea. One day, Jeff comes back in and says, "By the way, I'm the owner of this LLC, not the guy that you loaned the money to." No Bueno. They don't like that. All right, we got a lot of questions to go through so if you have questions, you can always email them in. I'm going to start going out through these things, and we have questions from almost an hour ago. People were asking questions before we even started. "I did a cash-out refinance from my residence to invest in private lending or to buy rentals. California only allows 150,000 to deduct interest expense for residence." That's actually the new federal rule. "For the portion that is more than 750, can I deduct the interest as investment expense?" All right, so here's the rule–and, Jeff, I'm [...] barding, but I deal with this stuff all the time. Your new limit is–unless you owned your house prior to–during 27 and perhaps during the first quarter of 2018 if your loan was already in process before December 15th of 2017, don't try to remember this stuff; just know that if you're in that weird period, you may qualify, then you're up to a million, but it has to be for acquisition indebtedness. Acquisition indebtedness means, "I bought the house," or, "I improved the house." That's for the mortgage person to be deductible on your Schedule A, which is your itemized deduction. If you're using the money for something else, then it has to be deductible on that something else. For example, if I am buying rental real estate, then the interest–you'd be writing off the interest on your Schedule A, essentially, against the income from that rental real estate. You are no longer writing off your mortgage interest personally as the individual residing in it; you are now writing it off as part of an investment. Anything you wanted to add on that? Jeff: No. If we're talking about buying a piece of investment property like you're just going out and buying more land, hoping that it'll go up in value, then it would be considered investment interests and go back on Schedule A. Typically, we want to keep it–if it's in a business interest or rental property, something like that, we want to keep it there. Toby: Again, the Canadians have been dealing with this for a lot longer than us guys. You cannot write off interest if it's not for your home in Canada unless it was used for an investment. People actually have to go re-file their houses, they get all the cash they could, pay down their house, re-file it so they could show that they used it for an investment so they could actually write off the interest. I think it was called Scotts transactions. It's weird. Hey, I'm not Canadian. This is another question: "Say I deducted a newsletter subscription in 2017 but received a refund for it in 2018. Do I need to add this back as income in 2018 or no?" If you wrote it off and it means your basis is zero, give you the money back, what does that sound like? Jeff: Income. Toby: Income. It is income. At the same time, I see people saying, "Hey, what if I reimburse myself from my cell phone out of two companies?" Now, each reimbursement represents–I said, "Well, you can reimburse yourself up to your expense. Anything above that is income so it becomes taxable." Fun stuff. Yes, you would report it, but only–your cash basis tax first. You report it in the year that you received the money back. "You've saved me so much money. I call y'all my friends." I love that when I get stuff like that. That's not really a question but I'm going to repeat it because it's better than, "Flip off the poll." Not that I had too many of those, but I had a few. "Can I write off costs for rehabbing out of the country?" This sounds like something for Jeff. Can you write off? US taxes. Jeff: Yeah, you do have investment in another country. Toby: Worldwide profits, baby. Yes. Jeff: If it's income-producing property, you're going to be reporting that to the United States. Any expenses you have on that property will go towards that also. Toby: If you're rehabbing a property, it sounds like dealer activity and active business. I may be little interest–I probably want to be looking at structures in the Bahamas if that's where it is. I'd be looking at something that's taxable there so you don't get into treaties and all sorts of fun stuff. "Do I have to pay $800 off the top to the franchise tax board when we start our corporation?" Jeff: No, California has an exemption to corporations that are first year only. Toby: Yeah, and that $800–this is, if you like tax cases, there's Veritas 1, there's Veritas 2, there's Northwest Energetic Services, there's Bakersfield Mall, and they're all versus your friendly–what is it called? Not the franchise tax. No, it's whatever. I forget what they're called. Jeff: We know what it's called. Toby: Yeah. Anyway, I'll remember it as soon as I could. I'm trying to think about it, but they keep suing the Board of Equalization, the BoE. It's $800 and they say that's the minimum tax, but they say, really, it's a fee because if it was a tax, then it'd be an unconstitutional tax because it's not attached to the income. They keep trying to call it a fee. They lose and then they change it a little bit and they lose again. That's just an aside. California is kind of evil. "We live in Washington. We have a Nevada C Corp which fully owns a watch and LLC and employs the kids. What are the recommended strategies to optimize for college tuition?" Wow, so you're doing a great thing. You are going to run them through payroll. When you're applying for things like scholarships, if it's going to be based on income, you're going to show that income. You're going to show those returns, but those kids should–most of that income is going to probably be underneath the standard deduction. Right now, it's $12,000. They're going to pay zero and they're going to pay very little on any amount over that. Plus, if you're smart, you're putting some of that money in a Roth IRA and they're never going to pay tax on that. It's smart to do this with your kids. If I paid tuition out of my tax bracket, it's coming out of my highest tax bracket. If I'm in the highest tax bracket, that's 37%. If my kids pay for their tuition and are working for the company, and they have to do something, then they pay at a third tax bracket, which, quite often, is zero. I do this with my own daughter. Last year, I think we paid $500 in taxes total for the year when it cost me $8,000 if I was doing it, but she has to do something. She has to actually work for the company and do stuff for the company. Other stuff you could do to optimize is dump it into–defer it into a retirement plan. If you want to do a 401K, they can put the first 18,500 of their income and they can defer it. You're still reporting it. I'm not sure it'll have an impact on scholarships or not. I have not seen it have much of an impact, but that's what I'd be doing, is the benefits far outweigh anything with this on the scholarship side. It is huge. Here's one: "I lent money to a real estate flipper. She gave me a promissory note, but it was not recorded with the deed of trust. Now, she is in default. Can I foreclose?" When you loan money to a flipper with no deed of trust, that's called a gift. I'm just kidding. You need to make sure that you're documenting it. You cannot foreclose until you actually file your secured interest. You got to have it filed and then, yes, you can actually start foreclosure proceedings if you want, if they don't pay it. You definitely want to make sure that, when you're giving notes–there's something called "first in time, first in right". You want to make sure you know it's recorded and you have your deed of trust against that house. Otherwise, somebody else could go slap theirs on first. There's also places where they get priority. In Nevada, for example, the HoAs get super liens. They actually step in front of the primary lender. It sounds weird but it's true. You want to make sure that you're documenting your loan and covering yourself as best you can, make sure that you're getting a personal guarantee and, if they have any other assets, you may want to slap a lien on those, too. All right, "With a new company, there's quite a lot of expense reimbursements. Since I don't have a lot of revenue yet, I haven't paid it back. Is it okay to carry it over a year or should I go ahead and pay it back even though I'm still in the red?" Jeff, this sounds like you unless you're zoning out there. She has a new company, she has lots of expenses, she doesn't have any money that she's made yet, so should they pay it back, carry it forward? "Can I pay myself, reimburse myself in the future year?" The answer is yes, you could reimburse yourself whenever. The question really becomes, "Do I want to capture all my startup expenses in the first year?" Jeff: Yeah, I think you do. You want to capture as many expenses as possible even if you're not getting directly reimbursed right away. Toby: Yeah, you have two choices whenever you fund a company. You can fund it with your cash and then it's going to have a loss and it's going to carry that loss forward if it's a C Corp. If it's an S Corp, you can actually take that loss. I've contributed $20,000. That's my basis and it loses 20,000 and, technically, I'd have a $20,000-loss with an S Corp. Usually, we're seeing this in C Corps, and you just carry it is a payable and a receivable. It's payable to you, you would say, "Hey, it owes me some money. It's kind of like this." I always use Krispy Kreme in my examples. I go out for Anderson and I bring in 12 dozen Krispy Kreme for a meeting or something, and the others say, "Hey, I'll pay you back but we don't have the money right now." It doesn't mean that it goes away; it means that I'm sitting there, waiting for them to pay me back. If they pay me back in two years, all it means is they can't write that off as a deduction until they pay me back so they're not going to have a loss if I'm carrying it as an IOU. If I give them the money to buy the doughnuts and they buy the doughnuts, they get the loss right away even though they haven't returned my money to me. They could return that money to me at any time. For me, it's always going to be tax-neutral. "Do I need to be on payroll with my real estate income or can I just take distributions from my LLC?" This is regarding Trump's 20% deduction on the plan. If it's investment real estate, you never have to take a seller as long as it's rental real estate. If it's flipping and it's in an S Corp, then you would have to take some salary if you're taking distributions. I don’t want to twist it. This sounds like it's just an LLC with rental property. You do not have to take it. The 20% is for 2018 onwards. If they think that it has a sunset clause, the end of 2025. Is it the end of 2025 that it ends? Jeff: Yeah. Toby: Yeah, so 2025. Here's a really long one. Boy, this is a really long one. Let me see if I can condense this. "I have a Wyoming LLC that is the sole member of a second LLC that is disregarded entity. I funded the Wyoming with 8,500 and the Wyoming funded the other bookkeeping QuickBooks balance sheet shows an owner equity 100% of 16,500. This is offset a balance sheet with capital contribution. While this does end up with net equity of 85, it gives the impression of the equity, which is incorrect. Is there a different way of handling?" Do you see what they're doing? Jeff: This is what we call–anytime you have combined financials or tax returns, you're going to have a–you may have a payable from one to the other where you've lent money to the other company, but when you do the combined financial or tax return, this is what you call an eliminating entry. If you lent $8,500 to one, those two entries are going to offset each other and it's going to be zero on your tax return. Toby: He's looking at it and saying, "Hey, they took the eight that I put into the second and added it to the 8,500 that I put in the first," and it's only 8,500 and then 8 went to the second LLC. Jeff: Yeah, I think you just need to clarify that it was the same money that– Toby: We're doing it and we'll take a look at it. We'll grab that name and, when we can, I'll print this out. "Can SMLLC, single-member LLC, disregard an entity under an MMLLC, which is a multi-member LLC taxed as a partnership, be converted to a single, multi-member LLC taxed as if–" you guys are killing me, "And would the tax changes be implemented?" What you're really saying, Billy, is, "Can I spin off a single-member LLC, make it into a multi-member LLC and change it to an S Corp?" The answer is yes. We just have to make sure that we follow the S Corp rules, which means there's got to be natural persons owning it, resident aliens–if it's somebody from out of the country, that they reside in the United States in certain trusts and even certain single-member LLCs. All right, to the question about–this refers to qualified business income. Sorry for lack of a better–no, Janet, you've already got it. "Since rental real estate is included for the 20%, are you also required to be a rep for that to be true?" No. You automatically get it. "High-tech network engineer, does it qualify as special services?" If you're not a network engineer and it's just you, then I would say probably yes. If you have a company and it's not so much you but your company has its own–like it's lots of people and it's just known, then the answer is no. Then, you're not. Jeff: Yeah, there were some specific carve-outs. I think the architects got a carve-out of this, but there's a few industries that have been specifically exempted from those specialized industries. Toby: I'm not sure but software engineer–I would say that if it's just you, chances are going to be under the special services. "When I file taxes, the taxes for the rental property show up on my tax showing a schedule form that is Schedule E. I almost $300,000 with my real estate and other income as a single woman." I think we already talked about this one. "Is there anything I can do to reduce my taxable income?" Yes, Janet, you can make contributions to qualified retirement plans. You can make contributions to charities, including your own. You can make contributions to C Corp if it has a business relationship. There are lots of things you can do or, if you have anybody that you need to pay salaries to like kids or somebody that's working with you, that would be something else you could do to lower the taxable income. "If you were writing out another slide, it's not showing up on my computer." Sorry, Sir. I think that's where all they go. "What about an IOL as a tax-deferred compensation for my property management income?" That would not work. An IOL is tax-neutral although you can do tax-deferred compensation where it's taxable to the entity and it's not taxable to you under certain circumstances. If I do tax-deferred income like, "Hey, I'm taking deferred compensation," I need to be at a losing. Usually, non-compete is going to be the thing that makes it work. We use these especially in the non-profit world where somebody says, "I don't want to be paid; I want to work, but I do want to get paid eventually for all the work I'm doing now. Rather than pay me this year, pay me when I'm 65 and maybe I wipe it out or not, but as long as I have a non-compete with that–" it's saying, "Hey, basically, if you go work for somebody else in a competing industry, you lose all that deferred compensation." You should be good. "I purchased a new computer that cost less than $2,500. Is that a straight expense in the current tax year or some weird depreciation thing?" Dean, it's called a Section 179 deduction. You can buy up to $1 million, you're good. You can write it all off. Otherwise, that would be depreciated. They also have 100% bonus depreciation, so we're going to catch it no matter what. Bonus depreciation is, if it's less than a 15-year property, you can write it off this year. You're not required to. Somebody says, "Is 199A or that 20% a 20% tax deduction or a 20% reduction?" No, it's a 20% deduction against your qualified business income. The net effect could be much more than 20% depending on your tax bracket. If you're not in a high tax bracket, then the net effect won't be huge. If I'm in the highest tax bracket in a state that's taxing me where I'm at 50%, that 20% deduction could be worth a ton. It could be worth significant amounts especially if I'm in a company that's not a specialized service and I meet the requirements. I could have hundreds and thousands of dollars of qualified business income being exempted, and that could be worth hundreds and thousands of dollars to me from a tax standpoint. We already did this one. Somebody who had their spinning left. You can go in bite-sized pieces, guys. We're going to break these things down, and I understand that we're going through fast, but that's half the fun. We're not dwindling around here. "My self-directed IRA received a K1 for net rental loss for a passive investment of $50,000. Do I need to file a 990 T to show loss? Does the IRA custodian sign the return or can I sign?" Jeff: Here's what happens: If your IRA is a partner in a partnership, that partnership is required to issue a K1 to all of its partners. That doesn't mean you have to do anything with the K1 in your IRA. You're not going to recognize any taxable income until you actually start taking money out of the IRA, especially since this is a rental property we're talking about. Toby: Cool. Hey, this is a really good one. By the way, if you ever do a 990 T and it says self-directed IRA, your custodian does have to sign, and they like to charge you for that. "401K, 401K." "I have a C Corp with accumulated losses and would rather close it than repurpose it. Is there a way to direct the loss of my personal taxes? Is it possible?" The answer is yes. It's called a 1244 election. It should have been made when you issued your stock. If Anderson did your C Corp, we already did that because I do it with every single corporation. You can then write off as a single person up to $50,000 or up to $100,000 if married, filing jointly, and then it could be used to offset even your W2 income. Jeff: Going back to one of the earlier questions, this is one reason we want to start recognizing reimbursements and stuff as early as possible to establish those debts to you early on. Toby: Yeah, I had this happen and we actually had–the one time this was ever audited was because this accountant refused to give him a $67,000-deduction. It was one of our clients who was a trader who was ready to launch and go into his business and then his employer made him an offer he couldn't refuse and gave him a whole bunch of our money. He took a $67,000-loss. He had never made a dollar in the corporation. We went under audit. We won. Yay. It took two seconds because it was a single letter and we gave him the law, and it's a statute. The IRS is just a policing agency. If there's a statute that's clear, they don't sit there and fight with it. I think it was a $38,000-reimbursement–what do you call it–refund. Awesome first-timer. We love first-timers. Thank you for joining us. "I want to receive an invite, a reminder to a different email." We can give you that. You can always use this when you register for the Tax Tuesday. Just put in your other email. "Interested doing sandwich lease options. What is the best business structure and what document can you provide to protect myself from sellers suing me if a tenant or buyer stops paying rent or if a tenant or buyer trashes the home?" That's a tough one. You're literally leasing it and then re-leasing it with the right to buy. Let me think about this one. How am I going to do this? I'm going to be doing that through an entity. The way you protect yourself is to keep very little amounts of asset in that entity so that if you're sued, it's not you; it's the entity itself, and the entity doesn't have much to lose. That's a tough one. I tend to stay away from stuff like that. I want to buy the property and then you do a lease option in an LLC. Jeff: Make sure you have insurance. Toby: Yup, make sure you have insurance, too. That could happen so the tenant trashes the place and somebody else says, "Hey, wait a second." That's why there's always risk. What you do is you just keep it to a low. "Is it hard to set up classes in QuickBooks? Does Anderson do this?" It's not hard and, yes, we do it. "How long does it take to set up a class in QuickBooks?" Jeff: No, you'd have to ask bookkeepers. Toby: Jeff's such an accountant. Yes, it's actually very easy. Jeff: Actually, the bookkeepers are really good at it. They do it all the time. Toby: It's literally all you're doing, is setting up another class. It's almost like a revenue class so you might have revenue that comes in from plumbing and then selling products in your plumbing business and then, "Hey, I have one that's a consulting," and that might be another class. It literally takes two seconds. "What if the Wyoming LLC owns a C Corp which owns an LLC?" I don't know what that means, but what we mean is–I imagine for the 199A. We're just going to look at it is the C Corp owns an LLC that's not going to be qualified for the 20% deduction. The LLC that owns the C Corp, if it's doing other activities, might qualify for the deduction. Here's the problem: In the qualified business, the part I didn't tell you about is what is qualified business income. Dividends, interest, capital gains are not included in that definition so if you're issuing interest from a C Corp to the LLC that flows under your return, you're not going to be getting the 20%. "If you set up QuickBooks with a single entity and use class as a separate income, can you also print a balance sheet by class?" Jeff: Yes, you can do it if the balance sheet is also classified. Toby: Okay. See, we're good. We're getting there. We only have about 200 more questions to go. I'm just teasing you. We've gone through about three-quarters of them. "What is Jeff's last name?" Webb. "I have a rental company. This will be my first year doing taxes. What can I expect to pay on my capital gains? What are some determining factors?" Isaac, if you're a rental company and you're selling–like if you have capital gains, it's going to be depending on whether you sold it within a year or after a year. If it's less than a year, it's going to be ordinary income to you. If it's over a year, it's going to be taxed with either 0%, 15% or 20%. If you make over 250,000, you're going to get to add no another 3.8% and then whatever your state tax is. What are the determining factors? How much you make. If you're married, filing jointly less than 77,000, your capital gains rate is zero. All those things come into it. You can always write us at webinar@andersonadvisors if you want to ask specific questions. "I'm in the process of setting up QuickBooks account for my C Corp. I have a construction business and a hair salon that are DPA-ed as C Corp. I am flipping single-family residents in Wyoming LLC? I have sub-expense and sub-income accounts for those." This is getting long. This one, we may want to answer next week because this is kind of cool. It's talking about sub-accounts. I'm just going to table that one unless you want to jump on it. Jeff: No, I think there were a couple of issues in there. Toby: Yup, "But you don't pay tax until the withdrawal, correct? That was just with regards to the IRA." Steve, you do need an account and, yes, you don't pay the tax until you withdraw, add up in IRA. If you have unrelated business income tax or debt finance income out of an IRA, you'd pay it in the year that it was generated. "Can I set up an entity to receive W2 income and max out top […]?" Yes, but you can't do it out of a self-directed IRA. The reason being is that you are a disqualified person so you cannot do that unless you do something called a ROBS transaction, and that's going to be a major topic for another day. That's if your IRA invests in a C Corp that you set up and there are ways to do it and then you could actually pay yourself, so there. "I recently rolled over a 401K to equity trust IRA account, lending funds to other investors charging interest. Is interest income taxable to the IRA?" No, you can do that all day long, and equity trust is having to sign all your docs. My recommendation would be to set up your own 401K so you can sign the loan documents. Somebody says, "How many times a year can you roll over from 401K to IRA or reverse rollover?" It depends on whether you're doing a direct rollover. Jeff: You can do a trustee to trustee every day if you want, meaning you're going from TDM trade to Bank of America. You can do those as long as it's directly being transferred. You can pull the money out once to yourself once every 12 months, and it's a rolling 12-month period. If I pulled it out today, then I wouldn't be able to do it again until next October. Toby: Somebody asks, "Can I roll individual stock holding into Roth trading account if the current value is under the 550 limit, and how?" The answer would be, really, no; you're going to have to liquidate the holdings, open up a new account in the Roth IRA and then contribute the 5,500. It's a pain in the butt, I know, but I don't make the rules. It's this whole Bank Secrecy Act and all this stuff since they flew planes into trade centers. "Is the old rule dead on personal residences two out of five years?" No, that's still the rule, and we still use it like crazy. That's exception 121. Jeff: Yeah, they were talking about making it five out of eight years, and that got thrown out so it's still the old two-out-of-five rule. Toby: Yup. "Do my startup costs carry over two years if my net was negative?" It's actually 20-something years. Jeff: 15 years. Toby: 15 years now? Nate, you can carry forward your startup costs. Is it 15? Jeff::Yeah. Toby:  "Hey, wait a second. I have an S Corp. They keep charging me the 800 fee ever