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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

It’s time for Toby Mathis and Jeff Webb of Anderson Advisors to answer your questions about taxes, the IRS, and much more. Do you have a tax question for them? Submit it to Webinar@andersonadvisors.com. Highlights/Topics: What is Nexus? Why do I care? Nexus is a state’s right to tax your income; different types (tax and physical), state laws, and throwback rule - how they affect you Does IRS reimburse me for corporate expenses? Misconception about reimbursement from the client’s company or IRS; IRS doesn’t give you money, but let’s you write it off How do I qualify for a real estate professional status? Requires 750 hours as #1 use of personal professional time; know importance of passive activity loss and logging time What are self-dealing rules for non-profits, IRAs, QRPs? Particular entities can’t interact with a disqualified person - can’t sell them anything; but self-dealing exceptions exist Am I dealer or investor? What’s the difference? Investor is passively involved, dealer is actively buying/selling real estate; can depend on the intent and timeframe Why set up an LLC that does flipping as a C or S Corp instead of a partnership? Because it’s taxed as ordinary income and subject to self-employment tax What is UBIT? Unrelated business income tax is when a plan/non-profit isn’t doing what it’s set up to do; can have passive activity until it competes with active businesses I hold rental property in a self-directed IRA. What can I do? There’s things you can/can’t do, especially add value to a property, so find a property manager and IRA custodian My wife’s previous employer’s stock options were exercised and have peaked. If we cash in, what’ll be the tax consequences/burden? Long-term capital gain and opportunity zone I’m helping a friend with a crowdfunding project. What are tax consequences with no deductions? Does he pay tax on donated money? No tax for less than $15,000 per donor How to aggregate all properties? Disadvantages? Election form that your print with your tax return to identify properties; doesn’t free up large losses tied up If real estate investing part time, are you considered a part-time investor? You’d be a part-time investor, not real estate professional; determining factor is to document time How do I get the 501(c)(3) tax-exempt? Use the 1023 application How do you create an LLC in an IRA? IRA custodian enters into a contract with a company to create an LLC, or set up a 401(k) to roll the IRA into it without a custodian Investing in LLC for holding rental property. How do you avail to a 1031 exchange? Need a 1031 exchange facilitator and LLC must buy or sell the next property within 180 days If I receive social security benefits at 62 and not currently employed, but do receive interest income. Will it affect my SS benefits? Can be isolated into its own taxable entity My wife and I are the only shareholders and both take a ⅓ salary. Is that the right amount? You should take a ⅓ of the net profit as salary instead How do you put an LLC on hold? Do nothing with it or pay the state; file non-activity return Will real estate holding LLC taxes partnership qualify for 20% pass-through deduction? Yes, if not triple net property For all questions/answers discussed, sign up to be a Platinum member to view the replay! Resources Anderson Advisors Tax and Asset Prevention Event Toby Mathis Anderson Advisors U.S. Supreme Court Reverses Long Standing Law On Collection Of Sales Taxes Northwest Energetic Services LLC vs. California Franchise Tax Board Throwback Rule SALT Limit After 24 years, wealthy inventor gets his day in tax court – and wins 10 Tax Deductions That Will Disappear Next Year Passive Activity Losses - Real Estate Tax Tips Real Estate Professional Status - Becoming More Important - Very Hard To Prove Acts of self-dealing by private foundation Unrelated Business Income Tax Opportunity Zones Frequently Asked Questions About Form 1099-INT | Internal Revenue Service Exemption Requirements - 501(c)(3) Organizations Form 1023 Taxbot MileIQ Tax Cuts and Jobs Act, Provision 11 011 Section 199A - Qualified Business Income Deduction FAQs   Full Episode Transcript Toby: Alright, welcome to Tax Tuesday, this is Toby Mathis joined by our tax manager Jeff Webb. Jeff: How do you do? Toby: We're going to get jumping on here. We're just going to jump right in. no time like the present to just get business done. So first off, happy Tuesday. Second off, let's jump into a bunch of questions that are giving us a steady feed from folks even before we got started. I'm sure I'll be more happy than to answer your questions. I also got emails in from folks that I may be trying to make sure I answer all of those and we'll just make sure that we're getting through each and every question to the extent humanly possible within this hour. So the first one is, what is Nexus and why do I care. Second one is going to be, does the IRS reimburse me for my corporate expenses. Third one is, how do I qualify for real estate professionals, technically real estate professional status. What are self doing rules for nonprofits in QRPs. I'm going to throw in IRAs in there as well. Am I a dealer or an investor, what difference does it make. Those are the ones that we're going to hit one after the other in succession. I'm making sure that we're getting through these. So the first one is, what is nexus and why do I care. Jeff, do you want to hit tax nexus because there's different types of nexus. There's physical presence for lawsuits and there's tax nexus for taxation. I'm going to have Jeff hit the tax and then I'll touch base on the physical nexus. Jeff: So when we're talking about tax nexus what we're primarily talking about is a state's right to tax you on your income. For example, you may live in Nevada, have a rental property in California. California has a right to tax any income on that property because you're doing business within California. There are different roles, there have been numerous cases on nexus. Toby: Most recently, our Supreme Court reversed a physical presence test that the error that Amazon, everybody that was an online retailer use to avoid state sales tax and that was just changed. Jeff: Yeah, on that one in particular the Supreme Court as Toby said, gave the states the right to tax online sales in their states. The thing is, the states now have to write tax walls to accomplish this. Most of the states don't have anything that accomplishes this. Toby: A lot of times, ignorance is bliss. People would avoid sales tax like for example, I live in Washington, Florida, Oregon and avoid the sales tax and they ignored Washington's use tax. A lot of states have this. You don't pay sales tax and you go someplace where there is no sales tax, you still owe sales tax on it but they call it use tax because you brought the physical item into your state and you never paid sales tax on it. So then they would say, "Aha." And the really interesting thing – there were actually some interesting cases that were popping up from the nexus, ones that came out of Washington, was Northwest Energetic Services too and that was a case in California where they tried to tax an organization that was registered to do business there that didn't actually do any business in California but they wanted to tax its worldwide revenue. The franchise tax board of the board of equalization lost that one and they had a few others but what you'll find is that this is a continuously active in generating area of tax law and we tend to fall into the category of ask for forgiveness not for permission all the time because if you ask a state whether you should be paying tax, they will gladly say yes even if it's not a legitimate tax. They'll tell you that you have to pay it even though it's made to be unconstitutional, unlawful, you fill in the blank. Even if you don't owe it, they'll oftentimes just answer, "Yes, of course you should." They can't actually be giving you any tax advice anyway so it's the wrong party to be asking. I'm sure Jeff you get to deal with that more than I do. Jeff: Yeah, in a state like California, it used to be an old joke for the CPA's that you could be flying over the state of California, make enough business phone call and California would want to so you have nexus and we can now tax you. They're also a state that's very difficult to leave if you're a resident. We had a case where somebody, NBA player for the Sacramento Kings was traded to Seattle Sonics and moved there. Toby: Yeah, now the Oklahoma City Thunder, I was there when they move, horrible. Jeff: The state of California wanted to say, "No, you're still resident of California, we're still going to be taxing you because you got friends here and you have club ownership, some relationships. California in particular is very tenacious with Nexus. Toby: Yeah, so you're going to see things evolving over the next few years since the Supreme Court decision was literally this last, I think it was just months ago or end of the year last year. You're going to see the states trying to fill in the blanks. So you have some states for example in drop shipping, Pennsylvania would tax you if you drop ship out of their state where it used to not be, other states did before. We were talking earlier before the webinar, Jeff and I were talking about what is like a claw back. Jeff: Yeah, it's called a throwback rule that says if your sales into a state that doesn't have taxes then where it got shipped from can tax instead. Toby: Somebody's asked, what are the worst three states for nexus. It really depends on what you're doing, but I would say just off the top of my head probably New York, Connecticut and California. They're pretty heinous. Look at the states that just filed a lawsuit against the federal government under the SALT limitation which is the State and Local Tax Limitation. You'll see I think there was four states Maryland was one of them, where they try to hit you with so many different taxes. It's not just business, it's on your personal as well. It's just for nexus, for a person, it's really easy to figure out, "Hey, where do you live?" Because when I say it's easy, it can be difficult if you have two residences that you spend time with equally. They're going to add up things like how much utility you use, where your driver's license is. Where your kids go to school, where your vehicles are registered, you're going to look at those types of things. There's Hyatt v. Commissioner Case or what was it, Hyatt versus board of equalization I think is actually what it was. Where a gentleman moved to Nevada and the California franchise tax board sent agents to Nevada they climbed to his garage and break into his apartment to prove that he was actually residing more in California than he was in Nevada because his tax bill would've been so great and when they got caught, they said they're immune. Our Supreme Court and Scully I remember the opinion was scathing on them saying, "No, you're immune in your jurisdiction. When you cross the state lines, don't expect any immunity." They just harassed that poor guy. They were climbing around his house. So let's just narrow it down though. You asked a question what is nexus. There's two sides, there's tax nexus and then there's physical nexus. In the physical nexus again where you reside, it's pretty easy. If you live there, then you have a physical nexus in that state, it's where you have a house. In the business it's no different. In a business, you have to decide where it's going to have its main presence and the courts have held having a bare office and nothing more isn't going to be sufficient. You actually have to do something there. That's when you actually have to have a physical office space. We use virtual office where it's doing more than just maintaining a registered agent. There we're actually giving conference facilities, phone answering, we'll do document prep and things like that for the governance of the company so the company can actually have a physical presence. The reason that you do that is to make sure it has a home. So if somebody's coming after one of its shareholders or members, one of its owners that it does not draw that entity into the state where they're located. So, if I have owners in a company and I have my company set up in Wyoming and they sue me in Nevada and they sue somebody else in Texas and somebody else in Florida, you don't have a choice between the Nevada, Texas and Florida where the shareholder or where the members of the LLC are located, they would actually have to go to Wyoming where the actual entity is located. That's what you're trying to do. So if Anderson does my meeting notes, that's why that's important. We're not talking about Canadian, US the nexus pass. I could tell you a fun one. We had a client that just got nailed by California. It's actually under the FBAR which is Foreign Bank Account Regulations. They had some interest on a bank account that was there for a condo they had in Whistler and they sold the condo in Whistler and they didn't report, I think it was like $70 or $76 worth of interest. Jeff do you know these off the top of your head? How much the penalty is? Jeff: No. Toby: If the IRS catches you, it's 50% of the account balance per year. But if you go under amnesty which they have taken an amnesty was a $38,000 fine which they paid for that $76. Canada is still offshore. Anyway, so what is nexus and why do I care. It gets a little convoluted but the reason you care is you don't want to draw your company into your state, you want to make it very difficult for somebody to get a hold of your assets if they're coming after you. From a tax standpoint, it matters because we want to keep our business activities to the extent possible in the lowest taxing jurisdiction as humanly possible. So that's that one. Jeff this is one of your favorites, I know. Does the IRS reimburse me for my corporate expenses? Jeff: Of course they do. IRS is really giving out money. We get this question more often than you would think. I think it's a misconception that clients are being told that their companies can reimburse them for certain expenses which will reduce our taxes and sometimes the clients are hearing IRS is going to reimburse us. The only time you get back money from IRS is if you pay money into IRS for taxes and you don't owe them any tax or maybe overpaid them. Toby: Yeah. IRS is a policing agency. Your taxes when you pay it, they don't even go to the IRS, it goes to the US treasury. So the IRS is merely, pay my boss, is all they are. So they don't give any money out whatsoever so the IRS does not reimburse you for your corporate expenses. What the IRS does is it enforced the laws which is the United States code and issues regulations interpreting that code and is basically the enforcement arm for the US department of treasury. What ends up happening for corporation is they're allowed to reimburse shareholders many expenses that are not included on the shareholder's personal tax returns. So it sometimes seems like they're giving you money when in all reality, they're allowing you to not pay tax on your expenses which is always the battle because there's lots of rules out there that say things are not deductible. Nothing more telling them what we just had happened in this tax change where they eliminated all miscellaneous itemized deductions. All of them are gone in case you've been sleeping. In 2018, you do not get to write them off anymore. Jeff: Now that's your union dues, your tax preparation fees. Toby: Any unreimbursed business expense if you're a teacher and you're providing stuff for your classroom, you don't get to write it off. Jeff: If you're paying substantial amounts to your broker for advisory fees. Toby: That's a huge one. We're going to see that one come back and bite people in their touché. Jeff: That's no longer deductible. Toby: So it's horrible. So no, the IRS does not reimburse you for your corporate expenses. Your corporation reimburses you for your corporate expenses and the IRS lets you write it off. How do I qualify for real estate professional status. Jeff do you want to play with this one or do you want me to handle it? Jeff: I'll do a little and then you can correct me. So real estate professional has a hours commitment. I believe it's 750 hours a year. Toby: So it's a minimum of 750 hours. There's a second part to that too, you know that. Jeff: And the 750 hours can be earned by you or your spouse. What's your second one? Toby: The second one is it has to be the number one use of your personal professional time. Jeff: Oh, correct. Toby: The way I always explain this is if you did 1001 hours doing bicycle repair and you did 1000 hours of real estate, you do not qualify as a real estate professional. But if it's reversed and you did 1000 hours of bicycle repair you did 1001 hours of real estate activities, then you do. And the reason this is important is because ordinarily, your real estate expenses are offset your real estate income and you can only take losses from real estate. In other words, the excess depreciation, or repairs, or whatever, your losses are limited to $3000 a year against your other active income. So that's called the passive activity loss rule. Jeff: $25,000. Toby: If you materially participate and then you have $100,000 to $150,000 scale up. There's some little nuances which don't bring your head with. At the end of the day, there are restrictions on taking passive activity loss. Real estate professional status removes that restriction. The other thing that's really important about real estate professional status is it is per property. So if you have three properties, you'd have to meet it for each of the three unless you elect to aggregate all your properties on your tax return. We have seen this missed by accountants who don't do real estate. They don't aggregate and there are actually cases on the book where people had to fight and they literally had tons of properties they easily met the 750 if you aggregate it but their accountants miss the aggregation election. Jeff: And the sum of 750 hours is not just for your rental properties. Toby: Any real estate. Jeff: Any real estate activity. Toby: Yeah. Jeff was actually right when he said your spouse could qualify, either you or your spouse if you're filing jointly. Jeff: So if you have a full time job and you're getting a W2, I can guarantee you that you will not legally qualify. Under audit, you're going to lose. However, if you have a full time job and your wife does not or your husband does not, they can qualify to be that real estate professional. Toby: We had a fun one. A good friend of ours and a colleague in Georgia was making somewhere between $2 million and $3 million a year in his professional practice. His wife qualified as a real estate professional and he quite literally bought enough commercial property and did something called cost segregation where you're rapidly depreciating it where he generated enough loss off the real estate to offset his income. The IRS audited it, he is self represented because he knew the rule. It withheld, he stood up. His wife just did their real estate activities and he did their practice and at the end of the day, she met the requirement for the real estate professional status and the rule is pretty straightforward. IRS didn’t like the outcome but that's not their job. So they picked a fight and lost the audit which is not uncommon. All right, so how do I qualify for a real estate professional. Keep a log of your time and make sure that you're aggregating all of your real estate activities. Even if it's for a closely held company, it's still going to match, it's still going to work. Next one, what are the self dealing rules for nonprofits in QRPs. I'm going to add in there IRAs as well since when we talk about a qualified retirement plan, we're really talking about 401K and 401A. This is going to dovetail in with one of our other questions that came in off the internet as well. But here's how it works. If you are in a particular type of entity where it says you cannot interact and engage in business with a disqualified person, you could not sell them a $1 million building for $1. It is an absolute prohibition against self dealing. The most important first step is determining whether or not you're within one of those rules. Then if you are, then you look and say are there any exceptions to that rule. So for nonprofits, nonprofits are going to fall into broad categories foundations, private foundations are one. These are nonprofits that aggregate money and give money to other nonprofits, they don't do anything. And in that one, you have an absolute bar from self dealing. The next one is an operating nonprofit that is doing something and in that case, you just have to use arm's length transactions. So we look at that, that's our step number one. So let's go back to the first one, private foundations then you look and say, are there any exceptions. The only exception is reasonable compensation, it can always be reasonably compensated. But other than that, no more transactions. So for nonprofits 501(c)(3) you can enter into transactions as long as it's an operating nonprofit. It can give you benefits, it can pay you and it can engage in sales and other transactions between you and the agencies so long as they are arm's length. And the way you make sure it is arm's length is you have non-interested parties looking at it saying, "Hey, that looks okay to me." somebody who doesn't have a dog in the fight. Now we go to QRPs and IRAs. In either one of those, you have absolute prohibitions against self dealing with disqualified parties and disqualified parties are lineal descendants which would be grandparents, children and their spouses, great children and their spouses. It does not include your siblings. So what's interesting is you could actually engage in transactions with your IRA for example, loan money to your brother. You cannot loan money to your mother. You could not loan money to your kids or your grandkids, you could not do a second on their house, you could not do anything between the company. You could not buy a house from them. That is an absolute bar that's called, disqualified party. Jeff: The way I kind of look at it as to whether you may be violating self dealing rules is, are you benefitting from a transaction between you and the nonprofit or the QRP or the IRA. That's really what they're out to prevent. And unfortunately the rules are pretty severe for violations of the self dealing. Toby: If you self-deal, you're just going to disqualify your IRA. If you're using a QRP and you're using a 401K, then we have different rules, and in that particular case, it would just disqualify the money that you actually were utilizing. Their far more lenient. Jeff: I had a client who had a QRP, it was actually defined benefit plan, who had a required minimum distribution to make and the plan was not funded at the time. The client had to make a loan to the QRP, which is a self-dealing but unfortunately there's an exception for that that one was quickly repaid. There was no profit or interest earned on it. Toby: Was it within the 60 days? Jeff: I believe it was within 60 days. Toby: There's some more fun stuff. Then we go into the 401Ks and this is where you get into people acting on behalf of the company. I know that there were some questions, that were already posed in the chat feature here. You're not supposed to be getting any personal benefit or using those funds at all when you have an IRA or a 401K. In an IRA, it's much more severe because you have a custodian. So if a renter for example is paying you money and they pay it to you individually, technically you have a violation of the self dealing rules because you just received money. Even if you go ahead and put it right back in the IRA, you're going to have an issue because technically you weren't supposed to receive the money, the custodian was supposed to be receiving the money. So you should actually have rental money going to your custodian if you’re using an IRA. If you’re using a 401K or 401A, which the profit sharing plan or 401K, then you are the trustee and you're able to accept the money and endorse it right into the account and make sure that the money goes to the right place. IRA's are a little more difficult. To get around this, a lot of people with IRA's will set up an LLC which you can be the manager of. Actually, the IRA is technically the member— you're in non compensated role and we have to make sure that the LLC agreement says that if we drafted it, then we make sure that we're putting in the non-prohibitionals. You cannot personally benefit from these activities. It has to all go back to the retirement plan. People will do the LLC and they will be all right, now I can go ahead and accept the funds through the LLC, that's how they do with an IRA. If you're doing with the 401K, we're going to suggest that you still set up an LLC anytime you have real estate, just because we don't want the liability to flow through to you. But there, now, you don't need the custodian. You could technically do it inside the 401K directly though you should still have the LLC and it's the same scenario where you're able to accept the proceeds. That's not going to be a technical violation because you're acting on behalf of the plan. And that is not a violation of the self dealing rules. So the biggest takeaway from all this, is that you can act on behalf of the plan. The second a just qualified person starts to get personal benefit, you have violated the rules and if it's an IRA, the whole thing is violating—considered a taxable event, which should be that 10% penalty plus income tax on it for the entire amount if it's at 401K or 401A, it would just be the portion that you violated. We tend to be very bullish on using 401Ks and 401A's, profit sharing plans around here also known as QRP. And this is why, because they're far more forgiving and they have a less moving pieces. I hope that explains that. We're going to have—I know there's a couple more questions that are in here, that are going to be relevant to this section as well. Let me jump on to something. The questions, this is something you can ask detailed questions via our email. I will answer them, Jeff or Tony, whoever's from the tax department here. We will answer these on the tax Tuesday. We will also more likely be responding back out to you directly as well because we want to make sure you get your questions answered, but just jot down that address, webinar@andersonadvisors.com and feel free to shoot them in. Since our last one, Tax Tuesday, we had a couple of questions and I want to go through these. Number one was from Karen out of Alaska, "I have a revocable trust in Alaska that owns and sells real property, does the trust to pay income taxes on the profit or does the profit end up on my personal tax return? Is it taxed at the same rate as everything else? So the most important word she used in her question was revocable, because trust come in two flavors, revocable are irrevocable. If they're irrevocable, then we have two choices, we don't have to worry about the irrevocable.. Since it's revocable, it's a grand tour trust is ignored, it's you, for tax purposes until your dead. So you're good, sorry, sometimes I'm blunt. So if you're buying and selling real estate, real property it's taxed no differently than if you're on the real property. Now here's the rub, it also gives you know asset protection. So revocable trust is giving you know asset protection with that real property, so I would really strongly suggest that the revocable trust actually be the owner of an LLC that is buying and selling the real estate and depending on how quickly you are turning this, will depend on whether that say, S or a C-Corp., if it's a flip versus if it is a long-term holds, then we just put it as an LLC. It would either be disregarded or taxed as a partnership. We want it to flow under our return. Those are kind of our choices. There was a question, I don't know if I got to that. I'm going to skip back to our slides. There's something about—Am I a dealer or an investor? So I want to make sure that I'm getting this one right here. Because this is relevant to one of these questions. A dealer and an investor is something that we talk about in real estate, you want to hit on this? Jeff: No, you're doing fine. Toby: An investor is someone who's passively involved, a dealer is somebody who is actively buying and selling real estate. So if you buy real estate with the intent to hold it for its long term appreciation cash flow, then you are an investor. If you buy real estate with the intent to sell it, then you are a dealer. The easiest way to conceptualize this is if I am an investor, I am passive. If I am a dealer, then I am a supermarket with inventory. And I'm putting my real estate on a shelf and it's constantly for sale. Just like at your grocery store, it may take a couple years for something to sell. I'm just imagining the items that are on the shelf. Jeff: Your durable goods. Toby: Right, so you sell something, I used to do liquidation. We would grab all the expired items we would sell them but let's say, it doesn't matter how long you held them. A lot of people think, well if I held it over a year, I can't be a dealer. That's not the case, we actually have cases on the book where they held it over 10 years. What matters is what your intent was when you buy it. And the difference it makes is active income versus passive income. The difference is an investor can 1031 exchange and defer all other taxes. An investor can get long-term capital gains, an investor can do installment sales, an investor can spread out the tax liability over a long period of time. Whereas a dealer is active. It's subject to social security taxes, it's taxable immediately even if you don't receive the money. It is active ordinary income, it's no difference than I just sold that box of Cheerios on the shelf that I've been waiting to sell. It makes a huge difference. Dealer activity we're going to isolate inside of an S-Corp or a C-Corp. Investor activity, we're going to make sure it flows on your personal return either by using a disregarded LLC or a partnership LLC, one of the two. Jeff: Intent has really made a difference in a couple of cases. One, where somebody bought a property that they go allow their child to live in, something end up happening then they sold it after a short time. They were considered to be an investor not a dealer. Toby: It doesn't even matter. It does not matter whether you ever rented it, there's plenty of cases where somebody tried to rent it and they were going to use it as a long term hold and then things change and they sold it. Just know that if you buy or sell within a year, the presumption is going to be that you're a dealer. If you hold for over a year, the presumption is going to be that you're an investor but it's not a guarantee. We're going to get back to these questions. How does Flip LLC income flow into S-Corp and then what will be distributions of the seller? So, we talked a little bit about this last week but I'm going to go and we're going to hit this. When you set up an LLC, it doesn't exist to the IRS. So when you say how does the Flip LLC flow into S-Corp, it doesn't. A Flip LLC is an S-Corp if you elect to have it be treated that way with the IRS. The income is just going into an S-Corp. Then you have to decide what your salary will be because if you know anything about an escort S-Corp, you want to make sure you pay yourself a reasonable salary if it's making money. The rule of thumb to use is, one third of your net income should be paid out as salary. That's just a rule of thumb but it's all in all reality the IRS has this funky test where you're supposed to say, "Hey, what would it be? What could it be paid?" they never tell us exactly. So I'll just say this, pay a third, don't worry about it. If you get too much money, if you start making over $300,000, then we're going to have a chat but where you're going to be on our radar anyway, we're going to be making sure you're paying a reasonable salary anyway. The reason this is important is because the salary is subject to old age death and survivors in Medicare also known as FICA or social security and the distributions are not. So what you would do is you'd be cutting your social security tax by about two thirds if you did it that way. I hope that explains it. So it makes its money and it pays it out. We do need to make sure that if you're flipping, that the money goes into the LLC. Jeff: A quick comment on distributions on an S-Corporation. Distributions are typically the money that's already been taxed are in you're just pulling the cash out. What you don't want to do is go out and get a bank loan in S-Corporation and take distributions from that for several reasons. One, you don't have basis in those distributions. Two, it gets into the whole finance distribution issues and things of that nature. So you really only want to be pulling money out of the company that you’ve already been taxed on. Toby: Fair enough and then if you don't pull any money out of an LLC that's taxed as an S-Corp, you don't technically have to pay yourself a salary. You just let it sit in there and keep growing which your accountant is not going to tell you because they don't know that. The reason I know that is because I have spoken to probably 100 accountants that missed that one. It says, why do you want the LLC that does flipping set up as an S-Corp or C-Corp instead of a partnership? Mark, we were just talking about that because it's taxed as ordinary income as subject to self employment tax. So the reason we want that in an SRC is so that you do not get classified as a dealer because then all of your real estate is dealer real estate and you could lose all your long-term capital gains, you to lose your 1031, you could lose your installment sale. So we want it to be a separate taxpayer from you so the IRS notes clearly who the investor is and who the dealers is and then you can reduce the amount of tax hit by using the S-Corp that will reduce your self-employment tax significantly, if you add a 401K to it, you could eliminate your tax or defer it out into the future. If you use a C-Corp, then depending on what your expenses are, we can also eliminate all your tax or at least reduce it significantly. So that's why we use that. All right, we have a whole bunch of questions to go through so I'll go through this. What is UBIT and UBITA. UBIT is unrelated business income tax and the easiest way to understand this is when you have a tax deferred entity or tax, it's not actually a tax rates, it can be tax rate if it's a Roth but when you have a qualified plan or a nonprofit and it is not doing what it's set up to do, so let's say in an IRA or a 401K or a 401A, or a nonprofit, they're all set up to do certain things. They're allowed to have a passive activity which is rents, royalties, dividends, interest, even capital gains and it can have those and you don’t have to worry about it at all. But once it starts competing with other businesses, active businesses, now you have an issue and that's what's called—let's say that you have these ordinary businesses. Then they would be taxed, generally speaking it's going to be the highest rate at 37% I believe is what it's going to be as kind of a disincentive to engage in traditional businesses inside those exempt organizations. The easiest way to look at this, let's say you set up an IRA and it runs a mini mart, you're going to pay tax on those profits just like anybody else would. The exception is if that IRA owns a corporation that does not pay out the profits directly. It would have to own C-Corp and then it would only receive dividends and then those are considered passive. So it gets funny and a little bit difficult. The other one is let's say you set up a nonprofit, that's for—what's a good one? Helping Vet and then it sets up a pizza business on the side and starts competing, it buys a bunch a Domino's franchises. It's going to pay tax on the Domino's franchise. It doesn't get a big huge competitive advantage selling pizzas because it's a nonprofit. It would have to be for its charitable purpose and that's UBIT. Jeff: One place we see a lot is like hospitals, they're usually tax exempt but they may have a gift shop which they have to pay the business income tax on because it's not directly supporting them but it is a business. Toby: But you're allowed to do that for like what is it, Salvation Army and some these other thrift stores. They'll let you have one for a church and whatnot. If it's ancillary, if it's completely ancillary and it's just being used like thrift stores I think are one of the few exceptions, gift shop absolutely, you're head to head. Here's another one and I think that this may be what Diane was looking at, it's debt financed income. What that is, is if I'm using the leverage, then there's an exception for IRA's where it cannot use loans to generate income, it's considered an unrelated debt financed income. It will be taxable That is not the case for 401Ks and for 401As, which is what—if you've ever been to one of our events, you hear us railing on the idea that if you are going to finance real estate, real estate is considered passive and it's considered okay not UBIT. The only way you make it taxable is if you leverage it inside of an IRA, so don't do that. If you're going to leverage it, make sure your rolling that IRA into a 401K or profit sharing plan which is the 401A. So there, that's my two cents. I figure that maybe they had a funky—UBITA, I have no idea what that is, but it looks neat. I think they were probably referring to get financed income, since those things usually go side by side. All right, we have a ton of questions that have been posed and this is so much fun, we have like literally a jillion questions, if that's the number. All right, so here's the first one, if I cash out refinance or borrow an equity loan from my primary residence, use the money to do private lending by rental property, can I deduct the interest expense as an investment expense beyond $750,000 amount? They're throwing some things in here. This is actually a really long question, I'm giving you the thumbnail sketch of it. Hey guys email those types of questions in, because nobody's going to be out to follow this, but here's what here's what they're saying, we now have a restriction on your mortgage interest, it's $750,000. If you borrow on your house, and by the way it's $750,000 now, if you had a loan on it up to $1 million, you're grandfathered in, if those prior to what was it, 12/15/2017, you're good or if you got your long before April 15th and you already started the process before December 15, don't you make my head hurt. Long and short of it is, let's say $750,000, but your house is worth $1.5 million. You borrow money out of your house. You will not be writing that off personally, you are capped at $750,000 and that's on your schedule A. Whether or not you're getting any benefit out of that is to be seen because you have your standard deduction. I imagine it's going to be above the standard deduction if you're borrowing up to $750,000. Let's just say we have our $750,000 and we borrowed an extra $500,000, it can't go on your schedule A, but it can go someplace else. The someplace else would be, for example, if I put it into my schedule E, because I'm using it to buy rental property. Then I can use the income of the rental property and I can use the interest being paid as a separate expense, it's just going on a different tax form. The other route that you can go is, if I give that $500,000 and I loan it to a corporation and the corporation re-loans, in the words the corporation is going out loaning its money out and it's reimbursing my interest, then in all reality the loan is really to the corp, and I'm not getting any tax benefit but the corporation is reducing its income by reimbursing me the right to use basically my line of credit. This is no different than if you do this with your credit card. It's reimbursing you, so you make no money on it, but you don't pay tax on it, it such a fancy work around. That's number one. Next question, I hold rental property in a self directed IRA. I do tenant screening, manage the rental, hire vendors to do the repair work and I don't physically work on the house. Good, because you can't physically work on the house, you can do everything else, you can hire, do screening. I would actually have a property manager on it. All income expenses come and goes to the same self directed IRA account, hopefully that's with the custodian or you have an LLC, disregarded to the IRA. Somebody asked this, the IRA custodian sets up the LLC, you can't do it. You shouldn't be going out and doing it yourself, paying your money, you should actually have the IRA do it to keep it clean. Is it allowed? Yes, some people say, "If only I don't work on the house myself, that's okay," and they're correct. Some people say, even screening, collecting rent is not allowed, can you please clarify? You should not receive the money, the IRA should receive the money, you can direct you to the custodian though. You can even get the check and hand it to the custodian, forward it to the custodian, whatever, as long as what you're doing is not adding value to the property. That's the big no, no. Don't go get a paint brush and start painting the house because you're increasing the value to your personal efforts. Next question, my wife's previous employer stock options were exercised and we feel have peaked, cost basis 132, market value 280, if we cash in, what will be the tax consequences and how can we reduce the tax burden? We need to pull the trigger shortly. Aziz, this is you, there's two ways you can do this. First off, you're going to end up with long term capital gains, so it's not horrible. Secondly, there's something called an opportunity zone which just enacted at the end of the year and the just published out all these zones. If you reinvest the money in a opportunity zone, you defer to the tax. In the opportunity zones, there's tons of them. It's any neighborhood that is considered—that needs public support and there's a laundry list. I would actually encourage you to go Google, opportunity zone, tax and you'll find a big old list. But the communities in your area that are typically low to moderate income house. If you took your entire amount of increase, so let's say that we have $150,000 of taxable capital gains, you could buy $150,000 of opportunity zone properties and pay zero tax. Now, the question is, what happens when I sell? So there's holding periods and the minimum holding period, I believe, is you're going to be looking at five years, where then you're going to not have to pay tax on 15%, I'm going off of memory. So you'll have to excuse me if I'm not spot on, but it's 15% then it jumps up. At 10 years, the entire $150,000 is no longer taxable. And I believe that you're not going to be paying tax on the gain in the opportunity zone, it's kind of a two pronged, are you familiar with that one, Jeff? Jeff: Somewhat, I know that you replaced the old enterprise some number of years back. Toby: Something to look at, but would be it. The last way to avoid tax is give them, before you exercise it, is give that to your non-profit, if you have one and you would get a $280,000 deduction. And then the nonprofit can sell it zero tax. You'd get a monster tax and you could have these too, you could say, "Hey, I really need to offset a bunch of the tax, so I'm going to make a contribution," it doesn't matter what your basis is, it only matters, the fair market value of those assets and if you transferred let's say $140,000, half of it, let's see transferred $140,000 worth of stock, you would get $140,000 tax deduction and it can offset your income up to 60%. In either case, if you're pretty confident that we can mitigate or eliminate that tax bill if you wanted to. If you keep it out of state, somebody says, if you keep it as state for 36 months, can it be avoided? I am helping a friend with crowdfunding project and due to medical needs, we'll need a large sum, maybe $100 million what would his tax consequences be if he has no deductions? Does he have to pay tax on donated money? Fred, generally speaking, if you're getting these little gifts, as long as they're less than $15,000 there's no tax and when I say $15,000 that's per donor. So if I do a crowdfunding and everybody gives $100, there's no tax to the recipient. So go ahead and raise them a bunch of money. Jeff: Keep in mind when you're doing this crowdfunding, if you're contributing to a crowd funding, it is a gift, it's not a donation. Toby: And it's not a tax deductible donation. In 2017, I sold a rental house and took a $40,000 note. In 2017, I received $944 in interest but have not issued a 1099-INT. I did report the amount on my personal 2017. What should my next step be? Wait until 2019 or file now. So he's the one who holds the note, he was paid interest. What do you have to say? Jeff: This is kind of a darn if you do and darn if you don't. There is a penalty for not issuing the 1099. You did the right thing by reporting the amount of interest. However, there's a penalty for not following the 1099. There's a penalty for filing them late. Toby: What's the penalty like? Jeff: I think it's $50 or $75. I think it's $50 up to $99. Toby: So what you're saying is do it next year? Jeff: I didn’t hear anything. Toby: Hey do it next year unless they start digging in. I've had that, we actually went through a super audit here once and they went through every—they let you fix it. So I just wouldn't do it. I would just do it next year and say, "Hey, oops." How to aggregate all properties. What are the disadvantages to doing. You file an aggregation election, is it a form or you just check in the box? Jeff: It's an election. It prints out a form with your tax return. It says exactly what properties or investments you're aggregating together. The only real disadvantage is. Once you aggregated these properties, let's say you have two houses and one has significant passive losses. When you become a real estate professional, those passive losses gets stuck in there. Normally they get freed up when you sell that property but once you aggregator properties, it's all considered one property. So it doesn't free up those if you have a large losses tied up, it doesn't free them up until you get rid of all your aggregated properties. Toby: Cool. Nicely put. Are the purchase and sale of mortgage notes considered real estate for real estate professional status I'm assuming. Jeff: This is my gut feeling, I would say no. it's more of a lending, more of an investment in the notes. Toby: Depends on whether you're ending up with the properties. It depends on what your intent is and if your intent is just to buy and sell mortgage notes, then you're dealing with lending. In order to be real estate, it's really got to be focused in on the purchase and sale of real estate. Jeff: So we kind of run into the same thing with construction companies and such that they meet the test for certain things but not for other test. There are some input to it so real estate broker is kind of the same thing. Toby: Here's the thing, so this is Dean. Dean, if I am in your shoes, I am documenting the time I'm spending in real estate. so even though I may be going after a note, if the reason that you're going after the note is with the intent that possibly end up with that property and you do the research and you can back it up, then you add it into the real estate column as far as your time and you aggregate all your time. The only time this is going to come up is if somebody audits you in goes through all of your records that thoroughly which is rare that that happens. But let's say that it does, then you're the one who's tracking all of your expenses and your time. Then it would be up to the IRS to sit there and say, "Hey, that was actually for the mortgage." and so the old adage is pigs get fat, hogs get slaughtered. You don't take all of it but you aggregate that a little bit. Jeff: Can I bring up a pet peeve? I hear on the radio frequently about all these auditors that IRS has hired and they haven't had a real hiring since 2010. Toby: They're so toast right now. Jeff: The last big hiring they did most recently was to deal with Obamacare for that audit purposes. But really, they're dealing with almost a skeleton crew anymore. Toby: We just got proposed tax forms for 2018. We don't even know, we just had proposed regulations issued on the tax changes two weeks ago, three weeks ago. They're way behind the eight ball and sometimes we put ourselves in a disadvantage. Don't be crazy about it, but you can be pretty aggressive and especially if it's the truth. If what you're spending your time on is real estate, count it towards real estate. So if you're doing real estate investing part time, can you be considered a part time investor? Yeah, you'd be a part time investor but you wouldn't be a real estate professional. So the biggest important thing and this is for Darlene and Ken, is to document your time and if you go over 750 hours and it's more than you spend than anything else, then you're going to be a real estate professional. Otherwise, you're just an investor, unless you are buying properties to sell. So when you say investing, that means you're going to hold on to them, you're letting them depreciate a little bit but you get the cash flow. Does time spent lending money on real estate for real estate qualifiers and real estate professional. No investing, didn’t we just answer that one? It depends on your real intent of investing in the note. A lot of people are buying notes to end up with a real estate in which case then I'd say probably. Jeff: No, what if she's gap funding? Toby: If you're gap funding then I would say no, then you're lending. So you really have to take a look at the totality of the circumstances. I wish I could say yes or no. what we want is a yes and there's a way to get there. So it's making sure that you're documenting things to support your position. We could dig into that a little bit more, if you want to shoot us the email then let us dig into it. Then the next tax Tuesday, I can answer that one and Jeff can answer that one with a little bit of research behind it. Nexus question, "I'm a resident in California, I'm moving to Arizona. I plan to keep a single family rental in California. The California houses and the land trust is owned by Wyoming LLC, does California have the right to tax my pension income after I move in addition to my income in California rental." Shelly the answer is, it depends on where the rental was earned and whether you're taking out over a 10 year period then the answer is, no. and my guess is that you're going to be a big no. They will be able to tax technically the rental income that is being derived from California but for the most part, that's going to be zero. Jeff: A really important number to remember when you have a property in more than one state is 183. That's typically the number of days you need to spend in a state to be a resident in that state. Toby: "How do I get the 501(c)(3) tax exempt?" Marie, that’s the 1023 application. Yes, it's the 1023 application. So with a nonprofit, I always look at these things in threes, we file with the state which is a corporation. We document it to make sure there's no shareholders which is for private parties, and then we file with the feds and we're telling them we want to be an exempted organization and that exemption is done via 1023. So we go through that process. When we set them up, we set up about 3,000 of them successfully. "How do you create an LLC and an IRA?" Darlene and Ken, what you do is you have the IRA custodian internal contract with a company like us and we create the LLC, or we set up a 401K, roll the IRA into it and then we'd let you do it so you don't need a custodian. "Is this recorded and will a replay be sent out?" Robin, it's made available to anybody who's platinum and then I'm cutting out a bunch of the Q&As and will throw them all over the internet. The recording, yes we record them. Join platinum, it's fun. "If I sell a partial note to a family member from my QRP, is that disqualified?" it depends on the type of family members. When they're your kids, yes. If it's to a brother or sister, no. then you can do it. When you make a contribution and that's just the whole disqualified person argument we had earlier. So you can always ask again, ask the question specific to your situation, we'll give you a very specific answer. But just know that if you sell a partial note out of your QRP, it depends on the relationship of the family member. If it's lineal, you have a problem. Which means kids, parents, grandparents you have a problem. If it's horizontal, siblings, not a problem. If it's the spouses of the disqualified person, you're going to have a problem. "Investing in LLC for holding rental property, how does one avail to a 1031 exchange?" Here's how it works, so I'm not going to worry about this. The 1031 exchange, you have to have a 1031 exchange facilitator. The LLC has to buy the next property. So you sell one and buy one within 180 days and there's some other roles in there about when you identify it or you do a reverse exchange where you buy the replacement property then sell the other property within 180 days. But neither cases, in the name of the LLC, you don't have to do anything else. "I should be able to still qualify as an investor and still be active in real estate by investing more than 750 hours." yes, but in actually is a full time job. So if you have a full time job as a real estate professional, then you're good. But remember, your activity as a real estate investor has to exceed your activities of any other profit making activity. So if you work and you work 1,500 hours, even if you did 1400 hours as real estate, you are not a real estate professional, still below that 1,500. Investment in LLC for holding rental property, how does or somebody asked that. If you in invest funds to have an equity in a project, oh my god, this one's going to kill me, built by someone else, I'm trying to think what this is. So you're investing funds for a piece of an LLC in which you are passive and they are a builder, are you a dealer? So Judith, no, you are a passive investor in an active business, is what you are. I see what you're saying, what she's asking is, "Hey, I have Bob the builder come up to me and says, 'Hey, we're going to build this big apartment complex, we're going to develop and everything. You put in $100,000 everybody else puts on $100,000.'" You are passive. You are not considered the dealer. Here's a fun one, did you already read this one? Jeff: No, I haven’t read this one. Toby: Okay, I am planning to receive social security benefits at 62, and currently not employed. I do private lending to real estate investors through promissory notes. So I do receive interest income in the amount of $40,000 to $50,000. Will this affect my social security benefits? At what point to social security benefits are taxable? So Joe, the answer is that there are certain types of income that are exempt from calculations, social security, Jeff you know off the top of your head? Jeff: If you're receiving earned income and that's all social securities could ever know about, so we're talking about self employment income, W-2 wages, that's going to affect your social security benefits. Toby: But if you're just receiving interest income, is it going to affect it? Jeff: Well, here's the thing, if you're in the business of lending money, we would typically set you up as a business, either on schedule C or through an S-Corp or something. That interest you receive wouldn't be, interest income, it would be business income. You'd be able to deduct certain expenses from that income… Toby: We got to look at it, because usually you're going to want to be treated as active, in this particular case you're not going to outdo yourself. Jeff: The downside of this is, any money, any net income you have from this business of lending money is going to affect security until you're 65, or 67, full retirement age. Toby: Joe, the answer is, we may one isolated into its own taxable entity, so that it doesn't affect you. We may. Jeff: I kind of feel like this would be in a great place for an S-Corporation. It's not earning income flowing through to them. Toby: Would he have to take a salary? Jeff: Yeah there we go. Toby: I'm going to take a look. Joe, that's a great question, could you submit it to the webinars at Anderson Advisors, so we can research it. In that way we can hit it in two weeks, to get you a much more thoroughly research, because you're asking a very complicated question. That’s just not going to be at the top of our head. We're going to make sure that we don't step on a landmine. Jeff: So the answer's, maybe. Toby: My wife and I are the only shareholders and we both take a one third salary. No, you should take about one third of the net profit as salary, total between the owners. So greater than 2% shareholders or you and your spouse, so you could each take, I'll throw numbers out, let's say you made $100,000, you could each take up to $18,500. If you're under 50 and immediately dump it into a 401K and not pay any tax. So, "Hey we like that." We have a medical coding business, perfect, yeah, so that's when we want to take a look at. "This is so much fun, really appreciate it," I hope that's not sarcastic, Al. "I opened a couple of LLC, I'm going to use to purchase flipping, can I put them on hold until I do? Do I have to do tax returns?" It all depends on what you're doing with those, the answer is, yes you could put them on ice. "Thanks for the answer on UBIT." Diane, no problem. See we actually do answer questions here. "What are the legal benefits of incorporating in Puerto Rico, if any compared to Nevada?" If you live there, I think they give you 4% tax rate, but you actually have to reside there. There's legal benefits, not really any, other than the tax benefits and the fact of the matter is Puerto Rico has Spanish law, which means they could probably take your company from you. But you can still go down there and Jeff… Jeff: Well, I mean, there are certain industries that have great tax benefits pharmaceutical companies was always a big one. Some of those old laws have sunsetted but might be a good opportunity. Toby: Cool, look at all these questions. All right, some people are saying nice things, great. I like nice things better than, "You guys are jerks." In 2017, I was self employed under my LLC, I have not filed my taxes yet and not considering retirement. Would I still be able to do that? What is best options?" Casey, are you under—self employment under my LLC. So it depends on whether—it was an S-Corp. Did you file an extension because you would be able to do a retirement plan either a sub-IRA or if you already had the 401K then you can make a contribution from the company for it. It would either be a 401A or a 401K. or sub-IRA, I think those are going to be your... Jeff: And if you do extension, you have 11 days to get it done. Toby: Yeah, you have 11 days. Casey, get off your butt. All right, Brian wants advice with the start up pre revenue, he is offering 10% stock, "Not sure I want ownership that subject to capital calls, expectation, potential—is it better to take an offshore [inaudible 01:06:53] until there's more value in the company?" It really depends, so Clark, nice to see you. Awesome. I know Clark's brother very well, studs, nice family. All right, friends, if I was going to have a piece, the whole thing is, if I'm putting money into an endeavor, it's going to be, "What am I going to get out?" It would really depend on the agreement, I don't want to be subject to having to put more money in, nor do I want my interest necessarily being diluted by somebody who is. So one of the one of the ways you can do it, is sometimes do it is a convertible note where you loan the money, so you know you can at least get it back, but it's convertible into equity at the fair market value at that time. You guys can actually agreed to this ahead of time. So that if you decide you want to contribute it, you see they're doing what you want but then you convert it into equity. Otherwise it just remains a note that they pay you on. Clark, that's probably the route I would go. Jeff: But the assumption here is, this is a C-Corporation he's talking about. Toby: I don't even care… Jeff: Well if it's an S-Corporation that we wouldn’t be able to have all these secondary notes and stuff. Toby: If it's an S, I could so convert it. Jeff: Could you? Toby: Yep. Jeff: As long as it converts into the same… Toby: Yep. The risk is I don't want to have a convertible debt to anything other than an individual that would qualify for S.. Jeff: Okay. Toby: But I don't see S-Corps raising money this way. It's almost always C-Corps with partnerships. So the ones that I've been personally involved in, we did three levels of financing this exact way with Vegas Tax fund. That's the little Tony Hseih group and they dumped a bunch of money to a company called Role Tech. You can look them up online, because we exited that wanted with the sale to Brunswick. In a way they did all their money was purely—that was a C-Corp, but it was purely through convertible notes. All right, "What are the best tools you can recommend for tracking time mileage and expenses for real estate investors? My desire to be paperless and get everything out…" People use Taxbot for mileage, it's mileage IQ, MileIQ, I think it's the one that I use, but if you're tracking time, it's just using—sometimes is just using your calendar or spreadsheet. Let's see, "Is full time realtor, a real estate professional?" Chances are, you're going to aggregate and all that. "I understand and agree." I'm not sure I understand that. "I executed a 1031 exchange where trust all the owned property, sold it, and took title of the up leg property in the trust using 1031 exchange. But now I want to transfer up leg property into an LLC." Diane, there is no time restriction that you have to hold it as long as you are the one and still the end beneficiary. If you extend loan through an LLC owned by Roth IRA, they want to transfer, sell the remainder, but then season it out to a lower interest rate. Can Roth continue to receive the full payment from the borrower and the relay the portion?" Yes, as lines is non-convertible, same as you do in an S-Corp. "Is the answer the same best self administer S 401K? So what they're asking is," If you extend a loan through—we're just going to call it the Roth IRA, because the LLC looks right into it from a tax standpoint. And then you sell the remainder of that then season notes. So you start collecting and then you sell the note because it's doing really well and you say, "Hey does anybody want to pay me for this?" I know a guy that that's what he does. He puts the notes together and he sells his notes out and so he can get the money to go to another one and he aggregates them altogether, they call it flying in flocks. The lenders flock together and together they do a loan and he sells his portion. Yeah, you could sell it and then you can continue to receive it and keep a portion of it. the only issue you have is if it's a convertible note then you wouldn’t want to do a convertible note because boom, that Roth IRA depending on the type of entity if it's an S-Corp you'd kill the S-Corp's status of it. How do you put an LLC on hold? You get quite literally do nothing with it or you just pay the state and then you file a non activity return. You say it's not doing anything. So you're allowed to do that or you just do nothing. Which is what I tend to do. It just depends on your state. If there's not much penalty then I just kind of sit it and then two years later I might reactivate it. Will real estate holding LLC taxes partnership qualify for the 20% passed through deduction? Yes, it will. Here's the deal, as long as it's not triple net property. What she's asking is, "Hey, I have a whole bunch of LLCs and they all receive rental income and there's a net income amount." let's say it comes through with $50,000 there's something called a 199A deduction that was enacted by the 2017 tax cut and jobs act. And it gives you a 20% deduction off that amount or 20% of your taxable income whichever one is less/ but if you earn over a certain amount so for individuals it's over, $100,575 if it's a married couple it's $315,000 which is going to make your head hurt I'm going to suffer memory here. Then you scale up and then you have a new test it's 50% of the W2 income that's being paid on that particular busine

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 back with our old routine – no special guests. Nachi: Don’t sound so sad about it! Jeremy was great last month, and he’s definitely paved the way for more special guests in upcoming episodes. Jeff: You’re right. But this month’s episode is special in its own way - we’ll be tackling Electrical Injuries in the emergency department - from low and high voltage injuries to the more extreme and rare lightning related injuries. Nachi: And this is obviously not something we see that often, so listen up for some easy to remember high yield points to help you when you get an electrical injury in the ED. And pay particular attention to the , which, as always, signals the answer to one of our CME questions. Jeff: I hate to digress so early and drop a cliché, “let’s start with a case…” but we, just a month ago, had a lightning strike induced cardiac arrest in Pittsburgh, so this hits really close to home. Thankfully, that gentleman was successfully resuscitated despite no bystander CPR, and if you listen carefully, we hope to arm you with the tools to do so similarly. Nachi: This month’s print issue was authored by Dr. Gentges and Dr. Schieche from the Oklahoma University School of Community Medicine. It was peer reviewed by Dr. O’Keefe and Dr. Silverberg from Florida State University College of Medicine and Kings County Hospital, respectively. Jeff: And unlike past issues covering more common pathologies, like, say, sepsis, this month’s team reviewed much more literature than just the past 10 years. In total, they pulled references from 1966 until 2018. Their search yielded 477 articles, which was narrowed to 88 after initial review. Nachi: Each year, in the US, approximately 10,000 patients present with electrical burns or shocks. Thankfully, fatalities are declining, with just 565 in 2015. On average, between 25 and 50 of the yearly fatalities can be attributed to lightning strikes. Jeff: Interestingly, most of the decrease in fatalities is due to improvements in occupational protections and not due so much to changes in healthcare. Nachi: That is interesting and great to hear for workers. Also, worth noting is the trimodal distribution of patients with electrical injuries: with young children being affected by household currents, adolescent males engaging in high risk behaviors, and adult males with occupational exposures and hazards. Jeff: Electrical injuries and snake bites – leave it to us men to excel at all the wrong things… Anyway, before we get into the medicine, we unfortunately need to cover some basic physics. I know, it might seem painful, but it’s necessary. There are a couple of terms we need to define to help us understand the pathologies we’ll be discussing. Those terms are: current, amperes, voltage, and resistance. Nachi: So, the current is the total amount of electrons moving down a gradient over time, and it’s measured in amperes. Jeff: Voltage, on the other hand, is the potential difference between the top and bottom of a gradient. The current is directly proportional to the voltage. It can be alternating, AC, or direct, DC. Nachi: Resistance is the obstruction of electrical flow and it is inversely proportional to the current. Think of Ohm’s Law here. Voltage = current x resistance. Jeff: Damage to the tissues from electricity is largely due to thermal injury, which depends on the tissue resistance, voltage, amperage, type of circuit, and the duration of contact. Nachi: That brings us to an interesting concept – the let-go threshold. Since electrical injuries are often due to grasping an electric source, this can induce tetanic muscle contractions and therefore the inability to let go, thus increasing the duration of contact and extent of injury. Jeff: Definitely adding insult to injury right there. With respect to the tissue resistance, that amount varies widely depending on the type of tissue. Dry skin has high resistance, far greater than wet or lacerated skin. And the skin’s resistance breaks down as it absorbs more energy. Nerve tissue has the least resistance and can be damaged by even low voltage without cutaneous manifestations. Bone and fat have the highest resistance. In between nerve and bone or fat, we have blood and vascular tissue, which have low resistance, and muscle and the viscera which have a slightly higher resistance. Nachi: Understanding the resistances will help you anticipate the types of injuries you are treating, since current will tend to follow the path of least resistance. In high resistance tissues, most of the energy is lost as heat, causing coagulation necrosis. These concepts also explain why you may have deeper injuries beyond what can be visualized on the surface. Jeff: And not only does the resistance play a role, but so too does the amount and type of current. AC, which is often found in standard home and office settings, but can also be found in high voltage transmission lines, usually affects the electrically sensitive tissues like nerve and muscle. DC has a higher let-go threshold and does not cause as much sensation. It also requires more amperage to cause v-fib. DC is often found in batteries, car and computer electrical systems, some high voltage transmission lines, and capacitors. Nachi: Voltage has a twofold effect on tissues. The first mechanism is through electroporation, which is direct damage to cell membranes by high voltage. The second is by overcoming the resistance of body tissues and intervening objects such as clothes or water. You’re probably familiar with this concept when you see high voltages arcing through the air without direct contact with the actual electrical source, leading to diffuse burns. Jeff: As voltage increases, the resistance of dry skin is -- not surprisingly -- reduced, leading to worse injuries. Nachi: And for this reason, the US Department of Energy has set 600 Volts as the cutoff for low vs high voltage electrical exposure. Jeff: It is absolutely critical that we also mention and then re-mention throughout this episode, that those with electrical injuries often have multisystem injuries due to not only the thermal injury, electrical damage to electrically sensitive tissue, but also mechanical trauma. Injuries are not uncommon both from forceful pulling away from the source or a subsequent fall if one occurs. Nachi: That’s a great point which we’ll return to soon, as it plays an important role in destination selection. But before we get there, let’s review the common clinical manifestations of electrical injuries. Jeff: First up is – the cutaneous injuries. Most electrical injuries present with burns to the skin. Low voltage exposures typically cause superficial burns at the entry and exit sites, whereas high voltage exposures cause larger, deeper burns that may require skin grafting, debridement, and even amputation. Nachi: High voltage injuries can also travel through the sub-q tissue leading to extensive burns to deep structures despite what appears to be relatively uninjured skin. In addition, high voltage injuries can also result in superficial burns to large areas secondary to flash injury. Jeff: Electrical injuries can also lead to musculoskeletal injuries via either thermal or mechanical means. Thermal injury can lead to muscle breakdown, rhabdo, myonecrosis, edema, and in worse cases, compartment syndrome. In the bones, it can lead to osteonecrosis and periosteal burns. Nachi: In terms of mechanical injury – electrical injury often leads to forceful muscular contraction and falls. In 2 retrospective studies, 11% of patients with high voltage exposures also had traumatic injuries. Jeff: While not nearly as common, the rarer cardiovascular injuries are certainly up there as the most feared. Pay attention to the entry and exit sites, as the pathway of the shock is predictive of the potential for myocardial injury and arrhythmia. Common arrhythmias include AV block, bundle branch blocks, a fib, QT prolongation and even ventricular arrhythmias, including both v-fib and v-tach, both of which typically occur immediately after the injury. Nachi: There is a school of thought out there that victims of electrical injury can have delayed onset arrhythmias and require prolonged cardiac monitoring – however several well-designed observational studies, including 1000s of patients, have demonstrated no such evidence. Jeff: It’s also worth noting that ST elevation MIs have also been reported, however this is usually due to coronary artery vasospasm rather than acute arterial occlusion. Nachi: Respiratory injuries are somewhat less common. Acute respiratory failure usually occurs secondary to electrical injury-induced cardiac arrest. Thoracic tetany can cause paralysis of respiratory muscles. Late findings of respiratory injury including pulmonary effusions, pneumonitis, pneumonia, and even PE. The electrical resistance of lung tissue is relatively high, which may account for why pulmonary injury is less common. Jeff: Vascular injuries include coagulation necrosis as well as thrombosis. In addition, those with severe burns are at increased risk of DVT, especially in those who are immobilized. In at least one study, the incidence of DVT in hospitalized burn patients was as high as 23%. That’s -- high. Nachi: Neurologic complaints are far more common as nerve tissue is highly conductive. While the most common injury from an electric shock is loss of consciousness, other common neurologic insults include weakness, paresthesias, and difficulty concentrating. Jeff: And if the entry and exit sites traverse the spinal cord – this also puts the patient at risk for spinal cord lesions. Specifically with respect to high voltage injuries – these victims are at risk for posterior cord syndrome. In addition, depression, pain, anxiety, mood swings, and cognitive difficulties have all been commonly described. Nachi: Rounding out our discussion of electrical injuries, visceral injuries are rather rare, with bowel perforation being the most common. High voltage injuries have also been associated with cataracts, macular injury, retinal detachment, hearing loss, tinnitus, and vertigo. Jeff: Perfect. I think that more or less rounds out an overview of organ specific electrical injuries. Let’s talk about prehospital care for these patients -- a broad topic in this case. As always, the first, and most important step in prehospital care is protecting oneself from the electrical exposure if the electrical source is still live. Nachi: In cases of high voltage injuries from power lines or transformers or whatever oddity the patient has come across, it may even be necessary to wait for word from the local electrical authority prior to initiating care. Remember, the last thing you want to do is become a victim yourself. Jeff: For those whose electrical injury resulted in cardiac arrest, follow your standard ACLS guidelines. These aren’t your standard arrest patients though, they typically have many fewer comorbidities – so CPR tends to be more successful. Nachi: Intubation should also be considered especially early in those with facial or neck burns, as risk of airway loss is high. Jeff: And as we mentioned previously, concurrent trauma and therefore traumatic injuries is very common, especially with high voltage injuries, so patients with electrical injuries require a complete survey and not just a brief examination of their obvious injuries. Nachi: When determining destination, trauma takes priority over burn, so patients with significant trauma or those who are obtunded or unconscious should be transported to an appropriate trauma center rather than a burn center if those sites are different. Jeff: Let’s move on to evaluation in the emergency department. As always, it’s ABC and IV, O2, monitor first with early airway management in those with head and neck burns being a top priority. After that, complete your primary and secondary surveys per ATLS guidelines. Nachi: During your survey, make sure the patient is entirely undressed and all constricting items, like jewelry is removed. Jeff: Next, make sure that all patients with high voltage injuries have an EKG and continuous cardiac monitoring. Those with low voltage injuries and a normal EKG do not require monitoring. Nachi: Additionally, for those with severe electrical injuries, an IV should be placed and fluid resuscitation should begin. Fluid requirements will likely be higher than those predicted by the parkland formula, and you should aim for a goal of maintaining urine output of 1-1.5 ml/kg/h. Jeff: With your initial stabilization underway, you can begin to gather a more thorough history either from bystanders or EMS if they are still present. Try to ascertain whether the current was AC or DC, and whether it was high or low voltage. Don’t forget to ask about the setting of the injury as this may point to other concurrent traumatic injuries, that may in fact take precedence during your work up. Nachi: Moving on to the physical exam. As mentioned previously, disrobe the patient and complete a primary and secondary survey. Jeff: If the patient has clear entry and exit wounds, the path through the body may become apparent and offer clues about what injuries to expect. Nachi: A single exam will not suffice for electrical injury patients. All patients with serious electrical injuries will require serial exams to evaluate for vascular compromise and compartment syndrome. Jeff: So that wraps up the physical, let’s move onto diagnostic studies. Nachi: First off -- I know we’ve said it, but it’s definitely worth reiterating. All patients presenting with a history of an electric shock require an EKG Jeff: In those with a low voltage injury without syncope and a normal EKG, you don’t routinely need cardiac monitoring. However, in the setting of high voltage injuries, the data is less clear. Based on current literature, the authors recommend overnight monitoring for at least 8 hours for all high voltage injuries. Nachi: While no routine labs work is required for minor injuries, those with more serious injuries require a cbc, cmp, CK, CK-MB, and urinalysis. Jeff: The CK is clearly for rhabdo, but interestingly, a CK-MB greater than 80 ng/mL is actually predictive of limb amputation. Oh and don’t forget that urine pregnancy test when appropriate. Nachi: In terms of imaging, you’ll have to let your history guide your diagnostic studies. Perform a FAST exam to screen for intra-abdominal pathology for anyone with concern for concurrent trauma. Keep a low threshold to XR or CT any potentially injured body region. Jeff: Real quick – in case you missed it – ultrasound sneaks in again. Maybe I should reconsider and do an US fellowship – seems like that’s where the money is at - well maybe not money but still. Let’s move on to treatment. Nachi: In those with minor injuries like small burns and a low voltage exposure – if they have a normal EKG and no other symptoms, these patients require analgesia only. Give return precautions and have them follow up with their PCP or a burn center. Jeff: In those with more severe injuries, as we mentioned before, but we’ll stress again, protect the patient’s airway early especially if you are considering transfer and have any concerns. In one study, delays in intubation was associated with a high risk of a difficult airway. Always make sure you have not only your tool of choice but also all of your backup airway devices ready as all deeper airway injuries may not be apparent externally. Nachi: Fluid resuscitation with isotonic fluids is the standard -- again -- with a goal urine output of 1-1.5 ml/kg/h. Jeff: Address pain with analgesia – likely in the form of opiates – and don’t be surprised if large doses are needed. Nachi: Dress burned areas with an antibiotic dressing and update the patient’s tetanus if needed. While there is ongoing debate about the role of prophylactic antibiotics, best evidence at this point recommends against them. We talked about thermal burns in Epsiode 13 also, so go back and listen there for more... Jeff: There is also a range of practice variation with respect to early surgical exploration of the burned limb with severe injuries. At this time, however, the best current evidence supports a conservative approach. Nachi: Serial exams and watch and wait it is. . We have some interesting special populations to discuss this month. First up, as is often the case, the kids. Jeff: Young children are sadly more likely to present with orofacial burns due to, well, everything ending up in their mouth. And since many of our listeners are likely in boards study mode – why don’t you fill us in on the latest evidence with respect to labial artery bleeding. Nachi: Sure – . There is up to a 24% risk of labial artery bleeding and primary tooth damage with oral electrical injuries. Although there isn’t a clear consensus, current evidence supports early ENT consultation and a strong consideration for admission and observation for delayed bleeding. Jeff: Keep in mind though, that labial artery bleeding is often delayed and has been reported as far as 2 weeks out from the initial insult. Nachi: Moral of the story: don’t put electrical cords in or anywhere near your mouth. Next, we have pregnant patients. Case reports of pregnant patients suffering electrical injuries have described fetal arrhythmias, ischemic brain injury, and fetal demise. For this reason, those that are past the age of fetal viability should have fetal monitoring after experiencing an electric shock. Jeff: If not already done, an ultrasound should be obtained as well and a two week follow up ultrasound will be needed. Nachi: We’re switching gears a bit with this next special population – those injured by an electrical control device or taser. Jeff: Tasers typically deliver an initial 50,000 volt shock, with a variable number of additional shocks following that. Nachi: Most taser injuries are thankfully direct traumatic effects of the darts or indirect trauma from subsequent falls. Jeff: While there are case reports of taser induced v fib, the validity of taser induced arrhythmias remains questionable due to confounders such as underlying disease and previously agitated states like excited delirium Nachi: Basically, [DING SOUND} those with taser injuries should be approached as any standard trauma patient would be, with the addition of an EKG for all of these patients. Jeff: The next special population --- the one I’m sure you’ve all been waiting patiently for -- is lightning strike victims. Lightening carries a voltage in the millions with amperage in the thousands, but with an incredibly short exposure time. Because of this, lightening causes injuries in a number of different ways. Nachi: First, because it’s often raining when lightning strikes, wet skin may cause the energy to stay on the skin in what is known as a flashover effect. Jeff: Similarly and not surprisingly, burns are common after a lightning strike. Lichtenberg figures are superficial skin changes that resemble bare tree branches and are pathognomonic for lightning injury. Thankfully, these usually disappear within a few weeks without intervention. Nachi: Next, the rapid expansion of the air around the strike can lead to a concussive blast and a variety of traumatic injuries including ocular and otologic injury like TM rupture which occurs in up to two thirds of cases. Jeff: An ophthalmologic consult should be obtained in most, if not all of these cases. Nachi: Making matters worse, lightning can also travel through electric wiring and plumbing to cause a shock to a person indoors nearby the strike! Jeff: And like we mentioned earlier, just as was the case with my fellow Pittsburgher or ‘Yinzer. Nachi: Yinzer? Jeff: Forget about it, it’s just what Pittsburghers call themselves for some reason or another - but we’re still talking lightning. Cardiac complications including death, contusion and vasospasm have all been reported secondary to lightning injury. But don’t lose hope – in fact – you should gain hope as these patients have a much higher than typical survival rates. Nachi: From the neurologic standpoint – it’s a bit more complicated. CNS dysfunction may be immediate or delayed and can range from strokes to spinal cord injuries. Cerebral salt wasting syndrome, peripheral nerve lesions, spinal cord fracture, and cerebral hemorrhages have all been described. An MRI may be required to elucidate the true diagnosis. Jeff: Clearly victims of lighting strikes are complex and, for that reason, among many others, the American College of Surgeons recommends that victims of lightning strikes be transferred to a burn center for a comprehensive eval. Nachi: Let’s touch upon any other details regarding disposition. Jeff: Those with low voltage exposures, a normal EKG and minimal injury may be discharged home with PCP follow up and strict return precautions. Nachi: High voltage injuries on the other hand require admission to a burn center and the involvement of a burn surgeon, even if it involves transferring the patient. Jeff: And remember, trauma takes precedence over burn and those with traumatic injuries or the possibility of traumatic injuries should be evaluated at a trauma center. Don’t forget to take the airway early if there is any concern, and consider transporting via air as the services of a critical care transport team may be required. Nachi: That wraps up Episode 22, but let’s go over some key points and clinical pearls. During evaluation, consider multisystem injuries due to not only the thermal injury and electrical damage to electrically sensitive tissue, but also mechanical trauma. Thermal injury can lead to muscle breakdown, rhabdomyolysis, myonecrosis, edema, compartment syndrome, osteonecrosis, and even periosteal burns. Mechanical injury can be a result of forceful muscular contractions, and trauma can manifest as fractures, dislocations, and significant muscular injuries. Electrical injuries due to grasping an electric source can induce tetanic muscle contractions and therefore the inability to let go, increasing the duration of contact and extent of injury. Current tends to follow the path of least resistance, which explains why you might have deeper injuries beyond what can be visualized in the surface. Nerve tissue has the least resistance and can be damaged by even low voltage without cutaneous manifestations. Bone and fat, on the other hand, have the highest resistance to electrical injury. High voltage injuries place patients at risk for spinal injuries, most notably posterior cord syndrome. High voltage injuries have also been associated with cataracts, macular injury, retinal detachment, hearing loss, tinnitus, and vertigo. All patients with electrical injury require an EKG. Low voltage injuries with a normal presenting EKG do not always require cardiac monitoring. High voltage injuries require cardiac monitoring for at least 8 hours. Intubation should be considered early in patients with facial or neck burns, as risk of airway loss is high. Make sure to have airway adjuncts and back up equipment at bedside, as deeper airway injuries may not be obvious upon external exam. For severe injuries, target a urine output rate of 1-1.5 mL/kg/hr. All patients with serious electrical injuries require serial exams to evaluate for vascular compromise and compartment syndrome. Address pain with analgesia. Larger than expected doses may be needed. Dress burned areas with an antibiotic dressing and update the patient’s tetanus if required. For pediatric patients with oral electric injuries from biting on a cord, consult ENT early and consider admission for observation of delayed arterial bleeding. Pregnant patients who are past the age of fetal viability should have fetal monitoring and ultrasound after experiencing an electric shock. Tympanic membrane rupture is a commonly noted blast injury after a lightning strike. Cardiac resuscitation should follow ACLS guidelines and is more likely to be successful than your tyipcal cardiac arrest patient as the patient population is typically younger and without significant comorbidities. When determining destination, trauma centers take priority over burn centers if those sites are different. So that wraps up episode 22 - managing electrical injury in the emergency department. 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 credits. 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. And the address for this month’s credit is ebmedicine.net/E1118, 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!

Show Notes Disclaimer: This is the unedited transcript of the podcast. Please excuse any typos. 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 and we’ll be taking you through the August 2018 issue of Emergency Medicine Practice. Nachi: This month’s topic is one that Jeff has significant personal experience with from his college days. We’re reviewing Cannabinoids -- and emerging evidence in their use and abuse. Jeff: Um… that is definitely not true. I was actually a varsity rower in college... Are we still reviewing talking points together before we start recording these episodes? Nachi: Sometimes… Jeff: This month’s issue was authored by Mollie Williams, who is the EM residency program director at the Brooklyn Hospital Center. It was peer-reviewed by Joseph Habboushe, assistant professor at NYU and Nadia Maria Shaukat, director of the emergency and critical care ultrasound at Coney Island Hospital in Brooklyn, New York. Nachi: We’re going to be talking about the pathophysiology of cannabinoids, clinical findings in abuse, best practice management, differences between natural and synthetic cannabinoids, and treatment for cannabinoid hyperemesis syndrome. So buckle up and get ready. Jeff: As you’re listening through this episode, remember that the means that we are about to answer one of the CME questions from the end of the print issue. If you’re not driving while listening, be sure to jot down these answers and get your CME credit when we’re going through this issue.. Nachi: As of June 2018, there are 31 states, the District of Columbia, and 2 US territories that possess state and local-level laws allowing the use of cannabis medicinally or in recreational formulations. Marijuana actually maintains the highest lifetime use of an illicit drug used within the US. Jeff: There are a shocking 22 million past-month users of marijuana in the US, followed by pain relievers at 3.8 million, and cocaine at 1.9 million. Clearly, an important topic worth discussion, especially as synthetic products have become more widely available. Nachi: And worth noting -- Colorado, where medicinal and recreational marijuana use has been decriminalized and later legalized, has shown a nearly 2-fold increase in the prevalence of ED visits, which may be related to marijuana exposure. Jeff: Medicinally, cannabinoids are currently used in the treatment of chronic pain syndromes, complications of multiple sclerosis and paraplegia, weight loss due to appetite suppression in HIV/aids, chemotherapy-induced nausea and vomiting, seizures, and many other neuropsychiatric disorders. In fact, cannabis use has been documented for medical use dating as far back as 600 BC in West and Central Asia. Nachi: All of that being said though, there is an absence of high-quality reviews and evidence to support the use of cannabinoids for any of the indications you just mentioned. And the US DEA maintains cannabis as a Schedule I substance. Jeff: This DEA designation limits the ability to do research and obtain federal funding for such research. General lack of federal regulations on chemical content also leads to product variation, which may be a cause of increased incidences of accidental overdoses. Nachi: To attain the most up to date information for this article, Dr. Williams searched the PubMed and Cochrane Databases from 1950 to 2018. This produced predominantly case reports and retrospective studies. There were just a few randomized prospective studies -- not surprising. Jeff: Let’s get started with the pathophysiology. There are 3 cannabis species to be aware of: Cannabis sativa, cannabis indica, and cannabis ruderalis. Within these species, over 545 active cannabis-derived components have been described. Nachi: There are ten main constituents of cannabis sativa. Of these, 9-tetrahydrocannabinol (delta-9-THC) and cannabidiol (CBD) are found in the greatest quantities. The neuropsychiatric and addictive properties of cannabis are due primarily to the delta-9-THC. Jeff: THC and other cannabis derivatives work through the endocannabinoid system and other neuroregulators. The endogenous cannabinoid system has 4 components: (1) endogenous endocannabinoids, (2) receptors, (3) degradation enzymes, and (4) transport mechanisms. Nachi: There are two endogenous endocannabinoids to know about: anandamide (AEA) and 2-arachidonoyl-glycerol. Jeff: Cannabinoid receptors are broadly dispersed through the central nervous system, and to a lesser degree, also to other organ systems. Nachi: Because CB receptors are concentrated within the central nervous system, they exert the majority of their effects on the neuropsychiatric systems. And   -- yes that’s a double ding -- the cannabinoid 1 (or CB1) receptor is most responsible for cannabis-induced neuropsychiatric effects. Jeff: Interestingly, the anti-emetic effects and possible palliative properties of cannabis derivatives are thought to be secondary to the inhibitory effects on serotonin receptors and the excitatory effects on the transient receptor potential vanilloid 1 (or TRPV1).  More on TRPV1 later... Nachi: So far we have been talking about cannabinoids from the cannabis plant, but with cannabis being illegal in many states, there has been a growing emergence of synthetic cannabinoids. Synthetics were initially developed in the 1980s largely for research purposes. Jeff: Because the current DEA controlled substances schedule designations are based on original chemical names, synthetics have gained popularity as manufacturers are able to produce newer compounds and circumvent DEA designation as well as routine urine drug screening tests. Nachi: You may be familiar with some of the street names for synthetics -- like spice, K2, scooby snacks, black mamba, kush, and kronic. These can often be purchased over the internet or through specialty smoke shops. Jeff: Scooby Snacks, what a fantastic name, mooovingggg on… Synthetic cannabinoids often have greater affinity for the CB1 receptor than naturally occurring cannabinoids -- and synthetics can produce 100 times the effect. As a result, the presenting symptoms with synthetic intoxication can be difficult to differentiate from crystal meth or bath salt abuse. Nachi: Manufacturers sometimes use solvents and other contaminants. Clusters of toxic ingestions and deaths have occurred. Emergency clinicians need to be aware of this and should report suspicious events immediately. Jeff: For more on synthetic intoxications in the ED, be sure to take a look at the recent May 2018 issue of Pediatric Emergency Medicine Practice on Synthetic Drug Intoxication in Children if you haven’t already read it. Also, just a quick FYI - If you’re not a current subscriber to Pediatric Emergency Medicine Practice, we’re giving away a free copy of the issue specifically for our listeners. Just head over to ebmedicine.net/drugs for the PDF of the issue. Nachi: A free issue for our listeners, that’s nice! Let’s move on to a discussion about current indications for cannabinoids. So, there is no clear consensus on these indications, but there is some research of varying quality that supports the treatment of some chronically debilitating diseases with cannabinoids. Jeff: A systematic review and meta-analysis from 2015 found low-quality evidence to support cannabis therapy for appetite suppression in HIV and aids patients; moderate-quality evidence for treatment of chronic pain and spasticity; and also moderate quality evidence for some chronic debilitating diseases. Nachi: While talking about evidence-based medicine here, another review by the National Academies of Science, Engineering, and Medicine on possible associations between cannabis and cancers arising in the lungs, head, and neck, or testicles -- showed no statistically significant associations exist. Jeff: So in case that wasn’t clear - the overall evidence to support cannabis therapy, in general, is weak. Also, be aware that there are various formulations of cannabis that allow for different routes of administration. We’re talking oils, tinctures, teas, extracts, edibles like candies and baked goods, parenteral formulations, eye solutions, intranasal, sublingual, transmucosal, tablets, sprays, skin patches, topical creams, rectal suppositories, and capsules -- just to name, a few. Nachi: A few! That seems pretty complete to me. Basically, any way you can imagine, it seems like a route of administration has been explored. But of importance, these formulations have different absorption times -- as you might expect. The shortest duration to peak plasma levels of delta-9-THC is through the inhalation route, which can produce effects within 3 minutes. On the longer end, rectal cannabis administration can take up to 8 hours to reach peak plasma concentrations. Jeff: Let’s talk about some of the clinical findings and systemic effects associated with cannabis use. First up is the link between cannabis use and stroke or TIA. Cannabis users who smoked at least once weekly had a 3.3 times higher risk of stroke or TIA. Nachi: And there is moderate quality evidence that this link may be dose-dependent. Larger amounts of cannabis use lead to cerebral vasospasm and a reduction in cerebral blood flow. Jeff: In terms of psychiatric effects, several low-to-moderate quality studies have shown statistically significant associations between psychosis and self-reported cannabis use. Some association between high potency cannabis or synthetic cannabinoid use with new-onset psychosis or relapse in previous psychiatric disorders has also been found. Lastly, there is weak data supporting a correlation between cannabis use and depression. Nachi: From a cardiovascular standpoint, cannabis use is associated with increased resting heart rate, hypertension, and decreases in the anginal threshold for patients with chronic stable angina. A 2001 study described an augmented risk of myocardial infarction within the first hour of cannabis use and found an almost 5-fold increase in those who reported smoking cannabis at least weekly when compared to those who smoked monthly or less. Jeff: Dysrhythmias, qt prolongation, av blocks, myocarditis, and sudden death have all been reported with cannabinoids. Nachi: In terms of pulmonary effects, these are not really related to cannabis use directly, but rather the smoke inhalation and combustion materials of synthetic cannabinoids. Effects from chronic use can be seen. Jeff: Renally speaking, acute kidney injury and rhabdomyolysis are associated with synthetic cannabinoids and have been observed in several case reports. The rhabdo is believed to be due, in part, to associated seizures, muscle tremors, and agitation. Nachi: Among metabolic abnormalities, patients can present with hyperthermia, hypoglycemia, hypokalemia, hyponatremia, and metabolic acidosis. Jeff: Orally and dentally, dry mouth is the most common finding in acute cannabis toxicity. Chronic use has also been linked to severe periodontitis. Nachi: And ophthalmologically, there is, of course, the commonly seen conjunctival injection. Cannabis has also been found to decrease intraocular pressure when used topically -- and of note, there have also been rare reports of acute angle closure glaucoma and central retinal vein occlusion. Jeff: While talking about clinical findings and systemic effects of cannabis use, we certainly need to go over cannabinoid hyperemesis syndrome (or CHS), which is -- quite simply put -- associated with frequent visits to the ED in chronic users. It presents with nausea, vomiting, and abdominal pain. Nachi: CHS is commonly misdiagnosed as cyclical vomiting syndrome. After the legalization of marijuana in Colorado, it was reported that nearly twice as many patients had presented for what was thought to be cyclical vomiting syndrome. And ironically, though cannabis has been used as an anti-emetic, chronic use can cause the opposite reaction, leading to CHS, which is typically refractory to traditional anti-emetics. Jeff: And the etiology of CHS is not well understood. Similarly, the exact criteria for CHS are poorly defined. It presents as a recurrent and relapsing disorder that can be divided into 3 phases: prodromal, hyperemetic, and recovery. Nachi: In the prodromal phase, patients complain of early morning nausea without vomiting, and they can have mild abdominal discomfort. This can last from months to years. In the hyperemetic phase, patients complain of severe, unremitting abdominal pain with repeated episodes of vomiting and retching. This is often associated with an inability to tolerate po. Jeff: The hyperemetic phase lasts 24-48 hours and can lead to dehydration, electrolyte abnormalities, and weight loss. Patients may learn to relieve symptoms by compulsively bathing in hot water. Nachi: Resolution of symptoms is seen when the patient stops using cannabis. This is during the recovery phase, which can last from days to months. But this can be short-lived if the patients begin using cannabis again. Jeff: On that note, we should also touch on cannabis withdrawal. Termination of heavy and habitual use can lead to withdrawal syndromes within 48 hours. Symptoms here include irritability, anxiety, restlessness, sleep difficulty, seizures, and aggression. Medications that can be helpful include benzodiazepines, neuroleptic agents, and quetiapine in refractory cases. Nachi: Moving on to the next sections in the article, let’s talk about differential diagnosis and prehospital care. The differential for acute cannabinoid intoxication, as you might suspect, is broad, and it includes some life-threatening processes. We won’t list them here, but be sure to think broadly before deciding on cannabis as the cause of your patient’s symptoms. Jeff: For the prehospital providers -- care here is mainly supportive. Provide airway protection as needed - gather information from the patient’s environment, looking for empty pill bottles or another empty packaging. Nachi: Let’s move on to care once in the ED. All patients who are in distress and suspected of drug ingestion should be disrobed completely and placed on a cardiac monitor. Fully assess for trauma and place an IV in the patient. Search the patient’s clothing for drugs and paraphernalia, which may help in making the diagnosis. Jeff: When getting a complete history from the patient, it may also be worthwhile to talk with any persons accompanying the patient to the ER for more information. In your history, be sure to ask about a pattern of use and possible co-ingestions. Nachi: When considering cannabis hyperemesis syndrome, a detailed history and physical exam are crucial for making the diagnosis. To differentiate between other etiologies of abdominal pain and vomiting, be sure to ask about the use of hot baths for relief, resolution of symptoms after stopping cannabis use, and the predominance of symptoms in the morning hours. Jeff: On physical exam, for cannabis intoxication, there isn’t a particular toxidrome to look for. Monitor vital signs closely, looking out for alterations in blood pressure and heart rate. A complete neurologic and mental status examination will be the key here. Nachi: Decisions for lab testing should be dependent on the patient’s presentation. Possible tests include CBC, BMP, LFT’s, lipase, cpk, ckmb, troponin, urinalysis, urine drug screening, serum tox screens (for alcohol, aspirin, and acetaminophen), and any other drug levels for medications that the patient is taking for medicinal purposes, like phenytoin or lithium levels. Jeff: One study supported point of care urine drug testing in the ED. However, know that acute cannabis intoxication can be difficult in the chronic user, as delta-9-THC will be present in urine for up to 24 days. Testing for synthetically derived cannabinoids is difficult due to changes in synthetic compounds. Nachi: Interestingly, there are a number of medications that are associated with false positive cannabinoid screenings. These include ibuprofen, pantoprazole, efavirenz, and lamotrigine. Jeff: For any patient arriving with suspected cannabis or synthetic abuse, consider checking an EKG. You’re looking for signs of ischemia, arrhythmia, and interval abnormalities. Serum and urine tox tests are not particularly helpful in the acute chest pain patient who is using synthetic marijuana. Nachi: Not surprisingly, there are no specific diagnostic imaging modalities to help diagnose cannabis or synthetic cannabinoid intoxication. But imaging may help with assessing other disease states on a patient’s differential, so stay mindful of that. Jeff: Now that we’ve talked about history, physical exam, and useful testing modalities, let’s talk about treatment for cannabis and synthetic cannabinoid toxicity… therapy is primarily focused on supportive care. Most ED visits only require a short stay. Nachi: That’s right, there are no antidotes to give for treatment here. Be sure to look for and treat dehydration, acute renal failure, and rhabdo though. In severe cases of neuropsychotropic effect, give benzodiazepines, like lorazepam, to help with control. Jeff: For GI effects, first-line treatment is traditional anti-emetics like ondansetron or metoclopramide. Recent literature and case reports have shown significant improvement with butyrophenones like haloperidol as a second-line treatment. Nachi: While talking about treating the gastrointestinal effects of cannabis toxicity, let’s also discuss methods to control cannabinoid hyperemesis syndrome. The mainstays for treatment here are actually supportive therapy and cessation of cannabis use. Jeff: And can you tell us more about why these patients crave hot showers and improve after? Is there a pathophysiology or mechanism to know about there? Nachi: There is a well-studied theory here and it relates to the TRPV1 receptor that we talked about earlier. Temperatures in excess of 109 degrees Fahrenheit, acidic conditions, and compounds found in certain foods and plants (like cannabis) activate this receptor. It’s believed that intermittent and repetitive exposure to agonists of the TRPV1 receptor leads to a persistent state of nausea and vomiting. Desensitization of the receptor happens after repeated stimulation, and repetitive topical capsaicin or hot water is believed to function as an exogenous agonist. Jeff: In any case of repetitive emesis, be sure to consider electrolyte replacement if needed. In many cases, hydration or repletion will need to happen through an IV. Proton pump inhibitors can also help in some cases where GI symptoms are a dominating complaint of the patient. Nachi: Recent literature supporting the use of haloperidol for nausea and vomiting has found that symptoms improve approx 1hr after administration. This can decrease the need for observation or admission. Jeff: Haloperidol works via dopamine 2 receptor antagonism. D2 receptors are found in high concentrations throughout the nervous system and bind with high affinity to haloperidol. The suggested starting dose is 2.5mg IV with a repeat dose of 5mg IV if needed. An RCT is underway in Canada on the use of ondansetron versus haloperidol with an estimated completion of July 2019. Nachi: Capsaicin has similarly shown promise in cannabis hyperemesis syndrome through the TRPV1 receptor as we discussed already. Currently, there are no dosing recommendations or application instructions for capsaicin. There is some evidence supporting relief within 30 to 45 minutes, and capsaicin can be applied topically to any nonmucosal surface like the abdomen, chest, or back. Jeff: So to recap -for cannabis hyperemesis syndrome, treat with anti-emetics, PPI’s, electrolyte repletion, and IV hydration as needed. As a second line treatment, consider haloperidol and topical capsaicin applied to the chest, abdomen, or back. Nachi: Let’s talk about some special populations next -- starting with Pediatrics. According to data from 2012, of the 130 million people reporting illicit drug use within their lifetime, 25% were children between 12 and 17 years of age. Jeff: And according to the national poison data system, states with marijuana use laws have seen a 30% increase in calls related to marijuana use by children. From 2010 to 2011, the number of ED visits by children aged 12 to 17 years old due to synthetic cannabinoid use also has doubled. Nachi: Many children and adults believe that synthetic cannabinoids don’t pose serious health risks, as these are not illegal to purchase. And this class of drugs is particularly attractive to adolescents since it will not readily test positive on urine drug tests. All of this is very concerning for emergency clinicians. Jeff: There have been several recent reports of myocarditis in association with marijuana use. One case resulted in death due to myocyte necrosis after an unknown amount of edible marijuana was consumed by a toddler. Nachi: Horrific! Jeff: And the exact mechanism through which the myocardial necrosis happens isn’t known. Nachi: For all children and adolescents who present to the ED with alteration in mental status, psychosis, or chest pain -- be sure to screen for cannabis or synthetic cannabinoid use.  There are case reports in the pediatric literature of STEMIs seen in patients without pre-existing cardiac disease or risk factors. Jeff: Keep in mind that urine drug screens can be falsely positive from certain proton pump inhibitors, so if possible, assess a urine drug screen prior to starting a PPI in these patients. Nachi: Moving on to our next special population… pregnant women. Know that it can be difficult to the differential between hyperemesis gravidarum and cannabis hyperemesis syndrome in pregnant patients. Ask specific questions regarding marijuana use before and during the pregnancy. Jeff: It’s also worth noting that cannabis is known to cause adverse outcomes on babies such as low birth weight and more frequent perinatal ICU placement. Nachi: Let’s move on to the final major section of the article, which is on the legal status of cannabis and cannabinoids. Much of the controversy surrounding cannabis for medicinal use relates to the absence of quality evidence. More research is needed to evaluate potential public health risks posed by variations in quality and potency, potential impact to our healthcare system, and ability to legislate for synthetic cannabinoids. Jeff: Though marijuana and all whole-plant derivatives are schedules I controlled substances, there are a few cannabinoid-based drugs approved by the FDA for medicinal purposes -- with lower schedule designations. Dronabinol is a schedule III drug derived synthetically from delta-9-THC. It’s used in chemotherapy-induced nausea/vomiting, as well as anorexia and weight loss from AIDS/cancer. Nachi: Nabilone, a schedule II synthetic variant of THC, has been approved in the treatment of aids-related anorexia and chemotherapy-induced nausea also. Jeff: Nabiximols, a plant-derived cannabinoid, has been approved in Europe and Canada for multiple sclerosis induced spasticity and cancer-related pain. Nabiximols are not yet approved in the US. Nachi: And lastly, we should mention cannabidiol, which is a schedule I controlled substance approved for treatment of seizures with 2 rare diseases -- Lennox-gastaut syndrome and dravet syndrome. Compared with placebo alone cannabidiol and other medications have shown efficacy in lowering the rate of seizures for these diseases. Jeff:  Lots of interesting stuff to look out for there in cannabinoid-related medications. Alright, on to disposition - Nachi: Most patients who present with uncomplicated acute cannabis or synthetic cannabinoid intoxication can be observed until clinically sober. Discharge home should be in the care of a sober family member or friend. Make sure that the patient knows not to operate vehicles or heavy machinery under the influence of drugs. Counsel them on drug abuse also. Jeff:   In more rare situations, patients will require admission. Consider this particularly for patients who have end-organ damage, rhabdomyolysis, acute renal failure -- evidence of cardiovascular, cerebrovascular, or ophthalmologic insults -- intractable vomiting, or acute psychosis. Nachi: And for cannabinoid hyperemesis syndrome, patients may require admission for IV hydration and electrolyte correction. Once the patient is tolerating PO and lab derangements have been corrected, they can be discharged. Jeff: Let’s wrap up the episode with key points and clinical pearls… N: Marijuana is the most commonly used illicit substance in the US. States that have legalized marijuana for medical and recreational purposes are showing increased rates of marijuana abuse and dependence. J: When concerned with drug intoxication, search your patient’s clothing for drugs and paraphernalia on arrival. N: The neuropsychiatric and addictive properties of cannabis are due primarily to delta-9-THC. J: Synthetic cannabinoids have gained popularity as manufacturers are able to produce newer compounds and circumvent DEA designations as well as routine urine drug screening tests. N: Manufacturers of synthetic cannabinoids sometimes use solvents and other contaminants, which have caused clusters of toxic ingestions and death. J: The shortest duration to peak plasma levels of delta-9-THC is through the inhalational route. Effects can be seen within 3 minutes. N: Cannabis users who smoke at least once weekly can have a 3.3 times higher risk of stroke or TIA. J: The risk of myocardial infarction is increased within the first hour of use, and there is an almost 5-fold increase for individuals who smoke at least once per week. N: Acute kidney injury and rhabdomyolysis have been noted with synthetic cannabinoid use in several case reports. J: Cannabis intoxication is associated with many metabolic abnormalities like hyperthermia, hypoglycemia, hypokalemia, hyponatremia, and metabolic acidosis. N: Cannabis hyperemesis syndrome, which presents with abdominal pain and vomiting, is associated with frequent visits to the ED in chronic users. J: The mainstay for treatment of cannabis hyperemesis syndrome is supportive therapies and cessation of cannabis use. N: Patients with cannabis hyperemesis syndrome crave hot showers because of activation of the TRPV1 receptor. J: Topical capsaicin may also help in the treatment of cannabis hyperemesis syndrome through activation of the TRPV1 receptors. N: Haloperidol at 2.5mg IV may help in refractory vomiting associated with cannabis hyperemesis syndrome. J: Many children and adults do not believe synthetic cannabinoids pose serious health issues as the they are not illegal to purchase. This is incorrect. N: Most patients with acute uncomplicated cannabis intoxication can be observed and discharged. Admit if there are any signs of end organ damage, intractable vomiting, or acute psychosis. Jeff: So that wraps up the August 2018 episode of Emplify. Nachi: For those of you looking for CME - the address for this months credit is ebmedicine.net/E0818, so head over there right away to get the credit you deserve.  Remember that the you heard throughout the episode corresponds to the answers to the CME questions. Jeff: And don’t forget to grab your free issue of Synthetic Drug Intoxication in Children at ebmedicine.net/drugs specifically for emplify listeners. Feel free to share the link with your colleagues or through social media too. See you next time! Most Important References 5. * Kim HS, Monte AA. Colorado cannabis legalization and its effect on emergency care. Ann Emerg Med. 2016;68(1):71-75. (Literature review; 21 studies)7. * Baron EP. Comprehensive review of medicinal marijuana, cannabinoids, and therapeutic implications in medicine and headache: What a long strange trip it’s been …. Headache. 2015;55(6):885-916. (Review)9. * Whiting PF, Wolff RF, Deshpande S, et al. Cannabinoids for medical use: a systematic review and meta-analysis. JAMA. 2015;313(24):2456-2473. (Retrospective chart review; 4 cases)64. * Tournebize J, Gibaja V, Kahn JP. Acute effects of synthetic cannabinoids: update 2015. Subst Abus. 2016:1-23. (Systematic review; 46 articles, 114 patients)83. * Wallace EA, Andrews SE, Garmany CL, et al. Cannabinoid hyperemesis syndrome: literature review and proposed diagnosis and treatment algorithm. South Med J. 2011;104(9):659-664. (Review)