• Intro to EDH¹

• Room 9 Follow up with Dr. Whitford
  1. -Thyrotoxic Periodic Paralysis is an extremely uncommon but high mortality condition (80-100%) complication of thyrotoxicosis
  2. -Replete potassium aggressively. Avoid steroids if possible. Can give propanolol in conjunction for those patients refractory to potassium repletion
  3. VV ECMO for patients primarily with ARDS or inability to oxygenate/ventilate. VA ECMO for patients in acute cardiogenic shock

• Social Work in the ED

– Common misconceptions is that social work in the ED is able to find housing for homeless patients

– Social work is able to pay for some low cost medications for patients and help with some DME during business hours (things like ostomy supplies not covered)

– Also can help with transportation to substance use disorder clinics

• Survival Guide to the Peds ED

– Complete your notes on time (within 24 hours). Recognize sick vs not sick. Utilize complaint order sets to your advantage

-Heme/Onc, NES admit to themselves. Very select pediatricians will admit to themselves. Only fellows and attendings call to give report on PICU patients

-FiO2 50-60% and 2L/kg for HHFNC in kids is threshold for PICU

-Pay attention to vaccination status. Certain febrile neonates will automatically get an LP and septic workup compared to other kids

-White hot is a febrile chemo patient.Red hot is a febrile neonate

-Straining does not mean constipation in newborn population. Be careful about putting words toxic/lethargic/irritable in note unless you’re intubating, performing LP, or resuscitating. Describe in your note and paint picture of what kid looks like (high fiving, smiling, interactive, etc)

• Cardiac Pacing¹

-Indications: unstable bradycardia, SSS with frequent pauses

-Can do both transcutaneous and TVP. Start with TC pacing but prep for TV pacing. Can place pads anterolateral or anteriorposterior

-TC pacing: Select pacer function, select rate (typically around 70), set current and look for capture. Can increase current until you get capture by 10 mA equivalents. If youre getting to 120 mA without capture, consider replacing pads. Capture will look like QRS complexes on tele after each pacer spike. Make sure you have mechanical capture as well (palpable pulse, BSUS)

-TV pacing: Set up on generator has three knobs: rate, output, and sensitivity. 80/20/20 is typical initial set up for asynchronous pacing.

-TV pacing: First step is placing Cordis (preferably R IJ). put sterile sheath on pacer wire and have non-sterile assistant attach connecting cables to generate. insert the swan pos and neg pins then insert swan into cordis and go to about 20 cm and stop. then you inflate balloon, and advance until you get capture. once you get capture, decrease output until you lose capture and then incr to lowest effective output.

• How to Break Bad News²

– Be aware of the setting and perception of family members when you are delivering bad news. You want to know what they already know before you talk to them. Invite them to explain how much they want to know

-Don’t use medical jargon. Allow time for frequent pauses. Use chaplains and their services, they will typically tell you ahead of time who is in the room and what/how much they know

1. ↩︎
2. ↩︎

Healthcare Disparities in the ED:

• -amongst persons experiencing homelessness (PEH), the rates of mental illness and substance used disorder is disproportionately higher compared to the non-PEH group
• – Implicit bias still affects medical care in the US today; black individuals are less likely to receive urgent triage score or to be admitted to the hospital for their complaints.
• – It has been well studied that patients receive better care and have better health outcomes when cared for by doctors who share similar identities in race or gender
• – Try to use preferred names and pronouns. Don’t ask intrusive questions or perform intrusive exams when not indicated. Be compassionate.
• – healthcare costs associated with undocumented immigrants (UI) largely felt by the ED. EMTALA applies to UI as well as documented immigrants.

• How to Give and Receive Checkout:
• – A TOC occurs when >2 providers exchange info about a pt. Happens more than you think
• -In a TOC, be clear, brief, timely and complete. Check your bias. Give the oncoming residents time to ask questions
• – Use IPASS mnemonic when transitioning care between providers
• – Check out your sickest patients first
• – Consult with a purpose and a specific request/question

I posted this paper and it’s revisited update on room9er about 3 years ago. July is always a good time for it!

Here is the original paper.

Here is the update.

The fundamentals do not change much!

Palliative care-

• Who- patients w/ end stage diseases, AIDs, malignancy, multi-organ failure, devastating injuries.
• Benefits to patients- improves quality of life, avoids undesired interventions.
• Benefits to providers- aids with burnout and staying focused on what patient would want.
• Symptom management- pain, dyspnea (opioids are first line, delirium, constipation.

DNR/DNI-

• Advanced directive indicating what patient would want from a care perspective.
• Otherwise consider POAs and next of kin.

Special Populations in the ED-

• Patient’s with intellectual disability: Consider barriers to health including physical, communicational, attitudinal, transportation, financial.
• Patient’s whose primary language is another language.
• Patient’s involved human trafficking.  Always be mindful of red flag signs.
• Elderly patient’s or those affected by dementia/cognitive decline.
• Patient’s affected by housing insecurity.

Systemic infections in children-

• Measles (Rubeola): symptom 10-14 days after exposure with cough, coryza, conuctivitis, Koplik spots.  Rash starts on face, spreading down, including palms and soles. First vaccine at 12 mo. Treatment = supportive.
• German measles (Rubella): symptoms include low grade fever, headache, sore throat and lymphadenopathy (post auricular). First vaccine 12 mo.  Treatment = supportive.
• Varicella: symptoms include fever, cough, rash with vesicular lesions at different stages of healing.  First vaccine at 12 mo. Treatment = supportive.
• Erythema infectiosum: nonspecific viral prodrome with slapped cheek rash caused by parvo. Treatment = supportive.  Most dangerous for sickle cell patients and pregnant patients.
• Roseola: characteristic pattern of high fever followed by rash, starting on trunk and spreading outward, caused by HHV6.  Treatment = supportive.
• Hand- foot- mouth disease: non specific viral symptoms with rash, caused by cocksackie.  Treatment = supportive.
• Papular acrodermatitis: immunologic response resulting in pruritic, popular rash in acral distribution often caused by EBV or hep B. Treatment = supportive.
• Scarlet Fever: sandpaper rash which is blanching and popular in the setting of Group A strep. Treatment = amoxicillin x 10 days.
• SSSS/TSS: peeling beefy red skin around moth, armpits, groin.
• Pediatic sepsis: consider the incredible ability to compensate in children.  Be wary of tachycardia not improved by bolus (up to 60 ml/kg of isotonic crystalloid).

Operations updates-

• East wing annex transitions to come May/June.
• Obs unit within the next year.
• 85% on sepsis compliance.

Restraints and Violent Patients:
• Agitation may be caused by a number of reasons including head trauma, hypoxia, infection, delirium, ingestion, psychiatric disorders. Always consider medical causes.
• Deescalating:
o Verbal- be honest and straightforward without be confrontational or threatening.
o Physical restraints- soft restraints, four-point, chest.
o Chemical sedation- offer voluntary administration with medications including IM ketamine, droperidol, haloperidol, midazolam and lorazepam.

Homelessness:
• Rates of homelessness are climbing within Louisville and the US.
• Patients experiencing homelessness are more likely to visit the emergency department.
• What can we offer? Respect, housing/shelter options, considerations to cost, complexity and availability of treatments


US Images:
• Chiari network: embryonic remnant of the sinus venosus which remains in the right atrium and is a benign finding.
• Use US for shoulder blocks with dislocations: palpate spine of scapula, marching out laterally to the acromion. After finding the posterior, inferior edge of the acromion, move two finger widths inferior and medially and inferiorly with injection directed forward towards to the coracoid process. Use 18 G spinal needle injecting 10-20 cc of lidocaine.
• Use US to confirm abscess before incision and drainage. Cellulitis is a clinical diagnosis but seeing a heterogenous collection on US.

Obesity in the ED:
• Obesity is a rising concern, especially in developed countries. Patients suffering from obesity are at increased risk of DM, CVD, HTN, HLD.
• BMI is a measuring tool which compares weight and height but may be lost to the favor of waist to hip ratio when describing obesity.
• Obesity in the ED:
o General interactions- ask permission to discuss weight, use “people first” language, consider bias, provide basic nutritional information, consider food insecurity and provide resources, referrals for physical activity and PCP.
o Airway- obesity creates different challenges regarding airway in the ED. Patients suffering from obesity have decreased respiratory reserve and decreased tolerance for apnea as well as increased airway pressure causing small ox reserve, increased work of breathing, higher risk of aspiration.
o Circulation- be sure blood pressure cuff is appropriately fitting and consider early arterial line. If venous access is difficult to obtain, consider using ultrasound guided lines as well as intraosseous lines.
o EKGs- findings more common in obesity include low voltages, longer QT intervals (not greater than 500), signs of LVH.
o Trauma considerations- more likely to have indeterminate FASTs, xrays are often underpenetrated, and CT scanners do have weight limits.

Tuberculosis by Dr. Marks

Incidence decreasing in the US

Latent TB infection approx. 5% in US. 25% in world

PPD screening:

If >5 mm PPD and immunocompromised = positive

If >10mm and been to high risk country, healthcare worker, or IVDU =positive

Otherwise >15mm = positive

Primary TB usually asymptomatic,

If suspect TB, isolate

Sputum PCR

Gold standard is cultures (6-8wk turnaround)

For latent TP rifampin+isoniazid +pyridoxine for 3 moths

For active TB:

RIPE therapy  8 weeks

Rifampin ,  (orange urine, CP450 induction)

isoniazid,  (B6 deficiency, seizures)

pyrazinamide (hepatotoxicity, hyperuricemia)

Ethambutol (optic neuritis)

Then rifampin/isoniazid for 18 more weeks

TB meningitis- RIPE + dexamethasone

Potts- RIPE + source control

Syphilis by Dr. Coffman

Incidence increasing since 1990.

Increasing in women. Congenital cases increasing.

Primary, Secondary, Tertiary

Painless ulcer on mucus membranes, rash involving hands and feet +nonspecific symptoms,

Jarisch Herxheimer reaction – treat symptoms with tylenol.

PEM: Endocrine by Dr. Magloire

DKA: defined by hyperglycemia, metabolic acidosis, and ketosis

30-40% are new onset T1DM

Risk factors include age <5, reduced access to medical care

Anorexia, N/V, abdominal pain, hyperventilation, dehydration

Often precipitated by missed insulin, acute illness, medications (steroids, antipsychotics)

Assume fluid deficit of 5-10%

Initial fluid bolus then 2 bag method over 24-48

Beware of cerebral edema. Treat with mannitol if developing

Avoid central lines due to increased risk of DVTs

Hypoglycemia:

Children and infants can have quicker shifts in glucose due to high metabolic demand and difference in gluconeogenesis.

If conscious, give 15 g of carbs (juice, glucose tabs etc)

IV D10 bolus if needed

If altered give 2-5ml/kg of D10 bolus, repeat and start infusion if needed

Adrenal Crisis:

Consider in known CAH, hypothalamic axis disorders, prolonged corticosteroid use, other autoimmune disorders, critically ill patients unresponsive to pressors, or neonates with atypical genitalia electrolyte abnormalities, hypoglycemia, hyperpigmentation, cushingoid features

Hyponatremia, hypoglycemia, hyperkalemia

Treat with hydrocortisone 50-100mg/m2 (25mg if <3yo, 50mg if 3-12 yo, 100mg if 12+yo)

Treat hyperkalemia if needed.

Tick-Borne Disease by Dr. Buchanan

Prevention is best

DEET and permethrin

DEET on skin, permethrin on clothes (last 6-8 weeks)

Combination of both decreased mosquito bites by 99%

Remove ticks >36hrs just use forceps.

Lyme – erythema migrans, vector is Ixodes, classic “target” rash. Disseminated disease in 60% if untreated

If bilateral bell’s palsy, treat for Lyme disease

If high clinical suspicion, can use IFA or EIA for testing

IgG +IgM if <1 month from exposure

Doxy+ceftriaxone  if neuro symptoms

STARI – southern tick associated rash illness

Causative organism unknown. Lone Star Tick

Probably best to treat as Lyme

Rocky Mountain Spotted Fever –

Maculopapular rash involving hands and palms. Flu like symptoms

Hyponatremia, transaminitis, thrombocytopenia

Rickettsia Rickettsii

Dermacentor sp. (wood tick or dog tick)

Clinical diagnosis, confirmed with IFA/EIA

Rickettsia Parkeri Rickettsiosis-

Inoculation eschar. Similar labs findings. Less severe disease. Gulf coast ticks

Erlichiosis-  Erlichia sp.

Lone star tick

Flu-like symtpoms

Leukopenia, hyponatremia, transaminitis

Whole blood PCR (most sensitive if <1week).

Otherwise IgG trending

Anaplasmosis –

Ixodes tick. More northeast than erlichiosis

Tick-borne relapsing Fever

Leukoytosis, thrombocytopenia, elevated bilirubin

recurring fevers. Every reccurence less and less severe

Borrelia sp.

Soft shell ticks are the vector. Western US.

Diagnoses with peripheral blood smear. Best checked during a fever.

Treatment for all the above is doxycycline

Babesiosis

Babesia microti. Vector is ixodes tick.

Fever, body aches, Scleral icterus, dark urine,

Transaminitis, anemia, thrombocytopenia, hyperbilirubinemia

Peripheral smear with intracellular organsisms, (maltese cross)

Treatment atovaquone +azithromycin OR Clindamycin + Quinnine

Tularemia

Franscisella tularensis

Vectors -Dermacentor and amblyomma spp.

Fevers, malaise, body aches.

Leukocytosis, thrombocytopenia, hyponatremia, transaminitis, sterile pyuria

Wound and glandular lymphadenopathy, conjunctivitis, oropharyngeal form. Pneumonic form, typhoidal form.

Confirmation by isolation of Tularensis (culture) or seroconversion (IgG/IgM) in paired sera

Treatment is streptomycin

Tick Bite prophylaxis

• Was it an ixodes tick? If no, no ppx
• Is it engorged or attached >36hr> if no, no ppx
• Has it been 72 hours since removal. If yes, no ppx
• Can they take doxy? If no, no ppx
• Is lyme endemic? If no, no ppx

Peds Pharm: PALS Drugs by Dr. Lucking

Bradycardia- atropine (min 0.1, max 0.5mg) epinephrine, treat as PEA if <60

Tachycardia-

• Sinus tach -treat underlying condition
• SVT- vagal maneuver, (ice to face), adenosine (proximal and fast) 0.1mg/kg
• Vtach- cardiovert, amio or procainamide
• Vfib- rare. Same as adults. Amio 5mg/kg

Epi spritzer

Used for brady/hypotension in a patient with a pulse to prevent cardiac arrest

Peri-intubation

0.001mg/kg (1/10 of a code dose)

RSI

If age <1 consider atropine as pre-medication

Historically, lidocaine was given for ICP, however this has fallen out of favor

Fentanyl 1mcg/kg max dose 100mct. Immediate onset, 30-60min duration

Midazolam 0.1mg/kg max 5mg. onset 3-5 mins. Duration <2 hours

Ketamine 2mg/kg. onset 30 seconds. Duration 5-10mins. Contraindicated in <3mo age

Etomidate 0.3mg/kg. does not provide analgesia. Can reduce sz threshold.

Propofol 1-2mg/kg.

Rocuronium 1mg/kg. duration 26-46 minutes

Succinylcholine 1-2mg/kg, hyperkalemia, malignant hypothermia

Endocrine Disorders (Kuzel)

• Hyperthyroidism:
• I.e. Graves Disease (most common), Toxic Multinodular goiter, Thyroiditis, Hashimotos (initially hyperthyroid, followed by hypothyroid) 
• Thyroid storm:
  • 15-50% mortality with tx (80-100% without) 
  • How they die: cardiac dysrhythmias, CHF, hepatic failure, hypotension, cardiovasc collapse
  • Tx: beta blocker (propranolol), thioamide (TPU/methimazole), steroid, iodide; avoid NSAIDs since they increase peripheral thyroid hormone conversion
  • PTU is Preferred because it has earlier onset and safe in Pregnancy 
• Hypothyroidism:
• Most commonly autoimmune, thyroiditis, iodine deficiency, post-ablation, panhypopituitarism 
• Euthyroid sick syndrome = low thyroxine syndrome w/ low or normal TSH, seen in critically ill pts
• Myxedema Coma:
  • 30-60% mortality
  • Often precipitated d/t sepsis, CHF, CVA, hypoxia, ACS
  • SLOW and SWOLE sx = bradycardia, hypotension, hypothermia, myxedema 
  • Tx: steroid, levothyroxine (be careful of dysrhythmias, ACS – give if hypotensive/altered)
• TSH can be helpful in NH patients w/ rapid decline and sx of hypothyroidism, & septic patients w/ refractory shock

Case Review (Loche, McGowan)

• AV fistula – most commonly in anterior forearm/upper arm, needs time to mature (6-12 mo) 
• Eval: should feel thrill; if you don’t feel thrill/pulse, assume thrombosis (get US/doppler) 
• AV fistula bleeding management:
  • Pinpoint pressure, can use bottle cap over bleed to let it clot off, use other adjuncts prn (surgicel, TXA, gelfoam)
  • Figure of 8 suture – DO NOT tie off vessel (damages fistula), just suture the superficial skin with non cutting suture 
  • If heavier bleeding, then do purse string suture 
  • If successful, have them move arm around, make sure it doesn’t rebleed, observe 1-2 hours
  • If you had to suture it or if any other major problems, you should give vascular surgery a call 
• Fistule thrombosis – loss of bruit/thrill, palpable clot
  • Management: Discuss with vascular, may or may not need emergent intervention, may get balloon angioplasty or thrombolysis 
• Pseudoaneurysm/aneurysm – bulging of vessel in outer wall (pseudo) or all layers (true) – get ultrasound, talk with vascular 
• Infection – much higher risk, especially if deeper infxn, need admission for IV abx, call vascular 

Supplements (Huecker) 

• Kefir should be first food of day – lots of good probiotics and vitamins 
• Daily supplement essentials: magnesium!, sunshine/VitD, vit K2, vit C, and iodine 
• Mag threonate is Huecker’s favorite form, oxide is trash; at least 200mg of elemental Mg/day 
• Labdoor.com is a good third party supplement tester
• Vitamin D: Most people need 3000-5000 IU in winter time, or 20 min in sun (if arms, legs, face exposed)
• Vitamin K2: helps prevent fractures, cancer incidence, neurocognitive fx 
• Fish oil: higher ratio of omega 3:6 is better, eating fish is best way to get it

Wernicke/Korsakoff (Blair)

• Wernicke = acute neuro change from thiamine deficiency = triad of encephalopathy, oculomotor dysfunction, gait ataxia 
• Korsakoff = chronic sx = antero/retrograde amnesia, confabulations, confusion, apathy 
• Thiamine important in energy production, lipid metabolism
• Most often d/t insufficient intake (alcoholism, starvation/anorexia, etc.), but also from malabsorption, increased metabolic requirements
• Tx: give thiamine (before glucose if they need that too), also give magnesium (as they’re usually hypomagnesemic)

Pheochromocytoma (Mattingly)

• Increased catecholamines d/t rare tumor in adrenal medulla
• Associated with familial syndromes (MEN 2A and 2B)
• Presentation: only 50% are symptomatic with episodic headache, tachycardia, diaphoresis
• Low vs high risk workups, but overall looking for (urine or plasma) metanephrines and catecholamines, if positive then get CT adrenal protocol or PET (usually inpatient side) 
• Treat hypertensive crisis with alpha-blockade (phenoxybenzamine or phentolamine), nitroprusside, or nicardipine; don’t give beta-blocker d/t risk of unopposed alpha activity! Eventually need tumor resection
• Be aware in ED of tumor recurrence even after tumor resection; avoid meds that cause crisis (BB, glucagon, histamine, reglan, corticosteroids)

Pharmacology in Hyperglycemic Crisis (Loudermilk) 

• Be aware of long vs short acting insulin > regular insulin drip is what’s used in DKA 
• Oral/injectable diabetic medications: biguanides (metformin), sulfonylureas (-zides), TZDs (pioglitazone), SGLT2i (jardiance), DPP4 (januvia), GLP-1 agonists (ozempic, trulicity) 
• DKA management: IV fluid therapy with 15-20 mL/kg over 1 hour
• Current protocol does NOT have insulin bolus, so just start the drip 
• Bicarb drip not recommended unless pH < 6.9
• Current order set is only “MED DKA”, but we will soon have ED specific DKA order set includes fluids, insulin gtt, K replacement, labs/VBG/vitals 

Pediatric Seizures (Isacoff) 

• Focal/partial (with or without impairment of consciousness) vs generalized seizures
• ABG/VBG in post-ictal patients not normally helpful – it’s already going to look bad even if not having respiratory failure
• BVM more favorable if still unconscious but starting to wake up, try not to intubate unless absolutely necessary 
• Look for metabolic derangements: sodium, glucose
• Management: ABCs, fyi: succinylcholine contraindicated in suspicion for muscular dystrophy, use roc or vec 
• Anticonvulsant tx for seizure > 5 min: rectal diazepam (home), intranasal versed (0.2mg/kg max 5), or IV ativan (0.1mg/kg up to 4mg)… treat with benzo x3 times, then phenytoin/fosphenytoin or phenobarbital; consider pyridoxine (vit B6) in kids < 1 with refractory seizures 
• Consider CT/MRI if signs of increased ICP, focal/persistent seizure

Diabetic Emergencies (Kuhl)

• 500+ million people affected by diabetes in world
• Common physician pitfalls: delayed ID of DKA, insulin therapy mistakes
• DKA = hyperglycemia + ketones + acidosis (bicarb < 15 or pH < 7.3) 
• HHS = glucose > 600, serum osm > 320, absence of ketoacidosis, presence/absence of coma no longer part of diagnosis 
• Don’t really need ABG/VBG to diagnose DKA (it costs ~ $300), utilize your serum bicarb instead
• End tidal CO2: low for DKA (<21, 100% specific) (d/t increased RR), high then not in DKA (>35, 100% sensitive)
• IV fluid choice: LR better in septic and medicine patients (SMART trial), no significant difference in ICU patients (SALT trial); large boluses of NaCl in DKA has risk of hyperchloremic metabolic acidosis
• Insulin drip 0.1 units/kg/hr going until ketoacidosis is resolved (normalization of pH, bicarb, and closure of anion gap)… NOT guided by blood glucose 
• K management: losing K d/t osmotic diuresis or falsely elevated as it’s extracellular but not in cells; if <3.5 then hold insulin, add in IVF, 3.5-5.5 then start insulin but also give K in IVF, if  >5.5 then just start insulin and no need to supplement
• Pseudohyponatremia – Na decreases by 1.6 for every 100 increase in glucose 
• Most common cause of DKA in US is med nonadherence, infection is 1st outside of US
• Euglycemic DKA possible with SGLT2i
• Consider D10 instead of amp of D50, less caustic and better outcomes

R1 Lightning Lecture – Thyroid Storm (Dr. Perling):

• Thyroid storm: “extreme hyper metabolic state caused by increased thyroid hormone” 
• Most commonly caused by Graves disease 
• Burch-Wartofsky Point Scale is a tool that can help point to thyroid storm, though be cautious as it can be nonspecific (sepsis, etc.)
• Tx: active cooling if hyperthermic (can give Tylenol too); beta blocker > PTU/methimazole > steroid > wait 1 hour > iodine (in that order) 
• Manage other concomitant conditions accordingly: i.e. amio for a-fib, benzodiazepines or olanzapine for agitation

R1 Lightning Lecture – Addison’s and Cushing’s disease (Dr. Hudson)

• Addisons = low steroids, Cushings = high 
• Addisons: usually autoimmune, “low” symptoms like hypotension, weight loss, fatigue, hyperpigmentation
• Tx: lifelong corticosteroid replacement (hydrocortisone) 
• Adrenal crisis – give high dose corticosteroid, treat hypotension and glucose as needed 
• Cushings: chronic exposure to excess corticosteroids, “big” symptoms like weight gain, buffalo hump 
• Cushing syndrome (problem with gland) vs Cushing disease (problem with brain)
• Dx and management is usually inpatient/outpatient (not in ED): need urine 24 hour cortisol level, treat sequelae in ED as needed (glucose, electrolytes) 

R2 Small Group Cases (Dr. Beard)

• Case 1 – DKA: look for hyperglycemia, ketones, acidosis. Watch potassium and rapid fluid administration (cerebral edema)
• Case 2 – HHS: severe hyperglycemia usually without ketones; high serum osmolality. Treat with aggressive fluids. Mortality much higher than DKA. 
• Case 3 – Adrenal crisis: consider in patients with unexplained hypotension, watch electrolytes (hyponatremia, hyperkalemia), give corticosteroids. 
• Case 4 – Myxedema coma: hypothyroidism, mental status change, hypothermia, +/- precipitating factor (infection, med noncompliance). Tx with levothyroxine, corticosteroid, passive warming, and precipitating cause (sepsis). 

R3 Case Review (Dr. Hill-Norby)

• Pre-Eclampsia: new onset hypertension in pregnancy (usually > 20 wks or up to 4 wks post-partum)
• Diagnosis made by BP + proteinuria, or based on BP and presence of end-organ damage (severe features) without proteinuria
• Treat BP with labetolol, hydralazine, or nifedipine
• Treat seizures with magnesium!
• Needs urgent delivery

• Severe Hyponatremia – usually symptomatic < 120
• If seizing w/ known hyponatremia -> 3% hypertonic saline bolus (around 150cc), can use sodium bicarb amp if do not have hypertonic saline easily

• Pres syndrome

Diagnosis of exclusion

Keep in your differential 

Treat for hypertension, consider MRI

• MS

3 associated conditions – INO, optic neuritis, dysautonomia

• Spinal cord syndromes

Anterior cord – hyperflexion

Central cord – hyperextension, elderly

Brown sequard – stab in the back classic

• Transverse myelitis

Bilateral, highly associated with MS

High dose steroids and plasma exchange 

• NMJ disorder

Botulism – presynaptic acetylcholine receptor

Myasthenia gravis – post synaptic acetylcholine receptor

Lambert Eaton -presynaptic ca channel

NIF is the negative inspiratory force, strength of inhale. 0- -20 is weak, needs intubation

• GBS

Steroids worsen mortality

Ascending weakness

Miller fisher variant 

Albuminocytologic disassociation 

• Bell’s palsy 

Peripheral cause of facial weakness

Does not spare the forehead

Steroids

Acyclovir if presents within time frame

Artificial tears

• Ramsey hunt syndrome 

Zoster

Vesicles of the ear

Steroids

Acyclovir

• Bilateral Bell’s palsy – Lyme disease

• Lumbar puncture 

Contraindications – Cellulitis, Fracture, Epidural abscess

Platelet must be atleast 50k

Head CT before LP , r/o increased icp 

L3-4 or l4-5

20 gauge is good, decreased spinal headache

Traumatic and larger needles have higher chance of LP headache

Lateral decubitus position (if you want pressure) versus sitting position 

• LP headache
  • need fluids
    • Worse with standing or position changes
      • Blood patch if refractory

• Multiple Sclerosis

Demyelinating CNS disease

INO

Optic neuritis – pulfrich test (feels something is coming at them when its not), red saturation test (changes to pink on affected eye)

MRI gold standard

Oligoclonal bands in CSF highy suggestive of MS

High dose steroids is treatment

• Posterior rib fractures in child should raise suspicion for fracture

• WPW

Short PR

Delta Wave

SVT is high yield test question, will need procaimaide If wider QRS

• Wellens Syndrome

Bipashic T wave in anterior leads

Chest pain usually resolved

Needs urgent catheterization

• Brugada

Needs AICD

Downsloping ST segment 

• AAA

Typically infrarenal 

When ruptured – need blood, but allow for permissive hypotension – call for your aorta team

• Heart blocks

Mobitz Type II and 3rd degree block need AICD/pacer

• SVT

Vagal maneuver —> Adenosine (6, 12, 12) if hemodynamically stable

If unstable, synchronized cardioversion

• Lefort fractures

3 types

Type III may have CSF rhinorrhea

Avoid NG tube placement

• Chest tube output for OR indication

1500cc of output right away (~20cc/kg)

200 cc an hour for 3 hours (~3 cc/kg)

• Boorhave syndrome

Hammans crunch

Massive vomiting or iatrogenic (most common)

Broad spectrum antibiotics

• Button battery needs emergent endoscopy if in esophagus

• Rectal prolapse

Slow, steady pressure

Sugar as pre treatment

Avoid if toxic appearing or nectroic appearing

• Trachinominate fistula

First attempt to overinflate the cuff

Next try manually compressing against the sternum through the trash

• PE

Most common sign is tachypnea

Most common symptom is dyspnea

Most common EKG finding is sinus tachycardia

Most specific finding on EKG Is S1Q3T3, T wave inversions in the anterior leads

• Status Epilepticus

Benzo first

Midazolam (can be given IM or intransal (great option for patient who doesn’t have access))

Lorazepam, Diazepam

Keppra (40-60 mg/kg IV. (Max dose of 4500 mg)), Fosphenytoin

Lacosamide or Valproic acid

Fosphenytoin and Valproic acid cannot be used together

Intubate with Propofol, Ketamine, or Versed as induction agents as these have anti-epileptic properties

Need continuous EEG to r/o subclinical seizures and further monitoring

GOODLUCK on ITE

Maryland pearls post about a recent paper in JEM about patients coming in with uncertain head trauma.

1. Subscribe to the Maryland pearls if you don’t already
2. Do not automatically go scan every geriatric patient who might have hit their head. But consider it on a patient to patient basis.

While the unknown patients had a lower % of positive head CT, it was not negligible. See the description below:

In this prospective study looking at geriatric patients with unknown head injury vs. known head injury, the unknown head injury group had an ICH 1.5%, neurosurgical intervention 0.3% and delayed ICH 0.1% when compared to known head injury (10.5%,  1.2% and 0.7% respectively).  The authors concluded that the risk of ICH was high enough in uncertain head injury patients to warrant scanning.

Turchiaro ML Jr, Solano JJ, Clayton LM, Hughes PG, Shih RD, Alter SM. Computed Tomography Imaging of Geriatric Patients with Uncertain Head Trauma. J Emerg Med. 2023 Dec;65(6):e511-e516. doi: 10.1016/j.jemermed.2023.07.009. Epub 2023 Jul 26. PMID: 37838489.

Brief but informative post from the Canadian Medical Protective Association (CMPA). They apparently do have lawsuit risk in Canada with as many as 24% of EM physicians named in a case in 5 years.

Check out our UL DEM 2018 article* that appeared in ABEM’s LLSA list. Many of the same diagnoses remain high risk today: Fractures, Lacs/wounds, Stroke, ACS, Appendicitis (And other GI), and less commonly seen in other reviews, respiratory system infections.

*Brian Ferguson, Justin Geralds, Jessica Petrey, Martin Huecker. Malpractice in Emergency Medicine-A Review of Risk and Mitigation Practices for the Emergency Medicine Provider. J Emerg Med. 2018 Nov;55(5):659-665.

Risk reduction reminders from the CMPA article:

The following risk management considerations have been identified for physicians providing care in the emergency department:

• Perform an objective and thorough assessment of patients and when appropriate, incorporate clinical practice guidelines and clinical decision rules for investigating common conditions encountered in the ED.
• Take time to pause and reflect on the differential diagnosis, being careful to consider any relevant risk factors, including comorbidities and surgical or family history. Obtain a second opinion if you are unsure of your diagnosis.
• Provide patients with appropriate follow-up and clear instructions (verbal or written), including symptoms and signs that should alert them to seek further medical attention and how urgently to do so. Confirm patients’ understanding of the information being provided, and answer questions honestly and openly.
• Communicate clear instructions during formal written handovers of care that include relevant patient history, pertinent findings on physical examination, differential diagnosis, diagnostic investigations performed, outstanding results, and the next steps in the patient treatment plan.
• For patients with continued or worsening symptoms or those who repeatedly return with unresolved complaints, re-evaluate the diagnostic assumption, repeat the physical examination, and consider alternative diagnoses, ruling out possibilities that may be life-threatening.
• Document differential diagnoses, pertinent positives and negative findings, reassessments, and discharge discussions

Arsenic (Aiello)

• Heavy metal, readily absorbed via GI tract
• Tasteless, odorless
• Poisoning , contaminated water, can be in some preservatives
• Acute ingestion-garlic smell of breath and tissues, GI symptoms, dehydration, pulmonary edema, shock
• Arsine gas exposure- homelysis, hematuria, jaundice
• Workup: Urine arsenic level, EKG, cbc with retic, CMP, mg, phos, ca, lfts, CK
• Management: Supportive care, ABCs, IV, O2, remove exposure, IVF, Avoid QTC prolonging meds
• CHELATION therapy if severe symptoms, Dimercaprol. (Tough to Find) DMPS may be better alternative but logistically tough. Call Poison Control Center ASAP to help manage. Charcoal absorbs poorly to arsenic, evaluate for exchange transfusion in arsine exposure
• Admit to ICU if symptomatic from acute exposure, Asymptomatic can be obs

Toxicology Oral Boards Prep (Eisenstat)

• Oral Boards Update: ABEM made significant changes to licensing exams starting in 2026. Stay tuned for updates and details on how this develops.
• Botulism
  • Infant, Wound, Food Bourne
  • Supportive Care: Early Vent support, Wound management
  • Foodborne/Inhalational: Equine Serum Botulism Antitoxin- through CDC, Department of Health
  • Infant: Botulism IG (BabyBIG) through CDC, Department of Health
  • Wound-  ID, broad spectrum, tx similar to nec fasc
• Carbon Monoxide Poisoning
  • Critical Actions:
    • Perform Complete Neurologic Exam
    • POC Glucose
    • ABG with carboxyhemoglobin
    • 100% NRB
    • Admit for O2 therapy or transfer for hyperbarics

Environmental Tox (McGowen)

• Sorry, was too busy playing Kahoot. Study up for ITE.

Lightning (Perling)

• Multiple Mechanisms of Strikes (Direct, Ground Current *most common*, Side Splash, Conduction, Streamer)
• Cardiopulmonary Effects- Cardiac Arrest: Asystole, paralysis of medullary respiratory centers
  • Spontaneous ROSC can occur, but will not be breathing spontaneous

• Neurologic Effects- Keraunoparalysis (compartment syndrome mimic), Intracranial hemorrhage, cerebral edema, seizure 
• Dermatologic Effects-lichtenberg figures, burns of varying severity, flashover/linear burn
• Eye/Ear Effects- pupillary dilation/anisocoria, perforated TM, cataracts, transient deafness
• Orthopedic Effects- Rhabdo possible, Compartment syndrome vs keraunoparalysis, posterior shoulder dislocation (lightbulb sign), spinal fractures
• Pregnant Effects- abruptio placentae
• Management: Reverse Triage Mass Casualty- Cardiac Arrest->ACLS immediately. Have higher survival rate, ROSC before breathing, apneic patients need assisted breathing. Cease efforts if no ROSC after 20-30 minutes. 
• Discharge- normal vitals, appears well, no other injuries
• Admit essentially everyone else, likely will require tele monitoring 
• Obtain CT imaging to rule out internal hemorrhage, as lighting can affect similar to blunt trauma
• What To Do: Get in a Car, go inside a deep cave, Go deep into a forest. Isolated Trees are bad. Go to Ravine if in the mountains. 

Toxic Mushrooms (Webb)

• mushrooms are closer to humans than plants genetically (trust me bro)
• 7500 ingestions annually, 3 deaths per year
• Typically Acute gastroenteritis, usually less than 3 hours post ingestion
• Cholinergic toxicity, disulfiram-like reaction, hallucinations, Liver/Nephrotoxicity
• Death Cap Mushroom-Amanita phalloides
  • 90% of mushroom associated deaths, moratlity rate 10-20%
  • Amatoxin, delayed toxidrome (6-12 hours)
  • Nausea vomiting diarrhea-> latent period (24-48 hours) ->fulminant liver failure
  • Tx: Silibinin (IV milk thistle) possible use, but evidence is weak 

Peds Toxicology (Graff)

• Blood brain barrier- more permeable to toxic substances until around 4 months
• Based on mg/kg for most ingestions
• Metabolism is your best antidote, Most declare themselves within 4-6 hours
• No hard contraindication to naloxone
• Charcoal- 1gm/kg, minimizes absorption, contraindications: caustic, typically within 2 hours
• Syrup of Ipecac- Not recommended
• One Pill can kill- CCB, SSRI, Lomotil, Opiates, Salicylates, Camphor, Antimalarials more
• Lomotil- can present like opiate toxicity: narcan and supportive care
• Iron: top cause of death in toddlers, 4 hour iron level, GI decontamination, IVF, deferoxamine IV
  • Remember stages of iron overdose including hepatic failure and delayed gastric outlet obstruction/pyloric stenosis

• Tylenol- check ASA too, charcoal, level 4 hours, Days 1-4 increased LFTs, liver failure, Tx: NAC ideally within 8 hours but still give after 8 hours
• Salicylates: Fever, N/V, tinnitus, seizures, metabolic acidosis, resp alkalosis.  Charcoal, alkalinize urine
• Drano- airway concern, liquefactive necrosis. Vomiting drooling stridor, supportive care, NO ipecac or gastric lavage
• Methanol- windshield washer fluid. Fomepizole, dialysis. CNS depression, HA, met acidosis
• Ethylene Glycol- antifreeze, CNS dysfunction
• Isopropyl- rubbing alcohol. ketones in urine, no fomepizole.
• Anticholinergic toxicity- think atropine. Sleepy then increased CNS symptoms, seizures GTC.  tx physostigmine, GI decon
• Organophosphates- SLUDGE, decontaminate patients. Lots of atropine, pralidoxime. 
• Hydrocarbons- gasoline, cleaners, polishes, risk is aspiration, obs 4-6 hours. Dc asymptomatic
• Sulfonylurea- profound hypoglycemia without response. D50 Octreotide,
• BP Meds- CCB typically hyperglycemia, BB typically hypo/normoglycemia: Tx – calcium, glucagon, insulin and dextrose, intralipid
• Benadryl- anticholinergic. disorientation/delirium, dry mouth, blurred vision Tx supportive care
• Opiates- remember some don’t come back + on drug screen, Heroin found in cbd gummies in community right now
• Bath salts: stimulants, aggressive, hallucinations, panic attacks, agitated “Cloud 9”, rhabdo. 
• CHEMICal Camp mnemonic
• Review Toxic Syndromes

Salicylates (Adams)

• MOA: analgesia, antiinflammatory, antipyretic. Works on COX1 enzyme, inhibits prostaglandins
• Absorption 30min-1hr, 2-4 hours in overdose. 
• Can form bezoar with enteric coated formulation
• Toxicity: >30 mg/dl
• Direct CNS stimulation. Directly stimulates respiratory drive  in medulla= resp alkalosis
• Decreased pH= increased non nonionized ASA= increased crossing BBB= increased CNS ASA
• Neuronal energy depletion -> neuronal apoptosis, neuroglycopenia -> seizures/ CNS symptoms
• Clinical Presentation: CNS: AMS, Seizures, coma, Resp: tachypneic resp alkalosis, Metabolic: hyperthermic, hypokalemic, AGMA, GI: nausea, vomiting, diarrhea, Tinnitus Effects
• Classic: Primary Met Acidosis with Primary Resp Alkalosis. Determine if decrease in CO2 is compensation or if there is another primary acid base disturbance
• Tachypnea is not an indication for intubation. AVOID INTUBATION IF POSSIBLE
  • Give 1-2 mEq/kg bolus of bicarb peri-intubation, awake intubation, Vent settings to match minute ventilation pre-intubation to prevent resp acidosis. High rate and volumes needed (Rate 30, 8 cc/kg example). 

• External and Internal Decon- remove any topical source like Bengay cream. Role of Charcoal depending on mental status. 
• Treatments: Sodium Bicarb
  • Dosing: Bolus 1-2mEq/kg. Maintenance: 3 amps in 1 L D5W, 150-200 ml/hr  maintenance rate
  • Goal serum pH 7.5-7.55, Goal Urine pH 7.5-8.0

• Treatment endpoints: ASA level below 30 x2. 
• Chronic Intoxications typically overlooked. Oil of Wintergreen is highly concentrated and potentially fatal.