Methemoglobinemia 

Background:

• Methemoglobin refers to ferric form of hemoglobin (Fe3+) that is unable to bind O2
• Suspect in any patient with cyanosis not responsive to supplemental O2

Causes:

• Rarely congenital, NADH reductase deficiency – unable to reduce ferric to ferrous iron (Fe³⁺ → Fe²⁺)
• Exposure to oxidizing agent
  • Benzocaine and other local/topical anesthetics
  • Nitrites, nitrates, well water (nitrates)
  • Antimalarials
  • Quinolones
  • Dapsone
  • Aniline dyes
  • Phenazopyridine
  • Sodium nitrite toxicity

Evaluation:

• Oximetry is inaccurate because methemoglobin (MetHb) absorbs light at both 660 nm (red) and 940 nm (infrared) wavelengths approximately equally. This causes the pulse oximeter to fail to distinguish it from oxygenated hemoglobin, resulting in a characteristic, fixed, and falsely low SpO2 reading of around 85%,
• Lack of improvement in oxygen saturation with high-flow oxygen plus discrepancy in oxygen saturation >5% between measurements by ABG vs pulse oximetry (“saturation gap”) 
• Diagnosis confirmed by measuring level of methemoglobin in blood
• Normal PaO2
• SpO2 will initially be falsely elevated
  • Once MetHb >30% → SpO2 will fall to 80-85%
  • Mid-80s SpO2 due to light absorption of both oxyHb and deoxyHb
• “Chocolate brown” color of blood

Management:

• High-Flow Oxygen
• Methylene Blue
• Treat if symptomatic OR asymptomatic with MetHb >25%
  • 1-2mg/kg Methylene blue IV over 5min; repeat dose if no effectImprovement seen within 20min
  • Contraindicated in G6Pd deficiency (may cause hemolytic anemia)
• Other treatment modalities
  • Exchange transfusion for symptomatic methemoglobinemia in patient with G6PD deficiency
  • Hyperbaric O2 when methylene blue ineffective or contraindicated
  • IV hydration and bicarbonate for metabolic acidosis

Dispo:

• Admit, likely ICU consider Floor if stable

Blood Transfusion Complications 

1. Acute Hemolytic Transfusion Reaction (AHTR)

Cause: ABO incompatibility (most dangerous; clerical error)

Pathophysiology:

• IgM-mediated → complement activation → intravascular hemolysis 

Presentation (minutes):

• Fever, chills 
• Flank/back pain 
• Hypotension 
• Hemoglobinuria → dark urine 
• DIC possible 

Labs:

• ↑ LDH, ↑ bilirubin 
• ↓ haptoglobin 
• Positive direct Coombs 

Management:

• STOP transfusion immediately 
• Aggressive IV fluids 
• Maintain urine output 
• Treat DIC if present 

---

 2. Febrile Non-Hemolytic Transfusion Reaction (FNHTR)

Cause: Cytokines or recipient antibodies to donor leukocytes

Presentation:

• Fever ± chills 
• No hemolysis 

Management:

• Stop transfusion (initially to rule out AHTR) 
• Antipyretics 
• Prevention: leukoreduced blood 

 3. Allergic Reactions

Mild:

• Urticaria, pruritus 

Management:

• Antihistamines → may restart transfusion 

Severe (Anaphylaxis):

Cause: IgA deficiency with anti-IgA antibodies

Presentation:

• Hypotension 
• Bronchospasm 
• Angioedema 

Management:

• Epinephrine 
• Avoid future IgA-containing products 

 4. Transfusion-Related Acute Lung Injury (TRALI)

Cause: Donor anti-leukocyte antibodies → neutrophil activation

Timing:

• Within 6 hours 

Presentation:

• Acute hypoxia 
• Noncardiogenic pulmonary edema 
• Bilateral infiltrates 

Key distinction:

• Normal BNP 
• No volume overload 

Management:

• Supportive (oxygen, ventilatory support) 

5. Transfusion-Associated Circulatory Overload (TACO)

Cause: Volume overload

Presentation:

• Dyspnea 
• Hypertension 
• Pulmonary edema 

Key distinction from TRALI:

• Elevated BNP 
• Signs of fluid overload 

Management:

• Diuretics 
• Slow transfusion rate 

 6. Delayed Hemolytic Transfusion Reaction

Cause: IgG antibodies (e.g., Kidd, Duffy)

Timing:

• Days to weeks 

Presentation:

• Mild fever 
• Anemia 
• Jaundice 

Management:

• Usually supportive 

7. Transfusion-Associated Graft-versus-Host Disease (TA-GVHD)

Cause: Donor T cells attack recipient

Risk:

• Immunocompromised 

Presentation (days–weeks):

• Fever 
• Rash 
• Diarrhea 
• Pancytopenia 

Prevention:

• Irradiated blood products 

Prognosis:

• Often fatal 

 8. Infectious Complications

Examples:

• Bacterial (platelets highest risk) 
• Viral: HIV, Hepatitis B/C (rare now) 

Presentation:

• Fever, sepsis 

9. Metabolic Complications

Hypocalcemia

• Citrate binds calcium 
• → Tetany, arrhythmias 

Hyperkalemia

• Stored blood leaks K⁺ 

Hypothermia

• Large-volume transfusion 

Rheumatic Fever

Pathophysiology:

• Inflammatory disease occurring 2–4 weeks after an untreated group A strep infection (strep throat or scarlet fever), primarily affecting children aged 5–15
• Connective tissue of heart, joints, CNS, subcutaneous tissues are targeted by immune reaction

Clinical Features:

• Polyarthritis, pericarditis, Sydenham’s chorea, erythema marginatum, nodules

Workup:

• CMC, CMP, ESR, CRP

• ASO (Antistreptolysin O) titer Elevated 1week to 1 month after GAS infection
• Anti-DNase B titer is elevated longer than ASO and may be useful for patient presenting later than 2-4 months or with a negative ASO
• ECG – Looking for prolonged PR or other AV block
• CXR
• Echocardiogram

Management:

• Eliminate underlying streptococcus bacteria with antibiotics (penicillin), reducing inflammation, pain, and fever with aspirin or other NSAIDs. Consider corticosteroids for heart inflammation.
• Long-term, secondary prevention with regular antibiotic injections (Penicillin G IM x1 month) to prevent recurrence and heart damage

Tumor Lysis Syndrome

Overview:

• Occurs when large numbers of cancer cells die and release their contents into the circulatory system
• Usually with onset of new chemotherapy or high tumor burden.
• -K, Phosphate, calcium, nucleic acids -> urine acid, proteins
• Can lead to AKI and renal failure
• Usually within 72 hours, can have later presentation up to 10 days (i.e.. Immune checkpoint inhibitors)
• Laboratory or clinical diagnosis

Risk factors:

• Cancer type (NHL, Lymphoma, AML, and ALL most common).
• Solid tumors with high tumor burden
• Age, kidney function, dehydration, renal and CNS involvement, presence of mediastinal mass, LDH >2x upper limit of normal indicates rapid cell turnover

Clinical Presentation:

• Nonspecific, commonly involved the renal, neurological, and cardiac systems
• Trousseau-muscle spasm with inflation of BP cuff = hypocalcemia

Workup:

• CBC, CMP, Phosphorus, Calcium, Uric Acid, LDH, EKG, UA
• Cairo-Bishop Diagnostic Criteria

Management:

• Treat electrolyte derangements, IVF (2-3x maintenance fluid dose), manage uric acid (rasburicase or allopurinol)
• Consult Heme Onc, Renal
• Likely admit

ITP (Immune Thrombocytopenic Purpura) Case

Overview:

• Immune mediated destruction of platelets
• Primary (idiopathic) vs Secondary (part of larger pathology or medications)
• Presentation: Petechia, purpura, epistaxis, gingival bleeding, mouth lesions, acute bleeds
• Thrombocytopenia plt < 100 with no change in other cell lines
• Need to differentiate between others (ITP, HIT, HUS, TTP, DIC)

Treatment:

• Minor OR Platelet < 30: Dexamethasone 40 mg IV
• Severe: Dexamethasone 40 mg IV, IVIG 1g/kg, Plt transfusion (goal 50-100), splenectomy?
• Treatment same in pregnant patients and pediatrics.

Diving Medicine

Key History to Obtain:

• Dive depth
• Dive duration
• Number of dives
• Ascent rate
• Safety stops performed
• Time since surfacing
• Air source
• Prior dive illness
• Look at diving watch to obtain this data quickly

1. Decompression Sickness (DCS)

Related to nitrogen bubble formation during ascent.

Mechanism:

• Increased pressure underwater dissolves nitrogen into tissues.
• Rapid ascent → nitrogen comes out of solution → bubbles form in blood/tissues.

Types:

Type I (Mild)

• Musculoskeletal pain (“the bends”)
• Joint pain (shoulder, elbow, knee most common)
• Skin findings
  • Pruritus
  • Mottled rash (cutis marmorata)

Type II (Severe): Involves neurologic, pulmonary, or vestibular systems

• Weakness
• Paresthesia
• Paralysis
• Ataxia
• Bladder dysfunction
• Confusion
• Vertigo
• Hearing loss

Pulmonary form (the chokes):

• Chest pain
• Cough
• Dyspnea

Diagnosis: Recent dive (usually within 6–24 hours), Compatible symptoms

Treatment:

1. 100% Oxygen
2. IV fluids
3. Supine positioning
4. Immediate hyperbaric consultation
5. Recompression therapy

Hyperbaric therapy dramatically improves outcomes.

---

2. Arterial Gas Embolism (AGE)

Most dangerous diving emergency.

Mechanism

• Rapid ascent → lung overexpansion → alveolar rupture
• Air enters pulmonary veins → systemic embolization

Presentation (often within minutes of surfacing)

Neurologic symptoms:

• Stroke-like deficits
• Seizures
• Altered mental status
• Paralysis
• Vision changes

Other symptoms:

• Chest pain
• Dyspnea
• Cardiac arrest

Treatment:

Same as severe DCS:

1. 100% Oxygen
2. Hyperbaric recompression (urgent)
3. IV fluids

---

3. Barotrauma

Occurs when air spaces cannot equalize pressure.

Ear Barotrauma (Most Common)

-Severe ear pain with descent. If ears are not equalized, pressure builds and eustachian tube collapses. Clear ears on water entry and often during dive.

Symptoms:

• Ear pain
• Hearing loss
• Vertigo
• TM rupture

Exam:

• Hemotympanum
• TM perforation

Treatment:

• Analgesia
• ENT follow-up
• Avoid further diving
• Give antibiotics only for perforated TM

---

Sinus Barotrauma

Symptoms:

• Facial pain
• Epistaxis
• Sinus pressure

Treatment:

• Decongestants
• Analgesia

---

Pulmonary Barotrauma

Causes:

• Pneumothorax
• Pneumomediastinum
• Arterial gas embolism

Symptoms:

• Chest pain
• Dyspnea
• Subcutaneous emphysema

Treatment:

• Manage pneumothorax
• Oxygen
• Hyperbaric if embolism suspected

---

4. Nitrogen Narcosis

Occurs at depth >30 meters (~100 ft).

Symptoms:

• Euphoria
• Poor judgment
• Confusion
• Impaired coordination

Treatment:

• Ascend to shallower depth

Symptoms resolve quickly, it is safe to continue diving after resolution of symptoms.

---

Immediate ED Management

1. High-flow oxygen
2. IV fluids
3. Neurologic exam
4. Call hyperbaric center
5. Transport if needed

In the U.S., consultation is often through:

• Divers Alert Network, they assist with hyperbaric referral and organizing transfer

---

Board Pearls

• Any neurologic symptom after diving = assume AGE or DCS → hyperbaric therapy
• Symptoms within minutes of surfacing → think AGE
• Symptoms hours later → think DCS
• Joint pain after diving = DCS Type I
• Stroke-like symptoms after diving = AGE until proven otherwise

Immunosuppression and Transplant

Common ED patients:

• Solid organ transplant
• Bone marrow transplant
• Chemotherapy
• Chronic steroids
  (>20 mg prednisone daily for >2 weeks)
• Advanced HIV
• Biologic therapy

Common immunosuppressive drugs:

• Typical regimen includes: calcineurin inhibitor + antimetabolite + steroid
• Calcineurin inhibitor (Cyclosporine, Tacrolimus)
• Steroids
• +/- Antimetabolite (Azathioprine, Mycophenolate mofetil)

Solid Organ Transplant Rejection:

• Hyperacute (Minutes–hours)
• Acute Rejection (Weeks–months)
• Chronic Rejection (Months–years)

Organ-Specific Rejection Clues:

Kidney Transplant:

• Rising creatinine
• Decreased urine
• Hypertension

Liver Transplant:

• Fever
• RUQ pain
• Elevated LFTs
• Jaundice

Heart Transplant:

• Dyspnea
• Heart failure symptoms
• Arrhythmias
• Because transplanted hearts are denervated, they may NOT present with typical chest pain.

Neutropenic Fever:

• ANC <500 OR <1000 with predicted nadir of <500 in 48h AND
• Fever ≥ 38.3˚C (100.9˚F) once OR sustained temperature ≥38 (100.4) for >1hr

Thrombotic Thrombocytopenic Purpura (TTP)

Pathophysiology:

• Insufficient ADAMTS-13 activity allows vWF multimers to accumulate in microcirculation which leads to platelet aggregation/thrombocytopenia and hemolysis of RBCs. 

Risk Factors:

• Congenitally deficient ADAMTS-13 activity AND:
  • Pregnancy OR
  • Infection OR
  • Inflammation OR
  • Medication use (quinolones, ticlopidine, clopidogrel)

Clinical Features:

• Microangiopathic Hemolytic Anemia
• Thrombocytopenia
• Fever
• Renal pathology
• CNS abnormalities (headache, seizure, altered mental status, CVA, coma)

TTP pentad mnemonic = FAT RN

• Fever, Anemia, Thrombocytopenia, Renal, Neuro Symptoms

Workup:

• CBC with peripheral smear (anemia, microspherocytes, thrombocytopenia are suggestive findings)
  • Microangiopathic hemolytic anemia produces schistocytes
• LDH (elevated)
• Haptoglobin (decreased)
• Reticulocyte count (appropriate)
• UA (hemoglobinuria)
• Creatinine (possibly elevated)
• LFT’s (increased bilirubin)
• PT/PTT/INR (normal; differentiates from DIC)
• Urine pregnancy (significant association between pregnancy and TTP)

Management:

• Heme Onc Consultation, Plasma exchange, FFP Transfusion, Glucocorticoids

Aplastic Anemia

Etiology:

• Absence or decreased number of hematopoietic precursor cells → pancytopenia (anemia, thrombocytopenia, neutropenia)
  • Drug induced, viral infection, autoimmune, congenital

Presentation:

• Anemia (weakness, fatigue, dyspnea), Thrombocytopenia (mucosal bleeding, petechiae, ecchymosis), Neutropenia (recurrent infection, fever)

Workup:

• CBC (pancytopenia), CMP, Reticulocyte Count (reduced or absent), peripheral smear, LDH, Haptoglobin, consider viral serologies

Management:

• Heme Onc consultation for all new cases, especially if severe
• Transfuse PRBS/platelets as needed for severe anemia/thrombocytopenia

Angioedema

Etiologies:

• Mast cell activation/Histamine-mediated
  • Allergic angioedema: IgE-mediated type I hypersensitivity
• Bradykinin-mediated

• Hereditary angioedema: Congenital or acquired loss of C1 esterase inhibitor
• Due to C1 esterase inhibitor deficiency
• Leads to unregulated activity of vasoactive mediators (bradykinin) associated with complement pathway
• Autosomal dominant
• ACE-Inhibitor induced angioedema: ACE-I adverse reaction from excessive bradykinin
• Unknown/idiopathic

Differentials: Anaphylaxis, Contact dermatitis, cellulitis, tonsillitis/uvulitis, PTA, retropharyngeal infection

Clinical features:

• Affects loose connective tissue (face/lips/throat, extremities, genitalia, bowel wall)
• Not gravitationally dependent
• Onset minutes to hours, Resolution hours to days

Workup:

• Testing not always needed, UTD recommends CBC, CMP, ESR/CRP, C4 level (c4 level +/- c1 inhibitor antigen testing used for future diagnosis, not part of ED management)
• Imaging not typically needed unless concern for concurrent dx (i.e. infection, abscess)

Management:

• General: Epi, Glucagon, TXA, FFP
• Hereditary/C1 acquired deficiency: Purified C1 inhibitor, kallikrein inhibitor, bradykinin b2, orally available Kallikrein
• FFP- can be used if other aren’t available.

Intubation strategies:

• Anticipate difficult airway, have backup available if possible
• Be prepared for being unable to oxygenate and ventilate, be ready to perform cric
• Be as gentle as possible- tissue is friable, irritation will cause more swelling.
• Consider intubation early-angioedema can surprise you and progress very rapidly.
• Consider intubation very early in post-TNKase cases, as cric could be devastating
• Digital (tactile) intubation strategy: Use the non-dominant index/middle fingers to palpate the epiglottis, directing a boujie or ETT into the trachea. 

Dispo:

• No consensus on timing needed for obs. If stable need to be observed until signs of improvement. Most non-allergic angioedema does not fluctuate in severity.
• Consider admission: If partly allergic picture, high risk body part (airway), poor social situation
• Consider transfer: Low resource facilities, no advanced airway clinician except you, consider airway compromise en route (sometimes early intubation is the safest option prior to transfer)

Anticoag/Antiplatelet Reversal

ITE review

Hypothermia

Modifications to standard ACLS algorithms in hypothermia

• Medications may fail to be metabolized and accumulate. Therefore, avoid repeated doses of medications.
• Defibrillation may be unsuccessful until the patient is rewarmed. Thus, serial shocks for VT/VF arrest are unlikely to add benefit. As the patient rewarms, further attempts may be made at defibrillation.

Rewarming patients with frostbite:

Goal for rapid rewarming. 40-42C is around 104-106F or about the temperature of a hot tub. This will rapidly rewarm but will not cause burns. Anything less will not rewarm tissue sufficiently. It is important NOT to rub/massage the affected digits, as the crystallized tissue is fragile and this will cause further cellular damage.

Tx: rewarm, liberal pain control, dressing/wounds care, reassess

High altitude cerebral edema (HACE) = always descend!

DERM

Rheumatic fever = Jones criteria = erythema marginatum (weeks later)

Core competencies

Interpersonal and communication skills: capacity

• not competence, an informed choice, alcohol use

Level A recommendation: established evidence, multiple RCT, meta-analysis

Level B recommendation: some evidence: single RCT; multiple population

Level C recommendation: limited evidence

Alex Bequer, MD; Kahra Nix, MD. Peer Review Jeff Baker, MD

Emergency Medicine (EM) physicians are already familiar with the Focused Assessment with Sonography in Trauma (FAST) to rapidly identify intraperitoneal or pericardial free fluid and guide time-sensitive decisions. [1,2]There is an image processing error that EM physicians should be aware of as it can be confused with intraperitoneal free fluid.

Modern ultrasound machines and software increasingly strive for sharp, high-contrast images, relying on post-processing in order to improve border definition and image clarity. These adaptions are enacted to prevent speckling and result in clearer, crisp images. While these features enhance visualization, they can also introduce other limitations in image interpretation. One example is the “lipliner” which appears as a thin, symmetric, anechoic line that can be seen along the edge of solid organs (see attached image). The lipliner can be found along the caudal edge of the liver and at the splenic tip, precisely where free fluid is expected on a positive FAST examination, thereby creating the potential for false-positive interpretations. [3] Unlike true free fluid, which typically forms a wedge-shaped, dependent collection that tracks into tissue planes, the lipliner outlines the solid organ margin itself. It is a result of real-time adaptive filtering, rather than anatomy or pathology, and because it is a mathematic result, the lipliner is not technically a sonographic artifact. [3]

It is important for EM physicians to recognize and understand the lipliner. Machine vendors and POCUS leaders are working on machine presets that may preserve image quality and minimize the appearance of the lipliner. Consider looking again and adjusting probe positioning to clarify if the anechoic area is wedge-shaped and extending into potential spaces. Consider serial FAST exams. [4]

In addition to other well-known mimics of free fluid, physicians should expect to encounter post-processing errors introduced by modern ultrasound advancements designed to improve image clarity and usability. Understanding how these technologies influence image appearance is critical to accurate interpretation and informed clinical decision-making. Watch out for the lipliner when interpreting FAST scans on your next shift.

References

1. Patel NY, Riherd JM. Focused assessment with sonography for trauma: methods, accuracy, and indications. Surgical Clinics of North America. 2011;91(1):195–207.

2. Rozycki GS, Ochsner MG, Feliciano DV, et al. Early detection of hemoperitoneum by ultrasound examination of the right upper quadrant: a multicenter study. Journal of Trauma. 1998;45(5):878–883.

3. Parker MA, Hicks BG, Kaili M, et al. The lipliner sign: potential cause of a false positive focused assessment with sonography in trauma (FAST) examination. Journal of Emergency Medicine. 2024;67(6):e553–e559.

4. Ferre, R. M., & Stolz, L. A. (2025, March 13). Lipliner artifact review. American College of Emergency Physicians, Emergency Ultrasound Section. https://www.acep.org/emultrasound/newsroom/march-2025/lipliner-artifact-review

ITE review

High yield ultrasound

Aortic aneurysm

• Most sensitive finding is aneurysm >3cm
• Most specific finding is a ruptured aneurysm with retroperitoneal hematoma

Hydroneprhosis

Cholecystitis

• Measure CBD inner wall to inner wall; normal <5mm

• Retinal detachment is tethered to the optic nerve
• Vitreous detachment is mobile and can lead to retinal detachment

(+) HCG

• Discriminatory zone 1500 IU/L
• IUP confirms requires intrauterine gestational sac plus yolk sac
• gestational sac alone = pregnancy of unknown anatomic location

The newborn exa

examine naked and head to toe, every time (think mini trauma assessment with more steps)

Newborn well-care

• The nursery
• If there is suspicion you may need to tap the baby, you MUST ask about vitamin k administration
• should receive hep b, erythromycin ointment to eyes, and vit k IM within 1-2 hours of birth
• Feeding
• newborns should take a minimum 1-2 oz of formula or breastmilk every 2-3 hous (including overnight). Normal 19 kcal/oz formula should be mixed 1 scoop of formula to 2oz of water. Water first then formula.

ITE month

Neck Zones

• Zone I: Clavicles/sternum to the cricoid cartilage
• Zone II: Cricoid cartilage to the angle of the mandible>> STRAIGHT TO THE OR
• Zone III: Superior to the angle of the mandible to skull area

Hard signs:

• Hypotension, arterial bleeding, rapidly expanding hematotma, pulse deficit, bruit >>> STRAIGHT TO THE OR

UNSTABLE C SPINE FRACTURES

“Jefferson Bit off a Hangman’s Toe”

• Jefferson Fx
• Bilateral facet joint dislocation
• Odontoid
• Atlanto axial dislocation
• Hangman fracture
• Teardrop fracture

LE FORT FRACTURES

Indication for ED thoracotomy

• Penetrating chest trauma + witnessed arrest/loss of vitals

Indication for OR Thoracotomy?

• Initial Chest tube output??
• 1500cc or 200cc/hr

Glasgow Coma Scale

Blast Injury

Most common site of basilar skull fracture:

• Petrous portion of temporal bone

Clonidine overdose>>Naloxone 0.1 mg/kg IV

• clonidine acts as an alpha 2 agonist and narcan at high dose will compete for same resceptor
• consider intubation for airway protection

TCA overdose

• Sodium channel blocking medications
• Tricyclic antidepressants (= most common)
  • In overdose, the tricyclics produce rapid onset (within 1-2 hours) of:
  • Sedation and coma
  • Seizures
  • Hypotension
  • Tachycardia
  • Broad complex dysrhythmias
  • Anticholinergic syndrome (tachycardia, mydriasis, dry mouth)
• QRS complex >120 ms

Treatment:

• Administer IV sodium bicarbonate until you see changes in EKG
• 1-2 mEq/kg as intravenous push every 5 minutes as needed for termination of wide-complex tachydysrhythmia or prolonged QRS interval >120 milliseconds (ms).

Compartment Syndrome

Risk Factors:

• Fractures (especially tibia and forearm)
• Crush injuries
• Vascular injuries with reperfusion

Presentation:

• 6 P’s (pain, pallor, paresthesia, paralysis, pulselessness, poilikothermia)
• Escalating analgesia requirements

Diagnosis: Centurion needle is stocked at ULH. Pressure >30 mmHg is diagnostic for compartment syndrome.

Dispo: admit to surgical service for fasciotomy

———————————–

Septic Arthritis

Risk Factors:

• Recent joint instrumentation
• Joint damage
• Other infection

Presentation:

• Red, warm, swollen, painful joint with decreased ROM

Workup: CBC, ESR, CRP, STI urine/swabs, arthrocentesis

Diagnosis: WBC >/= 50k, PMNs 90%

————————————————

Cervical Spine Injuries & Clearance

Jefferson Bit Off a Hangman’s Thumb

Spinal Cord Injuries

• Central cord
• Anterior cord
• Brown-Sequard
• Posterior cord

NEXUS: sens 99-99.6%, spec ~12%

Canadian: sens ~100%, spec ~42%

• Stiell et al., NEJM 2023 Canadian missed less injuries compared to NEXUS

MRI after negative CT in awake, neuro intact patients with midline tenderness very rarely identifies an unstable injury requiring acute management.

• West Trauma study does not recommend MRI

PECARN 2024: sens ~94%, NPV ~99.9%

—————————

Low Back Pain Emergencies

Red Flags:

• Fever
• h/o malignancy
• IVDU
• Incontinence
• Recent instrumentation
• Weight loss
• Age >50
• Immunocompromise
• Anticoagulation

Broad Diagnostic Categories:

1. Vascular – AAA, aortic dissection, spinal epidural hematoma
2. Infectious – epidural abscess, osteomyelitis/discitis
3. Malignancy – pathologic fx, bony metastatic disease
4. Anatomic

Imaging: MRI with contrast of the C/T/L Spine

Lightning Lecture – Rhabdomyolysis

Classic triad is rare unless severe.

Diagnosis: CK 5X upper limit of normal + causative factor OR characteristic signs/symptoms OR UA with myoglobinuria

Lightning Lecture – Crystal Arthropathy

Synovial fluid aspiration is gold standard for diagnosis, but not always necessary if the presentation is straightforward with infection unlikely.

• Negatively birefringent = gout
• Positively birefringent = pseudogout
• Presence of crystals does not exclude septic arthritis.

Workup: CBC, CMP, ESR//CRP, uric acid

• Uric acid is not reliable for diagnosis on its own

PEM – Ortho Injuries & Child Abuse

Reference developmental milestones when assessing viability of reported mechanism of injury (ex. 2 mo is unlikely to roll off of a bed on their own).

TEN-4-FACESp Rule for <4 yo – signs concerning for abuse

• Torso, ears, or neck
• Any bruising in 4 months and youngers
• Frenulum, angle of jaw, cheeks, eyelids, or subconjunctivae
• Patterned bruising

Workup: CBC, PT/PTT, CMP (or AST/ALT), amylase (or lipase), UA, tox screen, skeletal survey

• Consider CT Head if concern for head injury

Concerning Fractures:

• Bucket handle fracture
• Posterior rib fractures
• Spiral fracture of long bone
• Skull fracture

Non-Concerning Fractures:

• Buckle fracture
• Toddler’s fracture
• Nursemaid’s elbow
• SCFE

Gonorrhea/Chlamydia Arthopathy

Likely underdiagnosed. Think about this in your young patient with unexplained arthritis.

Consider incorporating GC/chlamydia, HIV, and syphilis testing on select patients who may benefit from testing from a public health standpoint.

• Do not have to start in the RUQ for eFast every time
• If eFast is possible in one view, do not have to continue to all views
• When looking for pneumothorax: Lung slide, lung point, lung pulse, B lines
  • Lung slide- no ptx when present, possible when absent
  • Lung point- ptx when present, no ptx when absent
  • Lung pulse- no ptx when present, maybe ptx when absent
  • B lines- no ptx when present
• Serratus block- anterior and lateral ribs, no posterior ribs
• Local anesthetic systemic toxicity
  • Perioral numbness, metallic taste, muscle twitching, seizures, unconsciousness, bradycardia, AV block, tachyarrythmia, hypotension, cardiac arrest
  • Treatment- intralipid

Dr. Graham- Necrotizing soft tissue infections

• Symptoms- erythema, swelling, crepitus, fevers, pain out of proportion to exam, hypotension, hemorrhagic bullae
• Labs- leukocytosis, elevated inflammatory markers, elevated creatinine, hyperglycemia, hyponatremia
• Imaging- CT with gas in subcutaneous tissue, fat stranding
• Treatment- fluid resuscitation, triple antibiotics (broad spectrum- meropenem or zosyn, MRSA- vancomycin, antitoxin- clindamycin), surgical consult

Dr. Stewart- SJS/TEN

• SJS- less than 10% total body surface area
• Overlap SJS/TEN- between 10 and 30% total body surface area
• TEN- greater than 30% total body surface area
• Causative medications- allopurinol, anticonvulsants, sulfa drugs, antibiotics
• Labs- CBC, CMP, inflammatory markers
• SCORTEN- severity of illness score for TEN
• Management- fluid replacement, temperature control, +/- steroids
• Dispo- trauma/derm/burn unit

Dr. Firquin- Pediatric respiratory emergencies

• Croup- URI symptoms, fevers, stridor, barking cough, symptoms worse at night, hypoxia is uncommon
  • Corticosteroids (0.6mg/kg with max 16mg), racemic epinephrine
• Bronchiolitis- URI symptoms, tachypnea, peak at <12months, retractions, poor PO
  • HFNC, suction
• Foreign body aspiration- cough, stridor, tachypnea, sudden episodes
  • XR, bronchoscopy
• Asthma- wheezing, cough, triggered by viral illness
  • Albuterol, ipratropium, steroids
  • Magnesium- side effects of bradycardia and hypotension
  • Epinephrine IM 0.1mg/kg for severe cases
  • Terbutaline for severe cases
  • Consider CXR on first time wheezer

Dr. Smith- Cutaneous ulcers

• Diabetic foot wound- neuropathic ulcer over bony prominences of foot, cover for MRSA and pseudomonas for infection, non-infected wounds can be discharged with outpatient follow-up
• Venous stasis ulcer- caused by poor venous return, shallow ulcers with irregular borders, wet to dry dressings, elevation of leg, compression stockings, oral antihistamines for itching
• Pressure ulcer
  • Stage 1/2- dressing changes, padding for pressure relief
  • Stage 3/4- debridement, wound care, ongoing pressure relief
• Arterial insufficiency ulcer- usually able to be managed as outpatient as long as patient has good capillary refill, pulse
  • Pulseless- CTA, trauma consult
• Calciphylaxis- ESRD patients, deposition into arteries, rapidly progressive lesions
  • treatment with calcium control and possible surgical intervention

Dr. Leasau- DRESS

• Morbilliform rash >50% of skin, facial swelling and edema, fever 
• Negative nikolsky sign
• 2-6 wk after new drug
• Common drugs: phenytoin, phenobarb, carbamazepine, allopurinol, sulfa drugs
• Treatment: discontinue offending drug, supportive care, +/- corticosteroids

Dr. Drury- abscesses

• Erythematous nodules, forming pus filled cavity anywhere on the body

• Mostly MRSA, some MSSA but can be any skin flora or fungi
• Consider consulting: perirectal, involvement of tendon sheaths, large size, pulsatile mass
• POCUS
  • Abscess- pocket of localized anechoic fluid
  • Cellulitis- cobblestoning
• Treatment: I&D, most will require antibiotics unless simple/single abscess and low risk

Dr. Shoff- patient experience

• When you triage a patient from room 9,  let the patient know what is happening before you roll them out
• Tell patient the buzzer means a trauma or a stroke that is an emergency, will be right back as soon as you are done
• Recap room 9 findings and tell patient what next steps are before you send the patient to CT
• Tell patient plan for the visit prior to leaving the room when you first see them
• Ask the patient what they are concerned about, tell them how you are going to address that concern

Dr. Klaszky- Invasive Mechanical Ventilation in the ED

• Starting settings: PEEP 5, TV 6ml/kg IBW, RR 16-18
• Modes of ventilation:
  • AC: full support, set RR, if patient breathes over that rate- ventilator takes over
  • SIMV: moderate support, set RR, if patient breathes over that rate- patient does the work of breathing
  • PS: minimal support, no set RR, patient does most of the work of breathing
• VC: set tidal volume, monitor pressure (peak/plateau) 
• PC: set pressure, monitor tidal volumes
• Combining AC with VC or PC
• Targeting sat with FiO2 is 88-95%
• ARDS- PEEP responsive
• Plateau pressure- want to keep less than 30 to avoid injury to the lung
  • Tidal volume and PEEP affect plateau pressure, can decrease one or the other if need to get plateau pressure below 30
  • If you have to drop tidal volume, will need to increase RR to get same minute ventilation, often have to increase to mid/upper 20s, low 30s 
• Alveolar ventilation = TV – dead space

Dr. Hudson/Dr. Blair- airway procedure sim

• LMA: supraglottic tube + mask with inflatable cuff that sits above vocal cords
• NPA: uncuffed tube inserted via nose that sits in posterior oropharynx
• OPA: rigid, inserted into the mouth resting behind the tongue to prevent tongue obstruction of airway
• Cricothyroidotomy: can’t intubate, can’t oxygenate

LL

Dr. Pehle – Palpitations

• Unpleasant , alarming, painful, noticeable feeling in the chest. 
• Afib fairly common 13% diagnosis
  • Tachyarrhythmias
  • afibw/rvr, aflutter, svt, vfib, vtach, torsades
• H&P red flags
  • Chest Pain, exertional, triggers, syncope, AMS
  • Risk factors CAD, DM, CKD
  • Heart failure signs on exam jvd, BLE
• Holter monitor
  • Underlie structural heart disease
  • Fam hx of sudden cardiac death
  • Frequent palpitation that can reproduce their palpitations
• Smart watch?
  • Afib sens and specificity is pretty good
  • Will still miss stuff
• Metabolic/drug causes
  • Thyroid storm
    • Preceding symptoms, gi distress anxiety, trauma, pregnancy, constrast
    • Hyperthermia, tachycardia, AMS
    • Burch-wartofsky criteria – MD Calc likely hood of thyroid storm
  • Caffeine
  • Sympathomimetics
  • Electrolyte disturbances
  • EtOH
• PE and ACS cant miss

Dr. Graham – Back Pain

• DDx Musculoskeletal (DDD, spinal stenosis, herniation), ankylosiing spondylitis, sacroilliits, cauda equina/cona medulari, spinal epidural abscess, metastatic spinal disease, AAA
• Red flags
  • Recen infections, IV Drug use, recent spinal procedure, immunocompromised HIV/AIDs, immunosuppression, cancer, major trauma, weight loss, unremmitting pain / night pain, abdominal pain, fevers/chills, saddle anesthesia, bowel/bladder incontinence, retention
  • PE: motor strength, gait disturbance, BLE sensory loss, saddle anesthesia, DTR BLE, focal tenderness
• Workup – red flags – CT for fractures, CTA vessels, MRI for spinal cord and discs
• Treat NSAIDs, muscle relaxants
• Walking core strength

Dr. King – One Pill can kill

• Opioids
  • Narcan

• Calcium channel blockers, elevated blood glucose, decreased heart rate, can do high dose insulin, ionotropes
• Opiods, fix the airway before giving naloxone. Can give bolus of naloxone every hour instead of drip to expedite transport
• Salycilates
  • Oil of wintergreen 1 tsp = 7g
  • Tinnitus, vomiting, pulm edema, hallucinations, hyperpnea, agitation, delirium
  • NaBicarb, dialysis

– Sulfonylureas

– Need to observe 24hrs

– Octreotide and dextrose

– Clonidine / imidazolines (affrin)

– opioid toxidromes, bradycardia, decreased consciousness, respiratory depression

– tx naloxone, atropin

– IV fluids

– inotropes

Camphor

• Smells of moth balls

• The main route for toxicity is through ingestion. Onset of symptoms can occur as early as 15 minutes after ingestion ranging from sweating and agitation to seizures, cardiac arrhythmias, and cardiopulmonary arrest [1,2].
• Benzos, phenobarbital for seizures in camphor

Amitriptyline

• Na channel blockade, CNS, Cardiac, anticholinergic 
• Long QRS
• Na bicarb tx for cardiac dysrhythmias
• Benzos for seizure

Lomotil

• Imodium
  • Antimuscarinic and opioid symptoms

• Tx naloxone maybe gtt
• Need admission for 24hrs

Ethylene glycol

• Antifreeze degreaser engine coolants
• Oxalate binds with calcium and deposits causing hypocalcemia 
• Thiamine, pyridoxine,
• Tx: fomepizole, dialysis 

Dr. Platt – Syncope

• Reflex, orthostatic, cardiac
• Initial eval – detailed history: prodrome, extertional, position, family history, chest pain, palpitations, hypotension at triage
• Physical exam (cardiac, neuro, orthostatics
• EKG
• High Risk: syncope during exertion or while supine, abnormal cardiac exam, family history or sudden cardiac death, short/ absent prodrome
• RBBw/ LAFB syncope no prodrome and exertion needs admission. 
• Risk stratification tools
  • San francisco syncope rule: CHF, hct, ecg abnormal, sob, SPO2
  • CHESS risk factors 
  • Predicts 30 day serious outcome (arrhythmia death, cardiac event)
  • Scoring history, ekg findings, troponin, ED diagnosis 
• Canadian syncope risk score
  • 0- – 3 low, 1-3 medium, 4-7 very high
• Diagnostic yield – ekg highest at 5-15%

Dr. Harris – Shock small group

• Septic shock
• Pocus for shock, RUSH
• Cardiogenic shock
• Norepi frist line pressor for all shock

LL: Diplopia by Dr. Chady

• Binocular vs Monocular
• Bi – Double vision that resolves when the other eye is closed
  • DDx: Posterior circulation stroke, Cavernous Sinus Thrombosis, Compressive intracranial aneurysm, Botulism, MG

LL: Hematuria by Dr. Sawmiller

• DDx: microscopic vs macroscopic
• Micro : stones infection, viral illnesses, trauma, exercise, menstruation, renal disease, instrumentation
• Macroscopic: renal tumors, avm, aortocaval fistula, kidney stone, trauma, uti, STI
• Workup:
  • UA microscopy, CT urogram ( Ct A/P w/ and wo
  • MRI urography, noncon CT, US abd/pelvis, retrograde pyelogram
  • Cystoscopy
  • Asymptomatic hematuria – Cancer 
  • Trauma >50 RBC get ct scan to assess for injury
  • RUG in urethral injury or pelvic fractures

Ophthalmology Lecture

Vahid

• Visual acuity: near vision card, count fingers, hand motion (what direction is the hand moving), Light perception
• Pupils : Shape, size, direct response and consensual response
  • Anisocoria – CTA head/neck Horner syndrome (ptosis, miosis, anhidrosis), carotid dissection, pancoast tumor
  • Dark room, small pupil horner syndrome dissection pancoast
  • Bright room, large pupil, poor constriction of the big pupil
    • Wipes and plants vs 3rd nerve palsy
    • 3rd nerve palsy, MRI MRA

– EYE Pressure (IOP)

– eye drop pocket technique

– Tap central cornea, breath normally, normal below 22, ED 23-30 could be reasonable. 

– Hold eyelid against orbital rim

– Eye Movements

– entrapment – ischemia of the muscle

– Oculocardiac reflex – bradycardia n/v

– exotropia (outward), esotropia (inward) – call optho

– Amblyopia lazy eye – could be a brain problem

– Pain full eye

– corneal abrasion 

– flip upper eyelid if linear abrasions 

– Pinch eyelash, place cotton tip above the tarsal plate

– Tx: mechanism wood sticks, fingernail, contactlens – moxifloxacin 4x/day for 5 days

– Large, central moxifloxacin QID for 5 days

– Corneal foreign body – qtip preferred , 30 gauge needle bend to 75 degrees, bevel away from the eye, sweeping movement up and down not at the eye

– rust ring remove in the optho clinic – burr increases risk of scar

Cases

Nail glue on eye – erythromycin ointments 

Chemical injury

• Irrigate the eye
• Check pH and recheck pH
• pH should be 7.5

Corneal ulcer and hypopyon

• Infiltration, satellite lesions
• Acanthamoeba – swilling corneal ulcer

Blunt trauma

• Subconjunctival hemorrhage – resolves 2-3weeks
• Hyphema – traumatic rupture of iris blood vessel
  • High IOP – glaucoma and cornea staining 
  • African american patients with hyphema check for sickle cell at high risk of IOP
  • Needs close follow up Grade 1 & 2, call optho 3&4
  • IOP most important 
  • Ipressure lower drops

Traumatic Iritis 

• Happens 2 to 3 days after trauma 
• Traumatic mydriasis 
• Photophobia 

Retrobulbar hemorrhage 

• Orbital compartment syndrome – blood in the back of the eye 
• Needs lateral canthotomy and cantholysis (C&C)
• Proptotic , cant move, pupil big, vision blurry, chemosis
  • Lateral Canthotomy and cantholysis
    • Numb the eye, clamp cantho tendo with hemostat, hold eyelid with forcep and cut with iris or wescot scissors if you have
    • Inferior ramus of the lateral canthal tendon
    • Cut so the inferior eyelid can be pulled up to the limbus
    • Superior cantholysis (superior ramus) be careful to avoid lacrimal gland

Lacerations

• Simple- 
• Margin – optho does this repair 
• Canalicular laceration – laceration lateral near the medial punctum
  • Needs a stent oculplastics does

Globe rupture – penetrating trauma 

• No IOP, no fluorocene no drops
• CT w/o contrast
• Vanc and levaquin
• Tear drop pupil – iris protrudes
• Fly the eye place an eyeshield 

CRAO – central retinal artery occlusion

• Cherry red spot

• Activate code stroke
• < 8 hr activate code LVO
  • tPA intraarterial 

Giant Cell Arteritis 

• Anterior ischemic optic neuropathy
• Visual acuity RAPD Relative afferent pupillary defect , jaw claudication (do you get tired when chewing), proximal stiffness 
• ESR, CRP, CBC 
• High dose IV steroid

Chalazion (Stye)

• Warm compress
• Abx ointment 

Preseptal cellulitis and orbital 

• Orbital cellulitis – eye bulging, pupil changing, subperiosteal abscess 
• Risk factor – sinusitis 
• CT orbits with constrast

Conjectivits

• Viral vs bacterial 
• Allergic pataday eye drops
• Bacterial Purulent topical moxifloxacin 

Optic Neuritis 

• Color vision problems
• pixelated/static vision poorly reactive pupil 
• Painful eye movement up and inward
• MRI Brain/orbit

Acute Angle closure glaucoma

• pain , blurry, headache, n/v
• Mid dilated nonreactive to light
• IOP 30s/40s
• Recent nasal decongestant
• Tx: IOP lowering drops, IV diamox, IV mannitol 

Kids

• Red light reflex absent is bad
  • White reflex 
  • Urgent optho
  • Causes retinoblastoma, congenital cataract

• Eye hand book app

Slitlamp 

• Cell and flare
• 1mm , mag 1.6x, brightest light, 30degrees

Jimmy webb travels

• Angioedema 
• Trips abroad
  • Drake passage is where the pacific meets the atlantic 
  • World explorer is a big boat
  • No boat if you are on dialysis 
  • McGowan watches how people walk
    • She gives people fall risk bracelets
  • Cruise ship doc really good a sea sickness, diarrhea
  • Practicing emergency medicine physician expedition doctor – 3 to 4 weeks
  • Complicating factors that influence patient care
  • Jimmy organized 
  • Too much scopolamine causes naked running
  • Really good boot cleaning 
  • Really cool rocks in antarctica
  • Watch out for the bird flu
  • Really cool rocks in argentina 
  • Wilderness med education swiss alps put on by Utah
    • Chamonix
      • Mount Blanc highest mount in the Alps
        • There is a higher mountain western russian 
    • Rich Ingerstein wilderness med book 
    • Jimmy looks good in jorts
    • 2 french girls said there was a demon on the trail
      • It was an Ibex
    • Nex care tape is the best for blister
  • Lithuania
    • Formal global health elective 

Lightning Lecture – Syphilis by Landon Pehle

• Treponema pallidum
• “The Great Imitator”
• Stages
  • Primary – painless chancre
  • Secondary – rash, lymphadenophty, condyloma lata
  • Tertiary – meningitis, aortitis, aneurysms, argyll robertson pupil
  • Congenital syphilis 
• Testing
  • PRP/VDRL (1st line screening)
  • FTA-ABS (specific testing)
  • Darkfield microscopy
• USPSTF recommends screening in high risk groups
• LP in neurologic, ocular, latent syphilis, HIV coinfection
• Treatment
  • Penicillin G
    • Jarisch-Herxheiner reaction
    • Desensitization

Lightning Lecture – Botulism by Madison Wilson

• Clostridium botulinum
  • Spores
  • Found in soil, water
  • Anareobic
• DDX for MG, GBS, tick paralysis, hypothyroid
  • Botulism with no CNS effects
• Workup
  • Neutralization assay is gold standard
  • CT head
  • Basic lab work
  • LP
• CDC algorithm for initiating treatment
  • Equine derived antitoxin
• Admit to ICU
  • Airway watch, NG tube, foley catheter
  • Recovery is slow
• Infantile botulism
  • pH is higher in GI tract, easier for spores to colonize and release in large intestine
  • Flaccid paralysis, loss of head control, respiratory failure, loss of reflexes
  • Human based botulism IG
• Wound botulism
  • In vivo toxin 
  • Treat with debridement, penicillin, and antitoxin
• Inhalation botulism
  • Aerosol for bioterrorism

Infectious Recommendations from Pharmacy – Dr. Hannah Moore

• Sepsis
  • 30CC/kilo fluids
  • Empiric antibiotic therapy
    • Assess risk factors
    • Previous + micro
      • Previous resistance?
    • MRSA – Vanc (IV), Doxy (PO)
    • Pseudomonas – Zosyn (IV), Cefepime (IV), Cipro/Levaquin (PO)
  • Bacterial meningitis
    • S pneumo, N meningitides, listeria, GBS, H influenza, HSV, VZV
    • CSF findings – bacterial vs viral vs fungal
    • Empiric therapy
      • Ceftriaxone, vanc, ampicillin, acyclovir
    • Steroids
      • Early treatment with decadron improvs outcomes wacute bacterial meningitis 
      • 10mg Q6
  • Bacterial PNA
    • S pneumo, N meningitides, listeria, GBS, H influenza, mycoplasma, chlamydia
    • Outpatient therapy
      • No comorbidities – amoxicillin or doxy, or macrolide
      • Comorbities – augmentin or cephalosporin and macrolide or doxy or respiratory fluoroquinolone
    • Inpatient therapy
      • Non severe vs severe
        • See IDSA guidelines, multiple therapy options given patients history, severity
  • Intraabdominal infections
    • Classifications – uncomplicated vs complicated
    • E coli, proteus, bacteroids, kleibsiella, bacteroides
    • Empiric therapy
      • Based on severity (mild to high risk)
        • See IDSA guidelines, usually recommending combination therapy with flagyl
  • UTI
    • Classifications – uncomplicated vs complicated
    • Asymptomatic bacteriuria
      • Treat pregnant women, patient undergoing urologic procedures, patient with kidney transplant w/n 3 months
    • E coli, klebsiella, proteus, pseudomonas, enterococcus, staph, enterobacter
    • Empiric therapy
      • See IDSA guidelines
  • Skin/soft tissue infections
    • Staph, strep, clostridial, aeromonas
    • See IDSA guidelines
  • Hypersensitivty reactions
    • Type 1 – IgE, anaphylaxis
    • Type 4 – T cell mediated, SJS/TEN
    • Penicillin desensitization in the ED

Sepsis – Dr Hugh Shoff

• Hospital scoring
• Patient safety measures and trends

Infective endocarditis – Dr Jarred Thomas

• Most common site of infection – tricuspid valve
• Most common bacteria – S aureus
• Highest risk factor – previous IE
• Average age of infection is now increasing
  • Current high risk: MRSA, prosthetic valves, ESRD, IV drug use
• Acute vs subacute
• Systemic issues from IE based on left vs right side infection
• Blood cultures
  • Ideally three sets as well as fungal culture
  • Do not obtain from port site
• Treatment
  • Abx
  • Surgery
• Valvular conditions that needs PPX as established by AHA 2021 Guidelines