Conference Notes 1/6

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  • Aspirin Toxicity (Harmon)
    • Sources of salicylates
      • Aspirin
      • Oil of Wintergreen
      • Pepto-Bismol
      • Bengay
      • Alka-Seltzer
      • Skincare products
    • Mechanism of toxicity
      • Fatal dose 10-30 g in adults
      • Dose dependent
      • Acute vs chronic
      • Increases respiratory center sensitivity, uncouples oxidative phosphorylation, inhibits TCA cycle/amino acid metabolism, stimulates chemoreceptor/trigger zone
    • signs/symptoms
      • Tinnitus, nausea, vomiting, dizziness, fever
      • Ataxia, anxiety, lethargy, AMS, seizure, arrhythmias, seizure
    • Evaluation in ED
      • Serum salicylate concentration and trend
      • ABG
      • CBC, CMP, coags, EKG, UA, tox
    • Management
      • Gastric decontamination (ingestion w/in past 1-2 hours)
      • Sodium bicarb (consider if level >40)
      • Avoid intubation as long as possible
      • Fluids
      • HD
      • Poison Control
  • Acetaminophen Toxicity (Cook)
    • Signs/Symptoms
      • Stage I: anorexia, n/v, elevated transaminases
      • Stage II: RUQ pain, elevated transaminases
      • Stage III: hepatic failure, acidosis, renal failure, pancreatitis, peak transaminase levels
      • Stage IV: multi-organ failure vs resolution
    • Lab Assessment
      • APAP levels
        • Within 1-4 hrs of ingestion, used to exclude ingestion
        • Obtain 4 hour level to get estimated peak absorption
      • CBC, CMP, ABG
    • Rumack Matthew Nomogram
      • Treatment line 
        • begins at 4 hr mark
        • If above line, treat
    • Treatment
      • Activated charcoal
      • N-Acetyl Cysteine
        • Replenishes glutathione stores to conjugate NAPQI to limit hepatocyte injury and promote renal excretion
  • TCAs (Weeman)
    • MOA
      • SSRI/SNRI, antihistamine, alpha antagonist, anti-muscarinic 
    • Symptoms
      • Early: anticholinergic effects, HTN, AMS
      • Late: myocardial suppression, QRS widening, seizures, ventricular dysrhythmia, hypotension
    • Mimics: diphenhydramine, carbamazepine, sympathomimetic toxicity, serotonin syndrome
    • Assessment
      • EKG, UDS, TCA level (does not correlate with severity)
    • Management
      • Activated charcoal if within 1 hour of ingestion
      • Do not treat early HTN as patients will likely develop hypotension as they progress, treat hypotension with normal saline
      • Sodium bicarbonate
        • IV push if QRS exceeds 100 msec
        • Infusion to maintain pH 7.5-7.55
      • If seizing, use IV benzos or phenobarbital if refractory
  • Clinical Pathway Opioid Overdose (Leavitt, Sizemore)
    • Duration:
      • Heroin half life: 3-8 min, metabolites ~3hrs
      • Fentanyl half life: 2-4 hrs
      • Oral opioid half life: 3 or more hours
    • Narcan
      • Opioid antagonist
      • In general, don’t exceed ~5-10 mg, but can titrate to effect
      • Route
        • IN/IM/SC: slower onset, longer duration
        • Intranasal can last ~3hrs
        • IV
        • Infusion: 
          • Mix 4mg naloxone in 100 mL D5W
          • Infusion rate at ⅔ of effective dose that initially reversed the patient
      • Can repeat dosing every 3 minutes 
    • St. Paul’s Early Discharge Rule
    • HOUR Study
    • Clinical Pathway to be posted soon
  • Envenomation (Giddings)
    • Ciguatera
      • Heat stable toxin
      • Barracuda, red snapper, mostly reef/tropical fish
      • GI symptoms, paresthesias, hot/cold reversal, bradycardia
      • Treatment: antiemetics, atropine, mannitol
      • Mechanism: increases permeability of sodium channels inducing membrane depolarization
    • Scombroid
      • Caused by improperly stored fish, heat stable toxin
      • Symptoms: flushing, warmth, urticarial rash, palpitations, itching
      • Causes histamine release
      • Tx: antihistamine
    • Coral Snake (Elapidae)
      • Presentation: minimal local symptoms, severe systemic symptoms, respiratory paralysis, AMS, CN palsies
      • Complications: hypovolemic shock, DIC
      • Work up: CBC, CMP, coags, fibrinogen, d-dimer
      • Treatment: anti-venom, aggressive supportive care
      • Dispo: Admit, concern for neurotoxic effects including respiratory failure, can have delayed presentation
      • Mechanism: cholinergic
    • Crotaline (Pit Vipers)
      • Presentation: Local pain/tissue damage, fang marks, coagulopathy, weakness, n/v
      • Complications: swelling, compartment syndrome, DIC, hypotension
      • Treatment: CroFab (give if bad systemic symptoms, abnormal labs, AMS, significant swelling)
    • Black Widow
      • Presentation: Pinprick bite, pain to whole extremity, muscle cramps, tachycardia, hypertensive, can mimic appendicitis
      • Management: supportive care, antivenin for severe symptoms
    • Tarantula
      • Barbed hair, can penetrate cornea, may need ophthalmology consult
      • Supportive care
    • Brown Recluse
      • Painless bite, local tissue necrosis
      • Systemic effects are rare
      • Treatment: supportive
  • High Altitude Medicine (Thurman)
    • Physiology
      • High Altitude: 1500m, Very High: 3500m, Extreme: 5500m
      • Begin to see altitude illness at around 2500m/8000ft
      • As altitude increases, percentage of oxygen available decreases
    • Acclimatization
      • Respiratory compensation by increasing minute ventilation, which decreases PaCO2
      • Renal compensation by increasing excretion of bicarbonate
        • Associated diuresis can exacerbate altitude illness and increase dehydration
    • Acute Mountain Sickness
      • Headache, GI symptoms, fatigue/weakness, dizziness/light-headedness
      • Prevention (ideally start 1 day before trip, continue 1-2 days after patient is at highest altitude)
        • Acetazolamide 125 mg q12hr
        • Dexamethasone 2mg q6hr or 4mg q12hr
        • Gradual ascent
        • Ibuprofen 600 mg q8hr
      • Treatment
        • Halt ascent until symptom free
        • Only need to descend for severe symptoms
        • Supplemental oxygen, dexamethasone, acetazolamide
    • High Altitude Cerebral Edema
      • Acute mountain sickness + mental status change, ataxia
      • Treatment
        • Immediate descent/evacuation
        • Supplemental oxygen
        • Dexamethasone
        • Portable hyperbaric chamber
        • Acetazolamide 
    • High Altitude Pulmonary Edema
      • Non-cardiogenic pulmonary edema
      • Symptoms (need at least 2)
        • Dyspnea at rest
        • Cough
        • Chest tightness/congestion
        • Weakness/decreased exercise tolerance
      • Signs (need at least 2)
        • Crackles or wheeze
        • Central cyanosis
        • Tachypnea
        • Tachycardia
      • Prevention
        • Gradual ascent
        • Nifedipine 30 mg q12hr or 20 mg q8hr
        • Tadalafil/Sildenafil
      • Treatment:
        • Immediate descent
        • Supplemental oxygen
        • Nifedipine
        • Portable hyperbaric chamber
        • tadalafil/sildenafil
        • CPAP
  • COVID (Brown)
    • Symptoms
      • Typical of most viral syndromes
    • Lab abnormalities
      • Elevated WBC, LDH, d dimer, ferritin, ESR/CRP, procal, ALT/AST, t bili, troponin, CK
      • Low lymphocyte count, albumin, platelet count, hemoglobin
    • Imaging
      • Normal vs bilateral pulmonary opacities
    • Airway management
      • Pre-oxygenate with NRB or HFNC
      • Consider supraglottic airway with viral filter
      • Video laryngoscopy
      • Trial HFNC or non-invasive ventilation prior to taking airway
      • Low tidal volumes, permissive hypercapnia, ARDSNet protocol
      • Consider proning
    • Treatment
      • Supportive treatment
      • Bamlanibimab
      • Dexamethasone
      • Remdesivir
      • DVT ppx if hospitalized
    • Disposition
      • Walking O2 test
      • 4C mortality score
  • Pacemakers (D. Thomas)
    • Prevent HR from falling below set limit
      • Pacing
      • Sensing
    • Malfunction
      • Failure to capture
        • Low battery
        • Inflammation
        • Loose or displaced lead
      • Sensing issues
        • Undersensing
        • Oversensing 
    • Management
      • Typical bradycardia management
      • Atropine, epinephrine, transcutaneous pacing, transvenous pacing
    • Magnet placement
      • Opens Reed switch with breaches sensing circuit and will pace regardless of intrinsic cardiac activity 

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