The sickest patients, who receive world-class care in the trauma/critical care bay of University of Louisville Department of Emergency Medicine
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- ITE- grab bag (E Thomas)
- Spider bite, necrotic wound>brown recluse
- MCC erythema multiforme> HSV
- Strawberry cervix>trich
- Pre-E, less than 24 weeks>mole pregnancy
- Abdominal pain after sex>ovarian torsion
- Most common personality disorder>borderline
- Patient intentionally fakes symptoms>malingering
- Sudden paralysis after traumatic event>conversion
- Discriminatory zone for TVUS>1500
- PID/RUQ pain/shoulder pain>Fitz Hugh Curtis
- MCC postpartum hemorrhage>uterine atony
- Pizza pie fundus>CMV
- Corneal dendrites>HSV keratitis
- Tachycardia out of proportion to fever>thyroid storm
- Alcohol, AMS, ataxia, nystagmus>wernicke
- Stingray wound>hot water
- Beta blocker OD>hypoglycemia
- One Pill Can Kill (Lund)
- Ingestions–fatal in small doses
- CCB
- Cyclic antidepressants
- Lomotil
- Opiates
- Salicylates
- Toxic alcohols
- Sulfonylureas
- Camphor
- Clonidine
- Antimalarials
- CCB OD
- Hypotension, bradycardia, bradydysrhythmias, hyperglycemia
- Tx: charcoal, fluids, atropine, calcium, intralipid
- Salicylates
- Oil of wintergreen, ASA, pepto-bismol
- n/v, tinnitus, delirium, hallucinations, pulmonary edema, cerebral edema, mixed anion gap metabolic acidosis with respiratory alkalosis
- Sulfonylureas
- Hypoglycemia, lethargy, irritability, confusion, HA, seizures
- Tx: observation x24 hrs
- Dextrose bolus, then consider infusion
- Can give octreotide (inhibits secretion of insulin)
- Clonidine
- Alpha 2 agonist, (afrin, visine)
- Opioid syndrome: lethargy, coma, miosis, respiratory depression
- Tx: naloxone, atropine, IV fluids, inotropes
- Camphor
- Campho-phenique, vicks vaporub
- GI distress, generalized warmth, CNS hyperactivity, CNS depression, n/v, oropharyngeal irritation/burning/stinging
- Tx: benzos, phenobarb
- Amitriptyline
- CNS depression, seizures, cardiac conduction abnormalities (QRS prolongation), hypotension, mydriasis, flushing, dry mucous membranes, hallucinations, hyperthermia
- Tx: benzos for seizures, sodium bicarb for QRS widening >100ms
- Lomotil
- Opioid receptor agonist +/-atropine
- Classically biphasic, with anticholinergic symptoms 2-3 hours s/p ingestion followed by opioid symptoms
- Tx: naloxone
- Dispo: admit
- Toxic Alcohols (Bosse)
- Ethanol
- Can cause hypoglycemia
- Is dialyzable
- Isopropanol
- Rubbing alcohol
- Metabolized to acetones
- No metabolic acidosis
- Supportive treatment, can be dialyzed
- Methanol
- Windshield washer fluids, solid cooking fuel, embaling fluid, tainted beverages
- Toxic metabolite is formate (formic acid)
- CNS effects, visual effects, pancreatitis, symptoms delayed in onset
- Metabolic acidosis with elevated anion gap
- Ethylene glycol
- Antifreeze (sweet taste)
- Toxic metabolites: oxalate, glycolaldehyde, glycolic acid, glyoxylic acid
- CNS effects, metabolic acidosis, renal toxicity, myocardial dysfunction
- Oxalate can cause hypocalcemia by calcium oxalate precipitation
- Oxalate crystals in urine
- Wood’s lamp to urine, antifreeze products may contain fluorescein, not a great test
- Osmol gap
- Difference between measured serum osmolality and calculated serum osmolarity
- Normal serum osmolality: 275-295 mOsm/kg
- Antidotes
- Ethanol, fomepizole
- Competitive inhibitors of alcohol dehydrogenase
- If ethanol must be used, give orally. Keep blood level >100mg/dL
- Treat if methanol or ethylene glycol level >20mg/dL
- Can be stopped once level less than 20mg/dL
- Dialysis
- Consider if patient has end organ manifestations (even if levels undetectable)
- Folic acid for methanol
- Thiamine and pyridoxine for ethylene glycol
- Send methanol and ethylene glycol levels ASAP