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. 

TCA Toxicity (Marks)

• Most Common Use for MDD, Neuropathic pain
• 3% of antidepressant overdoses but 20% of deaths
• Toxicity most typically seen within 2-6 hours of ingestion
• Most commonly presents as anticholinergic syndrome
• Workup: Tox, TCA level, BMP, VBG, EKGs (looking for QRS>100ms)
• Tx: Sodium Bicarbonate (1-2 mEq/kg rapid IVP, repeat, stop pH > 7.50-7.55)
• NEVER USE PHYSOSTIGMINE (can cause lethal bradyarrhythmia)
• For Seizure: 1) Benzos, 2) Barbituates/Propofol
• For Hypotension: 1) IVF boluses, 2) Norepi
• Asymptomatic: Observe 6 hours, discharge
• Symptomatic patient: high suspicion: floor vs ICU regarding presentation
• Eisenstat Pearl: Aggressive bicarb early on

Salicylate Toxicity (Hudson)

• Typically presents as Delirium, GI symptoms, Tinnitus, 
• Found in Aspirin, Oil of wintergreen, maalox, pepto bismol, wart removers
• Uncouples oxidative phosphorylation → increased metabolic rate and hyperthermia
• Toxic Dose= 150 mg/kg, Minimal lethal dose 450 mg/kg
• Triple-Mixed Acid Base Disturbance: Resp Alk, AG Metabolic Acidosis, Met Alk
• Workup: ASA, Acetaminophen, CMP, Mag, Phos, UA, VBG, EKG, Tox
• Airway: Avoid intubation unless absolutely necessary, difficult to achieve adequate minute ventilation on vent. Give bicarb prior to intubation
• Breathing: Acute lung injury leads to higher O2 requirements
• Circulation: Hypotension common due to systemic vasodilation, Tx IVF/pressors
• Decontamination: Charcoal, WBI 
• Dialysis: For AMS, Sz, Pulmonary Edema, Hypoxemia, pH<7.20.

Heavy Metals (Eisenstat)

• Metals EM Docs Need to Know- Iron and Lead

Iron

• Used therapeutically in various remedies for thousands of years
• Literally impossible to get iron toxic from normal dietary sources
• In Overdose, oxidative effects irritate GI lining
• 
• Drops cardiac inotropy, Combination of fluid loss, Multisystem organ dysfunction, Leads to Acidosis, shock
• Workup: Iron Level (don’t worry about TIBC/ transferrin) 

Answers to Know for Poison Control Center Consult

• Time and ingestion
• Form and amount
• Serum iron level (& how long from ingestion)
• pH, lactic acid
• Symptoms 
• Imaging (Abd XR)
• Treatment: Activated charcoal doesn’t work, Consider WBI, endoscopy

• Deferoxamine- binds up serum iron and lets you pee it out (5 mg/kg/hr increase to 15 mg/kg/hr)
• Side Effects: Can cause hypotension, ARDS, yersinia infections, Vin Rose urine

Lead

• No safe lead level
• Phased out of gasoline and paint in 1970s
• Toxicity rare in US
• Most common presentation is peds patient sent by PCP who is asymptomatic
• Screening in US done in Medicaid patients, high risk cities, immigrants
• Workup: Send venous blood lead level
• Treatment: Succimer, Calcium EDTA, BAL aka Dimercaprol
• Removing source-talk to health department, remediation of house, surgical removal of bullets

Altitude Sickness (Ganshirt)

Spectrum of diseases caused by too rapid of ascension, inadequate time to adjust to changes in O2 and atmospheric pressures

Acute Mountain Sickness

• Mechanism- We don’t know exactly
• Headache, nausea vomiting fatigue
• Older individuals are less likely to get this (less fit, don’t ascend as fast?)
• Treatment- immediate descent, Dexamethasone vs acetazolamide
• How to Avoid: Slow pace of ascent, Avoid alcohol, Hike day before to get used to partial pressures
• Acetazolamide as prophylaxis for those with history but it has side effects

HACE- High altitude cerebral edema

• Potentially fatal
• Mechanism- vasogenic vs cytotoxic edema
• Signs: AMS, ataxia, gait disturbance, stupor
• Tx- IV dexamethasone, hyperbaric for severe cases
• Prevention- acclimation, Diamox

HAPE- High Altitude Pulmonary Edema

• Mechanism- Heterogeneous pulmonary vasoconstriction
• Tx- slow descent, Supplemental O2, nifedipine gtt
• Nifedipine- reduction in pulmonary artery pressure
• Prevention- acclimation, slow ascent, nifedipine/sildenafil
• Nifedipine is effective prophylaxis in patients with prior episodes of HAPE

Decompression Illness

• Mechanism- pressure driven problem
• Presentation-organ system based
• Treatment- 100% FiO2, Hyperbaric O2
• Prevention- Slow ascent, avoid plane rides home for 24 hours

Hypothermic Cardiac Arrest (Edwards)

Passive External- Remove wet clothes, heated room, blankets

Active External- Heated blankets, bair hugger/ arctic sun, warm humidified air/02

Active Internal- Heated IVF, Bladder and thoracic lavage, ECMO, peritoneal lavage (not here) 

ACLS

• ERC guidelines: up to 3 defibrillations with epi held until temp >30C, then epi q6min until temp > 35C
• AHA guidelines: 3 defibrillations and 3x epi with further dosing guided by response

Termination of CPR

• K > 12
• Asystole persists beyond >32 C
• MUST BE WARM AND DEAD

Outcomes

• Impressive outcome statistics
• WITNESSED hypothermic arrest: approx 73% survival to discharge and 89% of survival with favorable neurologic outcomes

*Screenshots of charts taken from WikiEM.*