Toxic Alcohols – Dr Eisestat

Ethylene glycol is a glycol and not an alcohol, however still included with methanol as the more toxic alcohols.

Isopropanol and ethanol can still be toxic but significantly less so than methanol and ethylene glycol.

Isopropanol

• Rubbing alcohol
• Metabolizes to acetone
• Can have GI irritation and severe intoxication from this
• Hemorrhagic gastritis can result

Methanol can be found in windshield washer fluid, solid cooking fuel, embalming fluid, and tainted beverages

• Formalin (used in cadaver labs) contains methanol and formaldehyde which is fatal in small mL doses.
• Moonshine called “white lightning” because it causes a white out of your vision with damage to the retina, much like the sensation of being struck by lightning.

Methanol

• Toxic metabolite is formate (formic acid)
• Can result in ocular toxicity, pancreatitis, basal ganglia damage

Ethylene Glycol

• Antifreeze
• Sweet taste (which is a problem for pets and small children)
• Breaks down to glyoxylic acid which involves the renal tubules which results in renal toxicity.
• Oxalate can cause hypocalcemia by precipitation as calcium oxalate.
• Oxalate crystal can form in the urine and can be examined with a wood’s lamp because antifreeze usually contains fluorescein.

Can be treated with ethanol and fomepizole

• Blood ethanol 100-105 mg/dL for treatment
• Children will often be hypoglycemic with treatment
• Adults will become “rowdy.”

Fomepizole

• Approx. $2,000 per dose
• 15mg/kg loading dose then 10mg/kg every 12 hours for 4 doses.
• Increase to 15mg/kg after that if therapy still necessary
• Administer more frequently in hemodialysis

Anyone who has acidosis, clinical symptoms, or concentration greater than 20mg/dL gets treatment.

Hemodialysis

• Half life of ethylene glycol 15 hours
• Half life of methanol 50 hours

https://www.extrip-workgroup.org/ contains a list of recommendations for hemodialysis.

Pancreas – Dr Huecker

The pancreas is retroperitoneal and may not always show signs of peritonitis until very advanced disease.

Lipase will generally have to be 3x upper limit of normal to diagnose pancreatitis

Amylase sensitivity is less than 80%. Lipase is a better test.

CT

• Sensitivity 70-80%
• On a non-contrast scan you are more likely to miss necrotizing pancreatitis

If CT is positive, the patient should be evaluated with ultrasound for concern of gallstone / biliary pathology.

Scorpions and autoimmune are rarer causes of pancreatitis

Management

• Initial 10mg/kg bolus and then 1.5 mL/kg/hr

Multiple scores such as BISAP and Marshall score can be used to risk-stratify

Most patients do not require antibiotics, however if there is extrahepatic infection or necrosis, it is necessary.

Imipenem and meropenem are specific antibiotics which can penetrate the biliary system well.

Abdominal hypertension is a potential very serious risk

Encourage early enteral feeding in mild cases

Pseudoscysts:

• Consider this diagnosis and obtain CT A/P
• If you don’t think about it, you wont diagnose it.
• Can be drained with IR or GI

Pancreatic Cancer:

• 7^th leading cause of death
• Painless jaundice is a big indicator.

Pediatric Lower GI Bleeds – Dr. Lyvers

Usually occur inferior to the ligament of Trietz

80-90/100,000 complaints of peds ED visits

• Most are self-limited, however can be more complicated if there is severe bleeding, lethargy, fever, pallor, etc.

Some cases of suspected GI bleeding are not blood

Red Brick Diaper Syndrome

• Caused by increased concentration of uric acid crystals in a newborn. Common and benign finding.

Cefdinir – Often a cause of red-purple stools

Some cases are blood but patients are not sick

Melena Neonatorum – Swallowed maternal blood during delivery or breast feeding, is the most common reasonof melena in a neonate. Can use the Apt test looking for HbF.

Anal Fissures

Some cases are a result of very concerning pathology

Midgut Volvulus – Occurs within the first month with bilious emesis and abdominal distention. Hematochezia is a late finding. Diagnosed by abdominal x-ray or upper GI series.

Nectrotizing Enterocolitis – Most commonly presents in pre-term infants in the NICU, however 13% occur in term neonates. Usually occur with underlying predisposition with sepsis or CHD. X-ray will show pneumatosis intestinalis or ileus in the early stages.

Hirschsprung’s Disease – Failure of neural crest cells to migrate during intestinal development resulting in aganglionic segments of bowel. Typically diagnosed as a failure to pass meconium in first 48 hours.

Hirschsprung’s Associated Enterocolitis – Can be seen 3 weeks to years after surgical repair. Abdominal distension, fever, vomiting, lethargy, foul smelling and bloody stools which can lead to shock. Provide with broad spectrum abx + metronidazole, as well as good resuscitation.

Meckel’s Diverticulum – Painless rectal bleeding caused by incomplete obliteration of the omphalomesenteric duct. Occurs from bleeding mucosal ulceration. Diagnosed by technetium-99 scan which collects dye in the gastric mucosa. 2x more common in males. 2 feet proximal to the ICV. 2 inches long. Symptoms occur before 2. 2% of patients develop complications.

Intussusception – Occur with currant jelly stool in later stages. Most common cause of obstruction 6 to 36 months. Diagnosed via ultrasound. Management initially with air enema and surgery if not successful.

Milk Allergy – Painless blood in stool in an exclusively breast fed infant occurring from 2 weeks to 1 year which resolves by 18 months. Can have a cross reactivity to soy protein. Can continue breast feeding if child is growing appropriately.

Infectious Colitis – Most common cause of hematochezia across all ages. Most common pathogen causing complications is HUS O157:H7 and other shiga toxin producing E Coli. Triad of microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury. 5-10 days of diarrhea in children < 5 years old. Early antibiotic administration may increase risk. 50% of kids who develop HUS require a period of dialysis.

Inflammatory Bowel Disease – Collection of diseases which include crohns disease, ulcerative colitis

Solitary rectal ulcer syndrome

GI Duplication Cysts

IgA Vasculitis (HSP)

Abdominal Pain – Dr. Thomas

Leading cause of ED visits 8.9% of cases

Up to 40% of patients may be discharged with a diagnosis of nonspecific abdominal pain

7% of all abdominal pain patients with life-threatening processes will present with NORMAL vital signs.

Risk is higher in elderly patients, especially with vascular causes.

History:

Abrupt onset is typically worse. Nausea / vomiting is more likely a surgical process.

Information on location and migration are useful.

Severity and description can vary greatly and has a low sensitivity and specificity.

Physical Exam:

Start in areas AWAY from where they localize the pain. Be complete.

Do not forget pelvic exam, rectal exam, or testicular exam, if required.

Imaging:

Abdominal x-rays are useful for obstruction, free air, or foreign body.

CT is often the most useful test, however is typically overused and comes with risk such as contrast reaction, cost, radiation, and difficulty managing care on a sick patient in the CT scanner.

High Risk Abdominal Pain

• Elderly
• Immunosuppressed
• Hepatology patients with ascites
• Post-op patients
• Traumatic patients

Visceral pain – occurs with stretching of the organs. Colicky and difficulty to localize. Ex: umbilical pain in early appendicitis

Somatic pain – Peripheral nerve pain from irritation, such as peritonitis. Better location with intense / constant pain. This is when pain associated with peritonitis or rebound pain can occur.

Referred pain – Any pain felt at a distance from the source

Elderly patients with presentation to the ED with abdominal pain have an approximately 10% mortality rate. 42% of these patients required surgery.

• Immune function decreases with age.
• Underlying conditions decrease immune function and reserve
  • Such as vascular, pulmonary disease, as well as DM.

Hysterectomy does not require pregnancy test, however a tubal ligation always does.

UTI / Pyelonephritis increases the risk of miscarriage, however PID is rare once pregnancy is established.

Pregnant patients may have the same etiology of pain as non-pregnant patients

• Biliary / appendix / gerd

Always have concern for SBP in a cirrhotic patient

• E Coli is present in 43% of isolates
• SBP usually is treat with a 3^rd generation cephalosporin, however always add vancomycin if they have a history of a staphylococcus aureus positive blood culture.

Paraplegic Patients

• Present a large risk when they are unable to feel a large majority of pain. May be only able to feel visceral pain or cramping.

Post-operative patients with shoulder pain may be peritonitic.

CT Abdomen / Pelvis -Dr. Elsaidy

Aorta

• Dissection / aneurysm

Thrombosis

• PE (right heart strain)

Air

• Emphysematous infection
• Free air
• Obstruction

Search Pattern

1. Air  in the lower chest (lung / heart / PE) then bowel
2. Bone (ribs, VBs, pelvis)
3. Circulatory (PE / dissection / aneurysm / active bleeding)
4. Solid organs
5. Feather (soft tissues)
6. Genitals

Respiratory Pharmacy Lecture – Zacharry Dougherty PharmD

Community Acquired Pneumonia (CAP)

• ATS/IDSA guidelines for treatment of adults with CAP
• Typical organisms include strep pneumoniae, H. Influenzae, M. pneumoniae
• Be aware if the patient has a history of MRSA / Pseudomonas colonization
• Risk stratify patients with a calculator such as Pneumonia Severity Index (PSI) to determine inpatient vs outpatient treatment.

Outpatient:

• With vs without comorbidities
• Without (Single agents): Amoxicillin 1000mg TID, Doxy 100mg BID, Azithromycin 500mg daily for 3 days.

Azithromycin monotherapy not recommended due to local S. pneumoniae resistance rates

• With: Augmentin 875mg BID plus doxy or azithromycin for 7 days
• Cefpodoxime 200mg BID or Cefuroxime 500mg BID plus doxy or azithromycin for 7 days
• Levofloxacin 750mg daily for 7 days

Clinical success is highest with cephalosporins.

Cefdinir technically has appropriate coverage, however some strains of these bacteria have resistance to this, and for this reason, it is not recommended by the ATS/IDSA

Multi Drug Resistant (MDR) Coverage:

• Doxycyline 100mg BID for MRSA coverage and Levofloxacin 750mg daily for p. aeruginosa

Always consult your hospital antibiogram

Inpatient (Nonsevere vs Severe CAP):

Nonsevere:

• Ceftriaxone 2g Daily + Azithromycin

If Prior culture, or recent hospitalization, add MRSA coverage with Vancomycin

If Prior culture, for pseudomonas change ceftriaxone to cefepime.

Severe:

• Cefepime 2g Q8 or Zosyn 4.5g Q6 (plus vancomycin and azithromycin)

Anaerobic Infections:

• Less common, however lung abscess, empyema, and necrotizing pneumonia make this more likely to occur.

Room 9 Follow-up – Madelyn Huttner MD

Age 60s F found down at home confused by family with black sputum. Hx of suspected IBS. Seen initially in room 9. HR 100, BP 100/60, 94% NRB, afebrile. GCS 14, pale, dried black emesis and stool covering her body.

Orders:

• CBC, CMP, Type and cross, Lipase, Coags, UA, CXR, ABG, Lactic Acid

Consider CTA A/P – was not obtained in this case

Medications:

• Protonix, Octreotide, Ceftriaxone, IV Fluids, Blood products

Consider reversal of anticoagulation

Procedures:

• Intubation, Central line, A line

Consider Minnesota tube

Anticipate significant blood in the airway

SALAD (Suction Assisted Laryngoscopy) Technique

ABG 7.3 / 29 / 45 / 14. Hgb 11.6

Na 130, K 3.2, Cl 96, BUN 46, Cr 2.2

Lactic 4.4

GI and MICU consulted from room 9. Patient found to have a history of excessive NSAID use.

Taken for emergent EGD with GI. Found to have significant esophagitis, diffusely ulcerated gastric mucosa and duodenitis.

Overview of Lithuanian Healthcare System – Simona and Deimante

Universal coverage throughout Lithuania. Patients can choose private insurance, however emergency care is fully covered. Private care is used for elective care, and faster access to care, but not common for emergency care. Can show your ID and have no-copay emergency care throughout Europe.

ED systems are based in public hospitals in major centers in Vilnius, Kaunas, and Klaipeda.

Country has a shortage of emergency medicine specialists. General practitioners are gatekeepers to other specialists.

Vilnius and Kaunas are tertiary care centers and trauma centers.

Gallbladder / Biliary Disease – Tim Price MD

30s Male with 4 days of abdominal pain. Pain is consistent and has been steadily worsening. Described as a dull pain. Located in the upper abdomen. If he lays on his back and holds his hands up, his pain is relieved. Has had regular bowel movements but has some nausea a small amount of emesis 3 days ago, as well as decreased appetite. Denies fevers or chills. Has taken hydrocodone which did help somewhat. Denies dysuria.

Differential: Cholecystitis, Choledocolithiasis, Biliary colic, Pancreatitis, Pyelonephritis, Nephrolithiasis, Hepatitis, ACS, Gastroenteritis, AAA, Cannabis hyperemesis

Labs: Elevated tbili on labs. Normal leukocyte count with neutrophil predominance

POCUS Gallbladder US: Gallstone present without pericholecystic fluid. No anterior gallbladder wall thickening. +Sonographic murphy sign.

CT – Significantly enlarged gallbladder wall

Disposition to Baptist for surgery