Conference Notes 01/03/2024

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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.*

81 thoughts on “Conference Notes 01/03/2024”

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  6. Anavar has a major impact on strength, regardless of being a slicing
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    when one is extremely lean. It gets rid of subcutaneous water retention and brings out striations and vascularity that may in any other case be hidden.
    Beginners also have to be conscious the doses which would possibly be right for them won’t be as high as these utilized
    by more experienced steroid customers. Testosterone
    Enanthate additionally promotes nitrogen retention,
    which aids in muscle development and recovery.
    That’s why it’s a popular alternative in multi-compound slicing stacks.
    Yes, legal alternatives like CrazyBulk D-Bal and
    Testo-Max provide muscle-building benefits much like steroids without the risks or
    legal issues. Deca Durabolin is ideal for beginners
    looking to construct lean muscle while improving joint health and recovery.
    Dianabol is a top choice for bulking newbies as a outcome
    of it promotes quick muscle features and enhances energy throughout workouts.
    The really helpful CrazyBulk Winstrol dosage for novices usually ranges from 20 to 50 mg per day over 6 to 8-week cycles.

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    D-Bal’s highly effective formulation mimics the effects of Methandrostenolone, in any other case often identified as Dianabol, the granddaddy of steroids.
    It can really bulk you up, although you’ll need to work exhausting
    during the cutting cycle to get rid of the water you keep during the bulking cycle.
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    Primobolan sometimes ends in average strength and muscle mass positive aspects, whereas Trenbolone
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    Nevertheless, Primobolan has lower androgenic and estrogenic results compared
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    Anavar, also called oxandrolone, is often considered one of many
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    Newbie bodybuilders in search of to add a modest amount of muscle
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  7. Welcome to the superb bodybuilding world, the place every stance and
    flex reveals a story of passion, perseverance, and resilience.
    Posing isn’t only an artwork but an essential factor in determining the end result of bodybuilding reveals.
    It’s not about displaying muscle tissue however about being inventive
    enough to current your body in…
    Anadrol immediately stimulates estrogen receptors, causing noticeable quantities of extracellular fluid retention. For this cause, folks
    primarily use Anadrol as an low season bulking steroid.
    Dianabol is a poisonous oral steroid; thus, it frequently has undesirable results on liver values, aspartate aminotransferase (AST), and alanine aminotransferase (ALT).

    Customers can devour tauroursodeoxycholic acid (TUDCA), a liver assist supplement, to reduce hepatic strain.
    A SERM like Nolvadex might help management gyno, however aromatase inhibitors are ineffective with Anadrol.
    For most Anadrol customers, the appearance of gyno isn’t as pronounced because the water retention this
    steroid notoriously causes. Nonetheless, water retention and hypertension points don’t at all times cause the most bother for some Anadrol users.
    Many negative reviews give attention to unwanted
    side effects that aren’t usually talked about and aren’t common (in other words,
    it could be a bad particular person reaction). Not
    all weight gained with Anadrol shall be pure muscle; will probably
    be removed from it. A lot will be water weight (think 40% and even more), which gives your muscle tissue a pumped-up look.
    Yes, Anadrole is formulated to be a 100% protected and natural formula that doesn’t pose any risk
    to the liver, kidneys, cholesterol, or any other features of your health.

    I will inform you where you can get them legally within the United States and many other
    nations. Some think about Ibutamoren to be an efficient addition to slicing stacks due to
    its capacity to reduce subcutaneous fat mass. Nonetheless,
    one disadvantage is the potential for it to
    increase visceral fat.
    Though injectable Primo is the extra popular type, it’s worth
    noting that oral Primobolan just isn’t a c17-alpha alkylated
    steroid, so it doesn’t carry the same liver toxicity dangers as
    many different orals. Primobolan is a DHT-derived steroid, putting it in the same class as revered AAS like Masteron, Winstrol, and Anavar.

    This means Primo retains most of the properties and actions of DHT itself,
    specifically that there is not a estrogen aromatization exercise – eliminating the chance of water
    retention and gyno. Primo is commonly used to control and steadiness estrogen ranges
    when utilizing aromatizing steroids. The oral form of Primobolan is Metenolone Acetate in chemical type, with the acetate being a small ester hooked up to the Metenolone hormone so it can be consumed in best oral steroid for size kind.
    Unlike many other oral steroids, Primobolan doesn’t come with a excessive threat of liver toxicity; in reality, there are just
    about no known causes of liver stress or damage caused by
    this steroid. Just as it was a preferred golden-era steroid,
    Primobolan retains its reputation at present as an excellent
    and versatile compound for which we can find a quantity of uses.

    This is a extremely potent injectable steroid with potent anabolic and androgenic properties.
    If you had to use just one steroid then Dianabol
    is the one to decide on – it is common and can be
    utilized for both bulking and cutting phases. If you only wish to use one
    bulking steroid, Dianabol is the most effective one to decide on. Nevertheless,
    if you need to take things a step additional, adding it to a stack
    is the one method to go. It Is a quite common follow and probably the greatest
    ways to get even higher outcomes on your bulking cycle.
    If you wish to simply use one steroid to get shredded
    then Anavar (var) is the simplest. In brief; if you have to use one steroid for muscle gain use Dianabol.

    Although Primobolan contributes little to muscle acquire, Winstrol does provide some
    scope for mass achieve throughout this cycle. Women only require
    gentle anabolic results from a steroid to experience features
    in muscle, and Primobolan fits the invoice and comes with a lot much less danger of virilization effects than almost some other steroid.
    Oral Primobolan is most well-liked by females as each the results and unwanted effects are simpler to regulate in comparability with the injection.
    The finest approach to confirm the standard of AAS and steroids bodybuilding is through third-party lab testing.
    Reputable sellers usually provide lab reviews or certificates of analysis
    that verify the purity and potency of their merchandise.
    Anadrol is a very strong steroid to the body especially in relation to bulking.
    Being such robust, it’s not highly beneficial for novices until they
    have gotten used to testosterone already or even Dianabol.
    Even so, they may want low to average quantities to have the ability to tolerate the steroid.

    Consequently, stacking it with oral steroids can pose cardiac issues.
    In analysis, Proviron has been shown to suppress whole testosterone levels
    in megadoses of 450 mg/day (5). Nonetheless, in standard bodybuilding doses, testosterone suppression from Proviron is extra
    acute compared to different steroidal compounds. Complementing steroid use with a
    balanced diet and constant train routine is crucial for attaining and maintaining a lean physique.
    Correct diet, resistance coaching, and cardiovascular exercises,
    along with adequate recovery, can improve the effectiveness of slicing steroids and help
    long-term well being and fitness goals. Correct dosages, well-planned cycles, and post-cycle therapy (PCT) are important to
    mitigate these dangers.
    Because Winstrol just isn’t a bulking or weight acquire hormone, it’s especially suited
    to those wanting to retain as lean physique as possible.

    Winstrol is not a compound you will use for bulking up, neither is
    it one which advantages as a standalone steroid as a outcome of fact it’s not a robust muscle gainer like
    so many different anabolic steroids out there.

    When cycled together, fat loss, muscle positive aspects,
    and power shall be enhanced (as against running a Winstrol-only
    cycle). This is a robust cutting cycle when attempting to drop physique fats ranges rapidly with out shedding
    muscle or power. Steroid stacking has lengthy been a go-to
    strategy for bodybuilders looking to maximize their gains.

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