Wernicke/Korsakoff (Blair)

• Wernicke = acute neuro change from thiamine deficiency = triad of encephalopathy, oculomotor dysfunction, gait ataxia 
• Korsakoff = chronic sx = antero/retrograde amnesia, confabulations, confusion, apathy 
• Thiamine important in energy production, lipid metabolism
• Most often d/t insufficient intake (alcoholism, starvation/anorexia, etc.), but also from malabsorption, increased metabolic requirements
• Tx: give thiamine (before glucose if they need that too), also give magnesium (as they’re usually hypomagnesemic)

Pheochromocytoma (Mattingly)

• Increased catecholamines d/t rare tumor in adrenal medulla
• Associated with familial syndromes (MEN 2A and 2B)
• Presentation: only 50% are symptomatic with episodic headache, tachycardia, diaphoresis
• Low vs high risk workups, but overall looking for (urine or plasma) metanephrines and catecholamines, if positive then get CT adrenal protocol or PET (usually inpatient side) 
• Treat hypertensive crisis with alpha-blockade (phenoxybenzamine or phentolamine), nitroprusside, or nicardipine; don’t give beta-blocker d/t risk of unopposed alpha activity! Eventually need tumor resection
• Be aware in ED of tumor recurrence even after tumor resection; avoid meds that cause crisis (BB, glucagon, histamine, reglan, corticosteroids)

Pharmacology in Hyperglycemic Crisis (Loudermilk) 

• Be aware of long vs short acting insulin > regular insulin drip is what’s used in DKA 
• Oral/injectable diabetic medications: biguanides (metformin), sulfonylureas (-zides), TZDs (pioglitazone), SGLT2i (jardiance), DPP4 (januvia), GLP-1 agonists (ozempic, trulicity) 
• DKA management: IV fluid therapy with 15-20 mL/kg over 1 hour
• Current protocol does NOT have insulin bolus, so just start the drip 
• Bicarb drip not recommended unless pH < 6.9
• Current order set is only “MED DKA”, but we will soon have ED specific DKA order set includes fluids, insulin gtt, K replacement, labs/VBG/vitals 

Pediatric Seizures (Isacoff) 

• Focal/partial (with or without impairment of consciousness) vs generalized seizures
• ABG/VBG in post-ictal patients not normally helpful – it’s already going to look bad even if not having respiratory failure
• BVM more favorable if still unconscious but starting to wake up, try not to intubate unless absolutely necessary 
• Look for metabolic derangements: sodium, glucose
• Management: ABCs, fyi: succinylcholine contraindicated in suspicion for muscular dystrophy, use roc or vec 
• Anticonvulsant tx for seizure > 5 min: rectal diazepam (home), intranasal versed (0.2mg/kg max 5), or IV ativan (0.1mg/kg up to 4mg)… treat with benzo x3 times, then phenytoin/fosphenytoin or phenobarbital; consider pyridoxine (vit B6) in kids < 1 with refractory seizures 
• Consider CT/MRI if signs of increased ICP, focal/persistent seizure

Diabetic Emergencies (Kuhl)

• 500+ million people affected by diabetes in world
• Common physician pitfalls: delayed ID of DKA, insulin therapy mistakes
• DKA = hyperglycemia + ketones + acidosis (bicarb < 15 or pH < 7.3) 
• HHS = glucose > 600, serum osm > 320, absence of ketoacidosis, presence/absence of coma no longer part of diagnosis 
• Don’t really need ABG/VBG to diagnose DKA (it costs ~ $300), utilize your serum bicarb instead
• End tidal CO2: low for DKA (<21, 100% specific) (d/t increased RR), high then not in DKA (>35, 100% sensitive)
• IV fluid choice: LR better in septic and medicine patients (SMART trial), no significant difference in ICU patients (SALT trial); large boluses of NaCl in DKA has risk of hyperchloremic metabolic acidosis
• Insulin drip 0.1 units/kg/hr going until ketoacidosis is resolved (normalization of pH, bicarb, and closure of anion gap)… NOT guided by blood glucose 
• K management: losing K d/t osmotic diuresis or falsely elevated as it’s extracellular but not in cells; if <3.5 then hold insulin, add in IVF, 3.5-5.5 then start insulin but also give K in IVF, if  >5.5 then just start insulin and no need to supplement
• Pseudohyponatremia – Na decreases by 1.6 for every 100 increase in glucose 
• Most common cause of DKA in US is med nonadherence, infection is 1st outside of US
• Euglycemic DKA possible with SGLT2i
• Consider D10 instead of amp of D50, less caustic and better outcomes

R1 Lightning Lecture – Thyroid Storm (Dr. Perling):

• Thyroid storm: “extreme hyper metabolic state caused by increased thyroid hormone” 
• Most commonly caused by Graves disease 
• Burch-Wartofsky Point Scale is a tool that can help point to thyroid storm, though be cautious as it can be nonspecific (sepsis, etc.)
• Tx: active cooling if hyperthermic (can give Tylenol too); beta blocker > PTU/methimazole > steroid > wait 1 hour > iodine (in that order) 
• Manage other concomitant conditions accordingly: i.e. amio for a-fib, benzodiazepines or olanzapine for agitation

R1 Lightning Lecture – Addison’s and Cushing’s disease (Dr. Hudson)

• Addisons = low steroids, Cushings = high 
• Addisons: usually autoimmune, “low” symptoms like hypotension, weight loss, fatigue, hyperpigmentation
• Tx: lifelong corticosteroid replacement (hydrocortisone) 
• Adrenal crisis – give high dose corticosteroid, treat hypotension and glucose as needed 
• Cushings: chronic exposure to excess corticosteroids, “big” symptoms like weight gain, buffalo hump 
• Cushing syndrome (problem with gland) vs Cushing disease (problem with brain)
• Dx and management is usually inpatient/outpatient (not in ED): need urine 24 hour cortisol level, treat sequelae in ED as needed (glucose, electrolytes) 

R2 Small Group Cases (Dr. Beard)

• Case 1 – DKA: look for hyperglycemia, ketones, acidosis. Watch potassium and rapid fluid administration (cerebral edema)
• Case 2 – HHS: severe hyperglycemia usually without ketones; high serum osmolality. Treat with aggressive fluids. Mortality much higher than DKA. 
• Case 3 – Adrenal crisis: consider in patients with unexplained hypotension, watch electrolytes (hyponatremia, hyperkalemia), give corticosteroids. 
• Case 4 – Myxedema coma: hypothyroidism, mental status change, hypothermia, +/- precipitating factor (infection, med noncompliance). Tx with levothyroxine, corticosteroid, passive warming, and precipitating cause (sepsis). 

R3 Case Review (Dr. Hill-Norby)

• Pre-Eclampsia: new onset hypertension in pregnancy (usually > 20 wks or up to 4 wks post-partum)
• Diagnosis made by BP + proteinuria, or based on BP and presence of end-organ damage (severe features) without proteinuria
• Treat BP with labetolol, hydralazine, or nifedipine
• Treat seizures with magnesium!
• Needs urgent delivery

• Severe Hyponatremia – usually symptomatic < 120
• If seizing w/ known hyponatremia -> 3% hypertonic saline bolus (around 150cc), can use sodium bicarb amp if do not have hypertonic saline easily

• Pres syndrome

Diagnosis of exclusion

Keep in your differential 

Treat for hypertension, consider MRI

• MS

3 associated conditions – INO, optic neuritis, dysautonomia

• Spinal cord syndromes

Anterior cord – hyperflexion

Central cord – hyperextension, elderly

Brown sequard – stab in the back classic

• Transverse myelitis

Bilateral, highly associated with MS

High dose steroids and plasma exchange 

• NMJ disorder

Botulism – presynaptic acetylcholine receptor

Myasthenia gravis – post synaptic acetylcholine receptor

Lambert Eaton -presynaptic ca channel

NIF is the negative inspiratory force, strength of inhale. 0- -20 is weak, needs intubation

• GBS

Steroids worsen mortality

Ascending weakness

Miller fisher variant 

Albuminocytologic disassociation 

• Bell’s palsy 

Peripheral cause of facial weakness

Does not spare the forehead

Steroids

Acyclovir if presents within time frame

Artificial tears

• Ramsey hunt syndrome 

Zoster

Vesicles of the ear

Steroids

Acyclovir

• Bilateral Bell’s palsy – Lyme disease

• Lumbar puncture 

Contraindications – Cellulitis, Fracture, Epidural abscess

Platelet must be atleast 50k

Head CT before LP , r/o increased icp 

L3-4 or l4-5

20 gauge is good, decreased spinal headache

Traumatic and larger needles have higher chance of LP headache

Lateral decubitus position (if you want pressure) versus sitting position 

• LP headache
  • need fluids
    • Worse with standing or position changes
      • Blood patch if refractory

• Multiple Sclerosis

Demyelinating CNS disease

INO

Optic neuritis – pulfrich test (feels something is coming at them when its not), red saturation test (changes to pink on affected eye)

MRI gold standard

Oligoclonal bands in CSF highy suggestive of MS

High dose steroids is treatment

• Posterior rib fractures in child should raise suspicion for fracture

• WPW

Short PR

Delta Wave

SVT is high yield test question, will need procaimaide If wider QRS

• Wellens Syndrome

Bipashic T wave in anterior leads

Chest pain usually resolved

Needs urgent catheterization

• Brugada

Needs AICD

Downsloping ST segment 

• AAA

Typically infrarenal 

When ruptured – need blood, but allow for permissive hypotension – call for your aorta team

• Heart blocks

Mobitz Type II and 3rd degree block need AICD/pacer

• SVT

Vagal maneuver —> Adenosine (6, 12, 12) if hemodynamically stable

If unstable, synchronized cardioversion

• Lefort fractures

3 types

Type III may have CSF rhinorrhea

Avoid NG tube placement

• Chest tube output for OR indication

1500cc of output right away (~20cc/kg)

200 cc an hour for 3 hours (~3 cc/kg)

• Boorhave syndrome

Hammans crunch

Massive vomiting or iatrogenic (most common)

Broad spectrum antibiotics

• Button battery needs emergent endoscopy if in esophagus

• Rectal prolapse

Slow, steady pressure

Sugar as pre treatment

Avoid if toxic appearing or nectroic appearing

• Trachinominate fistula

First attempt to overinflate the cuff

Next try manually compressing against the sternum through the trash

• PE

Most common sign is tachypnea

Most common symptom is dyspnea

Most common EKG finding is sinus tachycardia

Most specific finding on EKG Is S1Q3T3, T wave inversions in the anterior leads

• Status Epilepticus

Benzo first

Midazolam (can be given IM or intransal (great option for patient who doesn’t have access))

Lorazepam, Diazepam

Keppra (40-60 mg/kg IV. (Max dose of 4500 mg)), Fosphenytoin

Lacosamide or Valproic acid

Fosphenytoin and Valproic acid cannot be used together

Intubate with Propofol, Ketamine, or Versed as induction agents as these have anti-epileptic properties

Need continuous EEG to r/o subclinical seizures and further monitoring

GOODLUCK on ITE

Maryland pearls post about a recent paper in JEM about patients coming in with uncertain head trauma.

1. Subscribe to the Maryland pearls if you don’t already
2. Do not automatically go scan every geriatric patient who might have hit their head. But consider it on a patient to patient basis.

While the unknown patients had a lower % of positive head CT, it was not negligible. See the description below:

In this prospective study looking at geriatric patients with unknown head injury vs. known head injury, the unknown head injury group had an ICH 1.5%, neurosurgical intervention 0.3% and delayed ICH 0.1% when compared to known head injury (10.5%,  1.2% and 0.7% respectively).  The authors concluded that the risk of ICH was high enough in uncertain head injury patients to warrant scanning.

Turchiaro ML Jr, Solano JJ, Clayton LM, Hughes PG, Shih RD, Alter SM. Computed Tomography Imaging of Geriatric Patients with Uncertain Head Trauma. J Emerg Med. 2023 Dec;65(6):e511-e516. doi: 10.1016/j.jemermed.2023.07.009. Epub 2023 Jul 26. PMID: 37838489.

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.*

Conference notes 12/6

• Ovarian cysts, rupture, and torsion (Dr. Williams)
  • Ovarian cysts: If cyst size is greater than 10cm consider OB consult for potential surgery
  • Infundibulopelvic ligament (suspensory ligament) contains the ovarian aa, vv, nn and is cause of ovarian torsion
  • If concerned for torsion and US inconclusive can get MRI
• PID (Dr. Mattingly)
  • Most common in 18-44 yo F
  • Physical exam findings: lower abdominal tenderness, cervical motion tenderness, cervical purulent drainage, adnexal tenderness or mass
  • Admission criteria: severe n/v, fever, pelvic abscess ruptured TOA, need for invasive diagnostic eval, unable to tolerate PO, concern for nonadherence
  • IP Tx: ceftriaxone and doxycycline+ flagyl, OP: ceftriaxone 1x then doxycycline + flagyl x 14d
• Perimortem C Section (Dr. Boland)
  • Gravid uterus can compress IVC impeding venous return> compressions w L lateral uterine displacement can alleviate this pressure
  • If fundus height at or above the umbilicus and ROSC is not achieved> recommend perimortem c-section (estimated gestational age >24wks)
  • Should be considered at 4 minutes after the onset of maternal cardiac arrest or resuscitative efforts
  • Do not attempt to take to the OR for the procedure
• Operations Update (Dr. Ross)
  • If an abortion presents to ED and ‘fetal tissue’ is removed, a series of forms regarding remains, cremation, and ‘death certificate’ must be completed by nursing staff.
  • Minors cannot give consent for cremation/disposal of fetal remains. If the patient refuses to tell their guardian about the pregnancy and abortion- ULH will manage tissue. ** Dr. Ross is in the process of confirming this.
  • ‘Fetal tissue’ must be sent to pathology.
  • CAR T-Cell Therapy Adverse Events: CRS (cytokine release syndrome- patients appear septic, fever, tachy, hypoxic, dyspneic, hypotensive) vs ICANS (Immune-effector cell-associated neurotoxicity syndrome- AMS, seizures, cerebral edema). Will be admitted to BMT. BMT Cytokine release syndrome and ICANS management order set on Cerner
• Preeclampsia and Eclampsia (Drs. Huttner and Stults)
  • HTN in pregnancy = >140/90 (gestational = diagnosed >20wks gestation and resolves after 12 wks post partum)
  • Pre-eclampsia: HTN w proteinuria (protein/Cr ratio >0.3 or 2+ protein on urine dipstick) or evidence of end-organ damage
    • PLT< 100,000
    • Cr> 1.1
  • Ecclampsia:
  • Pathophys- abnormal placentation leading to poor placental perfusion and hypoxia-reperfusion injury. Inflammatory markers target maternal endothelium.
  • Sxs: elevated BP, SOB, rapid weight gain, pitting edema (hands/face), decreased UOP, AMS, RUQ/epigastric pain, HA
  • Labs: thrombocytopenia, incr Cr/AST/ALT (HELLP), LDH (hemolysis), coagulopathy
  • Severe Pre-E management:
    • Seizure ppx: Magnesium
    • BP management
      • Labetalol, hydral, nifedipine
    • BP goal: decrease MAP by 20% in the first several hours
    • Labetalol 20 mg IV  q30 min total 300 mg
    • Hydral 10 mg IV q 20 min total 30 mg
    • Mag 4-6 g IV
    • Deliver at 37 weeks if regular pre-e; if severe: deliver at 34 wks
  • Eclampsia management
    • L Lat decubitus position
    • RSI if needed
    • Seizure treatment
      • Mag 4-6g bolus (over 20 min) followed by 1-2 g/hr infusion
      • Benzos if refractory
    • Delivery of fetus
  • Complications: pulmonary edema, MI, stroke, ARDS, coagulopathy, renal failure, retinal injury
  • Dispo: pre-e wo severe features likely dc, severe or eclampsia: admit

Conference 12/13

• Hyperemesis Gravidarum (Dr. Taylor)
  • Severe nausea/vomiting
  •  Weight loss >5% of pre-pregnancy weight
  • Onset <9 weeks gestation
  • Occurs in 0.3-3% of pregnant patients
  • Symptoms resolve 20-22 weeks
  • Risk factors
    • Family hx
    • Prior pregnancy with hyperemesis gravidarum
    • Hx of motion sickness, migraines
    • N/v related to estrogen medications
  • PUQE score to determine severity, based on duration, number of episodes of emesis
  • Complications
    • Dehydration
    • Electrolyte derangements
    • Mallory Weiss tear/esophageal injury
  • Treatment
    • For DC: Pyridoxine +/- doxylamine
    • In ED: IVF, diphenhydramine, metoclopramide, promethazine, prochlorperazine, Zofran is controversial
• Labor (Dr. Blair)
  • Shoulder Dystocia
    • HELPERR mnemonic
      • Help (call for help)
      • Empty bladder
      • Leg- McRoberts
      • Pressure- Suprapubic
      • Enter- Rotational maneuver
      • Remove posterior arm
      • Roll the patient onto her hands and knees
  • Umbilical cord prolapse
    • Have mom stop pushing
    • Use hand to elevate presenting part and decrease compression of cord
    • Attempt to not manipulate cord> can lead to vasospasm
  • Post-Partum Hemorrhage
    • Most common> uterine atony
      • Fundal massage
      • Oxytocin 10u IM/40 u in 1 L
      • Misoprostol 800-1000 mcg rectal or buccal
      • Methergine 0.2 mg IM/IV q2-4hr PRN
• Neonatal (Dr. Bhargava)
  • Neonatal conjunctivitis
    • Often without fever, just discharge
    • Ddx: gonorrhea vs chlamydia
      • Gonorrhea- first week of life
      • Chlamydia- day 7-14 of life
        • Pneumonia is common complication
    • Management:
      • Admit for abx
  • Neonatal mastitis
    • Etiology staph aureus
    • Dispo: admit for abx, drain abscess if present
    • Peak incidence at 2wks of life
    • Complications: cellulitis, necrotizing fasciitis, osteomyelitis
  • Neonatal seizures
    • Often focal- lip smacking or leg pedaling
    • Causes: hypoxic-ischemic encephalopathy, infection, ICH, metabolic abnormality, meningitis
    • First line tx is phenobarbital
  • Inconsolable infant
    • Easily consoled without source of crying> can be discharged
    • IT CRIES, causes for crying infant
      • Intussusception
      • Trauma
      • Cardiac
      • Rectal/anal fissures/reflux
      • Ingestion
      • Exposure, eyes (corneal abrasion, FB)
      • Sepsis, strangulation (hernia)
    • Hair tourniquet
      • Try application of Nair (less than 10 mins)
      • If color of extremity/ physical exam does not improve> cut down to bone with scalpel
  • Newborn rashes
    • Erythema toxicum neonatorum:
      • papules, pustules, erythema
    • Herpes simplex:
      • lesions are vesiculopustular on ill appearing neonate
    • Milia:
      • 1-1 mm pearly keratin plugs
    • Neonatal cephalic pustulosis:
      • unclear etiology, can be inflammatory reaction.
      • Tx daily cleaning with soap and water ***
    • Seborrheic dermatitis
      • Yellow flaky, often starts in scalp
      • Typically resolves in weeks to month
      • Can use emollient or low potency steroid
      • Ketoconazole shampoo if severe
  • Hypoglycemia
    • Rule of 50s
      • < 1 year old use D10 (5 mL/kg)
      • 1-8 years old use D25 (2mL/kg)
      • Greater than 8 years old D50 (1mL/kg)
  • Jaundice
    • ABO incompatibility: first day of life. Typically, mother’s blood type is O and Baby is A or B
    • Physiologic jaundice: seen at day 2-3 due to decreased conjugation of bilirubin due to immature liver
    • Severe neonatal hyperbilirubinemia
      • T bili > 25 mg/dL
      • Bili crosses BBB and causes neurologic dysfunction
  • Lower GI bleed
    • Meckel diverticulum is most common cause at 2y of age
    • Milk protein allergy should be suspected after introduction of new formula
    • NEC is complication of premature infants and presents with. Abdominal distension, bloody stools and feeding intolerance
    • To eval for swallowed mother’s blood as cause of blood in stool can use Apt Test
  • Pediatric vital signs
    • For children >1 y old SBP= 70+2x age (lower limit of normal)
  • Abdominal wall defects
    • Omphalocele
      • Often with other congenital defects
      • Membranous covering over abdominal contents
    • Gastroschisis
      • Direct exposure of abdominal contents
  • Omphalitis
    • Most often cause s. aureus
    • Presents before 14 days of life
    • Can become necrotizing fasciitis or sepsis
    • High morbidity and mortality rates
  • Intestinal malrotation
    • AXR: double bubble sign
    • Upper GI series: corkscrew sign
    • AIR in biliary tree is most often seen with NEC

I always say that it takes more skill to NOT intubate a patient. That is especially the case with severe CHF, where BiPAP, nitro and a couple of hours can turn them around completely. Intubation is a dangerous procedure, and I think we have come a long way in EM from the days when we had a low threshold to intubate intoxicated patients.

The TL;DR is that in patients suspected of “poisoning” (which to them means alcohol, drugs or medication), an expectant approach of “restricted intubation” led to improved outcomes of shorter ICU stay, shorter hospital stay, less pneumonia, and of course less adverse events from intubation.

Read this article and the commentary (both linked below). I thought this was too important to wait for Journal Club, but we could still cover it at JC in the near future. 20 different EDs, RCT, 225 total patients, excluded some poisonings that had easy reversal or needed antidotes. No patients died.

Here is the original research article. Here is the accompanying editorial.

HPI: 54 yo F with history of CAD s/p 4 previous stents (LAD and first diagonal branch) who presents with abdominal pain, nausea, and vomiting

EKG Interpretation: ST elevation (STE) in anterior, inferior with right ventricular extension, posterior, +/- lateral distributions (only elevation in V6). Reciprocal changes (ST depression) in leads I and aVL.

Cath Report: 100% occlusion of the RCA. 100% occlusion of the posterolateral subdivision. 50% in-stent restenosis of the mid LAD. 50% stenosis of the first diagonal branch

Procedure: Aspiration thrombectomy, PCI of distal and mid RCA x 2

Commentary:

-AHA/ACC for STEMI: Men < 40: 2.5 mm (2.5 small EKG boxes) ST-elevation in V2 or V3, 1 mm in any other lead, Men > 40: 2.0 mm ST-elevation in V2 or V3, 1 mm in any other lead, Women: >1.5 mm ST-elevation in V2 or V3, 1 mm in any other lead

-Leads and Vessel Correlation: V1-V4 are anterior/septal leads correlate with the Left Anterior Descending artery. II, III, and aVF are inferior leads correlate with the Right Coronary artery. I, aVL, V5-V6 are lateral leads correlate with Left Circumflex artery

-Posterior MI: Present if ST depression in the right precordial leads or presence of prominent R-waves and upright T-waves in these same leads. Accompanies 15-20% of STEMIs. Usually associated with inferior or lateral infarctions. Suggestive of a much larger area of myocardial damage. Can consider a posterior EKG to look for STE (V7-V9 in horizontal plane underneath the left scapula)

-Right Ventricular Infarction: Present if the magnitude of ST-segment elevation in lead V1 exceeds the magnitude of ST-segment elevation in lead V2, or if the ST-segment in lead V1 is isoelectric and the ST-segment in lead V2 is significantly depressed, or if the magnitude of ST-segment elevation in lead III exceeds the magnitude of ST-segment elevation in lead II. Associated with approximately 40% of inferior STEMIs. Patients tend to be very preload sensitive from poor RV contractility and nitrates are contraindicated. Consider EKG with right sided leads to look for STE (transfer V3-V6 to right side of chest)

Check out this recent lecture from Dr Stephen Smith of the famous ECG Blog. The link is to a google doc but it is still live after months. He describes some sophisticated ST segment and T wave changes that ER doctors must know to pick up subtle ischemia. You have to just love how Smith is so candid about his opinions. He does not mess around with anyone who argues with the Occlusion MI (OMI) paradigm or even individual tracings. He says that sadly some people just can’t see the subtle findings, but I maintain hope that every studious ER doc can master the image pattern recognition he teaches. And if they can’t, maybe AI can. Smith advises multiple companies that use AI to detect these subtle ECG findings, to determine when patients are having OMIs. His software appears to be quite effective.

Something to keep in mind while watching, he is going over (tons of) cases that all have a relatively high pretest probability of ischemia. He has selected them out. We are working on evaluating and treating more ‘cardiac patients’ at ULH, but his patient population (at Hennepin) would be more like Jewish or maybe even other centers in town with more active cath labs.

A few of the rules that came up repeatedly in the video:

Smith of course talks about the weakness of a STEMI/NSTEMI paradigm, arguing instead for the occlusion MI paradigm.

Proportionality, proportionality, proportionality – T wave size in proportion to the QRS. A medium sized broad T wave after a tiny QRS is concerning!

Similarly, the morphology of the Hyperacute T is usualy broad based, and not tall and peaked like hyperK+. Thus, thinking about the area under the curve of the T wave makes more sense.

Biphasic T waves (down up meaning recip change) – we usually talk about biphasic reperfusion T waves in the leads involved in ischemia, but here mostly shows biphasic T waves reciprocal to infarction pattern in other leads.

1st Trimester Pelvic POCUS

• All patients who are suspected to be pregnant need a transabdominal US
• WHY? -> RULE IN UP 
• Trans Abd US POCUS
  • Full bladder
  • Sagittal view – scan through full anatomy (1st view – best idea of what the anatomy is going to look like)
  • Transverse view 
  • Measurements
    • M -Mode for FHR
    • CRL
  • Adnexa? Probably good practice
  • Linear probe for superficial uterus for better resolution
• TVUS
  • Hold probe with indicator on top (thumb on top)
  • When: Unable to confirm IUP on TAUS
  • Need EMPTY Bladder
  • Probe movements: Rock/Fan only
  • Start with placing probe into introitus, look at screen and then slowly advance probe with gentle pressure
• MUST HAVE at least a YOLK SAC to be confirmed as an IUP
• Do not use BhCG to determine if patient needs US
  • Ectopics can have BhCG level of 0 

Pleural Effusion and Opportunistic infections

• Evaluation
  • CXR, CT, US
    • Left lateral decubitus XR more sensitive than PA,  less fluid required
  • Pleural fluid tap
• Lights Criteria
  • Transudative vs Exudative 
• Treatment
  • Chest tube placement for drainage
  • Antibiotics
• Parapneumonic effusion/Empyema
  • Higher rates of morbidity and mortality
  • Higher risk in certain pops (IVDU, alcoholics, immunosuppressed, etc)
• Antibiotics
  • Pathogens MC – S pneumo > Anaerobes > S aureus > G- bacilli
  • Empiric Tx: Pip/Tazo + vanc (meropenem, cefepime, metronidazole if PCN allergy)
• Incomplete Drainage?
  • Fibrinolytics via thoracostomy tube
    • Alteplase + DNAse 
• PCP (P jiroveci) Pneumonia
  • HIV patients w. CD4 <200
  • SMX/TMP 15-20mg/kg divided into 3-4 doses daily
    • Dapsone, primaquine, atovaquone if need alternative
  • Steroids if PaO2<70 mmhg
• MAC (M avium)
  • HIV, CD4<50
  • Macrolide, ethambutol, rifampin 
• Histoplasmosis
  • Fungal infection endemic to central and south central USA
  • Amphotericin B preferred
  • Itraconazole alternative
• TB
  • RIPE therapy (rifampin, INH, pyrazinamide, pyridoxine, ethambutol) 
• Candidiasis
  • Very common in HIV w/ low CD4
  • Fluconazole best, can use itraconazole

The Analytical Evaluation of an Unwanted Outcome

• 50 yo M w/ CP/SOA while washing dog
• pmh HTN, HLD, hypothyroidism, TB use
• FH: brother died of MI in 40s
• Initial EKG w/ NSR, T wave inversion III, normal otherwise
• 2 prior ED admissions for similar symptoms w/ negative workup
• Trop 63, sent to Jewish via Lyft for Personal vehicle 
• Coded at Jewish in Vfib, Cath w/ 100% LAD and RCA, stented
• Things to think about
  • ALS vs BLS vs Lyft transfer
  • Should we have stricter rules to transfer to Jewish Cards Obs?
  • Should we call the fellow or attending on cards more often?

Pneumonia

• Severity classification for pna – differentiates what treatments to use
• No comorbidities = Monotherapy (Beta lactam, Doxycycline)
• Comorbidities= Beta lactam + Doxy or Azithro / or monotherapy w/ Levaquin
• Inpatient = IV ceftriaxone + Azithro or Doxy
• Prev hospitalization or IV abx in last 90d?  –> Vanc or Linezolid for MRSA coverage
• 5 days usually adequate if no comorbidities
• 7 days if Comorbid or MRSA/Pseudomonal coverage
• Procalcitonin essentially useless, Clinical criteria alone should be used
• Aspiration
  • Chemical pneumonitis – no abx required
    • Severe periodontal disease present – should be treated 
  • HAP / CAP = treat

Acute Bronchitis

• Rule out: Asthma, COPD, HF, pna
• Usually no fevers
• CXR indicated if tachycardic, tachypneic, rusty sputum, febrile
• Supportive care options
  • APAP, Ibuprofen, cetirizine/diphenhydramine, codeine, dextromethorphan (best results), benzonatate, guaifenesin (best data), albuterol (if wheezing or underlying asthma/copd)
• Educate patient on why Abx may not shorten illness, give supportive therapies, and expectations of illness/cough duration
• Bacterial
  • Sx> 10 d
  • Fever>102F w/ purulent nasal discharge/facial pain
  • Double worsening of symptoms
• Flu
  • Oseltamivir (Tamiflu) – within 48hrs of onset
    • Initial study – sx improvement only 16hrs earlier than placebo
    • 2023 meta analysis shows no benefit over placebo w/ primary outcome of hospitalization 
  • Who should get treated?
    • Hospitalized, immunocompromised, >2 yo or <65yo, pregnant

Research

• Think, Do, Write
• Research is fun, rewarding, and part of being a well rounded EM physician 
• Many conferences that you can go to (and Department will pay your way)