Restraints and Violent Patients:
• Agitation may be caused by a number of reasons including head trauma, hypoxia, infection, delirium, ingestion, psychiatric disorders. Always consider medical causes.
• Deescalating:
o Verbal- be honest and straightforward without be confrontational or threatening.
o Physical restraints- soft restraints, four-point, chest.
o Chemical sedation- offer voluntary administration with medications including IM ketamine, droperidol, haloperidol, midazolam and lorazepam.

Homelessness:
• Rates of homelessness are climbing within Louisville and the US.
• Patients experiencing homelessness are more likely to visit the emergency department.
• What can we offer? Respect, housing/shelter options, considerations to cost, complexity and availability of treatments


US Images:
• Chiari network: embryonic remnant of the sinus venosus which remains in the right atrium and is a benign finding.
• Use US for shoulder blocks with dislocations: palpate spine of scapula, marching out laterally to the acromion. After finding the posterior, inferior edge of the acromion, move two finger widths inferior and medially and inferiorly with injection directed forward towards to the coracoid process. Use 18 G spinal needle injecting 10-20 cc of lidocaine.
• Use US to confirm abscess before incision and drainage. Cellulitis is a clinical diagnosis but seeing a heterogenous collection on US.

Obesity in the ED:
• Obesity is a rising concern, especially in developed countries. Patients suffering from obesity are at increased risk of DM, CVD, HTN, HLD.
• BMI is a measuring tool which compares weight and height but may be lost to the favor of waist to hip ratio when describing obesity.
• Obesity in the ED:
o General interactions- ask permission to discuss weight, use “people first” language, consider bias, provide basic nutritional information, consider food insecurity and provide resources, referrals for physical activity and PCP.
o Airway- obesity creates different challenges regarding airway in the ED. Patients suffering from obesity have decreased respiratory reserve and decreased tolerance for apnea as well as increased airway pressure causing small ox reserve, increased work of breathing, higher risk of aspiration.
o Circulation- be sure blood pressure cuff is appropriately fitting and consider early arterial line. If venous access is difficult to obtain, consider using ultrasound guided lines as well as intraosseous lines.
o EKGs- findings more common in obesity include low voltages, longer QT intervals (not greater than 500), signs of LVH.
o Trauma considerations- more likely to have indeterminate FASTs, xrays are often underpenetrated, and CT scanners do have weight limits.

Tuberculosis by Dr. Marks

Incidence decreasing in the US

Latent TB infection approx. 5% in US. 25% in world

PPD screening:

If >5 mm PPD and immunocompromised = positive

If >10mm and been to high risk country, healthcare worker, or IVDU =positive

Otherwise >15mm = positive

Primary TB usually asymptomatic,

If suspect TB, isolate

Sputum PCR

Gold standard is cultures (6-8wk turnaround)

For latent TP rifampin+isoniazid +pyridoxine for 3 moths

For active TB:

RIPE therapy  8 weeks

Rifampin ,  (orange urine, CP450 induction)

isoniazid,  (B6 deficiency, seizures)

pyrazinamide (hepatotoxicity, hyperuricemia)

Ethambutol (optic neuritis)

Then rifampin/isoniazid for 18 more weeks

TB meningitis- RIPE + dexamethasone

Potts- RIPE + source control

Syphilis by Dr. Coffman

Incidence increasing since 1990.

Increasing in women. Congenital cases increasing.

Primary, Secondary, Tertiary

Painless ulcer on mucus membranes, rash involving hands and feet +nonspecific symptoms,

Jarisch Herxheimer reaction – treat symptoms with tylenol.

PEM: Endocrine by Dr. Magloire

DKA: defined by hyperglycemia, metabolic acidosis, and ketosis

30-40% are new onset T1DM

Risk factors include age <5, reduced access to medical care

Anorexia, N/V, abdominal pain, hyperventilation, dehydration

Often precipitated by missed insulin, acute illness, medications (steroids, antipsychotics)

Assume fluid deficit of 5-10%

Initial fluid bolus then 2 bag method over 24-48

Beware of cerebral edema. Treat with mannitol if developing

Avoid central lines due to increased risk of DVTs

Hypoglycemia:

Children and infants can have quicker shifts in glucose due to high metabolic demand and difference in gluconeogenesis.

If conscious, give 15 g of carbs (juice, glucose tabs etc)

IV D10 bolus if needed

If altered give 2-5ml/kg of D10 bolus, repeat and start infusion if needed

Adrenal Crisis:

Consider in known CAH, hypothalamic axis disorders, prolonged corticosteroid use, other autoimmune disorders, critically ill patients unresponsive to pressors, or neonates with atypical genitalia electrolyte abnormalities, hypoglycemia, hyperpigmentation, cushingoid features

Hyponatremia, hypoglycemia, hyperkalemia

Treat with hydrocortisone 50-100mg/m2 (25mg if <3yo, 50mg if 3-12 yo, 100mg if 12+yo)

Treat hyperkalemia if needed.

Tick-Borne Disease by Dr. Buchanan

Prevention is best

DEET and permethrin

DEET on skin, permethrin on clothes (last 6-8 weeks)

Combination of both decreased mosquito bites by 99%

Remove ticks >36hrs just use forceps.

Lyme – erythema migrans, vector is Ixodes, classic “target” rash. Disseminated disease in 60% if untreated

If bilateral bell’s palsy, treat for Lyme disease

If high clinical suspicion, can use IFA or EIA for testing

IgG +IgM if <1 month from exposure

Doxy+ceftriaxone  if neuro symptoms

STARI – southern tick associated rash illness

Causative organism unknown. Lone Star Tick

Probably best to treat as Lyme

Rocky Mountain Spotted Fever –

Maculopapular rash involving hands and palms. Flu like symptoms

Hyponatremia, transaminitis, thrombocytopenia

Rickettsia Rickettsii

Dermacentor sp. (wood tick or dog tick)

Clinical diagnosis, confirmed with IFA/EIA

Rickettsia Parkeri Rickettsiosis-

Inoculation eschar. Similar labs findings. Less severe disease. Gulf coast ticks

Erlichiosis-  Erlichia sp.

Lone star tick

Flu-like symtpoms

Leukopenia, hyponatremia, transaminitis

Whole blood PCR (most sensitive if <1week).

Otherwise IgG trending

Anaplasmosis –

Ixodes tick. More northeast than erlichiosis

Tick-borne relapsing Fever

Leukoytosis, thrombocytopenia, elevated bilirubin

recurring fevers. Every reccurence less and less severe

Borrelia sp.

Soft shell ticks are the vector. Western US.

Diagnoses with peripheral blood smear. Best checked during a fever.

Treatment for all the above is doxycycline

Babesiosis

Babesia microti. Vector is ixodes tick.

Fever, body aches, Scleral icterus, dark urine,

Transaminitis, anemia, thrombocytopenia, hyperbilirubinemia

Peripheral smear with intracellular organsisms, (maltese cross)

Treatment atovaquone +azithromycin OR Clindamycin + Quinnine

Tularemia

Franscisella tularensis

Vectors -Dermacentor and amblyomma spp.

Fevers, malaise, body aches.

Leukocytosis, thrombocytopenia, hyponatremia, transaminitis, sterile pyuria

Wound and glandular lymphadenopathy, conjunctivitis, oropharyngeal form. Pneumonic form, typhoidal form.

Confirmation by isolation of Tularensis (culture) or seroconversion (IgG/IgM) in paired sera

Treatment is streptomycin

Tick Bite prophylaxis

• Was it an ixodes tick? If no, no ppx
• Is it engorged or attached >36hr> if no, no ppx
• Has it been 72 hours since removal. If yes, no ppx
• Can they take doxy? If no, no ppx
• Is lyme endemic? If no, no ppx

Peds Pharm: PALS Drugs by Dr. Lucking

Bradycardia- atropine (min 0.1, max 0.5mg) epinephrine, treat as PEA if <60

Tachycardia-

• Sinus tach -treat underlying condition
• SVT- vagal maneuver, (ice to face), adenosine (proximal and fast) 0.1mg/kg
• Vtach- cardiovert, amio or procainamide
• Vfib- rare. Same as adults. Amio 5mg/kg

Epi spritzer

Used for brady/hypotension in a patient with a pulse to prevent cardiac arrest

Peri-intubation

0.001mg/kg (1/10 of a code dose)

RSI

If age <1 consider atropine as pre-medication

Historically, lidocaine was given for ICP, however this has fallen out of favor

Fentanyl 1mcg/kg max dose 100mct. Immediate onset, 30-60min duration

Midazolam 0.1mg/kg max 5mg. onset 3-5 mins. Duration <2 hours

Ketamine 2mg/kg. onset 30 seconds. Duration 5-10mins. Contraindicated in <3mo age

Etomidate 0.3mg/kg. does not provide analgesia. Can reduce sz threshold.

Propofol 1-2mg/kg.

Rocuronium 1mg/kg. duration 26-46 minutes

Succinylcholine 1-2mg/kg, hyperkalemia, malignant hypothermia

Endocrine Disorders (Kuzel)

• Hyperthyroidism:
• I.e. Graves Disease (most common), Toxic Multinodular goiter, Thyroiditis, Hashimotos (initially hyperthyroid, followed by hypothyroid) 
• Thyroid storm:
  • 15-50% mortality with tx (80-100% without) 
  • How they die: cardiac dysrhythmias, CHF, hepatic failure, hypotension, cardiovasc collapse
  • Tx: beta blocker (propranolol), thioamide (TPU/methimazole), steroid, iodide; avoid NSAIDs since they increase peripheral thyroid hormone conversion
  • PTU is Preferred because it has earlier onset and safe in Pregnancy 
• Hypothyroidism:
• Most commonly autoimmune, thyroiditis, iodine deficiency, post-ablation, panhypopituitarism 
• Euthyroid sick syndrome = low thyroxine syndrome w/ low or normal TSH, seen in critically ill pts
• Myxedema Coma:
  • 30-60% mortality
  • Often precipitated d/t sepsis, CHF, CVA, hypoxia, ACS
  • SLOW and SWOLE sx = bradycardia, hypotension, hypothermia, myxedema 
  • Tx: steroid, levothyroxine (be careful of dysrhythmias, ACS – give if hypotensive/altered)
• TSH can be helpful in NH patients w/ rapid decline and sx of hypothyroidism, & septic patients w/ refractory shock

Case Review (Loche, McGowan)

• AV fistula – most commonly in anterior forearm/upper arm, needs time to mature (6-12 mo) 
• Eval: should feel thrill; if you don’t feel thrill/pulse, assume thrombosis (get US/doppler) 
• AV fistula bleeding management:
  • Pinpoint pressure, can use bottle cap over bleed to let it clot off, use other adjuncts prn (surgicel, TXA, gelfoam)
  • Figure of 8 suture – DO NOT tie off vessel (damages fistula), just suture the superficial skin with non cutting suture 
  • If heavier bleeding, then do purse string suture 
  • If successful, have them move arm around, make sure it doesn’t rebleed, observe 1-2 hours
  • If you had to suture it or if any other major problems, you should give vascular surgery a call 
• Fistule thrombosis – loss of bruit/thrill, palpable clot
  • Management: Discuss with vascular, may or may not need emergent intervention, may get balloon angioplasty or thrombolysis 
• Pseudoaneurysm/aneurysm – bulging of vessel in outer wall (pseudo) or all layers (true) – get ultrasound, talk with vascular 
• Infection – much higher risk, especially if deeper infxn, need admission for IV abx, call vascular 

Supplements (Huecker) 

• Kefir should be first food of day – lots of good probiotics and vitamins 
• Daily supplement essentials: magnesium!, sunshine/VitD, vit K2, vit C, and iodine 
• Mag threonate is Huecker’s favorite form, oxide is trash; at least 200mg of elemental Mg/day 
• Labdoor.com is a good third party supplement tester
• Vitamin D: Most people need 3000-5000 IU in winter time, or 20 min in sun (if arms, legs, face exposed)
• Vitamin K2: helps prevent fractures, cancer incidence, neurocognitive fx 
• Fish oil: higher ratio of omega 3:6 is better, eating fish is best way to get it

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.