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Emergency Medicine Pearls

Emergency Medicine Pearls. Steven M. Hochman, MD FACEP Dept of Emergency Medicine St. Joseph’s Regional Med Center October 28, 2009. Disclaimer.

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Emergency Medicine Pearls

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  1. Emergency Medicine Pearls Steven M. Hochman, MD FACEP Dept of Emergency Medicine St. Joseph’s Regional Med Center October 28, 2009

  2. Disclaimer • Any similarity between the information in this lecture and any material published by the American Board of Osteopathic Emergency Medicine is entirely coincidental • Emergency medicine is in the public domain, and the dissemination of accurate, relevant and up-to-date information about the evaluation and care of emergency patients is in the best interests of the medical community as well as the general public

  3. Part IMnemonic Mania

  4. Altered Mental Status DDx • Alcohol, other drugs A • Endo/exocrine, electrolytes E • Insulin (DM) I • Oxygen (low), opiates O • Uremia U • Trauma, temperature T • Infection I • Psychiatric P • Space occupying lesions, stroke, shock S

  5. Substances Removed by HD • Isopropanol I • Salicylates S • Theophylline T • Uremia U • Methanol M • Barbs B • Lithium L • Ethylene glycol, ethanol E

  6. Cholinergic Toxidrome(Muscarinic) • Diarrhea D • Urination U • Miosis M • Bronchorrhea B • Bradycardia B • Emesis E • Lacrimation L • Salivation S

  7. +AG Metabolic Acidosis • CO, Cyanide C • AKA A • Toluene T • Methanol M • Uremia U • DKA D • Paraldehyde, Phenphormin P • INH, Iron I • Lactic Acidosis L • Ethylene glycol E • Salicylates S

  8. (-)AG Metabolic Acidosis • Hyperalimentation H • Acetazolamide, Amphoteracin A • RTA R • Diarrhea D • Ureteral diversions U • Pancreatic fistulas P • Saline resuscitation S

  9. Elevated Osmolar Gap • Methanol M • Ethanol, Ethylene Glycol E • Diuretics (glyc, mann, sorb) D • Isopropanol I

  10. Toxic Alcohols etc.

  11. Serum Osmolarity • Sosm = 2 Na + BUN/2.8 + Gluc/18 + Ethanol/4.6 • Nl = 285 meq/L

  12. Toxics Induced Seizures(OTIS CAMPBELL) • Oral hypoglycemics, organophosphates, opiates • Theophylline, TCA’s • INH, insulin • Salicylates, sympathomimetics • Camphor, CO, cocaine, cyanide • Amphetamines, anticholinergics, antihistamines

  13. Toxics Induced Seizures(OTIS CAMPBELL) • Methylxanthines, mushrooms (gyromitra) • PCP, paraldehyde, plants (jimson, belladonna alkaloids, water hemlock) • B Blockers (propranolol), benzo/barb withdrawal • Ethanol withdrawal • Li, Lidocaine • Lead, Lindane, LSD

  14. Abdominal Flat Plate(CHIPES) • Chloral Hydrate C • Heavy Metals (Fe, Pb) H • Iodine I • Phenothiazines, Packets (cocaine P heroine) • Enteric-coated products E • Solvents S

  15. Substances Not Bound to AC • Caustics C • Lithium L • Iron I • Methanol, Metals M • Ethylene glycol, other alcohols E

  16. Multiple Dose AC • TCA’s T • Theophylline T • BarbiTuraTes T • Tegretol T • PhenyToin T • DigiTalis T • ASA??

  17. Whole Bowel Irrigation(PEG, 2L/hr, effluent clear) • Fe, heavy metals • Lithium • Sustained release, enteric-coated • Body packers/stuffers • Foreign bodies (batteries)

  18. Sick of this yet??

  19. More Toxicology

  20. Carbon Monoxide Poisoning • Fires, propane, home heating (kerosine), engine exhaust (rare) • Extremes of age, pregnancy (FETUS), CAD/pulmonary disease • CNS and CV systems most affected • COHb level—Nl 1-2%, smokers 5-10% • Levels correspond poorly to Sx

  21. CO Treatment • Elimination • Room air 21% 2-7 hrs (mean 4 hrs) • 100% 1 Atm 90 min • 100% 3 Atm 23 min • HBO—indications • End organ damage—LOC, coma, Sz, persistent Sx • CoHb >25% or >15% in pregnancy • Abnl neuro exam, dysrhythmia, poor SaO2

  22. Gastric Lavage • Ingestions potentially fatal or worsoning vital signs or MS • TCA’s, CCB’s, Li • Preferably within 1 hour • Protect airway, L lateral decub position • Adults 36-40 French, Peds 22-24+ French

  23. Gastric Lavage • Contraindications • Caustic ingestions • Large FB’s, sharp objects • Inability to protect airway • Drug not accessible in stomach • Complications • Aspiration • Perforation • Tension PTX, empyema • Impaired oxygenation/ventilation

  24. Acetaminophen Overdose • Rule of 140’s

  25. Acetaminophen Overdose • Rule of 140 • Toxic dose 140 mg/kg • 70 kg = 9.8 gms = 20 ES Tylenol

  26. Acetaminophen Overdose • Rule of 140 • Toxic level 140 mcg/ml (really 150) at 4 hours • Rumack-Matthew nomogram, single ingestion at known time

  27. Acetaminophen Overdose • Rule of 140 • Initial dose NAC 140 mg/kg po • Then 70 mg/kg q 4hrs X 17 doses • Off label: 100 mg IV X3 doses over 20 hrs

  28. Acetaminophen Overdose • Rule of 140 • Alternative: Acetadote 150 mg/kg IV over 1 hour • 2 more doses over next 20 hrs

  29. Acetaminophen Overdose • APAP, ASA level on all suicide attempt pts • 1/500 +tox level APAP without h/o APAP ingestion • Give AC to all; NAC if indicated (within 8hrs) • Potential toxic ingestion • Late presentation, ongoing toxicity • Chronic overdose, ongoing toxicity • Gastric lavage – only for coingestants

  30. Acetaminophen Overdose • If potential toxicity • LFT’s (AST, INR, Biliruben) • Electrolytes, renal function studies • New IV formulation: Acetadote • 21 hr protocol • Can use oral form IV ($18 vs. $416) – no good data

  31. TCA Overdose • -yline and -amine (nortriptyline,imipramine) • Amitriptyline (Elavil) • Block reuptake of NE, DA, Seratonin at central synapses • ↑Catecholamines – initial HTN • Anticholinergic – hot, dry, agitated • Na Channel blockade – negative inotropy • Alpha blockade -- hypotension • Antihistamine effects – sedation • GABA antagonism -- seizures

  32. TCA Overdose • Na channel blockade - Type 1A antiarrhythmic (quinidine-like) effects • Prolonged Phase 0 depolarization  QRS widening • EKG: Wide complex dysrhythmias • Sinus tachycardia • Terminal 40 ms R axis deviation (Big R in aVR and Big S in aVL)

  33. TCA Overdose • EKG as screening tool • QRS <100 ms – no significant toxicity • QRS >100 ms – 1/3 had seizures • QRS >160 ms – ½ had ventricular dysrhythmias

  34. TCA Overdose • Treatment • Orogastric lavage if timely • AC 1 gm/kg • MDAC ½ dose q2 hrs X1-2 • Ativan, Valium for seizures • NaHCO3 for dysrhythmias – 1-2 amps (Peds: 1-2 mEq/kg), repeat EKG • Hyperventilation (serum pH goal 7.45-7.55) • IVF, pressors for hypotension

  35. TCA Overdose • Disposition • 6 hour observation – no anticholinergic signs or seizures, nl MS and EKG, no Tx other than AC  DISCHARGE • Admit for • QRS ≥ 100 ms • Seizure, dysrhythmia, MS changes • ECG abnormalities  MICU, bicarb tx X 12-24 hrs

  36. Zebras & Other Minutiae

  37. What’s the Diagnosis? • 28 yo male, painful joints, discharge from eyes, burning on urination

  38. Reiter’s Syndrome • Triad: Arthritis, Urethritis , Conjunctivitis • Spondyloarthropathy, reactive arthritis • Mechanism unclear – post infect, AI? • Leading cause inflam arthritis, young men • Dx: cervical/urethr swab (**Chlamydia), arthrocentesis, CBC/D, ESR • Tx: NSAIDs, sulfasalazine, Tx cervicitis/urethritis; f/u Rheumatology

  39. What’s the Diagnosis? • 45 yo white female • Recurrent episodes of • Eye pain, visual blurriness • RLE weakness • UE paresthesias • Episodes last up to several hours, with incomplete resolution • Symptoms progressively worse over months

  40. Multiple Sclerosis • Myelin sheath destruction, ?cause • Most commonly periventricular white matter • Clinical Dx: 2+ episodes of neurological deficiency • Objective clinical signs >1 CNS lesion • Management: Refer to Neuro • MRI – periventricular plaques

  41. Multiple Sclerosis – S&S • INO – deficiencies of abduct/adduction • Optic neuritis – pain, visual impairment • Transverse myelitis – spinal cord synd • Diplopia • Ataxia, intention tremor • UMN signs – weakness, hyperreflex, Babinski’s signs

  42. Multiple Sclerosis – S&S • Post column, spinothalamic involvement • Urinary Sx, constipation, sexual dysfunction • Lhermitte’s sign – electric shock on flexion of neck

  43. What’s the Diagnosis? • 48 yo male, h/o lumbar disc disease • Lower back pain, radiating down posterior thighs • Urinary incontinence • B/L numbness of feet • Progressive difficulty ambulating • Sx started 2 hours ago

  44. Cauda Equina Syndrome • Compression of lumbar-sacral nerve roots • Below conus medularis (L1-L2) • Disc herniation most common cause • Also: trauma, mass effect from tumor, abscess

  45. Cauda Equina SyndromePhysical Exam • Bladder or rectal dysfunction – retention or incontenence • LE sensory/motor deficits • Foot dorsiflexion (L5-S1), quadriceps, DTR’s • Perineal sensation – saddle anesthesia • Reduced rectal tone (S3-4-5) • Absent anal wink • Straight leg raise – sciatica

  46. Cauda Equina SyndromeManagement • Emergent MRI – Confirm Dx and levels • But do not delay treatment • Immediate Neurosurgery Consult • Methylprednisolone 30+5.4 for trauma • Emergent decompression – improves outcomes • 6-24 hours – controversy • >48 hours, ?still benefit

  47. Optho Emergencies I-X

  48. Opthalmology I • Teardrop-shaped pupil, pt felt something hit his eye while mowing lawn

  49. Opthalmology I • Teardrop-shaped pupil, pt felt something hit his eye while mowing lawn • ORBITAL RUPTURE

  50. Opthalmology I • Teardrop-shaped pupil, pt felt something hit his eye while mowing lawn • ORBITAL RUPTURE • +Seidel test, NO TONOMETRY • TX: Eye shield (not patch), keep pt still, ABX • Emergent Optho consult

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