Sunday, November 27, 2016

Toxicology Review: Chronic Salicylate Poisoning

Image Credit: Flickr
Author: Pollianne Ward, MD
Temple University Hospital
Originally Published: Modern Resident January 2013

A 46-year-old female presented to an urban emergency department with complaints of a fall and altered mental status per family. It was reported that the patient had begun to experience nausea and vomiting followed by somnolence one day prior. She had no medical problems and did not take any medications regularly. Vital signs were heart rate 125, BP 130/86, temperature 99.6˚ F, respiratory rate 22 and oxygen saturation 99% on room air. The patient had some minor facial fractures from a fall, but no other injuries after trauma evaluation. EKG showed a sinus tachycardia with a widened QRS and peaked T waves. Basic metabolic panel revealed creatinine 8.5, potassium 7.3, and an anion gap metabolic acidosis. Treatment of hyperkalemia was initiated. A comprehensive drug screen was sent, which showed a salicylate level of 75mg/dl.

Salicylate overdose is a not uncommon chief complaint that emergency physicians encounter. Either intentional or accidental, acute toxicity is usually easily recognizable with symptoms of nausea, vomiting, tinnitus, tachypnea and lethargy in a known or suspected ingestion. However, chronic toxicity can often be indolent and present with non-specific symptoms.

Thursday, November 24, 2016

Six Clinical Pearls from Intern Year

Image Credit: Flickr
Author: Casey Grover, MD
Stanford/Kaiser Emergency Medicine
Originally Published: Modern Resident October/November 2011

Looking back after finishing a year as an emergency medicine intern, the lessons that I remember the most come from the mistakes that I have made. I had one particularly rough month late in my internship that was filled with bounce backs and mismanaged cases. I learned six important lessons that will hopefully help to avoid another such month in the future.

  1. Review every study that you order. While you may have ordered a chemistry panel just to check the creatinine, it's embarrassing to miss a sodium of 121.
  2. Document your discharge decision process. If a patient has a problem or bounces back, it is extremely helpful to have documented everything (i.e., normal vitals, well appearance, consultant recommendations) that you considered when sending that patient home.
  3. Review discharge vital signs. Vital signs are actually important – they reflect the patient's underlying physiology. Document normal vital signs when sending patients home; and when discharging someone with abnormal vitals, document your rationale and plan.
  4. Document your discussions with consultants. Record at what time and to whom you spoke, as well as what they recommended. This allows others to see the basis of your decisions, which is essential if an adverse outcome occurs.
  5. Be suspicious of patients signed out to you. Review the labs and vital signs of the patient you will be taking care of, and address all of their medical issues. Approach the case with fresh eyes and be willing to consider other diagnoses than those billed to you in sign out.
  6. Approach procedures carefully. While it's fun to do procedures, be aware that complications may arise – particularly in a patient who is high risk for bleeding. Review labs and history, particularly for things like coagulopathy, that may make procedures difficult.

Sunday, November 20, 2016

Tox Talks: Bath Salts

Author: Meaghan Mercer, MSIV
Western University of Health Sciences
AAEM/RSA Medical Student Council President '11-'12

Originally Published: Modern Resident October/November 2011

Walking onto my shift a few days ago, I heard shrieking coming from my pod, and I knew this would be an interesting night. I rushed over to find a female restrained by four police officers screaming that demons were out to get her. Witnesses reported that after snorting an unknown substance, the patient began running down the street, topless, yelling that something was after her. It required all four officers to control her and get her to the ED. She was agitated and combative, unwilling to answer questions, with a HR: 130, RR: 20, BP: 190/115, temp: 103, and an O2 saturation of 95% on room air. This was it, what I have been hearing so much about ... a bath salt ingestion.

There has been a recent insurgency of patients presenting to emergency departments across the country in an agitated delirium caused by a new designer drug called bath salts. On October 21st, the DEA issued a temporary one-year ban on methylenedioxypyrovalerone (MDPV), the main component of bath salts, classifying it as a schedule 1 substance. Manufacturers evade the restriction with minor alterations in the chemical structure, and bath salts are still available in gas stations, head shops and online.[1]

Thursday, November 17, 2016

Board Review: Toxic Alcohols

Image Credit: Dr. Wanner
This post was peer reviewed.
Click to learn more.

Authors: Gregory Wanner, DO
Emergency Physician/Clinical Faculty
Christiana Care Health System

Paul Kolecki, MD
Associate Professor, Emergency Medicine
Medical Toxicologist
Thomas Jefferson University

An 18-year-old male presents to the emergency department (ED) stating, “Doc, I’m really drunk.” He and a friend were drinking in the friend’s garage. The patient drank one “very strong” sweet-smelling drink, which was prepared by his friend. He began to feel sick and nauseated and rode his bike home (with difficulty due to this intoxication, but without any falls or trauma). He vomited twice and his mother referred him to the ED. Attempts to contact the friend were unsuccessful.

How would you evaluate this patient? 

Several intoxicants can cause similar symptoms. While ethanol is the most likely cause, in patients with unclear ingestions other alcohols should be considered as well. The following is a brief summary of the alcohols often tested on in-service and board exams; a summary table is included at the end:

Sunday, November 13, 2016

Board Review: Heat-Related Illnesses

Image Credit: Flickr
Author: Kaitlin Fries, DO PGY-1
Doctors Hospital
Originally Published: Modern Resident June/July 2015

Heat-related illnesses are responsible for approximately 400 U.S. deaths each year.[4] Drastic spikes in mortality can be seen during severe droughts and heat waves, the latter of which is defined as temperatures greater than 90°F for three or more consecutive days.[3,4] Those at greatest risk for heat-related emergencies are children, the elderly, people with certain predisposing medical conditions and those taking medications that interfere with the body’s thermoregulatory center.[3,4] The spectrum of heat-related illnesses ranges from cramps, syncope and heat exhaustion to more serious conditions such as heat stroke. All of these conditions are easily preventable with public education and adequate access to hydration and cool shelters.

The main two cooling mechanisms used by the human body are radiation and evaporation.[2,3,4] Radiation can account for up to 65% of total heat loss.4 However, radiation can only occur in a cool environment. Patients who do not have access to air-conditioning must rely on evaporation to dissipate heat by producing sweat, which then evaporates from the skin’s surface due to body heat.[2] However, as atmospheric humidity increases, the effectiveness of evaporation decreases.[2] Below is a brief review of the minor presentations of heat-related complaints.

Thursday, November 10, 2016

Sex-Specific Differences of Myocardial Infarction Presentation in the ED

Image Credit: Pixabay
Author: Jake Toy, MS3
Western University of Health Sciences, College of Osteopathic Medicine of the Pacific, Pomona, CA
AAEM/RSA Publications Committee '16-'17

This post was peer reviewed.
Click to learn more.

Heart disease is the leading cause of morbidity and mortality among women in the United States and accounts for approximately 1 in 4 deaths among women­.[1] Unfortunately, society fails to recognize this burden, often labeling heart disease as a “male problem”. In the past decade, only 54% of women recognized heart disease as a number 1 cause of mortality.[2] Exacerbating this issue further, the “classic” symptoms of myocardial infarction (MI) were historically based off studies analyzing MI in men.[3] Additionally, women often experience greater delays in care during an MI and have higher associated mortality rates when compared to men.[4, 5]

A significant body of literature exists describing sex-specific differences in MI presentation and outcomes. In the emergency department (ED), awareness of these variances in MI presentation is crucial toward providing timely and effective care to women presenting with an acute MI.

Typical vs. Atypical Chest Pain

The textbook symptoms of “typical” chest pain are well-defined – (1) precordial chest discomfort, pain, heaviness, or fullness, possibly radiating to the arm, shoulder, back, neck, jaw, or epigastrium; (2) symptoms worsened by stress or activity; (3) symptoms relieved by rest or medications, such as nitroglycerin; (4) associated symptoms that include shortness of breath, diaphoresis, weakness, nausea, vomiting, or lightheadedness.[3]

In comparison, “atypical” chest pain does not present in the aforementioned classic pattern. Signs may include: burning, sharp, pleuritic, or positional chest pain or discomfort; chest pain that is localized by one finger and reproducible; pain only in the arm, shoulder, back, neck, jaw, or epigastrium, or pain concentrated in regions of the body other than the chest, arm, shoulder, back, neck, jaw, or epigastrium.[3]

Sunday, November 6, 2016

A Crash Course in Sports-Related Concussions

Image Credit: Flickr
Author: Jennifer Reink, MSIV
Ohio University Heritage College of Osteopathic Medicine
AAEM/RSA Social Media Committee '16-'17

This post was peer reviewed.
Click to learn more.

With school back in session and autumn just around the corner, the fall sports season is upon us, and where there are athletic competitions, there are bound to be concussions. Nearly half of all emergency department (ED) visits for concussions are sports related, with 4 in 1000 children ages 8 to 13 and 6 in 1000 children ages 14 to 19 presenting to the ED each year for a concussion sustained during an organized team sport.[1] Furthermore, sports are second only to motor vehicle accidents as the leading cause of traumatic brain injury among people ages 15 to 24.[2] From football and cheerleading, to swimming and basketball, each sport has its own risk for head injury. For those of us who find ourselves caring for these young beaten warriors, here is what you need to know about what makes sports-related concussions such a challenging diagnosis.

1) Clinical symptoms are often subtle and may manifest with immediate or delayed onset.

A concussion is defined as a disturbance in brain function caused by a direct or indirect force to the brain resulting in a disruption of neural membranes.[1,3] This leads to a variety of non-specific signs and symptoms. Although symptoms typically present immediately after injury, some may not appear until several hours following impact. There are even patients who present days later with delayed or worsening symptoms. Common manifestations of concussions include:[2,3]

Thursday, November 3, 2016

Patient Satisfaction

Image Credit: Flickr
Author: Victoria Weston, MD
AAEM/RSA President '15-'16
Originally Published: Common Sense March/April 2016

Patient satisfaction. It feels like sometimes the concept is overemphasized, yet another addition to the countless expectations and constraints placed on doctors. I have felt this way at times, but recently my thinking has shifted. Instead of trying to meet arbitrary Press Ganey requirements, I have focused on trying to understand patients' wants and needs in order to better connect with them.

I recently had a shift with what seemed an unusually high number of patients with difficult personalities and “supratentorial pathology.”At times it was exceptionally frustrating, and although I started the shift feeling positive, by midway through the morning I could feel my spirits sinking. People had psychosomatic complaints. Some were drug-seeking and negotiating for narcotics. Some were demanding inappropriate care or tests. Some acted entitled and were rude to staff. I took this as a challenge, and tried to reframe my mind to see it as a learning experience in how to deal with difficult patients.