Conference Notes 6-8-2016

Ede/Herron   Oral Boards

Case 1.  Middle age woman with acute weakness and diarrhea.  Electrolytes showed hyponatremia and hyperkalemia.  Further history revealed that patient was not taking her daily steroids for several days.  Diagnosis was acute adrenal crisis.  Treatment required IV hydrocortisone or dexamethasone, IV fluids and correction of electrolyte abnormalities.

Elise comment:  When dealing with an endocrine emergency always look for an inciting cause such as infection or AMI. 

*Adrenal Crisis


Case2. Firefighter trapped in a house fire suffered burns and had altered mental status and metabolic acidosis.  Treatment required Intubation for airway protection, applying Parkland Formula to manage fluids. Patient had a profound metabolic acidosis so he also required presumptive treatment for cyanide toxicity. Finally, the patient required transfer for hyperbaric O2 for elevated CO Level.   


*Parkland Formula


Elise comment:  If you get a burn victim on the boards always look for other traumatic injuries.   Look for circumferential burns on extremities that require escharotomy.  Always consider CO and Cyanide toxicity. 


Andrea comment:  A “poor man’s” rapid cyanide level in a person trapped in a house fire is a lactate.  Cyanide poisoning should give you a lactate of 10 or higher.  Hydroxycobalamine is a safe drug and there really isn’t much downside to giving it presumptively.


Case 3.   50 yo male fell from ladder and injured his wrist.  Pt has wrist

swelling and tenderness on exam.   No other injury.


*Xray is c/w perilunate dislocation.  


Girzadas comment: Lunate and perilunate dislocations can be confusing.  To me the easiest way to remember it is if the lunate is out of line with the capitate and the radius, it is a lunate dislocation.  If the lunate is in line with the radius but the capitate is out of line with the radius and the lunate it is a perilunate dislocation.  “Peri” means around, so perilunate is not a dislocation of the lunate but rather of the bone around the lunate which is the capitate.  As an aside, any time you see overlapping bones on the AP view of the wrist, you have a dislocation of some sort.  Both the lunate and perilunate dislocations require operative repair. 


Carlson   Summer Toxicology Cases


Case 1. 16 yo male ate seeds from a “loco pod”  (black seeds)  and develops anticholinergic syndrome.  The seeds were jimson weed, which is basically, plant-based Benadryl.



*Anticholinergic symptoms


Treat antichoinergic syndromes with benzos and supportive therapy.  Most cases of anticholinergic ingestions are short lived and can be observed in the ED until symptoms improve.



Case 2.  Little kids frequently ingest caustic materials.   Caustics include swimming pool products, rust removers, toilet bowel cleaners, hair treatments, detergents, bleaches, and denture cleaners, etc.   Detergent pods for dishwashers are a common caustic ingestion because kids see them as candy and try to eat them.


Never induce emesis in a patient with a caustic ingestion.   You don’t want to bring the caustic material back up the esophagus and cause further injury.

Alkali ingestions cause deeper injury by liquefaction necrosis.

Acid ingestions cause coagulation necrosis and less local injury but cause more systemic effects due to acidosis.

If the patient is drooling, has stridor, has painful swallowing, vomiting, or chest pain they have a significant caustic ingestion.

Plain films of the chest and abdomen can be useful to identify mediastinal or intra-abdominal free air. 

Endoscopy does not need to be performed emergently.  It is best done at 12-24 hours after ingestion.

For ED management of symptomatic patients, have a low threshold for starting antibiotics such as Zosyn or Unasyn.  

Steroids are really not an Emergency Physician decision.  Your GI consultant should direct steroid administration.

Andrea said the only kids she would let go home after a caustic ingestion would have to be running around the exam room, happy, eating and drinking, no tachycardia.  They have to look fantastic. Also the history has to suggest a minimal exposure.



Case 3.   Poison ivy exposure.



*Poison ivy exposure

ED treatment options:  If the exposure is recent you can advise the patient to purchase Tecnu to remove the resin.   Benadryl can help with the pruritus.    Prednisone 60mg/day for 5 days then 50mg for 2 days, then 40mg for 2 days, then 30mg for 2 days, then 20 mg for 2 days, then 10 mg for 2 days.  Steroidslessen the hypersensitivity reaction.  Finally Andrea said astringents such as domeboro solution can help dry the weeping lesions.


*Tecnu Poison Ivy treatment product


John Meyers comment:  Topical Benadryl gel is very effective for localized itching from poison ivy.  Topical steroids are also very effective for small areas of poison ivy exposure.


Case 4.  There are actually venomous snakes in Illinois.  It is rare that a patient will get a significant envenomation from a snakebite in Illinois.  Treat with local wound care, update tetanus, give antibiotics and give antivenin based on usual recommendations


*Antivenin indications.  I would also add local progression of edema/pain/skin changes at the site of envenomation


Case 5.  4 yo child ate red berries growing in the yard.  It is climbing nightshade.  Climbing nightshade causes nausea and vomiting and in general is self-limited.   Deadly nightshade is rare in the US but can cause fatal anticholinergic syndrome. 


*Climbing nightshade


*Deadly night shade


Case 6.  Sitting in the grass can result in chiggers due to a trombiculid mite.  They are very itchy but self-limited.  Treat with antihistamines and topical steroids. 




*trombiculid mite



Case 6.  Tick paralysis can cause weakness of bilateral feet and knees.  It is rare and all reports are in kids under age 10.  Dog tick is most common. It usually requires 5-7 days of tick attachment.  When the tick is removed the symptoms resolve rapidly. 



Case 7.  Lyme disease is cuased by borrelia burgorferi vectored by the ixodes tick .  The tick needs to be attached at least for 36 hours to cause Lyme disease.


*Erythema migrans

Patients can also have heart block and facial palsy caused by Lyme disease.


*Tick removal

Harwood comment: While pulling a tick out with forceps, you can use an 11 blade to excise the skin in which the tick is embedded.  Andrea said if you hold traction for 1-3 minutes the tick will usually release on it’s own.



Unfortunately, I missed this excellent lecture.


Parker     TPA for CVA EBM

Dr. Parker went through all the evidence regarding TPA for acute CVA.  His conclusion was that:

If you have a patient with an acute CVA and a Rankin score of 4 or 5 (moderate to severe disability) the benefit of TPA outweighs the risks.  For patients with less severe disability the risk benefit analysis is closer to equipoise and is a tougher call. Shared decision making with the patient and their family is critical when deciding to administer TPA for acute CVA.


Okubanjo    5 Slide F/U

The management of patients with incarcerated hernias is manual reduction and out patient follow up for surgery.   Manual reduction frequently requires procedural sedation and placing patient in trandelenburg position.

Harwood comment:  To reduce a hernia, apply circumferential pressure to the hernia.  The reduction attempt may take up to 5 minutes of pressure.  After reduction, you need to observe patient for an hour or two to be sure they don’t develop peritonitis.   If you can’t reduce the hernia, consult surgery for possible emergent surgery.


Ohl    5 slide F/U

Doxylamine ingestion can cause an anticholinergic toxidrome.   The drug blocks acetylcholine at muscarinic receptors.   Patients with anticholinergic toxidromes will be grabbing at imaginary objects.  It is a peculiar aspect of altered mental status specific to anticholinergic overdoses.

Treat with IV Ativan.  This will calm the agitation and may help decrease the risk of seizures.

Physostigmine is indicated for anticholinergic toxidromes with seizures and/or severe mental status changes.

Check a CK in all these patients for possible rhabdomyolysis.

Charcoal is not indicated for anticholinergic overdoses. 

Andrea:  It is always OK to not give charcoal.


Jamieson/Walchuk    The EM-3 Final Lecture

A funny, yet sweet reminiscing of 3 years of training that went by so quickly.