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 I Mnemonic 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. +AG +OG +Ketones Ethanol - + Eth Glycol Isopropyl
Methanol ++
ASA
- (slight)

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 HBO—indications
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 French, Peds French

23. Gastric Lavage Contraindications Complications 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 )
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 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 Syndrome Physical 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 Syndrome Management
Emergent MRI – Confirm Dx and levels
But do not delay treatment
Immediate Neurosurgery Consult
Methylprednisolone 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

51. Opthalmology II Sudden painless monocular vision loss
PE: Afferent pupil defect
Fundoscopic: pale retina, cherry red spot at fovea

52. Opthalmology II Sudden painless monocular vision loss
PE: Afferent pupil defect
Fundoscopic: pale retina, cherry red spot at fovea
CENTRAL RETINAL ARTERY OCCLUSION
TX: Intermittant digital massage
OPTHO CONSULT (paracentesis of anterior chamber)

53. Opthalmology III Sudden painless monocular vision loss
Less severe than last case
Fund: Blood and thunder retina (retinal hemorrhages, tortuous retinal veins)

54. Opthalmology III Sudden painless monocular vision loss
Less severe than last case
Blood and thunder retina (retinal hemorrhages, tortuous retinal veins)
CENTRAL RETINAL VEIN OCCLUSION
RF’s: DM, HTN, hyperviscosity
Refer to Optho – confirm Dx and monitor complications; Tx: most ineffective

55. Opthalmology IV
Pt entered movie theater, then c/o eye pain, N/V, blurred vision, “halos” around lights
PE: Fixed, mid-dilated NR pupil, scleral injection, hazy cornea

56. Opthalmology IV
Pt entered movie theater, then c/o eye pain, N/V, blurred vision, “halos” around lights
Fixed, mid-dilated NR pupil, scleral injection, hazy cornea
ACUTE NARROW ANGLE GLAUCOMA

57. Opthalmology IV ACUTE NARROW ANGLE GLAUCOMA
Shallow ant chamber, iris sits too tightly on lens
Resistance of flow of aquaeous humor, elevated IOP (>40)
Farsighted elderly women

58. Opthalmology IV TREATMENT:
Acetazolamide, Beta blockers (timolol) (decrease production)
Cholinergics (pilocarpine) (increase flow)
Depress head (separates lens + iris)
E-F-Glycerol, Mannitol (hyperosmotics)
Steroids (topical prednisolone) (antiinflamm)
EMERGENCY OPTHO CONSULT

59. Opthalmology V Painful monocular central vision loss
Preservation of peripheral vision
PE: APD, +/- disc swelling

60. Opthalmology V Painful monocular central vision loss
Preservation of peripheral vision
PE: APD, +/- disc swelling
OPTIC NEURITIS
Associated with MS, Lyme, Neurosyphilis, Lupus, Sarcoid, ETOH, toxins
OPTHO consult, IV steroids (methylprednisolone)

61. Opthalmology VI Neonate, sticky discharge, conjunctival inflammation
6-8 hrs after birth

62. Opthalmology VI
Neonate, sticky eye discharge, conjunctival inflammation
6-8 hrs after birth
CHEMICAL CONJUNCTIVITIS

63. Opthalmology VI Neonate, sticky discharge, conjunctival inflammation
6-8 hrs after birth
CHEMICAL CONJUNCTIVITIS
TX: AgNO3, resolves hrs

64. Opthalmology VII
Neonate, sticky, purulent discharge, conjunctival inflammation
2-5 days after birth

65. Opthalmology VII
Neonate, sticky purulent discharge, conjunctival inflammation
2-5 days after birth
GONONORRHEAL CONJUNCTIVITIS
Aggressive, can ulcerate/perforate cornea in hrs/days

66. Opthalmology VII
Neonate, sticky purulent discharge, conjunctival inflammation
2-5 days after birth
GONONORRHEAL CONJUNCTIVITIS
Aggressive, can ulcerate/perforate cornea in hrs/days
TX: Topical erythro, IV ceftriaxone, irrigation
Optho consult

67. Opthalmology VIII Neonate, sticky discharge, conjunctival inflammation
5-14 days after birth

68. Opthalmology VIII Neonate, sticky discharge, conjunctival inflammation
5-14 days after birth
CHLAMYDIA CONJUNCTIVITIS
Leading cause of preventable blindness worldwide
Most common of last three; assoc nasopharyngitis

69. Opthalmology VIII Neonate, sticky discharge, conjunctival inflammation
5-14 days after birth
CHLAMYDIA CONJUNCTIVITIS
Leading cause of preventable blindness worldwide
Most common; assoc nasopharyngitis
TX: Oral and topical erythromycin

70. Opthalmology IX
Painless vision loss, spider webs across visual field, curtain coming down
Fund: retinal tears, vitreous hemorrhages

71. Opthalmology IX
Painless vision loss, spider webs across visual field, curtain coming down
Fund: retinal tears, vitreous hemorrhages
RETINAL DETACHMENT

72. Opthalmology IX
Painless vision loss, spider webs across visual field, curtain coming down
Fund: retinal tears, vitreous hemorrhages
RETINAL DETACHMENT
TX: Keep pt still, Optho consult
Retinal attachment surgery

73. Opthalmology X
58 yo female, sudden monocular vision loss, ipselateral headache
PE: AFD; Fund: pale swollen optic disc

74. Opthalmology X
58 yo female, sudden monocular vision loss, ipselateral headache
PE: AFD; Fund: pale swollen optic disc
TEMPORAL ARTERITIS
Vasculitis med-large arteries, can cause optic nerve infarction
F>M, 50+ yo

75. Opthalmology X TX: IV methylprednisolone, Optho/IM consult
DX: Temporal artery biopsy
DO NOT DELAY TX PENDING DEFINITIVE DX

76. Most Common…

77. Most Common:
Metabolic abnormality in newborns:

78. Most Common:
Metabolic abnormality in newborns:
Hypoglycemia

79. Most Common: Metabolic abnormality in newborns:
Hypoglycemia
Rhythm in pediatric cardiac arrest:

80. Most Common: Metabolic abnormality in newborns:
Hypoglycemia
Rhythm in pediatric cardiac arrest:
Bradycardias

81. Most Common: Metabolic abnormality in newborns:
Hypoglycemia
Rhythm in pediatric cardiac arrest:
Bradycardias
Site in pediatric esophagus where foreign bodies trapped:

82. Most Common: Metabolic abnormality in newborns:
Hypoglycemia
Rhythm in pediatric cardiac arrest:
Bradycardias
Site in pediatric esophagus where foreign bodies trapped:
Cricopharngeal narrowing (C6)

83. Most Common:
Cause of syncope during normal pregnancy:

84. Most Common:
Cause of syncope during normal pregnancy:
Vasovagal

85. Most Common: Cause of syncope during normal pregnancy:
Vasovagal
Cause of maternal death in 1st trimester:

86. Most Common: Cause of syncope during normal pregnancy:
Vasovagal
Cause of maternal death in 1st trimester:
Ectopic pregnancy (1.5% of all pregnancies)

87. Most Common: Cause of syncope during normal pregnancy:
Vasovagal
Cause of maternal death in 1st trimester:
Ectopic pregnancy (1.5% of all pregnancies)
Medical cause of death in pregnant women (overall):

88. Most Common: Cause of syncope during normal pregnancy:
Vasovagal
Cause of maternal death in 1st trimester:
Ectopic pregnancy (1.5% of all pregnancies)
Medical cause of death in pregnant women (overall):
Pulmonary embolism

89. Most Common:
Obstructive cardiac lesion in the elderly:

90. Most Common: Obstructive cardiac lesion in the elderly:
Aortic stenosis

91. Most Common: Obstructive cardiac lesion in the elderly:
Aortic stenosis
Valvular heart disease in industrialized countries:

92. Most Common: Obstructive cardiac lesion in the elderly:
Aortic stenosis
Valvular heart disease in industrialized countries:
Mitral valve prolapse (3% of population)

93. Most Common: Obstructive cardiac lesion in the elderly:
Aortic stenosis
Valvular heart disease in industrialized countries:
Mitral valve prolapse (3% of population)
Presenting symptom of L heart failure, MS, AI, all other acute valvular disorders:

94. Most Common: Obstructive cardiac lesion in the elderly:
Aortic stenosis
Valvular heart disease in industrialized countries:
Mitral valve prolapse (3% of population)
Presenting symptom of L heart failure, MS, AI, all other acute valvular disorders:
Dyspnea, especially on exertion

95. Most Common:
Radiographic finding in aortic dissection:

96. Most Common: Radiographic finding in aortic dissection:
Widened mediastinum

97. Most Common: Radiographic finding in aortic dissection:
Widened mediastinum
Top three cardiovascular diseases in US, in order:

98. Most Common: Radiographic finding in aortic dissection:
Widened mediastinum
Top three cardiovascular diseases in US, in order:
(1) Ischemic HD (2) Hypertension (3) Cardiomyopathies (all combined)

99. Most Common: Radiographic finding in aortic dissection:
Widened mediastinum
Top three cardiovascular diseases in US, in order:
(1) Ischemic HD (2) Hypertension (3) Cardiomyopathies (all combined)
Symptom of acute pericarditis:

100. Most Common: Radiographic finding in aortic dissection:
Widened mediastinum
Top three cardiovascular diseases in US, in order:
(1) Ischemic HD (2) Hypertension (3) Cardiomyopathies (all combined)
Symptom of acute pericarditis:
Precordial or SS CP, described as sharp or stabbing

101. Most Common:
Physical finding in acute pericarditis:

102. Most Common: Physical finding in acute pericarditis:
Pericardial friction rub (??)
Cause of acute arterial occlusion in limb:

103. Most Common: Physical finding in acute pericarditis:
Pericardial friction rub (??)
Cause of acute arterial occlusion in limb:
Embolus (80-90% originate in heart)

104. Most Common: Physical finding in acute pericarditis:
Pericardial friction rub (??)
Cause of acute arterial occlusion in limb:
Embolus (80-90% originate in heart)
Most common infection and 5th leading COD in elderly:

105. Most Common: Physical finding in acute pericarditis:
Pericardial friction rub (??)
Cause of acute arterial occlusion in limb:
Embolus (80-90% originate in heart)
Most common infection and 5th leading COD in elderly:
Pneumonia

106. Most Common:
Viral agent implicated in post-transplant pulmonary infection:

107. Most Common:
Viral agent implicated in post-transplant pulmonary infection:
Cytomegalovirus

108. Most Common:
Viral agent implicated in post-transplant pulmonary infection:
Cytomegalovirus
Cause of abdominal pain in adults presenting to ED:

109. Most Common:
Viral agent implicated in post-transplant pulmonary infection:
Cytomegalovirus
Cause of abdominal pain in adults presenting to ED:
Nonspecific abdominal pain

110. Most Common:
Viral agent implicated in post-transplant pulmonary infection:
Cytomegalovirus
Cause of abdominal pain in adults presenting to ED:
Nonspecific abdominal pain
GI diagnosis in ED patients above age 50:

111. Most Common:
Viral agent implicated in post-transplant pulmonary infection:
Cytomegalovirus
Cause of abdominal pain in adults presenting to ED:
Nonspecific abdominal pain
GI diagnosis in ED patients above age 50:
Biliary tract disease

112. Most Common:
Surgical emergency in older patients with abdominal pain:

113. Most Common: Surgical emergency in older patients with abdominal pain:
Acute cholecystitis

114. Most Common: Surgical emergency in older patients with abdominal pain:
Acute cholecystitis
Symptom of abdominal aortic aneurism:

115. Most Common: Surgical emergency in older patients with abdominal pain:
Acute cholecystitis
Symptom of abdominal aortic aneurism:
Abdominal pain

116. Most Common: Surgical emergency in older patients with abdominal pain:
Acute cholecystitis
Symptom of abdominal aortic aneurism:
Abdominal pain
Diagnostic mistake in patients with AAA:

117. Most Common: Surgical emergency in older patients with abdominal pain:
Acute cholecystitis
Symptom of abdominal aortic aneurism:
Abdominal pain
Diagnostic mistake in patients with AAA:
Diagnosing renal colic in these pts

118. Most Common:
Rhythm disturbance in PE:

119. Most Common: Rhythm disturbance in PE:
Sinus tachycardia (on Boards pts: S1Q3T3)

120. Most Common: Rhythm disturbance in PE: ECG abnormality in PE:
Sinus tachycardia (on Boards pts: S1Q3T3)
ECG abnormality in PE:

121. Most Common: Rhythm disturbance in PE: ECG abnormality in PE:
Sinus tachycardia (on Boards pts: S1Q3T3)
ECG abnormality in PE:
Non-specific ST-T wave changes

122. Most Common: Rhythm disturbance in PE: ECG abnormality in PE:
Sinus tachycardia (on Boards pts: S1Q3T3)
ECG abnormality in PE:
Non-specific ST-T wave changes
CXR abnormality in PE:

123. Most Common: Rhythm disturbance in PE: ECG abnormality in PE:
Sinus tachycardia (on Boards pts: S1Q3T3)
ECG abnormality in PE:
Non-specific ST-T wave changes
CXR abnormality in PE:
Infiltrate or atelectasis (50%), Elevated hemidiaphragm +/- pleural effusion (40%), NORMAL (30%)

124. Thank you for your Attention