In patients with bradycardias or cardiac arrest, have a high index of suspicion for hyperkalemia, especially in patients with renal failure or hemodialysis. Death from hyperkalemia is typically secondary to diastolic arrest or fibrillation, and common symptoms include weakness, paresthesias, and nausea/vomiting.
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Organophosphates, such as the VX agent used to kill Kim jong-nam this past month, are used as insecticides, nerve agents, and medications.
These fall into the category of acetyl cholinesterase inhibitors, which also includes many dementia medications. Symptoms of organophosphate poisoning (including overdose of dementia medications) includes muscle weakness, fatigue, muscle cramps, hypersalivation, and muscle fasciculations. The SLUDGEM mnemonic identifies many of the symptoms (salivation, lacrimation, urination, diarrhea, GI motility, emesis, miosis). Nicotinic Ach receptor over-stimulation initially causes fasciculations, however as muscles fatigue patients may become weak with poor respiratory function even after treatment, and may still require intubation. Treatment is based on empiric presentation, and should begin immediately with decontamination and atropine. Treatment should include atropine and pralidoxime. Organophosphates are extremely lipophilic, and could result in prolonged symptoms and, as such, prolonged need for treatment and potential for delayed symptoms after initial treatment. Of note, leather items such as belts must be discarded appropriately as leather can absorb nerve agents and result in additional poisoning. Since the 1950's, antipsychotics have become effective treatment for positive and negative symptoms of psychosis. With the introduction of second generation antipsychotics there was some decrease in the extrapyramidal effects associated with these medications, however side effects, including potentially deadly, are still commonly seen in the ER.
Antipsychotics bind and inhibit dopamine receptors, causing the varying effects of these medications. This is also the source of many of the adverse effects of the medications.
Burns of dilute hydrofluoric acid are difficult to distinguish from other chemical burns and can appear as minimally erythematous areas of skin without blistering. Over 12-24 hours, however, this can progress to severe burns and blistering, progressing to necrosis requiring debridement. Highly concentrated acids may present with severely reddened, swollen areas with blanched regions which rapidly progress to necrosis. Even burns without impressive physical appearance may cause severe pain due to nerve ending irritation. HF is unique in that it does not spontaneously dissociate from hydrogen ions, causing it to penetrate through the skin and cause deeper, even systemic damage and hypocalcemia and hypomagnesemia.
Identifying atypical headaches, treatment of primary headaches, and how to approach complicated and atypical headaches. Adapted from Sigrid Nasser's Grand Rounds lecture, January 25th, 2015
Blistering AgentsMustard Gas, Phosgene, and Lewisite are the three most prominent blister agents. These are warfare agents which are dispersed and cause severe blisters. Apart form Lewisite, there are no antidotes and treatment is supportive including decontamination. Sulfur Mustard (mustard gas) is a colorless, odorous liquid when pure, but is dispersed as a yellow/brown gas that smells like mustard when used as a warfare agent. Bullous lesions present 2-6 hours after exposure and can cause mucosal damage including the respiratory tract. Lewisite has a more rapid onset than mustard gas, and has an antidote called "British Antilewisite (BAL). Phsgene oxime has never been used in warfare, but can cause wheels with blanching welts, which turn to tissue necrosis within 24 hours. Tear AgentsMultiple chemicals are used to cause tearing and mucosal irritation. The most commonly used are pepper-spray (capsaicin), CS (2-chlorobenzalmalononitrile), CN (mace). Pepper spray ranges from 10%-90% capsaicin depending on the product. Pepper-spray is self-limiting and shouldn't require more treatment than washing out. CN, or 'mace' and CS are both used by military and police, and typically can cause severe irritation, corneal abrasions, and even skin blistering if the patient is not decontaminated. CS is known to provide worse effects. CS can induce severe coughing and vomiting. Effects usually last for 20 minutes to an hour, and effects can persist for hours. Clothing will need to be thrown away or washed multiple times.
Status epilepticus is a common neurological emergency when a patient has a prolonged seizure or a series of seizures with incomplete return to baseline. The approach to status epilepticus has focused on early seizure termination, and rapid escalation of care to include general anesthesia when needed.
Status Epilepticus: A prolonged seizure or multiple seizures with incomplete return to baseline. Six common causes of ST elevation (J point 1mm above the baseline)
Evaluating for concerning causes of ST elevation:
Adapted from Andy Simmon's Grand Rounds lecture, January 11th, 2017.
How to identify serious injury that requires admisison for neurosurgery or observation, and how to instruct discharged patients for recovery expectations, followup, and return precautions. Adapted from CPC presentation by Molly Graham, November 11th, 2016 Differential Diagnosis for joint pain in a pediatric patient
HSP is the most common systemic vasculitis seen in children, and is characterized by palpable purpura without thrombocytopenia or coagulopathy, as well as abdominal pain, joint pains, proteinuria or hematuria. To diagnose HSP, a patient must have palpable purpura with a predominance of the lower extremities, and one additional symptom or finding on physical exam. Diffuse abdominal pain is commonly the first symptom and may include the testicles in males, but other gastrointestinal symptoms such as nausea and vomiting may be the first sign of disease, followed by skin findings. Patients with severe abdominal pain should be evaluated with an abdominal ultrasound to evaluate for intussuception or peritoneal fluid.
HSP symptoms are due to IgA deposits, while the trigger is still unknown, These deposits may be associated with a recent URI, group A strep infection, cold weather, or insect bites. Glomerular inflammation is typically self-limited, but in rare cases can lead to life-long renal disease. Additional complications of HSP include neurologic symptoms (headaches, seizures) and intussusception secondary to intestinal wall inflammation. Most patients (90%) are under the age of 17, and present in the fall or winter. Diagnosis of HSP is typically clinical, however a skin biopsy of a lesion can be taken to identify leukocytoclastic vasculitis. Treatment includes NSAIDs for pain control, |
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