Hypocalcemia

Brief H&P:

34M with a history of HTN, polysubstance abuse, presenting with muscle cramps. He reported onset of diffuse muscle cramping 1-hour prior to presentation while showering. Symptoms involved bilateral upper and lower extremities and resolved spontaneously.

On initial evaluation, the patient was tachycardic and hypertensive. Examination was notable for tremors in bilateral upper extremities with outstretched hands, as well as of extended tongue. Other notable findings included spasm of the upper extremity during blood pressure measurement, hyperreflexia and clonus.

Laboratory evaluation was notable for normal total calcium level, low ionized calcium level, primary respiratory alkalosis, and elevated anion gap metabolic acidosis.

The patient was treated with intravenous fluids, benzodiazepines for alcohol withdrawal, and calcium gluconate 4g IV and was admitted.

Calcium Homeostasis1

  • Fraction
    • 15% bound to anions (phosphate, lactate, citrate)
    • 40% bound to albumin
    • 45% free (regulated by PTH, Vit-D)
  • Conditions causing changes in total calcium (without affecting ionized calcium)
    • Low albumin causes hypocalcemia. Corrected = measured + [0.8 x (4-albumin)]
    • Elevated albumin causes hypercalcemia
    • Multiple myeloma causes hypercalcemia
  • Conditions causing changes in ionized calcium (without affecting total calcium)
    • Alkalemia causes increased ionized calcium binding to albumin and decreases ionized calcium levels
    • Hyperphosphatemia causes increased ionized calcium binding to phosphate and decreases ionized calcium levels
    • Hyperparathyroidism causes decreased ionized calcium binding to albumin and increases ionized calcium levels

Causes of Hypocalcemia1,2,3

Algorithm for the Evaluation of Hypocalcemia

Symptoms1

Acute Chronic

Neuromuscular

  • Paresthesia
  • Tetany
  • Carpopedal spasm
  • Trousseau
  • Chvostek
  • Seizure
  • Laryngospasm

Cardiac

  • QT prolongation
  • Hypotension
  • Heart failure
  • Arrhythmia

CNS

  • Basal ganglia calcifications
  • EPS
  • Parkinsonism
  • Dementia

Ophthalmologic

  • Cataracts

Management

  • Severe (symptomatic, QT prolongation)
    • Calcium gluconate 1-2g IV in 50mL of D5W over 10-20min followed by slow infusion of additional 2g over 2 hours.
  • Asymptomatic
    • Calcium gluconate 1g PO q6h
    • Calcitriol 0.2mcg PO BID

References:

  1. Yu, AS. Relation between total and ionized serum calcium concentrations. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed on October 6th, 2016.)
  2. Cooper MS, Gittoes NJL. Diagnosis and management of hypocalcaemia. BMJ. 2008;336(7656):1298-1302. doi:10.1136/bmj.39582.589433.BE.
  3. Hannan FM, Thakker RV. Investigating hypocalcaemia. BMJ. 2013;346(may09 1):f2213-f2213. doi:10.1136/bmj.f2213.

Pediatric Emergencies

Diseases by Age

  • 1 week – 1 month: Ductal dependent cardiac lesions
  • 1st month: Malrotation with volvulus
  • 1 – 2 months: Pyloric Stenosis
  • 2 – 6 months: CHF
  • 3 months – 2 years: Intussusception
  • 6 months – 2 years: Croup
  • <2 years: Bronchiolitis
  • 2 years: Meckel’s
  • 2 years – 6 years: Epiglottitis

Cardiology

Ductal Dependent Lesions

  • Present 1st week to 1st month
  • Normal duct seals by 3 weeks
  • If dependent on shunt for pulmonary flow  cyanosis
  • If dependent on shunt for systemic flow cold shock (may be worse w/ fluids)
  • Prostaglandin E1
    • 1 mg/kg/min
    • Side effects include apnea, bradycardia, hypotension, seizure
      • Consider intubating prior to administration
    • IVF, cover for sepsis

Congestive Heart Failure

  • Present 2nd to 6th month
  • Presents with respiratory symptoms (wheezing, retractions, tachypnea)
  • Difficulty with feeding (the infant stress test)
  • Treatment: Supportive

 Tetrology of Fallot

  1. Calm the child, knee to chest
  2. O2 = reduction in PVR
  3. Analgesia: morphine 0.1mg/kg, fentanyl 1.5 mcg/kg, ketamine 0.25 mg/kg
  4. Establish Access: 10-20cc/kg bolus
  5. Phenylephrine 0.2 mg/kg IV (to increase SVR)
  6. +/- HCO3 1mmol/kg (if acidosis)
  7. +/- beta blocker (with cardiology consultation)
  8. PGE1 0.05mcg/kg/min titrating to 0.1mcg/kg/min

Dermatology

Slapped Cheek/5th Disease

  • Parvo B19
  • Slapped cheeks, lacy reticular pattern of rash on body
  • Complications:
    • Pregnancy hydrops
    • Sickle Cell Disease  aplastic crisis

Measles

  • Koplik spots, conjunctivitis, fever
  • Can cause blindness

VZV

  • Different stages of development
  • Treat with acyclovir if > 12 years old
  • Give VZIG in neonates and immunocompromised

Scarlet Fever

  • Erythematous rash, palatal petechiae, pastia’s lines
  • Strawberry tongue
  • Trunk to periphery
  • Treat with Pen VK: 50mg/kg BID x10d or Amox 20mg/kg BID x10d
  • Pen allergic: Azithro 10mg/kg day 1 then 5mg/kg 2-5

Staphylococcal Scalded Skin Syndrome

  • Toxin mediated, negative Nikolsky, good prognosis
  • Treatment: Anti-staphylococcal antibiotics
    • Nafcillin 25mg/kg/d IV
    • Augmentin 45mg/kg/d PO in 2 divdied doses 7-10d
    • Keflex 10mg/kg/d QID x7-10d

Henoch-Schonlein Purpura

  • Palpable purpura in dependent areas
  • Arthralgia/Arthritis (50-84%)
  • Abdominal pain (50%): vascular lesions in bowel, may be intussusception lead point
  • Renal Disease (20-50%) may develop within 2 months
  • Treatment: Supportive, NSAIDs

Kawasaki Disease

  • 5 days of fever + 4/5 of criteria
    • Diffuse polymorphous diffuse rash
    • Conjunctivitis
    • Mucous membrane change (strawberry tongue)
    • Cervical LAD (usually unilateral)
    • Extremity changes
  • Incomplete and atypical forms more common in infants
  • Treatment (drop complications from 25% to 4-5%)
    • Aspirin 20mg/kg/dose Q6H
    • IVIG 2gm/kg over 12H

Gastroenterology

Bilious Vomiting

  • Bilious vomiting malrotation with volvulus until proven otherwise  surgical emergency
  • 1st month of life “pre-verbal child’s disease”
  • Dx: Upper GI Series (10-15%) false positive rate

Necrotizing Enterocolitis

  • 10% of cases full term
  • XR w/ pneumatosis intestinalis

Hirschsprung’s

  • No meconium, slightly distended abdomen
  • Less severe  later presentation, p/w constipation

Pyloric Stenosis

  • Presents around 6 wks: vomiting but very hungry
  • Diagnosis
    • US pylorus > 4mm thick, >15mm long
    • NGT aspiration 5cc is abnormal
  • Treatment
    • Resuscitate
    • Correct metabolic abnormalities
    • Consult surgery

Intussusception

  • Most common infant emergency
    • 3 months – 2 years
  • Abdominal pain, currant jelly, palpable mass (30% only)
  • Typical presentation
    • Lethargy (may be only sign)
    • Vomiting
    • Paroxysms of pain
    • SBO
    • PO intolerance
  • Diagnosis: US
  • Treatment: Enema (80-95% successful), 10% recurrence

Meckel’s Diverticulum

  • Around 2 years of age, boys > girls
  • Obstruction, intussusception
  • Diagnose with technetium scan

Appendicitis

  • 1/3rd with vomiting and diarrhea (AGE-type syndrome)

Hemolytic Uremic Syndrome

  • Watery/bloody diarrhea
  • Three components
    • Acute renal failure
    • Thrombocytopenia
    • Microangiopathic hemolytic anemia (MAHA)
  • Signs
    • Pallor
    • Abdominal Pain
    • Decreased urine output
    • Low energy/AMS
    • Hypertension
    • Edema
    • Petechiae
    • Icterus
  • Treatment: Supportive vs. Dialysis (50%)

GI Bleed by Age

Age Well-Appearing Ill-Appearing
Neonate Allergic Proctocolitis Malrotation with Volvulus
Anal Fissure Necrotizing Enterocolitis
Swallowed Maternal Blood Coagulopathy
Infant/Young Child Allergic Proctocolitis Meckel’s
Gastritis Intussusception
Infectious Colitis Vascular Malformation
Older Child/Adolescent Gastritis IBD
Esophageal Bleeding Cryptic Liver Disease
Juvenile Polyps Intestinal Ulceration

Congenital Disorders

Congenital Adrenal Hyperplasia

  • Presents in first two weeks of life
  • Chief complaint may be vomiting
  • Lyte: HyperK, HypoNa, Hypoglycemia  dysrhythmias, seizures
  • Treatment
    • IVF (usual dose)
    • Glucose (usual dose)
    • Hydrocortisone: 25mg (neonate/infant), 50mg child, adolescent/adult 100mg

Inborn Errors of Metabolism

  • Possible CC: Vomiting, Lethargy, Seizures, Hepatomegaly, Metab Acidosis, Odor
  • May have normal labs and imaging
  • Life-threatening: Metabolic acidosis, Hypoglycemia, Hyperammonemia, Sepsis
  • Labs
    • VBG (acidosis),
    • CMP (liver, kidney, anion gap)
    • Ammonia, lactate, urine (ketones, reducing substance)
    • Bunch of extra tubes for labs later
  • Treatment
    • NPO
    • IVF bolus
    • D10 at 1.5x maintenance
    • Treat Sepsis
    • Control seizures PRN, correct hyperammonemia/acid/lyte (may need dialysis)

Pulmonary

Croup

  • Toddlers (6-24 months), 5% of all children, boys > girls
    • PIV #1
    • Rhinovirus, Metapneumovirus, PIV II-IV, RSV, Flu A/B
    • Frequent co-infections with one or more viruses
  • Sx: 1-3 days of URI Sx  Abrupt cough/stridor worse for one day, then better
  • Signs: Nontoxic, if wheezing likely RSV
  • Studies: XR to r/o FB (steeple sign if positive)
  • Treatment: Racemic Epi: 0.25-0.75 cc in 3 cc Q 20 minutes, lasts < 2 hours
  • Disposition: If stridor at rest then treat if no improvement, then admit
Stridor Steroids Racemic Epi Dispo
Mild 0.15 mg/kg No Home
At rest with WOB 0.30 mg/kg Yes Admit
Severe at rest 0.60 mg/kg Yes ICU

Bronchiolitis

  • Children < 2 years old, November through April (peak Jan/Feb)
    • Apnea in neonates and ex-premies < 2 months
    • Bacterial superinfection is very rare
  • Presentation: Desat, tachypnea, nasal flaring, intercostal retractions, secretions
  • Exam: Fine rales, diffuse/fine wheezing
  • Treatment: Suction, O2 (if < 90%), NPPV
  • Maybe albuterol, but no steroids/epi/abx

Epiglottitis

  • Bimodal (2-6, 20-40y), < 1% URI with stridor, boys = girls, al year
    • Non-typable H.flu, staph/strep, Moraxella
    • Candida, HSV, VZV, crack cocaine
  • Symptoms: Muffled voice, drooling rapid progression in hours
  • Signs: No pharyngeal findings with severely tender anterior neck
  • Studies: XR w/ thumb sign
  • Treatment: Laryngoscopy, airway management

Bacterial Tracheitis

  • Preschool (1-10y), boys = girls, Downs
  • Symptoms: Several days’ URI  toxic in hours, rapid progression
  • Signs: Subglottic diffuse inflammation, edema with exudates and pseudomembranes
  • Studies: CXR demonstrates narrow trachea
  • Treatment: Emergent intubation, 3rd generation cephalosporin

Altitude and Dysbarism

Altitude Illness

  • Risk factors: altitude, rapidity of ascent, sleeping altitude
  • Pathophysiology
    • Hypobaric hypoxia
      • Pulmonary: vasoconstriction  pulmonary hypertension capillary leak
      • Cerebral: vasodilation edema
    • Acclimatization
      • Hyperventilation primary respiratory alkalosis compensatory metabolic acidosis
      • Acetazolamide promotes renal bicarbonate excretion and accelerates acclimatization
  • Management: oxygen and descent

Acute mountain sickness (2000m)

  • Mild cerebral edema
  • Symptoms: headache, nausea/vomiting, fatigue (hangover)
  • Management: acetazolamide 250mg PO BID, dexamethasone 4mg q6h

High-altitude pulmonary edema (HAPE, 3000m)

  • Non-cardiogenic pulmonary edema
  • Symptoms: dyspnea at rest, cough, fever
  • Signs: hypoxia, crackles
  • CXR: patchy infiltrates
  • Management: nifedipine, PDEi (sildenafil), HBO

High-altitude cerebral edema (HACE, 4500m)

  • Cerebral edema
  • Symptoms: ataxia, altered mental status
  • Management: acetazolamide 250mg PO BID, dexamethasone 10mg then 4mg q6h, HBO
  • Gamow bag: portable HBO

Dysbarism (diving pathology)

  • Principles
    • Boyle’s Law: volume = 1/pressure
      • Volume changes greatest near surface
    • Henry’s Law: increased pressure increases proportion of dissolved gas

Barotrauma

  • Localized (descent)
    • Barotitis media
      • Mechanism: unequal pressure between external and middle ear.
      • Symptoms: pain, vertigo if ruptured
    • Barotitis externa
      • EAC edema/hemorrhage
    • Barotitis interna
      • Bleeding/rupture of round window
      • Symptoms: vertigo, tinnitus, hearing loss
      • Management: ENT referral
    • Sinus squeeze: pain and epistaxis
    • Mask squeeze: periorbital petechiae
  • Localized (ascent)
    • Barodontalgia
      • Air trapped in filling
      • Symptoms: pain, fracture
    • Alternobaric vertigo: Unequal ear pressure causing vertigo
    • GI barotrauma: belching, flatulence
  • Pulmonary overpressurization (ascent)
    • Mechanism: rapid ascent without exhalation, focal alveolar rupture leading to pneumomediastinum, rarely pneumothorax
    • CXR: continuous diaphragm sign
    • Symptoms: dysphonia, neck fullness, chest pain
    • Management: supportive
  • Air gas embolism (ascent)
    • Mechanism: similar to POP, air enters pulmonary venous circulation
    • Symptoms: MI, arrest, stroke, seizure within 10 minutes
    • Management: IVF, oxygen, HBO

Dissolved Gas Problems

  • Nitrogen narcosis
    • At >100ft, nitrogen enters nervous system and acts similarly to general anesthetic
    • Symptoms: similar to alcohol intoxication, complications arise from poor judgement
    • Management: ascent
  • Oxygen toxicity
    • Setting: industrial dives, deep
    • Symptoms: seizure, nausea, muscle twitching
  • Decompression sickness
    • Mechanism: nitrogen gas dissolves poorly in solution, with ascent forms bubbles, occurs 1-2 hours after ascent
    • Types
      • Musculoskeletal, integumentary (“bends”)
        • Symptoms: arthralgia, cutis marmorata
      • Neurological
        • Lower spinal cord (thoracic/lumbar/sacral)
          • Symptoms: paraplegia, paresthesia, bladder dysfunction
        • Cerebellum (“staggers”)
          • Symptoms: ataxia
        • Pulmonary (“chokes”)
          • Symptoms: similar to pulmonary embolus
        • Management: IVF, oxygen, HBO

Bites

Mammalian

  • Human: Eikenella corrodens
  • Dog/Cat: Pasteurella multocida

Athropod

  • Hymenoptra (bee, wasp, hornet, ant)
    • Venom: histamine reaction, anaphylaxis
    • Symptoms
      • Local: pain, swelling, pruritus
      • Toxic (<48h): multiple bits, N/V, syncope, HA
      • Anaphylaxis: minutes
      • Delayed (10-14d): serum sickness, fever, arthralgia, malaise
    • Management
      • Remove stinger
      • Wash, ice, anti-histamine, analgesia
  • Brown recluse (violin pattern)
    • Location: Midwest, wood pile
    • Symptoms: initially painless, cytotoxic venom may cause necrosis
    • Management: supportive, Tdap, delayed debridement if necrotic
  • Black widow (red hourglass)
    • Venom: neurotoxic, ACh, NE
    • Symptoms: painful, erythema, muscle contractions (“acute abdomen”), localized diaphoresis from ACh release
    • Management: analgesia, benzodiazepines, antivenom for refractory pain (may cause anaphylaxis)

Snake

  • Crotalid (rattlesnake, copperhead, cottonmouth, collectively “pit vipers”)
    • Venom: cytotoxic, hemorrhagic
    • Symptoms: erythema/edema (ecchymoisis/bullae), nausea/vomiting, metallic taste
    • Labs: DIC
    • Management
      • Immobilization (no tourniquet)
      • Local wound care, Tdap
      • CBC, INR, fibrinogen (q2h)
      • Antivenom (Crofab 4-6 vials): given until symptoms or laboratory abnormalities arrest
      • Compartment syndrome: avoid surgery
  • Elapidae (coral snake, “red on yellow”)
    • Venom: neurotoxic, delayed 10-12h
    • Symptoms: no significant local reaction, bulbar palsies, respiratory depression
    • Management: no antivenom, supportive care, intubation

Cnidaria (jellyfish)

  • Symptoms: local pain, erythema, pruritus
  • Management: 5% acetic acid, alcohol, remove stinger
    • Antivenom for box jellyfish

Stingray

    • Symptoms: local pain, edema
    • Management: Local wound care, Tdap, hot water immersion, antibiotics for Vibrio (cephalexin with doxycycline)

Vibrio vulnificus

  • Symptoms: necrotizing fasciitis, in cirrhotic primary septicemia after ingesting shellfish

Electrical Injuries

 

Physics

  • High-voltage defined as >1,000V
  • Voltage related to injuries current via resistance (V=IR)
  • AC is 3x more lethal than DC
    • Fluctuation at 60Hz causes tetany, maintained grasp on source

Effects

  • Dysrhythmia
    • DC: asystole
    • AC: ventricular fibrillation
    • Delayed dysrhythmia uncommon
  • Burn
  • Tissue ischemia: vascular spasm or thrombosis
  • CNS: AMS, seizure, ICH, neuropathy
  • MSK: posterior shoulder dislocation

Management

  • Asymptomatic: None
  • Mild (i.e. small burn): ECG, UA (rhabdo)
  • High voltage: Labs, CT, admit for observation
  • Pediatrics: oral commissure burn, discharge with plastic surgery follow-up if no LOC, normal ECG, tolerating PO. Risk of delayed labial artery bleeding.

Complications

  • Keraunoparalysis: current travels up and down lower extremities causing transient paresthesia and paralysis.
  • Trauma: TM rupture, other mechanical injuries

 

Heat Emergencies

Overview

  •  Spectrum
    • Cramps
    • Syncope
    • Exhaustion
    • Stroke
  • Physiology of cooling
    • Radiation: body warmer than environment, heat radiates away
    • Evaporation: environment warmer than body, sweat promotes heat exchange, affected by ambient humidity

Heat cramps

  • Mechanism: fluid/electrolyte depletion resulting in muscle cramps
  • Management: IVF, electrolyte repletion, cooling

Heat syncope

  • Mechanism: vasodilation resulting in hypotension
  • Management: IVF, cooling, rule out alternative etiologies

Heat exhaustion

  • Mechanism: similar to heat cramps
  • Symptoms: influenza-like, headache, fatigue, dizziness, nausea, normal mental status distinguishes from heat stroke
  • Findings: temperature <40°C
  • Management: IVF, cooling

Heat stroke

  • Mechanism: similar to heat cramps
  • Symptoms: prodrome of heat exhaustion
  • Signs: AMS, ataxia, seizure
  • Findings: temperature >40°C
  • Mortality: 30-80%
  • Labs: AST/ALT, coagulopathy, DIC, rhabdomyolysis, ATN/AKI
  • CXR: pulmonary edema
  • Types
    • Classical: elderly, dry skin, mild dehydration, increased mortality
    • Exertional: young athlete, diaphoretic, increased morbidity (organ failure)
  • Management
    • Evaporative cooling
    • Ice packs to large vessels
    • GI lavage
    • Liberal intubation
    • Benzodiazepines or thorazine for inappropriate thermogenesis (shivering)
    • Halt cooling at 40°C

Hypothermia

Overview

  • Risk factors
    • Extremes of age
    • Behavioral: psychosis, intoxication
  • Types
    • Chillblains
    • Immersion foot
    • Frostnip
    • Frostbite
    • Generalized

Hypothermia

Chilblains

  • Findings: red/white plaques on extremities
  • Symptoms: pruritus, pain
  • Management: supportive (gentle warming), topical corticosteroids, consider nifedipine

Immersion foot (trench)

  • Mechanism: prolonged immersion in non-freezing water, vasoconstriction leads to ischemia/necrosis
  • Findings: pale, mottled skin, paresthesia
  • Management: supportive, drying and rewarming
  • Complications: gangrene

Frostnip

  • Retrospective distinction from frostbite after rewarming if no tissue loss

Frostbite

  • Mechanism: extracellular then intracellular crystal formation (mechanistically similar to crush injury)
  • Reperfusion: cellular injury triggers cytokine release upon reperfusion, results in microvascular thrombosis and tissue ischemia/necrosis
  • Classification: grades I-II superficial to dermis, grades III-IV involve subcutaneous tissue to bone
  • Management
    • Rapid rewarming (immersion in warm water at 41°C)
    • Tdap
    • Debridement of clear blisters

Generalized

  • Causes
    • Exposure
    • Metabolic (adrenal, thyroid, hypoglycemia)
    • Sepsis
  • Grading
    • Mild (32.2-35°C)
      • Findings: excitation, tachycardia, hypertension, shivering thermogenesis
    • Moderate (30-32.2°C)
      • Findings: ataxia, AMS, bradycardia, hypotension, bradypnea
      • ECG:  Osborn wave
    • Severe (<30°C)
      • Complications
        • Increased risk of arrhythmia (bradycardia, slow atrial fibrillation, ventricular fibrillation, asystole)
        • Irritable myocardium
        • Decreased enzymatic activity
          • Renal: cold diuresis
          • Heme: coagulopathy (hidden on labs as blood rewarmed prior to testing)
          • Metabolic: hyperglycemia as insulin ineffective
      • Management
        • Ventricular fibrillation: attempt one shock, then focus on rewarming if ineffective
        • Goal >30°C

Radiation Exposure

Physics

  • Units
    • Gray (amount of radiation absorbed by body)
    • Sievert (toxicity associated with radiation exposure)
  • Types
    • Alpha: 0.1mm penetration, injury through ingestion
    • Beta: 1cm penetration, injury through skin or ingestion
    • Gamma: deep penetration
  • Factors
    • Time and distance (1/d2)
    • Shielding
    • Radiosensitive cells (rapidly dividing such as hematopoetic, GI)

Injury

  • Localized: epilation or burns, delayed by days
  • Internal (inhaled, ingestion)
    • Radioactive iodine: high dose results in thyroid ablation, low dose increases risk of thyroid malignancy
  • External: managed by removing clothing, soap/water shower
  • Whole body (gamma)
System Dose Time of onset Signs/Symptoms
Hematopoetic 2G 2d Pancytopenia, increased risk of infection
GI 6G Hours Nausea/vomiting, diarrhea, GI bleeding
CV/CNS 10G Minutes Shock, seizure

Key clinical features

  • Multiple affected individuals with nausea/vomiting suggests radiation exposure
  • Rapidity of onset of symptoms suggests increased dose/exposure
  • LD505G
  • Prognosis by lymphocyte count
    • ALC >1000 at 48h suggests good prognosis
    • ALC <300 at 48h suggests poor prognosis

Neurosyphilis

Brief H&P

A young male with a history of HIV (untreated for the last year, with unknown CD4 count), and syphilis (reportedly treated with an intramuscular injection 1 year ago), presents with 4 months of a painful rash on the palms and soles and diplopia. Examination revealed the rash pictured below, ocular examination with minimal papilledema and anterior chamber inflammation.

Labs were unremarkable. CSF sampling was notable for 34 WBC’s with lymphocyte predominance (92%), and elevated protein (56mg/dL). The patient was admitted for syphilis with presumed neurosyphilis. Serum RPR titer was elevated at 1:64,  FTA-ABS and CSF VDRL were reactive. The patient was treated with intravenous penicillin and anti-retroviral therapy was reinitiated.

Epidemiology1

  • Transmission
    • Sexual contact (estimated transmission probability 60% per partner)
    • Trans-placental
  • Race/Sex
    •  African-American, Hispanic
    • Male > Female
    • Male (primary syphilis), female (secondary syphilis) – lesion visibility
    • Urban > rural

Natural History1

Stage Signs/Symptoms Incubation Period
Primary Chancre, reginal lymphadenopathy 3 weeks
Secondary Rash, fever, malaise, generalized lymphadenopathy, mucous membrane lesions, condyloma lata, headache, meningitis 2-12 weeks
Latent Asymptomatic Early (<1 year)

Late (>1 year)

Tertiary Cardiovascular:

Aortic aneurysm, aortic insufficiency, coronary artery ostial stenosis

<2 years
CNS:
Acute syphilitic meningitis: headache, confusion, meningeal irritation <2 years
Meningovascular: cranial nerve palsy 5-7 years
General paresis: headache, vertigo, personality changes, vascular event 5-7 years
Tabes dorsalis: dementia, ataxia, Argyl-Robertson, [arrow-down] proprioception 10-20 years
Gumma:

Local tissue destruction

1-46 years

Diagnosis1

  • Serologic
    • Non-treponemal (screening)
      • RPR, VDRL
      • Limitations:  sensitivity, false positive (age, pregnancy, drugs, malignancy, autoimmune, viral infections)
    • Treponemal (confirmatory)
      • FTA-ABS
    • Neurosyphilis
      • Indications for CSF sampling: neurologic/ophthalmologic symptoms, tertiary syphilis (aortitis, gumma, iritis), HIV coinfection with elevated RPR titer (> 1:32)
      • CSF: leukocytosis (predominantly lymphocytes),  protein
      • CSF VDRL reactive
      • Negative CSF FTA-ABS may rule out neurosyphilis

Syphilis in HIV-infected Individuals2

  • Primary: larger and more lesion, multiple ulcers
  • Secondary: genital ulcers more common, higher RPR/VDRL titers
  • Tertiary: possibly more rapid progression to neurosyphilis

References

  1. Singh AE, Romanowski B. Syphilis: review with emphasis on clinical, epidemiologic, and some biologic features. Clin Microbiol Rev. 1999;12(2):187-209.
  2. French P. Syphilis. BMJ. 2007;334(7585):143-147. doi:10.1136/bmj.39085.518148.BE.

Submersion Injury

Pathophysiology

  • Breath-holding until eventual involuntary gasp which triggers reflexive laryngospasm. Resultant loss of consciousness may cause laryngeal relaxation and aspiration.
  • Fluid aspiration results in decreased surfactant activity and atelectasis. This is complicated by V/Q mismatch and atelectrauma which can lead to ARDS.

Symptoms

  • Progressive respiratory distress
  • AMS: due to cerebral hypoxia
  • Shock: uncommon, consider trauma

Management

  • Albuterol
  • BiPAP
  • Endotracheal intubation
  • ECMO

Disposition

  • Asymptomatic or minor event: observe 2-3 hours
  • Mildly symptomatic: observe 4-6 hours
  • Hypoxia: admit
  • PPV: ICU

Hematologic Emergencies

Sickle Cell Crises

  • Triggers: infection, acidosis, dehydration, cold-exposure, hypoxia, pregnancy
  • Presentation: exclude alternative more serious pathology prior to ascribing pain to vaso-occlusive crisis

Effects by Organ System

System Symptom
CNS Focal or generalized neurological symptoms, stroke, seizure
Pulmonary Acute chest syndrome (fever, chest pain, cough, hypoxia, pulmonary infiltrates), pulmonary embolism
GI Abdominal pain, nausea/vomiting
Renal Papillary necrosis
GU Priapism, testicular/ovarian ischemia
Muskuloskeletal Bone pain (back, proximal extremities), exclude osteomyelitis, avascular necrosis
ID Infection, functional asplenia (streptococcus, haemophilus)
OB Preterm labor, placental abruptions, SAB
Ophthalmology Acute retinal ischemia, hyphema (with intra-ocular hypertension)
Hematology
  • Sequestration crisis: acute anemia, often post-viral
  • Hemolytic crisis: acute anemia, reticulocytosis, hyperbilirubinemia
  • Megaloblastic crisis: folate deficiency
  • Aplastic crisis: inadequate reticulocytosis

Evaluation

  • CBC with reticulocyte count
    •  Hemoglobin: suggests sequestration or hemolytic crisis
    • Reticulocyte index: suggests aplastic or megaloblastic crisis
  • LDH/haptoglobin: evaluate for hemolysis
  • UA: evaluate for infection/infarction
  • CXR: evaluate for acute chest syndrome

Management

  • Rehydration (hypotonic fluids)
  • Analgesia
  • Supplemental oxygen if hypoxic
  • Exchange transfusion for priapism, neurologic symptoms, aplastic/sequestration/hemolytic crises

Transfusion Reactions

  • Epidemiology: overall 0.25%, 0.09% severe
  • Management: stop transfusion

Management by Presumed Etiology

Reaction Mechanism Signs/symptoms Management
Acute, Severe
Acute hemolysis Incompatibility Fevers, HR, BP, vomiting, back pain IVF, vasopressors if needed, furosemide
Anaphylaxis IgA-mediated 1min: flushing laryngospasm, bronchospasm, BP Epinephrine, steroids, diphenhydramine, IVF
Sepsis Bacterial contamination (Y. entercolitica), increased risk in platelet transfusion Fevers, BP IVF, vasopressors if needed, broad-spectrum antibiotics
TRALI (transfusion-related acute lung injury) Non-cardiogenic pulmonary edema, increased risk in FFP transfusion Hypoxia, respiratory distress, XR bilateral infiltrates Supplemental oxygen, PPV/ETT
TACO (transfusion-associated circulatory overload) Hypervolemia in patients with history of CHF Hypoxia, respiratory distress, heart failure Supplemental oxygen, PPV/ETT, furosemide
Acute, Minor
Simple febrile reaction Cytokine-mediated Isolated fever Acetaminophen
Minor allergic reaction Response to transfused plasma proteins Urticaria, pruritus, flushing Diphenhydramine
Delayed
Delayed hemolysis Minor RBC antigens 5-10d, low-grade hemolysis  
GVHD Immunocompromised host Fever, rash, N/V, transaminitis, pancytopenia  
Massive Transfusion
Massive transfusion Large-volume, refrigerated products Coagulopathy, hypothermia, hypocalcemia, hyperkalemia, lactic acidosis

Bleeding Disorders

Overview

  • Disorders of primary hemostasis
    • General: present with mucocutaneous, post-operative bleeding
    • vWD
    • Platelet disorders
      • Medication-induced: NSAID, valproate, B-lactam, SSRI
      • Systemic disease: hepatic, renal failure
    • ITP: antibody-mediated platelet destruction
  • Disorders of secondary hemostasis
    • General: present with bleeding into soft-tissue, joints
    • Hemophilia A (VIII)
    • Hemophilia B (IX)
  • Disorders of both primary and secondary hemostasis
    • DIC
    • Liver disease
    • Severe vWD
  • Evaluation
    • PT: VII, vitamin K
    • PTT: VIII, IX, XI, XIII, vWD, heparin
    • Increased PT/PTT: XI, V, vitamin K, heparin, DIC
    • CBC: degree of anemia, platelet count, differential (hematopoetic disorders)
  • Management
    • Thrombocytopenia
      • Prophylactic transfusion for avoidance of spontaneous hemorrhage for platelet count <10,000
      • Transfusion for active bleeding at platelet count <50,000
      • Dosing
        • Adults: one RDP increases platelet count by 7-10,000
        • Pediatrics: 5-10ml/kg
      • ITP
        • Transfuse platelets for active bleeding
        • High-dose steroids (prednisone 1mg/kg)
        • IVIG (1g/kg/d)
      • Uremia
        • Hemodialysis
        • DDAVP (0.3ug/kg IV)
      • vWD
        • DDAVP (0.3ug/kg IV)
        • Severe: VWF (Humate-P) 40-80IU/kg
        • Tranexamic acid
      • Hemophilia A
        • Minor: 20IU/kg
        • Major: 50IU/kg
      • Hemophilia B
        • Minor: 40IU/kg
        • Major: 100IU/kg

DIC/TTP/HUS

  • Disseminated Intravascular Coagulation
    • Etiology: severe systemic illness/injury
      • Trauma, burn, crush
      • Sepsis
      • Malignancy
      • Obstetric complication: abruption, amniotic fluid embolism
      • Hemolytic anemia
    • Exam: petechiae/purpura, hemorrhage (puncture site, GI, GU, pulmonary)
    • Labs:
      • PT/PTT
      • Fibrinogen
      • CBC: schistocytes, thrombocytopenia
      • FDP/D-Dimer
    • Management
      • Treat underlying illness
      • Transfuse (PRBC, FFP for INR > 2, cryoprecipitate for fibrinogen < 100)
      • Heparin if apparent embolic events
      • Consult hematology
  • TTP/HUS
    • Presentation
      • Thrombocytopenia
      • Altered mental status
      • Renal dysfunction
      • Fever
      • MAHA
    • TTP: more commonly associated with altered mental status
      • Etiology: drugs, pregnancy, infection (HIV)
      • Mechanism: ULvWF uncleaved by dysfunctional ADAMTS-13
    • HUS: more commonly associated with renal dysfunction
      • Mechanism: toxin from E. coli, Shigella
      • Timing: 1-2wks after diarrheal illness
    • Evaluation
      • CBC: anemia, schistocytes, thrombocytopenia
      • PT/PTT (normal)
      • BUN/Creatinine
      • LDH
    • Management
      • Platelets contraindicated except as stopgap measure in ICH (can worsen process)
      • Plasma exchange with FFP (replaces functional ADAMTS-13)
      • Steroids (prednisone 1mg/kg daily)
      • Hematology consultation

Complications of anti-thrombotic therapy

  • Agents
    • Anti-platelet
      • TXA: Aspirin
      • ADP: clopidogrel, ticagrelor, prasugrel
      • GPIIb/IIIa: abciximab, eptifibatide, tirofiban
    • Anti-coagulants
      • Anti-thrombin: heparin, LMWH (enoxaparin, dalteparin)
      • Vitamin K antagonist: warfarn (anti-II, VII, IX, X)
      • Direct thrombin inhibitor: bivalirudin, argatroban, dabigatran
      • Xa inhibitor: rivaroxaban, apixaban
    • Fibrinolytics
      • Alteplase, tenectaplase
  • Complications
    • HIT: platelet count decrease >50% at 5 days

Summary of Management

Agent Reversal
Aspirin, clopidogrel 5-10U platelets

DDAVP 0.3ug/kg

GPIIb/IIIa Abciximab: 5-10U platelets

Eptifibatide/tirofiban: none

Heparin Protamine 1mg/100mg heparin in last 2-3 hours
LMWH Enoxaparin: 1mg/1mg

Dalteparin: 1mg/100U

Warfarin See supratherapeutic INR algorithm
DTI Dabigatran: Praxbind, hemodialysis, consider Factor VIIa
Xa PCC
Fibrinolytics 10U cryoprecipitate, 2U FFP, consider platelets and aminocaproic acid (4-5g IV)

Oncologic Emergencies

Overview

  •  Complications
    • Airway obstruction
    • PNA
    • Pleural effusion
    • Pericardial effusion
    • VTE
    • SVC syndrome
      • Symptoms: dyspnea (airway edema), chest fullness, blurred vision, headache (increased ICP)
    • Massive hemoptysis
      • Management: ETT (large-bore for bronschoscopy), affected side down
  • Brain Metastases
    • Cancers: melanoma, lung, breast, colorectal
    • Management: dexamethasone 10mg IV load, elevated HOB, hypertonic saline or mannitol, prophylactic anti-eplipetics
  • Meningitis
    • Pathogens: Listeria (ampicillin), Cryptococcus (amphotericin)
    • Evaluation: CSF sampling with cytology (diagnose leptomeningeal metastases)

Metabolic Disturbances

  • Hypercalcemia
    • Cancers: MM, RCC, lymphoma, bone metastases (breast, lung, prostate)
    • Mechanism: metastatic destruction, PTH-RP, tumor calcitriol
    • Prognosis: 50% 30-day mortality
    • Symptoms
      • Chronic: anorexia, nausea/vomiting, constipation, fatigue, memory loss
      • Acute: CNS (lethargy, somnolence)
    • Findings
      • Calcium: >13.0mg/dL
      • ECG: QT shortening
    • Treatment
      • Mild: IVF
      • Severe: IVF, loop diuretics, bisophosphanate (pamidronate 90mg IV infused over 4 hours), consider calcitriol, consider hemodialysis if cannot tolerate fluids or unlikely to respond to diuretics
  • Hyponatremia
    • Cancers: lung (small-cell), pancreatic, ovarian, lymphoma, thymoma, CNS
    • Mechanism: SIADH
    • Symptoms: muscle twitching, seizure, coma
    • Management: fluid restriction, if seizing administer 3% hypertonic saline at 100cc/hr until resolution
  • Hypernatremia
    • Mechanism: decreased intake, increased GI losses from chemotherapy
    • Management: cautious fluid resuscitation
  • Tumor Lysis Syndrome (TLS)
    • Cancers: hematologic, rapid-growth solid tumors
    • Mechanism: release of intracellular contents (uric acid, K, PO4, Ca)
    • Timing: 1-4 days after therapy (chemo, radiation)
    • Diagnosis
      • Uric acid >8mg/dL
      • Potassium >6mEq/L
      • Calcium <7mg/dL
      • PO4 >4.5mg/dL
      • Acute kidney injury
    • Management
      • IVF, allopurinol, rasburicase, urinary alkalinization
      • Consider hemodialysis if volume overloaded

Localized Complications

  • Musculoskeletal Complications
    • Spinal cord compression
      • Cancers: prostate, breast, lung, RCC, non-Hodgkin lymphoma, MM (5-10% of all cancer patients)
      • Sites: thoracic (60%), lumbosacral (30%), cervical (10%)
      • Symptoms: pain (worse lying flat, cough/sneeze, heavy lifting)
      • Evaluation: MRI (se 93%, sp 97%)
      • Management: dexamethasone 10mg IV load, 4mg q6h, neurosurgical consultation, radiation oncology consultation
    • Pathologic fracture
      • Features: sudden onset, low-force mechanism
  • Therapy Complications
    • Neutropenic fever
      • Definition: ANC <500 or ANC <1000 with expected nadir <500 (nadir typically occurs 5-10d after chemotherapy) with Tmax >38.3°C or >38.0°C for >1h
      • Examination: subtle signs of infection, thorough examination is critical (skin, catheter, perineum)
      • Treatment: carbapenem monotherapy, vancomycin if indwelling catheter, oncology consultation for colony stimulating factors
    • Chemotherapy-induced vomiting
      • Management: ondansetron with dexamethasone, consider NK-1 antagonist (aprepitant)

Hematologic Malignancies

  • Acute leukemia
    • Signs/Symptoms: leukopenia (infection), anemia (weakness/fatigue), thrombocytopenia (bleeding)
    • Diagnosis: >5% blasts
  • Thrombocytopenia
    • Management
      • No bleeding, goal >10,000
      • Fever, coagulopathy, hyperleukoctosis, goal >20,000
      • One unit of platelets increases count by 5,000
  • Hyperleukocytosis
    • Definition: WBC > 50-100k
    • Complications: microvascular congestion (pulmonary, cerebral, coronary)
    • Symptoms
      • CNS: confusion, somnolence, coma
      • Pulmonary: dyspnea, respiratory alkalosis
    • Management: cytoreduction (induction chemotherapy, increased risk TLS)
  • Hyperviscosity
    • Cancer: macroglobulinemia, MM
    • Symptoms: epistaxis, purpura, GIB, neuro deficits
    • Diagnosis: serum viscosity > 1.4-1.8
    • Management: emergent plasmapheresis
  • Polycythemia
    • Diagnosis: Hb >17
    • Differential: dehydration, hypoxia, smoking, altitude
    • Symptoms: HA, vertigo, angina, claudication, pruritus (after showering)
    • Complications: thrombosis (stroke), bleeding
    • Management: emergent phlebotomy (500cc if otherwise healthy)
  • Thrombocytosis
    • Diagnosis: platelet >1,000,000
    • Symptoms: vasomotor (HA, lightheadedness, syncope, chest pain, paresthesias)
    • Management: low-dose aspirin

Adrenal/Pituitary Emergencies

Adrenal Emergencies

  • Hormones: aldosterone, cortisol, androgens, catecholamines
  • Adrenal insufficiency
    • Primary
      • Causes
        • Autoimmune (associated with other endocrinopathies, PTH, DM)
        • Infection (TB, viral, meningococcemia)
        • Infiltration (sarcoidosis, amyloidosis)
        • Hemorrhage (trauma, anti-coagulation)
        • Malignancy (primary, metastatic)
      • Signs/Symptoms
        • AMS
        • Hypotension (refractory)
        • GI: anorexia, nausea/vomiting, diarrhea
        • Hyperpigmentation
      • Labs
        • Hyponatremia
        • Hyperkalemia
        • Hypercalcemia
        • Mild metabolic acidosis
        • Hypoglycemia
    • Secondary
      • Causes
        • Iatrogenic (>5mg prednisone/day for > 2 weeks)
        • Pituitary/sellar tumors
        • Hemorrhage (Sheehan)
        • Cranial radiation
      • Signs/Symptoms
        • RAAS function maintained, hypotension rare
        • Features of pituitary/hypothalamic dysfunction: menstrual disturbances, headache, vision changes, galactorrhea, acromegaly
    • Adrenal Crisis
      • Precipitated by physiologic stressor: sepsis, MI, trauma, surgery
      • Diagnosis
        • AM cortisol <3
        • ACTH stimulation peak cortisol <15
        • ACTH level
      • Management
        • Glucose management
        • Fluid resuscitation
        • Dexamethasone 10mg IV
        • Identify and treat precipitant

Cushing syndrome

  • Causes
    • Pituitary adenoma (Cushing disease)
    • Malignancy (ACTH-producing): SCLC, pancreatic, carcinoid
    • Adrenal neoplasm
  • Signs/Symptoms
    • Obesity, fat deposition in face, neck
    • Skin atrophy with striae
    • Proximal myopathy
    • Hypertension

Pheochromocytoma

  • Familial: MEN 2A/2B, NF, Von Hippel-Lindau
  • Signs/Symptoms
    • Refractory hypertension (paroxysmal)
    • Heat intolerance, sweating, weight loss
  • Diagnosis
    • 24h urine metanephrine, catecholamine
    • CT/MRI

Hypopituitarism

  • Adenoma
    • Symtoms/Signs
      • Headache
      • Vision changes (bitemporal hemianopsia)
      • Cavernous sinus involvement (CN III, IV, V1, V2, VI)
  • Ischemic necrosis
    • Sickle cell disease, vasculitis, cavernous sinus thrombosis, infection, TBI, post-partum (Sheehan)
  • Pituitary apoplexy
    • Acute loss of pituitary function from infection/hemorrhage, rarely tumor
    • Symptoms/Signs
      • Abrupt onset headache
      • Vision changes
      • Meningismus
      • ALOC

Thyroid Emergencies

Hyperthyroidism

Symptoms

Constitutional Weight loss, heat intolerance, perspiration
Cardiopulmonary Palpitations, chest pain, dyspnea
Neuropsychiatric Tremor, anxiety, double vision, muscle weakness
Neck Fullness, dysphagia, dysphonia
Musculoskeletal Extremity swelling
Reproductive Irregular menses, decreased libido, gynecomastia

Signs

Vital signs Tachycardia, widened pulse pressure, fever
Cardiovascular Hyperdynamic precordium, CHF, atrial fibrillation, systolic flow murmur
Ophthalmologic Widened palpebral fissure, periorbital edema, proptosis, diplopia, restricted superior gaze
Neurologic Tremor, hyperreflexia, proximal muscle weakness
Dermatologic Palmar erythema, hyperpigmented plaques or non-pitting edema of tibia
Neck Enlarged or nodular thyroid

Causes

  • Grave disease
    • Mechanism: thyroid-stimulating antibodies
    • Female > Male (10x)
    • Findings: ophthalmopathy (lid lag), infiltrative dermopathy (pretibial)
  • Toxic adenoma, toxic multinodular goiter
    • Mechanism: Excess thyroid hormone production
  • Thyroiditis
    • Mechanism: inflammation results in increased thyroid hormone release, typically followed by depletion and TSH suppression resulting in hypothyroidism
    • Signs/symptoms: tachycardia, weight loss, irritability, sweating, anxiety, heat intolerance
    • Subacute thyroiditis
      • Post-viral
      • Symptoms: hoarseness, dysphagia, painful thyroid
    • Hashimoto
      • Typically hypothyroidism
    • Drug-induced: Lithium, amiodarone
    • Trauma: surgical, direct

Thyroid Storm

  • Essentially an exaggeration of thyrotoxicosis featuring marked hyperthermia (104-106°F), tachycardia (HR > 140bpm), and altered mental status (agitation, delirium, coma).
  • Precipitants
    • Medical: Sepsis, MI, CVA, CHF, PE, visceral ischemia
    • Trauma: Surgery, blunt, penetrating
    • Endocrine: DKA, HHS, hypoglycemia
    • Drugs: Iodine, amiodarone, inhaled anesthetics
    • Pregnancy: post-partum, hyperemesis gravidarum
  • Scoring (Burch, Wartofsky)
  • Management
    • Supportive measures
      • Volume resuscitation (with MVI, Thiamine) and cooling
      • Benzodiazepines for agitation
    • Beta-blockade
      • Propranolol 60-80mg PO q4h
      • Propranolol 0.5-1.0mg IV, repeat q15min then 1-2mg q3h
      • Esmolol continuous infusion
    • MTZ/PTU 1-hour prior to iodine
      • Methimazole 20mg (except pregnancy)
      • Propylthiouracil 600mg (hepatotoxic)
    • Steroids: dexamethasone
    • Iodine
    • Endocrinology consultation

Hypothyroidism

Symptoms

Constitutional Weight gain, cold intolerance, fatigue
Cardiopulmonary Dyspnea, decreased exercise capacity
Neuropsychiatric Impaired concentration and attention
Musculoskeletal Extremity swelling
Gastrointestinal Constipation
Reproductive Irregular menses, erectile dysfunction, decreased libido
Integumentary Coarse hair, dry skin, alopecia, thin nails

Signs

Vital signs Bradycardia, hypothermia
Cardiovascular Prolonged QT, increased ventricular arrhythmia, accelerated CAD, diastolic heart failure, peripheral edema
Neurologic Lethargy, slowed speech, agitation, seizures, ataxia/dysmetria, mononeuropathy, delayed relaxation of reflexes
Musculoskeletal Proximal myopathy, pseudohypertrophy, polyarthralgia
Gastrointestinal Ileus

Causes

  • Hashimoto: auto-antiboids
  • Thyroidectomy
  • Radiation, radioactive iodine ablation

Myxedema Coma

  • Precipitants
    • Critical illness: sepsis (especially PNA), CVA, MI, CHF, trauma, burns
    • Endocrine: DKA, hypoglycemia
    • Drugs: amiodarone, lithium, phenytoin, rifampin, medication non-adherence
    • Environmental: cold exposure
  • Recognition
    • History: hypothyroidism, thyroidectomy scar and acute precipitating illness
    • Hypothermia: temp <95.9°F (or normal in presence of infection)
    • AMS: lethargy, confusion, coma, agitation, psychosis, seizures
    • Hypotension: refractory to volume resuscitation and pressors
    • Bradypnea: with hypercapnia and hypoxia
    • Skin: non-pitting edema of face and hands
    • Hyponatremia
  • Management
    • Airway protection
    • Fluid resuscitation
    • Thyroid hormone replacement
      • Young, otherwise healthy patients: T3 10ug IV q4h
      • Elderly, cardiac compromise: 300ug IV x1
      • Steroids: dexamethasone 1h prior to thyroid hormone
    • Treat precipitating illness

Interpretation of Thyroid Function Tests

Condition TSH T4
None Normal Normal
Hyperthyroidism Low High
Hypothyroidism High Low
Subclinical hyperthyroidism Low Normal
Subclinical hypothyroidism High Normal
Sick euthyroid Low Low

Acid-Base Disturbances

Method

  • Primary disturbance (acidemia/alkalemia)
  • Primary process (metabolic/respiratory)
  • Presence of mixed disorder
    • Increase PCO2 of 10, increases HCO3 by 1 (acute) or 3 (chronic)
    • Decreased PCO2 of 10, decreases HCO3 by 2 (acute) or 5 (chronic)
    • Increase HCO3 of 1, increases PCO2 by 0.7
    • Decreased HCO3, add 15, result should equal PCO2 and number after decimal of pH
  • Anion gap

Causes

  • Anion Gap
    • Methanol
    • Uremia
    • DKA/AKA
    • Paraldehyde, propylene glycol
    • INH
    • Lactate
    • Ethylene glycol
    • Salicylate
  • Non-Anion Gap
    • Fistulae
    • Ureteral fistulae
    • Saline
    • Diarrhea
    • Carbonic anhydrase inhibitors
    • Spironolactone
    • RTA
  • Metabolic Alkalosis
    • Vomiting
    • Volume depletion
    • Diuretics
    • Steroids
  • Respiratory Acidosis
    • CNS lesion
    • Myopathies
    • Chest wall abnormalities
    • Obstructive lung disease
  • Respiratory Alkalosis
    • Anxiety
    • Fever
    • Hyperthyroidism
    • Hypoxia
    • Sympathomimetic

See Also

Dermatologic Emergencies

Urticaria/Anaphylaxis

  • Appearance: diffuse maculopapular, edematous plaques
  • Symptoms: known trigger, transient, pruritic
  • Management: remove trigger, epinephrine, glucagon

EM/SJS/TEN

  • EM
    • Causes: drugs, HSV
    • Appearance: target lesions, symmetric, palm/sole involvement
    • Management: remove offending agent, supportive care
  • SJS (<10% TBSA)
    • Cause: drugs
    • Appearance: >2 mucous membranes
    • Findings: +Nikolsky
    • Symptoms: flu-like
    • Management: burn center, dermatology consult
  • TEN (>30% TBSA)
    • Management: IVIG, steroids, burn center, dermatology consult

SSSS

  • Epidemiology: <6yo, older if immunosuppressed
  • Appearance: painful, diffuse erythema, bullae, no MM involvement
    • Stage 1: tender erythroderma
    • Stage 2: exfoliation
    • Stage 3: desquamation
  • Findings: +Nikolsky
  • Management: antibiotics (cephalosporin), no steroids

Rash Mnemonics

Palmar Rash

  • “sifting rocks scabbed Emma’s palms”
  • Syphilis (2°)
  • RMSF
  • Scabies
  • EM

Nikolsky Sign

  • SJS/TEN
  • SSSS
  • PV

Petechiae/purpura

  • RMSF
  • Meningococcemia
  • DIC
  • Endocarditis
  • TTP/HUS

Meningococcemia

  • Epidemiology: <20yo, dorm, military barracks
  • Appearance: diffuse petechiae, palpable purpura
  • Management: antibiotics, steroids

Necrotizing fasciitis

  • Symptoms: POOP, rapid progression
  • Appearance: bullae, crepitus, systemic toxicity
  • Management: surgery, antibiotics

RMSF

  • Symptoms: flu-like
  • History: tick bite, camping/hiking
  • Appearance: wrist/ankle spreading inward (centrifugal), petechiae
  • Diagnosis: clinical, titers
  • Management: doxycycline (increased mortality if not treated)

PV

  • Epidemiology: 40-60yo
  • Pathophysiology: autoantibodies (desmoglein), causes superficial epidermal separation (pemphigus for superficial)
  • Symptoms: painful oral blisters, small bullae
  • Findings: +Nikolsky
  • Management: steroids (methylprednisolone 1g IV), burn center

BP

  • Epidemiology: >70yo
  • Pathophysiology: autoantibodies, deeper dermal layer (pemphigoid for deep)
  • Symptoms: not painful, no oral lesions
  • Findings: large, tense, unruptured bullae
  • Management: steroids

Toxicology

Drugs of Abuse

Synthetic Cannabinoids (Spice, K2)

  • Symptoms: anxiety, paranoia, tachycardia
  • Unique symptoms compared to traditional cannabinoids: psychosis, seizure, diaphoresis

Hallucinogenic amphetamines (ecstasy, MDMA)

  • Increased serotonergic activity
  • Management: supportive care (IVF, cooling for hyperthermia), benzodiazepines

Gamma-hydroxybutyrate (GHB)

  • Symptoms: euphoria, hypersexuality, rapid onset/clearance
  • Signs: bradycardia, bradypnea, coma with rapid awakening
  • Management: intubation for depressed GCS
  • Withdrawal: symptoms and treatment identical to ethanol withdrawal, consider baclofen

Cathinone (bath salts)

  • Symptoms: hallucinations
  • Signs: tachycardia, hypertension, tremor, mydriasis, diaphoresis, hyperthermia, bruxism
  • Management: benzodiazepines, consider paralysis, avoid beta-blockers

Cocaine

  • MOA: increase catecholamines, Na-channel blockade
  • Toxicity: HTN, tachycardia, hyperthermia, rhabdomyolysis, MI, seizure, VT
  • Management: benzodiazepines, cooling, anti-hypertensives (nitrate, CCB, not B-blocker)

Amphetamine

  • Toxicity: HTN, tachycardia, hyperthermia, rhabdomyolysis, intracranial hemorrhage
  • Management: same as cocaine

Benzodiazepines

  • Toxicity: sedation, respiratory depression
  • Management: consider flumazenil 0.2mg IV q1min x1-5

Toxic Alcohols

  • Overview
    • Toxic metabolites produced by alcohol dehydrogenase which can be inhibited by ethanol or fomepizole
    • Fomepizole: 15mg/kg loading dose, 10mg/kg q12h x4 doses then 15mg/kg q12h (stimulates own metabolism); if dialysis, q4h
  • Diagnosis: osmolar gap (>14), 2Na + Glu/18 + BUN/2.8 + EtOH/4.6
  • Treatment
    • ADH inhibition
    • HCO3
    • Hemodialysis
    • Supportive care
    • Hypoglycemia: dextrose

Methanol

  • Component of antifreeze, windshield washer fluid
  • Metabolite formic acid which causes acidosis and blindness
  • Can give folate

Ethylene glycol

  • Component of antifreeze, automobile coolants, de-icing agents
  • Metabolite oxalic acid which precipitates calcium oxalate crystals and causes acute renal failure
  • Can give thiamine (100mg q6h), pyridoxine (500mg q6h), Mg

Isopropanol

  • Component of rubbing alcohol
  • Metabolite acetone which does not cause acidosis

Analgesics

Acetaminophen

  • Metabolism: glucoronidation, CYP450
    • CYP450 pathway produces toxic metabolite when glucoronidation overwhelmed
    • In pediatrics, sulfation process protective
  • Toxic dose: >150mg/kg, >3g/day
  • Injury: liver (centrilobular necrosis), renal, pancreatic
  • Increased risk: induced CYP450 (chronic EtOH, rifampin, anti-epileptics)
  • Nomogram: applicable to single ingestion at 4-hours
  • Labs: PT/INR, LFT, lipase, chemistry
  • Management: NAC
    • PO: 140mg/kg, 70mg/kg q4h
    • IV: 150mg/kg, 50mg/kg over 4h, 100mg/kg over 16h

NSAID

  • Symptoms
    • Acute: GI upset, low risk UGIB
    • Acute massive: acidosis, coma, seizures
    • Chronic: UGIB, nephropathy, agranulocytosis

Aspirin

  • Signs: tachycardia, hyperthermia, tachypnea/hyperpnea
  • Severe: cerebral and pulmonary edema, CNS hypoglycemia
  • Labs: primary respiratory alkalosis with metabolic acidosis
  • Management
    • Hypoglycemia (CNS) treatment
    • Bicarbonate infusion (urine pH > 8)
    • Hemodialysis for pulmonary edema, cerebral edema, renal failure, acidemia, level >100mg/dL (acute) or > 60mg/dL (chronic)

Opioids

  • Symptoms: respiratory depression, miosis
  • Management: naloxone 0.04mg, 0.4mg, 2mg
  • Withdrawal: nausea/vomiting, diarrhea, abdominal pain, piloerection
    • Neonates: seizure, death
  • Complications with specific agents:
    • Meperidine, tramadol: seizures
    • Methadone: QT prolongation

Anesthetics

Lidocaine

  • Mechanism: Na-channel blockade
  • Types:
    • Ester (one “i”): cocaine, procaine, benzocaine
    • Amide (two “i”): lidocaine, bupivacaine
  • Toxicity
    • Dose: 4mg/kg, 7mg/kg with epinephrine
    • CNS: perioral numbness, slurred speech, seizure
    • CV: VT, VF, AV block
    • Methemoglobinemia: methylene blue
  • Treatment
    • Seizure management
    • Bicarbonate for dysrhythmia
    • Intralipid

Anti-cholinergics

Sympathetic Parasympathetic
Mydriasis Miosis
Bronchodilation Bronchospasm/bronchorrhea
Tachycardia Bradycardia
Urinary retention Urinary incontinence
Hyperglycemia Salivation/lacrimation
Diaphoresis Increased GI motility
  • Examples
    • Atropine
    • Anti-histamine
    • TCA
    • Phenothiazines
    • Jimson weed
  • Symptoms
    • Peripheral: mydriasis, anhidrosis, flushing, hyperthermia, ileus, dry mucous membranes, AUR
    • Central: agitation (passive), delirium, coma, seizure
  • Treatment
    • Supportive
    • Benzodiazepines
    • Theoretically physostigmine
      • Avoid in seizure, QRS-widening, reactive airway disease
      • Possible diagnostic use

Drugs causing miosis (COPS)

  • C: cholinergics
  • O: opioids
  • P: phenothiazines
  • S: sedatives

Drugs causing QT-prolongation

  • Examples:
    • Phenothiazines
    • Anti-arrhythmics
    • Butyrophenones (ex. haloperidol)
    • Macrolides
    • Fluoroquinolones
    • Methadone
    • Ondansetron
    • Atypical antipsychotics
  • Treatment
    • Magnesium sulfate 2g IV over 1min
    • Overdrive pacing (transcutaneous, transvenous if not captured)
    • Consider isoproterenol (pharmacologic overdrive)

Serotonin syndrome

  • Cause: exposure to serotonergic agent(s)
  • Symptoms: agitation, mydriasis, tremor/clonus in lower extremities, tachycardia, hyperthermia
  • Management
    • Supportive care (IVF, vasopressors)
    • Cooling measures and paralysis for hyperthermia
    • Benzodiazepines
    • Cyproheptadine 12mg PO/NG
    • Dexmedetomidine infusion

Anti-emetics

Phenothiazines

  • Examples: compazine (prochlorperazine), phenergan (promethazine)
  • MOA: DA-antagonist
  • AE: sedation, dystonia, parkinsonism
  • Toxicity: seizure, VT, hypotension (TCA-like)

5-HT3 antagonists

  • Examples: zofran (ondansetron), granisetron
  • Toxicity: QT-prolongation

Anti-hypertensives

Calcium channel blockers

  • Toxicity: hypotension, bradycardia, AV blockade, hyperglycemia
  • Management
    • Atropine: 0.5mg IV q2-3min
    • Glucagon: 5mg IV q10min x2 (with anti-emetic)
    • IVF, vasopressors (norepinephrine, epinephrine)
    • Calcium: 3g gluconate, 1-3g chloride
    • High-dose insulin: 1 unit/kg, monitor hypoglycemia/hypokalemia
    • Intralipid: 1.5mL/kg bolus then 0.25mL/kg/minute
    • GI decontamination
    • Pacing, IABP, ECMO

Beta blockers

  • Toxicity: similar to CCB, hypoglycemia
  • Management: similar to CCB, calcium ineffective

Digoxin (foxglove, oleander)

  • MOA: inhibits Na/K ATPase, increases intracellular calcium (inotropic)
  • Toxicity
    • CV: bradycardia, hypotension
    • ECG: bidirectional VT, PVC, scooped ST-segment
    • CNS: agitation, psychosis
    • Visual: yellow-green vision, halo
    • Metabolic: hyperkalemia (acute), hypokalemia, hypomagnesemia
  • Treatment
    • GI decontamination
    • Atropine
    • Transcutaneous pacing (avoid transvenous, irritable myocardium)
    • Digibind
    • Avoid calcium

Clonidine

  • Toxicity: bradycardia, hypotension, opioid mimic (miosis, lethargy, respiratory depression)
  • Management: supportive care, stimulation for respiratory depression, atropine

Sodium-channel blockers

  • Drugs
    • TCA
    • Diphenhydramine
    • Procainamide
    • Carbamazepine
  • ECG
    • QRS prolongation
    • Prominent “R” in aVR
    • RAD
  • Treatment
    • Sodium bicarbonate

Anti-hyperglycemics

Sulfonylurea

  • Symptoms: recurrent severe hypoglycemia
  • Management: octreotide 50-75mcg SQ/IM q6h

Other agents that cause hypoglycemia

  • EtOH
  • B-blocker
  • Quinine
  • Salicylate

Environmental

Carbon monoxide

  • Source: combustion (gas heater, indoor barbeque)
  • Toxicity
    • General: influenza-like, multiple proximate affected individuals
    • GI: abdominal pain, nausea
    • CNS: headache, dizziness, confusion, ataxia, seizure
    • CV: palpitations, arrhythmia, hypotension, MI
  • Treatment
    • T½: RA 6h, NRB 1h, 3atm 0.5h
    • Hyperbaric: neuro deficit, syncope, pregnancy, CV toxicity

Cyanide

  • Mechanism: inhibits oxidative phosphorylation
  • Source: structural fire (wool, silk)
  • Symptoms: syncope, seizure, coma, cardiovascular collapse
  • Detection: severe lactic acidosis, “arterialization” of venous blood, “bitter almond” odor
  • Treatment
    • Hydroxycobalamin (Cyanokit): 5g IV, may repeat x1
    • Sodium thiosulfate 12.5g IV

Methemoglobinemia

  • Mechanism: Fe2+ converted to Fe3+, “functional anemia”
  • Source: nitrite (food), topical/local anesthetics, pyridium, dapsone, reglan
  • Detection: normal PaO2, SpO2 85% unresponsive to supplemental oxygen, ABG with co-oximetry
  • Management: methylene blue 1-2mg/kg IV if symptomatic or MetHb >25%
    • Contraindicated in G6PD deficiency, treat with exchange transfusion or HBO

Hydrogen Sulfide

  • Source: industrial, sulfur spring, sewer
  • Detection: “rotten egg” odor
  • Management: remove from source, supportive care

Hydrocarbon

  • Source: huffing canisters
  • Toxicity: VT/VF from myocardial sensitization
  • Management: beta-blockade
  • Complications: harmless if ingested, aspiration leads to ARDS

Hydrofluoric acid

  • Source: rust remover, wheel cleaner, glass etching
  • Symptoms: pain-out-of-proportion, delayed onset
  • Toxicity: Hypocalcemia (QTc prolongation, VT/VF/TdP), hyperkalemia, hypomagnesemia
  • Management: analgesia, topical calcium gluconate gel, intravenous calcium for large BSA involvement

Alkaline ingestion

  • Symptoms: esophageal perforation, delayed stricture

Acid ingestion

  • Symptoms: gastric perforation (rare), delayed gastric outlet obstruction
  • Findings: metabolic acidosis

Botulism

  • Sources
    • Adult: ingested preformed toxin
    • Infants: ingested spores (achlorhydric), in vivo toxin production
    • Wound: black tar heroin
  • Symptoms: dysphagia, ptosis, diplopia, respiratory failure, descending paralysis
    • Infants: constipation, floppy
  • Management: supportive care, intubation
    • Adults: Anti-toxin from CDC or local Department of Health
    • Infants: 100mg/kg IV x 1 dose (BabyBIG)

Heavy Metals

Iron

  • Dose
    • Ferrous sulfate: 20% elemental iron
    • Toxic: >20mg/kg
    • Lethal: >60mg/kg (1 tablet 325mg ferrous sulfate per kilogram)
  • Toxicity: corrosive, anti-coagulant, hepatotoxic
  • Course
    • Stage I: GI effects, emesis with hematemesis
    • Stage II: Quiescent
    • Stage III: Systemic, multi-organ system dysfunction
    • Stage IV: Resolution, gastric scarring and outlet obstruction
  • Workup
    • CBC/BMP
    • LFT
    • Lactate
    • Fe level
    • KUB (if positive consider WBI)
  • Treatment
    • Decontamination: no activated charcoal, consider WBI
    • Deferoxamine: 15mg/kg/hr

Lead

  • Source: paint, batteries
  • Toxicity
    • Acute: headache, encephalopathy, seizure
    • Chronic: malaise, weight loss, arthralgia, anemia (basophilic stippling)
  • Diagnosis: lead level, wrist drop
  • Management: chelation (BAL, EDTA, DMSA) for level >50ug/dL or asymptomatic >70ug/dL

Lithium

  • Source: iatrogenic, drug-drug interaction
  • Symptoms
    • GI: nausea/vomiting, diarrhea
    • CNS: tremor, coma
    • CV: TWI, QT-prolongation
  • Management
    • IVF, encourage renal elimination
    • Hemodialysis

Other Drugs

Disulfuram

  • MOA: aldehyde dehydrogenase inhibitor
  • Symptoms: increased acetaldehyde leads to flushing, headache, nausea/vomiting, tachycardia, hypotension
  • Management: antihistamine, IVF, vasopressors
  • Other agents causing disulfuram-like reaction: metronidazole, INH, sulfonylurea

Isoniazid

  • Toxicity: seizure
  • Management: pyridoxine 5g IV, repeat x1

Theophyline

  • Toxicity: seizure
  • Management
    • Decontamination: AC
    • Seizures: benzodiazepines
    • Tachyarrhythmia (commonly MAT): beta-blockade
    • Hemodialysis: acute > 100mg/L, chronic >30mg/L

Monoamine oxidase inhibitors

  • Toxicity: food/drug interaction
  • Symptoms: tachycardia, hypertension, hyperthermia, agitation
  • Management: cooling, IVF, management of hyper/hypotension

Phenytoin

  • Oral: cerebellar dysfunction (ataxia), CNS depression
  • IV: hypotension (suspension contains propylene glycol)

Nutritional Supplements

  • Fat-soluble vitamins
    • A: benign intracranial hypertension
    • D: hypercalcemia

Envenomations

Snake

  • Crotalid (rattle), elapidae (coral)
  • Symptoms
    • Local reaction: edema, hemorrhagic bullae
    • Systemic: perioral numbness, fasciculations
    • Severe: thrombocytopenia, decreased fibrinogen
  • Management: Crofab 5 vials

Spider

  • Black widow
    • Identification: hourglass on abdomen
    • Symptoms: painful bite, target-appearance, rarely “acute abdomen”
    • Management: analgesia, anti-venom, tetanus
  • Brown recluse
    • Identification: violin shape on head
    • Geography: Southeast, Midwest
    • Symptoms: painless bite, local reaction, delayed healing with eschar
    • Rare: hemolysis, DIC, shock
    • Management: supportive care, antibiotics if superinfected, consider dapsone, tetanus

Scorpion (Centruroides)

  • Geography: Arizona
  • Symptoms
    • Autonomic: HTN, tachycardia, diaphoresis
    • CNS: opsoclonus, slurred speech, dysphagia
  • Management: anti-venom, supportive care, analgesia, tetanus

Marine

  • Ciguatera
    • Source: toxin bioconcentrated in fish
    • Symptoms: gastroenteritis, hot/cold-reversal, “loose teeth” sensation
    • Management: mannitol
  • Scombroid
    • Source: poorly-refrigerated fish, histamine-like
    • Symptoms: flushing trunk/face (distinguish from allergic reaction), gastroenteritis
    • Management: supportive care, IVF, anti-histamine, bronchodilators if indicated
  • Paralytic shellfish poisoning
    • Source: bivalve
    • Symptoms: gastroenteritis, paralysis
    • Management: supportive, intubation
  • Jellyfish and Cnidaria
    • Source: nematocyst
    • Symptoms: burning pain, pruritus
    • Severe: Irakundji syndrome (HTN, pulmonary edema)
    • Management: supportive, analgesia, box jellyfish antidote, consider vinegar
  • Stingray
    • Source: heat-labile toxin
    • Management: affected area in warm water, tetanus, ciprofloxacin (Vibrio)

Mushrooms

  • Amanita: centrilobular necrosis, similar to acetaminophen
  • Gyronatum: similar to INH (seizure and treatment), may cause methemoglobinemia
  • Symptoms: muscarinic (SLUDGE)
    • Early onset generally benign, delayed onset (>6h) suggests more serious course
  • Management: atropine, glycopyrrolate, IVF

Pesticides

  • Organophosphate: irreversible
  • Carbamate: reversible
  • Symptoms: muscarinic (SLUDGE)
  • Treatment: atropine 2-6mg IV double q5min to control secretions, pralidoxime (for organophosphates)

Strychnine

  • Source: rodenticide
  • Symptoms: myoclonus, opisthotonus, agitation
  • Management: benzodiazepines, airway protection, paralysis

Spontaneous Intracranial Hemorrhage

Brief HPI

An approximately 40 year-old male with a history of aortic stenosis s/p mechanical aortic valve replacement (on Coumadin) as well as hypertension presented to the emergency department with a chief complaint of severe headache. The patient was in severe distress on arrival and was unable to provide detailed history, he complained of two days of severe left-sided headache while clutching his head and groaning. Examination was notable for sensory localization with directed movements of right hemibody, and no apparent response on the left. He was taken to emergently for CT head non-contrast.

Imaging

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CT Head non-contrast

57 mm right posterior parenchymal hemorrhage with intraventricular component. Moderate edema, mass effect and 9 mm of midline shift.

ED Course

Admission INR was 2.9, the patient received 25 units/kg of PCC as well as vitamin K 10mg IV x1. Neurosurgery was consulted and the patient was taken to the operating room for management.

Management of Supratherapeutic INR and Complications of Anti-Coagulation

Management of Supratherapeutic INR

References

  1. Ansell J, Hirsh J, Hylek E, et al. Pharmacology and management of the vitamin K antagonists: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008; (6 Suppl):160s

Rapid Pediatric Assessment

This post presents a tool for the rapid assessment of the cardiopulmonary status and cerebral/metabolic function of critically ill pediatric patients. The purpose is not to establish a diagnosis, rather to identify the particular physiological derangements to prioritize initial interventions. The tool was initially designed as a “triangle” – it has been adapted here (with permission) as a Venn diagram.1

Pediatric Assessment Diagram

Pediatric Assessment Diagram

Assessment of Appearance

  • Tone: Moves spontaneously, resists examination
  • Interactivity: Interacts with environment, reaches for items
  • Consolability: Comforted by caregiver
  • Gaze: Makes eye contact

Assessment of Work of Breathing

  • Airway Sounds: Stridor, grunting, wheezing
  • Position: Tripod
  • Retractions

Assessment of Circulation

  • Pallor
  • Mottling
  • Cyanosis

Management

Impression Interventions
Respiratory distress
  • Position of comfort
  • Oxygen, suction
  • Therapy as appropriate (albuterol, epinephrine, etc)
  • Labs/radiographs as indicated
Respiratory failure
  • Head/airway positioning
  • 100% oxygen
  • Ventilation support (BVM)
  • Advanced airway
Shock (compensated and decompensated)
  • Oxygen
  • Access
  • Fluid resuscitation
  • Specific therapy (antibiotics, surgery)
  • Labs/radiographs as indicated
CNS/Metabolic
  • Pulse oximetry
  • Rapid glucose
  • Labs/radiographs as indicated
Cardiopulmonary Failure
  • Head/airway positioning
  • 100% oxygen
  • Ventilation support (BVM)
  • Chest compressions as needed
  • Specific therapy (defibrillation, epinephrine, amiodarone)
  • Labs/radiographs as indicated

References:

  1. The pediatric assessment triangle: a novel approach for the rapid evaluation of children. Pediatr Emerg Care. 2010;26(4):312-315. doi:10.1097/PEC.0b013e3181d6db37.