SimWars
This post is part of a series developed in preparation for participation in ACEP SimWars. It contains a review of several prominent emergency medicine topics which may be relevant for board preparation. Unless otherwise cited, content is based on HippoEM videos.
- Toxicology
- Dermatologic Emergencies
- Acid-Base Disturbances
- Thyroid Emergencies
- Adrenal/Pituitary Emergencies
- Oncologic Emergencies
- Bleeding Disorders
- Hematologic Emergencies
- Submersion Injury
- Radiation Exposure
- Hypothermia
- Heat Emergencies
- Electrical Injuries
- Bites
- Altitude and Dysbarism
- Pediatric 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 |
|
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 | |