- Written by Ethan Abbott
The following is a post from Duc Tran, PGY-4 and 2019 recipient of the Yale/Stanford Johnson and Johnson Global Health Scholarship to travel to Uganda
Hello again from Uganda,
I’m still alive over here and doing well. I wrote a little something about one of my experiences here last week, and I wanted to share it with you all.
A 17 year old girl brought in by her mother for altered mental status that started today, and was preceded by a few days of generalized weakness. You see in front of you a young skinny female laying listless in a stretcher, minimally responsive to strong sternal rub. She has labored breathing, rapid pulse, diaphoretic skin, and normal pupillary response to light. No vitals are done as of yet. As any good ED physician, you know altered mental status automatically means you get a CBG. You were lucky enough to have CBG strips available. The CBG on this girl showed “HI”.
Here in Uganda, when people see you standing next to a patient, they come crowding over, looking to see what is going on and how they can join. The ED team is now mobilized. Nurses check vitals; it shows BP is 60s systolic, HR is 140s, and Oxygenation is high 90s. Concerned about brain perfusion, you drop the head of the bed down, and prop pillows below her feet. Two IV lines are now inserted in the patient, and she is receiving two 500 cc (there is no 1 liter fluids here) cartons of normal saline run wide open into her. After 4 Liters are in; BP is now 70s systolic, but overall still too low of a MAP for adequate brain perfusion. You make your dirty epinephrine drip (this and dopamine are the only vasoactive agent you have available). You take 0.5 mg of the code cart epinephrine (To save the rest for later, you simply tape over the top of the vial containing the rest of the 0.5 mg of epinephrine) and inject it into the 500 cc of normal saline. Since there is obviously no infusion pump, you titrate your dirty epi to affect. You’ve now reached a respectable MAP of 65, minimum MAP required for brain profusion. Patient has been successfully resuscitated.
It takes a couple hours for labs to come back. Your suspicion for DKA is high based on your history and physical; obtunded, young skinny girl, with reports of generalized weakness, elevated blood sugar, with Kussmal breathing, low blood pressure, and tachycardia. Although you would like to have labs confirm your diagnosis, you are better off treating the girl now if you suspect DKA, as her PH is likely less than 7.0, and she will likely go into cardiac arrest soon if you don’t. You bolus her 10 units (0.1 units/kg, assuming a weight of 100 kg) of regular insulin and start insulin infusion (0.1 units/kg/hr). To make an insulin infusion for 100 kg patient, you take 10 mg (0.1 units/kg) of regular insulin, inject it into 500 cc of normal saline, and make sure the drip rate will finish in one hour, giving you effectively a 0.1 units/kg/hr infusion rate. How do you do this? Dr. Google says there is approximately 20 drips in a milliliter. You want the entire 500 cc volume to finish within one hour. So there is 10,000 drips in a 500 cc container. Rate equals 166 drips/ min, which equals 2.77 drips/ sec. Now you take your wrist watch with a seconds hand, put it up in view with the drip, and titrate the drip to have 2-3 drips go in after 1 second has gone by on your watch. That gives you a 10 units/hour drip.
Labs come back a few hours later. NA = 150, K = 4.5, CL = 100. Where is the bicarb? Oh thats right, there is no reagent for the bicarb in this lab. So no bicarb for you. Also no ketones or a PH. So what do you do? How do you follow an anion gap when you can’t calculate an anion gap? Well first off, this is pretty much the only set of labs your gonna get for a while for this patient. Remember, family members are the upfront payers of healthcare here. Each chemistry costs 10,000 shillings (a little more than 2 USD); however, this is a lot for many of the patients that come through the hospital doors. 10,000 schillings is fine once, but 10,000 schillings every 4 hours until the anion gap closes is often burdensome for the family. As with this case, the patient’s who are in DKA, are in florid DKA. Often times, when patient’s present with DKA, they are altered, acidotic, and hypotensive; so you can expect the labs to represent this severity. If they are in florid DKA, taking the sodium, and subtracting the chloride and 30 (upper limit of normal for bicarb), you will still get an elevated anion gap (i.e 150-100-30 = 20 = still DKA!). Again we are using the upper limit of normal for bicarb, anion gap is likely significantly higher, as we expect the bicarb to be much lower in subacute presentations of DKA. You can assume ketones are positive from the patient’s history; assume low PH from altered mental status, poor perfusion, and Kussmal breathing. Voila! You’ve Diagnosed DKA, from part history, part physical exam, and part labs.
Your plan will be to continue IV hydration, continuous insulin infusion, monitor and give respiratory support (putting her onto her side so if she vomits, she will vomit onto her bed instead of her right bronchus) when needed. When the glucose goes below 250, switch normal saline to 5% dextrose and continue the insulin infusion, as you would in the U.S. Regarding potassium, add 10 meq of potassium chloride every once in a while (I know, not an exact science) to your IV fluids – better to under do this then over do it. How do you know her DKA has resolved? The best thing really is hope her mental status improves, which we would expect to happen once the ketones and the lactic acid resolves.
In the unfortunate case her mental status doesn’t go back to normal, ask the family members if you can repeat labs, and if the labs show a resolution of DKA, she may have something else going, and you may have to ask the family members to pay for a CT brain scan for the continued altered mental status. Here they cost 300,000 schillings (~ 80 USD).
For this specific patient, by the end of the night, she was fully talking!
Obviously, I can’t take much of the management I practice here back to the US. But what it has taught me was an understanding of illnesses and its course. Here, I won’t have labs, drips, etc, at my disposal. I won’t have numbers to follow, but I will have the same sick patient. For this case, we resuscitated her, then we gave her insulin — which is what her body was lacking, and hoped that was enough for her body to heal itself. I certainly don’t want to give the impression that with a little bit of ingenuity and close attention, many of diseases can be managed successfully here, and that Uganda’s, and Africa’s health problems can be fixed with simply an understanding of pathophysiology and pharmacology. There’s a lot of the same problems that we face in healthcare in the U.S here, but it is compounded many times over by limited resources.
Although I conveniently painted a neatly done resuscitation, and management, the reality was far from it. The girl in this case actually did get better, was talking, but overnight the limitations of the ED had caught up to her. It appears that overnight she did not get her insulin, and she went straight back into DKA. When the team saw her the next morning, she was again altered and now she could not move the right side of her body. CT scan done later showed significant cerebral edema.
Last week, I attended the resident’s lecture on DKA. Most of what they were taught is from our management of DKA, which is highly dependent on laboratory values, and fine titrations of drips. It was hard to listen in, as many seemed underwhelmed after realizing that they cannot do what is considered standard of care for what is a very common ED presentation. They were learning about following anion gaps, not starting insulin until the potassium is known, and EKG changes on hyper/hypokalemia. Nonetheless, in such a true resource limited setting, they will have to create their own protocols, as those in the western textbooks don’t suite them. They not only have to know what I was expected to know, but they must adapt what they learn to work for them. Their road will be difficult; they are paving their own path, and possibly unbeknownst to them, they will likely be the next pioneers of emergency medicine.
- Written by Ethan Abbott
The following is a post from Duc Tran, PGY-4 and 2019 recipient of the Yale/Stanford Johnson and Johnson Global Health Scholarship to travel to Uganda
Hello from Uganda,
I am two weeks into my trip, and have started to settle in quite nicely. The program placed two internal medicine residents, one from Yale and the other from Stanford, and myself at Makerere University in Lincoln Flats. It’s a little apartment, but we each get our own rooms, equipped with a mosquito net and a fan, which I need to manually turn at least 20 times before it would spin on its own. Running water, or lack there of, proves to be a challenge. We have to plan ahead for showers, as we wouldn’t know when the water will turn on next. But on the positive, since there is no water pressure, I’ve learned the necessary skill here of showering with a bucket.
Kampala, the largest city in Uganda, has divided its healthcare into two hospitals, the Mulago Hospital, which sees mainly surgical patients, and Kirrudo Hospital, which see predominately medical patients. The first two weeks, I’ve mainly been based at Mulago. While it is the country’s only surgical referral center, the hospital sees an overwhelming amount of road traffic accidents. Most people in Uganda get around with Boda Bodas, the colloquial term for small motorcycles. I would estimate the Mulago ER see over 90% traumas, with boda boda accidents making up the majority, and mob justice comprising the rest. This place sees its share of displaced long bone fractures, LARGE lacerations, but the most challenging cases are head traumas. Ambulance services would bring and plop patient right on the concrete floor, as free stretchers are often not available. These patients have significant external head injuries and altered mental statuses; patients who would undeniably be triaged as a Trauma CODE at Barnabas. CT brains scans are available, but will take at least a day to be done, as these patients typically don’t come in with family members who are the up-front payers for medical services. In such cases, waivers are filed, and are approved by administrators after a day. However, most of the patients with head injuries will not have gone for a head CT scan without arresting from likely aspiration first. In as single shift, having a row of at least five patients of road traffic accidents actively decompensating in front of you is not uncommon. These patient’s without a doubt would be intubated on arrival in the US. Unfortunately we cannot adequately protect a patient’s airway or oxygenate them here. I think equipment for intubation is available; however, ventilators are in short supply and are almost always in use by the ICU. The culture here is to place an oropharyngeal airway in altered patients in hopes of displacing the tongue enough to get a somewhat respectable oxygenation. Oxygenation does improve by this method, but it it also seems to increase the incidence of aspiration. I have not thought of a better solution. The majority of patients who pull through are the ones with relatively minor head injuries, and may have survived regardless of the limited interventions. Although the types of traumas here are what we would see at the Barnabas ED, they wear on me much more because of my feeling of helplessness; knowing very well what to do, but not being able to do it. I really don’t know how the doctors here cope, and wonder how I would fair after a year. Though its been a tough two weeks, I consider myself fortunate to have just glimpse at what being a doctor is like over here.
Near the end of last week, I had met Mary, an EM doctor from Yale, who is working on her global health fellowship; she is helping train the first EM residency in Uganda. She invited me out to work in Kirrudo, the medical ER. I’ve only spent two days there last week, but I am already having a more positive outlook on my experience here. Currently the EM residency is in its first year, and only a few months in at that. They’re a great bunch, but they have limited guidance. Being the first EM residency, there is no EM trained physician here; their program director is an anesthesiologist who seems to not be around much. A few big named EM residencies in the US have promised support by sending over EM faculty to train the residents, but it seems their collective time spent here is sporadic and short at best. Working with the residents have shed light onto what a unique bunch of physicians we EM doctors are. Without guidance, residents here don’t learn that go-getter, scrappy attitude that really sets EM physicians from the rest. And I think that is discouraging them. Most of the what the residents here know about medicine is through the optics of individual specialities. Residents know how to approach patients from the perspectives of the consultants when the patient is stable on their perspective wards, but don’t know the emergency side of stabilizing, diagnosing and managing patients until that point. Residents would see patients one after the next, in the order they arrive, regardless of acuity. A resident may be seeing a patient with a chronic diabetic foot ulcer; they would interview the patient and write up the chart before they move onto a the patient who is in severe respiratory distress, assuming that patient is next. But I really can’t blame them, as this is how the non EM doctors that train them practice. Mary has been trying to change that since she got here. She is doing a great job, already within a few days of me being there, I can see the culture change. There is now a sense of urgency in the residents. On arrival of an unstable patient, they all drop what they are doing, and work together, reminiscent of the residents at Barnabas. They are turning into real emergency physicians. It’s a small step, but in the right direction. The potential is here, the residents just need some guidance. Working with these residents have made my time much more enjoyable, and I hope to work with them more in the weeks to come. As I’m only here for a short time, I never did think that I could have any real impact, but I’m starting to think that I can possibly do a little something good with this residency.
Best,
Duc
- Written by Ethan Abbott
Toxicology Literature of Note
In NY and NJ, anyone is able to walk into a retail pharmacy and obtain naloxone without a prescription, but it appears that not all retail stores stock this life-saving drug. The following paper surveyed all retain pharmacies within 10 NJ cities to assess their availability of naloxone. They then looked at the cities population and socioeconomic demographics to assess any differences. They concluded that “naloxone deserts” do exist in select NJ cities, which are high risk. The pharmacy naloxone availability may be positively related to medical household income, and negatively related to population size. There was no relationship found between opioid-related hospital visits and naloxone availability. This is a study I would like to replicate in NY, and more specifically in the Bronx. Does anyone want to help?
Does your pharmacy stock Naloxone?
Higenamine is a compound found in plants with stimulant properties. In animal studies, it is demonstrated to be a beta-2 adrenergic agonist. The following study analyzed dietary supplements available in the US for the presence and quantity of higenamine. 24 products were analyzed, with most marketed for weight loss or as sports/energy supplements. None of the products were accurately labeled, and the quantity of higenamine in the products contained from <0.01% to 200% of the quantity listed on the label. The FDA does not have the ability to regulate the supplement industry, and this paper shows that what is on the label may not be accurate. Other studies have had similar findings, even with different pills from the same bottle containing different concentrations of reported supplement. Keep this in mind the next time you are discussing supplements with your patients. You are asking about supplements, right . . . ?
Do you know what is in your supplement bottle?
Toxicology in the News
Fugu, better known as the Blowfish, is a Japanese delicacy with a deadly twist. If not prepared properly, there is the potential for it to be your last meal. Tetrodotoxin is found in high concentrations in the liver, ovary, eyes, and skin is a potent neurotoxin, which can paralyze you while you are still conscious! An amazing episode of The Simpson follows Homer as he believes that he only has 24 hours left to live after consumption of the fish. Now it looks like the toxin has been modified out, leading to diners to enjoy safely. But yet . . . I think the fish now loses some of its awe, as the idea of cheating death is why some decide to pay the expensive price tag for this formerly potentially deadly dinner.
One Fish, Two Fish, Blowfish, Blue Fish will always be an amazing episode!
Australia has some beautiful beaches, expansive countryside, Hobbits and someone of the most venomous animals on Earth! The Eastern brown snake considered one of the most deadly snakes in the world was overpowered, killed and eaten by a Redback spider, all caught on camera!
Just don’t go to Australia, unless you love deadly snakes and spiders!
How do our individualized and specific genes affect the way our bodies handle a medication or overdose? The field of toxicogenomics looks at this specific question. An example is how codeine, which is metabolized to morphine by CYP2D6 does not provide any pain relief to those who do not have any active CYP2D6 (which is 5% of the Caucasian population). Another recently discovered example is how those with a variant of the CYP3A7 may quickly metabolize birth control pills, leading to them being ineffective and unintended pregnancy.
Toxicology Toxin of the Month
Everyone knows what an EpiPen is and what it is used for, but did you know that there is a naloxone autoinjector as well, EvzioTM The above blog post, by Dr. Andrew Stolbach, is a short and funny “interview” with the product. It explains how naloxone can be obtained without a prescription and without being seen by a doctor. But, although we are within a public health crisis, a simple autoinjector that could save lives is costing people between $400-$4100. Finally, it gives some examples of patients who are at risk of overdose and provides links to where you can learn more about naloxone laws by state.
- Written by Ethan Abbott
Toxicology Update November 2018
The following study looks to see if targeted temperature management (therapeutic hypothermia) improved hospital survival from presumed overdose related cardiac arrest. Their secondary endpoint was neurological recovery. Although the study of 121 patients found improvement in survival, there was no statistical significant improvement in neurological recovery. This goes against the belief that therapeutic hypothermia protects the brain, and requires further study in this population.
Impact of Targeted Temperature Management on ED Patients with Drug Overdose–Related Cardiac Arrest
This paper looks at the use of the medical record for toxicological studies, AKA chart reviews. It is not always easy, or ethical to perform studies on poisoned patients (you can’t ethically withhold an antidote), so chart reviews can serve as a way to study this population. It is important to understand the limitations of these studies. This is a great paper to read before undertaking a study of this type.
Medical Record Reviews for Medical Toxicology Research
It is often difficult to obtain a confirmed medication history from our patients, and even more difficult during nights and weekends when pharmacies are closed. This leaves our population, especially geriatrics at risk of adverse drug reactions (ADRs). The following paper looks at a novel approach to medical reconciliation, which will help us to know a full medication list. The algorithm looks at patterns to help prevent these ADRs.
Toxicology in the News
I may not look like the most fashionable attending, seeing as my work wardrobe consists of blue scrubs, a ponytail and no makeup, but I truly love fashion! The following short article is a promotion for a new book on the history of clothing, “Green ball gowns tinted with arsenic. Top hats made with mercury. Flammable crinoline.” A great short read, with amazing pictures! Can’t wait to buy the book.
The history of hazardous clothing
People will do anything to get intoxicated, although even this is a new one for me. Boiling, and then drinking used sanitary napkins! The article does not mention what substance is causing the hallucinations unfortunately. Thankfully, this just seems to be a trend in south east Asia . . . for now.
Is Kotex the new drug on the block?
As marijuana becomes decriminalized and legalized in more states (and countries), incidents of misadventure are increasing. Edibles are often more potent than expected and have somewhat confusing dosing (e.g. 1/8 of a cookie may be a therapeutic dose). Would keep this ingestion in your differential in the right clinical setting.
Don’t accept cereal bars from strangers
Toxicology Toxin of the Month
The following blog post highlights medical interactions and an interesting historical account about the first non drowsy anti-histamine. Don’t forget to watch the amazingly creepy pharmaceutical commercial!
Don’t you want your patients free from allergy suffering? Just don’t worry about the potential QTc prolongation and dysrhythmias.
Happy Thanksgiving!
- Written by Ethan Abbott
Toxicology Literature of Note
Here is a fascinating case of a 17 year old male who intentionally ingested 800 tabs of diphenhydramine and developed cardiovascular collapse. ECMO was initiated and he ultimately survived without neurologic deficits. Also interesting is that he had a biphasic clinical course, with an initial improvement but then a critical decline. A pharmacobezoar was discovered, with endoscopy pictures attached!
It’s good to believe that all overdoses are poly-substance until proven otherwise. This article looks at the prevalence of benzodiazepine use along with heroin. It showed that co-use of heroin and benzodiazepines was common, although the overall outcomes between co-users of heroin and benzodiazepines and heroin-only users were similar.
This study looks at self-reported medication allergies and adverse reactions, and what is documented on a patients chart. Not surprisingly, many self-reports were inaccurate. Something to consider the next time you perform a medication reconciliation and full history with your patients.
Medication allergy discrepancies in the ED
Toxicology in the News
We all enjoyed Dr. Fernandez’s lecture on political poisoning at the 2nd Annual Bronx Tox Symposium. Looks like she may have another potential case to add to her list. Only with time will we be able to determine if this patient was poisoned, and with what.
Another high profile poisoning
Good news, he is likely to recover
Old toxicologists talk about the ability of Visine™ in a drink can poison someone. The active ingredient in most of these eyedrops is tetrahydrozoline. This ingredient is part of the imidazoline family, which includes clonidine. In large enough concentrations toxicity is possible, and for the unfortunate husband in this article, his wife was dedicated to his demise.
I briefly mentioned this in my cyanide lecture during the 2nd Annual Bronx Tox Symposium, and this article highlights the event which lead to tamper resistant packaging.
Toxicology Toxin of the Month
This month I would like to present the following blog post from The Tox and The Hound on another potential use for naloxone. Opioids are not the only poison that can lead to small pupils, and CNS and respiratory depression. Can you name the toxin?
Just a funny Tox image from the world of Facebook:
- Written by Ethan Abbott
A 75 yo male with a PMH of HTN, HLD, DM, and PVD presents to the SBH emergency department with slurred speech and right sided weakness x 2 hours. He is awake and alert on arrival with a glucose of 122. The patient undergoes a non-contrast CT of the brain which is unremarkable. In consultation with neurology, tPA is administered and the patient is admitted to the hospital. While awaiting his transfer to the floor, you insure the patient’s head of bed is at 30 degrees, as this is considered the “standard of care.” Can a patient be positioned supine after an acute ischemic stroke?
Answer: The “head of bed elevated” theory is that patients would benefit from “reduced intracranial pressure” and “decreased risk for aspiration” if the head was elevated after an acute ischemic CVA. Recent, small, non-randomized trials of patients positioned supine after an acute ischemic stroke have called this practice of “head elevated” after ischemic stroke into question. These newer trials suggest that supine positioning “increases blood flow in major arteries and improves oxygenation of the brain.” A large trial in the NEJM published last month attempts to address this issue.
In the the Head Positioning in Acute Stroke Trial (HeadPoST)trial, published in the NEJM in June of 2017, the authors examined the question of whether this head positioning, either lying flat or head elevated for 24 hours after an acute ischemic or hemorrhagic stroke, in a variety of clinical settings, including the emergency department, had an effect. The study design was an international, multicenter, cluster-randomized, crossover, open-label trial with blinded outcome evaluation. The primary outcome of the study was disability at 90 days and secondary outcomes of death and disability using a modified Rankin scale. The study is powered by 11,093 patients in 114 centers (however ended up underpowered). Patients were randomized to either group and were required to maintain positioning for 24 hours. The authors found, “ no significant difference between the implementation — at a median of 14 hours after the onset of stroke — of the lying-flat head position and the sitting-up position with respect to the primary outcome of level of disability at 90 days. There were also no significant differences in mortality or in the rates of serious adverse events, including pneumonia.”
There are some potentially controversial issues regarding the data (did not reach sample size) and methodology (pragmatic cluster clinical trial), so take a look at the article and draw your own conclusions!
Anderson CS, Arima H, Lavados P, Billot L, Hackett ML, Olavarría VV, Muñoz Venturelli P, Brunser A, Peng B, Cui L, Song L, Rogers K, Middleton S, Lim JY, Forshaw D, Lightbody CE, Woodward M, Pontes-Neto O, De Silva HA, Lin RT, Lee TH, Pandian JD, Mead GE, Robinson T, Watkins C; HeadPoST Investigators and Coordinators. Cluster-Randomized, Crossover Trial of Head Positioning in Acute Stroke. N Engl J Med. 2017 Jun 22;376(25):2437-2447.
- Written by Ethan Abbott
Toxicology Literature of Note
Ketamine for everyone, when used with Ativan
Severe alcohol withdrawal can be complex and difficult to treat, especially when the patient is resistant to BZD. The follow study looks at the use of ketamine as an adjunct to lorazepam for patients admitted to the ICU for ETOH withdrawal. As ketamine is a NMDA receptor antagonist, it may play a role in treatment of withdrawal in combination with BZDs.
Can you trust that lab result?
We would like to think that we can trust our lab results. But, as we all know, nothing in medicine is absolute and patients do not read the textbook . . .
The following case report looks at a false positive salicylate concentration by the compound dinitrophenol (DNP) after an intentional ingestion. DNP is a rare, but often fatal, toxin with different management when compared with salicylate.
As with any lab result, always look at the clinical context! We treat patients, not numbers (or poisons!)
Into the mind of an intensivist.
Have you ever sent a patient up to the ICU and continued to follow their clinical course, but saw that the intensivists decided against certain elements of specialist recommendations. This paper tries to assess why this is done, specifically looking at high dose insulin euglycemic therapy for CCB overdose.
Toxicology in the News
Last week in Connecticut there were over 70 cases of synthetic cannabinoid overdose IN ONE DAY, possibly adulterated with fentanyl. This article mentions that “patients who didn’t respond to naloxone (an overdose reversal drug) administered on the Green showed some improvement after receiving higher doses over a period of time at the hospitals.” The utilization of resources in this community was massive, with the only good thing being that there were no deaths reported.
With summer coming to a close, there will be fewer ice cream trucks coming around the block. This unfortunate story is of the wife of an ice cream salesman who died when the dry ice used to keep the ice cream cold was not properly ventilated. Dry ice is the solid form of carbon dioxide, which when exposed to a temperature above it’s triple point (-109 F!!!) sublimates to gas. In an enclosed space, the heavier than air carbon dioxide gas displaces oxygen and leads to an environment without the O2 necessary to breath. It is a simple asphyxiant and can lead to death rapidly. So whether you need dry ice to cool your ice cream, or make that Halloween pumpkin smoke, always remember to have the area well ventilated.
Do not keep venomous animal as pets
A man in Michigan kept a albino monocled cobra as a pet, and not surprisingly was bitten. Some may think, no big deal, just give the patient some antivenom and watch him recover. Sadly, this is easier said than done. The standard CroFab antivenom is ineffective for cobra envenomations, and a species specific antivemon is often difficult to come by (and usually expired.) Luckily, antivemon specific to this snake was found in Florida and flown to the patient in Detroit.
Toxicology Toxin of the Month
Last week I gave a lecture on GI decontamination and enhanced elimination and just briefly touched on the use of hemodyalisis with the poisoned patient.
I would like to direct everyone to the following Tox and the Hound post by Dr Diane Calello, which goes deeper on this important topic. . . Dialyze This. And if you want to take a deep nerd dive, you can read more about whole bowel irrigation from our very own Dr Howard Greller in The Purge.
- Written by Jakub Bartnik
EMS calls ahead for a 35 year old male found altered and hypoxic in his apartment. Upon arrival, you note he is febrile, hypotensive, hypoxic on 100% oxygen to a spO2 of 70%. You decide to intubate after initiating fluid resuscitation, pressor support, and broad spectrum antibiotics. Your differential is broad and includes pulmonary embolism, pneumothorax, sepsis/pneumonia. After confirming ETT placement, you attempt to narrow your differential and place the phased array probe on the right anterior lung and find:
What do you see?
Here is another clip:
What’s your diagnosis?
Here is the corresponding chest xray:
This is what pneumonia looks like on ultrasound.
Note the dynamic air bronchograms within the consolidated lung
There are two type of air bronchograms – static and dynamic.
Static bronchograms are nonspecific and may be seen in atelectasis.
Dynamic bronchograms are specific for pneumonia.
Check out this great 5minutesono from Jacob Avila on air bronchograms with some great examples.
- Written by Ethan Abbott
Toxicology Literature of Note
The study of toxicology includes occupational and environmental health issues. Although possibly not as relevant to emergency medicine, the health effects from microplastics are something that every physician should be aware of. This short editorial defines microplastics and their effect of our marine life, with some questions on how this could affect human health.
In an effort to play their part in the judicious use of opioids in the ED, this hospital in Milwaukie implemented a management pathway for patients with acute and chronic pain. The follow study looks at the impact of the pathway on opioid prescribing.
Utility of a chronic pain pathway in the ED
Toxicology in the News
This short article is about Dr. William McBride, an Australian OBGYN who warned about the dangers of thalidomide. For those unfamiliar with the teratogenicity of this drug, which was used for morning sickness, I urge you to search Google images.
This article from our neighbors to the north discusses a seemingly harmless and beautiful little bead, which can be deadly if ingested. Used in jewelry and crafts, the jequirity bean (Abrus precatorius) contains the toxin abrin, which inhibits protein synthesis.
Be cautious about what you bring home from vacation!
Some people think this fish is ugly. But not only do I find him beautiful, I also have heard that he is actually quite tasty! The Lionfish (Pterois volitans) is a venomous fish, popular in aquariums and, sadly, destroying the ecosystem in certain tropical areas due to lack of natural predators. The following article highlights a chef doing his part to return balance to the Gulf of Mexico, one fish dish at a time.
Toxicology Toxin of the Month
This month I would like to highlight another amazing and educational blog post on The Tox and the Hound!
The Dirty on Dantrolene, a true muscle relaxer. Many likely have never used this medication in practice, but it’s use in emergency medicine should not be overlooked or forgotten. Here is just a taste of the post:
“The use of a RYR1 antagonist as a treatment for conditions of RYR1 dysfunction makes perfect sense. Because people often conflate one hyperthermic patient for another, dantrolene has been suggested as a therapy for other hyperthermic conditions, such as serotonin syndrome, neuroleptic malignant syndrome, and heat stroke. Is there a role for dantrolene outside of malignant hyperthermia?”
- Written by Jakub Bartnik
A 30 year old female presents to the emergency department with right lower abdominal pain. No vaginal bleeding.
Her vitals are: HR 101 BP 115/70 RR20 O2 100%. Upreg: positive
As she seems to be quite uncomfortable, you decide to perform a bedside ultrasound.
Having learned that free fluid in the right upper quadrant predicts the need for operative intervention in a suspected ectopic pregnancy, you start with a curvilinear probe in the RUQ:
With a positive urine pregnancy test and free fluid in Morrison’s pouch, you call ObGyn STAT to the bedside, order pre-op labs, start 2 large bore IVs, and type and cross 2 units of blood in preparation for possible clinical deterioration.
While waiting for OB, you decide to ultrasound the right adnexa and uterus trans-abdominally.
Right adnexa:
Pelvis, sagittal:
Note the complex free fluid in the pelvis and right adnexa, as well as the empty uterus.
OB comes down within minutes, looks at your bedside ultrasound and takes the patient to the OR for immediate intervention.
While waiting for a radiology-based ultrasound, this patient very well may have had a worse outcome.
POCUS saves the day!
Two studies to review for this critical application of POCUS:
Take home point: even if you are not comfortable with pelvic bedside ultrasounds in pregnant females, you can still save a life if you are competent at the FAST exam.