Core EM - Emergency Medicine Podcast

We discuss the approach to diagnosing and managing hypernatremia in the emergency department.

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Episode Overview:

Definition and Pathophysiology:

Causes of Hypernatremia based on urine studies:

Risk Factors:

Diagnosis:

Management Strategies:

Monitoring and Follow-Up:

Take Home Points:

We discuss an approach to the acutely agitated patient and review medications commonly used.

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Background/Epidemiology

•Definition and Scope: Agitation encompasses behaviors from restlessness to severe altered mental states. It’s a common emergency department presentation, often linked with acute medical or psychiatric emergencies.

•Significance: Patients with agitation are at high risk for morbidity and mortality, necessitating prompt and effective management to prevent harm to themselves and healthcare providers.

A Changing Paradigm in Describing Agitation

•Terminology Shift: Move away from terms like ‘excited delirium’ due to their politicization and stigmatization. Focus on describing agitation by severity and underlying causes.

Agitation as a Multifactorial Process

•Complex Nature: Recognize agitation as a result of various factors, including medical, psychiatric, and environmental influences.

Recognizing Agitation

•Signs and Symptoms: Identify agitation early by monitoring for behaviors such as hostility, pacing, non-compliance, and verbal aggression.

Initial Evaluation

•Severity Assessment: Determine the severity of agitation and prioritize reversible causes and life-threatening conditions.

•Diagnostic Steps: Perform vital signs check, blood glucose levels, ECG, and a targeted medical screening exam.

Life Threats

•Immediate Concerns: Identify and address immediate life threats such as hypoxia, hypoglycemia, trauma, and acute neurological emergencies.

Forming a Differential Prior to Treatment

•Prioritization: Severe agitation requires immediate treatment to facilitate further evaluation and reduce risk of harm.

Physician/Staff Safety

•Safety Measures: Ensure personal and team safety by maintaining a calm environment and preparing for potential violence.

Multimodal Approach

•Self-check In: Physicians should mentally prepare and approach the situation calmly to ensure effective management.

•Verbal De-escalation: Use techniques focused on safety, therapeutic alliance, and patient autonomy to manage agitation non-pharmacologically.

Medication Administration

•Oral/Sublingual Medications: Consider oral medications for less severe cases to maintain patient autonomy and avoid invasive procedures.

•IM or IV Medications: Use intramuscular or intravenous medications for rapid control in severe cases.

Specific Medication Regimens

•PO Regimens:

•Medications: Antipsychotics like Zyprexa (olanzapine) 5-10 mg, benzodiazepines like Ativan (lorazepam) 1-2 mg.

•Benefits: Empower patients with a sense of autonomy, avoid injection-related trauma.

•Pharmacokinetics:

•Olanzapine: Onset in 15-45 minutes, peak effect in 1-2 hours, duration 12-24 hours.

•Lorazepam: Onset in 30-60 minutes, peak effect in 2 hours, duration 6-8 hours.

•IV/IM Regimens:

•Medications: Droperidol, haloperidol, midazolam, ketamine.

•ACEP 2023 Guidelines: Recommend droperidol with midazolam or an atypical antipsychotic for severe agitation.

•Pharmacokinetics (IM):

•Haloperidol: IM onset in 15, time to sedation ~25 minutes, can last for 2 hours

•Droperidol: IM onset in 5-10 minutes, duration 2-4 hours but can last as long as 12 hours

•Midazolam: IM onset ~15 minutes, , duration 20 minutes – 2 hours.

•Lorazepam: IM onset ~15-30 minutes, , duration up to 3 hours

•Ketamine: IM onset in ~5 minutes, duration 5-30 minutes.

Special Situations

•Elderly/Dementia: Optimize environment, use non-pharmacologic measures, avoid benzodiazepines to reduce delirium risk.

•Parkinson’s Disease: Avoid antipsychotics that can precipitate a Parkinsonian crisis.

•Autism/Pediatrics: Engage caregivers, create a calming environment, avoid aggressive measures.

•Alcohol Withdrawal: Utilize benzodiazepines and phenobarbital.

Re-dosing and Physical Restraints

•Re-dosing: Use the lowest effective dose, consider continuous monitoring, and reassess frequently.

•Physical Restraints: Employ as a last resort, ensuring close monitoring for any adverse effects.

Final Points

•Clinical Leadership: Physicians should lead with clear communication, planning, and support for the team.

•Continuous Learning: Regular debriefing and assessment after each incident to improve future responses.

We discuss an approach to the critically ill infant.

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We review Acute Respiratory Distress Syndrome

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We review Nitrous Oxide Toxicity: Symptoms, diagnosis, and treatment overview

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Patient Case Illustration

Background and Recreational Use of Nitrous Oxide

Public Misconceptions and Health Consequences

Neurological Examination and Diagnosis

Physical Exam Findings: Upper vs Lower Motor Neuron Lesions

Localize the Lesion- Differential Diagnoses for Extremity Weakness 

Localize the Lesion- Differential Diagnoses for Extremity Weakness

Localize the Lesion- Differential Diagnoses for Extremity Weakness

MRI Findings and Subacute Combined Degeneration

Pathophysiology of SCD due to Nitrous Oxide

Treatment and Management

Conclusion and Preventive Measures

References

We review threatened abortion and the complexities in its care.

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Background

Initial Assessment and Management

Diagnostic Approach

Patient Counseling and Management

Follow-up and Precautions

Take Home Points

We review a general approach to syncope in children.

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Take Home Points:

We go over the treatment of rapid atrial fibrillation (afib with RVR).

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Understanding AF with RVR Categories

Stability Assessment in AF with RVR

ACLS Guidelines and ECG Findings

AF with Pre-Excitation (WPW Syndrome)

Treatment Approaches for AF Types

Systematic Evaluation of Tachycardia Causes (TACHIES Mnemonic)

Ultrasound in Diagnostic Assessment

Management of Chronic AF with HD Instability

Approaches in Complex AF Cases

Comprehensive Patient Disposition

Take Home Points

We discuss Electrical Storm (VT storm) and how to care for the very irritable heart.

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Background/Overview of VT:

Clinical Presentation:

Diagnostics in ER:

Acute Management in the ER:

Take Home Points

We revisit the topic of Hyperkelamia to update our prior episode from 2015 (pre-Lokelma)

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Introduction

Causes / Risk Factors

Clinical Presentation / eval 

Management in the ER

Take Home points