Contributor: Aaron Lessen, MD

Educational Pearls:

• Colchicine is most commonly used for the prevention and treatment of gout

• There is research investigating the anti-inflammatory and cardioprotective effects of colchicine 

• This drug has a narrow therapeutic index: a small margin between effective dose and toxic dose

• Colchicine overdoses can be unintentional or intentional and are associated with poor outcomes

• Phase 1: 10 - 24 hours after ingestion

• Patient looks well but may have mild symptoms mimicking gastroenteritis

• Phase 2: 24 hours - 7 days after ingestion

• Multiple organ dysfunction syndrome (MODS)

• Phase 3: recovery is usually within a few weeks of ingestion

• Treatment for colchicine overdose

• Treat early and aggressively

• Gastrointestinal decontamination with activated charcoal and orogastric lavage 

• Dialysis and ECMO for MODS treatment

References

1. Finkelstein Y, Aks SE, Hutson JR, Juurlink DN, Nguyen P, Dubnov-Raz G, Pollak U, Koren G, Bentur Y. Colchicine poisoning: the dark side of an ancient drug. Clin Toxicol (Phila). 2010 Jun;48(5):407-14. doi: 10.3109/15563650.2010.495348. PMID: 20586571.

2. Gasparyan AY, Ayvazyan L, Yessirkepov M, Kitas GD. Colchicine as an anti-inflammatory and cardioprotective agent. Expert Opin Drug Metab Toxicol. 2015;11(11):1781-94. doi: 10.1517/17425255.2015.1076391. Epub 2015 Aug 4. PMID: 26239119.

Summarized by Meg Joyce, MS1 | Edited by Meg Joyce & Jorge Chalit, OMS3

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Contributor: Travis Barlock, MD

Educational Pearls:

What is Portal Vein Thrombosis?

• The formation of a blood clot within the portal vein, which carries blood from the gastrointestinal tract, pancreas, and spleen to the liver

• Not only can this cause problems downstream in the liver, but the backup of venous blood can cause ischemia in the bowels

How does it present?

• Similar to acute mesenteric ischemia: Sudden onset of abdominal pain, nausea, vomiting, and fever

How is it diagnosed?

• Abdominal CT or MRI with contrast

What causes it?

• Cirrhosis

• Coagulopathy (Factor V Leiden mutation, Prothrombin gene mutation, Antiphospholipid syndrome, Protein C, protein S, antithrombin III deficiency, etc.)

• Oral Contraceptive Pills (OCPs)

• Cancer such as hepatocellular carcinoma

How is it treated?

• Aggressive fluid resuscitation

• Antibiotics. Be sure to cover enteric gram-negative bacteria and anaerobes

• Heparin, same dosing as a bolus for a DVT

• Endovascular treatment, such as a thrombectomy with IR

• Surgical evaluation if there has been tissue death in the mesentery

References

• Hilscher, M. B., Wysokinski, W. E., Andrews, J. C., Simonetto, D. A., Law, R. J., & Kamath, P. S. (2024). Portal Vein Thrombosis in the Setting of Cirrhosis: Evaluation and Management Strategies. Gastroenterology, 167(4), 664–672. https://doi.org/10.1053/j.gastro.2024.05.017

• Intagliata, N. M., Caldwell, S. H., & Tripodi, A. (2019). Diagnosis, Development, and Treatment of Portal Vein Thrombosis in Patients With and Without Cirrhosis. Gastroenterology, 156(6), 1582–1599.e1. https://doi.org/10.1053/j.gastro.2019.01.265

• Ju, C., Li, X., Gadani, S., Kapoor, B., & Partovi, S. (2022). Portal Vein Thrombosis: Diagnosis and Endovascular Management. Pfortaderthrombose: Diagnose und endovaskuläres Management. RoFo : Fortschritte auf dem Gebiete der Rontgenstrahlen und der Nuklearmedizin, 194(2), 169–180. https://doi.org/10.1055/a-1642-0990

Summarized by Jeffrey Olson MS3 | Edited by Jorge Chalit, OMS3

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Contributor: Jorge Chalit-Hernandez, OMS3

Educational Pearls:

• Acute mountain sickness (AMS) is the term given to what is otherwise colloquially known as altitude sickness

• High altitude cerebral edema (HACE) is a severe form of AMS marked by encephalopathic changes

• Symptoms begin at elevations as low as 6500 feet above sea level for people who ascend rapidly

• May develop more severe symptoms at higher altitudes

• The pathophysiology involves cerebral vasodilation

• Occurs in everyone ascending to high altitudes but is more pronounces in those that develop symptoms

• The reduced partial pressure of oxygen induces hypoxic vasodilation in the brain, which results in edema and, ultimately, HACE in some patients

• Symptomatic presentation

• Headache, nausea, and sleeping difficulties occur within 2-24 hours of arrival at altitude

• HACE may occur between 12-72 hours after AMS and presents with ataxia, confusion, irritability, and ultimately results in coma if left untreated

• Clinical presentation may be mistaken for simple exhaustion, so clinicians should maintain a high index of suspicion

• Notably, if symptoms occur more than 2 days after arrival at altitude, clinicians should seek an alternative diagnosis but maintain AMS/HACE on the differential

• Treatment and management

• AMS

• Adjunctive oxygen and descent to lower altitude

• Acetazolamide is used as a preventive measure but is not helpful in acute treatment

• +/- dexamethasone

• HACE

• Patients with HACE should receive dexamethasone to help reduce cerebral edema

• Immediate descent to a lower altitude

References

1. Burtscher M, Wille M, Menz V, Faulhaber M, Gatterer H. Symptom progression in acute mountain sickness during a 12-hour exposure to normobaric hypoxia equivalent to 4500 m. High Alt Med Biol. 2014;15(4):446-451. doi:10.1089/ham.2014.1039

2. Levine BD, Yoshimura K, Kobayashi T, Fukushima M, Shibamoto T, Ueda G. Dexamethasone in the treatment of acute mountain sickness. N Engl J Med. 1989;321(25):1707-1713. doi:10.1056/NEJM198912213212504

3. Luks AM, Beidleman BA, Freer L, et al. Wilderness Medical Society Clinical Practice Guidelines for the Prevention, Diagnosis, and Treatment of Acute Altitude Illness: 2024 Update. Wilderness Environ Med. 2024;35(1_suppl):2S-19S. doi:10.1016/j.wem.2023.05.013

Summarized & Edited by Jorge Chalit, OMS3

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Contributor: Meghan Hurley, MD

Educational Pearls:

• Gastroenteritis clinical diagnoses:

• Diarrhea with or without vomiting and fever

• Vomiting in the absence of diarrhea has a large list of differential diagnoses, so the combination of diarrhea and vomiting in a patient is helpful to indicate the gastroenteritis diagnosis

• Symptom timeline is usually 1-3 days, but can last up to 14 days – diarrhea persists the longest

• Treatment for mild to moderate dehydration: oral or IV rehydration

• Begin orally to avoid unnecessary IV in a pediatric patient

1. Administer ODT Ondansetron (Zofran) to prevent vomiting

   1. Meta-analysis showed that 2-8 mg orally, based on body weight, decreased vomiting quickly

2. Wait 15-20 minutes for the medication to take effect

3. Use streamlined method for oral rehydration: Fluids such as over-the-counter Pedialyte, Infalyte, Rehydrate, Resol, and Naturalyte may be used

   1. If patient weighs less than 10kg: administer 5mL of fluid per minute for 20 minutes

   2. If patient weighs 10kg or more: administer 10mL of fluid for 20 minutes

4. If the patient can keep the fluid down, double the fluid volume and repeat

5. If the patient once again keeps the fluid down, double the fluid volume and repeat

• If successful with each attempt, the patient may be discharged home

• Can prescribe ODT Zofran for 1-2 days at home

• If the patient vomits more than once during this oral rehydration process, intravenous rehydration must be initiated

References

1. Churgay CA, Aftab Z. Gastroenteritis in children: Part II. Prevention and management. Am Fam Physician. 2012 Jun 1;85(11):1066-70. PMID: 22962878.

Summarized by Meg Joyce, MS1 | Edited by Meg Joyce & Jorge Chalit, OMS3

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Contributor: Aaron Lessen, MD

Educational Pearls:

• If a patient sustains a cut, the provider has several options on how to close the wound. If they choose to suture the wound closed, it involves needles both in the form of injecting numbing medication (lidocaine) as well as with the suture itself. Other techniques are “needleless,” like closing the wound with adhesive strips (Steri-Strips) or skin adhesive (Dermabond). But which method is best?

• A recent study looked to compare guardian-perceived cosmetic outcomes of pediatric lacerations repaired with absorbable sutures, Dermabond, and Steri-Strips. It also assessed pain and satisfaction with the procedure from both guardian and provider perspectives.

• Participants: 55 patients were enrolled; 30 completed the 3-month follow-up.

• Cosmetic Ratings (Median and IQR):

• Sutures: 70.5 (59.8–76.8)

• Dermabond: 85 (73–90)

• Steri-Strips: 67 (55–78)

• (P = 0.254, no statistically significant difference)

• Satisfaction and Pain:

• No significant differences in guardian or provider satisfaction

• Pain levels were comparable across all methods

• Even though there was no statistically significant difference in guardian-perceived cosmetic outcomes, the Dermabond did have the highest ratings at the end of the study.

References

• Barton, M. S., Chaumet, M. S. G., Hayes, J., Hennessy, C., Lindsell, C., Wormer, B. A., Kassis, S. A., Ciener, D., & Hanson, H. (2024). A Randomized Controlled Comparison of Guardian-Perceived Cosmetic Outcome of Simple Lacerations Repaired With Either Dermabond, Steri-Strips, or Absorbable Sutures. Pediatric emergency care, 40(10), 700–704. https://doi.org/10.1097/PEC.0000000000003244

Summarized by Jeffrey Olson MS3 | Edited by Meg Joyce, MS1 & Jorge Chalit, OMS3

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Contributor: Jorge Chalit-Hernandez, OMS3

Educational Pearls:

• Serotonin syndrome occurs most commonly due to the combination of monoamine oxidase inhibition with concomitant serotonergic medications like SSRIs

• Examples of unexpected monoamine oxidase inhibitors

  • Linezolid - a last-line antibiotic reserved for patients with true anaphylaxis to penicillins and cephalosporins

  • Methylene blue - not mentioned in the podcast due to its uncommon usage for methemoglobinemia

• Other medications that can interact with SSRIs to cause serotonin syndrome

  • Dextromethorphan - primarily an anti-tussive at sigma opioid receptors that also has serotonin reuptake inhibition

• Clinical presentation of serotonin syndrome

  • Altered mental status

  • Autonomic dysregulation leading to hypertension (most common), hypotension, and tachycardia

  • Hyperthermia

  • Neuromuscular hyperactivity - tremors, myoclonus, and hyperreflexia

• Hunter Criteria (high sensitivity and specificity for serotonin syndrome):

  • Spontaneous clonus

  • Inducible clonus + agitation or diaphoresis

  • Ocular clonus + agitation or diaphoresis

  • Tremor + hyperreflexia

  • Hypertonia, temperature > 38º C, and ocular or inducible clonus

• Management of serotonin syndrome

  • Primarily supportive - benzodiazepines can help treat hypertension, agitation, and hyperthermia. Patients often require repeated and higher dosing of benzodiazepines

  • Avoid antipyretics to treat hyperthermia since the elevated temperature is due to sustained muscle contraction and not central temperature dysregulation

  • In refractory patients, cyproheptadine (a 5HT2 antagonist) may be used as a second-line treatment

  • Patients with temperatures > 41.1º C or 106º F require medically induced paralysis and intubation to control their temperature

References

1. Boyer EW, Shannon M. The serotonin syndrome [published correction appears in N Engl J Med. 2007 Jun 7;356(23):2437] [published correction appears in N Engl J Med. 2009 Oct 22;361(17):1714]. N Engl J Med. 2005;352(11):1112-1120. doi:10.1056/NEJMra041867

2. Dunkley EJ, Isbister GK, Sibbritt D, Dawson AH, Whyte IM. The Hunter Serotonin Toxicity Criteria: simple and accurate diagnostic decision rules for serotonin toxicity. QJM. 2003;96(9):635-642. doi:10.1093/qjmed/hcg109

3. Ramsay RR, Dunford C, Gillman PK. Methylene blue and serotonin toxicity: inhibition of monoamine oxidase A (MAO A) confirms a theoretical prediction. Br J Pharmacol. 2007;152(6):946-951. doi:10.1038/sj.bjp.0707430

4. Schwartz AR, Pizon AF, Brooks DE. Dextromethorphan-induced serotonin syndrome. Clin Toxicol (Phila). 2008;46(8):771-773. doi:10.1080/15563650701668625

5. Thomas CR, Rosenberg M, Blythe V, Meyer WJ 3rd. Serotonin syndrome and linezolid. J Am Acad Child Adolesc Psychiatry. 2004;43(7):790. doi:10.1097/01.chi.0000128830.13997.aa

Summarized & Edited by Jorge Chalit, OMS3

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Contributor: Aaron Lessen, MD

Educational Pearls:

• Many patients present to the ED with elevated BP

• Many are referred from outpatient surgery centers or present after an elevated measurement at home

• Persistent questions on the best way to treat these patients

• The AHA published a scientific statement on the management of elevated BP in the acute care setting

• Hypertensive emergencies: SBP/DBP >180/110–120 mm Hg with evidence of new or worsening target-organ damage

• Includes aortic dissection or subarachnoid hemorrhage 

• Require aggressive treatment

• Asymptomatic markedly elevated inpatient BP: SBP/DBP >180/110–120 mm Hg without evidence of new or worsening target-organ damage AND asymptomatic elevated inpatient BP: SBP/DBP ≥130/80 mm Hg without evidence of new or worsening target-organ damage

• No benefits to urgent treatment in the ED, but there are harms to treating patients in this manner

• These patients do not require IV medications

•  Provide reassurance and instructions on following up with their PCP to manage their BP in the outpatient setting

• Removed the term “hypertensive urgency”

References

1. Bress AP, Anderson TS, Flack JM, et al. The Management of Elevated Blood Pressure in the Acute Care Setting: A Scientific Statement From the American Heart Association. Hypertension. 2024;81(8). doi:https://doi.org/10.1161/hyp.0000000000000238

Summarized by Meg Joyce, MS1 | Edited by Meg Joyce & Jorge Chalit, OMS3 

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Contributor: Megan Hurley MD

Educational Pearls:

What is the mediastinum?

• The thoracic cavity is separated into different compartments by membranes

• The lungs exist in their own pleural cavities, and the mediastinum is everything in between

• The mediastinum extends from the sternum to the thoracic vertebrae and includes the heart, the aorta, the trachea, the esophagus, the thymus, as well as many lymph nodes and nerves.

What is a pneumomediastinum?

• Air in the mediastinum

How can pneumomediastinum be categorized?

• Traumatic

• Ex. Stab wound to the trachea

• Ex. Boerhaave’s Syndrome of the esophagus, possibly from an endoscopic procedure. This mechanism in particular is a higher risk of infection because not only air but food can accumulate in the mediastinum

• Ex. Intubation with a bougie

• These will likely need surgical repair

• Nontraumatic

• Ex. Forceful inhalation causing microperforations in the trachea. Possibly while inhaling something like drugs

• Ex. Bad asthma for similar reasons

• Ex. Gas forming bacteria

What happens if you use positive pressure ventilation on a patient with a hole in their trachea?

• The positive pressure will force extra air into the mediastinum

• The air will move between the layers of subcutaneous tissue and can track up into the neck and face regions recognized as crepitus on exam

• This can also cause a tension pneumomediastinum in which the air pressure in the compartment constricts the heart, impeding its ability to fill during diastole

• These patients can undergo bronchoscopy because that procedure does not require positive pressure and will not worsen the condition. Endoscopies do require positive pressure so endoscopies are not an option

How is a tension pneumomediastinum treated?

• By inserting a needle into the space from below the xiphoid process to allow the air to escape, similar to a pericardiocentesis

• As a temporizing measure, if the hole is high enough in the trachea, the intubation can be continued by deliberately pushing the endotracheal tube into the right main bronchus, creating a seal, and only ventilating the right lung while the patient heads to surgery. This is called right-mainstemming.

References

1. Clancy DJ, Lane AS, Flynn PW, Seppelt IM. Tension pneumomediastinum: A literal form of chest tightness. J Intensive Care Soc. 2017 Feb;18(1):52-56. doi: 10.1177/1751143716662665. Epub 2016 Aug 3. PMID: 28979537; PMCID: PMC5606356.

2. Grewal, J., & Gillaspie, E. A. (2024). Pneumomediastinum. Thoracic surgery clinics, 34(4), 309–319. https://doi.org/10.1016/j.thorsurg.2024.06.001

3. Underner, M., Perriot, J., & Peiffer, G. (2017). Pneumomédiastin et consommation de cocaïne [Pneumomediastinum and cocaine use]. Presse medicale (Paris, France : 1983), 46(3), 249–262. https://doi.org/10.1016/j.lpm.2017.01.002

Summarized by Jeffrey Olson, MS3 | Edited by Meg Joyce & Jorge Chalit, OMS3

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Contributor: Ricky Dhaliwal MD

Educational Pearls: 

• Etomidate was previously the drug of choice for rapid sequence intubation (RSI)

• However, it carries a risk of adrenal insufficiency as an adverse effect through inhibition of mitochondrial 11-β-hydroxylase activity

• A recent meta-analysis analyzing etomidate as an induction agent showed the following:

• 11 randomized-controlled trials with 2704 patients

• Number needed to harm is 31; i.e. for every 31 patients that receive etomidate for induction, there is one death

• The probability of any mortality increase was 98.1%

• Ketamine is preferable due to a better adverse effect profile

• Laryngeal spasms and bronchorrhea are the most common adverse effects after IV push

• Beneficial effects on hemodynamics via catecholamine surge, albeit not as pronounced in shock patients

• 2023 meta-analysis compared ketamine and etomidate for RSI

• Ketamine’s probability of reducing mortality is cited as 83.2%

• Overall, induction with ketamine demonstrates a reduced risk of mortality compared with etomidate

• The dosage of each medication for induction

• Etomidate: 20 mg based on 0.3 mg/kg for a 70 kg adult

• Ketamine: 1-2 mg/kg (or 0.5-1 mg/kg in patients with shock)

• Patients with asthma and/or COPD also benefit from ketamine induction due to putative bronchodilatory properties

References

1.  Goyal S, Agrawal A. Ketamine in status asthmaticus: A review. Indian J Crit Care Med. 2013;17(3):154-161. doi:10.4103/0972-5229.117048

2. Koroki T, Kotani Y, Yaguchi T, et al. Ketamine versus etomidate as an induction agent for tracheal intubation in critically ill adults: a Bayesian meta-analysis. Crit Care. 2024;28(1):1-9. doi:10.1186/s13054-024-04831-4

3. Kotani Y, Piersanti G, Maiucci G, et al. Etomidate as an induction agent for endotracheal intubation in critically ill patients: A meta-analysis of randomized trials. J Crit Care. 2023;77(April 2023):154317. doi:10.1016/j.jcrc.2023.154317

Summarized & Edited by Jorge Chalit, OMS3

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Contributor: Aaron Lessen MD

Educational Pearls:

• Pregnant patients at high risk of cardiac arrest, in cardiac arrest, or in extremis require special care

• A useful mnemonic to recall the appropriate management of critically ill pregnant patients is TOLDD

• T: Tilt the patient to the left lateral decubitus position

• This position relieves pressure exerted from the uterus onto the inferior vena cava, which reduces cardiac preload

• If the patient is receiving CPR, an assistant should displace the uterus manually from the IVC towards the patient’s left side

• O: Administer high-flow adjunctive oxygen 

• L: Lines should be placed above the diaphragm

• Lines below the diaphragm are ineffective due to uterine compression of the IVC

• May consider humeral interosseous line vs. internal jugular or subclavian central line

• D: Dates should be estimated

• > 20 weeks, can consider a resuscitative hysterotomy (previously known as perimortem c-section) to improve chances of survival

• The uterus is palpable at the umbilicus at 20 weeks and 1 cm superior to the umbilicus for every week thereafter

• D: Call the labor and delivery unit for additional help

References

1. ACOG Practice Bulletin No. 211 Summary: Critical Care in Pregnancy. Obstetrics & Gynecology. 2019;133(5)

2. Fujita N, Higuchi H, Sakuma S, Takagi S, Latif MAHM, Ozaki M. Effect of Right-Lateral Versus Left-Lateral Tilt Position on Compression of the Inferior Vena Cava in Pregnant Women Determined by Magnetic Resonance Imaging. Anesth Analg. 2019;128(6):1217-1222. doi:10.1213/ANE.0000000000004166

3. Jeejeebhoy FM, Zelop CM, Lipman S, et al. Cardiac Arrest in Pregnancy. Circulation. 2015;132(18):1747-1773. doi:doi:10.1161/CIR.0000000000000300

4. Singh, Ajay; Dhir, Ankita; Jain, Kajal; Trikha, Anjan1. Role of High Flow Nasal Cannula (HFNC) for Pre-Oxygenation Among Pregnant Patients: Current Evidence and Review of Literature. Journal of Obstetric Anaesthesia and Critical Care 12(2):p 99-104, Jul–Dec 2022. | DOI: 10.4103/JOACC.JOACC_18_22 

Summarized & Edited by Jorge Chalit, OMS3

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