

* “Sympathetic Crashing Acute Pulmonary Edema”



* Pathophysiology – Rapid onset of pulmonary edema caused by sudden hypertension

* Triggers- Missed Medication, Cocaine, Stress/Anxiety

* Increase in BP = Increase in afterload



* Increased afterload causes acute pulmonary edema (in patients with CHF)



* The worsening pulmonary edema causes shortness of breath which worsens blood pressure and further increases afterload







* Presentation- Sudden, severe respiratory distress AND hypertension

* Different than CHF exacerbation

* Not necessarily caused by hypervolemia



* More rapid in onset





* Typically crackles/rales on exam or diffuse B-Lines on POCUS





* Treatment

* BiPAP/CPAP



* High Dose Nitroglycerin



* Diuretics IF Hypervolemic




Flash Pulmonary Edema (aka SCAPE)

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You are working at Clerkship General when one of the nurses comes and grabs you. “Hey doc, we need you in bed 10. I think this patient is having a stroke.” 



Initial Vitals:



HR: 51



BP: 201/98



Temp: 98.0F



RR: 18



O2: 99% (Room Air)



Critical Actions:




* Check a Blood Glucose



* Activate a Stroke Alert



* Assess Contraindications to tPA



* Consent for tPA



* Transfer via Air for Thrombectomy


Round 20 (MW) Stroke Symptoms



* Common during the first year of life as well as during puberty



* Presents with nausea/vomiting, abdominal pain, and/or testicular pain



* ALWAYS examine a child for signs of torsion who presents with abdominal pain (especially lower abdominal pain)



* Look for tenderness, firmness, high riding testicle or testicle with unequal lie, swelling, and the absence of a cremasteric reflex   



* Consult Urology IMMEDIATELY if you have high suspicion, otherwise proceed to ultrasound



* Ultrasound is only 85% sensitive, so clinical gestalt can trump even a negative US



* Attempt manual detorsion if there will be a significant delay to surgery


Testicular Torsion (Deep Dive MW R19)


You are working at Clerkship General when the next patient is put into your rack. It is an 8 year-old male with vomiting



Initial Vitals:



HR: 119



BP: 104/63



Temp: 98.0F



RR: 20



O2: 99% (Room Air)



Critical Actions:




* Finger Stick Blood Glucose



* Treat Patient’s Pain



* Diagnose Testicular Torsion



* Immediate Urology Consult



* Perform Manual Detorsion




References:



Mellick LB, Sinex JE, Gibson RW, Mears K. A Systematic Review of Testicle Survival Time After a Torsion Event. Pediatr Emerg Care. 2019 Dec;35(12):821-825. doi: 10.1097/PEC.0000000000001287. PMID: 28953100.

Round 19 (MW) Tummy Ache in Child with Diabetes


Phase One: CNS




* Ataxia, Slurred Speech, Confusion, N/V, Seizures




Phase Two: Cardiopulmonary 




* CHF, Cardiogenic Shock/Hypotension, Pulmonary Edema, ARDS




Phase Three: Renal




* Flank pain, Hematuria, Oliguria, Renal Failure




Diagnosis:




* HIGH INDEX OF SUSPICION



* Ethylene Glycol Serum Level



* Elevated Osmolar Gap



* Serial Anion Gap Measurements




Treatment:




* Fomepizole or Ethanol to prevent breakdown to toxic glycolic acid/oxalic acid



* Hemodialysis



* Consider Bicarb drip, pyridoxine, and thiamine








Further Reading:



 EMCrit Toxic Alcohols





Ethylene Glycol (Deep Dive MW R18)


You are working at Clerkship General when you hear an EMS call on the radio. Clerkship General, we are bringing you Arthur. He is intoxicated… Again



Initial Vitals:



HR: 116



BP: 150/70



Temp: 98.8



RR: 26



O2: 85% (Room Air)



Critical Actions:




* Recognize Hypoxemia



* Diagnose Toxic Alcohol Ingestion



* Consult Nephrology Emergent Dialysis



* Administer Fomepizole



* Workup Anion Gap Metabolic Acidosis


Flash Pulmonary Edema (aka SCAPE)

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