REBEL Core Cast 28.0 – Conference Pearls

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Sweat PEA – Dr. Eric Steinberg

• Definition: the presence of organized rhythm without a palpable pulse
  • No palpable pulse doesn’t = no perfusion (ie may be profound shock)
  • Pulse palpation isn’t sensitive
• We are bad at manually feeling for a pulse, instead use POCUS 
  • Use POCUS on carotid or femoral artery to look for pulse
  • Establish an A-line
• The biggest challenge is finding the cause
  • 2014 established wide v. narrow complex causes. However, not well studied
  • Use the RUSH exam to help determine cause
• Patient Pre-Arrival
  • Prep your Norepinephrine drip
  • Equipment ready (airway, US, a-line, EtCO2)
  • 2 people ready for CPR or mechanical device ready
  • Get collateral info for cause

Lithium Toxicity – Dr. Monica Choski 

• Two forms of lithium 
  • Standard release peak 1-2 hours
  • Extended release peak 4 hours
• 95% renal excretion
• Increased lithium levels often result outside of overdose when the patient takes a kidney hit (infection/medications) and GFR goes down.
• Mild toxicity
  • nausea, vomiting, hyperreflexia, agitation, muscle weakness
• Mod toxicity
  • stupor, rigidity, hypertonia, hypotension
• Severe toxicity
  • coma, convulsions
• Chronic Li toxicity – can develop nephrogenic DI
• Pearl: make sure you don’t send a lithium level in a lithium salt tube – typically a green top in the US
• Management
  • Get on the phone with consultant
  • Activated Charcoal if the patient will take PO
  • IV fluids to help GFR get back up
  • Dialysis
    • Lithium >4
    • Lithium >2.5 w/ renal insufficiency
    • Moderate to severe signs of toxicity

Back Pain – Dr. Jim Gray

• Make sure the back pain isn’t from something dangerous; look for red flags

• Medications
  • First line: NSAIDs. Consider topical if patient cant systemic nsaid 
  • Trigger point injections
  • Lidoderm patch
  • Opiates and muscle relaxants never shown to be beneficial in comparison or addition to NSAIDs
• Send patients to follow up with PT & PMR

Burn Management – Dr. Jinal Sheth 

• Major burn patients can have concomitant traumatic injuries along with tox exposures (CO, CN)
• Airway – intubate early if significant injuries because airway can be dynamic. Don’t just intubate if singed nose hairs – look for respiratory distress, stridor, hoarseness 
• Overestimate of BSA leads to excess fluid administration
  • Use Lund-Browder chart
  • Patient hand as an estimate, hand with fingers approximately 1%
• Parkland may overestimate fluids needed
  • 4ml/kg x %TBSA x body weight in kg
    • First ½ in 8 hours, the second ½ in 16 hours
  • Use Parkland for first 8 hours then titrate fluids to urine output of 0.5ml/kg 
• Aggressive pain management is key
  • Consider ketamine if concomitant traumatic injury
• Who to transfer to Burn Center
  • Full Thickness burns
  • Partial thickness burn >10%
  • Burns to hand, face, genitalia, major joints, electrical/chemical burn, inhalation injury or special social needs

For More on These Topics Checkout:

• REBEL EM: What the Heck is Pseudo-PEA?
• LITFL: Lithium Toxicity
• LITFL: Burns
• Core EM: Nontraumatic lower back pain 

Shownotes Written By: Miguel Reyes, MD (Twitter: @miguel_reyesMD)

Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter: @srrezaie)