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Does your patient have a very elevated anion gap (AG) in the blood test results? It’s almost always associated with metabolic acidosis… even if your pH is elevated. That just means you now have a mixed acid-base status.  The way to think of AG is that it is a formula assessing the difference between measured cations (Na) and measured anions (HCO3- and Cl-). A decrease in unmeasured cations (K, Mg, Ca) can theoretically cause a trace elevation in AG, but it’s almost always an increase in unmeasured anions.  CATMUDPILES 🐈 is a helpful mnemonic to recall the causes of AG metabolic acidosis:  C Carbon monoxide, congenital heart disease, cyanide
A Aminoglycosides
T Theophylline, toluene  M Methanol
U Uremia
D DKA (also alcoholic/starvation ketacidosis)
P Paracetamol, paraldehyde
I Iron, INH, inborn errors of metabolism 
L Lactic acidosis
E Ethanol, ethylene glycol
S Salicylates  What are some rare exceptions when an elevated AG is NOT from metabolic acidosis?
* Hyperalbuminemia
* IgA myeloma  These are unmeasured anions.  Helpful read: https://acutecaretesting.org/en/articles/clinical-aspects-of-the-anion-gap  #postitpearls #foamed #emergencymedicine #nursepractitioner #physicianassistant #emresident #postit #endocrinology #acidbase #aniongap #mudpiles #catmudpiles

Does your patient have a very elevated anion gap (AG) in the blood test results? It’s almost always associated with metabolic acidosis… even if your pH is elevated. That just means you now have a mixed acid-base status.

The way to think of AG is that it is a formula assessing the difference between measured cations (Na) and measured anions (HCO3- and Cl-). A decrease in unmeasured cations (K, Mg, Ca) can theoretically cause a trace elevation in AG, but it’s almost always an increase in unmeasured anions.

CATMUDPILES 🐈 is a helpful mnemonic to recall the causes of AG metabolic acidosis:

C Carbon monoxide, congenital heart disease, cyanide
A Aminoglycosides
T Theophylline, toluene

M Methanol
U Uremia
D DKA (also alcoholic/starvation ketacidosis)
P Paracetamol, paraldehyde
I Iron, INH, inborn errors of metabolism
L Lactic acidosis
E Ethanol, ethylene glycol
S Salicylates

What are some rare exceptions when an elevated AG is NOT from metabolic acidosis?
* Hyperalbuminemia
* IgA myeloma

These are unmeasured anions.

Helpful read: https://acutecaretesting.org/en/articles/clinical-aspects-of-the-anion-gap

#postitpearls #foamed #emergencymedicine #nursepractitioner #physicianassistant #emresident #postit #endocrinology #acidbase #aniongap #mudpiles #catmudpiles
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Shoulder dislocations post-reduction care isn’t just “wear a sling”. You want to avoid a re-dislocation and a frozen shoulder (adhesive capsulitis).  So for anterior dislocations (which are almost all the shoulder dislocations), provide concrete instructions like:  1. Imagine you are wearing a large billboard sign on your back. Keep your arms in front of it. This avoids hyperextension of the shoulder. A special no-no is combing 🪮 the back of one’s hair (hyperextension AND significant abduction).  2. Every day for a few minutes take your arm out of the sling and bend over to allow your arm to dangle with gravity. You can prop your other arm on a table edge. Rock your body to create pendulous, circular ↔️ 🔄 movements of your shoulder joint. Increase the swinging radius over time. BONUS: While there, range your elbow, wrist, and hand to avoid loss of muscle tone and flexibility.  #postitpearls #foamed #emergencymedicine #nursepractitioner #physicianassistant #emresident #postit #orthopedic #shoulderdislocation

Shoulder dislocations post-reduction care isn’t just “wear a sling”. You want to avoid a re-dislocation and a frozen shoulder (adhesive capsulitis).

So for anterior dislocations (which are almost all the shoulder dislocations), provide concrete instructions like:

1. Imagine you are wearing a large billboard sign on your back. Keep your arms in front of it. This avoids hyperextension of the shoulder. A special no-no is combing 🪮 the back of one’s hair (hyperextension AND significant abduction).

2. Every day for a few minutes take your arm out of the sling and bend over to allow your arm to dangle with gravity. You can prop your other arm on a table edge. Rock your body to create pendulous, circular ↔️ 🔄 movements of your shoulder joint. Increase the swinging radius over time. BONUS: While there, range your elbow, wrist, and hand to avoid loss of muscle tone and flexibility.

#postitpearls #foamed #emergencymedicine #nursepractitioner #physicianassistant #emresident #postit #orthopedic #shoulderdislocation
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Is calcium chloride part of your last resort “kitchen sink” of medications for patients presenting in undifferentiated cardiac arrest?  It used to be. Increasingly retrospective studies, RCTs, and systematic reviews suggest that it isn’t beneficial. In fact, it may cause HARM (less ROSC and higher mortality). One RCT was stopped early for ethical reasons because the intervention arm (calcium) significantly caused more harm.  Why is calcium bad? A theory is that it causes hypercontraction and a “stone heart”.  This does NOT apply to special cases of cardiac arrest such as hyperkalemia, hypocalcemia, or other conditions where calcium is of direct benefit.  Use calcium judiciously in undifferentiated cardiac arrest. This recommendation was supported in the 2023 International Liaison Committee on Resuscitation (ILCOR) consensus statement (open access). PMID 37937881  #postitpearls #foamed #emergencymedicine #nursepractitioner #physicianassistant #emresident #postit #ilcor #cardiacarrest #calcium #resuscitation #ROSC #pharmacist

Is calcium chloride part of your last resort “kitchen sink” of medications for patients presenting in undifferentiated cardiac arrest?

It used to be. Increasingly retrospective studies, RCTs, and systematic reviews suggest that it isn’t beneficial. In fact, it may cause HARM (less ROSC and higher mortality). One RCT was stopped early for ethical reasons because the intervention arm (calcium) significantly caused more harm.

Why is calcium bad? A theory is that it causes hypercontraction and a “stone heart”.

This does NOT apply to special cases of cardiac arrest such as hyperkalemia, hypocalcemia, or other conditions where calcium is of direct benefit.

Use calcium judiciously in undifferentiated cardiac arrest. This recommendation was supported in the 2023 International Liaison Committee on Resuscitation (ILCOR) consensus statement (open access). PMID 37937881

#postitpearls #foamed #emergencymedicine #nursepractitioner #physicianassistant #emresident #postit #ilcor #cardiacarrest #calcium #resuscitation #ROSC #pharmacist
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Seems obvious but isolated finger injuries that need Xrays should get FINGER xrays and NOT hand xrays. More is not better.  Why? You can miss some critical details in the hand xrays because:  1️⃣ The xray beam focus is on the capitate rather than the PIP joint for finger films. This results often in more oblique angle (non-orthogonal) views of the fingers.  2️⃣ The other fingers in a hand film may create some overlap in the lateral view, obscuring some finger injuries.  3️⃣ Xrays of the finger can help you identify subtle rotational deformities because the xray beams are much more orthogonal to the areas of interest than hand xrays.  This may seem obvious but even a recent hand surgeon specialist dedicated part of her talk exactly to this point. Thanks 👏 Dr. Lauren Santiesteban for a great talk.  #postitpearls #foamed #emergencymedicine #nursepractitioner #physicianassistant #emresident #postit #orthopedics #radiology #EMconf

Seems obvious but isolated finger injuries that need Xrays should get FINGER xrays and NOT hand xrays. More is not better.

Why? You can miss some critical details in the hand xrays because:

1️⃣ The xray beam focus is on the capitate rather than the PIP joint for finger films. This results often in more oblique angle (non-orthogonal) views of the fingers.

2️⃣ The other fingers in a hand film may create some overlap in the lateral view, obscuring some finger injuries.

3️⃣ Xrays of the finger can help you identify subtle rotational deformities because the xray beams are much more orthogonal to the areas of interest than hand xrays.

This may seem obvious but even a recent hand surgeon specialist dedicated part of her talk exactly to this point. Thanks 👏 Dr. Lauren Santiesteban for a great talk.

#postitpearls #foamed #emergencymedicine #nursepractitioner #physicianassistant #emresident #postit #orthopedics #radiology #EMconf
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🚩 Beware of trusting xrays in ruling out a hip fracture, especially in older patients.  Occult hip fractures (xray negative) requiring surgery occurred in 39% of older patients in a 2020 meta-analysis with 2,000+ patients [1].  The American College of Radiology's Appropriateness Criteria [2] states that despite getting a negative XR, suspected hip fractures need additional cross-sectional imaging with either CT or MR, understanding their sensitivities:
🦴 CT: 69-87%
🦴 MR: 99-100%  If you are still suspicious after a negative CT, obtain a MR, which is the gold standard. Alternatively, if you have a high suspicion already for an occult fracture and can obtain a timely MR, skip the CT and go straight to MR.  Whether that MR happens in the ED or inpatient Medicine service is based on local hospital resource capabilities and protocols.  Refs
1. Haj-Mirzaian A, Eng J, Khorasani R, et al. Use of Advanced Imaging for Radiographically Occult Hip Fracture in Elderly Patients: A Systematic Review and Meta-Analysis. Radiology. 2020;296(3):521-531. PMID 32633673; doi:10.1148/radiol.2020192167 @rsnagram  2. American College of Radiology: https://acsearch.acr.org/docs/3082587/Narrative/ @radiologyacr  #postitpearls #foamed #emergencymedicine #nursepractitioner #physicianassistant #emresident #postit #orthopedics #hipfracture #occultfractures #proximalfemurfracture #radiology

🚩 Beware of trusting xrays in ruling out a hip fracture, especially in older patients.

Occult hip fractures (xray negative) requiring surgery occurred in 39% of older patients in a 2020 meta-analysis with 2,000+ patients [1].

The American College of Radiology`s Appropriateness Criteria [2] states that despite getting a negative XR, suspected hip fractures need additional cross-sectional imaging with either CT or MR, understanding their sensitivities:
🦴 CT: 69-87%
🦴 MR: 99-100%

If you are still suspicious after a negative CT, obtain a MR, which is the gold standard. Alternatively, if you have a high suspicion already for an occult fracture and can obtain a timely MR, skip the CT and go straight to MR.

Whether that MR happens in the ED or inpatient Medicine service is based on local hospital resource capabilities and protocols.

Refs
1. Haj-Mirzaian A, Eng J, Khorasani R, et al. Use of Advanced Imaging for Radiographically Occult Hip Fracture in Elderly Patients: A Systematic Review and Meta-Analysis. Radiology. 2020;296(3):521-531. PMID 32633673; doi:10.1148/radiol.2020192167 @rsnagram

2. American College of Radiology: https://acsearch.acr.org/docs/3082587/Narrative/ @radiologyacr

#postitpearls #foamed #emergencymedicine #nursepractitioner #physicianassistant #emresident #postit #orthopedics #hipfracture #occultfractures #proximalfemurfracture #radiology
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When your patient’s vitals start to CRASH (bradycardia, hypotension), think about BRASH. It’s a scary syndrome with these 5 findings:  Bradycardia
Renal failure
AV nodal blocker
Shock
Hyperkalemia  It is thought to be a synergistic effect where hyperkalemia and AV nodal blocking agents both lead to severe bradycardia and hypotension. Bradycardia then causes worse renal failure, which worsens hyperkalemia in terrible cycle. It is often resistant to standard ACLS protocols (atropine).  Treatment:
1. Treat bradycardia: calcium, epinephrine (or isoproterenol) - atropine often not effective since not vagal mediated  2. Treat hyperkalemia  3. Fluid resuscitate  4. Find and treat underlying trigger  5. Refractory cases may ultimately need pacing and/or hemodialysis  Great deep-dive articles on EMCrit site https://emcrit.org/ibcc/brash/ and StatPearls: https://www.ncbi.nlm.nih.gov/books/NBK570643/  #postitpearls #foamed #emergencymedicine #nursepractitioner #physicianassistant #emresident #postit #criticalcare #brash #bradycardia  👏 @raypoidog @kishaaaaan

When your patient’s vitals start to CRASH (bradycardia, hypotension), think about BRASH. It’s a scary syndrome with these 5 findings:

Bradycardia
Renal failure
AV nodal blocker
Shock
Hyperkalemia

It is thought to be a synergistic effect where hyperkalemia and AV nodal blocking agents both lead to severe bradycardia and hypotension. Bradycardia then causes worse renal failure, which worsens hyperkalemia in terrible cycle. It is often resistant to standard ACLS protocols (atropine).

Treatment:
1. Treat bradycardia: calcium, epinephrine (or isoproterenol) - atropine often not effective since not vagal mediated

2. Treat hyperkalemia

3. Fluid resuscitate

4. Find and treat underlying trigger

5. Refractory cases may ultimately need pacing and/or hemodialysis

Great deep-dive articles on EMCrit site https://emcrit.org/ibcc/brash/ and StatPearls: https://www.ncbi.nlm.nih.gov/books/NBK570643/

#postitpearls #foamed #emergencymedicine #nursepractitioner #physicianassistant #emresident #postit #criticalcare #brash #bradycardia

👏 @raypoidog @kishaaaaan
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Give HIGH DOSE INSULIN early in the management of severe beta-blocker (BB) and calcium channel blocker(CCB) toxicity. The new 2023 American Heart Association (AHA) update gives this recommendation a Class 1 level recommendation (strong). I used to think this was for refractory cases of hypotension, but now I'll be giving it super early. It can help reduce the need for vasopressors.  The starting dose is a whopping 1 unit/kg IV bolus, which is approximately 10 times that used for diabetic ketoacidosis. High dose insulin improves inotropy in cardiogenic shock with case reports of improving vasopressor-resistant hypotension.  Start concurrently with a dextrose infusion (usually D10).  Frequent q10-15 min initial monitoring is critical until numbers and presentation stabilize. Watch out for: 
* Hypo- and hyperglycemia
* Hypokalemia 
* Volume overload 
* Acid-base derangement  Link to AHA update in bio: https://www.ahajournals.org/doi/10.1161/CIR.0000000000001161  "2023 American Heart Association Focused Update on the Management of Patients With Cardiac Arrest or Life-Threatening Toxicity Due to Poisoning: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care"  #postitpearls #foamed #emergencymedicine #nursepractitioner #physicianassistant #emresident #postit #toxicology #highdoseinsulin #betablocker #calciumchannelblocker #criticalcare

Give HIGH DOSE INSULIN early in the management of severe beta-blocker (BB) and calcium channel blocker(CCB) toxicity. The new 2023 American Heart Association (AHA) update gives this recommendation a Class 1 level recommendation (strong). I used to think this was for refractory cases of hypotension, but now I`ll be giving it super early. It can help reduce the need for vasopressors.

The starting dose is a whopping 1 unit/kg IV bolus, which is approximately 10 times that used for diabetic ketoacidosis. High dose insulin improves inotropy in cardiogenic shock with case reports of improving vasopressor-resistant hypotension.

Start concurrently with a dextrose infusion (usually D10).

Frequent q10-15 min initial monitoring is critical until numbers and presentation stabilize. Watch out for:
* Hypo- and hyperglycemia
* Hypokalemia
* Volume overload
* Acid-base derangement

Link to AHA update in bio: https://www.ahajournals.org/doi/10.1161/CIR.0000000000001161

"2023 American Heart Association Focused Update on the Management of Patients With Cardiac Arrest or Life-Threatening Toxicity Due to Poisoning: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care"

#postitpearls #foamed #emergencymedicine #nursepractitioner #physicianassistant #emresident #postit #toxicology #highdoseinsulin #betablocker #calciumchannelblocker #criticalcare
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Intranasal fentanyl: Consider using this early for kids with sickle cell anemia presenting with a vaso-occlusive pain episode and usually need IV opioids for pain control. This reduces delays from not having IV access.  In a 2023 PECARN publication in American Journal of Hematology by Rees et al, the cross-sectional study at 20 pediatric EDs found that only 19% received IN fentanyl. Those who did receive it had an adjusted odds ratio of 8.99 (CI 2.81-30.56) for being discharged from the ED compared to those who did not receive IN fentanyl. Although this study did not assess causality but rather just association, it seems reasonable to administer early in their ED care.  @gruppphelan @pecarnteam  #postitpearls #foamed #emergencymedicine #nursepractitioner #physicianassistant #emresident #postit #pediatrics #sicklecell #intranasalfentanyl #fentanyl #pecarn #hematology

Intranasal fentanyl: Consider using this early for kids with sickle cell anemia presenting with a vaso-occlusive pain episode and usually need IV opioids for pain control. This reduces delays from not having IV access.

In a 2023 PECARN publication in American Journal of Hematology by Rees et al, the cross-sectional study at 20 pediatric EDs found that only 19% received IN fentanyl. Those who did receive it had an adjusted odds ratio of 8.99 (CI 2.81-30.56) for being discharged from the ED compared to those who did not receive IN fentanyl. Although this study did not assess causality but rather just association, it seems reasonable to administer early in their ED care.

@gruppphelan @pecarnteam

#postitpearls #foamed #emergencymedicine #nursepractitioner #physicianassistant #emresident #postit #pediatrics #sicklecell #intranasalfentanyl #fentanyl #pecarn #hematology
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Michelle Lin, MD
ALiEM Founder and CEO
Professor and Digital Innovation Lab Director
Department of Emergency Medicine
University of California, San Francisco
Michelle Lin, MD

@M_Lin

Professor of Emerg Med at UCSF-Zuckerberg SF General. ALiEM Founder @aliemteam #PostitPearls at https://t.co/50EapJORCa Bio: https://t.co/7v7cgJqNEn
Michelle Lin, MD