REBEL Cast

Discover the intriguing nature of shock as a clinical diagnosis, emphasizing that it's more than just a number. Learn to assess patients rapidly using the 'four L's' — mental status, limb temperature, urine output, and lactate levels. Find out how pulse pressure can reveal shock type, from narrow pressures indicating cardiogenic issues to wide pressures pointing towards distributive shock. The hosts stress the importance of systematic bedside evaluation, reinforcing that even basic techniques can uncover critical insights.

The podcast dives into the intricacies of sinus tachycardia, emphasizing it as a crucial clinical sign rather than just a number. It discusses how elevated heart rates can indicate underlying physiologic stress such as anemia or shock. The importance of a systematic evaluation and understanding the oxygen delivery equation is highlighted. Listeners learn to rethink reflexive treatments like beta blockers and the significance of addressing root causes before managing symptoms. Insights on fever, glucose levels, and pain-driven tachycardia are also explored.

Tachypnea can signal serious health issues, requiring swift bedside evaluation. Short, shallow breathing often indicates underlying neuromuscular problems or respiratory failure. Key signs to watch for include poor chest rise and symptoms like diaphoresis and tachycardia. Understanding lung compliance is crucial, especially in cases of pulmonary edema. The podcast emphasizes using all senses for a thorough assessment, combining clinical observations with urgent interventions to improve patient outcomes.

The podcast delves into the crucial differences between hypoxemia and hypoxia, emphasizing their significance in clinical settings. It outlines five causes of hypoxemia, including shunt and dead space, along with management techniques for each. Practical insights are shared on maximizing oxygen delivery and recognizing when to escalate care with positive pressure. The hosts also discuss the importance of rapid assessment in critical care, ensuring healthcare professionals can act swiftly in urgent situations.

Acetaminophen (APAP) overdose remains one of the most common causes of acute liver failure in the United States. While its therapeutic use is widespread and generally safe, unintentional overdoses and delayed presentations can lead to devastating outcomes. In this episode of REBEL Cast, we break down the pathophysiology, clinical course, diagnostic approach, and evidence-based management of APAP toxicity—including when to initiate NAC, how to apply the Rumack-Matthew nomogram, and the evolving role of adjunctive therapies like fomepizole. Whether you’re in the ED or elsewhere , this is core content every clinician should know. Click here for Direct Download of the Podcast. Definition and Physiology After ingestion of a therapeutic dose, immediate release APAP is absorbed with a time to peak concentration anywhere between 30-45 minutes. In the context of extended-release, formulations, full absorption is typically reached by 4 hours post-ingestion.1 In therapeutic dosing, the vast majority of APAP undergoes hepatic conjugation with glucuronide or sulfate to form benign metabolites that ultimately get excreted in the urine. The remaining ~5% is oxidized by CYP2E1 to form N-acetyl-p-benzoquinoeimine (NAPQI). NAPQI is hepatotoxic. Glutathione combines with NAPQI to generate non-toxic metabolites that are also eliminated in the urine. In overdose, the amount of NAPQI that is generated is increased as the typical metabolic pathways become saturated. The NAPQI that remains leads to hepatocellular death in Zone 3 of the liver (or the centrilobular location) which is the area with the largest degree of oxidative metabolism. Clinical Manifestations and Diagnostic Evaluation The clinical course of acute APAP toxicity is classically broken into four different stages. Stage1: this is generally within 24 hours. Patients are either asymptomatic or have non-specific GI symptoms (nausea, vomiting, malaise). At this point, hepatic function testing is normal. Stage2: ~24-72 hours. The onset of hepatic injury marks this stage. Aspartate aminotransferase (AST) is the most sensitive marker to detect hepatic dysfunction; AST elevated is nearly universal by 36 hours post-ingestion. Stage3: defined as peak hepatotoxicity; generally between 72-96 hours post-ingestion. Patients may manifest hepatic encephalopathy or coma. AST and/or ALT might rise above 10,000 IU/L. Other lab abnormalities include: INR/PT, glucose, lactate, pH, and creatinine. Death from fulminant hepatic failure usually occurs anywhere between 3-5 days after an acute ingestion. Mortality is often secondary to multiorgan failure, ARDS, sepsis, or cerebral edema. Stage4: often called the “recovery phase.” Patient who survive demonstrate complete hepatic generation without any evidence of hepatic dysfunction. The following labs should be obtained for severe APAP ingestions: APAP Concentration, hepatic panel, pH, coagulation panel, renal function, lactate and phosphate. These labs will ultimately dictate disposition (see King’s College Criteria below) Management Consider GI decontamination with activated charcoal as this can reduce systemic absorption and limit subsequent clinical sequalae. Ingestions should be classified as acute or repeated supratherapeutic (“chronic” ingestions) Single Acute Ingestion If feasible, obtain a 4 hour post-ingestion APAP concentration. Any concentration earlier than 4 hours is uninterpretable as subsequent concentrations may increase or decrease depending on the clinical scenario. Concentrations between 4-8 hour post-ingestion can be plotted on the Rumack-Matthew nomogram to determine when NAC should be initiated. If the APAP concentration is above the plotted line, NAC should be started. NAC is nearly 100% effective if started within 8 hours post-ingestion.2 If an APAP concentration is unable to be drawn before 8 hours or if LFTs are already elevated, NAC should be empirically started if the pre-test probability is high enough for clinical concern. Repeated Supratherapeutic/Chronic Ingestions Cannot apply the Rumack-Matthew Nomogram If LFTs are elevated or if there is a positive APAP concentration, NAC should generally be started however consultation with a toxicologist or Poison Control Center is advised as these cases are often complicated. N-Acetyl-Cysteine (NAC) Dosing “3 Bag Protocol” – 21 hour regimen 150mg/kg over 1 hour loading dose 50mg/kg over 4 hours = 12.5 mg/kg/hr 100mg/kg over 16 hours = 6.25 mg/kg/hr Risk: anaphylactoid reaction Reaction is rate related and typically occurs during the loading dose Symptoms: flushing, urticaria. NAC should be continued until all of the following criteria are met: Negative APAP concentration “Significant Decreased in AST”: defined as either <1000 IU/L or a 25-50% drop from the peak. No evidence of hepatic failure If criteria are not met, the third bag should be extended indefinitely. The King’s College Criteria should be used as this set of lab work is used to determine which patients should be referred for possible liver transplant evaluation.3, 4 Arterial pH < 7.30 INR > 6.5 (PT >100 sec) Creatinine > 3.4 Grade III or IV hepatic encephalopathy Hyperlactatemia Hyperphosphatemia Fomepizole (traditionally used for the treatment of toxic alcohols) has been used as an adjunctive treatment for massive acetaminophen toxicity as it has demonstrated efficacy in mitigating serum transaminase elevation, hepatic necrosis, and oxidative stress in both mouse and human models.5-8 As large scale human studies have yet to be published, fomepizole should NOT be routinely administered for APAP toxicity. Take Home Points Acetaminophen (APAP), most commonly referred to as “Tylenol” in the United States, is in a variety of pharmaceuticals. Medications like Excedrin, Fioricet, Percocet, Vicodin, and Day/Nyquil all contain acetaminophen. Given the lack of a toxidrome, there should be a low threshold to obtain a screening acetaminophen concentration in the undifferentiated poisoned patient. In overdose, acetaminophen leads to generation of NAPQI which is hepatotoxic. N-Acetylcysteine (NAC) is the antidote of choice and ideally should be administered within 8 hours of an acute ingestion. To determine which patients should be treated with antidotal therapy, the Rumack-Matthew Nomogram should be utilized. Of note, this nomogram was validated for a single concentration obtained at or greater than 4 hours after a single, acute ingestion. (i.e. patients with repeated ingestions cannot be applied to the nomogram). In patients with a high pre-test probability of APAP poisoning, the King’s College Criteria should be considered; this is a set of lab markers that help determine when patients should be immediately referred for liver transplant. While physiologic plausibility exists for the use of fomepizole to treat severe APAP toxicity, no large scale human studies exist at this time to suggest that it should be routinely given for toxicity. As with all cases of toxicity, please call your local poison control center for assistance. References Hendrickson RG, McKeown NJ. Chapter 33. Acetaminophen. In: Nelson LS, et al., editors. Goldfrank’s Toxicologic Emergencies. 11th ed. New York: McGraw-Hill; 2019. Smilkstein MJ, Knapp GL, Kulig KW, Rumack BH. Efficacy of oral N-acetylcysteine in the treatment of acetaminophen overdose: Analysis of the National Multicenter Study (1976 to 1985). N Engl J Med. 1988;319(24):1557-1562. PMID: 3059186 O’Grady JG, Alexander GJ, Hayllar KM, Williams R. Early indicators of prognosis in fulminant hepatic failure. Gastroenterology. 1989;97(2):439-445. PMID: 2490426 King’s College Criteria for Acetaminophen Toxicity. Available at: https://www.mdcalc.com/calc/532/kings-college-criteria-acetaminophen-toxicity#next-steps Akakpo JY, Ramachandran A, Duan L, et al. Delayed treatment with 4-methylpyrazole protects against acetaminophen hepatotoxicity in mice by inhibition of c-jun N-terminal kinase. Toxicol Sci. 2019;170(1):57-68. PMID: 30903181 Akakpo JY, Ramachandran A, Kandel SE, et al. 4-Methylpyrazole protects against acetaminophen hepatotoxicity in mice and in primary human hepatocytes. Hum Exp Toxicol. 2018;37(12):1310-1322. PMID: 29739258 Shah KR, Beuhler MC. Fomepizole as an adjunctive treatment in severe acetaminophen toxicity. Am J Emerg Med.2020;38(2):410.e5-410.e6. PMID: 31785979 Kang AM, Padilla-Jones A, Fisher ES, et al. The effect of 4-methylpyrazole on oxidative metabolism of acetaminophen in human volunteers. J Med Toxicol. 2020;16(2):169-176. PMID: 31768936 The post REBEL Core Cast 134.0 – Acetaminophen Toxicity appeared first on REBEL EM - Emergency Medicine Blog.

Introduction: In this episode of Rebel Cast, host Marco Propersi, along with co-hosts Steve Hochman and Kim Baldino, delve into the practice and importance of street medicine—the direct delivery of healthcare to homeless and unsheltered individuals. Special guests Dr. Jim O’Connell, a pioneer of street medicine, and Dr. Ed Egan, a recent street medicine fellowship graduate, share their experiences and insights on serving this vulnerable population. They discuss the origins, scope, and challenges of street medicine, the ethical dilemmas faced, and the profound impact of building trust and community with patients. The conversation underscores the necessity of integrating street medicine with mainstream healthcare systems and emphasizes that small acts of kindness and persistence can significantly improve the lives of those experiencing homelessness. REBEL Cast – Street Medicine: Compassionate Care for the Unhoused Click here for Direct Download of the Podcast. 00:00 Introduction to Rebel Cast 00:18 Meet the Hosts and Guests 00:47 Understanding Street Medicine 02:22 Origins and Early Challenges 07:23 Street Medicine in Practice 20:11 Barriers to Care 22:23 Housing First Experiment 26:56 Ethical Dilemmas in Street Medicine 27:52 Challenges of Providing Care on the Streets 29:56 The Role of Street Medicine Teams 31:17 The Importance of Building Trust 33:55 Limitations and Realities of Street Medicine 37:37 The Future of Street Medicine 41:42 Integrating Street Medicine with Emergency Medicine 43:36 Personal Reflections and Lessons Learned 48:56 Advice for Aspiring Street Medicine Practitioners 53:03 Final Thoughts and Encouragement Links: Street Medicine Institute National Healthcare for the Homeless Council EMRA Fellowship Guide: Opportunities for Emergency Physicians, 3rd ed. The post Street Medicine: Compassionate Care for the Unhoused appeared first on REBEL EM - Emergency Medicine Blog.

Discover the serious implications of traumatic arthrotomy, where even small lacerations can expose joints to infection. Learn about essential diagnostic techniques, including the importance of CT scans in evaluating joint injuries. The discussion emphasizes the need for prompt orthopedic consultation and antibiotic administration to prevent complications. You'll also hear about the nuances of physical exams and how specific findings can indicate joint involvement. It's a deep dive into a critical area of emergency medicine that could save lives.

Dive into the critical world of omphalitis, a serious infection affecting newborns. Discover the alarming signs of erythema and warmth around the umbilicus that necessitate immediate action. Learn why early diagnosis is crucial and the role of antibiotics in treatment. Hear about the importance of pediatric surgery consultations to prevent life-threatening complications. The discussion highlights the severe progression of this condition and the aggressive approach needed when symptoms escalate.

Explore the critical role of orogastric lavage in treating drug overdoses. Discover when this procedure is appropriate, especially for highly toxic substances. Learn about the risks associated with lavage and the importance of airway management to prevent aspiration. Timing is essential, and not every case warrants this intervention. Tune in for a deep dive into this rare but vital emergency care technique!

Sanjay Mohan, an in-house toxicologist, dives into the perilous world of toxic alcohols like methanol and ethylene glycol. He discusses how these substances can present symptoms mimicking ethanol intoxication, complicating diagnosis. The conversation highlights key diagnostic challenges, stressing that a normal osmolar gap doesn't rule out ingestion. Mohan also covers critical management strategies, including the use of fomepizole and the importance of early intervention, particularly in cases of severe metabolic acidosis or renal dysfunction.