Longing for the QT
A 58-year-old man presented to the ED with a reported overdose of an unknown medication. The patient was agitated, combative, and altered. Initial vital signs included a heart rate of 115 beats/min, blood pressure of 154/93 mm Hg, respirations of 22/min, and temperature of 99.5°F. The patient was difficult to evaluate because he was agitated, and he was given 5 mg of haloperidol IV and 2 mg of lorazepam IV. The patient continued to be agitated, and was given another 10 mg of haloperidol IV, followed by a repeat dose of 10 mg IV 15 minutes later. The patient then became unresponsive, and his cardiac monitor demonstrated th...
Source: The Tox Cave - March 1, 2016 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
Alkalotics Anonymous
A 50-year-old man with a past medical history of alcoholism presented to the ED with altered mental status, nausea, and vomiting. He is arousable but a poor historian. His girlfriend said he drinks a half-gallon of rum daily, and had his last drink two days earlier. She reported that he started to feel nauseous, vomit, and go through alcohol withdrawal. She said he also has been taking a lot of calcium carbonate for an upset stomach, but she was unable to say exactly how much. His blood pressure was 146/70 mm Hg, heart rate was 110 bpm, respiratory rate was 14 bpm, PO2 was 96% on room air, and blood glucos...
Source: The Tox Cave - February 1, 2016 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
To See or Not to See
A
A 17-year-old boy presented to the emergency department after having a seizure. Initial vital signs included a temperature of 38°C, heart rate of 134 beats/min, respiratory rate of 22 breaths/min, blood pressure of 142/93 mm Hg, and pulse oximetry of 97% on room air. His physical exam is significant for tachycardia and pupils are 5 mm bilaterally and reactive to light with horizontal nystagmus. He is awake, confused, and combative.
Paramedics report that his mother found him in his bedroom was acting strangely before he fell to the floor and began convulsing. ED staff administered 2 mg intravenous lorazepam, ...
Source: The Tox Cave - January 4, 2016 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
Legally High
A 24-year-old is brought to the emergency department by EMS after being found altered outside a fast food restaurant talking to inanimate objects. Initial vital signs on arrival include a blood pressure of 145/92 mm Hg, heart rate of 126 bpm, respiratory rate of 22 bpm, temperature of 98.4°F, and pulse oximetry of 100% on room air.
The patient is awake, alert, but oriented x 0. He is tachycardic, dry, flushed, and his mydriatic pupils measure 5 mm in diameter. The patient repeatedly was asking to go to the bathroom, and after multiple attempts, ultrasound was used to scan his bladder. It was determined that he had 50...
Source: The Tox Cave - December 1, 2015 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
Legally High
A 24-year-old is brought to the emergency department by EMS after being found altered outside a fast food restaurant talking to inanimate objects. Initial vital signs on arrival include a blood pressure of 145/92 mm Hg, heart rate of 126 bpm, respiratory rate of 22 bpm, temperature of 98.4°F, and pulse oximetry of 100% on room air.
The patient is awake, alert, but oriented x 0. He is tachycardic, dry, flushed, and his mydriatic pupils measure 5 mm in diameter. The patient repeatedly was asking to go to the bathroom, and after multiple attempts, ultrasound was used to scan his bladder. It was determined that he had 500 ...
Source: The Tox Cave - December 1, 2015 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
Don't Be Blue
A 21-year-old woman presented with a sore throat, low-grade fever, body aches, swollen glands, and generalized malaise for three days. The patient said her symptoms had worsened over the past day. She denied any difficulty breathing but endorsed pain and difficulty swallowing.
Her initial vital signs were blood pressure 132/84 mm Hg, heart rate 113 bpm, respiratory rate 22 bpm, temperature 100.4°F, and pulse oximetry 100% on room air. She was diagnosed with a peritonsillar abscess, and the EP applied a topical anesthetic to the area prior to draining it. During the procedure, the patient’s pulse oximetry dropped to...
Source: The Tox Cave - November 2, 2015 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
Don't Be Blue
A 21-year-old woman presented with a sore throat, low-grade fever, body aches, swollen glands, and generalized malaise for three days. The patient said her symptoms had worsened over the past day. She denied any difficulty breathing but endorsed pain and difficulty swallowing.
Her initial vital signs were blood pressure 132/84 mm Hg, heart rate 113 bpm, respiratory rate 22 bpm, temperature 100.4°F, and pulse oximetry 100% on room air. She was diagnosed with a peritonsillar abscess, and the EP applied a topical anesthetic to the area prior to draining it. During the procedure, the patient’s pulse oximetry dropped to 8...
Source: The Tox Cave - November 2, 2015 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
Altered Mental Status after a Handful of Pills
Credit
John Nakamura Remy
A 30-year-old woman presented with altered mental status. Her boyfriend reported that she took a handful of unknown pills about two hours before. Initial vital signs include a temperature of 38°C, heart rate of 130 beats/min, respiratory rate of 18 breaths/min, blood pressure of 112/83 mm Hg, and pulse oximetry of 97% on room air.
Her physical exam is significant for pupils 6 mm bilaterally and reactive to light, dry mucous membranes and skin, and decreased bowel sounds. She was alert but confused. Her initial ECG showed a sinus tachycardia with a rate of 133 and a QRS of 89 and QTc of...
Source: The Tox Cave - October 1, 2015 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
Altered Mental Status after a Handful of Pills
Credit
John Nakamura Remy
A 30-year-old woman presented with altered mental status. Her boyfriend reported that she took a handful of unknown pills about two hours before. Initial vital signs include a temperature of 38°C, heart rate of 130 beats/min, respiratory rate of 18 breaths/min, blood pressure of 112/83 mm Hg, and pulse oximetry of 97% on room air.
Her physical exam is significant for pupils 6 mm bilaterally and reactive to light, dry mucous membranes and skin, and decreased bowel sounds. She was alert but confused. Her initial ECG showed a sinus tachycardia with a rate of 133 and a QRS of 89 and QTc of 443....
Source: The Tox Cave - October 1, 2015 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
The Orange Juice Clue
The parents of a 16-month-old boy who presented to the ED were concerned that he was too sleepy. His initial point-of-care glucose was noted to be 42 mg/dL, and he was somnolent but arousable, and was given orange juice.
Twenty minutes later, the child’s symptoms had completely resolved. Toxicology was consulted for evaluation of a possible toxic ingestion, and a medication inventory was recommended.
Differential Diagnosis of Hypoglycemia in Children
n Ethanol intoxication
n Beta blocker intoxication
n Salicylate toxicity
n Sulfonylurea
n Insulin injection
n Endocrine disorder (hypopituitarism, Addison’...
Source: The Tox Cave - September 1, 2015 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
The Orange Juice Clue
The parents of a 16-month-old boy who presented to the ED were concerned that he was too sleepy. His initial point-of-care glucose was noted to be 42 mg/dL, and he was somnolent but arousable, and was given orange juice.
Twenty minutes later, the child’s symptoms had completely resolved. Toxicology was consulted for evaluation of a possible toxic ingestion, and a medication inventory was recommended.
Differential Diagnosis of Hypoglycemia in Children
n Ethanol intoxication
n Beta blocker intoxication
n Salicylate toxicity
n Sulfonylurea
n Insulin injection
n Endocrine disorder (hypopituitarism, Addison’s disease,...
Source: The Tox Cave - September 1, 2015 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
‘To Alcohol! The Cause of, and Solution to, All of Life's Problems’
A 37-year-old woman is brought into the emergency department by EMS after being found down next to a bottle of an unknown substance. (See photo.) Her family said she was initially tearful and repeatedly mumbling, “I’m sorry,” and became progressively less responsive.
She was obtunded and intubated for airway protection upon arrival to the ED. Her initial vital signs were a temperature of 98.8°F, heart rate 110 bpm, blood pressure 187/118 mm Hg, respiratory rate 22 bpm, and pulse oximetry 98% on ventilator. Initial ABG reveals a pH 6.89, pCO2 16, pO2 174, and bicarbonate 3.1. Pertinent lab results include a meta...
Source: The Tox Cave - August 3, 2015 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
