Author: Rachel Brady, MD
Hypercalcemia of malignancy:
- Hypercalcemia of malignancy can present with lethargy, muscle weakness, hyperreflexia, altered mental status, cardiac dysrhythmias, and even cardiac arrest.
- Treatment is based both on calcium level and symptoms
- Intravenous rehydration is first line treatment
- Other options include steroids, bisphosphonates and calcitonin.
Tumor Lysis Syndrome
- Occurs due to the breakdown of tumor cells after chemotherapy/radiation
- Presents as hyperkalemia, hyperuricemia, hyperphosphatemia, and hypocalcemia
- Treatment is very similar to severe hypercalcemia – hydration with crystalloids
- Hyperuricemia can be treated using rasburicase or allopurinol
Ñamendys-Silva SA, Arredondo-Armenta JM, Plata-Menchaca EP, Guevara-García H, García-Guillén FJ, Rivero-Sigarroa E, Herrera-Gómez A. Tumor lysis syndrome in the emergency department: challenges and solutions. Open Access Emerg Med. 2015 Aug 20;7:39-44. doi: 10.2147/OAEM.S73684. eCollection 2015. Review. PubMed PMID: 27147889; PubMed Central PMCID: PMC4806807.
Zagzag J, Hu MI, Fisher SB, Perrier ND. Hypercalcemia and cancer: Differential diagnosis and treatment. CA Cancer J Clin. 2018 Sep;68(5):377-386. doi: 10.3322/caac.21489. Epub 2018 Sep 21. Review. PubMed PMID: 30240520.
Summary by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD
Author: Chris Holmes, MD
- Symptoms commonly seen with mononucleosis are palatal petechiae, posterior cervical lymphadenopathy, inguinal/axillary lymphadenopathy, splenomegaly, and/or atypical lymphocytes > 10% on CBC.
- Among these, posterior cervical lymphadenopathy and atypical lymphocytes > 10% were the most sensitive (sensitivities of 0.64 and 0.66 respectively).
Welch, JL et al. What Elements Suggest Infectious Mononucleosis? Annals of Emergency Medicine. 2018. 71(4): 521-522. Doi: 10.1016/j.annemergmed.2017.06.014
Author: Dylan Luyten, MD
- Most important questions to answer with low potassium are 1. What are their symptoms? 2. Can they take potassium by mouth?
- Oral repletion is faster, cheaper, and more effective than IV repletion.
- Give IV potassium when patients have K < 2.5 mmol/L or present with arrhythmias and/or characteristic EKG changes (flattened T waves).
- Most patients who are hypokalemic are hypomagnesemic and require magnesium supplementation. Checking a level is unnecessary.
Ashurst J, Sergent SR, Wagner BJ, Kim J. Evidence-based management of potassium disorders in the emergency department. Emerg Med Pract. 2016 Nov 22;18(Suppl Points & Pearls):S1-S2
Whang R, Flink EB, Dyckner T, et al. Magnesium depletion as a cause of refractory potassium repletion. Arch Intern Med 1985; 145:1686.
Check out this episode!
Author: Nick Hatch, MD
- The sodium-glucose cotransporter in the gut is essential for rehydration.
- Oral rehydration therapies require an equimolar concentration of glucose and sodium to be effective.
- ORT has saved millions of lives globally.
- Consider using ORT in patients with dehydration. Especially useful in resource limited settings.
Victora CG, Bryce J, Fontaine O, Monasch R. Reducing deaths from diarrhoea through oral rehydration therapy. Bull World Health Organ. 2000; 78:1246.
Santillanes G, Rose E. Evaluation and Management of Dehydration in Children. Emerg Med Clin North Am. 2018. 36(2):259-273. doi: 10.1016/j.emc.2017.12.004.
Author: Dylan Luyten , MD
- Rare autosomal dominant condition that is often misdiagnosed as a psychiatric illness.
- Presents as profound muscle weakness with frank paralysis that is often precipitated by vigorous exercise, high carb diet, high sodium load, or by high temperatures.
- Supplemental potassium can rapidly reverse symptoms.
- Important to rule out thyrotoxicosis (get a TSH!).
- Prevention is key: adhering to a low carb and low sodium diet with supplemental potassium can help prevent episodes.
Vicart S, Sternberg D, Arzel-Hézode M, et al. Hypokalemic Periodic Paralysis. 2002 Apr 30 [Updated 2014 Jul 31]. In: Adam MP, Ardinger HH, Pagon RA, et al., editors. GeneReviews® [Internet]. Seattle (WA): University of Washington, Seattle; 1993-2018. Available from: https://www.ncbi.nlm.nih.gov/books/NBK1338/?report=classic
Statland JM, Fontaine B, Hanna MG, et al. Review of the Diagnosis and Treatment of Periodic Paralysis. Muscle & Nerve. 2018;57(4):522-530. doi:10.1002/mus.26009.
Author: Don Stader, MD
- The use of fecal occult blood tests is falling out of favor in emergency departments
- These tests have strong evidence suggesting their efficacy in colon cancer screening but clinical significance in ED is limited
- They have relatively high false positive and false negative rates
- Small/microscopic bleeding are often not clinically significant in the ED but can lead to increased costs from over-testing and other harms from fecal occult blood testing
Gupta A, Tang Z, Agrawal D. Eliminating In-Hospital Fecal Occult Blood Testing: Our Experience with Disinvestment. American Journal of Medicine. (2018). 10.1016/j.amjmed.2018.03.002
Author: Rachel Beham, PharmD
- Some synthetic cannabinoids have been contaminated with Brodifacoum. Brodifacoum is a Vitamin K antagonist and can present with a severe coagulopathy.
- Brodifacoum is commonly known as “superwarfarin” and has a very long half life of 120+ days.
- Check PT/INR in patients with a bleeding diathesis in setting of synthetic cannabinoid use.
- Treatment is activated charcoal and large doses of Vitamin K (10mg Q6H for months).
Lipton R.A.; Klass E.M. (1984). “Human ingestion of a ‘superwarfarin’ rodenticide resulting in a prolonged anticoagulant effect”. JAMA. 252: 3004?3005.
La Rosa F; Clarke S; Lefkowitz J. B. (1997). “Brodifacoum intoxication with marijuana smoking”. Archives of Pathology & Laboratory Medicine. 121: 67?69
Author: Jared Scott, M.D.
- Cardiac myocytes and vascular smooth muscle are dependent on an intracellular calcium influx for contraction. Pancreatic beta cells rely on calcium to release insulin.
- Calcium channel blockers will decrease cardiac contractility and heart rate, but will also cause vascular smooth muscle relaxation with a subsequent decrease in systemic vascular resistance.
- Resultant cardiac depression and hypotension.
- Pancreatic beta cells also use calcium to release insulin, so calcium channel blockade can cause hyperglycemia.
- Treatment for calcium channel toxicity include: fluid resuscitation, calcium gluconate, vasopressors, and high dose insulin.
- Dosing for insulin therapy is usually 1-5 Units/kg/hr. Make sure to add dextrose!
Boyer EW, Shannon M. (2001).Treatment of calcium-channel-blocker intoxication with insulin infusion. New England Journal of Medicine. 344:1721.
Proano L, Chiang WK, Wang RY. (1995).Calcium channel blocker overdose. American Journal of Emergency Medicine. 13:444.
St-Onge M, Dubé PA, Gosselin S, et al. (2014). Treatment for calcium channel blocker poisoning: a systematic review. Clinical Toxicology. 52:926.
Author: Nick Hatch, M.D.
- Methemoglobinemia is when the iron in hemoglobin is in the Fe3+ (ferric) state rather than the normal Fe2+ (ferrous) state. Methemoglobin cannot release oxygen at the tissues.
- Symptoms include cyanosis, headache, tachycardia, dyspnea, and lethargy.
- Suspect in setting of hypoxia that does not improve with oxygenation, and clinical cyanosis with a normal PaO2 on ABG.
- Treatment is methylene blue which reduces the iron back to the ferrous state.
- Causes can be Dapsone, Lidocaine, Benzocaine.
Agarwal N, Nagel RL, Prchal JT. Dyshemoglobinemias. In: Disorders of Hemoglobin: Genetics, Pathophysiology, and Clinical Management, 2nd ed, Steinberg M (Ed), 2009. P.607
Cortazzo JA, Lichtman AD. (2014). Methemoglobinemia: a review and recommendations for management. Journal of Cardiothoracic and Vascular Anesthesia. 28:1043.
Darling R, Roughton F. (1942). The effect of methemoglobin on the equilibrium between oxygen and hemoglobin. American Journal of Physiology. 137:56.
Author: Dylan Luyten, M.D.
- Lactate is a byproduct of anaerobic metabolism, a sign of dying tissue. Dangerous causes of high lactates will not normalize with repeat labs.
- Crush injuries, seizures, bowel necrosis, end-stage liver disease, and metformin toxicity are common causes of highly elevated lactate.