EM Quick Hits 11 Blunt Cerebrovascular Injury, Physostigmine, TEE in Cardiac Arrest, Understanding Nystagmus, Subtle Inferior MI, Choicebo
Emergency Medicine Cases - En podcast af Dr. Anton Helman - Tirsdage
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Topics in this EM Quick Hits podcast Emily Austin on physostigmine for anticholinergic toxidrome (1:02) Walter Himmel on understanding nystagmus to differentiate central vs peripheral causes of vertigo (07:00) Rob Devins on the role of transesophageal echocardiogram in cardiac arrest (18:43) Jesse MacLaren on nuances in inferior MI ECG changes and aVL (25:06) Andrew Petrosoniak on a practical approach to blunt cerebrovascular injury (29:43) Reuben Strayer on choicebo (38:46) Podcast production, editing and sound design by Anton Helman Podcast content, written summary & blog post by Andrew Petrosoniak, Emily Austin, Sucheta Sinha and Anton Helman Cite this podcast as: Helman, A. Petrosoniak, A. Austin, E. Devin, R. Himmel, W. Strayer, R. EM Quick Hits 11 - Blunt Cerebrovascular Injury, Physostigmine, TEE in Cardiac Arrest, Understanding Nystagmus, Subtle Inferior MI, Choicebo. Emergency Medicine Cases. December, 2019. https://emergencymedicinecases.com/em-quick-hits-december-2019/. Accessed [date]. The return of physostigmine for antimuscarinic poisoning delirium * Recall anticholinergic/antimuscarinic poisoning toxidrome: "mad as a hatter, blind as a bat, red as a beet, dry as a bone, hot as hell, full as a flask" - hyperthermic, hypertensive, tachycardic, dry axilla (compared to sympathomimetic patients who will often be diaphoretic), agitated, delirious, urinary retention, pupillary dilation. * Benzodiazepines are often used to control agitation, but they are sedating and will not resolve the delirium associated with the antimuscarinic toxidrome. * Physostigmine, the antidote for the antimuscarinic toxidrome reverses both agitation and delirium. * Physostigmine has suffered from a bad reputation after being incorrectly used in TCA overdose with QRS prolongation, leading to cardiac arrest in case reports. * It is safe and effective in anticholinergic overdose associated with delirium as long as the ECG shows a normal QRS and QTc. * Physostigmine dose is 1-2 mg IV over 10 minutes for adults and 0.02 mg/kg for children. It may need to be re-dosed if symptoms return. Expand to view reference list * Arens AM, Shah K, Al-abri S, Olson KR, Kearney T. Safety and effectiveness of physostigmine: a 10-year retrospective review<sup></sup>. Clin Toxicol (Phila). 2018;56(2):101-107. * Burns MJ, Linden CH, Graudins A, Brown RM, Fletcher KE. A comparison of physostigmine and benzodiazepines for the treatment of anticholinergic poisoning. Ann Emerg Med. 2000;35(4):374-81. Understanding nystagmus to differentiate central vs peripheral causes of vertigo * Differentiating the various types of nystagmus can help differentiate central vs peripheral causes of vertigo. * Two main types of nystagmus: pendular nystagmus (eyes move repetitively in a sinusoidal pattern) and jerk nystagmus (eyes move slowly in one direction and rapidly correct in the opposite direction). * Types of jerk nystagmus that are always central: pure vertical, pure rotational, and multidirectional nystagmus (where the fast component changes direction depending on which direction the patient is looking). * Types of jerk nystagmus that are almost always peripheral: unidirect...