EM Quick Hits 26 LAST, Sodium Nitrite Poisoning, Post-intubation Care, Tetracaine for Corneal Abrasion, ST Segment in Occlusion MI, Coping with COVID

Topics in this EM Quick Hits podcast Anand Swaminathan on LAST prevention, recognition and management (0:54) Emily Austin on sodium nitrite suicide kit poisoning, methemoglobinemia and methylene blue (10:51) Hans & Erin Rosenberg on post-intubation analgesia and sedation (17:29) Salim Rezaie on short-term tetracaine for corneal abrasions new evidence (25:58) Jesse MacLaren on differentiating ST deviation in occlusion MI from other causes (33:03) Robert Maunder on a 3 step approach to coping and building resilience during the COVID pandemic (40:52 ) Podcast production, editing and sound design by Anton Helman Podcast content, written summary & blog post by Anand Swaminathan, Hans Rosenberg and Anton Helman Cite this podcast as: Helman, A. Swaminathan, Austin, E. M. Rosenberg, H. Rezaie, S. MacLaren, J. Maunder, R. EM Quick Hits 26 - LAST, Sodium Nitrite Poisoning, Post-intubation Care, Tetracaine for Corneal Abrasion, ST depression, Coping with COVID. Emergency Medicine Cases. February, 2021. https://emergencymedicinecases.com/em-quick-hits-february-2021/. Accessed [date]. LAST prevention, recognition and management * LAST (Local Anesthetic Systemic Toxicity) is an iatrogenic life-threatening acute neurologic/cardiac adverse reaction resulting from infiltration of local anesthetic that enters the systemic circulation * The best treatment is prevention! Preventative measures include aspirating before injection of anesthetic to ensure that the needle is not in a blood vessel and using less than the toxic dose of the anesthetic (see table below) Consider LAST in any patient coming from outpatient surgical center in cardiac arrest * Initial symptoms/signs include perioral numbness and other paresthesias, tinnitus, muscle fasciculations, hypertension, tachycardia progressing to tonic-clonic seizures, decreased LOA, apnea, hypotension, bradycardia, dysrhythmias and cardiac arrest Neurologic symptoms typically precede cardiovascular symptoms in lidocaine toxicity while cardiovascular symptoms typically present first in bupivacaine toxicity Treatment in addition to withdrawal of anesthetic and usual CABs may include epinephrine, bicarb, lipid emulsion therapy Local anesthetic maximum doses adapted from Core EM Expand to view reference list Schwartz DR, Kaufman B. Local Anesthetics. In: Hoffman RS, Howland M, Lewin NA, Nelson LS, Goldfrank LR. eds. Goldfrank's Toxicologic Emergencies, 10e New York, NY: McGraw-Hill; 2015. Neal JM et al, American Society of Regional Anesthesia and Pain Medicine. American Society of Regional Anesthesia and Pain Medicine checklist for managing local anesthetic systemic toxicity: 2012 version. Reg Anesth Pain Med 2012;37:16–8. Cao D et al. Intravenous lipid emulsion in the emergency department: a systematic review. J Emerg Med 2015; 48(3): 387-97. Sodium Nitrite suicide kit poisoning, methemoglobinemia and methylene blue * Sodium nitrite (a yellow-white crystalline powder food preservative/additive) "suicide kits" can be purchased online resulting in ...