We are coming off a very special conference last week with special guest Dr Glaucomflecken! This was a fantastic guest who joined our live stream as a surprise organized by none other than our fearless leader Dr Ryan Kirby (PD-VC) https://twitter.com/kirbyERDR.
Dr Glaucomflecken (for those of you living under a rock) is an Ophthalmologist and comedian who frequents platforms such as twitter (@DGlaucomflecken https://twitter.com/dglaucomflecken?lang=en) and also is a long time contributor to GomerBlog. As you can imagine he has an incredible sense of humor. (https://gomerblog.com/author/glaucomflecken/). Dr Glauckomflecken is a two time cancer survivor with an incredible story you can read here https://www.drgcomedy.com/bio. If you have a free moment please check out First Descents, a nonprofit foundation for cancer survivors https://support.firstdescents.org/fundraiser/2727834 and consider donating to a great cause.
He delivered his signature brand of comedy and also a pretty great ophtho lecture for us, which kept us quite entertained, so shout out to him!
Also a big shout-out to our new interns who joined the live-stream with us this week, it was great seeing you and having you on our Virtual conference series. Again thanks to Dr Kirby and thanks to Dr Glaucomflecken, it was much needed!
In other news…
The Tiger King series seems to be all the rage these days.
For a while I didn’t want to buy in, but ended up nearly bingeing the series after getting swept up in the hype. Dr K Holmes told me to pace myself, for which I tried to do but ended up finishing the series in only a few days! Also that I have noticed, almost every meme that has come across the various social media platforms has been some sort of tiger king related meme – not that we are complaining- because most of them are hilarious!
Who else liked tiger king you ask? for your consideration….
Next up.. some throwbacks
Here are some throwbacks of EMRAP club from the archives of Dr K. Holmes worth sharing. Sometime in the future, this is the goal to return to… She has the best pictures! Contains several alumni.. can you spot them all?
Now onto business..
Acetaminophen and salicylate toxicity are definitely par for the course in emergency medicine, and things you should know well.
Acetaminophen is conjugated with glucuronide and excreted in the urine. 5% converts to toxic NAPQI (N-acetyl-p-benzoquinone imine) but conjugates to glutathione, which is non-toxic and is excreted renally in the urine. In overdose both of these systems are overwhelmed and NAPQI accumulates causing hepatic toxicity (1,2). Is it simply looking at a 4 hour nomogram and exceeding the threshold? What about if if they took multiple doses, or took extended release, or presented > 8 hrs after ingestion? Review this LITFL article which goes into detail in all of these scenarios and is a concise yet diligent review of acetaminophen toxicity
Not only aspirin contains salicylates – Oil of Wintergreen and Pepto Bismol (TM) also do as well and can serve as sources for unintentional overdose. Salicylic acid uncouples oxidative phosphorylation which leads to accumulation of lactic acid and pyruvic acid. This creates a elevated anion gap metabolic acidosis. It also decreases brain glucose due to uncoupling of oxidative phosphorylation. In turn it will directly stimulate the respiratory drive in the medulla which then leads to a primary respiratory alkalosis overlying the metabolic acidosis creating a mixed picture. (3)
Read more on salicylate toxicity here, courtesy of CORE-EM
Since we had a guest lecture on ophthalmologic conditions for the ED physician, I would like you to check out this post by EMDOCS on acute vision loss. It also covers quite a few scenarios in which emergent vs nonurgent ophtho evaluation would be necessary.
Since this week is typically a procedure day in sim lab, here are several procedural videos for you to review. The first is a review of POCUS for ocular evaluation (fitting in the case of the primer ophtho lecture), followed by US guided LP, US guided Subclavian CVC, and US guided paracentesis. As you have noted, all of these incorporate US.
See you this week in upcoming virtual conference.
- Silvalotti MCA, Yarema MC, Juurlink DN et al. A risk quantification instrument for acute acetaminophen overdose patient treatment with N-acetyl cysteine. Annals of Emergency Medicine 2005; 46(3):263-271
- Hoffman, RS. Howland, MA. Lewin, NA.. Nelson, LS. Goldfrank LR. Goldfranks’s Toxicologic Emergencies (10th ed.) New York: McGraw-Hill Education. 516-527.
K. Holmes DO FACEP
S. Meyering DO FAAEM