Carolinas Emergency Medicine Residency

HyperKalemia - Dr. von Marschall

12/8/2016

1) Use both EKG and absolute K value, in addition to clinical picture, to determine necessity for treatment of hyperkalemic emergency
2) Suspect HyperK in any renal patient who presents with arrhythmia, and correct before pursuing other interventions
3) Be aware of onset times and half-life of HyperK treatment meds (Ca, insulin, B-agonists), and redose as needed!
4) Glucose checks q30min or q1h in any patient treated with insulin for HyperK
5) "C BIG K Di" mnemonic (Calcium, bicarb/Beta agonist/Insulin/Glucose, Kayexelate/LasiKs, DIalysis)

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Heavy Metals - Dr.Kopec

12/2/2016

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ARSENIC

Acute arsenic toxicity can present wiht abdominal pain, vomiting, fluid shifts, hemolysis and prolonged QTc.
Chronic arsenic toxicity leads to peripheral sensory neuropathy, skin hyperpigmentation, Mee's lines and alopecia.
Arsenic toxicity is associated with lung and skin cancer.
Testing for arsenic needs a 24 hour urine sample that is speciated and no ingestion of seafood 72 hours prior to testing.
Treatment is with BAL or succimer.
Arsine gas classic triad is: abdominal pain, hemolysis and bronze skin.

MERCURY

Elemental mercury is found in thermometers and is not absorbed by the GI tract, however it is very toxic if it is vaporized.
Inorganic mercury is associated with renal failure.
Inorganic mercury has been associated with Pink's disease (acrodynia) with is a maculopapular rash with desquamation and swollen painful extremities.
Danbury shakes were from mercury used in the felt hat industry leading to chronic toxicity and is where the term "mad as a hatter" comes from.
Organic mercury crosses the BBB and placenta. It is teratogenic and highly fatal, with neurological demise. Classic finding is constricted visual fields.
To diagnosis organic mercury toxicity you check a whole blood mercury level.
To diagnosis inorganic mercury toxicity you check a 24 hour urine mercury level.
Treatment for inorganic mercury is succimer or BAL.

LEAD

Lead inhibits multiple steps in the heme pathway.
Children are more susptible to lead toxicity than adults.
Lead toxicity can present with a range of symptoms from: constipation, irritability, abdominal pain, tremors, headache, encephalopathy and seizures.
Diagnosis is made with a whole blood lead level.
Treatment initially is remove the source then chelate based on the level with BAL, EDTA or succimer.
Classic lead findings are: basophillic stipling, Burton's lines and lead lines on xrays.
Iron causes GI symptoms, metabolic acidosis and periportal hepatic necrosis.
There are various formulations of iron with different percentages of elemental iron.
There are 5 stages to iron toxicity: 1) GI symptoms, 2) latent 3) Multiorgan failure 4) Hepatic failure 5) Recovery/Long term effects
Fatal iron poisonings are >60mg/kg
Iron level after 4 hours if >500mcg/dL need to be treated.
Deferoxamine should be started for severe acidosis, refractory GI symptoms, shock, altered mental status, or level >500mcg/dL .
Deferoxamine has been associated with hypotension and Yersinia infections.
If there are GI symptoms and neurological symptoms think about metal toxicities.

Remember that metals are caustics.

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HyperKalemia - Dr. von Marschall

Heavy Metals - Dr.Kopec

Pediatric Fever - Dr. Young

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