Tox Talks 2025 Recap 2, Methemoglobinemia and Errors
Emergency Medical Minute
Contributors: Travis Barlock MD, Ian Gillman PA, Jacob Altholz MD, Jeffrey Olson MS4 In this episode, EM attending Travis Barlock and medical student Jeffrey Olson listen in to the two remaining cases presented from EMM’s recent event, Tox Talk 2025. Talk 1- Methemoglobinemia- Ian Gillman Cyanosis + chocolate-colored blood + normal PaO₂ + pulse ox stuck at ~85% = Methemoglobinemia → Treat with methylene blue The medications that can cause it can be remembered with… Watch out with methylene blue as it can cause serotonin syndrome While treating with methylene blue the...
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Podcast 992: Fentanyl for Asthma
Emergency Medical Minute
Contributor: Alec Coston, MD Educational Pearls: BiPAP is often effective in severe asthma, but many patients struggle with mask tolerance due to intense air hunger–driven anxiety, often compounded by hypoxia. Benzodiazepines are commonly used for anxiety, but they can depress respiratory drive, making clinical improvement difficult to interpret (a lower RR may reflect sedation rather than true physiologic improvement). Low-dose fentanyl is a useful alternative when patients cannot tolerate BiPAP despite coaching. Opioids blunt the perception of dyspnea and are well established for...
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Episode 991: BRASH
Emergency Medical Minute
Contributor: Aaron Lessen, MD Educational Pearls BRASH Syndrome: Bradycardia Renal Failure AV Nodal Blockade Shock Hyperkalemia Clinical Features: Profound bradycardia and shock in patients on AV nodal blockers: Commonly, Beta Blockers or Calcium Channel Blockers Etiology: Caused by an inciting kidney injury: Common triggers include precipitating illness, dehydration, or medications Results in hyperkalemia The enhanced effect of the combination of AV nodal blockade and hyperkalemia leads to a more profound presentation of shock. ...
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Episode 990: Tramadol, or rather, Trama-don’t
Emergency Medical Minute
Contributor: Taylor Lynch, MD Educational Pearls: What is tramadol and how does it work? Tramadol is a Schedule IV opioid analgesic used for moderate pain and is often perceived as safer than other opioids due to lower abuse potential. It is a prodrug with weak direct μ-opioid receptor activity. The parent compound also inhibits serotonin and norepinephrine reuptake, giving it SSRI/SNRI-like properties. Tramadol is metabolized by CYP2D6 into O-desmethyltramadol (ODT), which has significantly stronger μ-opioid receptor agonism than the parent drug. What are the concerns with...
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Episode 989: Young Strokes
Emergency Medical Minute
Contributor: Aaron Lessen, MD Educational Pearls: The Case 24F brought in for anxiety. Patient is tearful, not talking, and potentially hyperventilating. History from boyfriend is that she suddenly stopped talking and started crying and it was hard to understand what she was saying. On exam, patient appears anxious and has a gaze preference for the right side and is still having difficulty speaking. Decision is made to stroke alert patient. CT shows early MCA stroke and M2 occlusion. Patient is treated by IR with mechanical thrombectomy. What are the risk factors for strokes in young...
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Episode 988: Infant Botulism
Emergency Medical Minute
Contributor: Aaron Lessen, MD Educational Pearls: A 2025 multistate outbreak of infant botulism has been linked to ByHeart infant formula As of December 10-17th, there have been at least 51 infants with suspected or confirmed botulism who were exposed to this formula across 19 states All reported cases resulted in hospitalization but no deaths reported to date Infant botulism Occurs when C. botulinum spores germinate in the infant’s intestine, producing toxin Spores are classically found in honey but can also be in dirt or contaminated in infant formula Infants are...
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Carepoint Journal Club: Trauma Discussion
Emergency Medical Minute
Carepoint Journal Club is a quarterly series with discussions about a medical topic, brought to you by Carepoint's Emergency Physicians.
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Episode 987: Cough Suppressants
Emergency Medical Minute
Contributor: Meghan Hurley, MD Educational Pearls: OTC Medications Dextromethorphan (DM) Most common OTC cough suppressant Minimal efficacy: Little evidence that it shortens the duration or severity of cough. Potential side effects: At recommended doses: Mild dizziness, drowsiness, GI symptoms Higher doses: Decreased consciousness, dissociative effects Guaifenesin Found in Mucinex and other severe cough/cold products Thins secretions and loosens mucus in airways No more effective than increasing oral fluid intake Prescription Medications Codeine-containing products ...
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Episode 986: Lateral Canthotomy in Emergency Settings
Emergency Medical Minute
Contributor: Taylor Lynch, MD Educational Pearls: What is orbital compartment syndrome, and how is it assessed in the emergency room? Orbital compartment syndrome (OCS) is an emergent ophthalmic condition in which intraorbital pressure in the orbital compartment rises dramatically, compromising perfusion of the optic nerve and retina, leading to risk of irreversible vision loss. OCS occurs in the context of traumatic lesions with retrobulbar hemorrhage. Intraocular pressures (IOP) are measured via tonometry as a surrogate for intraorbital pressures, with emergent pathology being present when...
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Episode 985: Amiodarone vs. Lidocaine
Emergency Medical Minute
Contributor: Aaron Lessen, MD Educational Pearls: How do amiodarone and lidocaine work on the heart? Amiodarone Blocks potassium channels (Class III effect). Also blocks sodium and calcium channels. Additional noncompetitive beta-blocker effects. Stabilizes cardiac tissue, slows heart rate, and suppresses both atrial and ventricular arrhythmias. Lidocaine Blocks fast sodium channels in ventricular tissue (Class Ib). Shortens the action potential in ventricular myocardium, especially in ischemic tissue. Suppresses abnormal automaticity in damaged/irritable myocardium. Which one should...
info_outlineContributors: Travis Barlock MD, Jeffrey Olson MS4
Feel free to use the cases below for your own practice. All of the scenarios are completely made up and designed to hit several teaching points.
Case 1
25 M, presents to the ED with chest pain.
Stabbing, started a few hours ago, substernal. Thinks it is GERD.
After 2-3 minutes, pain worsens and radiates to the back.
VS: BP 125/50 (Right arm 190/110). HR 120. RR of 18. Sat 98% on RA.
Additional VS: Temp of 37.2, height of 6’5”, BMI of 18.
PMH: None, doesn’t see a doctor. Meds: None
FH: Weird heart thing (Mitral Valve Prolapse), weird lung thing (spontaneous pneumothorax), tall family members with long fingers and toes
Physical Exam:
Cards: Diastolic decrescendo at the RUSB, diminished S2. UE pulses are asymmetric, LE pulses are asymmetric, carotid pulses are asymmetric, BP is asymmetric
MSK: Knees, elbows, and wrists are hypermobile.
Imaging: CXR #1 normal, #2 widened mediastinum (no read yet but shows widened mediastinum), POCUS shows small effusion
CTA/MRA doesn’t come back until after the case.
ECG: Sinus Tach
Labs:
NT-proBNP 500 pg/mL
D-Dimer: 7000 ng/L
CBC: Hemoglobin: 13.5 g/dL, WBC: 20,000/µL, Platelets: 250,000/µL
Chem 7: Na 138, K, 5.7, Cl 102, Bicarb 17, BUN 45, Creatinine: 3.5 mg/dL, Glucose: 180
LFTs: Albumin 2.4, Total protein 5.5, ALP: 140, AST: 3500, ALT: 2800, TBili: 3.2, DirectBili: 2.4,
Ca: 7.8
LDH: 2200
PT: 20.5, INR: 2.2, Fibrinogen: 170
5th gen High-Sensitivity Troponin: <3
Lactate: 7 mmol/L
VBG: pH 7.22, paCO2 28, bicarb 15
Notes: Can have patient crash somewhere in middle and show 2nd xray
Case 2:
A 67-year-old female is brought to the ED by her daughter due to progressive weakness, confusion, and fatigue that have worsened over the past week.
Unable to get out of bed and has become increasingly lethargic. Also having some nausea, constipation. The daughter denies any preceding illness, recent trauma, or travel. Does not know her meds but will head home to get them after talking with you.
VS: BP 88/55 mmHg, HR 110, RR 20, O2 Sat 98% on room air.
Additional VS: Temp 36.8°C.
PMH: Hypertension, osteoarthritis, and depression.
Physical exam:
General: Thin, somnolent but arousable.
HENT: Dry mucous membranes
Neuro: Confused, A&Ox1 (self), hyporeflexia
Labs (Includes many that would not return in the ED in case you want to take this case forward to the floor)
CBC: WBC 9,500, Hb 16.5, Hct: 50%, Platelets 220,000
Chem7: Na 129, K 2.1, Cl 95, HCO3 34, Creatinine 1.6, BUN 40, Glucose 115
LFTs: normal
Magnesium: 1.1
Calcium: 10.8 mg/dL (corrects to 12.8)
iCal: 3.2
Phosphate: 2.3 mg/dL
Albumin: 2
BUN:Cr ratio: 25
VBG: pH: 7.49, PaCO2 45, HCO3: 34
Lactate: 2.8
Serum Osmolality: 276 mOsm/kg (Osmolal gap of 2)
Urine Osmolality: 550 mOsm/kg
Urine Sodium (UNa): 10 mEq/L (low). Urine Potassium (UK): 25 mEq/L (elevated). Urine Chloride (UCl): 12 mEq/L (low). Urine Magnesium (UMg): 20 (Elevated). Urine Calcium (UCa): 50 in 24 hrs (Low)
100 cc of urine with foley
FeNa <1%
Plasma renin activity: 15 mg/mL/hr (elevated), Aldosterone: 25 ng/dL (Elevated), ADH: Elevated, Diuretic screen: Positive for thiazides
PTH: 8 (low), HsTrop: 32, Cortisol and ACTH: Normal.
EKG: Hypokalemia features
CXR: Normal
Renal US: shows stones
Improves with fluids
Note: Can have daughter return with med list at some point including HCTZ, ibuprofen, and sertraline
Case 3:
Patient Presentation
EMS Report: A 27-year-old male involved in a high-speed motorcycle collision is brought to the emergency department by EMS. The patient was found unconscious at the scene with evidence of severe thoracic and extremity trauma. He was intubated en route for airway protection due to altered mental status (GCS 7).
VS: HR 130, BP 90/60, RR: bagging at 12 bpm, satting 88% on 100% FiO2
Primary Survey
Airway: Endotracheal tube in place.
Breathing: Decreased breath sounds on the left side with visible chest asymmetry and paradoxical chest wall movement.
Circulation: Mottled extremities noted, with significant deformity of the right thigh. Pulses are diminished in the right leg
Disability: GCS remains 7 (E1 V2 M4). Pupils equal and reactive.
Exposure: Full-body examination reveals an open fracture of the right femur, multiple abrasions, and bruising over the chest wall.
Vent alarms
Peak Inspiratory Pressure (PIP) 40 cm H₂O (elevated)
Plateau Pressure (Pplat) 35 cm H₂O (elevated)
EtCO₂ (End-Tidal CO₂) 55 mmHg
High-Pressure Alarm Triggering frequently
Glucose 120
CBC: Hgb 8.9, Hct 27, WBC 14.2, platelets 220,000
VBG: pH 7.28, pCO2 33, bicarb 18, lactate 4.5
CXR with tension pneumothorax
Patient improves after chest tube, pigtail catheter, or needle decompression.
Ready to be transferred upstairs and O2 starts tanking again
Vent alarms- second episode
Peak Inspiratory Pressure (PIP) 35 cm H₂O (elevated)
Plateau Pressure (Pplat) 30 cm H₂O (elevated)
EtCO₂ (End-Tidal CO₂) 20 mmHg
HR: 140, satting 84%, temp 38.5,
ABG: pH 7.32, pCO₂ 30 mmHg, pO₂ 60 mmHg on 100% FiO₂, HCO₃⁻ 18 mmol/L (hypoxemia and metabolic acidosis).
D-dimer: Elevated
Thrombocytopenia: Platelets 90,000/µL.
US shows blown right ventricle
ECG shows new RBBB
CT PE: Ground glass opacities, consolidation, centrilobular nodules, septal thickening, and fat-attenuating lesions.
Note: Management is largely supportive care so once the diagnosis is made, end the case.
References
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Carroll MF, Schade DS. A practical approach to hypercalcemia. Am Fam Physician. 2003 May 1;67(9):1959-66. PMID: 12751658.
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Coelho SG, Almeida AG. Marfan syndrome revisited: From genetics to the clinic. Rev Port Cardiol (Engl Ed). 2020 Apr;39(4):215-226. English, Portuguese. doi: 10.1016/j.repc.2019.09.008. Epub 2020 May 18. PMID: 32439107.
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Palmer BF. Metabolic complications associated with use of diuretics. Semin Nephrol. 2011 Nov;31(6):542-52. doi: 10.1016/j.semnephrol.2011.09.009. PMID: 22099511.
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Reed MJ. Diagnosis and management of acute aortic dissection in the emergency department. Br J Hosp Med (Lond). 2024 Apr 30;85(4):1-9. doi: 10.12968/hmed.2023.0366. PMID: 38708978.
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Roberts DJ, Leigh-Smith S, Faris PD, Blackmore C, Ball CG, Robertson HL, Dixon E, James MT, Kirkpatrick AW, Kortbeek JB, Stelfox HT. Clinical Presentation of Patients With Tension Pneumothorax: A Systematic Review. Ann Surg. 2015 Jun;261(6):1068-78. doi: 10.1097/SLA.0000000000001073. PMID: 25563887.
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Rothberg DL, Makarewich CA. Fat Embolism and Fat Embolism Syndrome. J Am Acad Orthop Surg. 2019 Apr 15;27(8):e346-e355. doi: 10.5435/JAAOS-D-17-00571. PMID: 30958807.
Produced by Jeffrey Olson, MS4
Special thanks to Evan Fisch MD
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