EM Quick Hits 17 Adrenal Crisis, Strep Throat, Posterior MI, DKA Just the Facts, Ovarian Torsion Imaging, HINTS Exam, Canadian CT Head Rule

Topics in this EM Quick Hits podcast Anand Swaminathan on recognition and ED management of adrenal crisis (00:33) Maria Ivankovic on indications for antibiotics in strep throat from EM Cases Course 2020 (7:13) Jesse McLaren on recognition of posterior MI from ECG Cases (10:37) Justin Yan & Hans Rosenberg on just the facts of approach to DKA (18:24)  Brit Long on ovarian torsion imaging myths (23:24) Walter Himmel on how to use the HINTS exam properly (29:21) Ian Stiell on how to use Canadian CT head rules properly (36:08) Podcast production, editing and sound design by Anton Helman Podcast content, written summary & blog post by Sucheta Sinha, Brit Long, edited by Anton Helman Cite this podcast as: Helman, A.  Swaminathan, A. Long, B. Rosenberg, H. EM Quick Hits 14 - Adrenal Crisis, Strep Throat, Posterior MI, DKA Just the Facts, Ovarian Torsion Imaging, HINTS Exam, Canadian CT Head Rule. Emergency Medicine Cases. April, 2020. https://emergencymedicinecases.com/em-quick-hits-march-2020/. Accessed [date]. Adrenal crisis recognition and ED management * Adrenal crisis results from an acute deficiency of adrenocortical hormones which carries a significant mortality rate if not recognized early and managed aggressively * The hallmark is severe hypotension/vasodilatory shock refractory to IV fluids and vasopressors * Other diagnoses to consider in patients with fluid and vasopressor refractory shock include B-blocker overdose, calcium channel blocker overdose, anaphylaxis, hypocalcemia, cardiogenic shock, occult bleeding, severe hypothyroidism * Diagnosis is challenging as symptoms are highly variable and non-specific, which may include nausea, vomiting, abdominal pain, weakness, confusion or fever, however a presumptive diagnosis can be made if the patient responds to IV steroid therapy within 1-2hrs * Adapt a cognitive forcing strategy to think of adrenal crisis in patients suspected of septic shock who are not responding to treatment as expected, as shock and fever may be the only signs, especially in those with pre-exististing adrenal insufficiency (e.g. Addison's) and in those with a history of steroid medications use * Lab clues include hypoglycemia, hyponatremia, hyperkalemia, non-anion gap metabolic acidosis, low bicarbonate, elevated BUN/creatinine, however these are neither sensitive nor specific * Hydrocortisone 100mg IV bolus, then 25 mg IV hydrocortisone IV q6hr is the preferred initial treatment for most patients * Dexamethasone 4-6 mg IV may be considered for those with pre-existing adrenal insufficiency as dexamethasone does not interfere with measurement of cortisol levels * Treat the underlying trigger whenever possible * Consider "stress-dose steroids" in any patient on chronic steroids or with chronic adrenal insufficiency to prevent adrenal crisis Expand to view reference list * Tucci V, Sokari T. The clinical manifestations, diagnosis, and treatment of adrenal emergencies. Emerg Med Clin North Am. 2014; 32(2): 465-484. * Allolio B.