REBEL Core Cast 28.0 – Conference Pearls

Take Home Points 

  • No palpable pulse does not equal no perfusion. We aren’t great at feeling pulses
  • Patients with moderate to severe signs and symptoms of lithium toxicity should be considered for hemodialysis
  • Always consider serious causes of back pain before simply treating with analgesics
  • Consider trauma as well as other toxic exposures (I.e. CO and CN) in patients with major burns

REBEL Core Cast 28.0 – Conference Pearls

Click here for Direct Download of Podcast

Sweat PEA – Dr. Eric Steinberg

  • Definition: the presence of organized rhythm without a palpable pulse
    • No palpable pulse doesn’t = no perfusion (ie may be profound shock)
    • Pulse palpation isn’t sensitive
  • We are bad at manually feeling for a pulse, instead use POCUS 
    • Use POCUS on carotid or femoral artery to look for pulse
    • Establish an A-line
  • The biggest challenge is finding the cause
    • 2014 established wide v. narrow complex causes. However, not well studied
    • Use the RUSH exam to help determine cause
  • Patient Pre-Arrival
    • Prep your Norepinephrine drip
    • Equipment ready (airway, US, a-line, EtCO2)
    • 2 people ready for CPR or mechanical device ready
    • Get collateral info for cause

Lithium Toxicity – Dr. Monica Choski 

  • Two forms of lithium 
    • Standard release peak 1-2 hours
    • Extended release peak 4 hours
  • 95% renal excretion
  • Increased lithium levels often result outside of overdose when the patient takes a kidney hit (infection/medications) and GFR goes down.
  • Mild toxicity
    • nausea, vomiting, hyperreflexia, agitation, muscle weakness
  • Mod toxicity
    • stupor, rigidity, hypertonia, hypotension
  • Severe toxicity
    • coma, convulsions
  • Chronic Li toxicity – can develop nephrogenic DI
  • Pearl: make sure you don’t send a lithium level in a lithium salt tube – typically a green top in the US
  • Management
    • Get on the phone with consultant
    • Activated Charcoal if the patient will take PO
    • IV fluids to help GFR get back up
    • Dialysis
      • Lithium >4
      • Lithium >2.5 w/ renal insufficiency
      • Moderate to severe signs of toxicity

Back Pain – Dr. Jim Gray

  • Make sure the back pain isn’t from something dangerous; look for red flags

  • Medications
    • First line: NSAIDs. Consider topical if patient cant systemic nsaid 
    • Trigger point injections
    • Lidoderm patch
    • Opiates and muscle relaxants never shown to be beneficial in comparison or addition to NSAIDs
  • Send patients to follow up with PT & PMR

Burn Management – Dr. Jinal Sheth 

  • Major burn patients can have concomitant traumatic injuries along with tox exposures (CO, CN)
  • Airway – intubate early if significant injuries because airway can be dynamic. Don’t just intubate if singed nose hairs – look for respiratory distress, stridor, hoarseness 
  • Overestimate of BSA leads to excess fluid administration
    • Use Lund-Browder chart
    • Patient hand as an estimate, hand with fingers approximately 1%
  • Parkland may overestimate fluids needed
    • 4ml/kg x %TBSA x body weight in kg
      • First ½ in 8 hours, the second ½ in 16 hours
    • Use Parkland for first 8 hours then titrate fluids to urine output of 0.5ml/kg 
  • Aggressive pain management is key
    • Consider ketamine if concomitant traumatic injury
  • Who to transfer to Burn Center
    • Full Thickness burns
    • Partial thickness burn >10%
    • Burns to hand, face, genitalia, major joints, electrical/chemical burn, inhalation injury or special social needs

For More on These Topics Checkout:

Shownotes Written By: Miguel Reyes, MD (Twitter: @miguel_reyesMD)

Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter: @srrezaie)

Cite this article as: Anand Swaminathan, "REBEL Core Cast 28.0 – Conference Pearls", REBEL EM blog, February 26, 2020. Available at:
The following two tabs change content below.

Anand Swaminathan

Clinical Assistant Professor of Emergency Medicine at St. Joe's Regional Medical Center (Paterson, NJ)
REBEL EM Associate Editor and Author

Latest posts by Anand Swaminathan (see all)

Like this article?

Share on facebook
Share on Facebook
Share on twitter
Share on Twitter
Share on linkedin
Share on Linkdin
Share on email
Share via Email

Want to support rebelem?