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

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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:

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