Wednesday Wrap-Up 10/10/18 - Local Anesthetics and Salicylate Toxicity

Welcome to our weekly Wednesday Wrap-Up from our academic conference today:

Dr. Jesus Granados discussed how to eat better as residents:

Dr. Sage Wiener discussed local anesthetics:

Local anesthetics like lidocaine are sodium channel blockers, so overdose leads to neurological and cardiac toxicity
If severe toxicity – use lipid emulsion therapy; go to lipidrescue.org to see how to give it
Two i’s in the name = amide, not ester; if patient is allergic to ester, they are allergic to all esters, so use an amide; if allergic to an amide they are only allergic to that drug, so can give any other drug
Use 1% lidocaine (not 2%) for most (if not all) procedures as it achieves adequate analgesia without risk of overdose
1% lidocaine = 1g/100 mL or 10 mg per mL
Max dose of lidocaine is 3 mg/kg without epinephrine; 5-7 mg/kg with epinephrine
If you get stuck with an epipen in the finger – use hot packs; can inject phentolamine or apply nitro paste
If you think the wound will need anesthesia for a long time, use bupivicaine (lasts 200+ minutes)
Apply cetacaine spray dose for 1 second, any more can cause methemoglobinemia
Pulse ox will go to 85% and stay there for significant methemoglobinemia – have to get an ABG

Dr. Antonia Quinn discussed how to teach a skill:

Teaching is not telling, don’t sit and regurgitate all the great knowledge you have learned in your life
Break down the procedure into several micro-skills
Go slow – accuracy is everything when first learning a skill
Let them struggle – don’t grab the ultrasound probe away so quick

Dr. Ted Segarra gave our EM-Critical Care Medicine lecture on salicylate toxicity:

High dose of salicylates uncouples the electron transport chain resulting in heat and lactic acid production
Symptoms: UNEXPLAINED TACHYPNEA with respiratory alkalosis, elevated temperature and nausea —> metabolic acidosis —> altered mental status —> coma —> death
Alkalinization of the serum and urine using sodium bicarbonate is key to management: this changes salicylate to ionized form which prevents it from crossing BBB or being reabsorbed by kidneys
Sodium bicarbonate drip: mix with D5 as these patients often become hypoglycemic; use urine output and pH to guide infusion rate
Give potassium: must have normal K to enable salicylate excretion in urine
For seizure – give benzodiazepine AND bicarbonate bolus
Hemodialysis indications: salicylate 90 to 100 mg/dL, signs of end organ damage (AMS, AKI, hypoxia), shock, hypoxia
Beware of intubation: these patients rely on maintaining their very high levels of minute ventilation to keep their pH up; it is difficult to match this MV with mechanical ventilation — try NIV first
ECMO? Exchange transfusion?

Wednesday Wrap-Up 10/10/18 – Local Anesthetics and Salicylate Toxicity