In this episode, we tackle STEMI mimics—conditions that mimic ST-segment elevation myocardial infarction on an EKG but aren’t always a heart attack.

Why’s it critical? Because ST elevation doesn’t always mean STEMI, and misdiagnosis can waste time or miss critical conditions.

ELEVATION

Electrolytes (Hyperkalemia),

Left Bundle Branch Block,

Early Repolarization,

Ventricular Hypertrophy (Left),

Aneurysm (Ventricular),

Thailand (Brugada Syndrome),

Inflammation (Pericarditis),

Osborn J Wave,

Non-Ischemic Vasospasm

We use the ELEVATION mnemonic to guide you through each mimic with clear explanations, repeated key points, and rapid-fire quizzes to lock in your recall.

How to Mix Push-dose Epi: One out, one in — makes ten

Goal concentration: 10 mcg/mL

Step-by-Step Mixing:

1. Start with a 10 mL syringe of normal saline (NS)

• empty 1 mL to retain 9 mL of NS in the syringe.

2. Use the code cart 1:10,000 epi (100 mcg/mL)

• This is the standard “cardiac arrest epi” amp (usually 1 mg in 10 mL)…the 1:10,000 prefilled syringe used during ACLS

3. Withdraw 1 mL of the 1:10,000 epi (this gives you 100 mcg) using 3 mL syringe.

4. Inject that 1 mL (100 mcg) into your syringe of 9 mL NS.

• Now you have 10 mL of epinephrine at 10 mcg/mL — ready to use.

So what we just did is the mnemonic: One out, one in — makes ten

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• What’s the concentration of the code cart epi?

• How much do you withdraw?

• What do you inject it into?

• What’s the final concentration?

You should be able to say it out loud, now. If not — just repeat the podcast a couple of times to get it solid.

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How to Administer:

• Dose: 1–2 mL IV push every 1–5 minutes PRN hypotension

• That’s 5 to 20 micrograms per dose — meaning 0.5 to 2 mL of your push-dose epi, depending on the patient’s response.

• Titrate to clinical effect (aim for MAP >65 or ROSC support)

E-MOTIVE Mnemonic for Postpartum Hemorrhage: A Lifesaving Strategy

The E-MOTIVE mnemonic stands for a six-component bundle aimed at tackling postpartum hemorrhage (PPH), a major cause of maternal death, especially in low-resource settings. This approach, tested in a cluster-randomized trial across 80 hospitals in Kenya, Nigeria, South Africa, and Tanzania, was published in the New England Journal of Medicine in 2023. Here’s what E-MOTIVE stands for and why it matters:

• E – Early Detection: Uses a calibrated blood-collection drape to objectively measure blood loss after vaginal delivery. This ensures PPH (blood loss ≥500 ml) is identified quickly and accurately, unlike visual estimation, which can be unreliable.

• M – Massage: Uterine massage is performed to stimulate contractions and control bleeding, particularly for uterine atony, the most common cause of PPH.

• O – Oxytocic Drugs: Administers drugs like oxytocin to promote uterine contractions and reduce bleeding. These are critical for managing uterine atony effectively.

• T – Tranexamic Acid: An antifibrinolytic drug given to stabilize clots and reduce bleeding, especially when administered early after PPH onset.

• I – Intravenous Fluids: Provides fluids to maintain blood volume and prevent shock in women experiencing significant blood loss.

• V – Vaginal Examination and Escalation: Involves a thorough genital tract exam to identify trauma or retained tissue, with escalation to surgical or advanced care if bleeding persists.

• E – Effective Teamwork: Emphasizes communication, cooperation, and rapid response among healthcare providers to ensure all components are delivered promptly.

Why It’s a Game-Changer: The trial showed that E-MOTIVE reduced the risk of severe PPH (blood loss ≥1000 ml), laparotomy for bleeding, or maternal death by 60% compared to usual care.

PPH was detected in 93.1% of cases in the intervention group versus 51.1% in the control group, and the treatment bundle was used in 91.2% of cases versus 19.4%.

This bundle ensures evidence-based interventions are applied consistently and concurrently, saving lives by addressing PPH faster and more effectively.

E-MOTIVE is a practical, scalable solution, especially for low- and middle-income countries where PPH is deadliest. Its use of low-cost tools like the blood-collection drape makes it accessible, while the mnemonic simplifies training and implementation for healthcare teams under pressure.

This summary is based on the New England Journal of Medicine article.

This is a Neonatal Resuscitation Algorithm flowchart, specifically the NRP (Neonatal Resuscitation Program), published by the AHA in 2020. It provides a step-by-step guide for healthcare providers to follow during the resuscitation of a newborn immediately after birth, focusing on stabilizing the infant’s breathing, heart rate, and oxygenation.

Starting Point

• Antenatal Counseling and Team Briefing: Before birth, the team prepares and checks equipment.

• Birth: The process begins at the moment of birth.

Initial Assessment (Within the First Minute)

1 Term Gestation? Good Tone? Breathing or Crying?

◦ If Yes: The infant stays with the mother for routine care (warming, maintaining normal temperature, positioning airway, clearing secretions if needed, drying, and ongoing evaluation).

◦ If No: Proceed to resuscitation steps.

2 Apnea or Gasping? HR Below 100/min?

◦ If Yes:

▪ Start PPV (Positive Pressure Ventilation) using a SpO₂ monitor and consider an ECG monitor.

▪ Check if the heart rate (HR) is still below 100/min after PPV.

◦ If No:

▪ Check for Labored Breathing or Persistent Cyanosis.

3 Labored Breathing or Persistent Cyanosis?

◦ If Yes:

▪ Position and clear the airway, monitor SpO₂, and provide supplementary O₂ as needed. Consider CPAP (Continuous Positive Airway Pressure).

▪ Follow up with post-resuscitation care and team debriefing.

◦ If No: Continue with routine care as described earlier.

Further Resuscitation (If HR Remains Low)

4 HR Below 100/min After PPV?

◦ If Yes:

▪ Check chest movement and take corrective ventilation steps if needed (e.g., using an endotracheal tube (ETT) or laryngeal mask).

◦ If No: Monitor and continue care.

5 HR Below 60/min?

◦ If Yes:

▪ Intubate if not already done.

▪ Start chest compressions coordinated with PPV using 100% O₂.

▪ Use an ECG monitor and consider an umbilical venous catheter (UVC) for access.

◦ If No: Continue monitoring.

6 HR Still Below 60/min After Compressions?

◦ If Yes:

▪ Administer IV Epinephrine.

▪ If HR remains persistently below 60/min, consider hypovolemia (low blood volume) or pneumothorax (collapsed lung) as potential causes.

Additional Information

• Targeted Preductal SpO₂ After Birth: The chart lists target oxygen saturation (SpO₂) levels for a newborn at different time intervals post-birth:

◦ 1 min: 60%–65%

◦ 2 min: 65%–70%

◦ 3 min: 70%–75%

◦ 4 min: 75%–80%

◦ 5 min: 80%–85%

◦ 10 min: 85%–95%

Context

This algorithm is used in clinical settings, particularly in delivery rooms or neonatal intensive care units (NICUs), to guide healthcare providers in managing newborns who aren’t breathing adequately or have a low heart rate at birth. It emphasizes rapid assessment and intervention to ensure the infant stabilizes within the critical first minutes of life.

The 3-Step Approach to Acute Hyperkalemia

1. Stabilize: the Heart (If ECG changes) → Calcium

2. Shift: K+ Into Cells → Insulin + Glucose, Albuterol, Bicarb (if acidotic)

3. Send-it: Remove K+ From Body → Diuretics (if making urine), Kayexalate (if GI motility intact), Dialysis (if severe/refractory)

I – IV Fluids

C – Calcium

B – Beta-2 Agonists

B – Bicarbonate

I – Insulin & Glucose

K – Kayexalate (Sodium Polystyrene Sulfonate)

D – Diuretics

D – Dialysis

1. First Step: Assess ECG & Risk of Arrhythmia

• Peaked T waves, QRS widening, sine wave = Give Calcium ASAP

• Calcium doesn’t lower K+, but it prevents cardiac arrest.

2. Temporary vs. Definitive Treatments

• Shifting K+ into cells (Beta-agonists, Bicarb, Insulin) buys time.

• Excreting K+ (Diuretics, Dialysis, Kayexalate) removes K+.

3. Timing of Interventions:

• Calcium: Immediate (stabilizes heart).

• Insulin/Albuterol/Bicarb: 15–30 min (shifts K+).

• Diuretics/Kayexalate: 1–6 hours (removes K+).

• Dialysis: Immediate, definitive.

4. Common Pitfalls & Pro Tips

• Insulin can cause hypoglycemia – recheck glucose in 30 minutes.

• Albuterol requires high doses – typical 2.5 mg nebs won’t cut it.

• Bicarb only works if acidotic – don’t rely on it in normotensive patients.

• Kayexalate is slow & controversial – consider patiromer or zirconium cyclosilicate instead in chronic cases.

• If oliguric or ESRD → Straight to dialysis.

USED CARS mnemonic for non-anion gap metabolic acidosis (NAGMA):

Why “USED CARS”?

• Ureterosigmoidostomy

• Saline & Chloride infusion (excessive).. chloride offsets AG

• Endocrine disorders (Addison’s disease aka adrenal insufficiency, hypoaldosteronism)

• Diarrhea

• Carbonic anhydrase inhibitors

• Ammonium chloride

• Renal tubular acidosis

• Spironolactone

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U – Ureteroenteric fistula (or diversion surgery)

• Why NAGMA?

• Ureter attached directly to colon; bicarbonate lost into bowel, chloride absorbed, causing hyperchloremic acidosis.

• Symptoms:

• History of bladder/colon surgery, urine-like smell from stool, chronic acidosis.

• Labs: Normal AG, elevated chloride, chronic metabolic acidosis.

• ED Management:

• Identify, refer to urology or general surgery for definitive repair.

• Correct electrolyte disturbances (usually potassium, bicarbonate).

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S – Saline Infusion (Excessive)

• What: Excessive infusion of normal saline (0.9% NaCl).

• Why (Pathophysiology): High chloride content of NS dilutes bicarbonate → hyperchloremic metabolic acidosis (common in hospitalized patients).

• Symptoms: Usually subtle (fatigue, mild confusion, fluid overload signs).

• Labs: Normal AG, hyperchloremia, normal renal function initially.

• ED Management:

• Switch to balanced solutions (Lactated Ringer’s, Plasmalyte).

• Monitor fluid and electrolyte balance.

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E – Endocrine Disorders (Addison’s Disease/Adrenal Insufficiency):

• Why: Lack of aldosterone = inability to excrete acid & retain sodium.

• Clinical Clues: Weakness, fatigue, low BP, dizziness, hyperpigmentation (skin darkening), abdominal pain.

• Labs: Low sodium, high potassium, normal anion gap, metabolic acidosis.

• ED Management:

• IV fluids (Normal saline), hydrocortisone, monitor electrolytes closely.

• Admit for adrenal crisis management.

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D – Diarrhea

• Pathophysiology: Loss of bicarbonate-rich fluids via stool → bicarbonate depletion.

• Clinical Clues: Frequent watery stools, dehydration signs (tachycardia, low BP).

• Labs: Normal anion gap, hypokalemia common, hyperchloremia.

• ED Management:

• Aggressive fluid resuscitation (often NS or LR).

• Electrolyte replacement (especially potassium).

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C – Carbonic Anhydrase Inhibitors (Acetazolamide)

• Mechanism: Prevent bicarbonate reabsorption → bicarbonate loss → acidosis.

• Clinical clues: Medication history (glaucoma treatment, altitude sickness prophylaxis, idiopathic intracranial hypertension).

• Labs: Normal AG, mild hypokalemia, mild hyperchloremia.

• ED Management:

• Stop offending medication, supportive care, and electrolyte replacement.

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A – Ammonium Chloride Ingestion

• Mechanism: Direct chloride ingestion overwhelms bicarbonate buffers.

• Rare cause today, often historical or industrial exposure.

• Clinical clues: History of ingestion, occupational exposures, metabolic symptoms (nausea, vomiting, confusion).

• Labs: Normal AG, hyperchloremia.

• ED Management:

• Supportive care, stop exposure.

• Correct metabolic acidosis if severe (sodium bicarbonate IV if severe).

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R – Renal Tubular Acidosis (RTA)

• Mechanism: Kidneys fail to reabsorb bicarbonate or excrete acid properly.

• Bicarbonate replacement.

• Potassium correction (careful monitoring).

• Referral to nephrology.

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R – Renal Tubular Acidosis (Already covered above)

• Included in detail in the “A” section, given its complexity.

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S – Spironolactone (and other Aldosterone Antagonists)

• Mechanism: Blocks aldosterone receptors → reduced acid and potassium excretion.

• Clinical clues:

Use in CHF, cirrhosis, hypertension treatment.

• Hold spironolactone, manage hyperkalemia aggressively (calcium gluconate, insulin/dextrose, albuterol, kayexalate).

• Consider bicarbonate if severely acidotic.

The GOLD MARK causes are divided into three major pathophysiologic groups based on the source of the acid production:

1. Alcohols (Toxic Ingestions) → Emergency Toxins

• Glycols → Ethylene glycol (antifreeze) and propylene glycol

• Methanol → Windshield washer fluid, homemade alcohol substitutes

• Why grouped together?

• Common in suicide attempts, accidental ingestions, or chronic alcoholics.

• Key labs: Serum osmolality, anion gap, osmolar gap.

• Imaging: Calcium oxalate crystals on urine microscopy (ethylene glycol).

• Treatment: Fomepizole or ethanol (blocks alcohol dehydrogenase), hemodialysis in severe cases.

2. OTCs & Medication-Related Causes → Common but Easily Missed

• Oxoproline → Chronic acetaminophen (Tylenol) use, often in malnourished patients

• Aspirin → Salicylates, including bismuth subsalicylate (Pepto-Bismol)

• Why grouped together?

• Often overlooked in chronic users or the elderly.

• Key signs: Tachypnea (respiratory alkalosis), tinnitus (aspirin), altered mental status.

• Key labs: Salicylate level, ABG (mixed acid-base disorder).

• Treatment: Alkalinization (sodium bicarb drip), dialysis for severe cases.

3. Metabolic Causes → Endogenous Acid Production

• L-lactate → Type A (ischemia), Type B (mitochondrial dysfunction)

• D-lactate → Short gut syndrome, bacterial overgrowth

• Renal Failure → Uremia, organic acids

• Ketones → Starvation, alcohol, diabetic ketoacidosis (DKA)

• Why grouped together?

• These involve internal production of acids due to organ dysfunction.

• Key labs:

• Lactate level (for sepsis, ischemia).

• BHB (beta-hydroxybutyrate) for DKA.

• BUN/Cr for renal failure.

• Urinalysis (ketones, glucose, uremia markers).

• Treatment:

• Fluids, treat underlying cause (DKA → insulin drip, renal failure → dialysis).

Clinically Important Considerations for EM Physicians

In the ED, when a patient has metabolic acidosis with an elevated anion gap, think:

1. What is the patient’s history?

• Suicide attempt or confusion? → Alcohols, aspirin

• Chronic Tylenol use or malnourished? → Oxoproline

• Sepsis, shock, ischemia? → L-lactate

• Short gut, diarrhea, recent antibiotics? → D-lactate

• Known diabetes, alcoholism, or fasting? → Ketones

• Chronic kidney disease? → Uremia

2. What tests should I order immediately?

• ABG/VBG → Confirms metabolic acidosis.

• Anion gap calculation → Determines if the acidosis is anion gap or non-anion gap.

• Serum osmolality & osmolar gap → Alcohol toxicity (ethylene glycol, methanol).

• Lactate level → Sepsis, ischemia, mitochondrial dysfunction.

• BHB (Beta-hydroxybutyrate) → DKA vs. alcoholic/starvation ketosis.

• Salicylate level & acetaminophen level → Toxic ingestion screening.

• CMP (BUN/Cr, glucose, liver enzymes, electrolytes) → Renal failure, DKA, liver dysfunction.

Takeaway: What’s an Emergency?

• Dialysis Emergencies → Methanol, ethylene glycol, severe aspirin toxicity, uremia.

• Toxin Emergencies → Alcohols (treat with fomepizole), salicylates (alkalinization & dialysis).

• Septic Shock / Tissue Hypoxia → Elevated L-lactate = immediate resuscitation with fluids & source control!

• DKA → Fluids, insulin drip, and monitor for electrolyte shifts (esp. potassium).

Mister Ronald McDonald (MR RM) is a helpful flowchart for interpreting acid-base disorders, specifically for determining whether a patient’s condition is due to a metabolic (M) or respiratory (R) cause:

1. Check the pH (7.4 is the cutoff)

• pH > 7.4 → Alkalosis

• pH < 7.4 → Acidosis

2. Assess Carbon Dioxide (CO₂) Levels (PaCO₂)

• The key threshold is 40 mmHg:

• If CO₂ > 40 mmHg, this suggests respiratory acidosis or metabolic alkalosis.

• If CO₂ < 40 mmHg, this suggests respiratory alkalosis or metabolic acidosis.

3. Determine the Cause

• In Alkalosis:

• If CO₂ > 40, the cause is Metabolic (M) Alkalosis.

• If CO₂ < 40, the cause is Respiratory (R) Alkalosis.

• In Acidosis:

• If CO₂ > 40, the cause is Respiratory (R) Acidosis.

• If CO₂ < 40, the cause is Metabolic (M) Acidosis.

Key Takeaway

• The chart helps determine whether a patient’s acid-base imbalance is due to a metabolic or respiratory cause by analyzing pH and CO₂ levels.

To determine if the patient requires admission or can be discharged, the Glasgow-Blatchford Score (GBS) is used.

Here’s the ABCDEF mnemonic and why these factors increase the risk of an upper GI bleed:

• ​ A - Active: Conditions like syncope or melena indicate ongoing or significant bleeding, increasing risk severity.

• ​ B - Blood Urea Nitrogen: Levels ≥ 7 mg/dL suggest impaired kidney function, which is often associated with poor systemic clearance and bleeding risk.

• ​ C - Circulation: A systolic blood pressure ≥ 110 mm Hg may reflect hemodynamic instability or stress response to bleeding.

• ​ D - Drop in Hemoglobin: Hemoglobin levels ≤ 12.9 g/dL (men) or ≤ 11.9 g/dL (women) indicate anemia, suggesting significant blood loss.

• ​ E - Elevated Pulse: A pulse rate ≥ 100/min signals compensatory tachycardia, often a response to blood loss.

• ​ F - Failure: Cardiovascular or liver disease impairs clotting and hemodynamic stability, exacerbating bleed risk.

Developed in Scotland, the GBS is a risk assessment tool for upper GI bleeds and considers symptoms, vital signs, and lab values on admission. Key factors in the score include melena, syncope, liver disease, heart failure, heart rate, blood pressure, hemoglobin, and BUN levels. Points are assigned based on these variables to assess the severity of bleeding and volume loss.

For example:

• ​Melena suggests significant GI bleeding, whereas isolated hematemesis (like coffee-ground emesis) has no scoring points.
• ​Syncope, tachycardia, hypotension, and changes in Hb/BUN levels suggest volume loss.
• ​Comorbid conditions (e.g., liver disease) may indicate a need for admission, especially if variceal bleeding is suspected.

Discharge criteria also include access to follow-up care, a support system, and a nearby hospital for emergency returns if symptoms worsen.

For more on current recommendations, consult the 2021 American Journal of Gastroenterology guidelines on upper GI bleeding.

CENTOR criteria Fever PAIN: Strep Throat mnemonic

The “H’s and T’s” refer to a mnemonic used in medicine to help healthcare professionals quickly recall the most common causes of cardiac arrest during a code (a medical emergency requiring CPR). Memorizing these is crucial because identifying and addressing these causes rapidly can improve the chances of saving a patient’s life.

Here’s a breakdown:

The H’s: OK TV

Hypoxia - Lack of oxygen to tissues can lead to a heart stopping, so ensuring proper oxygenation is key.

Hypo-/Hyperkalemia - Abnormal potassium levels affect the heart’s electrical activity, potentially causing it to stop.

Hypothermia - Low body temperature can slow heart function and lead to cardiac arrest.

Hypovolemia - Loss of blood or fluids can lead to insufficient circulation and cardiac arrest.

Hydrogen ion (acidosis) - A build-up of acid in the blood (often due to respiratory failure or shock) can disrupt heart function.

The T’s: THROW TEN TOXIC TAMPONS

Thrombosis (pulmonary or coronary) - Blood clots in the lungs (pulmonary embolism) or heart (myocardial infarction) can obstruct blood flow, leading to cardiac arrest.

Tension Pneumothorax - Air trapped in the chest cavity compresses the heart and lungs, affecting circulation.

Toxins - Certain substances (medications, drugs, poisons) can disrupt heart rhythms.

Tamponade (cardiac) - Accumulation of fluid around the heart prevents it from pumping effectively.

Importance of Memorizing the H’s and T’s:

These causes cover many reversible conditions that may lead to cardiac arrest. During a code, time is critical, so having these potential causes at the top of your mind helps quickly assess and treat the patient. Remembering the “H’s and T’s” mnemonic ensures that a healthcare provider methodically works through possible causes and provides the best chance of resuscitation.

These are the adventitious lung sounds Mneumonics.

Strider:

Everyone can take in stride.

Crackles:

A fine chap with firecrackers.

Wheezing:

Just ask any whale: Can you HAC the wheeze?

Rhonchi:

I BOPped the wrong guy

Plural friction rub:

PPP (3 words 3 P’s)

The “KEEP” mnemonic is a tool to remember the most common organisms causing urinary tract infections (UTIs). Here’s how the mnemonic breaks down, followed by key information relevant for emergency medicine boards:

K - Klebsiella species

• Relevance: Klebsiella is the second most common organism causing UTIs, especially hospital-acquired infections.

• Key Points:

• Gram-negative rod.

• Often seen in patients with underlying conditions like diabetes, or those with urinary catheters.

• Resistant to many antibiotics, so susceptibility testing is important.

• Treatment Options: Cephalosporins (like ceftriaxone), carbapenems in resistant cases.

E - Escherichia coli (E. coli)

• Relevance: The most common organism causing both community-acquired and some hospital-acquired UTIs.

• Key Points:

• Gram-negative rod.

• Responsible for approximately 70-90% of uncomplicated UTIs.

• Often originates from the gut.

• Can exhibit antibiotic resistance, particularly to trimethoprim-sulfamethoxazole.

• Treatment Options: Trimethoprim-sulfamethoxazole (Bactrim), nitrofurantoin, fosfomycin, or ciprofloxacin based on resistance patterns.

E - Enterococcus species

• Relevance: More common in complicated UTIs, particularly in hospital settings.

• Key Points:

• Gram-positive cocci.

• Often found in patients with catheters, immunocompromised status, or structural abnormalities in the urinary tract.

• Can be resistant to many antibiotics, including vancomycin-resistant Enterococcus (VRE).

• Treatment Options: Ampicillin or amoxicillin when susceptible; for resistant cases, vancomycin or linezolid.

P - Proteus species

• Relevance: Known for causing complicated UTIs and is associated with kidney stones.

• Key Points:

• Gram-negative rod.

• Produces urease, which increases urine pH and can lead to the formation of struvite stones.

• Can cause upper UTIs and is known to colonize catheters.

• Treatment Options: Ciprofloxacin, trimethoprim-sulfamethoxazole, cephalosporins; nitrofurantoin is usually not effective.

Summary of the Mnemonic ‘KEEP’

• Klebsiella: Second most common UTI organism; hospital-acquired; antibiotic resistance common.

• E. coli: Most frequent cause of UTIs; community-acquired; potential resistance to some antibiotics.

• Enterococcus: Complicated and hospital-acquired UTIs; often found in patients with urinary abnormalities.

• Proteus: Associated with kidney stones; catheter-related UTIs; produces urease.

By remembering “KEEP,” you can recall the key organisms responsible for UTIs and their relevance to diagnosis and treatment in emergency settings.

The **SPIT** mnemonic is used to help remember common causes of **altered mental status in children**. Here's what each letter stands for:

- **S**eizures: Includes both febrile and non-febrile seizures that can cause confusion or unconsciousness.

- **P**oisoning: Exposure to toxins or ingestion of substances like medications, household chemicals, or recreational drugs.

- **I**nfections: Infections such as meningitis, encephalitis, sepsis, or any systemic infection that can lead to altered mental status.

- **T**rauma: Head injuries, concussions, or other physical trauma leading to changes in consciousness.

This mnemonic helps quickly identify potential life-threatening causes of altered mental status in a pediatric patient.

Procedure Timeout Mnemonic:

This mnemonic covers the key elements to verify before starting, ensuring patient safety and team communication. Here's what **IMPACTS** stands for:

1. **I – Identify**:

- **Verify the Patient's Identity**: Confirm the patient's full name, date of birth, and medical record number using their wristband and verbally with the patient if possible.

2. **M – Match the Procedure**:

- **Verify the Procedure Being Done**: State the exact name of the procedure to be performed. Ensure the team agrees, and that it matches the consent form and the patient's understanding.

3. **P – Position and Site**:

- **Verify the Correct Site, Side, and Patient Positioning**:

- Mark the **correct site** and **laterality** if applicable (e.g., right arm, left knee).

- Confirm the patient's **positioning** on the table (supine, prone) to avoid confusion during the procedure.

4. **A – Allergies**:

- **Confirm Allergies**: Double-check any known allergies (medications, latex, iodine) and ensure the team is aware so appropriate precautions can be taken.

5. **C – Consent**:

- **Verify Consent**: Ensure that **informed consent** has been obtained, signed, and documented. Confirm that the patient or guardian understands the risks, benefits, and alternatives to the procedure.

6. **T – Tools and Equipment**:

- **Check Equipment and Instruments**: Make sure all necessary instruments, tools, and medications are prepared, functional, and sterile. Have backup supplies ready as well.

7. **S – Staff Roles and Safety Concerns**:

- **Assign and Confirm Roles**: Ensure each team member knows their specific role during the procedure.

- **State Safety Concerns**: Allow a moment for the team to voice any concerns or potential issues before proceeding.

Using **IMPACTS** ensures that all the critical components are reviewed before starting a procedure, enhancing both patient safety and team coordination.

This is the CATS mnemonic to remember the signs for hypocalcemia.

### **Causes of Hypocalcemia**

- **Hypoparathyroidism**: Often due to surgical removal of parathyroid glands.

- **Vitamin D deficiency**: Impaired calcium absorption.

- **Renal disease**: Reduced conversion of Vitamin D to its active form and poor calcium reabsorption.

- **Pancreatitis**: Fat saponification binds calcium.

- **Hypomagnesemia**: Leads to impaired PTH secretion.

- **Medications**: Bisphosphonates, loop diuretics, phenytoin, etc.

### **Clinical Presentation**

- **Neuromuscular Irritability**:

- **Tetany**: Involuntary muscle contractions (e.g., carpopedal spasms).

- **Paresthesias**: Numbness, tingling around the mouth, fingers, and toes.

- **Seizures**: Can be a presenting symptom.

- **Chvostek's Sign**: Facial twitching when tapping the facial nerve.

- **Trousseau’s Sign**: Carpal spasm when inflating a blood pressure cuff above systolic pressure for 3 minutes.

### **EKG Findings in Hypocalcemia**

- **Prolonged QT Interval**: Due to delayed ventricular repolarization.

- Risk for **Torsades de Pointes** if significantly prolonged.

- **Bradycardia and Heart Block**: May be seen in severe cases.

### **Management of Hypocalcemia**

1. **Asymptomatic or Mild Hypocalcemia**:

- Oral calcium supplements (e.g., calcium carbonate).

- Vitamin D supplementation (if deficient).

2. **Severe or Symptomatic Hypocalcemia (e.g., seizures, tetany, prolonged QT)**:

- **IV Calcium Gluconate** or **Calcium Chloride** (more potent but more irritating to veins).

- **Magnesium Replacement**: If low magnesium is present, replace it to aid calcium levels.

3. **Monitor for Cardiac Arrhythmias**: Especially if administering IV calcium.

### **Associated Conditions to Remember**

- **Hypoalbuminemia**: Can lead to low total calcium, but ionized (free) calcium may be normal.

- **Renal Failure**: Leads to high phosphate, low active Vitamin D, and thus low calcium.

- **Pseudohypocalcemia**: Low total calcium but normal ionized calcium, usually related to hypoalbuminemia.

Understanding these clinical features, causes, and management strategies, alongside the EKG findings, is crucial for emergency medicine board preparation and practice.

In emergency medicine education, understanding the fat-soluble vitamins A, D, E, and K (ADEK) is important because they play crucial roles in the body, and both their deficiency and toxicity can have serious health consequences. Here's a breakdown:

### Vitamin A:

- **Function**: Important for vision, immune function, and skin health.

- **Deficiency**: Can lead to night blindness, dry eyes, and increased infection risk.

- **Toxicity**: Excessive intake can cause symptoms like headache, dizziness, nausea, and liver damage (known as hypervitaminosis A).

### Vitamin D:

- **Function**: Key for calcium absorption, bone health, and immune system regulation.

- **Deficiency**: Causes bone disorders such as rickets in children and osteomalacia in adults, leading to weak or soft bones. It may also increase the risk of fractures.

- **Toxicity**: Overconsumption can lead to hypercalcemia (high calcium levels), resulting in confusion, abdominal pain, kidney stones, or even kidney failure.

### Vitamin E:

- **Function**: Acts as an antioxidant, helping protect cells from damage.

- **Deficiency**: Rare, but can result in neurological issues such as muscle weakness, vision problems, and impaired immune function.

- **Toxicity**: Large doses can interfere with blood clotting and increase the risk of bleeding, especially if the person is also taking blood-thinning medications.

### Vitamin K:

- **Function**: Essential for blood clotting and bone health.

- **Deficiency**: Can lead to bleeding disorders, as the body cannot clot blood effectively.

- **Toxicity**: Generally low risk because the body does not store much vitamin K, but supplementation can interfere with anticoagulant medications like warfarin.

**Emergency Medicine Takeaways**:

1. **Deficiency and Toxicity**: Be aware that both deficiency and toxicity can present with acute symptoms that may require immediate intervention.

2. **Drug Interactions**: Especially for vitamin K, consider how vitamin intake can interact with medications like anticoagulants.

3. **High-Risk Populations**: Pay attention to populations at higher risk of deficiencies, such as those with malabsorption issues (e.g., celiac disease, cystic fibrosis) or those with poor dietary intake.

4. **Fat Solubility and Storage**: Since these vitamins are fat-soluble, they are stored in the body and can accumulate over time, making toxicity a more significant risk compared to water-soluble vitamins.

Understanding these factors helps in diagnosing and treating patients who present with symptoms related to these vitamins, ensuring proper care and avoiding potential complications.

The C-MOPS mnemonic represents conjunctivitis, meningitis, otitis media, pneumonia and sinusitis.

Streptococcus pneumoniae classically causes rusty colored sputum, which can help identify the pathogen.