AIR Series: Toxicology Module 2015

ALiEM-AIR-Badge only 200x200Welcome to the sixth ALiEM Approved Instructional Resources (AIR) Module! In an effort to reward our residents for the reading and learning they are already doing online we have created an Individual Interactive Instruction (III) opportunity utilizing FOAM resources for U.S. Emergency Medicine residents. For each module, the AIR board curates and scores a list of blogs and podcasts. A quiz is available to complete after each module to obtain residency conference credit. Once completed, your name and institution will be logged into our private Google Drive database, which participating residency program directors can access to provide proof of completion.

AIR Stamp of Approval and Honorable Mentions

In an effort to truly emphasize the highest quality posts, we have two subsets of recommended resources. The AIR stamp of approval will only be given to posts scoring above a new, strict scoring cut-off of ≥30 points (out of 35 total), based on our scoring instrument. The other subset is for “Honorable Mention” posts. These posts have been flagged by and agreed upon by AIR Board members as worthwhile, accurate, unbiased, and appropriately referenced despite an average score <30. All posts will still be part of the quiz needed to obtain III credit.

AIR Series: Toxicology

Below we have listed our selection of the 13 highest quality blog posts within the past 12 months (current as of December 2014) related to Toxicology, curated and approved for residency training by the AIR Series Board. In this module we have 6 AIRs and 7 Honorable Mentions. We strive for comprehensiveness by selecting from a broad spectrum of blogs from the top 50 listing per the Social Media Index.

After reading, please take the quiz. Feel free to ask questions in the blog comment section below. The AIR Board faculty will answer them within 48 hours of posting. Be sure to include your email or contact information where requested in the Disqus blog comment area, so that you will be notified when we reply. We recommend programs give 4 hours (just over 20 minutes per article) of III for this module.


Article TitleAuthorDateLinkCategory
Management of Iron ToxicityMary A. Wittler, MDAugust 6, 2014ALiEM: Iron ToxicityApproved Instructional Resource
5 Tips in Managing Acute Salicylate PoisoningKristin Fontes, MD|November 4, 2013ALiEM: Salicylate ToxicityApproved Instructional Resource
Valproic Acid-Induced Hyperammonemic EncephalopathyJill Logan, PharmD BCPSOctober 16, 2014ALiEM: Valproic Acid ToxicityApproved Instructional Resource
Podcast 98 – Cyclic (Tricyclic) Antidepressant OverdoseScott Weingart, MDMay 1, 2014EMCrit: TCA ToxicityApproved Instructional Resource
Carbon Monoxide Poisoning: Common Questions and DilemmasDan Repplinger, MD|December 23, 2013ALiEM: CO ToxicityApproved Instructional Resource
Cyclobenzaprine vs TCA ToxicityJill Logan, PharmD BCPSFebruary 13, 2014ALiEM: Cyclobenzaprine Vs TCAApproved Instructional Resource
Are Acetaminophen Levels Necessary in All Overdose Patients?Bryan D. Hayes, PharmD, FAACT September 4th, 2013ALiEM: Acetaminophen LevelsHonorable Mention
6 Pearls About Metformin and Lactic AcidosisLeon Gussow, ED February 13, 2014, 4:00 pmThe Poison Review: Metformin and Lactic AcidosisHonorable Mention
Boring Question: Does this medication cause prolonged QTc?Jatin Kaicker, MDSeptember 8, 2014Boring EM: Prolonged QTcHonorable Mention
PV Card: Local anesthetic toxicity calculationsDavid MurphyJune 13, 2014ALiEM: Anesthetic OverdoseHonorable Mention
Cardiac Arrest After the Toxicology of Smoke InhalationScott Weingart, MDApril, 2014EMCrit: Smoke InhalationHonorable Mention
Methadone in the EDAndy Neill, MD February 2, 2014EM Ireland: MethadoneHonorable Mention
Really wide QRS, Pt found down with WCTAmal Mattu, MD, FACEP September 8, 2014UMEM ECG: WCTHonorable Mention


Take the quiz below, or click HERE to take you to the quiz site.
Be sure to enter your name and program, if you desire III credit.

Do you belong to a residency program that is not currently participating? No problem! Any one can read the AIR series curated post and complete the quiz for educational value!

If a residency program is interested in participating, please contact us!

Author information

Andrew Grock, MD

Andrew Grock, MD

Associate Director/Co-Founder of ALiEM Approved Instructional Resources (AIR)

PGY-4 EM resident

Kings County Hospital Emergency Medicine Residency

The post AIR Series: Toxicology Module 2015 appeared first on ALiEM.

the important things are close by.

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In the past, I thought the important things were far away from me. I worked hard and thought hard every day in order to get to those important things. But soon I realized that these were actually close by. — Lee Kang-hyo, master potter

Lee Kang-hyo is a master of the Korean onggi, which means large jars. These pots originated as plain domestic storage containers for fermenting food such as chilli-paste, soy sauce and kimicmotif. But Lee saw them as something more and wanted to explore the beauty in their sculpture.

Lee is an unassuming individual. His clothes are a little dirty and he is not a leader or in any position of authority. Nor is he particularly successful, or wealthy. He is a worker.

But he does seems to have a quiet integrity born from the stability and confidence of one who has found their way.
He has something I would like to have.

This is a slow and gentle video, but there is a lot to see here. Are we looking for the important things in the right place?
Can we learn to imbue art and elegance into our everyday work? And should we bother?

If you cannot see the player above you can watch the video here.

developing a resilience training program for nurses.

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This study published in the American Journal of Critical Care looked at the feasibility and acceptance amongst ICU nurses of implementing a resilience training program.

It has been acknowledged that ICU nurses have an increased incidence of burnout syndrome, anxiety disorders and post traumatic stress disorders resulting from the extraordinary environments in which they spend a large chunk of their lives. They don’t call it intensive care for nothing.

The development of a strong resilience capacity has been recognised as one of the most important factors in managing this critical intensity.

This randomised controlled pilot study developed a 12-week resilience intervention program including a 2 day workshop, event-triggered counselling sessions, mindfulness based stress reduction exercises and an aerobic exercise regime.

The 29 nurses in the treatment and control groups completed a series of existing questionnaire tools including a resilience scale, post traumatic diagnostic scale, hospital anxiety & depression scale and a burnout inventory.

Quite alarmingly, the pre-study questionnaires found:

  • 100% of nurses were positive for symptoms of anxiety.
  • 77% were positive for symptoms of depression.
  • 81% were positive for emotional exhaustion.
  • 44% of these nurses met the diagnostic criteria for PTSD.

Following the 12 week program nurses in the intervention group were found to have a significant reduction in symptoms of depression compared to the control arm.
Interestingly, both groups had a significant reduction in PTSD symptoms and improved resilience scores. This was thought to be due to ‘intervention contamination’ as both groups worked together in the ICU.

This is the first intervention, in ICU nurses, that has adopted specific coping mechanisms and cognitive behavioral therapy as a multifaceted approach to teaching resilience. The specific components of the intervention were chosen on the basis of evidence supported in the literature, and from our qualitative assessments of resilient ICU nurses. Resilience can be strengthened and taught through cognitive flexibility, learning to be adept at facing fear, developing active coping skills, having a supportive social network, exercising, and having a sense of humor.

Writing about traumatic and stressful events has been associated with improved physical and mental health. Additionally, written exposure therapy significantly reduces symptoms of PTSD by emphasizing the importance of confronting traumatic memories instead of avoiding the memories.

In ICU nursing, resilience is associated with a positive social network that includes communication, connectivity, and emotional support, which is attained through strong personal, family, and professional relationships. The 2-day resilience training workshop allowed ICU nurses to meet and discuss similar problems related to trauma in the workplace. Informal feedback from participants suggested that it was comforting to learn that fellow nurses had similar reactions to traumatic experiences at work, and the group sessions made the nurses feel less isolated and more connected with their peers. Additionally, the event-triggered counseling sessions used cognitive behavioral therapy to reinforce existing personal and professional relationships and promote resilient strategies to overcome negative cognitive appraisal of work-related events that were viewed as traumatizing.

Finally, self-care and balance help maintain a healthy lifestyle by incorporating psychological, physical, and emotional mechanisms into daily practice. Highly resilient ICU nurses have described healthy coping mechanisms that include exercise and engaging in spiritual resources to promote a balanced lifestyle. The interventions adopted for this resilience training program included a fairly rigorous exercise component and MBSR practices. MBSR is used to develop enhanced awareness of “in-the-moment” experiences and reduces negative affect and improves coping in persons with a variety of chronic health issues such as pain, cancer, anxiety disorders, depression, and situational stresses such as the ICU work environment.

Inevitably, the authors acknowledged that this study had several limitations and noted the need for more powered studies to be performed.

Let us hope that in the future nurse supportive initiatives such as this become commonplace within all areas of the health system.

Reference: Feasibility and Acceptability of a Resilience Training Program for Intensive Care Unit Nurses [Internet]. [cited 2015 Jan 28]. Available from:

Featured image via: MilitaryHealth

Research and Reviews in the Fastlane 068

Research and Reviews in the Fastlane

Welcome to the 68th edition of Research and Reviews in the Fastlane. R&R in the Fastlane is a free resource that harnesses the power of social media to allow some of the best and brightest emergency medicine and critical care clinicians from all over the world tell us what they think is worth reading from the published literature.

This edition contains 6 recommended reads. The R&R Editorial Team includes Jeremy Fried, Nudrat Rashid, Soren Rudolph, Anand Swaminathan and, of course, Chris Nickson. Find more R&R in the Fastlane reviews in the R&R Archive, read more about the R&R project or check out the full list of R&R contributors

This Edition’s R&R Hall of Famer


R&R Hall of Famer - You simply MUST READ this!


Cao D et al. Intravenous Lipid Emulsion in the Emergency Department: A Systematic Review of Recent Literature. J Emerg Med 2015. PMID: 25534900

  • An excellent systematic review that aims to familiarize emergency care providers with the indications, dosing recommendations and common adverse reactions associated with Intralipid emulsion usage.The American Heart Association recommends use in local anesthetic systemic toxicity, and the American College of Medical Toxicology recommends consideration for circumstances of hemodynamic instability that results from lipid-soluble xenobiotics.
  • Recommended by: Sa’ad Lahri

The Best of the Rest

Emergency Medicine, CardiologyR&R Hot Stuff - Everyone’s going to be talking about this
Bangalore S et al. Anticoagulant therapy during primary percutaneous coronary intervention for acute myocardial infarction:a meta-analysis of randomized trials in the era of stents and P2Y12 inhibitors. BMJ 2014. PMID: 25389143

  • One size does not fit all when it comes to anticoagulant/antiplatelet therapy in acute MI. In this meta-analysis the authors found that the combination of LMWH and GIIb/IIIa inhibitors had the best outcomes in terms of MACE but bivalarudin was associated with less bleeding events. Each patient must be considered individually before an agent is selected.
  • Recommended by: Anand Swaminathan

Emergency MedicineR&R Game Changer? Might change your clinical practiceGreen SM et al. Ketofol for Procedural Sedation Revisited: Pro and Con. Ann Emerg Med 2014. PMID: 25544732

  • This editorial updates a 2011 iteration written by the same authors on the same topic, to reflect new studies on ketofol. These new studies again demonstrate that combining ketamine and propofol in the same syringe is safe and effective for procedural sedation. However, they also (again) demonstrate that the combination is not superior to propofol monotherapy. Ketofol advocates continue to point to theoretical advantages of the combination which have not been borne out in patient-oriented (or even physician-oriented) study endpoints. I recommend propofol monotherapy for brief procedures, especially when muscle relaxation is desired (e.g. cardioversion, joint reduction), and dissociative dose ketamine for longer procedures, with propofol available to use as needed for recovery agitation, muscle rigidity, or concerning hypertension.
  • Recommended by: Reuben Strayer

 Systems and AdministrationR&R Mona Lisa -Brilliant writing or explanation” width=R&R Boffintastic - High quality researchRising KL et al. Return Visits to the Emergency Department: The Patient Perspective. Ann Emerg Med 2014. PMID: 25193597 

  • Great qualitative look at where ED bouncebacks come from. There aren’t a lot of surprises here: poor followup options, ED as great one-stop shopping, and dissatisfaction with ED care (i.e. “they didn’t do anything!”). Not a lot of answers but we probably have some room to improve our communications on what we did for the patient and why they don’t need that CT.
  • Recommended by: Seth Trueger

Emergency Medicine, PsychiatryR&R Hot Stuff - Everyone’s going to be talking about thisR&R Game Changer? Might change your clinical practiceCalver L et al. Droperidol v. haloperidol for sedation of aggressive behaviour in acute mental health: randomised controlled trial. Br J Psychiatry 2014. PMID: 25395689

  • Although not widely available, droperidol is often used for the management of agitated delirium. This paper compares droperidol (10mg IM) in 118 patients vs. haloperidol (10mg IM) in 100 patients. Appropriate sedation within 120 seconds occurred in 92% of patients without differences between agents. While sedation with droperidol required less rescue doses, it also had higher adverse events (5% vs 1%).
  • Recommended by: Daniel Cabrera

Critical CareR&R Hot Stuff - Everyone’s going to be talking about thisNoto MJ et al. Chlorhexidine Bathing and Health Care–Associated Infections: A Randomized Clinical Trial. JAMA 2015. PMID: 25602496

  • Health care acquired infections remain a huge issue for critical care physicians contributing to increased mortality, increased hospital length of stay and increased costs. This large randomised cluster trial from the US did not support daily bathing of critically ill patients with Chlorhexidine as there was no reduction in the incidence of health care–associated infections including CLABSIs, CAUTIs, VAP, or C difficile.  Unncessary exposure to Chlorhexidine may itself lead to the development of resistance to Chlorhexidine itself as well as increased costs associated with its use.
  • Recommended by: Nudrat Rashid

The R&R iconoclastic sneak peek icon key

Research and Reviews The list of contributors R&R in the FASTLANE 009 RR Vault 64 The R&R ARCHIVE
R&R in the FASTLANE Hall of Famer R&R Hall of famer You simply MUST READ this! R&R Hot Stuff 64 R&R Hot stuff! Everyone’s going to be talking about this
R&R in the FASTLANELandmark Paper R&R Landmark paper A paper that made a difference R&R Game Changer 64 R&R Game Changer? Might change your clinical practice
R&R Eureka 64 R&R Eureka! Revolutionary idea or concept R&R in the FASTLANE RR Mona Lisa R&R Mona Lisa Brilliant writing or explanation
R&R in the FASTLANE RR Boffin 64 R&R Boffintastic High quality research R&R in the FASTLANE RR Trash 64 R&R Trash Must read, because it is so wrong!
R&R in the FASTLANE 009 RR WTF 64 R&R WTF! Weird, transcendent or funtabulous!

That’s it for this week…

That should keep you busy for a week at least! Thanks to our wonderful group of editors and contributors Leave a comment below if you have any queries, suggestions, or comments about this week’s R&R in the FASTLANE or if you want to tell us what you think is worth reading.

The post Research and Reviews in the Fastlane 068 appeared first on LITFL.

strangers story.

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Knowing someone’s story helps to make the patient more real, and it makes the job more personal. The shared narratives of others’ lives incorporate and become stories about us. I feel myself to be a part of a stranger’s story, when it is shared with me, and passing it on feels like my sharing of a parable we’ve all heard- we know the plot, even the climax and the ending. Only the names have changed, or the costumes, or the settings, but the story is the same and is this: we are all vulnerable; we are all a little bit crazy; we are all funny, entertaining, delicate, bold, horrible, and fantastic. We are all, in our unique and individual ways, as equally and universally fucked up as the next person. Every one of us. Theres comfort in knowing this.
—-Pamela Baker





TouchéMedical’s Cheap Patch Insulin Pump (VIDEO)

touche-pumppatch-pumpInfusion pumps that deliver insulin and other drugs have been getting quite advanced thanks to wireless technology, new algorithms, and connectivity with other devices. Yet, while work toward an artificial pancreas that combines a continuous glucose meter with an insulin pump is producing promising results, many people around the world simply can’t afford even existing pumps. TouchéMedical, an Israeli firm, is developing a small, cheap, and accurate infusion pump that would be within the budgets of millions of diabetics and people with other diseases treated by drug pumps.

The device has a disposable cartridge that is particularly cheap to manufacture, and a reusable core that contains the actual pump and the electronics to drive it. It includes Bluetooth connectivity to be able to interface it with a smartphone can even send out SMS messages to keep physicians and loved ones informed on how the drugs are being delivered.


Link: TouchéMedical…

More at ISRAEL21c: World’s smallest, cheapest patch pump for diabetics…

The post TouchéMedical’s Cheap Patch Insulin Pump (VIDEO) appeared first on Medgadget.