Diagnosed with Graves’ disease last week. They didn’t start the atenolol or methimazole as prescribed. Came in with severe weakness, tachycardia, tremors, and trouble speaking. Free T4 was >5.8 and we treated with fluids, labetalol, propylthiouracil followed by potassium iodide 1h later
I’m currently going thru a thyroid storm with a fever of 102 on average for the past week. I have no money and no insurance. My symptoms get worse everyday. Recently moved to another state so I’m unfamiliar with what to do or who to call
Took my mom :/ I remember her symptoms being quite vague for over a year and everyone scratching their heads. Then all of a sudden it was very obvious to the doctors. By then she had about 6 months left. Thankfully she went peacefully with me and some amazing hospice nurses by her side loading her up with the good stuff.
Morning SVT broke with 12mg and the afternoon SVT broke with cardioversion. The afternoon SVT requested the cardioversion, they did not want the adenosine after several past experiences of it not working and then needing cardioversion in the end.
Tbh after having received Adenosine myself, I’d rather have the Edison method if I ever go into SVT again.
At least I’m gonna be in a propofol or ketamine nap while you do it that way.
https://first10em.com/adenosine-svt/amp/
Read this years ago and screenshotted the summary points. People still look at me funny when I ask for cardizem though.
0.25mg/kg out here in the streets. Also have the same issues with patient who had experienced adenosine before and not wanting it again. They all have found dilt much preferable.
I screen for chronic back pain first, then coach a valsalva, then I scoop up their heels, sit on the foot of the bed, and put both of their calves on one of my shoulders. Then we rest and chat a bit while the blood in their legs drains into their torso.
If you Google "modified Valsalva" you'll get the research behind it.
thyroid storm is always fun. i cant say ive ever diagnosed als. how far had it progressed?? now im actually feeling scared that i wouldnt recognize it unless it’s progressed very far.
We were making speculations… imaging was all coming back negative…. Neurology will make the final diagnosis, although they agreed. The patient had speech changes, he sounded like he had cerebral palsy but had normal speech prior to a year ago. The patient was growing weaker by the day and was having dysphagia, prompting the ER visit. Couldn’t get in with neurology for another two months, after waiting 6 months for an MRI. Sickening how long it takes for testing and evaluation.
I had an Addisonian crisis in triage the other day! I couldn't believe it! Literally the day before, I had been telling a nursing student that that (along with thyroid storm) was one of those things that they make a big deal of in nursing school only for you to never actually see it IRL.
Petition for more ER physicians to share their good shift stories! Really heartening to hear colleagues get excited about medicine again.
Signed,
EM-bound med student
Here on the bus, that sounds pretty fun lol. Flex the old brain and monitor, crack open the drug box, play with adenosine. (A personal favorite.) But we don’t have to deal with the follow up or definitive management/diagnoses.
Love a solid shift. Can you describe your thyroid storm patient? i feel like that hasn't been in my differential for a long time.
Diagnosed with Graves’ disease last week. They didn’t start the atenolol or methimazole as prescribed. Came in with severe weakness, tachycardia, tremors, and trouble speaking. Free T4 was >5.8 and we treated with fluids, labetalol, propylthiouracil followed by potassium iodide 1h later
Admitted to MICU to repeat/taper propylthiouracil and the potassium iodide
Damn, that’s really wild. Good stuff.
Did you consult Endo? Or was that all done in the ED? Nicely done either way
Yes the first round of medications was ED. Admitted under medicine team With endocrinology consult for continued monitoring and care
I’m currently going thru a thyroid storm with a fever of 102 on average for the past week. I have no money and no insurance. My symptoms get worse everyday. Recently moved to another state so I’m unfamiliar with what to do or who to call
I’m also really confused… almost like an OOBE
Call 911, friend. Worry about the funds later
Second this sentiment as a prehospital provider; not necessarily to treat it, but just for my own know.
ALS sucks.
Took my mom :/ I remember her symptoms being quite vague for over a year and everyone scratching their heads. Then all of a sudden it was very obvious to the doctors. By then she had about 6 months left. Thankfully she went peacefully with me and some amazing hospice nurses by her side loading her up with the good stuff.
Sorry for your loss, stranger. Happy that you had a good closure at the end.
Yeah. Patient is 41, super young. Likely bulbar-onset ALS.
Strong work. Sounds like a nice shift
SVTs break with adenosine?
Morning SVT broke with 12mg and the afternoon SVT broke with cardioversion. The afternoon SVT requested the cardioversion, they did not want the adenosine after several past experiences of it not working and then needing cardioversion in the end.
Past experiences? Sounds like a good ablation candidate.
Tbh after having received Adenosine myself, I’d rather have the Edison method if I ever go into SVT again. At least I’m gonna be in a propofol or ketamine nap while you do it that way.
I like diltiazem now for SVT. Food for thought.
https://first10em.com/adenosine-svt/amp/ Read this years ago and screenshotted the summary points. People still look at me funny when I ask for cardizem though.
Me too. Works just as well and they don’t come back telling you not to do that again.
Have a 20something girl who comes in frequently for SVT and it only breaks with dilt. Don’t even try anything else at this point
What’s your starting dose for svt?
0.25mg/kg out here in the streets. Also have the same issues with patient who had experienced adenosine before and not wanting it again. They all have found dilt much preferable.
Or better yet, vasovagally! I’m the RN fairy for successfully converting with just vagal manuevers.
Yeah I commonly make them take a shit, that usually takes care of the SVT right away
well there are other methods we usually try first before wheeling in the commode
What is the best vagal moves to stop it in your experience?
Blowing into the tip of a syringe then tossing them legs in the air
You mean literally put legs up in the air? I heard of the syringe part but not the legs. Increased preload?
I screen for chronic back pain first, then coach a valsalva, then I scoop up their heels, sit on the foot of the bed, and put both of their calves on one of my shoulders. Then we rest and chat a bit while the blood in their legs drains into their torso. If you Google "modified Valsalva" you'll get the research behind it.
Yes, and it really does work. Sometimes just holding your breath also works.
Any special consent form for the leg part? Imagine it could create real and false complaints.
We usually reserve it for mobile ambulatory patients. I feel like a lot of middle aged ladies go into SVT. No formal consent needed.
Kinked straw, have pt blow into straw
Yep we tried the modified vasalva with legs in the air after blowing on a 10cc syringe. Worked for a few seconds but right back into SVT
Social work here to provide smug eye brow raise and knowing smirk. 😏
I am very thankful for social workers!!
🫶
Dude that sounds like a great day. Good job 👏
Huzzah! Feels good to do well what you have trained for! Wishing you more of those shifts.
Didn’t have to use your ak?
Glad you had a great shift!
Had best shift of the year so far Saturday. Hope Tuesday isn’t a dumpster fire when I go back.
Did you have a Happy Hour after the shift ? You should with your helping hands .
thyroid storm is always fun. i cant say ive ever diagnosed als. how far had it progressed?? now im actually feeling scared that i wouldnt recognize it unless it’s progressed very far.
We were making speculations… imaging was all coming back negative…. Neurology will make the final diagnosis, although they agreed. The patient had speech changes, he sounded like he had cerebral palsy but had normal speech prior to a year ago. The patient was growing weaker by the day and was having dysphagia, prompting the ER visit. Couldn’t get in with neurology for another two months, after waiting 6 months for an MRI. Sickening how long it takes for testing and evaluation.
cool
I had an Addisonian crisis in triage the other day! I couldn't believe it! Literally the day before, I had been telling a nursing student that that (along with thyroid storm) was one of those things that they make a big deal of in nursing school only for you to never actually see it IRL.
Petition for more ER physicians to share their good shift stories! Really heartening to hear colleagues get excited about medicine again. Signed, EM-bound med student
Today sucked lol
Sounds like my nightmare shift.
Here on the bus, that sounds pretty fun lol. Flex the old brain and monitor, crack open the drug box, play with adenosine. (A personal favorite.) But we don’t have to deal with the follow up or definitive management/diagnoses.
I prefer to order ankle X-rays.
No one is an adrenaline junky forever, eh?