Insulin Bolus for DKA?….Not so fast

DKA is a very common endocrine emergency that we encounter very frequently in the ED in both pediatrics and adults. Standard therapy of care includes IVF, correction of electrolyte disturbances, +/- bicarb, and of course insulin. Prior to starting the insulin drip many providers administer an insulin bolus with the thought that it will overcomeRead more

Keeping Myxedema Coma in the Mix: Is Hypothyroidism in Your Differential?

Myxedema coma, or severe hypothyroidism, is an emergent condition with a high mortality rate (30-60%). Our patients rely on us to catch it early and treat aggressively. About 90% of cases occur during the winter months, and it is rarely seen in patients younger than 60.   Causes: Myxedema coma is usually precipitated by anotherRead more

Doc, I got the sugars, I cannot go home? Or can I…

Before answering that question, I need to acknowledge EM topics ( for bringing this important article to my attention since this is nearly a daily occurrence in our ED. So, do you need to lower blood sugar to a magical, non-evidenced based threshold prior to discharge? Like everything, the answer is…. It depends, but inRead more

It’s Stormy

28 you F with no known PMH, p/w palpitations x 3 days after bus trip to Washington DC, states she is feeling “awful”, symptoms have been constant and worsened today.  Also endorses b/l LE swelling, nausea, vomiting x1 per day, fatigue, diaphoresis, mild SOB.  Notes generalized yellowing of skin.  Denies CP, no fevers, no cough.Read more

Endocrine Emergencies

The nurse in triage, hands you an EKG of a 40 year old female with palpitations, worsening over the past few weeks.  You look at the EKG and it demonstrates atrial fibrillation at at rate of 150.  She also hands you a note from the patient’s primary care physician that states “new onset rapid atrialRead more


A 46 year old female with a history of rheumatoid arthritis, on daily steroids, presents complaining of abdominal pain, nausea, and vomiting x 5 days. She has been unable to tolerate PO, including her medications for the past three days. Upon arrival, she is afebrile, with a BP of 69/40, and HR 130. Fingerstick glucoseRead more

Daily Pearl

A 4 year old boy is brought into the peds ED for 4 days of profuse vomiting.  The mother reports that he has vomited 10-15 times per day, at first stomach contents but by now empty retching.  No F/C, no diarrhea, no urinary symptoms.  In fact, he seems to be urinating more than usual.  HeRead more

Interesting Therapy

33M with no PMH presented to the ED with one day of palpitations, complicated by a week of nausea, non-bloody non-bilious emesis, generalized weakness. On physical exam, the patient is diaphoretic, tachycardic with atrial flutter to 140s,  febrile to 103F, initially AO x3, but now becoming drowsy and fatigued. The patient denies headache, neck stiffness,Read more

Fever and Tremor

38yoF with hypothyroidism prevents with drowsiness, palpitations and tremors. Pt with fever  to 38C, Hr to 120.Read more

E M Pearl, June 1

Tip of the hat to Raj Patel for inspiring this clinical question.   26F h/o lupus is brought into resus for positive sepsis screen at triage.  Patient c/o pleuritic CP, SOB, headache, n/v starting today. Vitals are 101.3  140  74/55  24  96%. Patient is on prednisone for lupus. In addition initiating your work-up for infectiousRead more