Contributor: Taylor Lynch, MD

Educational Pearls:

Dilutional Hyponatremia:

• Occurs when there is an excess of free water relative to sodium in the body.
• Causes a falsely low sodium concentration without a true change in total body sodium.

Commonly seen in DKA:

• Hyperglycemia raises plasma osmolality.
• Water shifts from the intracellular to extracellular space.
• This dilutes serum sodium, creating apparent hyponatremia.

Corrected sodium calculation:

Use tools like MDCALC, or apply this formula:

• Add 1.6 mEq/L to the measured sodium for every 100 mg/dL increase in glucose above 100.

Clinical relevance:

• Considering corrected sodium in DKA is crucial, as the lab value may not be reflective of actual sodium depletion.
• True severe hyponatremia can lead to complications like seizures
  • May require treatment with hypertonic saline.

References:

1. Fulop M. Acid–base problems in diabetic ketoacidosis. Am J Med Sci. 2008;336(4):274-276. doi:10.1097/MAJ.0b013e318180f478
2. Palmer BF, Clegg DJ. Electrolyte and Acid–Base Disturbances in Patients with Diabetes Mellitus. N Engl J Med. 2015;373(6):548-559. doi:10.1056/NEJMra1503102
3. Spasovski G, Vanholder R, Allolio B, et al. Diagnosis and management of hyponatremia: a review. JAMA. 2014;312(24):2640–2650. doi:10.1001/jama.2014.13773

Summarized by Ashley Lyons, OMS3 | Edited by Ashley Lyons & Jorge Chalit, OMS4

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Contributors:

Col. (Dr.) Stacy Shackelford
Dr. Sean Keenan
Paramedic Alan Moreland
Dr. Chris Tems
Kara Napolitano

From military-inspired trauma protocols to behavioral health alternatives and cardiac resuscitation, EMS is evolving fast. Our Medical Minutes from EMSAC highlight the growing need for prehospital providers to think critically, act quickly, and adapt to new approaches in trauma, crisis response, and patient advocacy.

Educational Pearls:

What was covered & recorded at EMSAC 2024 by EMM?

Col. (Dr.) Stacy Shackelford, U.S. Air Force trauma surgeon and Director of the Joint Trauma System, emphasized the critical importance of early hemorrhage control and timely transfusions in prehospital trauma care. She highlighted military studies showing that interventions within 30 minutes can dramatically increase survival, underscoring the value of rapid response and frontline readiness.

Dr. Sean Keenan, retired Army emergency physician and EMS doctor, introduced the concept of prolonged field care—managing critically injured patients in environments where evacuation is delayed. He discussed how this model, developed in the military, is now being taught to civilian EMS providers in rural areas.

Paramedic Alan Moreland from Denver’s STAR Program (Support Team Assisted Response) explained how alternative response teams, pairing paramedics with clinical social workers, are reshaping how we respond to behavioral health emergencies, reducing reliance on police or ambulance transport and focusing on trauma-informed care.

Dr. Chris Tems, an emergency physician working with ECMO (extracorporeal membrane oxygenation), shared data on using ECMO for refractory cardiac arrest. With a survival rate of 87.5% in select emergency department cases, he highlighted ECMO’s growing role in cardiac resuscitation for patients not responding to CPR.

Kara Napolitano, of the Laboratory to Combat Human Trafficking, outlined the role EMS plays in recognizing human trafficking. She offered key indicators to look for and encouraged providers to stay alert to the signs of exploitation, emphasizing EMS’s role in early intervention.

Recorded by: Steven Fujaros, Brian Parga, & Ahmed Abdel-Hafiz
Summarized by: Steven Fujaros

Contributor: Jorge Chalit-Hernandez, OMS4

Educational Pearls:

• What is the toxic dose of acetaminophen?
  • 7.5 grams, in an adult. The safe daily limit is 4 grams in an adult with a normally functioning liver.
  • This is equivalent to fifteen 500mg pills.
• What are the symptoms of acetaminophen toxicity?
  • First 24 hours, symptoms are non-specific e.g. nausea, vomiting, lack of appetite. Can also be asymptomatic.
  • 24-72 hours, hepatotoxicity occurs (causing yellow skin, pruritus, abdominal pain, bleeding, and confusion)
  • Fulminant liver failure at 72-96 hours
  • Liver function tests (LFTs) peak at 72-96 hours.
• When would you give activated charcoal?
  • Within 4 hours of ingestion.
  • The risk of activated charcoal is that it can be very dangerous if aspirated so use with caution with a poorly mentating patient
• When would you give N-acetylcysteine (NAC)?
  • The peak absorption of acetaminophen occurs at about 4 hours with acute ingestions
  • Use the Rumack–Matthew nomogram to plot the serum level of acetaminophen versus the time since ingestion to see if you are above the treatment line.
  • If the ingestion time is unknown then just give it.
• How do you dose NAC?
  • 3 bag system: First, a 150 mg/kg bolus is administered IV over 15-60 minutes (Bag 1), then a 50 mg/kg drip is administered over 4 hours (Bag 2), then a 100 mg/kg drip is administered over the following 16 hours (Bag 3).
    • This is the Prescott Protocol that requires three bag of IV fluids
  • 2 bag system: There is a simplified protocol that only requires 2 bags, 200mg/kg IV over 4 hours (Bag 1) followed by 100mg/kg over 16 hours (Bag 2)
    • Less risk of anaphylactoid reactions with a 2-bag system due to the high rate of IV NAC given in the 3 bag system.
• What are the endpoints for stopping NAC?
  • If the INR is <1.5
  • If the acetaminophen level is < 10 mcg/mL or undetectable

References

1. Hodgman MJ, Garrard AR. A review of acetaminophen poisoning. Crit Care Clin. 2012 Oct;28(4):499-516. doi: 10.1016/j.ccc.2012.07.006. PMID: 22998987.
2. Rumack BH, Matthew H. Acetaminophen poisoning and toxicity. Pediatrics. 1975 Jun;55(6):871-6. PMID: 1134886.
3. Sudanagunta S, Camarena-Michel A, Pennington S, Leonard J, Hoyte C, Wang GS. Comparison of Two-Bag Versus Three-Bag N-Acetylcysteine Regimens for Pediatric Acetaminophen Toxicity. Ann Pharmacother. 2023 Jan;57(1):36-43. doi: 10.1177/10600280221097700. Epub 2022 May 19. PMID: 35587124.

Summarized by Jeffrey Olson, MS4 | Edited by Jeffrey Olson and Jorge Chalit, OMS4

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