Contributor: Aaron Lessen, MD

Educational Pearls:

• There are many techniques for reducing a shoulder dislocation
• A recent study discussed a new variation of closed reduction technique: wrist-clamping shoulder-lifting
  • The patient is in a sitting position
  • The provider holds the wrist of the injured arm with both hands and slowly rotates the arm to 90 degrees of abduction and 60 degrees of external rotation
  • After this traction, the arm is slowly moved to 45 degrees of abduction and 60 degrees of external rotation
  • The provider then secures the patient’s wrist between the provider’s knees and places their hand on the axilla to gently lift the shoulder upward for successful reduction
• There were 36 patients with shoulder dislocations in this study, and all 36 dislocations were successfully reduced with this technique
  • There were no neurovascular complications or fractures
  • No sedation or medication was required
  • All procedures were performed by a single provider without assistance

References

1. Dai W, Liu L, Zong S, Zhou Y, Zheng J, Li X. An original closed reduction technique for acute shoulder dislocation: the wrist-clamping and shoulder-lifting. Int J Emerg Med. 2025 Mar 26;18(1):60. doi: 10.1186/s12245-025-00866-8. PMID: 40140973; PMCID: PMC11948627.

Summarized by Meg Joyce, MS2 | Edited by Meg Joyce & Jorge Chalit, OMS4

Donate: https://emergencymedicalminute.org/donate/

Contributor: Megan Hurley MD
Educational Pearls:

Acute toxicity of heavy metals:

• Gastrointestinal upset is the most common presentation

Chronic toxicity of heavy metals:

• Symptoms depend on the metal ingested
• Increased risk of cancer
• Altered mentation
• Developmental delays (in children)
• Kidney failure

Four heavy metals that are tested for in a general panel and their sources:

• Lead
  • Old paint (homes built before 1977) or some older toys
  • Pipes of older homes or those with corrosive agents
  • May obtain testing kits from home improvement stores to test water supply
• Mercury
  • Previously in thermometers, although much less common now
  • Compact fluorescent lightbulbs, LCD screens, and some batteries
  • Large predatory fish like tuna, swordfish, dolphins, and shark
• Arsenic sources
  • Most commonly found in pesticides
  • Contaminated groundwater (especially private wells)
• Cadmiun sources
  • Most commonly found in tobacco smoke
  • Batteries
  • Metal plating and welding
• Additional heavy metals that require specific testing
  • Chromium, Nickel, & Thallium
  • Thallium is found in rodenticides, pesticides, and fireworks

Management of heavy metal toxicity depends on the intoxicant

• Generally, chelation therapy is used for acute and severe cases
• Arsenic: dimercaprol or DMSA
• Mercury: DMPS (chronic or mild) or DMSA (severe)
• Lead: succimer is first line, followed by dimercaprol or EDTA

References

1. Baker BA, Cassano VA, Murray C; ACOEM Task Force on Arsenic Exposure. Arsenic Exposure, Assessment, Toxicity, Diagnosis, and Management: Guidance for Occupational and Environmental Physicians. J Occup Environ Med. 2018;60(12):e634-e639. doi:10.1097/JOM.0000000000001485
2. Balali-Mood M, Naseri K, Tahergorabi Z, Khazdair MR, Sadeghi M. Toxic Mechanisms of Five Heavy Metals: Mercury, Lead, Chromium, Cadmium, and Arsenic. Front Pharmacol. 2021;12:643972. Published 2021 Apr 13. doi:10.3389/fphar.2021.643972
3. Kinally C, Fuller R, Larsen B, Hu H, Lanphear B. A review of lead exposure source attributional studies. Sci Total Environ. 2025;990:179838. doi:10.1016/j.scitotenv.2025.179838
4. Jannetto PJ, Cowl CT. Elementary Overview of Heavy Metals. Clin Chem. 2023;69(4):336-349. doi:10.1093/clinchem/hvad022
5. Järup L. Hazards of heavy metal contamination. Br Med Bull. 2003;68:167-182. doi:10.1093/bmb/ldg032
6. Zhang H, Reynolds M. Cadmium exposure in living organisms: A short review. Sci Total Environ. 2019;678:761-767. doi:10.1016/j.scitotenv.2019.04.395

Summarized & Edited by Jorge Chalit, OMS4

Donate: https://emergencymedicalminute.org/donate/

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

Donate: https://emergencymedicalminute.org/donate/