ERcast: Clinical Perspectives Podcast Preview
The summary below is from an episode of ERcast: Clinical Perspectives
High-altitude illness is a clinical diagnosis driven by recent ascent, symptom timing, and severity, not by labs alone. Acute mountain sickness, HACE, and HAPE can present independently, and severe disease demands descent. Separately, most acute sinusitis is viral, and casual fluoroquinolone prescribing can leave patients with permanent neuropathy.
High-Altitude Illness Pearls
- Recent ascent history: Recent altitude exposure should immediately reshape the differential in patients with headache, nausea, dizziness, dyspnea, or altered mental status, even when they present far from the mountains.
- Spectrum not progression: AMS, HACE, and HAPE are best understood as parallel altitude syndromes rather than a tidy progression, so patients may arrive with cerebral and pulmonary features together.
- Hyperbaric hypoxia mechanism: Altitude illness is driven by lower barometric pressure rather than a change in oxygen percentage, making this a tissue-delivery problem when rapid ascent outpaces acclimatization.
- HACE red flag findings: Ataxia and altered mental status after ascent should be treated as high-altitude cerebral edema until proven otherwise, a neurologic emergency where delay is dangerous.
- HAPE treatment framing: HAPE is noncardiogenic pulmonary edema from hypoxic pulmonary vasoconstriction, so oxygen and descent matter while diuretics do not. We get into the common mimics in the episode.
- Recurrence and risk profile: A prior altitude illness history is a major warning sign, with recurrence around 60%, while physical fitness offers little protection if the ascent profile is aggressive.
Sinusitis and Fluoroquinolone Legal Lessons
- Bacterial sinusitis criteria: True acute bacterial sinusitis is uncommon; the key patterns are persistent symptoms beyond 10 days or a double-worsening course, not isolated facial pain after a day or two.
- Watchful waiting default: Most sinusitis presentations are viral, and even suspected bacterial cases often support watchful waiting rather than reflex antibiotics, a distinction worth hearing in the chapter.
- Fluoroquinolone neuropathy risk: Fluoroquinolones can cause rapidly developing peripheral neuropathy that may be permanent, and the drug should be stopped immediately when concerning sensory symptoms appear.
- Small fiber neuropathy clue: Stocking-glove paresthesias with a normal EMG do not exclude medication injury; small fiber neuropathy may only declare itself on skin biopsy.
- Reassessment before escalation: Switching or escalating antibiotics without seeing the patient again creates both clinical error and medicolegal exposure, especially when the original sinusitis criteria were never documented.
- High-risk prescribing documentation: When a fluoroquinolone is truly necessary, the rationale and risk discussion need explicit documentation, including tendon and neuropathy counseling. The bedside dot-phrase template is shown in the episode.
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References:
- Davis C, Hackett P. Advances in the Prevention and Treatment of High Altitude Illness. Emerg Med Clin North Am. 2017;35(2):241-260. PMID: 28411926
- Fiore DC, Hall S, Shoja P. Altitude illness: risk factors, prevention, presentation, and treatment. Am Fam Physician. 2010;82(9):1103-1110. PMID: 21121556
- Luks AM, Beidleman BA, Freer L, et al. Wilderness Medical Society Clinical Practice Guidelines for the Prevention, Diagnosis, and Treatment of Acute Altitude Illness: 2024 Update. Wilderness Environ Med. 2024;35(1_suppl):2S-19S. PMID: 37833187
Faculty
- Geoffrey Comp, DO, FACEP
Dr. Comp is an Associate Program Director for the Creighton University / Valleywise Health Emergency Medicine Residency Program in Phoenix. A clinician-educator at heart, Geoff spends his time mentoring the next generation of Emergency Medicine residents and advocating for better ways to teach and learn medicine. His professional world revolves around wilderness medicine, clinician wellness, and finding innovative ways to bridge the gap between theory and the bedside. When he isn’t in the ED or the classroom, you’ll likely find him combining his love for medicine with his passion for the outdoors, always looking for a new trail to explore or a new way to collaborate with fellow clinicians.
- Kelly Heidepriem, MD
Dr. Heidepriem is a board-certified emergency medicine physician. She completed her residency at Brown University before getting homesick for the Midwest and returning closer to home where she practices in the community. She is also an associate professor at the University of South Dakota Sanford School of Medicine. Her podcasting journey began as a guest on Urgent Care RAP, which quickly led to a regular hosting role. Outside of work, Kelly is a dedicated runner, logging miles with her husband and the occasional guest star, Pete.
- Anne Steckowych, APRN
Emergency medicine is in Anne’s blood; her father has been an Emergency Medicine physician for the last 30 years. After earning her nursing degree from the University of New Hampshire (UNH) in 2018, Anne worked as an EMT at her local fire department, gaining practical experience that prepared her for five years as a nurse in the emergency department. She eventually returned to UNH to become an NP and has spent the last 8 years in the same ED, building relationships with a clinical team dedicated to providing the best possible patient care. Outside of the hospital, she’s usually skiing, hiking, or running in the New Hampshire hills. ERcast is her first podcast, and she’s thrilled to be part of the Hippo team.
- Brett Murray, MD
Dr. Murray is an Emergency Medicine physician practicing at a busy community trauma center. After attending Boston University School of Medicine, he completed his residency training at Brown University / Rhode Island Hospital, where he also served as Chief Resident from 2020 – 2021. His clinical interests center on medical education, performance science, and Emergency Medical Services.
- Julia Morrison, PA-C
- Ari Bosch, PA-C
