Conference Notes 5-15-2012

Conference Notes 5-15-2012

Patel/Collins    Oral Boards

Case #1:  Hemophiliac with an intracranial hemorrhage.   Give factor 8 to get level to 100%=50U/kg.  Give factor 8 prior to CT imaging.  If compartment syndrome suspected don’t check pressure  until after giving factor 8. 

Case #2: Splenic injury with intraperitoneal bleeding.   Diagnose with FAST exam.  Treat with fluid and PRBC resuscitation.   Spleen is the most common organ injured due to blunt abdominal trauma in both adults and kids.

Case #3:  Firefighter  exposed to heat and smoke.  He has airway injury, burns, and CO exposure.   Have to know the Parkland Formula for burns.(4ml/kg/%BSA burned; half given in first 8 hours post injury, 2nd half given over the next 16 hours)  Treat CO exposure with 100% FIO2 and get hyperbaric therapy arranged.   Treat with pain meds/update tetanus status.     CO is the most common tox cause of death.    Smokers can have a baseling CO level up to 10%.   Give hyperbaric therapy for syncope, confusion, seizure, neuro deficit, cardiac ischemia or level more than 25% in a normal adult or more than 15% in a pregnant patient.


Flash Pulmonary Edema:

STuPID HPI: Surgeries/Trauma/Pain or paresthesias/Infection or fever/Drugs or toxins.  Ask this in a format to get yes or no answers.

Communication is vital during a resuscitation.  You have to take leadership of a code situation and designate team members to certain tasks.   Consider what the ramifications of your action will be prior to taking an action.

Dan discussed the multiple utilities of using ultrasound in the crashing patient.   Do RUQ view, suprapubic view, sub-xiphoid and parasternal long views.  

There are cardiac and non cardiac causes of Flash pulmonary edema.   Non-cardiac causes  include ASA or opiate overdose and HAPE.

Sgarbossa  Criteria for AMI in LBBB: 5mm of discordant ST elevation anteriorly,  or 1mm of concordant st elevation or depression in any lead.

Comments from Joan Coghlan:

First I would reiterate what all the attendings voiced:  this wasn't a case to feel chagrined about.  It was a sick lady on the cusp and she was going to get sicker no matter what was done.  In fact she survived because of your actions.
Just in terms of approach to the acutely dyspneic patient:
As true of every patient and every condition, stay diagnosis-oriented.
SOB?  Listen to lungs -- should get a good feel if it is COPD (quiet, no air movemnt), pneumothorax or effusion (decreased on one side only)  or CHF (rales) or noncardiogenic pulm edema or pneumonia.
If lungs seem clear and well aerated, then consider
Valvular disease, aortic stenosis/regurg
Septic Emboli to the lungs
Generalized sepsis
Lymphangitic spread of undiagnosed cancer
Sarcoid, TB, etc.
Or  tox/metabolic like DKA or lactic acidosis or ASA causing compensatory resp alkalosis and fatigue.   Anemia  also may cause some low grade DOE, though not severe like this pt.
The point is stay DIAGNOSIS- ORIENTED  and use your physical exam and cxr, ABG to help you systematically rule each in or out.
Also remember if you decide the pt has copd or chf, you need to consider what CAUSED the pt to go into that state.  Don't just stop at that condition, find the DIAGNOSIS.
Once you established the pt is in Pulm edema, consider the causes of pulm edema --
1.Acute ischemia/MI    
   2. Arrhythmia -- this pt clearly had p waves on EKG but sometimesyou can miss slow VT when pt has those wide complex LBBB
3. Acute valvular incompetence due to ruptured papillary muscle/MI or to aortic dissection into aortic root (or endocarditis)
4.  Hypertensive emergency.   
5. High output failure from thyrotoxicosis or anemia (maybe beri beri or something like that)
6.  Acute myocarditis/ cardiomyopathy
Third, in addressing the fluid bolus, I totally agree with Christine and Elise, I would have given fluids.  I don't consider that as a mistake.  Again this lady decompensated due to her disease process not something you did.
BUT ask yourself what DIAGNOSIS you are treating if you give fluids --  the patient got hypotensive while you were in the process of discerning the cause of her acute dyspnea. Ask yourself why pt got hypotensive (dont just shoot from the hip as Gromis mentioned; ie an automatic reflex, hypotension = fluids) 
Lets get DAIGNOSIS-ORIENTED in deciding what to do for that hypotension:
1. sepsis  -- fluids
2. tamponade -- fluids
3. Pe with right heart failure -- fluids
4. pneumonia and dehydration -- fluids
5. vasodilation due to meds like ntg/morphine  --- fluids
6. tension pneumothorax --- NOT fluids ( REassess pt when RN says they got hypotensive, look at them, listen to lungs, check trachea for deviation, look at vent, make sure IV didnt infiltrate or central line got disconnected and pt is bleeding out --for real)
Many of the diagnosis you are contemplating are treated with fluid boluses.
And when you look at the diagnoses that may not especially benefit from fluid boluses, you are probably going to intubating them anyway because their disease state is going to follow its natural course which will need ventilatory support.     Once these patients are on the ventilator,  oxygenation is not a problem. So give them the fluids to expand their intravascular volume, fill their right heart because they may need that and if you get behind the 8-ball on that there is no coming back.  Conversely, if you overshoot on volume, you can intubate and support them through some diuresis.   ARDS is going to be the only major problem with oxygenation and again, somebody with ARDS has much greater problems.
So, my few comments became diatribe but I think we do best when we stay DIAGNOSIS-ORIENTED  and tailor and modify our treatments based on those assessments.   I would have done the same thing Gromis did and I would still do that today.  Don't fear the fluid. (fear the reaper).