Conference Notes 12-20-2017Dr.

Sunbulli       Respiratory Failure

 Dr. Sunbulli discussed the 4 types of respiratory failure.

Dr. Sunbulli discussed the 4 types of respiratory failure.

Tissue hypoxia occurs when the patient's O2 sat drops to less than 70%.  Keeping the O2 sat above 90% provides a margin of safety.

CPAP or BIPAP is used in the setting of sleep apnea to stent open the upper airway while the patient is sleeping.

Nasal mask vs Face mask for BIPAP is really determined by patient comfort and the presence of secretions that patient will need to clear by throat. If there are significant secretions, a nasal mask may be better than a face mask.

BiPAP has been shown to be effective for COPD exacerbations and Pulmonary edema.  Illnesses such as pneumonia that take longer to reverse are less optimal for BiPAP therapy.  It is probably better to intubate hypoxic patients with pneumonia because they will require multiple days of support.

If you are going to intubate a septic patient.  Give them IV fluids and minimize sedation prior to induction and intubation.  Sedation and positive pressure ventilation will unmask and exacerbate a borderline hypovolemic state and can result in CV collapse.

 Basically if the patient has significantly altered mental status, has worsening acidosis, has a process causing respiratory failure that is not rapidly reversible, or the patient has significant secretions or emesis, BiPAP has a higher risk of failure and intubation may be indicated. Haven't seen the BAP-65 guideline before but seems simple and using MD Calc it gives you risk of mechanical ventilation.

Basically if the patient has significantly altered mental status, has worsening acidosis, has a process causing respiratory failure that is not rapidly reversible, or the patient has significant secretions or emesis, BiPAP has a higher risk of failure and intubation may be indicated. Haven't seen the BAP-65 guideline before but seems simple and using MD Calc it gives you risk of mechanical ventilation.

 Haven't seen this BAP-65 decision guideline before.  If a patient has a score of 3 or 4, 70% were intubated and 50% died.  Any patient with a score of 3 or 4 should be strongly considered for ICU admission.

Haven't seen this BAP-65 decision guideline before.  If a patient has a score of 3 or 4, 70% were intubated and 50% died.  Any patient with a score of 3 or 4 should be strongly considered for ICU admission.

 

Friend           Bowel Obstruction

Most common cause of SBO is adhesions.

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With acute SBO, you can still have passage of stool or flatus for 24 hours

Closed loop bowel obstructions can be difficult to diagnoses and are at high risk of perforation.

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 Small Bowel Obstruction on X-Ray shows air fluid levels, dilated bowel in the central portion of the abdomen, and visible valvulae coniventes (lines that go completely across the bowel, stacked coins).

Small Bowel Obstruction on X-Ray shows air fluid levels, dilated bowel in the central portion of the abdomen, and visible valvulae coniventes (lines that go completely across the bowel, stacked coins).

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Gallstone Ileus: Repeated bouts of cholecystitis result in adhesion of the gallbladder to the small bowel (usually duodenum) with eventual fistula formation and passage of gallstones into the lumen. The most common site of entry by erosion is thought to be to the duodenum. Small stones presumably pass without incidence. However, large cholesterol stones can become impacted typically at the ileocaecal valve. As such, gallstone ileus is a mechanical small bowel obstruction. Ileus is a misnomer as the term ileus is usually used to describe a functional, rather than, mechanical obstruction.  (Radiopaedia reference)

 

You don't usually need IV antibiotics for small bowel obstruction management. The small bowel does not harbor significant levels of bacteria.  Do Treat pain.  Do Give IV fluids and NG drainage. Do consult surgery in the ED.

 Nice pearl to help differentiate Cecal vs Sigmoid volvulus. Sigmoid volvulus will have large bowel dilatation.  Cecal volvulus will have small bowel dilitation.

Nice pearl to help differentiate Cecal vs Sigmoid volvulus. Sigmoid volvulus will have large bowel dilatation.  Cecal volvulus will have small bowel dilitation.

There was consensus among faculty that CT Abd/Pelvis is the optimal initial imaging choice to diagnose bowel obstruction rather than plain x-rays.  Dennis Ryan advocated oral contrast in suspected bowel obstruction if the patient can tolerate it.

Girzadas comment: If you identify a bowel obstruction on imaging, you have to go back and examine the patient for a hernia especially if they do not have a history of prior surgery.

Twanow comment: If an infant has bilious emesis, they need an emergent upper GI study to evaluate for malrotation and midgut volvulus.

Pecha Kucha

Miner       Management of Constipation in the ED

I missed this outstanding Lecture

Tran       ED EKG Findings

 Epsilon Wave is associated with arrythmogenic right ventricular dysplasia, a cause of sudden death in young patients.

Epsilon Wave is associated with arrythmogenic right ventricular dysplasia, a cause of sudden death in young patients.

 Wellen's syndrome is associated with critical LAD stenosis

Wellen's syndrome is associated with critical LAD stenosis

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Johns   Targeted Temperature Management after Cardiac Arrest

 2013 NEJM Study did not find benefit of 33 degrees C over 36 degrees C so the target temps in this chart are a bit low.  You can use a target temp of 36 degrees C. The rest of the chart is reasonable.

2013 NEJM Study did not find benefit of 33 degrees C over 36 degrees C so the target temps in this chart are a bit low.  You can use a target temp of 36 degrees C. The rest of the chart is reasonable.

After cooling, need to re-warm slowly 0.25-0.5 degree C per hour. If you re-warm too fast it eliminates any benefit derived from cooling.  Need to avoid fever.

Cooling can increase risk of infection and bleeding.  Another side effect is hypokalemia and arrythmias.

Estoos     Evaluating the Patient with Altered Mental Status

mnemonic: He Stops for TIPS on Vowels

 Detailed mnemonic, but it covers a lot of potential etiologies of altered mental status

Detailed mnemonic, but it covers a lot of potential etiologies of altered mental status

Delbar    Sports Injuries

Depressed skull fractures should be covered with broad spectrum antibiotics.

 Posterior shoulder dislocation with humeral head behind the scapula.

Posterior shoulder dislocation with humeral head behind the scapula.

 Delta pressure, the difference between systolic BP and compartment pressure, is a useful indicator of need for fasciotomy.

Delta pressure, the difference between systolic BP and compartment pressure, is a useful indicator of need for fasciotomy.

Schroeder     Study Guide  Pediatrics

Acute chest syndrome can be caused by fat emboli, infection, and thromboemboli.  If Infection is identified, the most likely organism to cause acute chest syndrome in sickle cell patients is a virus or mycoplasma pneumonia in kids under 9yo.  In kids older than 9yo chlamydia and mycoplasma are the most common organisms.

 An algorithm to help with using lab testing to evaluate for Kawasaki's disease.

An algorithm to help with using lab testing to evaluate for Kawasaki's disease.

Practice Changer*   Bill made the point that in children with ankle injuries near the physis of the distal fibula with no sign of fracture on x-ray you can treat with an air cast rather than post mold.  There are studies showing that the outcomes of patients with suspected occult Salter 1 fractures are excellent without full post-mold splinting.  Similarly, isolated buckle fractures and possible occult Salter 1 injuries at the wrist can also be treated without a post-mold and use just a velcro splint.

Rule of 50 for administering dextrose to kids to treat hypoglycemia.  ML's/kg X dextrose concentration should always equal 50.

1ml/kg  of  D50  

2ml/kg of  D25    

5ml/kg of  D10  This is Bill's go-to for all kids if available. 

10ml/kg of D5

 Klein's line can help identify slipped capital femoral epiphysis.

Klein's line can help identify slipped capital femoral epiphysis.

 Forscheimer spots on palate from scarlet fever.  They are not specific for scarlet fever and can be seen in rubella and measles as well.

Forscheimer spots on palate from scarlet fever.  They are not specific for scarlet fever and can be seen in rubella and measles as well.

 The rash of scarlet fever is like "sandpaper" or "goosebumps"  It may not always be erythematous.  Darker skinned patients may have bumps that are close to their skin color.

The rash of scarlet fever is like "sandpaper" or "goosebumps"  It may not always be erythematous.  Darker skinned patients may have bumps that are close to their skin color.

Be agressive in treating hypokalemia in DKA.  Consult with PICU Intensivist early on. Hypokalemia in DKA can be life-threatening due to large potasium deficit.

Sweiss      Neurocritical Care  of Intracerebral Hemorhage

Unfortunately I missed this outstanding presentation.