Sunbulli 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.
Friend Bowel Obstruction
Most common cause of SBO is adhesions.
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.
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.
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.
Miner Management of Constipation in the ED
I missed this outstanding Lecture
Tran ED EKG Findings
Johns Targeted Temperature Management after Cardiac Arrest
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
Delbar Sports Injuries
Depressed skull fractures should be covered with broad spectrum antibiotics.
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.
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
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.