Conference Notes 3-22-2017S

Stanek/Walchuk      Oral Boards

Case 1.   Patient with history of schizophrenia on multiple antipsychotic medications (Latuda, Lithium, Cogentin) presents with altered mental status. Patient has history of ataxia.  Patient has clonus on neurologic exam.  Lithium level was elevated.  Management included contacting poison control and initiating dialysis.  Any lithium level over 3.5 is considered severe.  Any change in mental status or significant neuro symptoms indicate dialysis.

Main point of discussion was to also consider serotonin syndrome and neuroleptic malignant syndrome in the polydrug psychiatric patient.

Case 2. 86yo female presents with 4 days of dyspnea. Patient has history of rheumatic heart disease and a mitral valve problem.   Lung exam reveals crackles. CXR shows cardiomegaly and congestive changes.  BNP is markedly elevated.  Patient's echo shows incompetent mitral valve.  Patient is in congestive heart failure due to severe mitral valve regurgitation.  Patient has valve rupture.  Treatment is afterload reduction with nipride followed by CV surgery consult.

Case 3.  7yo child suffered bite on finger from rat.  Treatment is copious irrigation of wound. Give antibiotics. No suturing or dermabonding. Tetanus prophylaxis is not indicated for rat bites.  People are at risk of Rabies from bites by Bats, Foxes, Raccoons, skunks, cattle, and horses.  No rabies risk from rats, squirrels, hamsters, guinea pigs.  The only lagamorph that can transmit rabies is groundhogs.  However, you can get rat bite fever which has a 13% mortality.   You can prevent rat bite fever with penicllin or augmentin at the initial treatment of wound.  Treat with penicillin, unasyn,or ceftriaxone.

Carlson     Oral Board Day Debrief

1. Unstable Afib requires cardioversion.  Cardioversion requires procedural sedation and a pre-sedation assessment. You also need to get informed consent, and do a Time Out.  Choose a sedative with minimal hemodynamic effects.

Cardioversion has a 90% success rate for unstable A-fib.  100J biphasic is the most commonly cited dosage for normal weight patient.  For obese patients start at 200J.  Anterior/Poster electrode pad placement seems to have a higher success rate.

Components of Pre-Sedation Assessment: Mallampati score, ASA Class, Prior Complications, Allergies, PO intake.

2. Consider abuse in the setting of an infant with altered mental status.  Check a blood sugar. Do a thorough physical exam to look for injuries.  Take custody of child.  Report the case to DCFS.

Infants are prone to head injury for shaken baby syndrome due to large heavy head compared to overall body size and large amount of water in head.   On exam look for bulging fontanelles and retinal hemorrhages, and inappropriate bruising. CT will show subdural or subarachnoid hemorrhage. Get a skeletal survey to look for prior fractures.

3. Patients with sickle cell disease are at increased risk for cholecystitis. They are also at increased risk for meningitis and infection from any encapsulated bacteria due to funtional asplenia.

4. Treat salicylate toxicity with alkalinization of serum/urine (goal: urine ph of 7-7.5) and hemodialysis. You have to replace potassium to effectively alkalinize the patient.  Method of alkalinization is initial 2 amps of bicarb bolus followed by bicarb drip of 3 amps in D5W and run at 4 hour rate.   This is an easy diagnosis to miss to elderly patients with chronic toxicity. Many OTC products have salicylate as a component. Goodies is an example.  Look for metabolic acidosis and respiratory alkalosis on the ABG.

5.  For neonates unstable with suspected congenital heart disease, give prostaglandin infusion. These kids will have mottling or cyanosis. Be prepared for apnea as a side effect of prostaglandin.  Prostaglandins can also have the side effect of fever and hypotension which can mimic sepsis.   If you have to transfer a neonate who is receiving prostaglandin, intubate prior to transfer. Lovell and Harwood felt that a septic work up in an unstable neonate may be potentially risky if you attempt to perform an LP.  Andrea felt you should still give antibiotics even if you have concerns about doing the LP.  

6. Be alert for testicular torsion in kids with lower abdominal pain.  Pediatric patients frequently will not say their testicle hurts.  Consult GU, Attempt detorsion. Get an ultrasound and get them to surgery.  Two peaks of incidence: First year of life and in adolescence.  If you can detorse or get to surgery in less than 6 hours there is a 90% salvage rate. 

7. Treat CO poisoning with 100% FIO2 with NRB and transfer for HBO. 

8.  Consider pericardial tamponade in patients with dyspnea and or hypotension/tachycardia. Electrical alternans is a sign of pericardial effusion. 

 Electrical Alternans

Electrical Alternans

 

Echo is key to the diagnosis of pericardial tamponade.  Treat with pericardiocentesis and consultation for pericardial window. 

                                              Pecha Kucha

Alexander           Lipids to the Rescue!

Lipid emulsion has a protective effect from local anesthetic toxicity.  The best studied toxicity is from bupivicaine.

Lipid emulsion can be used also for toxicity due to tricyclics (amitriptylene, buproprion), beta-blockers and calcium channel blockers.

Hart    Vocal Cord Dysfunction

Predominantly seen in Caucasian females.  Can be confused with asthma, upper airway problems and panic attacks. Probably is due to combiniation of physiologic and psychiatric etiolgies. Standard dyspnea work up will be negative.  Flexible laryngoscopy will show paradoxical closure of the cords with inspiration.  The cords will have an opening at the base.

 Can treat with dissociative doses (0.5mg/kg) of ketamine.

Einstein   TEE for Cardiac Arrest

TEE gives you a better view of heart. Less frequent pulse checks.  It stays out of your way during resuscitation.  More sensitive test for cardiac contractility.  EM case reports and studies show anecdotal unexpected saves and improvement of CPR quality and diagnoses of dissections.  The probes are expensive.

Erbach   Cyanotic Congenital Heart Disease in the ED

If a child with a shunt has no murmur that indicates a big problem. Contact Peds CV surgery right away.

Use O2 to get patient back to their usual baseline, not higher than that.

Patients with a single ventricle have a higher risk of stroke.

Consider endocarditis in cardiac kids with fever.  Get blood cultures.

When consulting CV and Cards, know the patient's last procedure and when it occurred.

Donepudi       U/S in the Acute Management of Elevated ICP

Normal ICP is under 20mm Hg

 Monroe-Kellie Doctrine

Monroe-Kellie Doctrine

You can use a high frequency probe to measure to optic nerve sheath diameter.  Use alot of ultrasound gel on a closed eyelid.  You can use tegaderm to keep the eyelid closed.  Measure 3 mm from globe.  Any diameter greater than 6 mm is abnormal.

Kennedy    Status Asthmaticus

Treat with aggressive bronchodilators, 10-20mg nebs.  Give 2grams of IV magnesium over 20 minutes.  IV steroids. Bipap using IPAP as the key to relieving work of breathing . Terbutaline 0.25mg SubQ. Epinepherine titrated as a drip.  Ketamine can be used for sedation for bipap or induction for intubation.  Intubation requires careful management to avoid air trapping and barotrauma.   Work to keep a limited plateau pressure.  Use a high I to E ratio.  Use smaller tidal volumes and lower respiratory rates.   Heliox can be used to improved air flow.  Heliox can't be used in hypoxic patients due to low FIO2 with Heliox.  Last ditch strategies are general anesthesia and ECMO/ECCOR (simplified ECMO).

Carlson    Toxicology

QT prolongation due to TCA can be treated with IV Bicarb and if that is ineffective, IV Lidocaine drip can be effective.

Physostigmine can be used in pure anticholinergic toxidromes that have coma, severe agitation, or intractable seizures.  Don't use empirically in patients with undifferentiated coma/agitation or polysubstance overdose.  Contraindications are TCA overdose, QRS wide, AV block, bronchospasm, bowel or bladder obstruction.   Andrea feels physostigmine is most indicated in pure anticholinergic overdose in pediatric patients. 

There was some difference of opinion between Harwood and Girzadas about the use of physostigmine.  Harwood felt he would use it in kids and teenagers with pure anticholinergic overdose and coma or severe agitation. It could potentially avoid intubation or complication of agitation. Girzadas was concerned about side effects of physostigmine particularly risk of bronchospasm and would do supportive care only (benzos for agitation, airway protection for coma) and avoid physostigmine. 

The common board question about an anticholinergic plant is Jimson weed.  Deadly nightshade, climbing nightshade, and Mandrake are other botanical anticholinergics. 

Treatment of TCA overdose includes sodium bicarb to a serum ph of 7.5.  Serum alkalinization is the goal not urinary alkalinization.  You are not trying to trap ions in urine. You are trying to keep the TCA out of the CNS.   Give bicarb for wide QRS, acidosis, hypotension, ventricular arrythmia.

TCA EKG from Life in the Fast Lane

Ohl    Safety Lecture

Sean discussed the content and organization of our ENT equipment.

Quick note on pancreatitis management: We need to treat pancreatitis with IV dilaudid for pain and somewhere around 350ml/hour of LR for the first 12 hours. The message from our GI consultants is to be more aggressive with our IV hydration for pancreatitis patients.