Conference Notes 9-19-2018

Hart/Nakitende U/S Monopoly

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 You can measure the width of the pericardial fluid to grade the severity of a pericardial effusion. More than a centimeter (10mm) is significant.

You can measure the width of the pericardial fluid to grade the severity of a pericardial effusion. More than a centimeter (10mm) is significant.

An echo finding suggestive of tamponade is incomplete filling of RV in diastole. The RV wall will be scalloped.

 Large pericardial effusion with incomplete filling/scalloping of RV suggestive of tamponade

Large pericardial effusion with incomplete filling/scalloping of RV suggestive of tamponade

When using echo to differentiate acute PE vs chronic pulmonary hypertension, the RV wall in acute PE will be thin while the RV wall in chronic pulmonary hypertension will be hypertrophied.

 D-sign showing PE. Elevated pressure in the RV flattens the LV septal wall making the LV look like the letter D on a parasternal short view.

D-sign showing PE. Elevated pressure in the RV flattens the LV septal wall making the LV look like the letter D on a parasternal short view.



 McConnell sign. The apex of the RV contracts OK despite overall RV hypokinesis. This is a specific sign of PE.

McConnell sign. The apex of the RV contracts OK despite overall RV hypokinesis. This is a specific sign of PE.

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Bartgen/Erbach Oral Boards

Case 1. 75yo female with fever, cough, and wheezing. O2 sat 92%. CXR shows pneumonia. Patient has SIRS. IV fluids and IV antibiotics started. Patient deteriorated late in her ED course with worsening weakness. Son noted that patient has had weakness at the end of each day for weeks now. Patient was diagnosed with Myasthenic crisis precipitated by pneumonia/sepsis. Treatment with plasmaphoresis was arranged. IVIG and steroids are also indicated. Airway needed to be managed due to expected course of illness with worsening weakness.

Dr. Bartgen made the following points about nueromuscular blocking agents in the setting of myasthenic crisis. I used a Tintinalli reference to encapsulate his comments:

The most significant ED complication of myasthenia gravis is respiratory failure, which is usually precipitated by infection, surgery, or the rapid tapering of immunosuppressive drugs. Although intubation should be considered in patients with a low forced vital capacity or in the presence of abnormal blood gas analysis, this decision is made primarily on clinical grounds. Patients may have increased sensitivity to nondepolarizing agents based on their concurrent use of acetylcholinesterase inhibitors. Additionally, they can have either resistance or prolonged duration from depolarizing agents. Because of the increased sensitivity of myasthenia gravis patients to neuromuscular junction inhibitors and an unpredictable reaction to succinylcholine in particular, avoid the administration of depolarizing or nondepolarizing paralytic agents in preparation for intubation.27 Patients with myasthenia are extremely sensitive to these agents, and the paralytic effects can be expected to persist at least two to three times longer than in normal patients. Consider using short-acting agents such as fentanyl or propofol in smaller doses, as it is important to avoid further respiratory depression. Sugammadex may be used to reverse rocuronium if necessary.28 If paralytic agents are absolutely necessary, consider using one with a shorter half-life, such as etomidate, at one-half the dose of these agents, although this recommendation is anecdotal. (Tintinalli 8th ed.)

Case 2. 70yo female with cough, shortness of breath and O2 sat of 85%. Patient was cleaning bathroom with a mix of clorox bleach and lime-away. The combo of these cleaning supplies caused strong fumes that overcame the patient. Mixing bleach with either an acid or ammonia can cause the release of chlorine or chloramine gas. The patient was treated with intubation. Steroids should be given to intubated patients with lung injury due to chlorine gas.

Case 3. 90yo female presents with scalp rash for about 6 weeks. The rash had a boggy consistency. Diagnosis was a kerion which is more common in pediatric patients and the elderly.

 Kerion, treat with griseofulvin or fluconazole. Kerion causes hair loss which can help differentiate it from other scalp lesions.

Kerion, treat with griseofulvin or fluconazole. Kerion causes hair loss which can help differentiate it from other scalp lesions.

Tinea capitis (scalp) presents as a pruritic, erythematous, scaly plaque. This may develop into a delayed-type hypersensitivity reaction, where the initial erythematous, scaly plaque becomes boggy with inflamed, purulent nodules and plaques (kerion). The hair follicle is frequently destroyed by the inflammatory process in a kerion, leading to a scarring alopecia. Systemic antifungals are required to treat tinea capitis infections. Due to the long-term treatment requirement and associated side effects, referral to a dermatologist is recommended. (Tintinalli 8th ed.)

Dr. Napier comment: Consider checking LFT’s as a baseline prior to starting griseofulvin.

Ginsburg Endovascular Treatment of PE

RV/LV ratio 0.9 or greater is a sign of RV strain on CTPE study.

 Massive PE patients are candidates for systemic TPA. Sub-massive PE patients are candidates for catheter directed thrombolysis. Patients with a low risk of bleeding who have RV dysfunction and elevated troponin are probably the most likely to benefit from catheter direct thrombolysis in the submassive group.

Massive PE patients are candidates for systemic TPA. Sub-massive PE patients are candidates for catheter directed thrombolysis. Patients with a low risk of bleeding who have RV dysfunction and elevated troponin are probably the most likely to benefit from catheter direct thrombolysis in the submassive group.

 High risk PESI scores warrant consideration of ICU admit.

High risk PESI scores warrant consideration of ICU admit.

Risk of ICH with systemic TPA is 3%. Risk of ICH on heparin is 0.3%

50% of patients with massive PE have a contraindication to TPA.

 This slide just gives an idea of the total incidence of PE and PE deaths in the US.  As a comparison  MVC’s account for 30-40,000 deaths/year and drug overdoses account for approximately 80,000 deaths/year.

This slide just gives an idea of the total incidence of PE and PE deaths in the US. As a comparison MVC’s account for 30-40,000 deaths/year and drug overdoses account for approximately 80,000 deaths/year.

Schroeder Management of DKA

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Type 1 DM has a genetic component but it is not all genetic. Only 40% of identical twins will have Type 1 DM.

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DKA patients are more dehydrated than they look because they are losing intracellular water with glucose in the urine rather than water and sodium in the stool.

Expect DKA patients to be potassium depleted. Begin replacing potassium very early in the management of DKA.

Younger kids, those with limited access to care, and low BMI kids are more likely to present in DKA and are more likely to have a delay in diagnosis.

If a patient has an insulin pump and presents in DKA, turn off the pump and treat with IV insulin. It is better to have complete control of the insulin the patient is receiving.

There is no indication to give an initial bolus of insulin. Just start a continuous drip drip after first priming the line with insulin. The IV tubing adheres the initial insulin and if you don’t first prime the line with insulin, it can take hours before the patient starts receiving insulin because the infusion is getting absorbed by the IV tubing.

10ml/kg bolus is probably fine and safe as your initial fluid administration. Use LR to avoid hyperchloremic acidosis associated with NS.

PECARN IV Fluid in DKA Study (NEJM 2018)

Critical Results:

  • 1,389 distinct episodes of DKA were evaluated in 1,255 patients, but only 1361 episodes of DKA were included in the primary analysis. 132 children had a second episode of DKA and underwent randomization as well.

  • There were a total of 48 episodes (3.5%) resulting in a GCS <14 with 22 episodes (1.6%) requiring hyperosmolar therapy for cerebral edema, and 12 episodes (0.9%) of clinically apparent brain injury.

  • There were no statistically significant differences in the percentage of episodes among the 4 groups where the GSC decreased to less than 14, the magnitude of decline or duration GCS remained less than 14

  • Incidence of a GCS decline <14 & clinically apparent brain injury was actually lower in fast rehydration groups (21 vs 27 & 4 vs 8 episodes respectively), but both were not statistically significant

  • Memory assessed by forward and backward digit-span scoring did not significantly differ between the 4 groups

  • Hyperchloremic acidosis was more common among patient receiving 0.9% NaCl vs 0.45% NaCl and more common in patients receiving fluid at a rapid rate vs slow rate

 DKA Protocol for ACMC/Hope Children’s Hospital

DKA Protocol for ACMC/Hope Children’s Hospital

Tekwani Medical Student Rotation Review