Conference Notes 10-18-2011

ROHIT GUPTA/DAN BARTGEN  ORAL BOARDS

Case1:Retro/parapharyngeal abscess in a child.  Give ABX and consult ENT for I and D.

Case2:Iatrogenic Perforated Bowel.  Emergent surgical consultation.

Case3:COPD exacerbation complicated by a pneumothorax. Place chest tube.

JOAN COGLIN  STUDY GUIDE ENT

Most common source of bleeding in posterior nosebleed: sphenopalatine artery.

Complications of posterior nasal packing: hypoxia, cardiac arrest, obstructed airway, necrosis of collumella

Ludwig’s Angina is a complication of a dental infection.  Soft tissue swelling under tongue. Intubate early to protect airway.

Lemierre’s syndrome: Septic thrombophlebitis of IJ.  Severe sore throat, fever, and neck pain.  Patients can develop septic emboli to lungs. Fusobacterium species are most common cause.

Auricular burns need non-emergent referral to burn center.  Chondritis is common.  No silvadene above clavicles due to skin discoloration.

Floxin otic solution is the only FDA ototopical abx approved for use with perforated tm.  Floxin otic is very expensive.   Cortisporin otic suspension is second choice and is less expensive so more commonly used. 

Don’t use carbonic anhydrase inhibitors in sickle cell patients with hyphema.  CAI’s will lower ph in anterior chamber and increase sickling.  

 Malignant Otits Externa is most commonly due to pseudomonas.  Usually in adult diabetics.

CRAO: treat with digital massage, IOP lowering meds and paracentesis, Rebreathing to raise pco2 and vasodilate.

Aphthous stomatitis is due to allergic reaction to unidentified trigger.  Usually on labial or gingival mucosa.  Tx with steroid swishes.  Betamethasone syrup.

Orbital cellulitis: pain with eom, most common cause is sinusitis usually ethmoid,  most common cause is staph aureus and strep.

Optic Neuritis: Eye pain, altered vision, optic disc edema. Tx with iv steroids.   Think MS.

 Dental concussion: tooth is tender but not mobile

Subluxation: tooth is tender and mobile

Luxation: tooth is displaced

ANUG: acute necrotizing gingivitis treat with metronidazole and chlorhexidine rinses

Last ditch procedure to stop life threatening posterior epistaxis is lido/epi

DAVE BAROUNIS  VENTILATORS

Ideal Body Weight is almost always somewhere between 50 and 80 kg.

Tidal Volumes can be 6-8cc/kg. 

 In asthmatics start with a low respiratory rate of 8 to avoid stacking breaths.  Can be 12-16 in a normal patient.

Be sure to titrate your patients pAO2 to between 70 and 200max.   If pAO2 is  above 200 at 4 hours there is increased mortality

5 common causes of hypoxia: low fio2,  hypoventilation, impaired diffusion, shunting, V/Q mismatch such as pneumonia/pulmonary edema/ARDS

PEEP stents open the alveoli.   PEEP reduces preload and afterload in CHFer’s.

Peak airway pressure mostly dependent on resistance of airways because this is calculated to the power of 4.

Trouble shoot a patient with High Paw (level of bronchial tubes/trachea): disconnect the vent and evaluate how hard it is to bag.  If pt is hard to bag the airway not the machine is the cause.  Listen to patient, suction, get a CXR.   Next check Plateau Pressure (level of alveolus).  If no change then there is some type of obstruction such as aspiration or bronchospasm or secretions.  If PP increases could be due to abdominal distension or autopeep)

In asthmatics you have to use low rate, small tidal volumes, and prolonged time for expiration to avoid stacking breaths.  You are willing to tolerate a ph of 7.1-7.2 as long as oxygenation is ok. 

 

Similar strategies for COPD.  In addition only give enough fio2 to keep sats just over 90%.  Higher o2 sats will diminish COPDer’s respiratory drive.

There is an ARDS Network scale to Titrate FIO2 and PEEP.

ACMC has capability to use ECMO for both kids and adults.

Acidotic patients need A LOT of ventilation.   Pt’s can arrest peri-intubation if you don’t keep ventilating them during induction somehow.   Think bagging or bipap ventilation during sedation and paralysis.

PAARUL CHANDRA    TRAUMA LECTURE PELVIC FX’S AND GU TRAUMA

Pelvic fracture with shock has a 35-50% mortality rate

Single break is usually stable. Two or more breaks is unstable.

CT of abdomen/pelvis is considered GOLD STANDARD for  diagnosing pelvic fx’s.

Main issue with pelvic fx’s is hemorrhage control.  Resuscitate with generous blood products, stabilize the pelvis with sheet wrap.   If still unstable, next move may be angiography to embolize an arterial vessel.  If patient is unstable there is usually arterial bleeding.

Most common organs injured with pelvic fx are bladder and urethra.

When considering GU trauma, don’t place foley prior to urethrogram.  If foley already in place, leave it in place.

If urethral tear is partial, some contrast will get into bladder.  If complete, no contrast in bladder.

There is greater risk of bladder injury when trauma occurs with full bladder.

2 types of bladder rupture: intra and extraperitoneal.  Intraperitoneal are treated with surgery. Extraperitoneal are treated with foley catheter.  

Bladder injury symptoms: gross hematuria, inability to void, suprapubic pain.  DX with retrograde cystography.

Renal injuries are graded 1-5 with 5 being most severe (shattered kidney). Grade 1 0% go to surgery. Grade 2, 15% have surgery. Grade 3, 76% have surgery.   Grades 4 and 5  increase from there.   There is also renal pedicle injury.