Conference Notes    11-8-2011

STEMI CONFERENCE

Some code 60’s are very tough calls.  

STUDY GUIDE  TOX   ANDREA CARLSON

Asymptomatic kids who ingested  sustained released verapamil need admission.

Eating a cigarette by a kid will not cause significant nicotine toxicity.  It will only cause vomiting.  Eating a tobacco plant is more likely to cause toxic nicotine levels.

NAC increases glutathione supply, detoxifies NAPQI and enhances microvascular function.   It can also scavenge free radicals.     

NAC is equally effective if given at any time in the first 8 hours after ingestion.   So you can give AC and wait until you get a 4 hour APAP level.

LSD gives you synesthesias which are you can taste sounds or feel  sights.    MDMA (ecstasy) causes bruxism.   Think of Ravers using pacifiers.

Glucagon increases CAMP to overcome beta blocker toxicity.

Things that cause wide QRS (quinidine effect): TCA’s, Carbamazepine, Propoxyphene, Benadryl, Cocaine 1a’s (PDQ: procainamide/disopyramide/quinidine), some 1c’s(encainide/flecanide).   All also have an an anticholinergic appearance to their toxidrome.

Avoid the interation between clarithromycin and digoxin.  Will increase risk of digoxin toxicity.

Intubation of patients with salicylate toxicity is fraught with hazard due to need for hyperventilation to maintain relatively normal ph.

Insulin in the setting of calcium channel blocker toxicity acts by providing glucose to myocytes for energy.

Glucagon causes emesis.

All antidotes work for CCB and Beta Blocker overdose: atropine, glucagon, high dose insulin.

Pepto Bismol contains asa.   Oil of wintergreen has a lot of asa (methyl salicylate)in it.  Ben Gay has oil of wintergreen in it.

Caffeine competes with adenosine at the adenosine receptor.   Also theophylline competes at the adenosine site.

ORAL BOARDS    RICCARDI  and KATIYAR

Case1:Splenic/renal  artery aneurysm rupture in a pregnant woman.  More common in multips due to repeated progesterone/estrogen fluxes in pregnancy.  Treat hemorrhagic shock.

Case2: ASIS avulsion.  Treat conservatively with pain control and crutches.

Case3: ASA toxicity.  Treat with fluids/bicarb drip/dialysis.   ABG with metabolic acidosis and respiratory alkalosis.    Important to give potassium when al

Comments on technique of examnee: Good pace.  Thorough exam.  Increase blood type and cross to 4-6 units.  Important to do a FAST at the bedside.  Once you identify intraperitoneal fluid you are going to OR.  Good to  Start transfusion.

Difficult cases.  Good rapid review of systems.  Good to ask about appearance of injured extremity.   Good nv exam of injured extremity.

PATIENT AUTONOMY      SHAYLA GARRET-HAUSER

Great read on medical ethics: The Immortal Life of Henrietta Lacks

Non malficience, justice, beneficence, patient autonomy are the pillars of Medical Ethics.    Hippocratic Oath only covers the first three pillars.

Voluntary consent to procedures did not become a medical concept until the Nuremburg Code post WW2.

Autonomy is a right to non-interference, not a right to every requested medical treatment . Doctors are not obligated to provide treatment they consider of no benefit.

There is a power/knowledge differential between doctor and patient.   Thus we control option that are offered to patients.   We need to understand patients values to know how to tailor their options.   

 Nothing trumps the MD in charge of a resuscitation.  If MD feels it is futile, the MD can stop resuscitation despite family wishes. 

Case discussion on should you perform drug testing on a 15yo patient who refuses test and parents demand it.     No one in auditorium will forcibly obtain urine from patient. But if patient voluntarily gives urine most would do test.    Same with pelvic exam or other evaluation.  The bright line for most MD’s in the room was if you have to forcibly restrain/sedate pt to get some evaluation done, they would not do it.

MED STUDENT REVIEW