Conference Notes 12-6-2011
URUMOV STUDY GUIDE ENVIRONMENTAL EMERGEN CIES 2
Sorry I didn’t take great notes for this one. I was just absorbing the info.
Treat hydrofluoric acid burns with calcium gluconate gel or bier block or intra-arterial calcium gluconate.
Exercise does not protect you from high altitude pulmonary edema or other altitude illnesses.
HAPE: first finding is rales in RML 2-4 days after ascent. Pt has marked dyspnea on exertion. Treat with nifedipine, cialis. Descent also is therapeutic.
HACE: Most sensitive physical finding is cerebellar ataxia. Medical treatment is steroids. Probably more important is to descend.
Mushroom poisoning toxicity can be estimated by the time of onset of symptoms. If vomiting starts after 6 hours toxicity is likely.
Aminita phylloides and Gyromytra case 50% of mushroom toxicity. Both cause liver toxicity.
Poison Ivy: Leaflets of 3, beware of me. Urushiol is the chemical culprit. Spread by direct contact, indirect contact, airborne. Fluid in bullae does not contain urushiol. Tx with IvyBlock, wash skin and clothes, symptomatic treatment, systemic steroids for severe cases.
Inocybe and Clitocybe mushroom poisoning is treated with atropine. You get SLUDGE syndrome.
Electrical cord bite injury can result in delayed labial artery hemorrhage.
Kauranoparalysis: transient paralysis from lightning strike
Digitalis containing plants: Foxglove, Oleander, Lily of the Valley.
BADILLO ACLS MEGACODES
Supraglottic airway is recommended as initial airway management.
Unstable VT: altered mental status, hypotension, chf, ischemic chest pain, or other signs of shock.
Diagnosing VTach: Fusion beats, capture beats, av dissociation, or concordance.
New recommendation for VTach: Procainamide.
Tx for polymorphic v-tach: Defibrillation acutely, mag for torsades, isoproterenol for brugada. Could also try overdrive pacing.
Afib with WPW will have an extremely fast ventricular rate. Synchronized cardioversion is the way to go. You may need higher doses of electricity. More powerful defibrillator is in the cath lab if needed. Procainamide also can be tried but it takes some time. Mag bolus can also be tried.
Energy doses: regular rhythm 100J Irregular rhythm 200J
In cardiac arrest, Amiodarone is your first choice as an anti-arrythmic. Give 300mg.
VF or Pulseless VT: shock/cpr/epi or vasopressin/amio.
No atropine, bicarb, pacing, calcium in cardiac arrest.
BAROUNIS EMERGENT REVERSAL OF NOVEL ORAL ANTICOAGULANTS
4 UNITS OF FFP is needed to reverse Coumadin. This amounts to a liter. This costs $1000.
ACMC has FIBA but no PCC’s.
The INR of FFP=1.5.
Rivaroxaban is an oral 10a inhibitor, like oral lovenox.
Factor 7, 10, 2 are the ER important factors.
Coumadin inhibits 7, 10. Factor 7 drives INR.
Heparin inhibits factor 10. Lovenox inhibits 10a
Pradaxa is a direct thrombin inhibitor. Renal excretion.
Pradaxa inhibits thrombin production.
If PTT is nl in a patient on pradaxa then don’t work on reversing pradaxa. There is no benefit.
PCC (prothrombin complex concentrates) we don’t have this at ACMC. 3 factor PCC has a lot of factor 2,9,10 and some Factor 7. 4 factor PCC also has a lot of factor 7.
PCC’s reversed PTT in volunteers with rivaroxaban. No effect with volunteers on pradaxa.
Protamin (manufactured from salmon sperm) is indicated for reversal of heparin and also less so for lovenox.
Novo 7 is recommended for reversal of pradaxa (dabigatran) based on animal studies. Very expensive because multiple doses are required. (@$50,000) Novo7 has risk of thrombotic complications. No proven human benefit for reversing head bleed.
FEIBA (factor 8 inhibiting bypassing agent) is in the ER at ACMC. It has factors 2,7,9,10. $1600/dose. Dose at 500-1000units. Works to reduce !NR within an hour. No mortality benefit, but did show reduced hematoma expansion in ICH. Most of the data is for reversing warfarin.
Recommendations:
Pradaxa Bleed check ptt is <1.5X normal=no action needed. Can give FEIBA or FFP and dialysis.
Rivaroxaban Bleed give FEIBA or PCC’s
Warfarin Bleed 4u FFP or FEIBA
Bottom Line: Consider using FEIBA for all you critical bleeding patients that require reversal.
KERWIN LOUGHLIN ORAL BOARDS
Case 1: Endocarditis: Empiric treatment is Vanco and Gent, add nafcillin and rifampin for IVDA
Case2:Carotid dissection: Can result from neck trauma, sudden twisting, stretching. Think about with complaint of head and neck pain. Manage with IV heparin.
Case3:Sickle Cell related stroke: Treat with exchange transfusion.
Test Taking Points: Moved expeditiously thru the cases.
MED STUDENT REVIEW
VILLANO METHEMOGLOBINEMIA
Ferrous iron is oxidized to ferric iron. There is equipoise usually in the body between ferrous and ferric iron in hgb. Methemoglobinemia is an increase in the ferric form.
Risk Factors: Dapsone, benzocaine spray, nitrites/nitrates, pyridium, sulfonamides, amyl nitrate, auto exhaust, poppers, analine dyes, and smoking.
Suspect methemoglobinemia if: cyanosis not susceptible to 100% o2, chocolate brown blood, lactic acidosis. Also in real life and on boards think about methemoglobinemia if the pulse ox is around 85%.
ABG with Co-ox: look for gap between O2 sat and Co-ox measurement.
Tx with methylene blue in symptomatic patients or if methem level is >20%. Not recommended for children under 6 years old. If you have a young kid consult tox and use a low dose.
Other considerations: exchange transfusion or hyperbaric oxygen therapy
Admit: if you use meth blue put them in the unit. Can go home if level comes down to <15% without methblue.
LOVETT PI UPDATE
EICU attendings will be following patients waiting for MICU bed.
There are CHF and Asthma protocols in PICIS Forms.
Sign out culture : be sure to review labs prior to signing out
Bounce back report being developed.
SAYGER ADMIN/PT RELATIONS
I was not present for this lecture unfortunately