Conference 7-19-2011

7-19-2011  Conference Highlights
STUDY GUIDE Tetanus shot  (td) safe in pregnancy.   Avoid Tdap in pregnancy.  Rapid sequence drugs are ok. Propofol and narcotics are ok if not near delivery.   Avoid NSAID's because it reduces uterine blood flow.
Highest radiation risk to fetus neuro development is 8-15 weeks post conception  Highest teratogenicity is 2-8 weeks as this is period of organogenesis.
Mastitis: staph most common organism, have mom continue breast feeding unless there is an abscess
Hydatidifrom mole:  presents with 1st or 2nd trimester bleed, hyperemesis, very high beta hcg.  Treatment with d and c.   Associated with choriocarcinoma.
Kleihauer Betke test is basically only for identifying large fetomaternal hemorrhage that would require extra rhogam. 
Mondor's Disease:sperficial phelbitis nar breast, benign and disappears spontanously
Arachnoid Cyst:  Can present with headache or seizure.   Cysts can also occur in spine.   JoEllen's pt had cervical cord compression from the cyst.
In the fussy child always consider shaken baby or other types of abuse.   Look for incarcerated hernia, hair tourniquet, corneal abraision, torsion, cardiac disease etc.
Intussusception:  usually ileocolic junction.  6-36 month old child.  male:female ratio 4:1.   70% will be heme positive.  Atypical presentations include lethargy in 20%.   Child will progressively worsen.  
Diagnosis with ultrasound or barium enema. Recurrence rate of 30% usually in the first 48 hours. 
EKG Basics:  Systematic Approach is Rate,  rhythm, axis, conduction, s-t segments
wandering pacemaker=slowed down version of MAT 
Heart Block analogy of your significant other "stepping out on you" .  The relationship gets worse untile in third degree block,  the p and the QRS never see each other. 
Tachyarrythmias:  Break it down to Wide/Narrow and Regular/Irregular
V-tach has fusion and capture beats
Can't miss issues:brugada, wellen's,  long qt, wpw
EKG case presented with tachycardia and posterior ami findings
Vijay and Elise
Case #1=Lemierre's Syndrome (septic thrommbophlebitis of IJ) with septic emboli to lungs.  Lungs are most common secondary site.  Broad spectrum abx and consider anticoagulation.  Affects young patients.
Case#2=Multiple Trauma with flail chest/ pulmonary contusion and hemoperitoneum.    Hypoxia is max at 48 hours after pulmonary contusion.
Case#3=Ulnar Collateral ligament rupture of thumb.  Thumb spica Splint with outpt ortho follow up.
KILLER BABIES, HTN in pregnancy
Treatment of pre-existing htn: don't treat for less than 150/100.  po labetalol or methyl dopa
Gestational htn: no proteinuria
Pre-ecclampsia: BP=/>140/90, proteinuria, edema no longer in definition.  risk fractors: first kid, obesity,htn, dm.   Severe pre-ecclampsia is defined by signs of organ failure.  Definitive treatment is delivery. Treat BP with labetalol or hydralazine.  Get BP down to 130/80
Ecclampsia: seizures are self limited.  It can be ecclampsia even if BP is ok and there is no proteinuria.  Also consider other structural or metabolic causes of seizure in the patient without elevated BP or proteinuria.
Magnesium 6 grams bolus then 2gram/hour.  Can give IM magnesum 5gm in each buttock.   Calcium gluconate is antidote for magnesium toxicity.  
Preecclampsia/ecclampsia can occur up to 6 weeks after delivery.
THink HELLP Syndrome in pregnant patients with epigastric or ruq pain.
Intra-nasal administration of drugs: need low volume and high concentration of drug to use this route.   Can use this route for fentanyl, versed, narcan, flumazenil.     
Fentanyl dosing this route is 2micrograms/kg.  Morphine is 0.1mg/kg.  Versed is 0.2mg/kg.  Narcan is 1mg in each nostril.  Ref.