Conference Topics 8-9-2011

Conference Notes 8-9-2011
If pt has other issues such as endocarditis, fever, mental status changes in addition to STEMI, discuss with cardiologist prior to activating STEMI alert.   Going to cath lab is not always the best option for the complicated MI patient. 
Biphasic t waves V1-V3/4 identifies Wellen's Syndrome.   Which is a tight proximal LAD lesion.  Don't do a Stress Test in this case.   Consult cardiology for consideration of a cath. 
Think twice about activating STEMI when any of these Red Flags are present: Fever, Altered Mental Status, Severe Acidosis or Hyperkalemia, or Trauma.
Case #1   Pediatric SVT treated with Adenosine (0.1mg/kg up to 0.4mg/kg) and then Cardioversion with 0.5-2J/KG
Case#2 Posterior Shoulder Dislocation.  Xray shows lightbulb on a stick.  This is a rare dislocation.    Treat with traction/counter traction.
Case #3 Cyanide Poisoning from a house fire.   Pt with severe metabolic acidosis, nl SPO2, and had a CO level of 12.   Tx with Hydroxycobalamine or sodium thiosulfate or both.
Testicular torsion is complete when cord is twisted over 360 degrees.
Inadequated fixation of testes to tunia vaginalis allows twisting
Bell Clapper deformity is a transverse lie of testicle in scrotum.
Common ages are neonates and 12-18yo.  But can occur at any age. 
Torsed teste should have an absent cremasteric reflex but its not a perfect sign.
Salvage is 90% if you get to OR by 6 hours.   50% salvage at 12 hours.  0% salvage at 24 hours.   
To manually detorse, open the book motion.   End point is pain relief.  Problem is 30% are torsed laterally and opening the book will increase the torsion in these cases.
Patient will likely need pain control or mild sedation to make manual detorsion  possible. 
Epididymitis TX= Rocephin/Doxy for sexually active patients.  Flouroquinalone for those not at risk for STD.    Keflex for kids. 
Torsed appendix testes is the third ddx for the acute scrotum. 
A=aorta (dissection or aaa) A=acidosis (6-8cc/kg TV with high rate maybe 18 for the severely acidotic patient),   B=bagging (watch for overventilation), 
Baby on board (think ectopic, displace uterus from ivc, defib is ok, avoid amio), C=chest compressions (100/min and minimize interruptions),  C=cooling,  D=defibrillation, D=dopes (dislodgement, obstruction, pneumothorax, equipent failure, stacking breaths), E=echo for effusion and embolism (t wave inversion inferior and anterior and tall terminal r wave in avr is  specific for pe), F= forget about it (bicarb, mag, amio, lido, atropine, trandelenburg, lido/defassiculating dose prior to intubation)
Car Buyers can ask the Dealer what their profit  margin is on the car. They are legally required to tell you.   Bottled water has a higher fecal content  than tap water.  
Getting to know how to minimally troubleshoot problems with the IV pumps improves your professionalism with your patients and with the nurses on the care team. 
Cannulate the basilic vein using u/s if you have a patient with poor iv access. Gotta use the long angiocaths.   You can also use u/s to identify veins in the antecubital fossa that can be cannulated. 
When doing IJ central line, pt should be in about 10 degrees of trandelenburg. Don't use too much suction with the syringe.  You can collapse the vessel around the needle.   If the wire gets hung up turn the bevel of the needle 180 degrees.
Bimanual intubation is a very effective way to improve your view of the larynx.