Conference Notes 1-3-2012

CARLSON  TOXIC ALCOHOLS

Ethylene Glycol:  Metabolized to oxalic acid that can cause renal failure. Severe metabolic acidosis  can cause Kussmaul respirations. 

Calcium oxylate can cause renal tubular necrosis.

Presumptive diagnosis with ph <7.3, bicarb <20, Osmolar Gap>10, Urinary oxylate crystals. 

Definitive DX= serum EG level

Osmolar Gap: 2Na + BUN/2.8 + Glucose/18 + ETOH/4.6.   Nl OG is -14 to +12

Rough EG Level= Osmolar gap X 6.2

To get an EG level you gotta order it stat and make sure the lab call Quest Lab to pick it up.  Gotta follow up on it!

Other causes of elevated osmolar gap:propylene glycol (iv ativan, iv dilantin), acetone, mannitol, sorbitol, ivp dye, glycerol from scope mouth wash.

Anion Gap= Na-(CL + Hco3)

EG poisoning urine may show calcium oxylate crystals (50%) or flourescence.

TX: NaBicarb to keep ph over 7.3, Mag, Calcium, Fomepizole to inhibit ADH,

Indications for Fomepizole: EG level >20, Early suspicion + OGap >10,  Late suspicion + 2 presumptive criteria.

Fomepizole dosing: 15mg/kg up to 1 G followed by 10mg/kg Q12 hours x 4 doses  then 15mg/kg Q12 hours.  Reduce interval to Q4 hours during dialysis.   Increasing acceptance of using fomepizole  as monotherapy without dialysis.  Criteria for monotherapy is ph>7.3, modest anion gap, no renal dysfunction, adequate supply of fomepizole.  Kids are better candidates for monotherapy than adults due to metabolism differences, but adult could possibly use this therapy as well.   Headache is a common side effect of Fomepizole.  Patients with significant acidosis will need dialysis.

ETOH Therapy: Only use if no access to Fomepizole.  It can cause hypoglycemia in kids. 

Also give pyridoxine when treating EG poisoning.

Methanol:     Dermal and inhalation exposure can be significant.  Metabolized to formic acid which goes to eyes and can cause blindness.   Patients will have CNS depression and vision disturbances.  Renal function should remain normal.    Classic CT/MRI finding is basal ganglia hemorrhage.   Two things can cause that finding CO and Methanol.

TX: Folate, Dialysis, Fomepizole.  Fomepizole can be used as monotherapy with same caveats as noted above for EG poisoning.

 

ISOPROPANOL    Very intoxicating.  Patients will have Osmolar gap with elevated serum acetone and ketonuria.   Patients won’t have significant acidosis.  May have GI bleeding.

CHASTAIN/ANNEKEN  ORAL BOARDS

Case 1:Type A Aortic Dissection.   Think dissection with sudden symptoms above and below diaphragm.  BP was low due to early pericardial fluid.

Case2: Fight Bite.  Should give IV Unasyn promptly.   Pt needs admission for IV ABX and Hand Surgery.

Case3:Hypertensive Encephalopathy/Seizure  from cocaine overdose.  TX with hi-dose benzos and nipride or nicardipine.

KUTKA   PENETRATING NECK INJURIES

Current mortality is 3-10%.   Laryngotracheal injury is 20% and

Zone 1: sternal notch to cricoid cartilage

Zone 2: circoid to angle of mandible

Zone 3:above the angle of mandible

Anterior and posterior triangles are bisected by SCM.

Brown Sequard: Hemi section of cord with ipsilateral hemiplegia and loss of pain and temperature sensation on contralateral side.

Can get Horner’s syndrome in Zone 3 injuries.

Evaluating for trachea-laryngo injuries can be done with CT.  

Evaluate for Pharyngo-esophogeal injuries with CT, esophogram, endoscopy.

Evaluate for vascular injuries with CTA. Can also use color flow Doppler but it is operator dependent and some vessels have a limited view.

Controversy on surgical vs non-invasive management of Zone 2 injuries.   Most Trauma centers will do noninvasive work up for  Zones 1 and 3.  

MISTRY  ADMIN  UPDATE

Please give feedback on new cordless speculums.

Were are collecting data on ED thruput for the government (CMS).    Please fill out specific Blue section of Dr. Note in IBEX as soon as you have an admit discussion with an attending.

New Electronic Med Record  Kick Off tomorrow in 190W.

New Admission Process.   For uncovered admits transfer attending call to 4590 so they can give admit orders.

KESSLER   CONSULTATION  IN THE ED

We lack training in communication and consultation in undergrad and graduate medical education.

Important components of a consultation: organized, prompt, pleasant, polite.   #1 is Be Nice!

Small talk helps alittle.  It builds relationships.  Be cautious with this.  The consultant may be in a hurry.

Prior to speaking with a consultant, know your choices, gather up all the data, decide what your question or direct need is.

5C’s of Consultation

contact: identify yourself and the consultant

 communicate: concise and accurate of clinical picture

 core question: what’s the question/need of consultation

 collaborate: open to and incorporates consultant’s recommendation

 close the loop: Review and repeat patient care plan, Thank consultant

 Be sure to document your conversation.

Behavioral Profile: Get other people to do what you want them to do and be happy about it. 

The Platinum Rule: Treat others the way they want to be treated.

Consultant personality types: Open/Guarded     and   Indirect/Direct

Tailor your style of consultation to the specialty of the consultant.

Use problem solving and creative thinking to get what the patient needs.

Practice is important to perfect your consultation style.