Conference notes 5-1-2012

Conference Notes 5-1-2012


Case 1  Eczema herpeticum.  Treat with anti-virals and anti-staph antibiotics.   Acyclovir takes mortality down from @10% to 0%.  Can complicate eczema.   Staph is a frequent co-infection.   Eczema herpeticum is more likely to be painful lesions in contrast with impetigo. Diagnosis more likely in patients taking immunomodulators for eczema.    DO NOT GIVE STEROIDS!   


Case 2   Fish hook embedded  in thumb.  EP should remove fishhook, examine for nerve or tendon injury.  Irrigate wound if possible. Consider prophylactic antibiotics.  Check tetanus status.


Case 3 Cervical Epidural Abscess.  MRI is superior to CT for diagnosis.  Consider in pt’s with: iv drugs, dm, steroids, invasive procedures, trauma, immucompromised.   Consult neurosurgery.  IV antibiotics.


  1. Peds SVT : treat with adenosine 0.1-0.2mg/kg, next amiodarone 5mg/kg.  If unstable can cardiovert 0.5-1j/kg.
  2. V-fib: Defibrillate with 2j/kg double dose if unsuccessful.  Epi  0.01mg/kg, amio 5mg/kg.  Post resuscitation avoid hyperoxia and consider cooling.
  3. V-tach: synchronized cardioversion 0.5-1j/kg,  if failure then increase to 2j/kg.
  4. Hypoglycemia and shock: 0.5-1g/kg dextrose which means D25W: 2-4 mL/kg, D10W: 5-10mL/kg.  For hypovolemic shock give repeated 20cc/kg boluses



Use a high frequency 5-10MHz probe

Graded Compression: slow gently increased compression on abdomen.

Appendicitis:  Appendix is medial to psoas and anterior to iliac vein.  Target sign on transverse view.  Non compressible, Fluid collection, Target sign, Diameter>6mm (mnemonic is NFTD nothing further to do)

Intussusception: Use graded compression.  Follow the expected contour of the colon.  Again look for a target sign.

Pyloric Stenosis: find stomach first and go to pyloris.  Anterior and lateral to aorta. Abnormal pyloris is too thick or too long.


The 4 step approach to acid base disorders


Step 1: Get the labs (VBG=ABG), you need Na, Cl, HCO3, pH and PCO2


Step 2: Calculate the anion gap (Na - (HCO3+ Cl) Normal is < 15, abnormal > 15


Step 3: RULE of 15, the PCO2 and the last two digits of the pH should be the bicarb + 15. 

ie- if bicarb is 15, PCO2 should be 30 and the pH should be 7.30

3 Possibilities of PCO2:

1. it is what it should be (simple wide gap metabolic acidosis with respiratory compensation)

2. The PCO2 is lower than it should be (patient is breathing faster) primary respiratory alkalosis

3. The PCO2 is higher than it should be (patient is breathing slower) primary respiratory acidosis


Step 4: 1:1; Normal bicarb - 24, normal gap = 15

The CHANGE or increase in anion gap from baseline should = the change or decrease in the bicarbonate

ie if the anion gap is 30, the change or delta gap is 15 (30-15=15) therefore the bicarb should decrease by 15 (24-15= 9)

3 possibilities of bicarb:

1. It is what is should be (simple wide anion gap acidosis)

2. The bicarb is LOWER than it should be (in the above case if the bicarb was 5 instead of 9) additional primary non-gap metabolic acidosis

3. The bicarb is HIGHER than it should be (in the above case if the bicarb was 15 instead of 9) additional primary metabolic alkalosis



Remember at SEVERLY low bicarbs the pH and the pCO2 will be less reliable. the PCO2 is not +15 when bicarb <5, it is 15. 


Sorry I went a little fast and I can send out the ppt later if you want to practice the cases.



Alpha Agonists, Beta Blockers, Calcium Channel Blockers, Digoxin

Alpha Agonists (clonidine): centrally acting antihypertensive.  Onset  30-60 minutes after ingestion.  Pt will get hypotensive.   They wil have respiratory depression, lethargy and coma, miosis.   Treatment is supportive.   Try narcan, it may help.   This overdose will look somewhat like an opioid overdose with more hypotension.

Beta blockers:  Usually symptomatic by 2 hours.  Look for hypotension, bradycardia, and early altered mental status.   Seizures are possible.     Pt’s can have normo to hypoglycemia and mild hyperkalemia.  Tx with atropine,  glucagon (activates g protein that increases cyclic amp by alternate no beta receptor pathway) 5 mg over 5 minutes.   Glucagon may induce vomiting.  Tx also can include calcium, pressors,  hyperinsulinemia-euglycemia ,  intra-lipid can be tried in crashing pt.   Pacing and balloon pump may be required.   Can d/c to psych for immediate release form and asymptomatic after 6 hours.  All other admit to tele or icu if abnormal vitals.

Calcium Channel Blockers: Dihydropyridines cause decrease in smooth muscle tone andlower bp.  Monohydropyridines affect cardiac conduction and cause bradycardia.   Look for hypotension, bradycardia, hyperglycemia, late mental status changes, acidosis.  Treat with Calcium  (1g chloride central, 3g gluconate peripherally) , iv fluids, iv atropine,  insulin-glucose therapy (insulin is a pressor/response may take 60 minutes/bolus 1u/kg and infuse 0.5-1u/kg/hr/titrate to bp>90/give D50/hypoglycemia doesn’t happen as much as you would think), glucagon, intra-lipid.  Have a low threshold to put pt in ICU.


Digoxin:  Recently covered in a previous conference.   Look for nausea/vomiting and arrhythmia.