McKean/Logan Oral Boards
Case 1. 10 month old child drank gasoline. Child had respiratory distress and bilateral pulmonary infiltrates. Patient was intubated to treat aspiration of gasoline.
In addition to pneumonitis, patients with hydrocarbon ingestions can develop CNS depression, seizures, and arrhythmia. Catecholamines, antibiotics, and steroids should be avoided.
"Treat hypotension with aggressive fluid resuscitation. Avoid administration of catecholamines such as dopamine, norepinephrine, and epinephrine. Catecholamines may cause dysrhythmias, especially after exposure to halogenated hydrocarbons and aromatic hydrocarbons. Hydrocarbon-induced dysrhythmias are generally seen shortly after the exposure, especially with inhalational use. Continuous cardiac monitoring should be initiated, and an ECG should be obtained. For hydrocarbon-induced ventricular dysrhythmias, class IA (procainamide) or class III (amiodarone, bretylium, and sotalol) antiarrhythmics should be avoided because of the risk of QT-interval prolongation.18 Propranolol, esmolol, and lidocaine have been reported to treat these ventricular dysrhythmias successfully.10,18,39
There is no benefit to gastric lavage because risks of aspiration far outweigh any theoretical benefits.40 Activated charcoal does not adsorb hydrocarbons well and poses a risk for vomiting and aspiration, so charcoal is not recommended either. I (Tintinalli reference)
Case 2. 29 yo female with syncope. Upreg is negative.
Arrythmogenic RV Cardiomyopathy
Case 3. 74 yo male with knee pain. Patient fell at Wrigley field. On exam patient cannot extend the knee against gravity.
Patient needs orthopedic consult for surgrical repair.
Kishi 5- Slide Follow Up
Treatment for Acute Flash Hypertensive Pulmonary Edema also known as Sympathetic Crashing Acute Pulmonary Edema (SCAPE)
Nitro sprays followed by Nitro drip at 100mcg/min
Start patient on bipap
Limit diuretic use as these patients are frequently hypovolemic. If you think the patient is hypervolemic, cautious IV lasix may be indicated.
Dennis Ryan comment: sublingual sprays give 400micrograms per dose. This is a good way to give big doses of nitro early on.
Miner 5 Slide Follow Up
Microangiopathic hemolytic anemia, one of the cardinal features of hemolytic-uremic syndrome, may be profound with a hemoglobin level between 5 and 9 grams/dL. A peripheral smear demonstrates schistocytes, helmet cells, and burr cells. The Coombs test is negative. The platelet count is <150 000/mm3. The WBC count may be elevated.
Hyponatremia and hyperkalemia develop as a result of metabolic acidosis from renal failure, and hyperbilirubinemia results from acute hemolysis. (Tintinalli reference)
Aytpical HUS is differentiated from HUS by the fact that it is not caused by toxin producing ecoli.
Jones 5 Slide Follow Up
Bedside echo is key to the evaluation of acute chest pain and hypotension.
If you see cardiac tamponade on bedside echo, think aortic dissection.
Johns 5 Slide Follow Up