Conference Notes 1-16-2019
Katiyar Billing and Coding Lecture
Unfortunately I missed this outstanding lecture.
Katiyar Study Guide Orthopedics
Pediatric Hip pain differential
Kennedy/Jurkovic Oral Boards
Case 1. 47 yo male presents with abdominal pain and hematemesis. Patient has history of ETOHism. On exam, patient was hypotensive and vomiting large volumes of blood. Diagnosis was life-threatening variceal bleeding. Management included crystalloid and blood product resuscitation. Intubation. octreotide, PPI, reverse coagulopathy, antibiotics, and blakemore tube. GI consult and emergent endoscopy were all also indicated. Consider vasopressin. If endoscopy is not successful, consider IR for TIPS procedure.
Case 2. 62yo male patient with altered mental status. BP=85/62. Heart rate 46. Patient had history of thyroidectomy and clinical picture of hypothyroidism. Diagnosis was myxedema coma with hypoglycemia, hypothermia, and bradycardia. . Patient was intubated and paced. Patient was given IV dextrose, IV Synthroid, and IV hydrocortisone. Beware of massive tongue in patients with myxedema coma. It may make intubation more difficult.
Case 3. 27 yo female involved in a motorcycle crash. BP=165/105 P=105. Patient injured her wrist. X-ray shows perilunate dislocation. You can attempt reduction in the ED using finger traps. Most of these patients need surgery.
Goodmanson The Legend of the Ventilator
Thanks to Dr. Lovell for writing the notes for this lecture!
Initial Settings:
Lung Injury:
Mode: AC
TV: 6-8 cc/kg IBW (protective)
Rate: 16 higher side....mid/high teens
FiO2: start high, titrate down ASAP!
PEEP: 5 to start, may go up
-versus-
Obstructive Disease:
Mode: VC
TV: 8 cc/kg IBW
Rate: 8-10 (lower, think permissive hypercapnea)
FiO2: start high, titrate down ASAP!
PEEP: 5 to start, may go down
Goals: Higher flow rate, higher I:E ratio which is most impacted with slow RR
Increase oxygenation: increase FiO2 or increase PEEP
Increase ventilation: increase RR or TV, but really it’s all about the RR-shouldn’t exceed 8 cc/kg IBW
Airway Pressures:
Peak Pressure = Vt + Insp flow rate + airway resistance + lung compliance (focus on resistance and compliance)
Plateau Pressure = Vt + lung compliance (focus on lung compliance)
Hi peak + nml plateau = Hi resistance
Hi peak + Hi plateau = decreased compliance
Peak pressure continuously reported, but Plateau pressure obtained through inspiratory hold
The Crashing Ventilated Patient: DOPES mnemonic
Think:
Dislodgement
Obstruction (of tube or of patient)
Pneumothorax or Patient (eg big PE)
Equipment failure
Stacked breaths (auto PEEP)
Do:
Disconnect from the ventilator (P, E, S)
Begin BVM ventilation
Feel, look, listen (D, O, P, S)
Pass a suction catheter or bougie through the ETT (O)
Consider needle/finger thoracostomy (P)
Consider manual expiration maneuver (S)
Auto-PEEP (aka breath stacking):
Look at Flow display on ventilator for incomplete emptying-expiratory flow is still occurring at the beginning of the next breath
Prevent by decreasing respiratory rate
Correct by disconnecting ventilator, manual expiration maneuver (lean on chest)
Remember, tension pneumothorax and breath stacking represent same end-pathophysiology (obstructive). Use US if you have time, otherwise needle the chest bilaterally if patient coding.
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