Brought to by: Maninder Singh and Priya Ghelani
EM-CCM Interdisciplinary Rounds (Dr. Petrie and Arshad)
- An approach to Petechial/Purpura Rash:
- Febrile and Toxic
- Palpable
- Meningococcemia
- Disseminated GC
- Endocarditis
- RMSF
- HSP
- Non-palpable
- Purpura Fulminans/DIC
- TTP
- Palpable
- AFebrile and Nontoxic
- Palpable
- Cutaneous vasculitis
- Not palpable
- ITP
- Palpable
- Febrile and Toxic
- TTP Classic Pentad:
- Fever (present in 90% of pts)
- Renal disease (hematuria, proteinuria, AKI)
- AMS (strokes, seizures, paresthesias, AMS, coma)
- Thrombocytopenia (10,000-50,000 / cubic mm w/ purpura and bleeding)
- Microangiopathic hemolytic anemia (jaundice, pallor, schistocytes, fragments)
- Helpful Labs
- TTP- decreased activity of the metalloprotease ADAMTS13 (can send level)
- Cr < 2.26mg/dL
- Platelet < 30 x 106/L
- Positive ANA
- Positive Anti RNP
- Positive Anti Smith
- Elevated D-Dimer
- Negative Direct Coombs
- Negative Stool Culture
- Negative vWF protease inhibitor
- Treatment/Supportive Care
- Plasma Exchange
- Antiplatelet agents
- Antithrombic therapy
- Hepatitis B prophylaxis
- Folic Acid
- Steroids for rapid immunosuppresion
- Rituximab- anti CD20 antibody- mainstay of treatment for relapsing disease
- TTP during pregnancy- differentiate from pre-eclampsia, HELLP syndrome and DIC
- Achieve adequate virological suppression- important part of therapy in HIV-associated TTP
Troubleshooting the Ventilator (Dr. Santavicca)
- With obstructive disease (Asthma/COPD), be mindful of Auto-peep
- If hemodynamically unstable, think “thoracic compartment syndrome”
- Distended Alveoli –> choke off IVC –> decrease preload –> decrease CO
- Disconnect the ventilator!!
- Decrease inspiratory time and expiratory phase (I:E ratio of 1:3-4)
- If hemodynamically unstable, think “thoracic compartment syndrome”
- If there is increased work of breathing in a ventilated patient, think “air/flow hunger”
- Look at pressure waveform
- Increase flow and tidal volume (as allowed)
- Consider pressure control
- If you return volume does not match your tidal volume, check for a cuff leak
- Check that tube is all on the way in
- Check that cuff is inflated
- If persistent, may need to exchange tube
- Goals of Oxygenation (PEEP, FiO2)
- SpO2: 88-95%
- PaO2: 55-80mmHg
- FiO2 < 60%
- Goals of Ventilation (TV, RR)
- TV: 6-8 cc/kg ideal body weight
- pH: 7.25-7.33
- Goals of Mechanics
- Driving pressure < 14cm H2O
- Plateau pressure < 30cm H2O
- Peak inspiratory pressure < 40cm H2O (if possible)
- Synchronous flow loops
- Driving pressure < 14cm H2O
- Further reading on Ventilator Settings for Lung Protection
- Further reading on Ventilator Settings for Obstructive Lung Disease
Hematemesis from Jail (Dr. Rueben Strayer of EM Updates)
- If your patient is not responding appropriately to your management options, rethink your diagnosis.
- Always be aware of cognitive biases.
- For a list of cognitive biases, check out Croskerry: Importance of Cognitive Errors in Diagnosis and Strategies to Minimize Them