Brought to by: Nicole Leonard, Maninder Singh and Priya Ghelani
Morbidity and Mortality (Dr. Ghelani and Dr. Barbera):
- Reassess all your patients at sign out. Your consult service or admitting service should never know your patient better than you do.
- As Reuben Strayer emphasized a few weeks ago: If your patient does not respond to your management based on your empiric diagnosis, reevaluate your diagnosis.
- Restraints for unknown etiology for AMS (physical or chemical) should be used with extra caution, especially when there is lack of clear understanding for the etiology.
- Anion gap? Think LKTR
- Lactic acidosis
- Ketosis
- Toxicology
- Renal failure
- AG>30 will have a metabolic acidosis with an identifiable organic acidosis
- Order VBG, Lactate, Ketones, Tox screen (toxic alcohols/EtOH/Salicylate/Acetaminophen levels), and serum Osmolality for these patients
- If you have an Osmolar gap>25, think about toxic alcohol use
- Based on time of ingestion of toxic alcohol, AG and/or OG may not be elevated. Trends can be more useful.
SIM Case 1 (Dr. Yoon):
- Don’t forget your H’s and T’s
- Hypovolemia (give fluids)
- Hypoxia (give O2 via bag mask, LMA or ETT)
- H+ ions (consider bicarbonate and ventilate appropriately)
- Hypo/hyper-kalemia (consider EKG or empiric treatment)
- Hypothermia (warm when possible)
- Thrombosis (Cardiac- consider fibrinolytics or PCI)
- Thrombosis (PE- consider tPA)
- Tamponade (use ultrasound to diagnose and consider pericardiocentesis)
- Tension PTX (consider bilateral needle decompression)
- Toxins (consider TCA, Digoxin, Beta blockers, CCB overdoses or cocaine)
- Trauma (consider ED thoracotomy for trauma)
- TCA overdose presentation = sodium-channel blocking drugs
- Clinical Manifestations
- N/V or Sedation/AMS
- Hypotension/Tachycardia
- Seizures (usually QRS > 100ms)
- Ventricular dysrhythmias (usually QRS > 160ms)
- EKG:
- QRS > 100ms in lead II
- Terminal R wave (R’) > 3mm in aVR
- R/S ratio > 0.7 in aVR
- Management:
- IV sodium bicarbonate (1-2 mEq/kg): start with at least 2 amps
- Repeat sodium bicarb every few minutes until QRS begins to narrow
- Consider intubation/hyperventilation to maintain to maintain pH 7.5-7.55
- Seizures- IV Benzos and consider Fosphenytoin
- NG tube to administer Activated Charcoal (1g/kg)
- Consider Intra-lipid emulsion therapy – will bind lipid soluble toxins
- Remember: not useful during a code setting because it will bind some of your code meds too
- Clinical Manifestations
SIM Case 2 (Dr. Restivo):
- Everyone involved in the resuscitation needs to speak through the code leader to make sure you function as one cohesive team (Ex: “Code Leader, the baby is having agonal breaths”)
- Never forget your fifth vital sign: Fingerstick (especially if altered mental status)
- Infant Botulism
- Intestinal colonization from Clostridium botulinum (blocks presynaptic cholinergic transmission)
- Affects infants from 1 week of life to 1 year of life
- Presentation: Constipation, Poor Feeding, Vomiting, Hypotonia, Decreased gag/suck
- Diagnosis: Stool to isolate C. botulinum spores (but difficult since usually constipated)
- Treatment: IV infusion of Botulism immune globulin (50mg/kg)
- Half-life is 28 days so only need one dose
Further Conference Discussion Points:
- Get comfortable with the Bougie before you need it- it’s very flimsy!
- Neonates: prefer uncuffed tube for concern of tracheal malacia
- Under 1 y/o, ETT: 3.5 (uncuffed) or 3 (cuffed)
- Pediatric Uncuffed ETT size: (Age/4) + 4
- Pediatric Cuffed ETT size: (Age/4) + 4 – 0.5