September 27th Conference Pearls

Trauma Rounds (Dr. Sun and Dr. Farber):

• Consider the possibility of Class II shock in young adult who remains tachycardic after trauma, despite pain control. Caution when sending them to CT Scan!
• Don’t ignore seat belt signs- There is a high association with neck fractures and deceleration, visceral, solid organ, and hollow viscus injury if you see it.
• If you have stable-appearing patients with stable-appearing vitals that underwent significant trauma, get an iSTAT lactate and ETCO2 so you can assess for occult shock early!
• Consider permissive hypotension (~90s systolic) for blunt injury trauma patients if they’re waiting to go to the OR.
• 2+ rib fractures in 3+ adjacent ribs = consider Flail Chest
  • Bare minimum management for Flail Chest: Supplemental O2, analgesics
  • Consider CT chest if stable patient for better assessment of rib fractures
  • Intubation is not always necessary; CONSIDER it if patient is
    • In shock
    • Severe head injury
    • Age >65
    • 8+ rib fractures
    • Underlying lung disease
  • Instead of pain control-only management (with thoracic epidurals), our surgeons are starting to make rib-plating a first to second line treatment (especially in patients with unremitting pain or unable to breathe without a ventilator)

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Alcohol and Alcoholic Ketoacidosis (Dr. Mai Takematsu):

• Anion gap metabolic acidosis with lactate insufficient to account for the gap in alcoholics- think AKA.
  • Ketone test may be negative
  • Treat with dextrose
• Most common ocular symptom for Wernicke’s encephalopathy: nystagmus
  • The classic triad- AMS, ophthalmoplegia, and gait ataxia only seen in 10%
  • If you suspect the diagnosis, have a low threshold to give thiamine.
• No sufficient data for thiamine dosing:
  • Start with 100mg IV
  • Escalate to 500mg if they fail 100mg and you strongly suspect diagnosis of Wernicke’s encephalopathy

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Ketamine in Agitated Delirium (Dr. Vince Nguyen vs Dr. Howard Greller):

Pro:

• Conventional sedating agents work well for the vast majority of agitated patients
• For more on conventional agents, refer to our previous post on Chemical Sedation
• For the 4-8% of patients who are refractory to conventional sedating agents, Ketamine 4-5mg/kg IM can be used as a rescue sedation agent
• For severely agitated patients, use ketamine as 2nd or 3rd line agent to minimize the serious side effects of Ketamine (?increased intubation)

Against:

• Say No To Ketamine for excited delirium syndrome (“SNOT KIDS”)
• Excited delirium is dysregulated dopamine
• Ketamine = etomidate + drooling

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Carbon Monoxide (Dr. Denise Fernandez):

• CO continues to be a leading cause of deaths from unintentional poisoning in the US
• Mechanism of toxicity: Decrease oxygen delivery to tissue and mitochondrial dysfunction –> lipid peroxidation –> cellular death
• Can lead to acute effects and delayed neuro/neuropsychiatric sequelae (DNS/DNPS)
• COHb levels correlate poorly with Sx and poor predictor of who will develop DNS/DNPS
• Treatment is easy:
  • Removal from exposure,
  • Supplemental oxygen with 100% O2 via NRB mask, and
  • Consider HBO therapy early (if indicated):
    • Signs of end organ damage (ex: LOC, AMS, seizures, coma, focal neurologic deficit, cardiac dysrhythmias, myocardial injury) regardless of COHb level
    • COHb level >25% (or >15% in pregnant woman and children)

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Newer Drugs of Abuse (Dr. Angela Regina):

• Know your toxidromes and how to treat them.
• Treat the patient, not the reported ingestion. Use your toxidromes!
• Drugs of abuse are constantly evolving, keep a high suspicion but always exclude any other potential medical issue that may also be present. ​

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Toxic Alcohols (Dr. Sage Wiener):

• If you have an Osmolar gap>25, think about toxic alcohol use
• For further reading, check out our case on Ethylene Glycol Poisoning