The sickest patients, who receive world-class care in the trauma/critical care bay of University of Louisville Department of Emergency Medicine
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Termination of resuscitation (Nichols)When to stop resuscitation in out of hospital arrestDNR order No chance of saving them–safety, signs of irreversible death Nothing left to do–unwitnessed arrest, no shockable rhythm, ROSC does not return in the out of hospital setting Stop CPR if:No ROSC No shocks Unwitnessed CCU follow up (French)Arrhythmogenic RV dysplasia2nd MCC sudden cardiac death in young patients Greek or Italian descent Male:Female= 3:1 PresentationAsymptomatic Palpitations Syncope Ventricular dysrhythmias/cardiac arrest FH of unexplained syncope/sudden death RV failure Cards consult–>admission Arrhythmogenic RV dysplasia EKG: V1-V3 T wave inversions, epsilon wave HOCM EKG changes: high voltage, LVH, lAD, tall R wave V1 MICU follow up (Schutzman)Myxedema comaHypotension Bradycardia Electrolyte derangements Altered mental status Give levothyroxine Jeopardy (Daughtery)Activated CharcoalAdsorbs toxins and inhibits GI absorption Must be given in 1-2 hours, but still consider if ingested drug is extended release Contraindications: GI perforation, need for endoscopic procedures Concerns: emesis, CNS depression and aspiration risks Consider risk vs benefit of administration DeferoxamineMOA: complexes with trivalent ions (ferric ions) to form ferrioxamine which is eliminated in urine by the kidneys Indications: iron level >500, metabolic acidosis, lethargy/coma, shock, toxic appearance Can cause urticaria, flushing of skin, hypotension, shock with rapid IV administration, ARDS Itralipids (lipid emulsion)Reversal of local anesthetic systemic toxicity Consider for severe hemodynamic compromise of lipophilic xenobiotics or drugs with significant neurological or CV toxicity–last line 20% emulsion solution PhentolamineMOA: competitively blocking alpha adrenergic receptors Indicated in pheochromocytoma hypertensive crisis, extravasation of norepinephrine/epinephrine, hypertensive emergency with end organ damage secondary to cocaine toxicity not responsive to appropriate sedation Concerns: hypotension, medication safety LevocarnitineAntidote to valproic acid Give when: moderate to severe hyperammonemia, valproate level >450, CNS depression, severe hepatotoxicity Naloxone for clonidine reversalBig doses- 10mg Consider for reversal of CNS depression Fluids and vasopressors may also be required BenzodiazepinesMidazolam: IV onset of action 2 min Lorazepam: onset of action 5-20 minutes Physostigmine Reversal of anticholinergic toxicity Primarily for agitation and delirium reversal MOA: inhibits acetylcholinesterase and prolongs the central and peripheral effects of acetylcholine Have physician and atropine at bedside No significant risk of seizures Low dose, push slow FlumazenilBenzodiazepine overdose or reversal only Competitively inhibits activity of BZ receptor site on GABA/BZ receptor complex Not effective on other medications that affect GABA ConcernsCould precipitate withdrawal seizures if patient regularly uses benzos Seizure history outside of withdrawal seizures Risk vs benefit–goal of therapy Project ECHOOptimal Aging Clinic will be added to discharge follow up options Have a “what matters” conversation Advance DirectivesLiving will POA POLST/MOST EMS DNR Advanced care planning–ICD code, must spend 16 minutes to bill MOST formA physician’s order Must be honored by all KY healthcare providers in all KY settings State of KY Hierarchy of Decision making authority if no advance directivesCourt appointed guardian Healthcare surrogate Spouse Adult children Parents Adult siblings Closest living relative ECMO (Ritchie)ComponentsMotor/pump Filter/oxygenator Blender Ventilation–to increase, go up on gas flow aka sweep Oxygenation–to increase, go up on blood flow aka flow Cannulas (single vs double) CircuitsVein-Vein ECMOIs the heart still able to pump Vein-Artery ECMOHeart pump function not ideal Vein-Artery-Vein ECMO VV ECMO IndicationsHypoxic respiratory failure, 50% mortality risk consider ECMO Hypoxic respiratory failure, 80% mortality risk, put on ECMO CO2 retention on mechanical ventilation despite high Pplat Severe air leak syndromes Need for intubation in a patient on lung transplant list Immediate cardiac or respiratory collapse (PE, blocked airway, unresponsive to optimal care) Anytime patient is on dangerous vent settings Murray Score: conventional ventilation or ECMO for severe adult respiratory failure Score of 3–consider transfer to ECMO center Score of 4– ECMO indicated ContraindicationsNo absolute contraindicationsMechanical ventilation at high settings for 7 days or more Major pharmacologic immunosuppression CNS hemorrhage that is recent or expanding Non-recoverable co-morbidity When making the decision to begin ECMOIs this condition reversible? Is it a bridge to transplant? RESP score (estimated survival once on VV ECMO) ARDS Ventilator traumaVolutrauma Barotrauma Atelectrauma Biotrauma (cytokine storm, inflammation) Energytrauma (goal for driving pressure 15 or less) Settings once cannulation successfulSet flow: 4L Set Sweep: 4L Lung rest settings while on ECMO PC 10/10/10/40% Goals VA ECMOIndicationsHeart failure bridge to recovery, heart transplantation, VAD Cardiogenic shock Myocarditis ECPR Right heart failure PE Medication overdose SAVE score Trans pulmonary pressureConsider in morbidly obese patients May have higher PEEP requirements given pressure from chest wall/abdomen When intubated, they lose the ability to autopeep Page Jewish thoracic or cardiac surgery –consult early
ITE- grab bag (E Thomas)Spider bite, necrotic wound>brown recluse MCC erythema multiforme> HSV Strawberry cervix>trich Pre-E, less than 24 weeks>mole pregnancy Abdominal pain after sex>ovarian torsion Most common personality disorder>borderline Patient intentionally fakes symptoms>malingering Sudden paralysis after traumatic event>conversion Discriminatory zone for TVUS>1500 PID/RUQ pain/shoulder pain>Fitz Hugh Curtis MCC postpartum hemorrhage>uterine atony Pizza pie fundus>CMV Corneal dendrites>HSV keratitis Tachycardia out of proportion to fever>thyroid storm Alcohol, AMS, ataxia, nystagmus>wernicke Stingray wound>hot water Beta blocker OD>hypoglycemia One Pill Can Kill (Lund)Ingestions–fatal in small dosesCCB Cyclic antidepressants Lomotil Opiates Salicylates Toxic alcohols Sulfonylureas Camphor Clonidine Antimalarials CCB ODHypotension, bradycardia, bradydysrhythmias, hyperglycemia Tx: charcoal, fluids, atropine, calcium, intralipid SalicylatesOil of wintergreen, ASA, pepto-bismol n/v, tinnitus, delirium, hallucinations, pulmonary edema, cerebral edema, mixed anion gap metabolic acidosis with respiratory alkalosis SulfonylureasHypoglycemia, lethargy, irritability, confusion, HA, seizures Tx: observation x24 hrs Dextrose bolus, then consider infusion Can give octreotide (inhibits secretion of insulin) ClonidineAlpha 2 agonist, (afrin, visine) Opioid syndrome: lethargy, coma, miosis, respiratory depression Tx: naloxone, atropine, IV fluids, inotropes CamphorCampho-phenique, vicks vaporub GI distress, generalized warmth, CNS hyperactivity, CNS depression, n/v, oropharyngeal irritation/burning/stinging Tx: benzos, phenobarb AmitriptylineCNS depression, seizures, cardiac conduction abnormalities (QRS prolongation), hypotension, mydriasis, flushing, dry mucous membranes, hallucinations, hyperthermia Tx: benzos for seizures, sodium bicarb for QRS widening >100ms LomotilOpioid receptor agonist +/-atropine Classically biphasic, with anticholinergic symptoms 2-3 hours s/p ingestion followed by opioid symptoms Tx: naloxone Dispo: admit Toxic Alcohols (Bosse)EthanolCan cause hypoglycemia Is dialyzable IsopropanolRubbing alcohol Metabolized to acetones No metabolic acidosis Supportive treatment, can be dialyzed MethanolWindshield washer fluids, solid cooking fuel, embaling fluid, tainted beverages Toxic metabolite is formate (formic acid) CNS effects, visual effects, pancreatitis, symptoms delayed in onset Metabolic acidosis with elevated anion gap Ethylene glycolAntifreeze (sweet taste) Toxic metabolites: oxalate, glycolaldehyde, glycolic acid, glyoxylic acid CNS effects, metabolic acidosis, renal toxicity, myocardial dysfunction Oxalate can cause hypocalcemia by calcium oxalate precipitation Oxalate crystals in urine Wood’s lamp to urine, antifreeze products may contain fluorescein, not a great test Osmol gapDifference between measured serum osmolality and calculated serum osmolarity Normal serum osmolality: 275-295 mOsm/kg AntidotesEthanol, fomepizole Competitive inhibitors of alcohol dehydrogenase If ethanol must be used, give orally. Keep blood level >100mg/dL Treat if methanol or ethylene glycol level >20mg/dL Can be stopped once level less than 20mg/dL DialysisConsider if patient has end organ manifestations (even if levels undetectable) Folic acid for methanol Thiamine and pyridoxine for ethylene glycol Send methanol and ethylene glycol levels ASAP
Aspirin Toxicity (Harmon)Sources of salicylatesAspirin Oil of Wintergreen Pepto-Bismol Bengay Alka-Seltzer Skincare products Mechanism of toxicityFatal dose 10-30 g in adults Dose dependent Acute vs chronic Increases respiratory center sensitivity, uncouples oxidative phosphorylation, inhibits TCA cycle/amino acid metabolism, stimulates chemoreceptor/trigger zone signs/symptomsTinnitus, nausea, vomiting, dizziness, fever Ataxia, anxiety, lethargy, AMS, seizure, arrhythmias, seizure Evaluation in EDSerum salicylate concentration and trend ABG CBC, CMP, coags, EKG, UA, tox ManagementGastric decontamination (ingestion w/in past 1-2 hours) Sodium bicarb (consider if level >40) Avoid intubation as long as possible Fluids HD Poison Control Acetaminophen Toxicity (Cook)Signs/SymptomsStage I: anorexia, n/v, elevated transaminases Stage II: RUQ pain, elevated transaminases Stage III: hepatic failure, acidosis, renal failure, pancreatitis, peak transaminase levels Stage IV: multi-organ failure vs resolution Lab AssessmentAPAP levelsWithin 1-4 hrs of ingestion, used to exclude ingestion Obtain 4 hour level to get estimated peak absorption CBC, CMP, ABG Rumack Matthew NomogramTreatment line begins at 4 hr mark If above line, treat TreatmentActivated charcoal N-Acetyl CysteineReplenishes glutathione stores to conjugate NAPQI to limit hepatocyte injury and promote renal excretion TCAs (Weeman)MOASSRI/SNRI, antihistamine, alpha antagonist, anti-muscarinic SymptomsEarly: anticholinergic effects, HTN, AMS Late: myocardial suppression, QRS widening, seizures, ventricular dysrhythmia, hypotension Mimics: diphenhydramine, carbamazepine, sympathomimetic toxicity, serotonin syndrome AssessmentEKG, UDS, TCA level (does not correlate with severity) ManagementActivated charcoal if within 1 hour of ingestion Do not treat early HTN as patients will likely develop hypotension as they progress, treat hypotension with normal saline Sodium bicarbonateIV push if QRS exceeds 100 msec Infusion to maintain pH 7.5-7.55 If seizing, use IV benzos or phenobarbital if refractory Clinical Pathway Opioid Overdose (Leavitt, Sizemore)Duration:Heroin half life: 3-8 min, metabolites ~3hrs Fentanyl half life: 2-4 hrs Oral opioid half life: 3 or more hours NarcanOpioid antagonist In general, don’t exceed ~5-10 mg, but can titrate to effect RouteIN/IM/SC: slower onset, longer duration Intranasal can last ~3hrs IV Infusion: Mix 4mg naloxone in 100 mL D5W Infusion rate at ⅔ of effective dose that initially reversed the patient Can repeat dosing every 3 minutes St. Paul’s Early Discharge Rule HOUR Study Clinical Pathway to be posted soon Envenomation (Giddings)CiguateraHeat stable toxin Barracuda, red snapper, mostly reef/tropical fish GI symptoms, paresthesias, hot/cold reversal, bradycardia Treatment: antiemetics, atropine, mannitol Mechanism: increases permeability of sodium channels inducing membrane depolarization ScombroidCaused by improperly stored fish, heat stable toxin Symptoms: flushing, warmth, urticarial rash, palpitations, itching Causes histamine release Tx: antihistamine Coral Snake (Elapidae)Presentation: minimal local symptoms, severe systemic symptoms, respiratory paralysis, AMS, CN palsies Complications: hypovolemic shock, DIC Work up: CBC, CMP, coags, fibrinogen, d-dimer Treatment: anti-venom, aggressive supportive care Dispo: Admit, concern for neurotoxic effects including respiratory failure, can have delayed presentation Mechanism: cholinergic Crotaline (Pit Vipers)Presentation: Local pain/tissue damage, fang marks, coagulopathy, weakness, n/v Complications: swelling, compartment syndrome, DIC, hypotension Treatment: CroFab (give if bad systemic symptoms, abnormal labs, AMS, significant swelling) Black WidowPresentation: Pinprick bite, pain to whole extremity, muscle cramps, tachycardia, hypertensive, can mimic appendicitis Management: supportive care, antivenin for severe symptoms TarantulaBarbed hair, can penetrate cornea, may need ophthalmology consult Supportive care Brown ReclusePainless bite, local tissue necrosis Systemic effects are rare Treatment: supportive High Altitude Medicine (Thurman)PhysiologyHigh Altitude: 1500m, Very High: 3500m, Extreme: 5500m Begin to see altitude illness at around 2500m/8000ft As altitude increases, percentage of oxygen available decreases AcclimatizationRespiratory compensation by increasing minute ventilation, which decreases PaCO2 Renal compensation by increasing excretion of bicarbonateAssociated diuresis can exacerbate altitude illness and increase dehydration Acute Mountain SicknessHeadache, GI symptoms, fatigue/weakness, dizziness/light-headedness Prevention (ideally start 1 day before trip, continue 1-2 days after patient is at highest altitude)Acetazolamide 125 mg q12hr Dexamethasone 2mg q6hr or 4mg q12hr Gradual ascent Ibuprofen 600 mg q8hr TreatmentHalt ascent until symptom free Only need to descend for severe symptoms Supplemental oxygen, dexamethasone, acetazolamide High Altitude Cerebral EdemaAcute mountain sickness + mental status change, ataxia TreatmentImmediate descent/evacuation Supplemental oxygen Dexamethasone Portable hyperbaric chamber Acetazolamide High Altitude Pulmonary EdemaNon-cardiogenic pulmonary edema Symptoms (need at least 2)Dyspnea at rest Cough Chest tightness/congestion Weakness/decreased exercise tolerance Signs (need at least 2)Crackles or wheeze Central cyanosis Tachypnea Tachycardia PreventionGradual ascent Nifedipine 30 mg q12hr or 20 mg q8hr Tadalafil/Sildenafil Treatment:Immediate descent Supplemental oxygen Nifedipine Portable hyperbaric chamber tadalafil/sildenafil CPAP COVID (Brown)SymptomsTypical of most viral syndromes Lab abnormalitiesElevated WBC, LDH, d dimer, ferritin, ESR/CRP, procal, ALT/AST, t bili, troponin, CK Low lymphocyte count, albumin, platelet count, hemoglobin ImagingNormal vs bilateral pulmonary opacities Airway managementPre-oxygenate with NRB or HFNC Consider supraglottic airway with viral filter Video laryngoscopy Trial HFNC or non-invasive ventilation prior to taking airway Low tidal volumes, permissive hypercapnia, ARDSNet protocol Consider proning TreatmentSupportive treatment Bamlanibimab Dexamethasone Remdesivir DVT ppx if hospitalized DispositionWalking O2 test 4C mortality score Pacemakers (D. Thomas)Prevent HR from falling below set limit MalfunctionFailure to captureLow battery Inflammation Loose or displaced lead Sensing issues ManagementTypical bradycardia management Atropine, epinephrine, transcutaneous pacing, transvenous pacing Magnet placementOpens Reed switch with breaches sensing circuit and will pace regardless of intrinsic cardiac activity
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