04/06/2022

• Lightning Lectures – Pulmonary Cases (Drs. Bishop and Slaven)
  • Tuberculosis
    • TB concern à NAAT + sputum cultures to assist with diagnosis (95% sensitive)
      • Negative pressure room with airborne precautions, PPE precautions for providers, HIV test if TB suspected  
    • Mycobacterium tuberculosis à aerobic rod, highly antigenic à can disseminate systemically if initial granuloma formation fails to contain the infection
    • Immunocompromised population at highest risk (2x)
    • bCG vaccine recipients all have positive TB skin tests (PPD)
    • Interferon test does not distinguish between latent and active TB
    • Active TB àINH, RIF, pyrizanimide, ethambutol x8 weeks à INH/RIF x18 weeks + B6
      • Hepatotoxicity
    • Latent TB à INH x9 months + B6
    • Must contact Public Health Department prior to discharge
  • Spontaneous Pneumothorax
    • Sudden pleuritic chest pain, increased work of breathing, hypoxia
    • DDx with examination + upright CXR
      • CT chest is very sensitive/specific but takes time to obtain
      • Consider US
    • Management:
      • Supplemental O2
      • Unstable à Decompression (treatment for tension PTX)
      • Stable, small à consider observation 4-6 hours, repeat CXR, must ensure follow-up within 24 hours à admit any recurrent or complicated PTX
      • Admit everything else and all PTX caused by comorbidities
• Inhaled Intoxicants (Dr. Eisenstat)
  • Huffing/bagging à toluene is intoxicating substance (higher in gold and silver paints)
    • Can cause NAGMA, renal tubular acidosis, hypokalemia, chronic encephalopathy
    • Sudden sniffing death syndrome à hydrocarbon (huffing) + high levels of catecholamine surge à death
      • Generally not recommended to use epinephrine/norepinephrine in patients suspected of hydrocarbon toxicity
  • Aluminum encephalopathy from black tar heroin use à basal ganglia lesions on MRI
  • High water solubility à chlorine, tear gases, ammonia (mucous membrane effects)
  • Low water solubility à phosgene, chloramine, nitrogen dioxide (delayed pulmonary edema)
  • Phosphine gas/aluminum phosphide à occurs when aluminum phosphide interacts with moisture à can expose providers during ventilation efforts/resuscitation
  • Nitrogen dioxide à silo fillers
  • Phosgene à choking agent, delayed pulmonary edema
  • Tear gases à OC spray AKA pepper spray AKA mace à capsaicin-based tear gas à causes severe burning and irritation, CS (military grade) is more potent
    • Treatment is irritation (consider Morgan lens for eye involvement)
  • Organophosphates à nerve agents àdecontamination, atropine, pralidoxime, supportive care
  • Asphyxiants à methane, propane, argon gas à sudden collapse, helper also collapses, etc.
  • Carbon monoxide à can be high in smokers (COHgb of 10) and large cities
    • Treatment is controversial à begins with O2 therapy (100% FiO2, NRBM)
    • Consider hyperbaric in COHgb levels >25 (15 in pregnant patients due to fetal Hgb affinity for CO) or signs of organ dysfunction (AMS, NSTEMI)
    • The reason for HBO therapy is to reduce long-term symptoms, which are often delayed (up to 6-8 weeks), not life-saving
  • Cyanide à combustion of nitriles in house fires à leads to unconsciousness and CV collapse à elevated lactate (>8 with ingestion, >10 in house fires) with high suspicion
    • Amyl nitrite (induces methemoglobinemia) vs. Hydroxocobalamin/Cyanokit (safer, colors urine organe/red) with levels >8 
  • Hydrogen sulfide à cellular asphyxiant similar to cyanide à rotten-egg smell in low concentrations (odorless in high concentrations), used in chemical suicide

• COPD and Asthma Cases (Dr. French)
  • COPD à titrate goal O2 to 88-92%
  • Patients need PPV
  • Antibiotics for COPD exacerbation à some evidence for reduced rate of readmission/representation
  • Remember to consider breath-stacking/auto-PEEP in MV
  • PRAM Score for asthma exacerbation à follow-up 3 hours with additional PRAM Score, can assist with disposition planning
    • PRAM >12 à marker of impending respiratory failure

• ED Management of Brain Aneurisms (Dr. Ding)
  • Unstable à repair
  • Stable à timely outpatient follow-up
  • 1/3 will die, 1/3 will be self-sufficient at discharge, 1/3 will have poor recovery
  • Surgery (clip) vs. endovascular (coiling)
    • Treatment modality depends on multiple factors à age, medical comorbidities, multiple aneurisms, location, size, symptoms
  • Which aneurisms will rupture à location (anterior communicating, posterior communicating aa. higher risk) vs. size of aneurism vs. risk factors vs. family history vs. connective tissue disease/AAA vs. stress vs. growth of aneurism  
  • Enlarging and symptomatic unruptured aneurisms should be treated
  • Before/after stent-coiling or flow diversion à DAPT
  • Consult NES for incidentally found aneurisms on imaging, both admitted and discharged
  • CTA/MRA for history of aneurism and symptoms
  • Consider SAH in post-coital headache 
  • Don’t forget about LP vs. MRI in patients suspicious for SAH with negative CT/CTA