Conference 10/12/2022

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  • Alaina: Room 9 M&M:
    • Symptomatic Bradycardia:
      • Atropine -> transcutaneous pacing -> Transvenous pacing
    • Bifascicular Block: extensive fibrosis of conducting system – if presenting with syncope high risk need to admit due to high risk of complete heart block
  • Status Epilepticus in Peds:
    • Give kids a first pass for first seizure if unprovoked and simple and otherwise well-appearing child
    • Status Treatment: Def: >5 min or back to back without normal mental status between
      • 1st line meds:
        • Ativan: 0.1mg/kg max 4mg IV, takes about 2-5 min to work last 4-6 hours
        • Versed: 0.2mg/kg with max 10mg IM or 0.2mg/kg IN divided btwn both nostrils, stops seizures in less than 1 min
        • Diastat: 0.5mg/kg with max of 20mg rectally
        • Phenobarbital: 1st line in neonates (<1mo) 20mg/kg with max of 1000mg
      • If still seizing give 2nd dose after 5 min
      • 2nd line:
        • Keppra 60mg/kg IV with max 4500mg
        • Fosphenytoin 20mg/kg IV with max 1500mg
        • Valproic Acid: 40mg/kg IV with max of 3000mg
      • If still seizing 10 min after 1st and 2nd line then go 3rd line:
        • Pentobarbital 15mg/kg bolus with infusion of 5mg/kg/hr IV – will need to intubate patient/PICU
    • Pyridoxine for refractory seizures
    • Neonatal Seizures and infants less than 6mo: many are subclinical and not normal seizure activity
      • check glucose and electrolytes and septic workup (with LP) and antibx plus acyclovir
    • Febrile Seizures: 100.4 and above 6mo-5yo with normal neuro exam and have a seizure while febrile – not seizure then febrile afterwards
      • 30% chance of having another, 2-3% chance of developing epilepsy
      • Simple if <15min not recurrent/need to be vaccinated/GTC – give supportive care (tylenol/ibuprofen) – okay for DC home
      • Complex: >15min with more than 1 seizure in 24 hrs/focal seizure – admit
  • Hyperkalemia/Hemodialysis
    • Causes: kidney/CKD, intake, tissue damage/leakage, endocrine (Addison’s/adrenal insuf)
    • Rate of change in potassium is more important than actual number
    • Treatment:
      • Calcium – 3g CaGlu or 1g CaCl stabilizes cardiac membrane/stabilizes voltage across membrane
      • Insulin – shifts potassium into cells through activation of ATPase 10 U plus 25g glucose decreases K by 1mEq/L
      • Albuterol: shifts potassium into cell by activation of ATPase decreases by about 0.5mEq/L – 15-20mg neb
      • Bicarb: Only use in Metabolic Acidosis otherwise do not give – doesn’t really decrease K until later in the course
      • Remove K: Lasix/Bumex, BInders/Lokelma renal likes – do not usually give in ED
      • Dialysis: Takes 60 min to decrease by 1 mEq/L
    • Succinylcholine: healthy people increases 0.5 per dose
    • Emergent Dialysis: A: acidosis, E: electrolytes, I: Ingestions/intoxicaitons, O: overload fluid, U: uremia (encephalopathy, pericarditis)
      • Chronic Dialysis Patient:
        • Electrolyte abnorm
        • Volume overload
        • Remove toxins/BUN/acidosis
      • Acute Renal Failure:
        • Electrolyte abnorm
      • Normal Renal Fxn:
        • Ingestions
    • Dialysis Basics:
      • Small molecule
      • Charged
      • Examples:
        • Toxic Alc: methanol and ethylene glycol
        • Lithium
        • ASA/Salicylates
        • Valproic Acid

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