McGowan – Teaching series

Scaffolding – 

• Establish a baseline (Know your audience)
• Cues
• Leading qs vs reflective
• Breakdown tasks

Ex ) 

• SOAP notes
• ACGME milestones
• Certifying exam checklist
• Procedural skill learning
• Sim
• OSCE
• SLOE

• Consider graphic organizers for ddx
  • Gridded Charts
  • Flow charts 
  • Worksheets 

Final thoughts

• Assess learners baseline
  • Adjust level of intervention based on thiss

• Have clear objectives
• Short and sweet
• break down to smaller tasks
• Foster safe environment
• Failing is ok if you learn from it

Coffman – Question

Kelesis – RM9 Follow Up

27 F  w ho asthma, prior suicide attempt presents after unknown but large ingestion ibuprofen

• 5 large bottles 200mg ibuprofen empty

VBG 7.3/33.5/82/-9.5

CHEM8 139/3.6/108/143/1.14

Lactic 5.0

Intubated for aspiration risk w prop fent

CXR ok

CT head ok

C/f for lactic acidosis (AGMA), bleed, kidney injury

Rpt gas w ph 7.1, lactic to 8.3, Gap 19

HD placed, admitted to MICU underwent HD, still admitted to 3N

Reversible binding COX1/2 -> depletion of thromboxane = bleed

Peak plasma concentration 1-2hrs

Activated charcoal within 2 hrs of ingestion can be considered

Davenport – Shock US

I – indications

A – acquisition

I – interpretation

M – MDM

Pump – heart squeeze, beating, effusion

Pipe – IVC – plump, collapsable

Problem

Cardiogenic shock

• LV dysfunction w PLAX, PSAX
• IVC – plethoric
• EPSS on PLAX
  • Line on mitral valve
  • Measure peak of valve to septum
  • >7 = poor LVEF
• Lungs
  • Needs to be 15cm to be considered B line
  • Consider turning off tissue harmonics for brighter B line
  • 3 B lines per view for dx

Obstructive

• Tamponade
  • Speed of accumulation important 
  • Mitral valve inflow integral
    • Doppler at mitral valve outflow on A4C
    • Measure tallest expiration wave to lowest expiration wave
    • >25% = pulsus paradoxus
  • Plethoric IVC
• PE
  • D sign on PSAX, bc higher pressure in R heart
  • Mcconnel sign on A4C, bc RV free wall hypokinetic
  • Tricuspid annular plane systolic excursion
    • M node on  A4C on tricuspid
      • Measure peak to valley <16-17 = acute heart strain
• Tension ptx
  • Plethoric ivc
  • Heart could be hyperdynamic, flattening of R heart
  • Lung slide
    • Can mmode for barcode sign
    • US more sensitive than CXR
  • Lung point

Hypovolemic

• Hyperdynamic echo
• FAST
• Aorta – measure outer to outer, anterior to anterior

Distributive 

• Hyperdynamic echo
• Flat IVC
• RUQ
  • Pericholecystic fluid
  • Anterior wall thickening in short access
    • <3mm normal
  • Sonographic murpheys
  • CBD
    • Measure inner to inner

VEXUS (on icu pts s/p open heart sx)

• Measurement on venous congestion
• Organ perfusion pressure
• Determine modality of tx
• Prevent AKI, HF, pulm edema, poor wound healing

IVC widest diameter in subcostal view, >2cm moveone, less thant 2 = noncongestion

Hepatic vein w indicator towards pt head, find vein entering IVC

• Doppler

Portal vein w indicator towards back

• Doppler

Renal vein

Compare waveforms and grade

• High grade = diuretics

Obrien – Pituitary

Sheehan – pituitary grows in pregnancy but not blood supply, vulnerable to hypotension

• Tx w hydrocortisone

Pituitary apoplexy 

• Tx w hydrocortisone to address ACTH deficiency

Acromegaly – excess GH from pituitary adenoma

• Dx w serum insulin like growth factor level

SIADH – 

• Tx hypona sz with hypertonic, consider amps of bicarb
  • Aim to correct 4-6 meq/L
  • Beware of cerebral edema
  • Avoid isotonic fluids – makes them worse cause they hold onto free water

Congenital hypopituitary

• Hypoglycemia, sex organ weirdness, jaundice, midline deficits
• Tx glucose and hydrocortisone

Optic chiasma – pituitary masses compress this 

• Bitemporal hemianopsia
• Little = endocrine issues
• Big = mass effect

Prolactinoma – most common pituitary tumor

• Tx cabergoline to inhibit prolactin release

Zach; Vitamins

B1 Thiamine

• Deficiency
  • Early Beriberi (wet – cardiac) (dry- muscle wasting)
  • Late Wernicke- Korsakoff 
• Malnutrition, AIDS, Alcoholics
• Tx, replete 

B2 Riboflavin

• Erythematous lesions, ulceration, mucositis
• Breast fed children, skim milk, pregnant women
• Tx, replete

B3 Niacin

• Pellagra
  • 4ds
    • Diarrhea, dermatitis, dementia, death
• Alcoholics, aids, IBD, malnutrition

B5 Pantothenic Acid

• Fatigue, headache, muscle weakness, nausea
• Usually deficient with another b vitamin

B6 Pyridoxine

• Dermatologic, dental changes
• Consequence of medicines
  • INH,  valproic acid, phenytoin, hydralazine, carbamazepine
• Also decreased renal function, autoimmune disease, inborn metabolic errors

B7 Biotin

• Dermatologic and neurologic manifestation
• In pregnant women, IBD, isotretinoin, long term antiepileptics 

B9 Folate

• Megaloblastic anemia, glossitis
• Don’t confuse w B12
  • Normal MMA, elevated homocysteine
  • Elevated in both for B12
• Deficiency, pregnancy, burns, alcoholics

B12 Cobalamin

• Megaloblastic anemia, SCD, neuropathic symptoms
• Old people, vegans, IBD

C

• Scurvy
• Corkscrew hair, gingival hemorrhage, petechiae
• Malnutrition, alcoholics, pirates

Caroline; Hypoglycemia

• <70
• Symptoms generally develop <50-55
• More common in T1DM vs T2DM
• Whipple’s triad
  • Do you have low glucose
  • Do you have symptoms from low glucose
  • Do you get better with glucose
• Mechanisms against hypoglycemia
  • Glycogenolysis, gluconeogenesis
• S/Sx
  • Adrenergic; anxiety, diaphoresis, hangry, tremor
  • Neuroglycopenic; lethargy, confusion, seizures, agitation
• Most commonly in diabetics, usually overcorrection
• Nondiabetics; malnourishment, drugs/alcohol, insulinoma, critical illness, adrenal insufficiency, hypopituitary
• Workup
  • POC glucose
• Tx
  • Sugar
  • Glucagon
• D50 vs D10
  • Risk of overshooting w D50
  • D50 and be caustic
• Refractory?
  • D10 drip
  • Consider octreotide
• Has insulin pump?
  • Don’t dc pump
  • Supportive treatment 
  • Contact manufacturer to troubleshoot
• Pediatric hypoglycemia
  • Often asymptomatic until seizure
  • New onset T1DM
  • Maternal dm in neonates
  • Medicine ingestion; bb, ethanol, sulfonylurea
  • Glucose bolus 2ml/kg D10

Lyvers; pediatric endocrine

Hypoglycemia

• Causes
  • Fatty oxidation disorder
  • Insulin mediated
  • Ketotic hypoglycemia
  • Disorder of gluconeogenesis
• Other
  • Ingestion
  • Munchausen

– Obtain critical sample during hypoglycemic <50 episode

– for metabolic disorders

Fatty oxidation

• Can crump quick when glycogen depleted
• Test carnitine

Insulin mediated

Ketotic hypoglycemia

• Glycogen storage disorders
• Hormone deficiency
  • hypopit
• Idiopathic (kids grow out of this by 6-8)

Disorders of gluconeogenesis

• Glactosemia
• Fructose disorders

Tx – Rule of 50

• D10 = 5ml/kg
• D50 = 1ml/kg
• Consider steroid
• Glucagon?
  • Only helps with insulin mediated diseases bc they need preexisting hepatic stores of glycogen

Hyperglycemia

• DKA
  • New onset
    • p/w weight loss, polyuria, polydipsia, vomiting
    • Look for kussmaul  breaths
  • Glucose >200
  • pH <7.3
  • Ketones
• Tx
  • Correct acidosis, dehydration, glucose
  • Fluid resuscitation
    • Aggressive
    • 10-20 cc/kg bolus LR or NS
    • Add potassium due to shifts intracellularly
      • <3.5 = bolus
      • Defer if >5.5
        
    • Inulin 0.05 – 0.1 ug/kg
• Complications
  • Cerebral edema
  • Avoid bicarb
  • Could be from hypoperfusion from dehydration
  • Usually develops first 12hrs
  • Tx, mannitol

Shaw; Acid Base

Look at pH (primary disorder) >  check for compensation 

Respiratory

Metabolic

Metabolic acidosis is usually complicated by compensation

Winters = paCO2 = 1.5 (HCO3) + 8 +- 2

Anion gap = Na – Cl – HCO3

NAGMA = GI vs renal bicarb loss 

• Body takes in chloride

MUDPILES

Excess anion gap

• If change in anion gap > change in bicarb then too much bicarb = less acidotic
• AG – 12 + serum bicarb
  • >30  = 
  • <30 = underlying NAGMA (too  much Cl)

Use base deficit to predict resuscitation goals

VBG for people that don’t need exact pCO2, pulse ox accurate

ABG for people in shock

R acidosis – minute ventilation

R alkalosis – treat underlying cause

M alk – stop offending agent, consider CA inhibitor

M acidosis – treat underlying cause

Bicarb- need control or respirations to make sure co2 is blown off

• Otherwise benefits are primarily from Na and fluid replacemen t
• Na blocker overdose

Thomas; DKA/AKA

Gluconeogenesis/ glycogenolysis not as efficient glycolysis

Gluconeo breaks down fats and proteins

• Fat breakdown = ketones
• Happens in the liver primarily

Glyco

• No ketones
• Happens in muscle and liver

T1DM no insulin production

T2DM insulin resistance

Insulin = store

Glucagon = burn

T1DM more likely to have DKA

AKA

Wide gap acidosis in chronic drinkers

• Following a binge
• Abrupt stoppage of drinking prior to ED

Due to shift of carb metab due to malnutrition

Alcohol w no glucose

• Fasting state = glucagon secretion > gluconeogenesis (mainly lipolysis)
  • If functioning liver

S/Sx 

• N/V/abd pain
• Tachycardic, tachypnea

Labs 

• Etoh often negative
• Anion gap
• Usually w LFT abnormality

Does not need to be acidotic 

• 15% normal ph
  • compensation

Padget

Alcoholic ketoacidosis

Presents; n, v, dehydration, ams

Suspect in poor po + alcoholism

Alcohol increases NADH/NAD+ = higher ketones and lactic acidosis

• Malnutrition presents compensation
• p/w other metabolic derangements

Dx overlaps to some degree w starvation ketosis, DKA

• Correlate clinically

Tx

• Thiamine  (WK)
• Fluids
• D5LR preferred, thiamine before
• Can treat glucose >250 w insulin
• Supportive care otherwise
• Beware CIWA

If lactic >4 something else going on

Disposition; resolution in symptoms, acidosis = home

Rizzo; small group 

Case 1 – HyperK

• Ddx; medicines, renal disease, diet, rhabdo

• Ekg changes, spectrum, peaked t wave – prolonged qrs – sinusoidal 
• Tx, insulin, glucose, Ca, lasiks, albuterol, fluids, dialysis
  • Ca
    • Gluconate through PIV
    • Chloride in codes, central lines
  • Dialysis
    • K refractory to treatments

Case 2 – HypoK

• Ekg changes – U waves
• Ddx; diet, DM, GI loss, medicines
• Tx;
  • Mg, repletion
  • K repletion
    • 10meq = .1 increase

Case 3 – HypoNa

• Ddx; Polydipsia, SIADH, polypharm, CKD, aldosterone deficiency

• Tx; Replete w hypertonic 150mg / 10-20min
  • Can use x2-3 amps bicarb 
• <120 = ICU
• Don’t correct too quickly

Case 4 – HyperCa

• Ddx; exogenous, PTH, genetic disorder, bone resorption, addison, pagets, malignancy, polypharm
• Tx; Fluids, supportive, Ca binders, bisphos, dialysis
• EKG changes = osborne J wave, shortened QT

Case 5 – HypoMg

• Ddx; malnutrition, alcohol, gi loss, renal loss
• Ekg changes – prolonged qtc, risk for ventricular arrhythmia
• Tx; replete
  • Beware of rapid infusion – respiratory depression, hyporeflexia, hypotension

Ross; Small group

Case 1 – thyroid storms

• Precipitant; trauma, infection, contrast, medicines
• Burch and Wartofsky score to sound smart to endocrinology 

• Tx
  • Ptu vs methimazole (avoid in 1st trimester pregnancy)
  • Propranolol vs esmolol (beta selective)
  • Iodine, can substitute Li if allergic
  • Steroid
  • Cholestyramine
• Avoid, amio, asa

Hashimoto – low thyroid

Exogenous – dont need ptu, methimazole

Case 2 – HTN emergency (pheo)

• Ddx; pheochromocytoma, substance use, idiopathic, kidney disease, carcinoid, angina
• If pheo/cocaine avoid beta blockade
• Plasma metanephrines for pheo, urine catacholamines
• Tx;
  • Phentolamine
  • Oral doxazosin if stable
  • Cardine
  • Nitroprusside
• Imaging – CT scan w adrenal protocol
• Associated w MEN2, neurofibromatosis, von hippel lindau
• Reglan, TCA, steroids can exacerbate
• Common sx; palpitation, diaphoresis, HA

Case 3 – Myxedema coma

• Ddx; hypothermia, sepsis, chf, trauma, renal
• Tx;
  • Levothyroxine, consider T3 too (if TSH> 10)
    • T4 preferred in old people, significant CAD
  • Hydrocortisone if c/f concomitant adrenal insufficiency
  • Passive rewarm
  • Beware of pericardial effusion – low voltage ekg
    • Get an echo

Bequer/Baker; US

Fascia Iliaca Block

Blocks femoral/obturator/lateral cutaneous nerves

Indications 

•  femoral head/neck/trochanter fractures
• Anterior thigh lac/abscess

Careful on anticoagulated pts

Ropivicaine/bupivicaine preferred (longer acting)

Use linear probe

2 person procedure

• X2 syringe
• Threeway stopcock

Enter laterally between fascial planes