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