Conference 11/9/2022

Operations- Ross

Provide discharge instructions that coincide with chief complaints, as well as put chief complaints that are relevant.
If you have a code aorta (ascending aortic dissection) dial 8008 and select code aorta, don’t page cardiothoracic surgery etc.
- Descending aortic dissections managed by vascular here at ULH
Cerner Camera Capture
- 2 phones available (1 in room 9, 1 at attending desk)
- Log into cerner on phone using “Cerner Camera Capture” app
- Put in MRN
- Put in location folder
- Will find picture in multimedia manager on left hand menu list
Code Green
- Imminent Delivery
Road Rash
- If truly severe consider calling trauma and/or burn nurse to help get wound care managed
- Can write for more than 3 days of opioid pain meds if medically justified
New Kasper
- When in patient chart click on ED provider view
- Click on Kasper within white menu list on the left
Dispo Times
- NES if waiting for recommendations for multiple hours consider discussing with ED attending about escalating to NES attending.
- Ortho should put in bedslip within approx. 2 hours

PEM Endocrine- Kopp

DKA in Peds
- 45kg child slow fluid resuscitation
  - 1.5x maintenance fluid rate
- 45kg fast fluid resuscitation
  - 2x maintenance fluid rate
- With resuscitation, if K is greater than 5 do not include K in initial fluid resuscitation
- Add in dextrose when there is a decrease in glucose of >100 in 1 hour
  - Keep in mind to continue to check glucose every hour
- Bicarb administration not recommended… except for life-threatening hyperkalemia or acidosis with pH <6.9 with evidence of compromised cardiac contractility
- Avoid intubation
  - Increased CO2 > decreased pH CSF > cerebral vasodilation > cerebral edema
  - Make sure you match RR if you do intubate, and be quick to bag during RSI, 45 sec of apnea can be drastic
Hypoglycemia
- Rule of 50
  - 50/D50=1ml/kg
  - 50/D25=2ml/kg
  - 50/D10=5ml/kg
  - 50/D5=10ml/kg
- Recommend D10 or D5 fluids for correcting hypoglycemia
  - D50/D25 > will blow small IVs which is most peripheral IVs in kids
Inborn errors of metabolism
- Most will have a cheat sheet
- D10 45% NS with electrolytes run at 1.5x maintenance fluid
  - Dextrose fluids is mainstay
Adrenal insufficiency
- Stress dose steroids
  - 3x base dose steroids
- Hydrocortisone (IV or IM)
  - 0-3: 25mg (Can pick kid up with 1 arm)
  - 3-12: 50mg (Can pick kid up with 2 arms)
  - >12: 100mg (Too big to pick up)
Diabetes insipidus
- DDAVP IN, IV, SubQ
- Goal of lowering Na

Pharm Lectures

Magnesium
- Normal level 1.7-2.3
- Hypomagnesia (<1.5)
  - Causes: poor nutrition chronic EtOH, excessive GI or renal loss, medications (thiazides etc.
  - Symptoms
    - Cramps
    - Fatigue
    - Vertical nystagmus
    - Ataxia
    - Seizures
    - Dysrhythmias, QTc prolongation
  - Tx: Mag oxide 300mg tablet, Mag sulfate 1-4G IV
  - Torsades de pointes> 2G IV over 15 min
  - V fib > Mag 2G IV over 2-5 min
- Hypermagnesemia (>4)
  - Cause: overuse of mag supplements/laxatives
  - Symptoms
    - Muscle weakness
    - Absence of deep tendon reflexes
- Mag Pearls
  - Predominantly intracellularà when serum levels are low= intracellular is likely very depleted
  - Potassium and magnesium levels are linkedà if difficulty repleting potassium check a magnesium level and replace
Potassium
- Normal Range 3.5-5.0 (Cards patients 4.5 goal)
- Physiologic function
  - Action potential regulation
  - Muscle contraction
- Hyperkalemia: K > 5.5 mEq/L
  - Causes:
    - Renal dysfunction (ESRD/AKI)/rhabdomyolysis;
    - Medications (ACE inhibitors, ARB’s, potassium sparing diuretics, immunosuppression (cyclosporine, tacrolimus), trimethoprim-sulfamethoxazole (Bactrim®)
  - Symptoms: EKG changes, arrhythmias
- Hypokalemia: K < 3.5 mEq/L
  - Causes: GI losses, medications (diuretics, insulin, albuterol)
  - Symptoms: Cramping, weakness, myalgias, malaise, arrhythmias
- EKG changes
- Hyperkalemia treatment
  - Cardiac stabilization
    - Calcium gluconate
  - Shift K
    - Regular Insulin + Dextrose, Albuterol
  - Targeted Elimination
    - Dialysis
    - Loop diuretics
    - Cation Exchange Resins/Polymer
- Hypokalemia treatment
  - Check and replete Mag
  - 3.2-3.5 mMol/L
    - 40 mEq KCl PO or per tube
    - KCl IV over 1 hour x 4 doses
  - 2.7-3.1 mMol/L
    - 40 mEq KCl PO or per tube x 2 doses 4 hours apart
    - KCl IV over 1 hour x 4-8 doses
  - < 2.6 mMol/L
    - 10 mEq KCl over 1 hour x 8 doses
Phosphorus
- Normal: 2.5-4.5
- Hypophosphatemia
  - Causes: Refeeding syndrome, chronic alcohol abuse, hyperparathyroidism, vitamin D deficiency, diabetic ketoacidosis (DKA) chronic diarrhea, antacids, hungry bone syndrome

Serum Phosphorus	Replacement	Recheck Level
2.1-2.5 mg/dL	1-2 packets PhosNaK2-4 times daily15 mMolNaPhosin D5W over 2 hours	With AM labs
1.6-2.0 mg/dL	30 mMolNaPhosin D5W over 4 hours	With AM labs
< 1.6 mg/dL	45 mMolNaPhosin D5W over 6 hours	Recheck 4 hours after infusion

Symptoms: Loss of appetite, Bone pain/fragile bones, Irregular breathing, Irritability, Fatigue/Weakness, Encephalopathy, Seizures

Hyperphosphatemia
- Causes: Abnormal renal function (AKI/CKD), rhabdomyolysis, tumor lysis syndrome, hypoparathyroidism, hypothyroidism, phosphate containing laxatives, vitamin D toxicity, bisphosphonates, fosphenytoin.
- Treatment:
  - Phosphate restricted diet (800 – 1000 mg/dL)
  - Fluid resuscitation to euvolemia
  - Forced diuresis (acetazolamide +/- furosemide)
  - Phosphate binders: Bind phosphate in the gastrointestinal track (dosed 3 x daily with meals) à several drug interactions
Calcium
- Normal: 8.8 – 10.4 mg/dl
  - 1.10-1.30 mmol/l (ionized)
- Hypocalcemia
  - Muscular
    - Hyperflexia
    - Fasciculations
    - Cramping, myalgias
  - Neuro
    - Anxiety, delirium, coma
    - Paresthesias
    - Seizure
  - Cardiovascular
    - Hypotension
    - Vtach
    - Bradycardia, heart block
  - Indications for treatment:
    - QT prolongation
    - Seizure, delirium, coma
    - Severe Muscle cramping
    - Pre-emptive in blood product transfusion
    - Caution: EG toxicity, severe increase in phosphate
- Hypercalcemia
  - Signs and Symptoms: Muscle weakness, hyporeflexia, GI (constipation, ileus, n/v), hypertension, Delirium, coma, Paresthesia
Sodium

Hyponatremia
Moderate(125-130 mEq/L)Nausea / vomitingHeadache, fatigueMuscle cramps	Severe(< 120-125 mEq/L)Altered mental statusSeizuresComa
Hypernatremia
Moderate(145 – 155 mEq/L)ThirstIrritabilityRestlessness	Severe(> 160 mEq/L)HyperreflexiaSeizuresComa

Hyponatremia
- Treatment for Hypotonic Hyponatremia (Serum Na <135, Serum Osm (<280 mOsm/kg)
  - Hypervolemic
    - Fluid restriction
    - Diuresis
  - Euvolemic
    - Fluid restriction
    - Stop offending medication
  - Hypovolemic
    - Stop offending medication
    - Isotonic crystalloid (Saline)
  - Causative meds
    - SSRIs, TCAs, Antipsychotics, antineoplastics, NSAIDs, AEDs
- Hypertonic Saline
  - Indications for hypertonic Saline
    - Seizure
    - Confusion (use with caution and consider other etiologies first)
    - Gait instability
    - Coma or cerebral herniation
  - Initial management
    - 3% NaCl infusion 2ml/kg over 5-10 min
    - If no clinical improvement > Repeat 3% bolus
    - Ensure correction does not exceed 6 mEq/L in 24 hours
    - What if no 3% NaCl at your facility?
      - Hypertonic sodium bicarb can be used
        Push slow over 3-5 min, 2amps ~ 200 mL 3% Saline
- Hypernatremia
  - Initial Labs
    - BMP
    - Mg, Phos
    - Urine Na
    - Urine Osm and/or Urine SG
  - Treatment
    - Hypovolemia with hypotension
      - Isotonic fluids are recommended
    - Normotensive Hypovolemia
      - D5W or 0.45 % NaCl
    - Na Correction
      - Goal: restore sodium balance
      - Lower Na: <10-12 mEq/L per 24hr
    - Free Water Deficit
      - Correct first half within 24 hours
      - Correct remainder over 72 hours
  - Diabetes insipidus
    - Labs
      - Serum Na > 145 mEq/L
      - UOP > 200 mL/hr (sustained)
      - Urine SG < 1.005
      - Urine Osm < 300 mOsm/kg
      - Serum Osm > 300 mOsm/kg
    - Treatment
      - Hemodynamically Stable:
        DDAVP (desmopressin) 1 mcg IV q8hr
        May be administered subcutaneously*
      - Hemodynamically Unstable:
        Vasopressin continuous infusion
      - Goal of Therapy:
        Maintain UOP < 200 mL/hr

Room9er ["Room Niner"]:

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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