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