Pharm review with Jade 

DILI- can be from ABX, antiepileptics, Tylenol

FDA recommendation for Tylenol reduced to 3g for OTC safety however 4g daily is still safe to give 

Max tpa for stroke is 90 mg, otherwise .9 mg/kg. 10% over 1 min, remainder over 1 hour 

BP goal for tpa administration in stroke is 185/110

Criteria is same for alteplase and Tenecteplase 

Bactrim can cause hyperkalemia as an adverse effect 

Keppra load in status 40-60 mg/kg with a max of 4.5 g

Etomidate may lower seizure threshold- not ideal for status patients 

Rocuronium duration of action prolonged in renal and hepatic impairment, advanced age 

GI Review with Dr. Ross

IV glucagon first line for esophageal food bolus however low success rates

Second to adhesions, adenocarcinoma is most common cause of bowel obstruction 

Proctitis- sexually transmitted, treat with same empiric STI abx

Traveler’s diarrhea- give azithromycin if pregnant otherwise cipro is fine 

IBS- FODMAPS diet 

Esophageal candidiasis: if immunocompromised give systemic antifungal, otherwise topical 

Pyloric stenosis: hypochloremic hypokalemic metabolic alkalosis 

Pancreatic cancer- troussaeau syndrome aka thrombophlebitis 

HBsAg- active infection, anti- HBs is recovered or immunized

Sigmoid volvulus- flexible sigmoidoscopy 

Wilderness Review with Dr. McGowan 

Lightning strike triage is different- go to the coding pts 

Pulseless leg after lightening stroke- kerunoparalysis 

EKG finding in hypothermia- J wave/Osborn wave 

Mild hypothermia 90- 95. Shivering uncontrollably. Moderate hypothermia stop shivering 

Severe hypothermia- risk of dysrhythmia with movement 

Normal ACLS not beneficial with temp below 88-90. Reasonable to attempt 1 defib and 1 epi

K>12 is reason to cease efforts 

Rewarm frost bite with hot water immersion, do not warm if potential for refreezing 

AMS differentiates b/t heat exhaustion and heat stroke 

Air gas embolism occurs on surfacing-> hyperbarics

Nifedipine can be used to treat HAPE if unable to descend 

Immediate descent for HACE

OBGYN Review with Dr. Platt 

AUB= consider cancer in women over 45 yo F

US imaging of choice for genital tract pathology 

Ovarian cyst > 8cm, solid, multiloculate are worrisome for neoplasm, dermoid cysts, or endometriomas

An ovary > 4 cm in size is the most common US finding associated with torsion 

False labor= uterine contractions that don’t cause cervical changes 

Amniotic fluid changes nitrazine paper dark blue 

Sterile speculum exam, no digital exam if ROM suspected 

If vaginal bleeding during second half of pregnancy, perform US prior to speculum or digital exam

DED/72 Hr Return Learning highlights with Dr. Royalty

A patient is considered refractory after 3 or more defibrillators, 3 or more doses of epinephrine, AND 300 mg Amiodarone 

What therapies can you try?

-Hold additional epinephrine 

-Administer Esmolol for electrical storm: 500 mcg/kg bolus followed by infusion (50-100 mcg/kg/min)

-Dual-sequential Defibrillation: Place a second set of pads (R upper chest/left lateral and anterior/posterior), deliver 200J simultaneously from both defibrillators

Pediatric Cardiac Disease with Dr.Wadih

Cyanotic lesions: 5 T’s-Tetralogy of Fallot, Transposition, Tricuspid atresia, Truncus arteriosus, TAPVR

Truncus arteriosus: Associated with 22q11 deletion (DiGeorge), Primitive truncus does not divide into PA and aorta, Leads to significant pulmonary over circulation, Ductal independent 

Tetrology of Fallot: Large VSD, RVOT obstruction, RVH, overriding aorta. Tet spells= episodes of cyanosis usually triggered by crying. Treat tet spells by calming, knees to chest, supplemental O2, morphine, IN fentanyl or versed if no IV, IVF to increase preload. If these fail, move to beta blocker propranolol or esmolol, ECMO last resort. Degree of RVOT obstruction determines if lesion is ductal dependent. All require surgery

Total anomalous pulm venous return: Pulm vein do not return to L atrium, degree of illness depends on degree of obstruction of pulm venous return. Ductal independent. Must have ASD to survive 

Transposition of Great arteries: Must have large ASD , VSD, or PDA to survive. Usually presents within hours of birth. If not responding to prostin need a balloon atrial septostomy.

Tricuspid atresia: Absence of tricuspid valve w/ hypolastic RV. Relies on ASD 

L->R shunts: ASD, VSD, PDA, AV canal 

ASD: rarely symptomatic, usually close on their own. Typically close ASD around age 2-5 if becomes larger or persists. “fixed split S2” is a buzzword for ASD on exam 

AV canal (AV septal defect) commonly associated with trisomy 21. Spectrum of severity, all require repair 

VSD: Highly variable. Bigger VSD= more likely to cause heart failure, less likely to hear on exam. Smaller VSD= less likely to cause issues and may close on their own, louder murmur on exam. Over time will lead to increased PVR, increased RV pressure and RVH. May present at 4-8 weeks of life in heart failure, slightly later in trisomy 21

PDA: Machine like murmur at left upper sternal border. Persistence of ductus arteriosus. Ibuprofen used to encourage closure. More common in premature infants 

Ductal dependent lesions (depend on PDA): HLHS, critical aortic stenosis, critical coarctation of aorta, pulm atresia, +/- tet

These NEED PGEs. Prostaglandins cause apnea. Presents with murmur, cyanosis, heart failure on exam. Poor feeding with poor weight gain, sweating with feeds, irritability, tachypnea. W/u with pulse ox: R hand is pre ductal, >3% difference b/t pre and post ductal sats. Need CXR, EKG, Echo. Give prostaglandin .05-.1 mcg/kg/min, watch for apnea. Milrinone typically inotrope of choice due to vasodilation (doesn’t increase SVR). Consider epi for shock 

Coarctation of aorta: As PDA closes- hypoperfused lower extremities, hypertensive upper extremities, associated with turner’s. Present in shock as PDA closes. Coarct located pre-ductal is ductal dependent. Coarct other locations may not present until later in life 

HLHS:Hypoplasia of LV and ascending aorta, mitral valves with ASD and PDA. Cardiogenic shock when PDA closes. Mortality highest in 1^st year of life. Staged repair, first stage is Norwood(BT shunt connects PA and aorta) which is done during the 1^st few weeks of life. IF BT shunt clots they will die. 12% rate of clotting. Post op period is high risk. Listen for a shunt murmur

If you think shunt closed, bolus heparin and start drip. Consider ECMO, likely needs emergent surgery. Increase SVR with pressors (epi first choice), sedate and paralyze to reduce PVR( intubate). Once make it through staged repair survival rate is 90% at 30 years old. Atrial arrythmia is common comorbidity, also liver failure 

Ebstein’s anomaly- associated with maternal lithium use. R atrium enlargement, malformed tricuspid valve 

Eisenmenger syndrome: complications of uncorrected L->R shunt. Can occur in childhood or adulthood depending on the lesion. Cyanosis, syncope, dyspnea, fatigue, chest pain, sudden death. Increased pulm resistance, pulm HTN causes shunt to switch to R->L

Thoracic review with Dr. Baker 

Light’s criteria- if any one of the following is present the fluid is almost always an exudate: pleural fluid/serum protein ratio > 0.5, pleural fluid/serum LDH ratio > 0.6, pleural fluid LDH > 2/3 upper limit for serum LDH 

TB drug side effects: Ethambutol can cause optic neuritis.. starts with E and is eye pathology. Rifampin= orange body fluids. Isoniazid= peripheral neuropathy, seizures, B6

-Spontaneous PTX >20% needs chest tube. Smaller can be observed with oxygen administration 

-To prevent BPD in neonates: within one hour of birth give neonate surfactant, after an hour give caffeine. Risk factors are tobacco use, IUGR, preeclampsia

-Tracheoinonomate artery fistula. Overinflate cuff-> intubate-> remove trach-> digital compression of innominate artery 

-Pertussis buzz words: several weeks, eye sxs, post-tussive emesis 

-Coin position on xray: SAFE= sideways airway, frontal esophagus 

Most common symptom in PE: dyspnea

Most common sign in PE: tachypnea 

Tolerating secretions and toxic= tracheitis

Drooling and toxic= epiglottitis (Hib), thumbprint sign 

Spontaneous and stable Pneumomediastinum: dc with f/u. asthma most common trigger.. Hamman sign, pleuritic pain and neck pain. Usually self-resolving 

-Gram+ cocci in clusters= staph aureus 

-PNA+ bullous myringitis= Strep pneumo Phosgene smells like hay or cut grass 

CURB65: confusion, BUN>19, RR > 30, SBP <90 or DBP < 60, Age > 65

Berylliosis= Aerospace, fluorescent bulbs

Silicosis: glass, sand blasting, miners

Asbestosis: shipyard workers

Siderosis: arc welding (iron)

Most specific US finding for PTX: lung point sign 

Pneumocystis jirovecci: elevated LDH

Give prednisone if PaO2 less than 70 

Fat embolism: IVF and supplemental O2, may see petechial rash

Case Reviews with Dr. Weeman and Dr. McMurray

Meningitis

• Strep Pneumo most common pathogen, consider when recent sinusitis or OM
• N meningitis: group living, recent exposure, rash 
• S aureus: IVDU
• HIV/immunocompromised: also consider Listeria, cryptococcus, TB
• Perform CT prior to LP if any focal deficit, seizure, AMS,  hx tumor, age > 60, papilledema 
• Give steroids (10 mg IV dexamethasone) 20 min prior to Abx as part of your empiric coverage because it decreases mortality in S pneumo 

TTP 

TTP is decreased ADAMTS-13 which cleaves vWF, without it vWF forms multimers that lead to microthrombi 

Present with fever anemia thrombocytopenia, renal failure, AMS, only 20-30% of pts have the classic pentad 

Microthrombi result in end organ damage 

Dx with plt <20K, MAHA, schistocytes, elevated retic count, LDH, unconjugated bilirubin

Normal coags and normal fibrinogen

Tx: steroids, FFP, HD can temporize 

Gold standard is PLEX which removes autoantibodies and replaces ADAMTS-13

Avoid platelet transfusion-> provokes thrombosis

Caplacizumab is a monoclonal antibody against vWF to impede interaction with platelets, very expensive.. not prescribed if plts >30K. Prescribed for prevention but may also be used in inpatient management 

Tox Review with Dr. Eisenstat

-Contraindications to activated charcoal include aspiration risk (think of toxins with high risk of seizures, somnolence, vomiting, etc)

-GHB acts on GABA receptors. Short acting. Classic case is obtunded requiring intubation then later self extubates

-Organophosphate toxicity: Tx with atropine and pralidoxime 

-Serotonin syndrome: clonus, give cyproheptadine 

-NMS give bromocriptine, malignant hyperthermia give dantrolene

-Cyanide toxicity: house fire with lactic acidosis, hypotension, bradycardia. Gives hydroxycobalamin 

-Amatoxin containing mushroom-> NAC

-Digoxin toxicity-> Don’t give calcium. 

-Indications for hyperbaric for carbon monoxide: Carboxyhemoglobin level >25% or >15 if pregnant, also anyone with LOC or severe lactic acidosis 

ID Review with Dr. Shoff

-Flexor tensynovitis-> Kanavel’s signs: pain with passive extension, percussion tenderness, uniform swelling, flexion posture

-Most common septic arthritic: Staph aureus 

-Missisppi Valley-> histoplasmosis

-Southest US-> blastomycoisis 

-California-> coccidiomycosis 

Varicella: lesions in various stages

Smallpox: lesions in same stage 

Pertussis: treat close contacts

Rabies: PEP for any bat exposure. Vaccine day 0,3,7,14. Administer immune globulin around wound, any leftover goes IM