Conference Notes 1/28

Posted on January 28, 2021 by ccapocaccia

Termination of resuscitation (Nichols)
- When to stop resuscitation in out of hospital arrest
  - DNR order
  - No chance of saving them–safety, signs of irreversible death
  - Nothing left to do–unwitnessed arrest, no shockable rhythm, ROSC does not return in the out of hospital setting
- Stop CPR if:
  - No ROSC
  - No shocks
  - Unwitnessed
CCU follow up (French)
- Arrhythmogenic RV dysplasia
  - 2nd MCC sudden cardiac death in young patients
  - Greek or Italian descent
  - Male:Female= 3:1
  - Presentation
    - Asymptomatic
    - Palpitations
    - Syncope
    - Ventricular dysrhythmias/cardiac arrest
    - FH of unexplained syncope/sudden death
    - RV failure
  - Cards consult–>admission
  - Arrhythmogenic RV dysplasia EKG: V1-V3 T wave inversions, epsilon wave
  - HOCM EKG changes: high voltage, LVH, lAD, tall R wave V1
MICU follow up (Schutzman)
- Myxedema coma
  - Hypotension
  - Bradycardia
  - Electrolyte derangements
  - Altered mental status
  - Give levothyroxine
Jeopardy (Daughtery)
- Activated Charcoal
  - Adsorbs toxins and inhibits GI absorption
  - Must be given in 1-2 hours, but still consider if ingested drug is extended release
  - Contraindications: GI perforation, need for endoscopic procedures
  - Concerns: emesis, CNS depression and aspiration risks
  - Consider risk vs benefit of administration
- Deferoxamine
  - MOA: complexes with trivalent ions (ferric ions) to form ferrioxamine which is eliminated in urine by the kidneys
  - Indications: iron level >500, metabolic acidosis, lethargy/coma, shock, toxic appearance
  - Can cause urticaria, flushing of skin, hypotension, shock with rapid IV administration, ARDS
- Itralipids (lipid emulsion)
  - Reversal of local anesthetic systemic toxicity
  - Consider for severe hemodynamic compromise of lipophilic xenobiotics or drugs with significant neurological or CV toxicity–last line
  - 20% emulsion solution
- Phentolamine
  - MOA: competitively blocking alpha adrenergic receptors
  - Indicated in pheochromocytoma hypertensive crisis, extravasation of norepinephrine/epinephrine, hypertensive emergency with end organ damage secondary to cocaine toxicity not responsive to appropriate sedation
  - Concerns: hypotension, medication safety
- Levocarnitine
  - Antidote to valproic acid
  - Give when: moderate to severe hyperammonemia, valproate level >450, CNS depression, severe hepatotoxicity
- Naloxone for clonidine reversal
  - Big doses- 10mg
  - Consider for reversal of CNS depression
  - Fluids and vasopressors may also be required
- Benzodiazepines
  - Midazolam: IV onset of action 2 min
  - Lorazepam: onset of action 5-20 minutes
- Physostigmine
  - Reversal of anticholinergic toxicity
  - Primarily for agitation and delirium reversal
  - MOA: inhibits acetylcholinesterase and prolongs the central and peripheral effects of acetylcholine
  - Have physician and atropine at bedside
  - No significant risk of seizures
  - Low dose, push slow
- Flumazenil
  - Benzodiazepine overdose or reversal only
  - Competitively inhibits activity of BZ receptor site on GABA/BZ receptor complex
  - Not effective on other medications that affect GABA
  - Concerns
    - Could precipitate withdrawal seizures if patient regularly uses benzos
    - Seizure history outside of withdrawal seizures
    - Risk vs benefit–goal of therapy
Project ECHO
- Optimal Aging Clinic will be added to discharge follow up options
- Have a “what matters” conversation
- Advance Directives
  - Living will
  - POA
  - POLST/MOST
  - EMS DNR
- Advanced care planning–ICD code, must spend 16 minutes to bill
- MOST form
  - A physician’s order
  - Must be honored by all KY healthcare providers in all KY settings
- State of KY Hierarchy of Decision making authority if no advance directives
  - Court appointed guardian
  - Healthcare surrogate
  - Spouse
  - Adult children
  - Parents
  - Adult siblings
  - Closest living relative
ECMO (Ritchie)
- Components
  - Motor/pump
  - Filter/oxygenator
  - Blender
  - Ventilation–to increase, go up on gas flow aka sweep
  - Oxygenation–to increase, go up on blood flow aka flow
  - Cannulas (single vs double)
  - Circuits
    - Vein-Vein ECMO
      - Is the heart still able to pump
    - Vein-Artery ECMO
      - Heart pump function not ideal
    - Vein-Artery-Vein ECMO
- VV ECMO
  - Indications
    - Hypoxic respiratory failure, 50% mortality risk consider ECMO
    - Hypoxic respiratory failure, 80% mortality risk, put on ECMO
    - CO2 retention on mechanical ventilation despite high Pplat
    - Severe air leak syndromes
    - Need for intubation in a patient on lung transplant list
    - Immediate cardiac or respiratory collapse (PE, blocked airway, unresponsive to optimal care)
    - Anytime patient is on dangerous vent settings
  - Murray Score: conventional ventilation or ECMO for severe adult respiratory failure
    - Score of 3–consider transfer to ECMO center
    - Score of 4– ECMO indicated
  - Contraindications
    - No absolute contraindications
      - Mechanical ventilation at high settings for 7 days or more
      - Major pharmacologic immunosuppression
      - CNS hemorrhage that is recent or expanding
      - Non-recoverable co-morbidity
  - When making the decision to begin ECMO
    - Is this condition reversible?
    - Is it a bridge to transplant?
    - RESP score (estimated survival once on VV ECMO)
  - ARDS
  - Ventilator trauma
    - Volutrauma
    - Barotrauma
    - Atelectrauma
    - Biotrauma (cytokine storm, inflammation)
    - Energytrauma (goal for driving pressure 15 or less)
  - Settings once cannulation successful
    - Set flow: 4L
    - Set Sweep: 4L
    - Lung rest settings while on ECMO
    - PC 10/10/10/40%
    - Goals
      - Sat >85%
      - MvO2 >65%
- VA ECMO
  - Indications
    - Heart failure bridge to recovery, heart transplantation, VAD
    - Cardiogenic shock
    - Myocarditis
    - ECPR
    - Right heart failure
    - PE
    - Medication overdose
  - SAVE score
- Trans pulmonary pressure
  - Consider in morbidly obese patients
  - May have higher PEEP requirements given pressure from chest wall/abdomen
  - When intubated, they lose the ability to autopeep
- Page Jewish thoracic or cardiac surgery –consult early

Conference Notes 1/13

Posted on January 14, 2021 by ccapocaccia

ITE- grab bag (E Thomas)
- Spider bite, necrotic wound>brown recluse
- MCC erythema multiforme> HSV
- Strawberry cervix>trich
- Pre-E, less than 24 weeks>mole pregnancy
- Abdominal pain after sex>ovarian torsion
- Most common personality disorder>borderline
- Patient intentionally fakes symptoms>malingering
- Sudden paralysis after traumatic event>conversion
- Discriminatory zone for TVUS>1500
- PID/RUQ pain/shoulder pain>Fitz Hugh Curtis
- MCC postpartum hemorrhage>uterine atony
- Pizza pie fundus>CMV
- Corneal dendrites>HSV keratitis
- Tachycardia out of proportion to fever>thyroid storm
- Alcohol, AMS, ataxia, nystagmus>wernicke
- Stingray wound>hot water
- Beta blocker OD>hypoglycemia
One Pill Can Kill (Lund)
- Ingestions–fatal in small doses
  - CCB
  - Cyclic antidepressants
  - Lomotil
  - Opiates
  - Salicylates
  - Toxic alcohols
  - Sulfonylureas
  - Camphor
  - Clonidine
  - Antimalarials
- CCB OD
  - Hypotension, bradycardia, bradydysrhythmias, hyperglycemia
  - Tx: charcoal, fluids, atropine, calcium, intralipid
- Salicylates
  - Oil of wintergreen, ASA, pepto-bismol
  - n/v, tinnitus, delirium, hallucinations, pulmonary edema, cerebral edema, mixed anion gap metabolic acidosis with respiratory alkalosis
- Sulfonylureas
  - Hypoglycemia, lethargy, irritability, confusion, HA, seizures
  - Tx: observation x24 hrs
  - Dextrose bolus, then consider infusion
  - Can give octreotide (inhibits secretion of insulin)
- Clonidine
  - Alpha 2 agonist, (afrin, visine)
  - Opioid syndrome: lethargy, coma, miosis, respiratory depression
  - Tx: naloxone, atropine, IV fluids, inotropes
- Camphor
  - Campho-phenique, vicks vaporub
  - GI distress, generalized warmth, CNS hyperactivity, CNS depression, n/v, oropharyngeal irritation/burning/stinging
  - Tx: benzos, phenobarb
- Amitriptyline
  - CNS depression, seizures, cardiac conduction abnormalities (QRS prolongation), hypotension, mydriasis, flushing, dry mucous membranes, hallucinations, hyperthermia
  - Tx: benzos for seizures, sodium bicarb for QRS widening >100ms
- Lomotil
  - Opioid receptor agonist +/-atropine
  - Classically biphasic, with anticholinergic symptoms 2-3 hours s/p ingestion followed by opioid symptoms
  - Tx: naloxone
  - Dispo: admit
Toxic Alcohols (Bosse)
- Ethanol
  - Can cause hypoglycemia
  - Is dialyzable
- Isopropanol
  - Rubbing alcohol
  - Metabolized to acetones
  - No metabolic acidosis
  - Supportive treatment, can be dialyzed
- Methanol
  - Windshield washer fluids, solid cooking fuel, embaling fluid, tainted beverages
  - Toxic metabolite is formate (formic acid)
  - CNS effects, visual effects, pancreatitis, symptoms delayed in onset
  - Metabolic acidosis with elevated anion gap
- Ethylene glycol
  - Antifreeze (sweet taste)
  - Toxic metabolites: oxalate, glycolaldehyde, glycolic acid, glyoxylic acid
  - CNS effects, metabolic acidosis, renal toxicity, myocardial dysfunction
  - Oxalate can cause hypocalcemia by calcium oxalate precipitation
  - Oxalate crystals in urine
  - Wood’s lamp to urine, antifreeze products may contain fluorescein, not a great test
- Osmol gap
  - Difference between measured serum osmolality and calculated serum osmolarity
  - Normal serum osmolality: 275-295 mOsm/kg
- Antidotes
  - Ethanol, fomepizole
  - Competitive inhibitors of alcohol dehydrogenase
  - If ethanol must be used, give orally. Keep blood level >100mg/dL
  - Treat if methanol or ethylene glycol level >20mg/dL
  - Can be stopped once level less than 20mg/dL
  - Dialysis
    - Consider if patient has end organ manifestations (even if levels undetectable)
  - Folic acid for methanol
  - Thiamine and pyridoxine for ethylene glycol
- Send methanol and ethylene glycol levels ASAP

Conference Notes 1/6

Posted on January 13, 2021 by ccapocaccia

Aspirin Toxicity (Harmon)
- Sources of salicylates
  - Aspirin
  - Oil of Wintergreen
  - Pepto-Bismol
  - Bengay
  - Alka-Seltzer
  - Skincare products
- Mechanism of toxicity
  - Fatal dose 10-30 g in adults
  - Dose dependent
  - Acute vs chronic
  - Increases respiratory center sensitivity, uncouples oxidative phosphorylation, inhibits TCA cycle/amino acid metabolism, stimulates chemoreceptor/trigger zone
- signs/symptoms
  - Tinnitus, nausea, vomiting, dizziness, fever
  - Ataxia, anxiety, lethargy, AMS, seizure, arrhythmias, seizure
- Evaluation in ED
  - Serum salicylate concentration and trend
  - ABG
  - CBC, CMP, coags, EKG, UA, tox
- Management
  - Gastric decontamination (ingestion w/in past 1-2 hours)
  - Sodium bicarb (consider if level >40)
  - Avoid intubation as long as possible
  - Fluids
  - HD
  - Poison Control
Acetaminophen Toxicity (Cook)
- Signs/Symptoms
  - Stage I: anorexia, n/v, elevated transaminases
  - Stage II: RUQ pain, elevated transaminases
  - Stage III: hepatic failure, acidosis, renal failure, pancreatitis, peak transaminase levels
  - Stage IV: multi-organ failure vs resolution
- Lab Assessment
  - APAP levels
    - Within 1-4 hrs of ingestion, used to exclude ingestion
    - Obtain 4 hour level to get estimated peak absorption
  - CBC, CMP, ABG
- Rumack Matthew Nomogram
  - Treatment line
    - begins at 4 hr mark
    - If above line, treat
- Treatment
  - Activated charcoal
  - N-Acetyl Cysteine
    - Replenishes glutathione stores to conjugate NAPQI to limit hepatocyte injury and promote renal excretion
TCAs (Weeman)
- MOA
  - SSRI/SNRI, antihistamine, alpha antagonist, anti-muscarinic
- Symptoms
  - Early: anticholinergic effects, HTN, AMS
  - Late: myocardial suppression, QRS widening, seizures, ventricular dysrhythmia, hypotension
- Mimics: diphenhydramine, carbamazepine, sympathomimetic toxicity, serotonin syndrome
- Assessment
  - EKG, UDS, TCA level (does not correlate with severity)
- Management
  - Activated charcoal if within 1 hour of ingestion
  - Do not treat early HTN as patients will likely develop hypotension as they progress, treat hypotension with normal saline
  - Sodium bicarbonate
    - IV push if QRS exceeds 100 msec
    - Infusion to maintain pH 7.5-7.55
  - If seizing, use IV benzos or phenobarbital if refractory
Clinical Pathway Opioid Overdose (Leavitt, Sizemore)
- Duration:
  - Heroin half life: 3-8 min, metabolites ~3hrs
  - Fentanyl half life: 2-4 hrs
  - Oral opioid half life: 3 or more hours
- Narcan
  - Opioid antagonist
  - In general, don’t exceed ~5-10 mg, but can titrate to effect
  - Route
    - IN/IM/SC: slower onset, longer duration
    - Intranasal can last ~3hrs
    - IV
    - Infusion:
      - Mix 4mg naloxone in 100 mL D5W
      - Infusion rate at ⅔ of effective dose that initially reversed the patient
  - Can repeat dosing every 3 minutes
- St. Paul’s Early Discharge Rule
- HOUR Study
- Clinical Pathway to be posted soon
Envenomation (Giddings)
- Ciguatera
  - Heat stable toxin
  - Barracuda, red snapper, mostly reef/tropical fish
  - GI symptoms, paresthesias, hot/cold reversal, bradycardia
  - Treatment: antiemetics, atropine, mannitol
  - Mechanism: increases permeability of sodium channels inducing membrane depolarization
- Scombroid
  - Caused by improperly stored fish, heat stable toxin
  - Symptoms: flushing, warmth, urticarial rash, palpitations, itching
  - Causes histamine release
  - Tx: antihistamine
- Coral Snake (Elapidae)
  - Presentation: minimal local symptoms, severe systemic symptoms, respiratory paralysis, AMS, CN palsies
  - Complications: hypovolemic shock, DIC
  - Work up: CBC, CMP, coags, fibrinogen, d-dimer
  - Treatment: anti-venom, aggressive supportive care
  - Dispo: Admit, concern for neurotoxic effects including respiratory failure, can have delayed presentation
  - Mechanism: cholinergic
- Crotaline (Pit Vipers)
  - Presentation: Local pain/tissue damage, fang marks, coagulopathy, weakness, n/v
  - Complications: swelling, compartment syndrome, DIC, hypotension
  - Treatment: CroFab (give if bad systemic symptoms, abnormal labs, AMS, significant swelling)
- Black Widow
  - Presentation: Pinprick bite, pain to whole extremity, muscle cramps, tachycardia, hypertensive, can mimic appendicitis
  - Management: supportive care, antivenin for severe symptoms
- Tarantula
  - Barbed hair, can penetrate cornea, may need ophthalmology consult
  - Supportive care
- Brown Recluse
  - Painless bite, local tissue necrosis
  - Systemic effects are rare
  - Treatment: supportive
High Altitude Medicine (Thurman)
- Physiology
  - High Altitude: 1500m, Very High: 3500m, Extreme: 5500m
  - Begin to see altitude illness at around 2500m/8000ft
  - As altitude increases, percentage of oxygen available decreases
- Acclimatization
  - Respiratory compensation by increasing minute ventilation, which decreases PaCO2
  - Renal compensation by increasing excretion of bicarbonate
    - Associated diuresis can exacerbate altitude illness and increase dehydration
- Acute Mountain Sickness
  - Headache, GI symptoms, fatigue/weakness, dizziness/light-headedness
  - Prevention (ideally start 1 day before trip, continue 1-2 days after patient is at highest altitude)
    - Acetazolamide 125 mg q12hr
    - Dexamethasone 2mg q6hr or 4mg q12hr
    - Gradual ascent
    - Ibuprofen 600 mg q8hr
  - Treatment
    - Halt ascent until symptom free
    - Only need to descend for severe symptoms
    - Supplemental oxygen, dexamethasone, acetazolamide
- High Altitude Cerebral Edema
  - Acute mountain sickness + mental status change, ataxia
  - Treatment
    - Immediate descent/evacuation
    - Supplemental oxygen
    - Dexamethasone
    - Portable hyperbaric chamber
    - Acetazolamide
- High Altitude Pulmonary Edema
  - Non-cardiogenic pulmonary edema
  - Symptoms (need at least 2)
    - Dyspnea at rest
    - Cough
    - Chest tightness/congestion
    - Weakness/decreased exercise tolerance
  - Signs (need at least 2)
    - Crackles or wheeze
    - Central cyanosis
    - Tachypnea
    - Tachycardia
  - Prevention
    - Gradual ascent
    - Nifedipine 30 mg q12hr or 20 mg q8hr
    - Tadalafil/Sildenafil
  - Treatment:
    - Immediate descent
    - Supplemental oxygen
    - Nifedipine
    - Portable hyperbaric chamber
    - tadalafil/sildenafil
    - CPAP
COVID (Brown)
- Symptoms
  - Typical of most viral syndromes
- Lab abnormalities
  - Elevated WBC, LDH, d dimer, ferritin, ESR/CRP, procal, ALT/AST, t bili, troponin, CK
  - Low lymphocyte count, albumin, platelet count, hemoglobin
- Imaging
  - Normal vs bilateral pulmonary opacities
- Airway management
  - Pre-oxygenate with NRB or HFNC
  - Consider supraglottic airway with viral filter
  - Video laryngoscopy
  - Trial HFNC or non-invasive ventilation prior to taking airway
  - Low tidal volumes, permissive hypercapnia, ARDSNet protocol
  - Consider proning
- Treatment
  - Supportive treatment
  - Bamlanibimab
  - Dexamethasone
  - Remdesivir
  - DVT ppx if hospitalized
- Disposition
  - Walking O2 test
  - 4C mortality score
Pacemakers (D. Thomas)
- Prevent HR from falling below set limit
  - Pacing
  - Sensing
- Malfunction
  - Failure to capture
    - Low battery
    - Inflammation
    - Loose or displaced lead
  - Sensing issues
    - Undersensing
    - Oversensing
- Management
  - Typical bradycardia management
  - Atropine, epinephrine, transcutaneous pacing, transvenous pacing
- Magnet placement
  - Opens Reed switch with breaches sensing circuit and will pace regardless of intrinsic cardiac activity

Transvenous Pacing

Posted on August 13, 2020 by ccapocaccia

Full Transvenous Pacemaker Setup:
1. 6F Cordis
2. Swan Ganz Pacing Catheter
3. Nonsterile Connecting Cable
4. Pacing Generator

Indications

Symptomatic sinus bradycardia (after atropine, +/- dopamine/epinephrine, and transcutaneous pacing have failed)
Mobitz type II second degree AV block
Complete heart block
Beta blocker or calcium channel blocker overdose

Preparation

Patient positioning: supine/Trendelenburg
6 French Cordis (“percutaneous sheath introducer kit”)
Swan Ganz/Bipolar pacing catheter
Pacer generator (“temporary pacemaker”)
Nonsterile connecting cable (within pacer generator case in inside sleeve)
Ultrasound + sterile probe cover

Supplies and room 9 location

Pacer generator (Nonsterile connecting cable in the inside sleeve)

6 French Cordis (“percutaneous sheath introducer kit”)

Pacer generator—initial settings

Turn on
Rate—80 bpm, rate at which patient will be transvenously paced, at least 20 bpm over the intrinsic rate
Output—20 mA, electrical output of pacer with every paced beat, decrease until patient has both mechanical (palpating patient’s pulse) and electrical capture
Sensitivity—3 mV, pacer’s ability to sense intrinsic rate (the lower the sensitivity, the more the pacer will detect intrinsic rate; for example, at 3 mV, the pacer will only detect impulses generated from the heart that are greater than 3 mV)
- Oversensing- Sensitivity is set too LOW so electrical signals are inappropriately recognized as cardiac activity and pacing is inhibited
- Undersensing- Sensitivity is set too HIGH so pacemaker ignores native cardiac activity

Location

Right internal jugular—preferred
Left subclavian—use as second option, preferred to leave site available for possible permanent pacer

Steps to placing transvenous pacemaker

Place cordis
Set up nonsterile connecting cable (helpful to have assistant connect cable to pacer generator as these are not sterile)
Ensure proper balloon inflation on Swan Ganz
Position sterile sleeve over pacer wire and ensure correct orientation
Insert pacer wire into cords and advance to 20cm (indicated by first two black lines)
Insert Swan-Ganz + and – pins into nonsterile connecting cable (proximal to positive, distal to negative)
Have assistant turn on pacer generator with the above settings (remember it is non sterile)
Inflate balloon and lock purple stopcock (stopcock is on Swan, catheter see below image)
Advance pacer wire to ~30-35cm (three black lines on pacer wire) while watching monitor for capture (STEMI pattern)
Troubleshooting:
- if wire coils in RA, pull wire back, twist 180˚ towards patient’s right and re-advance
- if wire fails to capture, can adjust pacer generator settings, consider increasing output and decreasing sensitivity
Verify capture by either palpating pulse or by pulse ox waveform
Decrease output until there is no longer capture, then titrate up to the lowest effective output
Deflate balloon and turn stopcock off
Expand sterile sleeve
Suture cordis and place sterile dressing
Secure pacer wire to patient with tape (can dislodge easily)