Author Archives: ccapocaccia

Conference Notes 1/28

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  • 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

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  • 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

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  • 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

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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

Room 9 bay 1, bottom shelf on right
Swan Ganz/Bipolar pacing catheter
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)
Stopcock that comes attached to Swan-Ganz pacing catheter

Complications

  • Misplacement—can verify with ultrasound or chest x-ray
  • Ventricular perforation
  • Dysrhythmias
  • Pneumothorax