Wernicke Encephalopathy

• Encephalopathy, ophthalmoplegia, ataxia only present in 15% of cases
• Clinical Diagnosis
• Treatment
  • Start empiric thiamine, give with glucose
    • Prehospital though, give glucose first since thiamine not available for EMS
  • 500mg IV Thiamine TID for 2-3 days
• Ocular changes improve in 1 day
• Ataxia and confusion may take a week to improve

HHS

• Typically T2DM
• Mortality 10-20%
• Complications- cerebral edema
• Evaluation
  • Glucose (Typically >600)
  • Osmolarity >320
  • Bicarb relatively normal
  • pH relatively normal
  • Ketones (Low or negative)
• Treatment 
  • Fluids typically 8-12 L deficit
  • ICU admission

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 daily​15 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 / vomiting​Headache, fatigue​Muscle cramps​	Severe​(< 120-125 mEq/L)​Altered mental status​Seizures​Coma​
Hypernatremia​
Moderate​(145 – 155 mEq/L)​Thirst​Irritability​Restlessness​	Severe​(> 160 mEq/L)​Hyperreflexia​Seizures​Coma​

• 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

Emma Ganshirt Cushing’s

• Presentation
  • Psychosis
  • Hypertensive emergency
  • Hypokalemia
  • Cardiomyopathy
• Broad Differential, consider it a risk factor for multiple etiologies
• Physical exam and Hx key

Dana Roberts Adrenal Crisis

• Adrenal crisis most common cause primary adrenal insufficiency
• Risk factors: 
  • History of adrenal crisis
  • On steroid therapy
  • Meds that increase cortisol (levothyroxine, phenytoin, phenobarbital, rifampin)
• Clinical manifestation
  • Volume depletion and hypotension not responsive to fluids (other: weakness, fatigue, weight loss, decreased appetite, hyperpigmentation, abdominal tenderness)
• Labs: 
  • Low Na, Glucose, aldosterone
  • High K, Ca, Creatinine (prerenal), ACTH, renin
  • Normocytic normochromic anemia
• Tx: 
  • Hydration, usually need 4-6L in first 24 hours, be mindful of likely low Na and don’t correct too quickly, steroids (100mg bolus IV or IM hydrocortisone with additional every 6-8 hours)
• Mortality: as high as 25%

Huecker Micronutrients/Supplements

• 5 Pillars of Wellness: Move, Rest, Nutrition (Micronutrients/Supplements), Wisdom, Community
• Deficiency avoidance vs Optimization (Daily % on box is minimum, not optimum)
  • Example 100% daily vitamin C is enough to not get scurvy, not to help build tendon etc. 
• For more reading: Perfect Health Diet, discusses ins and outs of a healthy diet in easy to read way
• Daily Supplements: Mag >200mg, Vit D (~2000IU), Vit K2 100mcg, Vit C (1G), Idodine
• Most important mineral: Mg 
  • Used in 800 bodily reactions
  • Deficiency Symptoms: Muscle cramps/HA arrythmia, tremor, reflux, mitochondrial decay, poor immune function, death
• PO mag oxide trash, best PO: mag threonate (Brain mag, Mag mind)
• Probiotics: Food > Pill
• Collagen: Glycine: Methionine ratio (Bone in meats better)
• Lab Door: Website that tests supplement products for authenticity

Huecker Handout

Daily Supplements

Ask yourself “Am I going take this pill or powder every day for the rest of my life?” One should decide to take a supplement only after thoughtful consideration of ability to maintain long-term compliance. Macro- and micronutrients should come from whole food sources as often as possible. The package of vitamins in foods has millions of years of evolution backing its design. Thus, infant formula makers continue to strive for the same profile and clinical benefits of breastmilk. 

The backbone of these recommendations comes from the book Perfect Health Diet. Written by PhD husband and wife, the book covers macronutrients and micronutrients, with focus on nutrient density of foods and avoidance of toxins. 

Nutrition should begin with regular consumption of nutrient-dense foods:

• 3 egg yolks daily (5 for pregnant or trying to become pregnant) for choline, folate, vitamin A.  

• Soup made with bone stock 3 days per week for calcium, phosphorus and collagen.

• Fermented vegetables (kimchi, sauerkraut, or fermented mixed vegetables) for nucleotides, probiotic bacteria, and vitamins K2 and B12. Add other vegetables such as tomato, avocado, potato, sweet potato, banana, green leafy vegetables, and seaweeds such as dulse, daily for potassium. 

• ¼ lb beef or lamb liver, weekly for copper, vitamin A, folate, choline. You can substitute ¼ lb chicken, duck, or goose liver weekly plus 30 g 85% dark chocolate daily. 

• Fish, shellfish, eggs, weekly (for selenium)

You want to supplement the nutrients from the foods on this list that you do not consume. Potential issues with food recommendations include the 3 eggs per day (saturated fat and cholesterol), the fermented food not mentioning fermented milk (ie. kefir or yogurt), and no mention of omega 3 fatty acid supplementation (should consider whole oil supplement depending on amount of fish in diet). If you are not eating some of these foods, consider supplementation, for instance collagen powder if you do not regularly eat bone broth. 

Other important food considerations include polyphenols, plant molecules that induce hormesis in our bodies that will lead to longer life. Common sources include coffee and tea, chocolate, mushrooms, colorful vegetables and fruits, nuts, herbs and spices, algae, wine, olive oil. 

DAILY Supplements

• Sunshine or vitamin D3 as needed to achieve serum 25OHD of 50-60 ng/ml

• Vitamin K2 100mcg

• Magnesium 200mg

• Iodine 200mcg

• Vitamin C 500mg 

• Activated vitamin B complex (see this formulation)

• Pantothenic acid (vitamin B-5) 500mg

OPTIONAL supplements, with some dietary caveats:

• Chromium, 200-400 mcg per week (not necessary if you cook in stainless steel pots)

• FOR PEOPLE WHO DO NOT EAT LIVER: Copper 2 mg per day, Vitamin A from cod liver oil, 50,000 IU/week

• Taurine 500 mg to 5000 mg per week (higher doses may be therapeutic for small intestinal or systemic infections)/(also helpful for blood pressure lowering)

• Selenium 200 mcg per week depending on selenium content of food (if food is produced in dry, flat areas = high selenium, no supplements; rainy, well-drained areas = 200 mcg/wk)

• Molybdenum 150 mcg per week

OTHER supplements depend on goals. The list above covers most of the supplements needed in the context of balanced, diverse diet. Individuals with restrictive diets should do research potential deficiencies. 

Special Considerations

Sleep – magnesium, glycine, L-theanine, vitamin D (in AM), resveratrol, LIGHT, rarely melatonin

Calorie Reduction/Weight Loss – sleep, chromium, high protein, creatine

Muscle Mass – sleep, creatine, omega 3, whey protein, collagen

Hormone Optimization – sleep, adaptogens (e.g., cordyceps, ashwagandha), Zinc, Vitamin D, B vitamins

Immunity – sleep, vitamin C, vitamin D, Zinc, garlic, elderberry, quercetin, probiotics

Recovery from Injury – sleep, glucosamine and chondroitin, hyaluronic acid, collagen

Hyperlipidemia – niacin, psyllium, phytosterols, red yeast rice

Nelson Thyroid Disorders

• Hyperthyroidism
  • Tachycardia, fever, exophthalmos, etc
  • Subclinical hyperthyroidism
    • TSH low, T3/T4 normal
  • Primary hyperthyroidism
    • TSH low, T3/T4 high
    • Graves Disease (85% of cases)
    • Thyrotoxicosis
    • Toxic nodular goiter
  • Secondary
    • TSH High, T3/T4 high
• Hypothyroidism
  • Subclinical hypothyroidism
    • TSH high, T3/T4 normal
  • Primary hypothyroidism
    • TSH high T3/T4 low
    • Hashimoto’s thyroiditis
    • Subacute painful thyroiditis
    • Subacute painless thyroiditis
    • Surgical/ablation
  • Secondary
    • Panhypopituitarism
    • Pituitary adenoma
    • CNS infection
• Thyroid Storm
  • Typically caused by stressor such as infection, recent surgery, trauma, PE, MI, DKA, med non-adherence
  • Triad: Hyperthermia (Usually >104F), tachycardia, AMS
  • Point Scale: Burch-Wartofsky Point Scale
  • Evaluation: Thyroid function panel, Tox, UDS, UA, CXR, EKG
    • Thyroid function: Low or undetectable TSH plus high free T3/T4
  • Treatment: Propranolol, Propylthiouracil or Methimazole, Cholestyramine, Fluids, Cool
    • Be careful wit B-blocker due to some patients having heart failure associated, can exacerbate and precipitate shock
    • PTU- Hepatotoxic
    • Methimazole- Avoid in pregnancy (can cause aplasia cutis)
    • Cholestyramine- Prevent free thyroid hormone reabsorption
• Myxedema Coma
  • Hypothyroidism, Altered mental status, Hypothermia/bradycardia
  • Precipitated by Sepsis, Medication nonadherence MI, heart failure, and cold exposure
  • Work-up
    • Thyroid panel: Elevated TSH, low T4 (Labs not correlated with severity)
    • Hyponatremia, hypoglycemia
    • Acidotic, retain CO2 and poor perfusion causing elevated lactate
    • Infectious work-up, Head CT, Possibly LP
  • Treatment
    • ABCs
    • Fluid resuscitation +/- vasopressors
    • Electrolyte replacement
    • Levothyroxine- 1^st line
      • Safe, give if suspected don’t wait for labs
    • Adrenal insufficiency cause > give steroids
• External Causes of  Hyperthyroidism
  • Amiodarone induced thyroiditis
    • Increased iodine load
    • Destructive thyroiditis- Thyrotoxic, can cause to release more thyroid hormone which then leads to hypothyroidism as thyroid
  • Other meds:
    • Lithium, HIV meds, immunotherapy, iodine, contrast
  • Munchhausen’s
  • Cancer
    • Struma ovarii, metastatic thyroid cancer

Shaw Acid/Base Disorders

• Anion Gap Acidosis
  • Decrease in HCO3, Increase in Gap
  • MUDPILES
    • Methanol
    • Uremia
    • Diabetic or alcoholic ketoacidosis
    • Paraldehyde (Tylenol)
    • Isoniazid/Iron
    • Lactic acidosis
    • Ethylene glycol
    • Salicylate
• Non Anion Gap Acidosis
  • Loss of HCO3 replaced by Cl ions
    • USEDCAR
      • Ureteroenterostomy
      • Saline Administration
      • Endocrine Disorder (Addison’s disease)
      • Diarrhea
      • Carbonic anhydrase
      • Ammonium Chloride
      • Renal tubular acidosis 
• How to Calculate Excess Anion Gap
  • Note in DKA (Don’t correct sodium to figure out gap)
  • Excess anion gap = Anion gap – 12 + HCO3
    • Sum >30: underlying metabolic alkalosis
      • Change in  AG > Change in HCO3
      • Less acidotic than should be
    • Sum <23: Underlying non-anion gap
      • Change in HCO3 > change in AG
      • More acidotic than should be
• Compensation in Metabolic Acidosis
  • Winters Formula
    • PaCO2=1.5 (HCO3) + 8 +/- 2
    • PaCO2 ~ last 2 digits of pH
• Treatment
  • Respiratory Acidosis
    • Correct ventilation problem
      • Example Opiate- Narcan
      • Anatomical- NPA, BiPAP, Vent
    • Two parameters to treat respiratory acidosis or increase minute ventilation
      • Respiratory rate
      • Tidal Volume (6-8 cc/kg)
  • Respiratory Alkalosis
  • Treat hyperventilation
    • Treat pain, Treat Toxidrome, Etc.
  • Metabolic alkalosis
    • Excessive loss of H+ through NG or vomiting > Zofran
    • Halt diuretics if contraction alkalosis
    • Stop Excess oral supplementation
    • Acetazolamide / Carbonic anhydrase
  • Metabolic Acidosis
    • Treat cause
    • Increased fixed metabolic acids? (Lactic acid, ketoacids, salicylic acid, toxic alcohols, etc.)
    • Uremic acidosis > Dialysis
    • Excess loss of HCO3 through kidneys of GI
    • Increased plasma Cl, limit Saline fluids
  • IV Bicarb?
    • Giving bicarb requires pt be able to blow off CO2 they will produce when HCO3 combines with free H+
    • If not able to compensate or when intubated RR is not matched to pre intubation RR can make acidosis worse
    • Cardiac arrest
      • Don’t use in MOST cardiac arrest
      • If cardiac arrest due to known TCA > consider it
    • Sepsis
      • Don’t use it, not helpful in improving hemodynamics or reducing vasopressor requirements
    • DKA
      • No benefit between pH of 6.9 to 7.1
      • Risk of hypokalemia, dereased O2 uptake, CSF acidosis, cerebral edema
      • No studies <6.9, so maybe
      • If pH < 6.9 Bicarb given 100mmol in 400mL sterile water with 20 mmol KCl at a rate of 100ml/h for 2 hours until pH greater than 7.0
    • Buffer pressors?
      • Theory: norepi needs to be converted to epi in vessels and if acidotic enzymes won’t work as well
      • What does data say: No evidence
    • Advantage
      • Provide fluid and sodium replacement
      • Increased arterial pH (does this matter, probably not)
      • ASA and TCA overdose, give it
    • Disadvantage
      • Na and water overload
      • Paradoxical CSF tissue acidosis
      • Cerebral edema
      • Hypokalemia
      • Decreases ionized Calcium
• Summary
  • Look at pH to discover primary disorder
  • AGMA is the accumulation of anions, NAGMA is a problem with GI or kidneys
  • If you have to calculate Winter’s formula on boards, it’s an ASA toxicity
  • VBG is okay if PCO2 not needed, pulse ox reading ok, not hypotensive