Conference Notes 11-22-2011

CHANNON-PAQUETTE  ORAL BOARDS

Case1:  CO Poisoning with cardiac ischemia.  Treat with hyperbaric oxygen.  NTG for chest pain.   Also give ASA.

Case2: Hip Fracture

Case 3:Temporal Arteritis.  Consider DX in patient with headache over 50.  ESR is commonly over 50 with this diagnosis.   Treat with oral prednisone.

Test Taking Comments: Thorough ROS and Organized efficient Physical Exam.  Need to really push to get thru the three cases on time.  As the examinee, you have to take on a take charge demeanor.

CUMMINS   SHOULD PARAMEDICS INTUBATE?

Asking paramedics if they should be intubating in the field is viewed as an attack on their core skill.

Paramedics have been shown to be very competent in getting the ET tube in the trachea.  (@90-95% success rate)

However,  field intubations have been shown to increase mortality when compared to BVM.

Intubation is frequently followed by unintentional hyperventilation.   Which can worsen outcome.  Intubation may delay or interrupt chest compressions.

Average paramedic does  1-5 intubations per year.

If paramedics are going to intubate a patient with cardiac arrest in the field, they cannot interrupt chest compressions, they cannot miss an esophageal intubation, and they  cannot over-ventilate.  Those three things will worsen outcomes.

GIRZADAS  INTUBATING THE OBESE PATIENT

Obese patients desaturate more rapidly than normal weight patients

RAMPED Postion will improve oxygenation and laryngoscopic view.

Consider Ketamine sedated laryngoscopy prior to/in place of  RSI.

Bag-valve-mask ventillate using two handed/two person technique.  Also use CPAP valve on bag-valve-mask.

If you can't get the tube, try using an intubating LMA as your go-to rescue device.    ASA recommended.   

 

DR. SILVER   INITIAL CARE OF THE ACUTE CHF PATIENT

 The number of admissions for CHF a patient has is inversely proportional to life expectancy.

Approach to the CHF patient

Step 1:NYHA Functional Classification of CHF:   1=no symptoms,   4=symptoms at rest,  2 and 3 =somewhere in between.

Step 2: Assess  volume and perfusion.   Dry/wet   warm/cold

Step 3: Figure out their medications.  Diuretics for volume control.  Digoxin 0.125mg as a neuro hormonal depressor.   ACEI,  ARB’s

Step 4: Make an assessment of how sick they are.   Systolic BP/ CR/BUN are predictors of in-hospital mortality .   Seattle Heart Failure Risk is an iphone app.

Step 5: Integrate all the above info.

Be judicious with iv diuretics.   They can increase mortality/los.

NTG is a wonderful drug for CHF.  It lowers systemic and pulmonary vascular resistance.  Also lower wedge.  Gotta use enough of it.  Monitor patient and titrate up based on patient response.

Aldosterone antagonists are expected to be more commonly used.  A side effect is hyperkalemia.

In the hypotensive chf pt you need inotropes/diuretics.  Use milrinone for the tachycardic patient. Use dobutamine in the patient without tachycardia.

BNP can be not super high in copder’s and obese patients despite them being in decompensated chf.

Consider  ace-I’s in hypertensive chf patients.

No role for nesiritde in acute decompensated heart failure.

TOERNE   ACUTE ETOH WITHDRAWL

Brain responds to chronic etoh exposure  by altering receptors for glutamate and gaba.   The GABA related receptor affects Chloride influx into the cell.    Gaba receptor decrease and phenobarb receptors increase in the face of chronic etoh exposure.

Earliest withdrawl syndrome is Seizures.  Less than 3% of seizures result in status epilepticus.   30% of withdrawl seizures progress to DT’s.  

Next syndrome is uncomplicated withdrawl

Alcoholic hallucinosis is diagnosis of exclusion.  More likely is DT’s

Delerium Tremens occurs 2-7 days after stopping etoh.  Key is delirium.  They also have hyperadrenergic surge.   Risk factors are heavy daily eoth use, previus dt’s, older age, concurrent medical illness, abnormal liver function.

Proof is twice percentage of etoh.   151 rum is 75.5% etoh.  

Labs that suggest etohism: anemia with mcv around 105 which is a marker of folate deficiency.  Others are hyponatremia, thrombocytopenia.

Treat DT’s with large dose benzos and Phenobarbital.    Benzos increase the frequency of Chloride  channel opening and phenobarb increases the duration of channel opening. 

Give phenobarb 260mg slow ivp every 10-15 minute.  

Ketamine may be helpful to antagonize the glutamate receptor.