Conference Notes 10-23-2012

Lovell  Study Guide Pulmonary

Massive hemoptysis: 600ml of blood in 24 hours.   For an ED perspective, hemoptysis that impairs oxygenation/ventilation.   Stabilize with likely bleeding side down.  Get them to CT and consult IR for bronchial artery embolization.

Tracheo-Innominate Artery Fistula:  Usually in the first several weeks after placement of trach (85% occur in first month).  Can have herald bleed followed by exsanguination or severe bleeding impairing ventilation.  Treatment is putting your finger in trach hole and applying anterior pressure against the sternum.  Other option is to over- inflate trach cuff.

Hermmann question followed by Harwood, Lovell comment: You have to work up 100% of patients with Trach tube and bright red bleeding from trach with CTA or bronch.  More likely in patients who had trach placed in the last month.

 Platypnea: SOB when sitting up. It is the opposite of orthopnea.   Elise’s factoid.

Aspiration pneumonia: CXR findings develop in dependent portion of lung.  Aspiration initially is a chemical pneumonitis followed by pneumonia.  No prophylactic antibiotics and no steroids.  There is controversy about NH patients whether to start antibiotics with early signs of aspiration.

FDA approved method of treating hiccups is Chlorpromazine (Thorazine).   Harwood method is having patient suck water through a straw while they holding their fingers in their ears.    Alternative home method is dry granulated sugar in the back of the throat.

Before you put a chest tube in a COPD’r is make sure what you think is a pneumo is not really a big bleb.  If they are SOB treat with nebs and steroids, don’t put in a chest tube. 

Deep sulcus sign is highly suspicious for a pneumothorax.  The costophrenic angle dips much further inferiorly on the affected side than on the unaffected side.

Catch phrase for Legionella pneumonia:  dry cough with diarrhea.

Catch phrase for Strep pneumonia: rust colored sputum

Catch phrase for Staph aureus: post-influenza pneumonia

Catch phrase for Klebsiella: alcoholic or NH pt, abscess

Catch phrase for Mycoplasma: upper airway and lower airway symptoms, bullous myringitis

T B: Pott’s disease is TB to the spine.  Scrofula is large lymphadenopathy in the neck due to TB. Gohn complex (pulmonary scarring with hilar adenopathy)is classic CXR finding of latent primary TB.  These patients  are treated with 9 months of INH similar to newly positive ppd .  Reactivation TB is active TB and need 4 drug treamtment.   Miliary TB is diffuse lung findings in an immunocompromised patient means TB out of control.

Spontaneous pneumothorax in young stable patient: Catheter aspiration or Heimlich valve techniques are superior to placing a standard chest tube.

Harwood comment: Can you extrapolate this data to iatrogenic pneumothorax? Elise  response: yes.

Elise said she would observe any patient treated with catheter aspiration for 6 hours in the ED.

Villano/E Kulstad  Oral Boards

Case #1 Acute MI: ASA/O2/screen for contraindications/give thrombolytic.  Start IV heparin.

Case#2 Acute Angle Closure Glaucoma: Identify diagnosis, start treatment promptly, consult ophtho.  Look for iris bowing forward on slit lamp exam.  You can see the light beam with curve over iris.  Treat with timolol/apraclonidine/pilocarpine/prednisolone/acetazolamide.  If IOP still over 40 give mannitol.  Treat pain and nausea.

Case#3 Digital hair tourniquet:  Identify affected finger and remove tourniquet.  The third toe and third finger are the most common digits involved. There is an association older clothing and mittens.  Bill Schroeder comment: use intranasal fentanyl prior to digital block.   Removal with fine scissors/scalpel and forceps.   Sarah Herron comment: Nair removal takes too long.  Bill Schroeder comment: you don’t always know that the tourniquet is hair so Nair may not be effective if not hair.  It could be synthetic/thread.

Schroeder  Peds Resuscitaiton

ET tube size: (age/4 +4) for uncuffed.   (Age/4) +3 for cuffed tube.  Easiest way to calculate is a Broslow tape.

 EPI dose is 0.01mg/kg or 0.1ml/kg of the 1:10,000 for PEA.

Ketamine sedation is 1-2mg/kg IV.

Treatment for TCA OD is sodium bicarb.  Dose is 1meq/kg.   Amp of 8.4% bicarb has 1meq/ml or 50meq in an amp.

Lower limits of systolic BP is 70mm hg + (age x2).  Under one month is 60mm hg.  90mm hg for ages 10 and up.

Goal of fluid boluses in the first hour for the critically ill can be up to 60ml/kg.  This is done by repeated 20ml/kg boluses as needed.

IM versed 0.01mg/KG is the fastest way to get anti-seizure meds into a child with no iv access until you get an IO or IV line.

Atropine for brady arrest dose is 0.02 mg /kg.  Minimal dose is 0.1mg and max dose is 1mg.

The  first line pressor for peds patient with volume refractory shock is dopamine.  The reason is that kids generally have an already high SVR in shock.

Give pyridoxine for refractory seizures in kids.   Can be due to B6 deficiency in a neonate or infant.  Also can be used for INH related seizures.

D50 in an infant can cause cerebral edema due to hyperosmolarity.  It can also cause tissue damage in the extremity if it extravasates.  It can also lead to hyperglycemia followed by rebound hypoglycemia.

Succinylcholine may cause bradycardia in young children and infants.  Can use with atropine. Can cause hyperkalemia in kids with muscular disorders like muscular dystrophy.  Rocuronium is an alternative but has slower onset of action than succinylcholine.  Bill personally uses rocuronium on all infants he intubates.

Ductal dependent lesions causing shock in infants can be treated with prostaglandin IV.

Bill Schroeder comment: In a critical case, don’t be calculating doses, use the broslow tape or a pediatric dosing app on your phone. 

Klinker/Wolfe Inhaled Medications in Asthma

Atrovent MDI’s  have peanut oil and should be avoided in kids with peanut allergy.

Conversion: Albuterol 5mg= 4 puffs Q30 minutes.  10mg=8puffs Q 30min.    15mg=8puffs Q20 min.   20mg=11puffs Q20 minutes.

Home treatment should be 4puffs QID to Q 4hours.  If child is having difficulty breathing advise parents to continue to give puffs on the way to the ED.   Bill Schroeder said his rule of thumb is if child is requiring 8 puffs at a time or needs mdi tx more frequently than q 4 hours return to ER.

 Bronchiolitis:  Kids under 4 months are obligate nose breathers.  If their nose gets stuffed up, they have a lot of trouble breathing.   Don’t routinely do a CXR.  Treat with suctioning, maintain hydration, O2 to keep sat over 90%.  When suctioning with bulb syringe tell parents to stick it into the nose and aim at the toes.   NoseFrida is a suction tool that parents can suck on to remove mucous from the nose.  On the NoseFrida website you can find a local store that has this device.  Parent who have used this rave about it.  Good suctioning can improve upper airway movement and decrease wheezing in lower airways. Antibiotics, CPT and steroids are not recommended.  For sicker bronchiolitic patients you can try albuterol or hypertonic nebs.