Endocrine/Metabolic/Nutrition

Fluid and electrolytes

• Water
• 60% total body water - adult man
• Water loss – Insensible, Urinary
• Water handled via 2 mechanisms
• ADH
• Inc body water/Dec serum osm → SUPPRESSES ADH → diuresis free water
• Dec free water/Inc serum osm → STIMULATES ADH → water retention
• Aldosterone – released in response to renin release by the kidney in low volume states → stimulates Na retention → water retention
• Dehydration
• Hypotonic - Na>H2O, serum Na low – diuretics, vomiting, adrenocortical insufficiency
• Isotonic - loss of Na = loss of H2O, serum Na nml - vomiting
• Hypertonic - H2O>Na, serum Na high - diarrhea, lack of access to H2O, HHK, DI

SODIUM

• Major extracellular cation
• HypoNa - <135mEq/L
• CP: HA, confusion, N/V, cramps, seizures. No ECG findings
• Etiology:
• Hypervolemic- CHF, Cirrhosis
• Tx: diuresis
• Hypovolemic - V/D, nephrosis, diuretics, adrenocortical insufficiency
• Tx: Isotonic fluid
• Euvolemic - SIADH, Thyroid dysfunction
• SIADH - low BUN, high urine osm and uNa – Tx water restriction
• Psychogenic polydispia
• Pseudo - hyperglycemia, MM (inc protein), hyperlipidemia
• Tx: Slow correction to prevent CPM – if low for >2 days - 0.6meq/l/hr or 12meq/d\l/24hrs
• In acute hypoNa can rapidly correct (calculate sodium deficit)
• Give Hypertonic NaCl - if severe neurologic symptoms (seizures)
• HyperNa - >145
• CP: AMS, dehydrated, seizures
• Etiology:
• Water loss - poor intake, abn thirst mechanism, osmotic diuresis (DKA), DI, Drugs
• Sodium gain - saline administration, hypertonic feedings, Bicarb
• Tx: if chronic go slow to prevent cerebral edema.
• Give saline if water loss state. If sodium gain state consider diuretics + D5W and/or dialysis

POTASSIUM

• Major intracellular cation
• HypoK <3.5meq/l
• CP: mm weakness, hyporeflexia, paralysis, arrhythmias/palpitations, ileus
• ECG: Flat T waves, U waves
• Etiology: GI losses, renal dysfunction, Cushing, Familial periodic paralysis, intracellular shifts, excess mineralcorticoids, sweating, hyperthyroid, hypermag
• Tx: Give K
• Subacute or Chronic → 150 meq needed to increase K by 1meq/L
• Acute → 40meq needed to increase serum y 1meq/l
• HyperK >4.5
• CP: anything really → weakness, lethargy, shock, dysrhythmias
• ECG: peaked T waves → wide QRS → sine waves
• Etiology: factitious, renal dysfunction, increased potassium load, decreased cellular uptake
• Tx: If no ECG changes – diuretics/kayexalate (sodium polystyrene)
• If ECG changes → Calcium, Insulin (+Glu), Albuterol, Bicarb, Lasix, Dialysis

calcium

• HypoCa <8.5 mg/dl
• CP: Paresthesias, carpopedal spasm, chvostek or trousseau sign, hyperreflexia, seizures, shock, dysrhythmias
• ECG: Long QTc
• Etiology: Renal disease, hypoPTH, acute pancreatitis, chronic diarrhea/malabsorption, MTP, Rhabdo
• Tx: Repletion
• HyperCa >10.5 mg/dl
• CP: Stones, bones, groans, moans
• ECG: Short QTc
• Etiology: Cancer, Excessive intake (Milk-Alkali, Vit D or A), Acute osteoporosis, hyperPTH, drugs (lithium, thiazides)
• Tx: Symptomatic patients or anyone with Ca >14
• IVF, Lasix (1,g/kg), Hydrocortisone, Calcitonin/Bisphosphonates

MAGNESIUM

• HypoMg<1.4 meq/l
• CP: usually hypoCa/K - so all hypoCa symptoms + tetany, tremors, dysrhythmias
• ECG: Prolonged PR and QTc, wide QRS, STD, broad flat T waves with precordial TWI
• Etiology: Inadequate intake/absorption, IV hyperalimentation, DKA, HyperPTH, EtOH, Pancreatitis, Drugs
• Tx: Repletion
• Life threatening – 1-2g over 1-5 minutes → 1-2 g/hr
• HyperMg>2.2
• CP: weakness, drowsy, slurred speech, hyporeflexia, coma, resp failure, shock (Mg>10-12)
• ECG: Bradycardia → AV block → Asystole, Long PR and QTc
• Etiology: Iatrogenic (PreE), renal failure, DKA, adrenal insufficiency, Rhabdo
• Tx: Discontinue exogenous Mg, CALCIUM, Diuretics, Dialysis prn

Vitamin and nutrient deficiencies

• FAT SOLUBLE
• Vit A – night blindness, keratomalacia, Bitot spots, dry skin/hair, follicular hyperkeratosis, pruritus, broken finger nails
• Vit D - rickets, osteomalacia
• Vit E - Ataxia, hyporeflexia, peripheral neuropathy, spinocerebellar degeneration
• Vit K - bleeding with minor trauma, epistaxis, gingival bleeding
• WATER SOLUBLE
• B1 (thiamine) - Wernicke-Korsakoff, Beriberi, Anorexia, Constipation
• B2 (riboflavin) - dermatitis, glossitis, keratitis, neuropathy
• B3 (niacin) - pellagra, hyperpigmentation in sun exposed areas
• B6 (pyridoxine) - glossitis, cheilosis, impaired proprioception, confusion, seborrheic dermatitis, seizure, microcytic anemia
• B9 (folic acid) - angular stomatitis, megaloblastic anemia, patchy hyperpigmentation
• B12 (cobalamin) - neuropathy, visual disturbance, paresthesias, dementia, weakness, demyelination of dorsal column (subacute combined degeneration)
• Vit C - scurvy, poor wound healing, gingival bleeding
• Iron - anemia, fatigue, pallow, spooning fingernails
• Selenium - cardiomyopathy, heart failure
• Zinc - decreased taste, impaired immune function, dwarfism

ACID BASE

• Determine Acidosis (pH<7.35) or Alkalosis (pH>7.45), Is there an AG?, Respiratory or Metabolic, Is it compensated?
• Respiratory
• Alkalosis (Inc pH, Dec CO2) – Hyperventilation 2/2 Anxiety, primary CNS, ASA, Sympathomimetics, increased ICP, liver failure, hypoxia, CHF, sepsis, PE, psychogenic
• Acidosis (Dec pH, Inc CO2) - sedative hypnotics, opioids, respiratory failure (COPD, Obstruction, Pickwickian)
• Expected compensation:
• Acute: Expected pH = 0.08 x {(Actual PCO2 - 40)/10}; Chronic: Expected pH = 0.03 x {(Actual PCO2-40)/10}
• Metabolic
• Alkalosis (Inc pH, Inc HCO3) - volume depletion (NGT suctioning, diuretics, vomiting), Barter syndrome, hyperaldosteronism, milk-alkali syndrome, Hypercalcemia, massive transfusion
• Cl-sensitive – ie Saline responsive - ie vomiting
• Cl-resistant - ie Saline unresponsive – ie mineralocorticoid excess
• Acidosis (Dec pH, Low HCO3)
• AG - MUDPILES
• Non-AG - toluene, RTA, Diarrhea, ketone-wasting, Hypoaldosteronism, Hyperkalemia, Ion-exchange resin (kayexalate)
• Pure Metabolic Acidosis?
• Resp compensation should not raise pH to normal.
• Expected pCO2 compensation = 1.5xHCO3+8 +/-2 (Winter’s Formula) OR last 2 of pH
• Respiratory compensation in MA?
• Too much – Superimposed respiratory alkalosis → ie: ASA poisoning, early CN poisoning, sepsis
• Too little - Superimposed respiratory acidosis → ie sedative-hypnotic overdose, primary ventilatory impairment

Mixed Acid-Base DISTURBANCES

• Can have a normal pH
• Delta Gap - identifies if 2 simultaneous AB processes are occurring, based on if the anion gap is accounted for by the change in serum HCO3 by the absolute difference btw change in each from normal
• dG = (AG-12) - (24-HCO3)
• Assumes normal AG of 12 and normal HCO3 of 24
• Interpretation:
• Elevated AG and dG < +6 = AGMA
• Elevated AG and dG > +6 = metabolic alkalosis + metabolic acidosis
• Elevated AG and dG < - 6 = mixed AG and non AG MA
• Delta Ratio – same function as the dG
• dR = (AG-12) / (24-HCO3)
• Interpretation:
• <0.4 = non AG MA
• 0.4-0.8 = Mixed AG and non AG MA
• 0.8-2 = AGMA
• >2 = AGMA + Met Alk
• Pure AG acidosis → increase in AG should equal the decrease in HCO3
• Is the increase in AG = to decrease in HCO3?
• HCO3 Greater? Superimposed metabolic alkalosis → ie Vomiting with DKA or EtOH KA
• Less? Associated hyperCl metabolic acidosis → ie: resuscitation with NaCL and HCO3, severe diarrhea, RTA, renal excretion of ketones with retention of chloride
• Examples:
• Met Acid + Resp Alk = met acidosis with pCO2 lower than predicted = lactic acidosis, sepsis, ASA
• Met Acid + Resp Acid = met acid with pCO2 lower than predicted = pulmonary edema
• Met Alk + Resp Alk = pCO2 does not increase as predicted, pH higher than expected = liver disease, diuretics
• Met Alk + Resp Acid = pCO2 higher than predicted, pH normal = COPD on diuretics
• Met Acid + Met Alk = AGMA with dAG much higher than dHCO3 = uremia with vomiting, DKA
• AGMA + NAGMA = dHCO3 accounted for by combined dAG and dCl = diarrhea and lactic acidosis, Toluene

Hypoglycemia

• S/S typically present when <60mg/dl
• Hunger, Fatigue, Diaphoresis, Tremor, Anxiety, Tachycardia, AMS, Seizures, LOC
• Causes: Medications (DM meds, Beta Blockers, excessive EtOH, poor intake, severe infection, cancer, kidney/liver failure, inborn errors of metabolism, insulinoma, Dumping syndrome
• DM Meds: Insulin and Sulfonylureas
• Dumping - large carbohydrate loads cause excessive insulin release → hypoglycemia
• Tx: Glucose - orally if awake/able, IV if not + meal once can tolerate PO (ideally combo of carbs and protein)
• Glucagon 1mg IV or 5mg IM
• Do not give if hypoglycemia 2/2 sulfonylyreas - instead give dextrose and octreotide!

DKA

• Etiology: metabolic derangement d/t relative insufficiency of insulin and excess of glucagon
• Typically T1DM
• Precipitated by: infection, non compliance, AMI, CVA, trauma/surgery, pregnancy, EtOH, steroids
• Dx: Hyperglycemia (>250mg/dl), Ketones, AG Metabolic Acidosis
• Hyperglycemia → Dec total body water, dec electrolytes → hypotension, tachycardia, dehydration → low Na, K
• Ketogenesis → fruity breath, hyperventilation (Kussmaul), hyperK
• Can have concomitant metabolic alkalosis d/t contraction alkalosis from vomiting/dehydration
• Tx: IVF resuscitation, Insulin, Electrolyte repletion (Mg, PO4, K)
• Fluids - 1-2L bolus NS/LR in the first hour followed by 1.5xMIVF
• Change to D5 ½ NS when glucose <250
• Insulin
• Hold if K<3.3 until K replete
• If K 3.3-5 - add KCl to IVF, if >5 no supplementation needed
• Continuous infusion 0.5-1u/kg/hr sufficient, dont need bolus
• Add dextrose containing fluid once glu <250
• Continue until AG closes x 2 - then start SQ insulin regimen and feed.
• Goal is to decrease glucose by 50-75,g/dL per hour

Hyperglycemic Hyperosmolar Nonketotic COMA (HHK)

• Etiology: Infection, Non compliance, AMI, GIB, CVA, Medications (thiazides, steroids), PE, Rhabdo, etc
• More common in T2DM
• CP: Coma, weakness, fatigue, dehydration, anorexia, exacerbation of chronic disease
• Hyperglycemia (>600mg/dl) without/minimal ketones and acidemia, serum Osm >315 (hyperosmolarity), Dehydration
• Tx: IVF, IVF, IVF → average deficit 8-12 L
• When glu ~250, add dextrose
• Insulin (can stop once glu ~300), Electrolyte replacement

Alcoholic KETOACIDOSIS

• Heavy EtOH + No food → dec insulin, inc glucagon, EtOH inhibition of gluconeogenesis → inc lipolysis → inc ketoacids → N/V, abdominal pain, tachycardia, tachypnea
• Dx: High AG MA d/t elevated BHB, glucose <200mg/dl, EtOH negligible, HypoK/Na/PO4
• Tx: Dextrose containing IVF, typically 3-6L needed over 24-48hrs
• Add thiamine before glucose if possible
• Correct electrolytes
• Feed patient once able

Thyroid Storm

• Continuum – Hyperthyroid → Thyrotoxicosis → Storm
• Precipitants: undertreated/undiagnosed hyperT + physiologic stressor
• CP: Fever, restless, tachycardia/dysrhythmias, hypertension, diaphoresis, agitation, hyperreflexia, psychosis, V/D
• Sympathomimetic syndrome – CNS hyperactivity + Emotional lability
• If underlying Grave’s disease may see lid lag, exophthalmos
• +/- goiter, myopathy
• Dx: Low TSH, Hi T4
• Tx: ORDER IS IMPORTANT
• Propanolol → PTU/Methimazole → 1 hour → Iodide → Dexamethasone
• AVOID: ASA, Sedatives, Atropine

Myxedema Coma

• Etiology: Primary or Secondary hypothyroidism
• Primary – prior treatment of grave disease or surgery, Hashimoto thyroiditis, Iodine deficiency, meds (lithium), congenital abnormalities
• Secondary - pituitary tumors, postpartum hemorrhage, sarcoidosis, hypothalamic dysfunction
• More common in older women in winter
• Hypothyroid + physiologic stressor
• CP: hypotension, hypothermia (without shivering), bradycardia, weakness, alopecia, hypoventilation, hypoxia, dry/scaly skin, seizures, personality changes, cerebellar signs, abdominal distention (fecal impaction), urinary retention, pretibial/orbital edema, pseudomyotonic reflexes
• Commonly associated with rhabdo and adrenal insufficiency
• Dx: T4 low, TSH high, Glu low, Ca low, CK high
• ECG: bradycardia and long QTc
• Tx: Levothyroxine 200-500mcg IV
• Slow rewarming, IVF prn, Hydrocortisone 100mg IV prn, correct electrolytes prn

Addisonian crisis

• Primary, Secondary, Tertiary
• Primary - Addison’s disease – destruction of the adrenal cortex or adrenalectomy
• Secondary - dysfunction of the pituitary – tumor, hemorrhage, infarct
• Tertiary - dysfunction of hypothalamus - prolonged steroids
• 2nd/3rd – will have low-normal K and normal aldosterone
• Adrenal crisis results when adrenal reserve is exhausted of cortisol + New stress (infxn)
• CP: Lethargy, weak, postural hypotension, syncope, N/V, anorexia, circulatory collapse, seizures, abdominal pain
• Heart tones may be soft or inaudible
• Brownish pigmentation - only seen in Addison’s secondary to MSH
• Dx: HypoNa, HyperK, HyperCa, Hypoglycemia, azotemia, Acidemia possible
• Increased Eosinophils (Addisons only)
• ECG: Signs of HyperK + low voltage, STD
• Signs of Aldosterone deficiency → postural hypotension, syncope, azotemia, low Na, HyperK
• Random cortisol not recommended - use ACTH stimulation test
• Tx: IVF (D5+NS) - typically 2-3L in first 8 hours
• Glucocorticoid replacement - Decadron 4mg IV
• Decadron is the DOC if new onset or unknown if adrenal insufficiency because it does not interfere with corticotropin stimulation testing but no MC activitiy
• If known adrenal insufficiency – Hydrocortisone 100-500mg IV
• Has inherent MC activity so do not need additional fludrocortisone typically
• Mineralocorticoid replacement - Fludrocortisone
• Correct electrolyte abnormalities - especially K and glucose

Pheochromocytoma

• Catecholamine producing tumor
• Rule of 10s - 10% bilateral, extra-adrenal, malignant
• Etiology: Sporadic, Inherited
• MEN2A - medullary thyroid CA (MTC), Pheo, HyperPTH
• MEN2B - MTC, Pheo, Mucosal neuromas, marfanoid, developmental delay
• CP: Paroxysmal Episodes of: Palpitations, Headache, Diaphoresis, HYPERTENSION
• Nausea, abdominal pain, weight loss, polyuria/dipsia, hyperglycemia, hypercalcemia
• Catecholamine crisis: acute CHF, Pulmonary edema, Arrhythmias, ICH
• Paroxysms usually last <1 hour and can be precipitated by surgery, position change, exercise, pregnancy, meds
• Dx: Serum/Urine Catecholamines/Methanephrines + CT or MRI with contrast
• Tx: Control BP with alpha blockers FIRST!!!
• Phentolamine or Prazosin → BB, CCB, ACE inhibitors
• Surgical removal of tumor

Panhypopituitarism

• Inadequate production of pituitary hormones
• Adult disease is typically acquired
• Mass effect from tumor, trauma, inflammatory, pituitary apoplexy (hemorrhage), Sheehan’s syndrome (ischemic insult d/t hypoTN during labor/delivery)
• CP: headache, bilateral vision changes, hypoglycemia, LOC, Cardiovascular collapse
• Growth Hormone def - short stature/growth delay if congenital or abnormal body composition in adults (increased visceral fat)
• Gonadotropin def - decreased libido, infertility, menses changes
• Thyrotropin def - symptoms of hypothyroid
• ACTH def - symptoms of hypocortisolism
• PRL def - failure of lactation
• Posterior Pit - loss of ADH secretion – polyuria, polydipsia
• Dx: CT/MRI to eval for tumor, Check hormone levels
• Tx: Hormone replacement - steroids, thyroid, sex hormone, growth hormone, vasopressin

HEMATOLOGY

Hematology Quick Hits

• 1u PRBC = Inc Hb by 1-1.5 and Hct ~3%
• Adult total: 70ml/kg, Type O = universal donor, AB = universal recipient
• Watch for hypoCa (d/t citrate), hypothermia in MTP
• 1u Plts = Inc by ~10k (1 pack plts = ~50-60k)
• <10K = Risk spontaneous hemorrhage - Must transfuse
• Dysfunction:
• Nonpalpable purpura = low or dysfunctional plts
• Dysfunctional: ASA, Plavix
• Low: Aplastic anemia, ITP/TTP/HUS/DIC, Splenic sequestration, bleeding
• Palpable purpura = vasculitis
• TTP - Thrombotic Thrombocytopenic Purpura
• Clinical Criteria: FAT RN → Fever, Anemia, Thrombocytopenia, Renal Failure, Neurologic symp
• VS HUS → Anemia, Thrombocytopenia, Uremia → kids after EHEC, Shigella
• Causes: Deficiency/Non-working ADAMTS-13 (prevents breakdown of vWF multimers)
• Patho: fibrin deposition and platelet aggregation in capillaries and arterioles
• Tx: Steroids, Plasmapheresis/Plasma Exchange, FFP. AVOID PLT TRANSFUSION

Hemolytic Anemias

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• Abnormal Membranes (hereditary spherocytosis, elliptocytosis) and immune related
• Immune related = Warm (SLE, medications), Cold (mycoplasma, EBV)
• Abnormal Enzymes (G6PD) or MAHA (DIC, TTP, HUS)
• G6PD -- X linked recessive, RBC more susceptible to stress, hemolysis caused by drugs (dapson, pyridium, antimalarials), infection, fava beans.
• Labs: Heinz bodies, Bite cells
• Tx: Supportive
• Sickle cell, Splenic sequestration, PNH
• Can be intravascular or extravascular → inc LDH, Low Haptoglobin, Hburia, Schistocytes, inc Indirect Bili, inc retic count

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Hemophilia

• A = VIII, B = IX (Xmas), C = XI
• CP: Hemarthrosis, Excessive bleeding after procedures, Hematuria, Hematomas
• Dx: increased PTT, remained of coags normal
• Tx: Factor replacement or DDVAP (A=VIII only)
• A = 1u/kg = 2% factor replacement
• Ie: 50u/kg = 100% replacement
• DDVAP → releases vwf from endothelial storage sites → allows extra VIII to be carried in plasma and increases it’s survival
• B = 1u/kg = 1%
• Ie: 100u/kg = 100% replacement
• Replace to 100% if:
• CNS trauma of ANY kind → REPLACE factor BEFORE imaging, GIB
• Replace to 50% if: Joint, Muscle, or Oral mucosal bleeding

Von Willebrands Disease

• MC hereditary bleeding disorder, multiple variants and severities (Type I-III)
• vWF facilitates platelet activation/adhesion and carries VIII in plasma.
• CP: Gingival bleeding, epistaxis, menorrhagia, hemarthrosis
• Dx: PT/PTT normal, BT increased, abn vWF activity
• Tx: DDVAP, Factor VIII concentrate, Crytoprecipitate

ITP - Immune Thrombocytopenic Purpura

• Immune destruction of plts by RES usually triggered by idiopathic antigen
• Low plt count, can be acute or chronic
• CP: Petechiae, Gingival bleeding, Epistaxis, Menorrhagia, GIB
• Adults → insidious onset, chronic duration, usually women
• Kids → ~5 yo, sudden onset over several weeks after recent infxn
• Resolves without treatment within 2 months, Avoid physical activity/NSAIDs until resolved
• Tx: Transfuse if plt <20k OR if active bleeding and count 30-50k
• Steroids
• RhoGAM
• IVIG
• Cx: ICH

DIC - Disseminated Intravascular Coagulation

• Consumptive coagulopathy → Extrinsic complement pathway problem
• Can be clotting or bleeding or both
• Tissue Factor → small fibrin/blood clots deposit in microcirculation → fibrinolysis → fibrin split products
• Causes: STOP Making New Thrombi
• Sepsis, Trauma, OB (retained POC), Pancreatitis, Malignancy, Nephrotic syn, Transfusions
• CP: Purpura fulminans, Gangrene, Thrombosis, Bleeding, MODS
• Labs: Prolonged PT/PTT, LOW plts/fibrinogen, HIGH FDP/Ddimer, Schistocytes
• Tx: Treat cause
• Primarily bleeding → give FFP, Vit K, Folate, Kcentra
• Primarily clotting → low dose heparin

Sickle Cell Anemia

• Inherited disorder → glutamate substituted for valine at position 6, abn B globin chains → HbS mutation
• First presentation if not caught on routine prenatal testing → usually baby with sausage digits (dactylitis)
• Complications:
• Vasoocclusive Crisis → Pain d/t sludging of sickled RBC, can be precipitated by infection, cold, dehydration, altitiude, exertion, etc
• CP: Pain in muscles, joints, abdomen
• Tx: Pain control, Hydration
• Acute Chest Syndrome → leading cause of death, caused by either infection or infarction
• CP: New infiltrate on CXR, Cough, Fever, Resp Distress
• Tx: Oxygen, Antibiotics (Rocephin, Azithromycin), Supportive care (vent, pain control, etc)
• If severe consider exchange transfusion
• CNS Crisis → acute CVA, Seizure, Paresthesias → Exchange transfusion
• Renal Crisis → Acute RF, hematuria, flank pain, papillary necrosis
• Priapism → Usual therapy plus Exchange transfusion
• Splenic Sequestration → 2nd MCC death, 6mo-6yr usually occurs in setting of viral illness
• Hypovolemic shock, Painful HSM, Pallor
• Tx: Exchange transfusion, Splenectomy
• Aplastic Crisis → usually caused by B19 infection, presents with low Retic count
• Infection → predisposition towards encapsulated organisms d/t autoinfarction of spleen, need regular immunizations
• OM → Staph still MOST COMMON, however predisposition to Salmonella
• Dx: CBC, Reticulocyte count

TACO

TRALI

• Volume Overload → presents like CHF exacerbation
• Most common in large volume transfusions or in those with comorbid disease
• Tx: Slow rate of infusion, Diuretics prn

• Acute Lung Injury d/t Abs in donor product reacting with Ag in recipient
• PMNs adhere to pulmonary endothelium → inc permeability → edema
• PMNs activated by HLA/HNA abs
• SOB, Hypoxemia, BL Pulmonary Infiltrates, Fever
• Tx: Same as ARDs, Stop transfusion
• MCC death associated with transfusions

GRAFT VS HOST DISEASE

• Occurs when immunocompromised pts are transfused with PRBC containing immunocompetent T cells
• Think of it like an “unintentional bone marrow transplant”
• S/S: Rash, Elevated LFT, pancytopenia
• Tx: Supportive
• Prevention: Use irradiated products in immunocompromised pts

LAST ITE REVIEW

Random assortment of facts and things to know for the exam….feel free to purge all of this as soon as 5pm Wednesday rolls around.

EMS

• Multiple levels - EMR → EMT (BLS) → Advanced EMT (Airway/IVF) → Paramedic (ACLS)
• Types of Transportation:
• Ground - Ambulance, ~30 miles or less (or <30 min)
• Rotary Wing - Helicopter
• Indications: long distance, rough terrain, heavy ground traffic. Best for 50-150 miles.
• 4 S’s -- Speed, Special Skills, Smoothness, acceSS
• Fixed Wing - Plane - >100 miles. Rapid transport is essential. +Ambulance to/from airport
• Watch out for altitude problems
• Medical Control
• On-line/Direct: Direct medical orders via phone/rado to providers in field or direct observation
• Off-Line/Indirect: Development of standing orders/medical care protocols and education
• On scene physician - must act within the confines of what can be done by the EMS crew OR will assume full medicolegal responsibility including going with them to the hospital.

Mass Casualty/Disaster

• Classification:
• I - Local resources only II - Regional mutual aid III - Statewide or Federal assistance
• Phases of Preparedness
• Mitigation -- activities to lesson impact of a potential disaster
• Preparedness -- plans/preparations to help with response and rescue
• Response
• Activation - notification and organize ICS
• ICS:
• IC: overall management responsibility
• Planning - what is needed
• Logistics - supples what is needed
• Operations - uses what is needed
• Finance - tallies budget
• Implentation - Assessment of event, search and rescue, coordinating treatment
• Recovery - Debrief, return to normal operations
• Communication is most important

START Triage

• Tags:
• Red - Immediate care, First priority…. Examples?
• Yellow - Delayed care…. Examples?
• Green - Walking wounded…. Examples?
• Black - Dead/Expectant…. Examples?
• If apneic and unresponsive - can try jaw thrust and repositioning, if this does not resolve the problem give them Black tag and move on
• What disaster requires reverse triage? Lightening
• Reassess regularly and update triage category prn
• JumpSTART - pediatric casualties - categories the same however….
• Give 5 rescue breaths if apneic with a pulse after airway repositioning
• If respiratory effort but no palpable pulse → Red
• Neurologic assessment → AVPU

Most Commons

Coding

• E/M = 5 levels plus critical care. CPT = what you did, ICD = why you did it

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Don’t bill for stuff you did not do.

CC - Condition which impairs 1+ vital organ systems, that there is a high probability of imminent or life-threatening deterioration in condition.

LEGAL

• HIPAA - Health Insurance Portability and Accountability Act 1996
• Protects PHI, improves portability and continuity of health care
• PHI = ANYTHING that could potentially ID the patient. ANYTHING
• Disclosures for the purpose of treatment is permitted EXCEPT Psychotherapy notes.
• Ethical Principles:
• Autonomy - let them do what they want
• Beneficence - do good
• Nonmaleficence (primum non nocere) - dont hurt them
• Justice - be fair
• Consent
• Implied - actively cooperate with procedure (holding arm out for blood)
• Active (rolling up sleeve) or Passive (lack of resistance to injection)
• Informed - decision making capacity
• Can be written or verbal
• 5 Elements: What you want to do, harms/benefits, alternatives, harms/benefits, harms/benefits of doing nothing.
• 911 exception: need to alleviate severe pain., risk of serious disability, risk of death

• Decision-Making Capacity = ED DECISION
• Comprehension of options
• Awareness of consequences
• Comprehension of risks and benefits
• Decision remains stable over time and is consistent with patients values/goals
• Competence = LEGAL TERM = JUDGE. Longer word, Longer process
• Involuntary Psych Hold
• Danger to self
• Danger to others
• Grave disability
• Lack of insight
• Emancipated Minor: legally married minor, has kids, supporting themselves with separate address, in the military, court approved, high school graduate
• Ok to treat minors without parental consent if: STI, mental health, drugs, pregnancy related care and in some cases pregnancy prevention. (Most require parental consent for abortion)
• AMA - document capacity to make decision, sign appropriate paperwork, still provide the best possible treatment AND arrange follow up
• Confidentiality Exceptions: Potential harm to others, High likelihood of self harm, No alternative means exist to warn or to protect those at risk
• Tarasoff decision -- law requires Dr to directly inform and protect potential victims

• Advanced Directives/DNR
• AD - patients wishes when they are UNABLE to direct their own care, legal document
• DNR - physician order indicating patients wishes
• EMTALA - Emergency Medical Treatment and Active Labor Act 1985
• Any patient coming to the ED (w/in 250 yards of main campus) requesting care must receive a MSE to determine if an emergency medical condition exists and if so must be stabilized
• Emergency Medical Condition: acute symptoms of sufficient severity such that absence of immediate medical attention could result in impairment/dysfunction
• Who can do the medical screening exam? “Qualified” medical personnel
• On-call physician → if requested must come to the hospital in a reasonable amount of time
• When and if the patient is stabilized EMTALA no longer applies.
• Appropriate Transfer:
• Transferring hospital must minimize the risk of transfer
• Receiving hospital must have available space and capability to manage
• If they have the capacity, they CANNOT refuse appropriate transfers.
• Transferring hospital must send records
• Transfer must use qualified personnel and equipment

• Mandatory Reporting
• STI
• Community outbreaks
• Illness related to foreign travel
• Suspected biological terrorist threat
• Statute of Limitations -- time period in which a person can file a claim for malpractice. Varies from state to state but usually 2-3 years from injury or the discovery of negligence
• 4 Required Elements of Malpractice:
• Duty to treat → according to the prevailing standard of care
• Breach of duty (ie negligence) → Malfeasance, Misfeasance, Nonfeasance, Failure to diagnose, Failure to diagnose in a timely manner
• Causation (Proximate cause) – most difficult to establish
• Damages caused
• All 4 proved via a preponderance of evidence or “likely based on the evidence”
• Physician is judged based on medical standard..ie “How would a reasonable EP have performed in the same or similar situation?”
• Malpractice Insurance:
• Occurrence -- coverage for events that occur no matter when the allegation is initiated
• Claims made - coverage only if there is a claim made during the coverage period of that policy

• Intentional Torts
• Differs from negligence torts in 3 ways: No expert witnesses needed because not based on standard of care, no actual/physical injury is needed, proximate cause is not required
• Assault – in fear of offensive touching
• Threatening to restrain a nonconsenting, competent patient
• Battery - unconsented touching
• Performing an LP without consent
• False Imprisonment - unconsented and unintentional confinement
• Infliction of emotional distress or outrage (mental assault)
• Notifying the wrong family about a death
• Who can you restrain? Implied consent (intubated patient), Self-defense or defense of others
• Termination of Resuscitation → varies based on local protocols
• Pulseless adult without a shockable rhythm who have had an adequate trial of resuscitation
• Reasons to Withhold CPR?
• Documented terminal illness for which all therapeutic options have been exhausted
• DNR or durable POA and decision to not proceed
• Any licensed physician can pronounce a patient dead

• Ethical Situations
• Must report -- Elder abuse/neglect, Child abuse/neglect AND protect patients if they are unable to protect themselves
• If decision making capacity exists in adult abused patients, your resources are limited
• Jehovah’s Witness -
• No blood products of any kind - PRBC, plts, plasma
• OK for HD
• If child has a life threatening condition and parents are refusing treatment → EP has the RIGHT to override parental wishes and treat the child.
• Only if life threatening, otherwise parental consent is required.
• Parens patrie doctrine → states paternal interest in children, parents cannot forbid saving their child’s life
• ED physician takes over temporary protective custody of the child, provide care as needed, then admit child for concerns for abuse and contact proper authorities
• If no life threat → refusal for care should be respected it can still report for neglect.
• Child wishes to know more about their disease?
• Parents of the child decide what information can be relayed
• Good Samaritan Laws → state specific, designated to protect non-compensated responders to an emergency.
• Does not prevent a lawsuit, anyone can sue, but offers legal protection

​

Sensitivity/Specificity/PPV/NPV

Type II Error

Type I Error

Other Important Stats Equations:

• Odds Ratio = AD/BC
• Measure of association between exposure and outcome. Indication of strength of association between groups. Used in Meta-analysis and case control studies.
• 1 = no association, >1 = control is better than intervention , <1 = intervention is better than control
• Relative Risk = A/(A+B) / C/(C+D)
• Probability of getting a disease based on exposure. Can be used in RCT/Cohort studies
• 1 = no difference in risk, <1 = event is less likely to occur in the risk group, >1 = event is more likely to occur in the risk group
• Attributable Risk = (A/A+B) - (C/C+D)
• Difference in risk between exposed and unexposed groups
• Absolute Risk Reduction = (C/C+D) - (A/A+B)
• Measure of treatment effect
• NNT = 1/ARR
• Effectiveness of a medical intervention
• NNH = 1/AR
• Number need to be exposed to a risk factor to cause harm

Types of Studies

• Case Control -- compares a group of people with disease to a group without, useful for uncommon events, controls are matched to participants.
• Observational or Retrospective
• Odds ratio
• Cohort Study -- compares a group with a given risk factor to a group without, to assess whether the risk factor increases the likelihood of disease. Requires a long time to acquire data or outcome of interest. Relatively inefficient.
• Observational or Prospective
• Relative Risk
• Cross-Sectional Study -- collect data from a group of people to assess frequency of disease at a particular point in time
• Disease prevalence
• Meta Analysis - combines individual studies, pooled estimate of effect, allows for an objective appraisal of evidence, may reduce the probability of FN results.
• RCT - “Gold Std”. controlled clinical trial that randomly assigns participants to two or more groups (ie treatment vs control). Can be blinded.
• Only level of evidence to establish causation
• Case Report - a report on a series of patients with an outcome of interest. No control

Bias

• Selection -- non random assignment to study group
• Recall - knowledge of presence of disorder alters recall by subjects
• Sampling - subjects are not representative
• Late-look - information gathered at an inappropriate time
• Hawthorne Effect - phenomenon of behavior changing simply by being observed
• Confounding - a variable or factor that influences the results of an experiment unintentionally
• Lead time bias - artificial increase in survival time of patients because disease was detected earlier when length of time from onset doesn’t change
• Observer - occurs when the observer is able to be subjective about the outcome
• Detection - occurs when observations in one group are not sought as diligently as in the other
• Response - occurs when patients who enroll in a trial may not represent those of the population as a whole

TESTS

• T test -- checks difference between the means of 2 groups
• ANOVA -- checks difference between the means of 3+ groups
• Chi Squared - strength of association between 2 categorical variables
• Regression:
• Simple - test how change in predictor variable predicts the level of change in the outcome variable
• Multiple - test how change in the combination of 2+ predictor variables predict the level of change in the outcome variable

​

Need to Know Equations:

• Osmolar Gap = 2Na+BUN/2.8+Glu/18+EtOH/4.6 - >10 is considered elevated
• Anion Gap = Na - (HCO3+Cl) = 10-12
• Corrected Na in Hyperglycemia = 1.6 for every 100 over 100
• MAP = ⅓ SBP + ⅔ DBP
• CPP = MAP-ICP
• Water Deficit = 0.6 x [(measured Na/140) - 1]
• ETT Kid: Age/4 +4 (uncuffed) +3.5 (cuffed)
• Depth = 3x tube size
• Kid Lowest BP = 2xAge + 70
• Parkland: 4ml x wt kg x %BSA ...1st half in 1st 8 hours, next half over next 16
• Winter’s: pCO2 = 1.5 x HCO3 + 8 (+/-2)
• Or last 2 of pH should ~CO2
• Resp Acid/Alkaosis
• Acid: 1 x 10mmHg CO2 over normal acute and 3 x 10mmHg CO2 over normal chronic
• Alk: 2 and 4
• A-a gradient = PAO2 - PaO2 = 10-20
• FeNa = UP/UP = UNa*PCr/UCr*PNa
• Prerenal <1%, Renal >1%, Postrenal>4%
• Hemophilia: A: 2% = 1u/kg, B: 1% = 1u/kg

Eye Drop Cap Colors

• Red = Mydriatics/Cycloplegics
• Orange = CA Inhibitors
• Yellow = BB (Blue = BB + something else)
• White = Tetracaine

• Green = Miotics
• Pink = Steroids
• Tan = Antibiotics

​

HIGH YIELD IMAGES

Kid with sore throat

Kid with cough

Adult with sore throat

Trauma patient FAST - positive or negative?

Trauma - positive or negative

Tender SQ nodules?

70 yom with chest pain

30 YOF with URI symptoms and cough

22 yom tall thin male with SOB

Peds patient with limp

AA Adolescent with limp and hip pain

Cystography...normal, extraperitoneal, intraperitoneal?

Dx:

Tx:

Associated syndrome:

Biz Buzz Mushroom Poisoning

• Looks like Tylenol poisoning?
• Presents with seizures?
• Cholingeric crisis?
• Disulfiram Reactions?
• Ataxia, visual hallucinations, hyperkinesis?
• Presents with N/V/D within 6 hours?

Random additional pearls…..