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A Protocol for O2 Escalation (goal sat low 90s, unless end stage lung disease):
1. up to 6L nc (40% FiO2). Treat pleuritic pain to prevent splinting.
2. 12-15L facemask (50-60% FiO2)
3. HFNC if available. Use ROX index to determine failure.
Who to definitely intubate? End organ injury/hypoperfusion (ex elevated lactate), AMS, hypotension, respiratory acidosis/hypercapnea (w/o hx of CHF or COPD)
CPAP failure: PEEP >8? and 100% FiO2, not cooperative
Use ROX Index to determine failure of HFNC:
ROX = (SpO2/FiO2) / RR
ROX < 4.88 – intubate
failure with trial of HFNC @2h: ROX < 2.85, @6h: ROX < 3.47, @12h: ROX < 3.85
Note that PF ratio is meant for intubated pts (FiO2 is most accurate on vented pt).
-NIV may be useful in preventing ETI if concomitant COPD or CHF – NIV shown to work for hypercapnea
NIV has also been studied as an alternative to intubation, with occasional reports showing benefit . Positive studies on hypoxaemic, nonhypercapnic respiratory failure, mainly caused by community- or hospital-acquired pneumonia, have enrolled carefully selected patients who are cooperative with no associated major organ dysfunction, cardiac ischaemia or arrhythmias, and with no limitations in clearing secretions [29, 60, 85–87], which may explain the benefits seen.
Until recently, almost all studies on NIV for de novo ARF compared it with oxygen delivered with standard air entrainment (Venturi masks) or reservoir masks. Recently, high-flow nasal cannula therapy has been shown to offer several advantages compared with NIV, including better tolerance and dead space reduction . One recent RCT reported a survival benefit of high-flow nasal cannula over standard oxygen therapy and bilevel NIV, although the primary end-point of intubation was not significantly different .
The main risk of NIV for the indication of de novo ARF is to delay a needed intubation . Early predictors of NIV failure include higher severity score, older age, ARDS or pneumonia as the aetiology for respiratory failure, or a failure to improve after 1 h of treatment . Although the reasons for a poorer outcome are not completely understood, patients with NIV failure have higher tidal volumes before intubation  and develop more complications after intubation . Studies have shown that NIV failure is an independent risk factor for mortality specifically in this population, although careful patient selection seems to reduce this risk [91, 92].
midazolam 0.05mg/kg IV, or haloperidol 5mg IV pretreatment to prevent recovery agitation after ketamine
–elbow technique (new!)
–scapular rotation: scapular tip pushed medially, acromion inferiorly (open-book)
–vertical pull (Spaso): lift arm vertically, fully externally rotate, and pull toward ceiling
–external rotation (Kocher): slowly rotate externally with humerus parallel to torso, then maintain externally rotate until cross midline
–lateral extension (Milch): while externally rotated and providing traction on the humerus, slowly extend laterally until above 90′
–traction-countertraction: tie sheets so that traction is pulled on humerus while body in place
–passive traction (Stimson): apply weight to extremity while pt prone (for young healthy pts only)
–oscillating method (Fares): while keeping traction, oscillate up and down while slowly extending laterally. Best if kept extremity in external rotation.
–up-close-and-personal (Cunningham): pt’s hand on your ipsil shoulder, put downward pressure on their elbow. With free hand, massage biceps and rotator cuff muscles.
–POSTERIOR dislocation traction-countertraction:
–INFERIOR dislocation traction-countertraction:
PECARN 2019 for infants 29d-60d workup (small trial):
***from 2013 EBM
Burn transfer criteria:
3 mL of lactated Ringer’s solution x weight in kilograms x % of body surface area burned (partial- and full-thickness burns)
Trauma in pregnant pts
–have a low threshold for giving Rhogam
-types II & III may disrupt cribriform plate – look for CSF rhinorrhea
Traumatic iritis = inflam of ciliary body
-cycloplegic (homatropine. Relieve photophobia) +/- topical steroids (ONLY optho can Rx)
Globe rupture – elevate bed >30′ to reduce ocular pressure and prevent further extravasation (avoid sux if intubating – incr IOP)
-give abx prophyl
Infraorbital anesthesia is associated with this fracture due to injury to the infraorbital nerve. Other findings on physical exam include enophthalmos due to herniation of globe contents before the onset of edema. Diplopia on upward gaze occurs with entrapment of the inferior rectus muscle leading to binocular diplopia
7 areas of ICH on CT Head: spinal cord, midbrain, 4th ventricle, lateral ventricles, gyri and sulci, gray-white matter differentiation
Spinal shock = cord concussion
3 types of pelvic fractures:
– lateral compression (T-bone MVC/pedestrian hit from side)
—look for vertical fracture of sacrum
—no benefit from pelvic binders
—mostly “elderly” (age >55) pts at risk of bleeding – calcified vessels break easily
—if suspect bleeding or binder already placed, benefits generally outweigh potential harm of overreduction so do not remove
– AP fracture (head on MVC)
– vertical shear (fall)
-Send serum osmolality!
-determine fluid status: hypo-, eu-, or hypervolemic
-if asymptomatic, fluid restriction. Don’t give fluids!
-max rate of correction = 8 mEq/h
-Goal: <10-12 mEq total increase in 24h
Hypovolemic hyponatremia mechanism = decreased arterial perfusion of kidneys -> ADH secretion -> reabsorption of free water
–fix the underlying problem: volume replete
Hypervolemic hyponatremia (CHF, cirrhosis) mechanism = depleted intravascular volume despite excess extravascular volume = decreased effective arterial perfusion of kidneys -> ADH secretion -> reabsorption of free water
-SIADH – inappropriate excess ADH secretion
-psychogenic (excess free water intake), beer potomonia + “tea and toast syndrome” (inadequate solute intake)
-bolus NS if shock/hypoperfusion
-replace total body water (TBW) deficit
1. Treat Neurologic Emergencies Related to Hyponatremia
In the event of a seizure, coma or suspected cerebral herniation as a result of hyponatremia, IV 3% hypertonic saline should be administered as soon as possible according to the following guide:
What if hypertonic saline is not readily available? –> Administer one ampule of Sodium Bicarbonate IV over 5min.
Ringer’s lactate has a sodium concentration of 128mmol/L which will be more isotonic to the hyponatremic patient. Although never shown in clinical studies, administering Ringer’s lactate will likely result is a slower rise in serum serum sodium than Normal Saline, and therefore have a lower risk of potentiating osmotic demyelination syndrome. Ringer’s lactate is therefore recommended by our experts as the fluid of choice for resuscitation of the hypovolemic/hyponatremic patient.
Practical Approach to the Differential Diagnosis of Hyponatremia
Note: if by history the hyponatremia is acute, it is safe to correct it quickly. The patients who are at risk of central pontine demyelinolysis are those whose hyponatremia is chronic.
Other lytes concepts:
-replete low ionized Ca after PRBC transfusions (contains citrate)
-alkylosis (ex: primary hyperventilation) causes more Ca from its ionized state to be bound to albumin (may develop signs of hypoCa)
-severe hypocalcemia -> cardiovascular collapse (loss of contractility/inotropy)
-hypocalcemia -> QTc prolongation -> torsades
-CaCl2 = 3x more ions than Ca-gluconate
-beware of further increasing serum bicarb for a pt that is hypoventilating (ex CHF exacerbation) – will worsen compensatory respiratory acidosis (hypercarbia). This is why MICU gives acetazolamide to CHF pts on BIPAP
-Dialysis dysequilibrium syndrome (dizziness during dialysis) – due to the rather rapid removal of BUN, which has an osmotic effect
—–serum osmolality = 2x(Na) + glucose/18 + BUN/2.8
0.9% NS = 154 mEq Na
0.45% NS = 77 mEq
plasmalyte = 140 mEq
LR = 128 mEq
D5W = 0 mEq
3% hypertonic saline = 513 mEq (3 / 0.9 = 3.33 x 154mEq)