M&M - Dr. Zahn

Gastric Perforation
13 yr old female w/ abdominal pain - recent admission for abdominal pain with EGD (with biopsies taken). Became hypotensive, tachycardic, lactate 3.5 - surgery consulted & CT showed gastric perforation.

• Plain films for identifying perforation

1. Sensitivity 70-90% - significant variability in the studies
2. Consider addition of L lateral decubitus to increase sensitivity
   

Hypotension - Beta Block Toxicity
49 y/o male from rehab - was found obtunded and hypotensive w/ BP 60/20

    > ESRD dialysis patient
    > Hypothermic w/ temp of 93, pulse 59, BP 60/18;  answering questions
    > Labs relatively unremarkable, EKG basically unchanged, CXR with pulmonary vascular congestion

    > List of meds reviewed - a LOT of antihypertensives including 1600 mg of labetolol in the past 24 hrs

• Started on high dose insulin w/ improvement in blood pressure 
• Beta blocker/CCB Toxicity Management: 
  

1. Atropine
2. Volume
3. Glucagon
4. Calcium
5. Vasopressor
6. High Dose Insulin = 1-10U/kg/hr; dextrose 0.5 gm/kg/hr
   

(D25 need CVL); POC glucose q30 min with goal BG of 200-300


Wernickes Encephalopathy
57 yr old "drunk" from medic

    > Normal vital signs, hx of COPD cirrhosis GERD and no meds
    > Wide based gait & tremulous & confused; while at rest normal neuro exam
    > Wernickes Encephalopathy - got thiamine and got better

           - Thiamine i500 mg iV over 30 minutes
           - At risk patients - anyone prone to malnutrition
           - Clinical diagnosis - consider with 2/4 nutritionally deficient, ocular findings, encephalopathy, ataxia

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