M&M Extravaganza - Dr. KEller

All that and then some...

Lip and facial swelling - Angioedema to the Max!

• Call anesthesia and surgery at same time if difficult airway predicted.

• Fiber optic intubation:
  

1. Sitting up and Preoxygenate
   
2. Prepare the Nare - glycopyrolate, afrin/phenylephrine spray, nebulized lidocaine 4ml of 4% lidocaine with 1ml of phenylephrine, visous lido soaked cotton balls in nares followed by viscous lido coated NP airway, hurricane spray
3. Dilate the Nare with Nasopharyngeal airway.
4. Put ET into the dilated Nare, then pass the fiberoptic scope through the tube.
5. Advance scope, see carina, pass tube!
   

Our New Scope is found in Room 1 of pixis- "endoscopy storz'.
Attached to cmac to black plug,

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29 yo bilateral leg pain

Lactic acidosis

• Type A - decreased tissue oxygenation (shock, carbon monoxide, decreased tissue perfusion-bowel ischemia)
  
• Type b - drugs (metformin, HAART therapy) and diseases such as AIDS, liver disease, renal fialure

In severe undifferentiated Anion Gap Metabolic Acidosis:

    1. Resusucitate/supportive care

    2. Identify cause with appropriate lab ordering

    3. Empirically give Thiamine 500mg IV

    4. Consider empiric Fomepizole after tox consult

    5. Sodium Bicarbonate is controversial

    6. When in doubt, call nephrology and dialyze

Alcoholic KetoAcidosis
    -- Heavy etoh use with a recent binge, sudden cessation with abd pain, N/V. GI symptoms seen in 80%.
    -- Present with Absent ETOH level and Anion Gap metabolic acidosis.
    -- Due to increased betahydroxybutyrate ketone body, UA does not pick up ketone bodies on dip.
    -- Rarely will see severe lactic acidosis and if present think sepsis, seizures or thiamine deficiency.

Tx:

1. Dextrose - very important to promote ketone metabolism and decrease lactate,
2. Thiamine
3. IV fluids

Thiamine deficiency

Pyruvate cannot enter TCA cycle causing high lactic acidosis resulting in Dry (neurologic) and Wet (cardiac) Beriberi. Also causes Wernicke (triad of AMS, opthalmoplegia, and ataxia seen only in 10% of patients).
At risk- etoh, iatrogenic, aids, malignancy, gastric bypass, TPN

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44yo fall from standing

• Canadian Head CT Rule vs New Orleans Criteria
• New Orleans Criteria - HA, vomiting, older than 60, intox, anterograde amnesia, sz, trauma above clavicle (can use only in patients with GCS 15, not on anticoagulation and >17 yo)
• Canadian Head CT Rule - Can use in patients with GCS 13-15 and age >15 yo. Can not use on patients on anticoagulation.
• Both 100% sensitive with regards to identifying lesions requiring NEUROSURGICAL INTERVENTION.
• Canadian Head CT Rule is more specific.
• Continue to diligently reexamine vs scan intoxicated patient with head trauma