31 Oct 2019

October 31, 2019

Written by REBEL Cast, REBEL Core
Take Home Points  
  • Stress cardiomyopathy looks like ACS/STEMI, with patient presenting with chest pain, dyspnea or maybe syncope. It looks like ACS and should be treated as such until you prove to yourself it’s not.
  • Classic patient is an older woman with chest pain or syncope after a stressful event.
  • Bedside echo will show left ventricular dysfunction with one of a variety of patterns of wall motion abnormality. The most common is apical, but there are also variant patterns including mid-ventricular, basal, focal and global.
  • Watch for QTc prolongation as this could precipitate an arrhythmia. Be sure to stop all QT prolonging meds and replete magnesium
  • Consider the differential in the patient who has cardiogenic shock because the treatment differs. Avoid catecholamines and if you need inotropic support use dobutamine or dopamine. Look for evidence of left ventricular outflow tract (LVOT) obstruction, as this should be treated like a hypertrophic cardiomyopathy with beta blockers rather than inotropes.
Medical Categories: Cardiovascular
5 Likes
9 Oct 2019

October 9, 2019

Written by REBEL Cast, REBEL Core
Take Home Points 
  • Acute closed angle glaucoma is an ophthalmologic emergency that usually presents with sudden, painful, monocular vision loss.
  • Physical exam will reveal conjunctival redness, corneal haziness or cloudiness due to edema and a pupil that is mid sized and minimally reactive to light, a rock hard globe and IOP >/= 21.
  • These patients require emergent ophthalmology evaluation but treatment should be started empirically while waiting for the evaluation. Initial treatment to decrease IOP usually includes a topical BB such as timolol and topical AB such as apraclonidine and either IV or PO acetazolamide.  
 
Medical Categories: Head, Eye, Ear, Nose, and Throat
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25 Sep 2019

September 25, 2019

Written by REBEL Cast, REBEL Core

Take Home Points
  • When looking at pH and bicarb, the differences between VBG and ABG are miniscule. For DKA patients, stick with the VBG as is less painful and has fewer complications. 
  • LR is probably a better fluid for the large volume resuscitation required in DKA. Start with a 20 cc/kg bolus and then reassess the patient’s perfusion status.
  • Stay on top of your electrolyte repletion. If the patient has a working gut, you can aggressively replete potassium orally and don’t forget that when you are repleting potassium you also must replete magnesium.
  • Bolus dose insulin gets the patient to super-physiologic levels and has been associated with higher potassium requirements and more episodes of hypoglycemia. It’s probably fine to skip the bolus and stick with a drip alone
  • Don’t forget to think of all possible etiologies of DKA, while we most often find this in patients who have not been taking their home meds for whatever reason, don’t forget a good history to look for sources such as infection and ischemia. 
Medical Categories: Endocrine, Metabolic, Fluid, and Electrolytes
3 Likes
11 Sep 2019

September 11, 2019

Written by REBEL Cast, REBEL Core

Take Home Points:

  • Get definitive airway control when necessary
    • Use modality you’re most comfortable with
  • Hard signs -  pulsatile bleeding, bruit or thrill, expanding hematoma, airway compromise, massive hemoptysis (think airway injury), hematemesis (think esophageal injury), grossly injured trachea, neurologic deficit, subcutaneous emphysema.
  • Soft Signs are hypotension that resolves, stable hematoma, wound in proximity to major vascular structure, minor hemoptysis, dyspnea, dysphagia, chest tube air leak, vascular bruit or thrill (depends on surgeon).
  • Hard Sign on presentation goes straight to the OR. Soft Sign on presentation gets some imaging done
  • Resuscitate with blood products -> Activate massive transfusion protocol
  • Most hemorrhage will respond to direct pressure
  • Don't miss other injuries!
Medical Categories: Trauma
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21 Aug 2019

August 21, 2019

Written by REBEL Cast, REBEL Core

Take Home Points

  • Myxedema coma is severe, decompensated hypothyroidism with a very high mortality.
  • Classic features include: decreased mental status, hypothermia, hypotension, bradycardia, hyponatremia, hypoglycemia, and hypoventilation
  • Work up includes looking for and treating precipitating causes, most commonly infection as well as serum levels of TSH, T4 and cortisol
  • Treat for the possibility of adrenal insufficiency with stress dose steroids such as hydrocortisone 100 mg IV
  • The exact means of thyroid replacement is controversial. Definitely given 100-500 mcg levothyroxine and discuss the simultaneous administration of T3 with your endocrine and ICU teams.
Medical Categories: Endocrine, Metabolic, Fluid, and Electrolytes
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