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Traumatic Brain Injury

EMP March 2013


GCS 8 = ETT
ETT = 1.5 mg/kg [100mg] lidocaine iv (3 min prior)
4H: head up (30), hyperosm (Mannitol 1 G/kg), hypervent (PCO2
30), heli(copter)!
Post intubation 50/150: 50mcg/k/min propofol, 150 mcg fentanyl/hr
Decrease BP if MAP 120mmHg
Warfarin: Profilnine v. FFP, Vit K if life threatening
Dabigatran dialysis, rivaroxaban = [FFP/Vit K = no efficacy]
Tranexamic Acid: Crash-2 = Non-significant reduction in cerebral
hematoma growth & death [Crash-3 trial (2017)]

LVAD

Have UC call LVAD coordinator/hospital perfusionist


Evaluate patient for poor perfusion
Check MAP (1st sound heard on manual BP w/doppler- nl = 70-90)
Check for power lights and precordial hum- no power or hum --> check
connections/change batter/change controller
Check alarm lights
Low flow = fluid bolus
Large RV/LV with low MAP with increased rpms and decrease flow =
thrombosis, ? heparin/tpe in consultation with cardiac surgery
Small LV with low map = suction event (pump with lv wall) = fluid bolus and CSx
Low battery wo replacement = LVAD coordinator will try to arrange for back up
battery transport
Standard ACLS protocols should be applied as appropriate, but compressions
should only be a last resort as catheter malposition will lead to death. First
contact coordinator to ensure all other problems ruled out. Pads should NOT be
placed over pump, but defibillation, cardioversion and pacing are all O

Neuro signs!!

PEx: [CREAMS] CN, DTR, EOM, aff pupillary response, Motor/Sensory


Consider UMN, LMN, NM jx, & muscles!!
Disease

Characteristics

PE findings

MS
CNS
10-50 yo demyelination

Optic neuritis
Paresthesias, Motor,
Diplopia, Trigem
neuralgia, Trans myelitis

Pain EOM, blurry,


APD, IN
ophthalmoplegia/dipl
opia, ( Add CNII),
spasticity
*(Worse in heat

Dose iv
steroids
Prednisone!!
Tx fever aggr!!

Guillain
Barre

Hrs-days
Imm mediated
periph
Schwann
demyelination

Ascending paralysis
Paresthesias

Prox trunk muscle


weakness,
ophthalmoplegia, NM
dysphagia, facial
asymmetry

Labs, CSF p
7d, FVC/NIF
pulm tests, IVIG

Descending
paralysis

Ophthalmoplegia,
ataxia, areflexia

-cholinergic
exotoxin
permanently inh Ach
release

Bulbar Weakness
Diplopia, dysphagia, dysarthria, dysphonia)
desc weak & DTR Ventilation

Miller-Fisher
variant

Botulism
12-1 wk
Recovery =
mos!

MG

Pathophysiology

Post-synaptic
-cholinergic
immune destrx

UMN: Stroke, MS, ALS


LMN: GB, Diphtheria, Bells

Worse with
repetitive
movements

Tx with -toxin
(adults), notify
CDC, ETT prn
Tensilon test for
dx!

NM Jx: MG, EL, Botulism


General: SLE, Sarcoid, Psych, tetrodotoxin, Lyme, alcohol abuse (Vermian atrophy),

Pancreatitis
RF:
Findings:
Ransons Immediate:
Ransons p-48 hrs:

Treatment

EtOH, stones, ercp, E,


steroids, HCa+, HL,
sulfas, HCTZ
Cullen, Grey-Turner, fox
Lipase = 2.5x normal
55 yoa, Glu > 250, wbc >
16K, AST > 250, LDH >
350
Fluid Seq > 6L, BUN inc >
5, Base Def > 4, PaO2 <
60, Ca < 8, HCT dec >
10
Admit ICU v. floor,
Sx consult if gall stone
pancreatitis

Crohns Disease
Treatment:
GI: Skip inflamm
Sx: cholestyramine (bile acids)
Obstrx, perf, fistula,
hyoscyamine (cramps)
malabsorption ( prot,
loperamide (diarrhea)
ox acid = nephrolith)
Topical anti-inflam (5-ASA)
Assoc: Episcleritis,
Mesalazine (Sm Int)
aphthous ulcers,
Sulfasalazine (Lg Int)
Sacroiliitis, autoimm
Systemic anti-inflam
hep/cirrhosis, sclerosing
Prednisone 2 wk taper
cholangitis
ImmSupp: Azathioprine/6MP
Abx prn
Surgery if med failure

ABX

Gall bladder / Appy


Cholangitis
Pneumonias
CAP
Admitted
ICU
HCAP
Fracture inv sinus
Fracture inv oral flora
Pulm abscess/empyema
UTI with F in preg

2nd gen cephs (fox, te, fur)


Unasyn, zosyn
Doxy v. Levo

CTX & Doxy

CTX & Levo Vanc/Levo/Zosyn


Amoxacillin
PCN, clinda
3rd gen ceph & clinda
Admit for iv ABx

Migraine
Phases
Prodrome, aura, mild HA, mod-sev HA

Dx:
episodic, recurring, 4-72 hrs
2 of: unilateral, throbbing, worse w/motion, mod-sev
1 of N/V/photo/phonophobia

Tx:
Mild: NSAID, APAP, Reglan, MgSO4
*No opioid 2ry inc dev of chronic migraines

Mod: 5HT rec agonist


DHE 45 *NOT for preg, CAD, elderly
Triptans within 90min
80% painfree in 2 hrs

Rescue: Olanzapine 10mg po 6-8 hrs sleep


* ? Lidocaine IN

Bacterial Meningitis
CTH if: {60 CSII}
>60, ImmComp, CNS Dx, Sz w/in 1 wk, S/Sx inc ICP

Tx:
Neonates: cefotax & amp (GEL)
Children: cefotax/ceftriaxone & amp
(Young) Adults: ceftriaxone/cefotax & vanc

Dexamethosone 10mg PT Abx (NEJM 2002)


Ceftazodine if H/O trauma, NSx, or gram (-)
Amp for listeria
Rifampin for neisseria
Acyclovir for HSV
Antifungal for HIV

CO Poisoning
Inh cytochrome A-3 (sim to CN- tox)
Initiates lipid peroxidation
* CO-Hb not the destructive mech

Tx: Hyperbaric O2 (normobaric O2 ineffective)


Tx for cytochrome tox
Reverses lipid peroxidation

Latent CNS degeneration (3wks)


Oligodendrocyte destrx -> erosion of myelin sheath

PTX
RF: Smoking
20x men (80x if > 1ppd)

10x women (40x if > 1ppd)

< 15% observe vs catheter w/asp


4 hr f/u xr.. Vs d/c with catheter
NL xr = d/c cath, 2hr obs & d/c

> 15%, trauma or secondary = thoracostomy & admit


* Sed & analgesia, 5th IC space, 4 cm incision, post and
sup angle, 5cm past last CT hole

Oral DM Agents
Hypoglycemics
Inh ATP K+ chnl mem depol & ins rel
Sulfonylureas: glyburide, glipizide
Non-sulfonylurias: repaglinide (TID-QID)

Tx:
Octreotide iv/sc (=somatostatin) inh insulin rel
Dextrose prn, food!

Anti-hyperglycemics: multiple
Biguanides c lactic acidosis (*ren/hep/card/pulm dx)
Metformin (3:100,000pt-yrs): OD = obs 6-8hrs

PO DM tx initiation
Metformin 500mg po QD/BID (> sulfonylureas)

Emtala transfer reqs

The treating physician may transfer the patient in the following scenarios:
The emergency medical condition has been stabilized and the patient requires a
higher level of care.
The emergency medical condition has not been stabilized, but the treating
physician certifies that the benefit of transfer outweighs the risk.
The patient or health care proxy requests transfer regardless of whether the emergency
medical condition has been stabilized.
The on-call physician fails or refuses to appear within a reasonable period of time,
& without the services of the on-call physician, the benefits outweighs the risk.
When transferring, the treating physician must document the name of the accepting individual
and facility. The treating physician must also send pertinent documents, imaging studies, and
test results relating to the emergency condition to the receiving facility.
The receiving hospital must accept the transfer as long as they have the capacity and space to
do so. It is the obligation of the receiving hospital or physician to report any transfer received
in violation of EMTALA. The receiving hospital may be penalized for failure to report an
EMTALA violation.
The transferring hospital must provide all medical treatment within its capacity, which
minimizes the risk to the individual's health. Qualified personnel, with the appropriate medical
equipment, must accompany the patient during transfer.

Acute Chest Syndrome


Dx: CP, cough, pulm infiltrate, hypoxia, +/- fever
Tx: Hypoxia
O2 to PaO2 > 70mmHg
Incentive spirometry
Transfusion (reg v. exchange) if Hb<10
Albuterol
Dexamethasone (Proven Ped efficacy)
Sickle:
Hypotonic saline (0.25 - 0.45%)
Infx:
Abx: 3rd gen ceph/B-lactam inh + macrolide
*Caution w/potential for ceph-induced hemolysis

Idiopathic Intracranial HTN


(formerly pseudotumor cerebri)
RF: obese female, childbearing age, ? SLE
Hx: HA, pulsatile tinnitus, hor. diplopia
PE: papilledema, visual fields (inf. nasal def
early), visual acuity, P-opening > 20 in nonobese & > 25 in obese pts
Rx: Acetazolamide (> dig), wt, pred if visual
defects
: VP/LP drainage, Ophtho fenestration

1rst Trimester Bld/Pain


Pregnancy: Ovary-in
1 C. Luteal Cyst Rx, 1% massive bld
2 Ectopic pregnancy
3 Implantation Bld
4 Molar Pregnancy
5 Abortion (C/M/I/I/T)
W or W/O
6 Adnexal torsion
7 Ovarian cyst rx
*Risk of miscarriage: 50% w/VB, 5.5% if (+) FHT

Early Pregnancy
Wk/HCG TVUS strx
4
AmnSac (Fuses w/Chorion@12-16wk)
5
1500 YolkSac (GS>8mm,<2nd Trim),ChVilli
GS 8mmTV/18mmTA w/o YS/embryo = miscarriage
6
2500 Embryo & YS
7
5000
8-9 17,000 FHT
Indeterminate US: TV 18%, TA 50%

Sonographic Criteria for Fetal Demise


Abnormal heterogenous material in utero
Empty GS > 25mm
Empty amniotic cavity
AS > crown-rump length
15mm Crown-Rump w/o FHT
No FHT after 10-12 weeks
Poor outcome
FHT < 100 pt 6wks, < 120 pt 7wks

Ectopic w/u & tx


CBC, coag, quant, progesterone (>22?), Typen Rh
0 Anti-D IG (rhogam) prn
1 Non-Dx US & HCG<1500D&C for C.Villi/POC smpl
2 Peritoneal w/non-dxc US laparoscopy
3 MTX - HCG levels = best predictor success (<4000)
1 dose if < 1000, 2 dose (d1&4) if > 1000
Rel contraindx: GS > 3.5cm, cardiac activity
citrovorum (reduced form of folate) = reversal agent
SE: AP, tubal Rx, ARF, hep-tox, IPulmDx
4 Laparoscopy/otomy if unstable, intraperitoneal bleed

Statistics
Test (+)

Test (-)

Disease (+)
Disease (-)
Sensitivity = True (+)/[True (+) + False (-)]
# of people who have dx who test (+)
Specificity = True(-) / [True (-) + False (+)]
# people w/o dx who test (-)
PPV = True (+) / [True (+) + False (+)]
NPV = True (-) / [True (-) + False (-)]
Type 1 error: Attributing stat significance when none exists. [= p (0.05)]
Type 2 error: Attributing no difference when a stat sign diff does exist
Receiver Op Curve (ROC) 1 = perfect, 0.5 = coin toss

Statistics 2
Disease (+)

Disease (-)

Pop at risk
Baseline Pop

RR = [a/(a+b)] / [c / (c+d)]
Odds ratio = (a/b) / (c/d)
Chi Sq = discrete data
T-test = means
Regression technique = to predict a single
variable from w/in single - mult regressors

Platelet Antagonists
1) *Aspirin: inh cox TBXa2 inh plt plug
2) *Clopidogrel inh ADP induced plt fx
3) Dipyridamole: inh adenosine cAMP plt rx
to PAF/collagen
4) IIbIIIa inh inh fibrinogen-IIbIIIa binding
* = irreversible effect
Adenosine produced in plt, endoth, RBC
Ticlo/ASA/Clop/Abcix bleeding 5-10u plt trsfx (50K plt )

INR
<9
>9

No Bld re- INR in 24


No Bld 5mg po Vit K
re- INR in 24
INR Sig. Bld Admit
3-6u FFP
10mg po/iv Vit K

Medications in occult OD
CCB/BB
HoTN, brady
Li
CNS excitability
Dig
hx, QRS,
ASA
hypervent, confusion
Warfarin
bleed risk
Theophylline
Phenytoin
cerebellar dysfunctn

Vent Management (EBM)


Nl Pplateau < 30cm H2O
acc c/w Vt for ards

Set peep at P-flex 2+Lower Inflx point


Avoid air trapping w/Ppl (Vt) changes
Listen to the pt w/asthma/copd!!

Use peep to overcome auto-peep


P-Flex (815 in CHF)

FiO2 60-80; PaO2/FiO2 > 400 = nl


Vt max = 10cc/kg (w/Ppl < 30cmH2O)

Vent Management (EBM)


PIP Pplateau
Nl Pp F.O.B.S.
{ flow, obstrx(kink/displace), bronchoconstrx, secs}

= A.P.A.R.T.
{auto-peep, PTX, atelectasis, rt mainstem ett, Tidal vol}

CHF: Optimal peep compliance &


pulm shunt
Asthma/COPD: WOB, air trapping,
O2

Onc Emergencies
SCHNEBTS
SVC Syndrome: Red face and sob
Ca++:PTHrpleth/conf/N/const/UO. Tx ++ivf &
pomidronate
Hyperviscosity syndrome:
Sx=MS/papilledema/bleed or F/infiltrate. Tx = plasma/leukopheresis

Neut Fever: 38.4 & < 1000= ceftaz and c/s


Effusions: pleur and card
Brain mets: ICP=dex + sz = anticonvulsants
Tumor lysis Synd: PUP (Potass/UricAcid/Phos)
Sx: EKG, ARF, Sz and Ca++

Spinal Cord Comp: dose dex, RadOnc

Traumatic Eye Treatment - EMP


Treatment

Dispo

Comments

Corneal
abrasion

Top. ketorolac
Top. polymyxB/trimeth.
Analgesia

24h if ?
pseud;
otw: 48h if
sxc

Contacts or
veg/wood contam
= cipro/oflox
(pseud)

Traumatic
uveitis

Homatropine 5%
Pred acetate 1%*

2-3d

IOP for ? 2ry


glaucoma

Traumatic
-blocker
glaucoma -blocker
Acetazolamide
Mannitol
Q hr eval
Pilocarpine: when IOP < 40

Immediate
ophtho

Miotics contraindx
if lens surg or
cataract extraction.

Hyphema

Admit if
>50%,
bleeding
, visual
or IOP

Check IOP, =
admit;
persistent =
surgery
*No phys activity!

Eye shield: clear or w/holes


Elevate head
Analgesia
Homatropine 5%
Top. Steroid*

* In consultation with ophtho

Trauma Resuscitation
NS and D-LR inflammation/edema
HoTN: r/o shock, TPTX, PCardT,
myocard contusion, neurogenic
Tx: ABC, stop bleeding
Massive Tx 6:4:1 (pRBC, FFP, Plt)
Use L-LR to temporize w/fluid warmer
Tranexamic acid for all patients with
uncontrolled bleed

Dabigatran (Pradaxa)
Does not need bridging or monitoring.
There are no food or drug interactions.
No proven reversal agent. 16x more
expensive!
Try prothrombin complex concentrates
or Factor VII. FFP may have some
efficacy.
Vitamin K has no efficacy.

APAP toxicity
Rumack-Matthew nonogram
Tx if: indicated or until cessation criteria
met, more info is obtained, course
completed
Repeat ingestions, tx if:
APAP > 20, elevated ALT, hx of 4+ gram/d
ingestion

D/c criteria, but also coordinate with


ALT levels.

Potassium
Hypokalemia
R/O: diuretics, V/D, high
aldosterone, steroids
Tx: Tomatos, oranges,
bananas, spinach, KCl
IV K+ and Mg+ if severe

Hyperkalemia
R/O: BB, CCB, ACEI/ARB, NSAID,
Digoxin
Tx: C the BIG K Drop