2009年11月13日 星期五

ED grand round 11/13/09

Again, I join the Hopkins weekly grand round today. Along with the residents candidate interviewing to day, many attending physicians join the meeting today, which made the meeting more interesting. Just again share my note with everybody who might be interested.

Today the topic is Sedation

Pharmacology

Importance of ETCO2:
CO2 decrease before O2 (more sensitive and earlier)
Brady = hypoxia
Tachy = hypercapnia until proven otherwise
Hypoxia sequence (EtCO2 down, SpO2 down, then Bradycardia)
Cyanosis: happens when SpO2 <>

Advocate the usage of Propofol
Propofol 20+% hypotension, bolus only otherwise redistribute propofol
infusion syndrome lactic acidosis
(Hopkins have yet started the usage of Propofol in ED, but will be soon.)

One person does procedure one does sedation (will be policy)
This is not new to me. At my visit in U of Alberta, I realized that's a two man procedure. When can we really start to do EM @ TW sophisticated like this?

Fasting rule 8hr solid food 4 breast milk 2 clear liquid (policy)

www.Hopkinsinteractive.org (everyone needs to have certificate)
will share more information after I visit the web

Midazolam peak in 2-5min whoch might be the reason over
Mike never use that to sedate unless intubated already
(quite different from the practice @ CGMH back in TW)
Diazepam is quicker than mid (oral is opposite) he thinks safer drop blood pressure

Barbitals
Methohexital barbituate peds like but not great for RSI though it's
quick onset and offset
Pentobarbital longer
Thiopental longer and quick safe

Etomidate is better (widely used drug for RSI in US)

Choral hydrate oldest great for peds slow onset last hrs t1/2 10hrs

Etomidate has myoclonus effect, however some say transient. adrenal
insufficiency is owing to prolonged use. NEJM article (for randomized trial)
Propofol has musclelysis (do we have this term?)

Ketamine in peds iv im (the reason why ppl loves it)

Nitrous oxide for dentist (in his rotation)

Single vs mixed drug use debate eg ketofol

Hopkins RN or not creditential personnel can't give deep sedation agents

High risk pt want to involve anesthesia
Previous problem
Extreme of age
Sleep apnea
Obesity
Pregnancy
Multiple trauma
Substance abuse

ASA category
Evaluate
Discharge plan

Cuff20-50% should be greater than arm circum

Paradoxical motion
SpO2 -30 = PaO2

Head position picture shoulder should be higher (different airway structure)

Sequence of getting Epi or atrop depends on availability (brady get epi first then atropin in peds)

Add bicarbonate in local (1:9 in lidocaine)

Simulation room:
same situation like ACLS different from TW: give compliment before criticize

Meningitis:
Nuchal rigidity only has 30% sensitivity
Burski sign even worse
the head rotation test has 93% sen, of course, not specific
chemoprophylactis done throughly in there
steroid need to be given
worry about the Listeria for >50, immunocompromised, etc. give ampicillin
RBC found in non-traumatic tap, worry about HSV. tap before given acyclovir

Chairman chat again panel type
Synco-pe
again they use the interactive remote answer card
www.turningtechnologies.com
http://www.turningtechnologies.com/professionalaudienceresponse/audienceresponsesolutions/
Head or facial trauma hints the duration or severity of cause of syncope
Open discussion is interesting but need the culture to do that
TnI for risk stratification

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