Carotid Doppler Worksheet EMERGENCY PHARMACOLOGY – Capstone COMPLETE NOTES Terry by avd13583

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									       EMERGENCY PHARMACOLOGY – Capstone
                               COMPLETE NOTES
                                     Terry J. Mengert, MD
                                     Professor of Medicine
                                 Emergency Department, UWMC
                                          Spring 2008


                                      OBJECTIVES
     1. Know the Basic Tools in an Emergency (beyond calling your resident for help –
         remember, always, the ―power‖ of the telephone).
          ―Three Pillars‖: O2—IV—Monitors; + Vital Signs; + Primary Survey
          ―Vital Signs‖ Expanded
          Shock concepts
     2. Different PRIMARY SURVEYS in Different Emergency Situations
         The Usual A B C D & E’s
         In Cardiac Arrest (the ACLS 1° & 2° Surveys)
         In Coma: Neck, A, B, C, D, E, F, G, H, I
     3. Clinical Cases – Common Emergencies
         Acute Myocardial Infarction
         Acute Cerebrovascular Accident
         Shock Review + Goal Directed Therapy
         ―Code‖ Review
         Acute Congestive Heart Failure
         Anaphylaxis
         Asthma Exacerbation
         Atrial Fibrillation with a Rapid Ventricular Response
         Status Epilepticus


I. YOUR BASIC TOOLS in an EMERGENCY (besides the phone!)
  A. “Three Pillars” (employ these at the bedside when your patient is in trouble!)
     1. The “Safety Net”: oxygen, IV access, monitors (cardiac monitor & oxygen
                       saturation monitor)

     2. Vital Signs: pulse, blood pressure, respiratory rate & oxygen saturation, temperature

     3. The Primary Survey (see this topic elaborated below)

  B. “Vital Signs” Expanded
     1. Patient with Chest Pain: also obtain a rhythm strip & 12-lead ECG.
     2. Patient with Dyspnea: oxygen saturation, rhythm strip, & 12-lead ECG.
         (Remember, in the elderly patient, dyspnea is a more common chief complaint
         reflecting an acute coronary syndrome that is chest pain).




                                             1
          3. Patient with Diabetes Mellitus: check a bedside fingerstick glucose (should be >
               60 mg/dL).
          4. Patient with Altered Mental Status: oxygen saturation (should be ≥ 95% in most
               people, but in patients with COPD who are chronic CO 2 retainers 89-91% is a
               reasonable goal) & bedside fingerstick glucose. In addition, consider the
               possibilities of opioid overdose, benzodiazepine overdose, and/or thiamine
               deficiency.
          5. Pregnant Patient: with a bedside Doppler device we should be able to Doppler
               the fetal heart tones at ≥ 10-12 weeks of pregnancy. Normal is 120-160 bpm.
          6. Pediatric Patient: body weight (because all of our drugs are weight based in
               kids). Here are approximate weight and vital sign correlations with age in the
               pediatric population:


        Age               Mean Weight (kg)         Normal Heart Rate   BP sys minimum   Normal Respiratory
                                                                                              Rate

    Premature                     2.5                   120-170             40               40-60
       Term                       3.5                   100-170             50               40-60
    3 months                       6                    100-170             50               30-50
    6 months                       8                    100-170             60               30-50
      1 year                      10                    100-170             65               30-40
      2 years                     13                    100-160             65               20-30
      4 years                     15                     80-130             70                 20
      6 years                     20                     70-115             75                 16
      8 years                     25                     70-110             80                 16
     10 years                     30                     60-105             85                 16
     12 years                     40                     60-100             90                 16

Expected average systolic BP is 70 to 80 + [(age in years) X 2].
Source: Table 48-4, p. 1043 in Current Emergency Diagnosis & Treatment. Lange 2004


          7. Patient with a Visual Complaint: assess visual acuity in the right eye (OD), the
               left eye (OS), and then both eyes (OU).


     C. Define SHOCK: shock is defined as inadequate tissue perfusion.
          Question: How do you recognize the shock state at the bedside?

          1. Vital Signs: please beware the tachycardic patient. In the setting of hemorrhage, the
              patient will lose 30% of their blood volume before they start to drop their blood
              pressure in a supine position. We don’t want to wait for people to get sicker before



                                                             2
       acting. The concept here is to do our best to be pro-active instead of simply re-
       active.

   2. Skin: the first organ to be ―abandoned‖ in the setting of inadequate tissue perfusion.
       We want our patients warm and dry. Beware the clammy or diaphoretic patient.
       Beware the patient with cool distal extremities.

   3. Urine Output: consider this as an approximate gauge of internal organ and renal
       perfusion. As a measure of a successful ―resuscitation‖ we would like to see 1
       ml/kg/hr in most patients and 2 mL/kg/hr in infants. I once heard a surgeon call the
       Foley catheter a ―poor man’s Swan-Ganz catheter.‖ Not a bad way to think of it.

   4. Mental Status: the brain is the last organ to be hypoperfused. Most patients will
       become lethargic. Some will become agitated and combative. A patient with altered
       mental status is a patient in significant trouble.

   5. Additional considerations: auscultate chest (? Crackles ≥ ½ way up each posterior
       pulmonary field – then volume isn’t an option and they definitely have a ―pump‖
       problem), auscultate heart [? rhythm, murmurs, rubs, or gallops], check neck veins
       (the external jugular vein will do – we are using this to get an idea of the patient’s
       pre-load, although right-sided valvular problems or right ventricular dysfunction will
       make this less reliable), palpate trachea in suprasternal notch (it is deviated AWAY
       from the side of a tension pneumothorax or hemopneumothorax – you won’t see that
       however, you will need to feel for it), and palpate peripheral pulses (if you can feel a
       radial pulse, their BPsys is at least 80-90 mm Hg; if you can’t feel a radial put you can
       feel a femoral, then their BPsys is 70 mm Hg; if all you can feel is a carotid pulse,
       then their BPsys is only about 60 mm Hg).

D. What is the Cardiovascular Triad?
   (All forms of shock can be explained by one or more of the following three primary
   mechanisms).

   1. Rate / Rhythm Problem (e.g., atrial fib with a rapid ventricular response; ventricular
                     rd
       tachycardia, 3 degree heart block)

   2. ―Pump‖ Problem
        Primary (something is ―wrong‖ with the heart itself): examples include an acute
         myocardial infarction or myocarditis.

       Secondary (something is ―wrong‖ around the heart): examples include tension
         pneumothorax, cardiac tamponade, and massive pulmonary embolism.

   3. ―Tank‖ Problem
        Pure Volume problem: examples include GI hemorrhage, gastroenteritis, diabetic
         ketoacidosis, and trauma related hemorrhage.

       Volume & resistance problem (begin therapy with crystalloid resuscitation, but
         consider adding a medication to ―tighten up‖ the abnormal vascular resistance if the
         patient doesn’t rapidly respond to the crystalloid). Mnemonic for common causes
         of vascular / resistance problems is ―S A N T A‖ = sepsis, anaphylaxis, neurogenic
         shock, toxins, & adrenal insufficiency.




                                            3
           Two common pressors to consider in resistance issues:

             Dopamine -- dose: 5-20 mcg/kg/min IV (Pediatric dose is the same)
             Norepinephrine – dose: typical maintenance dose of 2-4 mcg/min IV, but
             higher doses are frequently needed. (Pediatric dose is 0.1 – 2
             mcg/kg/min titrated to effect)

  E. GOAL Directed Therapy in Severe Sepsis & Septic Shock (source: NEJM
     2001; 345:1368-77). The idea is to think sequentially in terms of what needs to
     be done with a seriously ill patient with either of these conditions and to proceed
     down the list in a timely fashion. Address each item in turn to optimize your
     patient’s care.
     1. Airway & Ventilation Support (and consider central access monitoring).

     2. Next: optimize volume with crystalloid (or colloid) to increase central venous pressure
        to 8-12 mm Hg. Crystalloid = normal saline or lactated Ringer’s solution. Typical
        adult ―doses‖ may be 2 liters or more wide open in a patient without known cardiac
        dysfunction. Typical pediatric IV volume challenges will be 20 mL/kg X 2-3.

     3. If Mean Arterial Pressure (MAP = {[2 X diastolic] + systolic} / 3 ), despite volume
        resuscitation, is:
         < 65 mm Hg: support blood pressure with dopamine or norepinephrine
         > 90 mm Hg: then reduce blood pressure with a vasodilator like nitroglycerin or
            sodium nitroprusside (if the patient’s blood pressure is too elevated, we want to
            decrease it to assist with afterload reduction and thereby increasing cardiac
            output).

     4. Next, assess central mixed venous oxygen saturation (SvO 2). If < 70%, then
        transfuse packed red blood cells until the Hct ≥ 30%. (Reminder: depressed SvO2
        may be because of anemia, poor cardiac output, hypoxia, or increased oxygen
        consumption).

     5. Re-assess the SvO2. If still < 70% despite all of the above, then initiate inotropic
        support (e.g., with dobutamine) with the goal being to raise SvO2 ≥ 70%. Dose of
        dobutamine is 2.5-10 mcg/kg/min IV, but titrated upward as necessary based on
        patient response.



II. Different PRIMARY SURVEYS in Different Emergency Situations
     (I think of putting on a different priority “thinking cap” or “frame of
     reference” depending on the clinical situation).
  A. In the Advanced Trauma Life Support (ATLS) Course, the approach to the
     seriously injured patient is a four tiered process (this, by the way, works for
     almost all patients, whether surgical or medical; recall, however, that
     resuscitation takes place hand in hand with the primary survey).

     1. Classical Primary Survey (the typical A, B, C, D, & E’s): each step has two
        components

         A: airway support and spinal immobilization (adequate spinal immobilization should
         include a padded backboard, a hard cervical collar, bolstering around the head with
         IV fluid bags or blanket rolls, the patient strapped to the backboard [including a strap



                                              4
       across the forehead], and suction on at the bedside. If the patient starts to vomit, we
       will log roll the patient to the left and suction clear the oropharynx).

       B: breathing & ventilation

       C: circulation & hemorrhage control (as well as establishing IV access and initiating
          volume resuscitation)

       D: disability (a quick neuro exam that assesses mental status, pupil size, eyelid
       opening, and whether motor movements are symmetrical) and the DON’T regimen
       (see below).

       E: expose and environmental control

   2. Resuscitation (this goes ―hand in hand‖ with the primary survey above – meaning, if
      you encounter a life-threatening problem, you deal with it immediately before moving
      further down the primary survey)

   3. Secondary Survey (Head-to-Toe physical; SAMPLE history [S = signs & symptoms,
      A = allergies, M = medications, P = problem list & past history, L = last oral intake, E
      = event history], Labs, Radiographs, CT scans, Ultrasound, Consultation, etc.)

   4. Definitive Care: for example, upper endoscopy for intervention and control of upper
      GI hemorrhage.

Important Concept: in the ―D‖ Part of the Primary Survey, if the patient’s mental
   status is altered, we should consider three additional interventions besides
   OXYGEN (oxygen should have been applied immediately as part of our O2—
   IV—monitors rule at the start of all this). What are those other three items
   (include dosage)?

       D = Dextrose: in the adolescent or adult patient, the treatment for
       hypoglycemia is 50 mL of D50W (= 25 grams). (In the infant age range, we
       use D25W instead of D50W, with the dose being 0.5 g/kg IV; and
       newborns get D10W).

       O = Oxygen

       N = Naloxone: dose this carefully. Our goal is not to completely reverse the
       opioids on board, but to stabilize the vital signs and the patient’s ability to
       protect their airway. If you can’t get an IV in, you can give naloxone IM, or
       SQ. I typically start with 0.1-0.2 mg naloxone IV. (The pediatric dose of
       naloxone is listed as 0.1 mg/kg).

       T = Thiamine: the typical dose is 100 mg IV given slowly (or better yet, just
       ask the nursing staff to add it to the hydration fluid). Pediatrics: don’t give it
       as an IV bolus, it may cause some hemodynamic instability.




                                            5
B. For an UNRESPONSIVE PATIENT, what is your immediate approach?
    Answer: “C – A – C”
      C: confirm unresponsiveness

      A: activate the emergency medical response system – in the hospital, call a
      code. Outside of the hospital, call 911.

      C: = CALL for an automatic external defibrillator (an AED).

      (Variation on ―C – A – C‖ for a lone rescuer: in the adult patient with an
      unwitnessed arrest believed to be asphyxial, administer 2-min of CPR
      BEFORE calling 911. In the pediatric age group, regardless of presumed
      cause of arrest, administer 2-min of CPR BEFORE leaving the patient to call
      for help).

C. Reminder, if a patient is in Cardiac Arrest, there are only three possible
   code “algorithms” to guide our care: (I used to think that I resuscitated
   people. But I try not to think that now. I figure that whether the patient
   survives or not is between them and their “higher power.” I try not to
   worry about the outcome of a code – and instead, worry about the process
   of the code. My focus is to do all that I can to make sure the process
   follows established guidelines. The outcome is mystical . . .).

   1. Ventricular Fibrillation or Pulseless Ventricular Tachycardia: these are
      shockable rhythms.

   2. Pulseless Electrical Activity: not a classic shockable rhythm, although if the
      patient has a significant tachycardia (> 150 bpm that is not a sinus
      tachycardia) then one could shock that.

   3. Asystole: not shockable.

D. In a CARDIAC ARREST setting as outlined in the ACLS guidelines by the
   American Heart Association, our “Primary Survey” and “Secondary
   Survey” are different than the typical primary survey already described on
   pages 4-5 above.

   1. The Primary Survey in CARDIAC ARREST (initiate CPR until the defibrillator
      arrives; then D = “defibrillate” if the patient is in Vfib or pulseless Vtach)

      A: establish an airway by using the head tilt-chin lift if the spine is not injured,
      but use the jaw thrust and keep the cervical spine in a neutral position if
      spinal injury is a possibility.

      B: look, listen, and feel for the patient’s breathing. If the patient is not
      breathing, deliver two breaths, each over 1 second. You can deliver the
      breaths via mouth to barrier device, or more likely in the hospital, via a bag-
      valve-mask device attached to high flow oxygen at 15 L per min. A simple
      airway (nasopharyngeal or oropharyngeal) will assist with airway
      management until circumstances demand a more definitive airway.



                                            6
   C: assess for a carotid pulse (but take no more than 10 seconds to do so).
   (Pediatrics: check for a brachial or femoral pulse instead in patients < 1 yo). If
   the patient is pulseless, then start chest compressions: 100 per min, each
   sternal compression should be 1.5-2 inches in patients ≥ 8 years old.
   Stagger chest compressions with breath delivery in the ratio of 30
   compressions, pause for 2 breaths, then resume compressions. One set of
   30 compressions with subsequent 2 ventilations is considered ―one cycle‖ of
   CPR.
        Patients 1-8 years old: depth of compression is 1/3rd to ½ the depth of
           the chest. Single rescuer: 30 compressions: 2 ventilations. Two
           rescuers: 15 compressions: 2 ventilations. After intubation, deliver 8-
           10 breaths per minute with ongoing chest compressions at 100/min.

          Patients < 1 year old: use 2-3 fingers just below nipple line for chest
           compressions and compress to a depth of 1/3-1/2 depth of chest
           (single rescuer). If two rescuers, the chest compressor should
           encircle the chest with their hands and use both thumbs to compress
           the sternum just below the nipple line. Single rescuer: 30
           compressions: 2 ventilations. Two rescuers: 15 compressions: 2
           ventilations. After intubation, deliver 8-10 breaths per minute with
           ongoing chest compressions at 100/min.
          CPR in newborns: compress chest 1/3rd depth of chest and deliver 90
           compressions and 30 ventilations per minute (3 compressions: 1
           ventilation at the rate of about 120 events per minute) with or without
           an advanced airway. Try to avoid simultaneous compressions and
           ventilations.

   D: stands for defibrillate. Recall that when the AED arrives, you should set it
   up and turn it ON before attaching the pads with leads to the patient. Attach
   the pads as diagramed on the Pads. Then ask people to quit touching the
   patient. Press the ANALYZE button – the AED will analyze the rhythm and
   tell you if a shock is indicated. If a shock is indicated, tell your assistants to
   ―stand clear‖, say ―I am shocking on three: one, Two, THREE‖ and then press
   the shock button. Immediately resume CPR for 5 cycles (about 2 min) before
   reanalyzing the rhythm. If the rhythm is not shockable, then resume CPR
   and proceed with the ―secondary survey.‖ (Although, in the setting of
   pulseless VTACH or VFIB, you may want to alternate shocks and 2 min of
   CPR one or two more times before proceeding down the secondary survey
   as outlined as follows).

2. The Secondary Survey in CARDIAC ARREST (assumes the patient is still pulseless
   after the ―primary survey‖ – meaning, they didn’t respond to the first or second or
   even third shock with 2 min of CPR between each if the rhythm was pulseless Vtach
   or VFib, or they were in PEA or asystole and shock simply wasn’t indicated).

   A: establish a definitive airway with endotracheal intubation.

   B: confirm that endotracheal intubation has placed the tube in the right place,
   and then secure the tube.




                                      7
Important clinical Question: How do you confirm endotracheal (ET) tube
placement post-intubation?

   a) Intubator should see the endotracheal tube cuff pass the cords by about 1 cm.

   b) Immediately post-intubation, a colorimetric end-tidal CO2 detector should
       change color from purple to yellow (or an esophageal detector device should
       rapidly re-inflate when applied to end of ET tube – suggesting the tube is in
       an air filled structure – like the trachea).

   c) auscultate both sides of the chest (usually in the mid-clavicular lines and the
       mid-axillary lines); we want to hear reasonable breath sounds bilaterally.

   d) auscultate over the epigastrium – we do NOT want to hear bubbling.

   e) the chest should rise and fall with ventilation.

   f) the tube depth should be appropriate: 21 cm at the incisors in an adult woman,
        23 cm in an adult man. The recommended tube depth in the pediatric patient
        is 12 + (age in years/2). Please also remember that in kids < 8 years old we
        use UN-cuffed endotracheal tubes instead of the cuffed tubes we use in
        adolescents and adults.

C = Circulation: intravenous (IV) access, with appropriate medications. At the
   minimum, there are two choices of vasoactive drugs that should be
   used as long as the patient is pulseless. Please dose them appropriately
   now --

   a) Epinephrine: 1 mg IV every 3-5 min for as long as the patient is
      pulseless. The pediatric dose is 0.01 mg/kg [max 1 mg] IV push
      every 3-5 min.

   b) Vasopressin: 40 units IV once only. If no response and 10 min have
      passed, then proceed with epinephrine as per above. We don’t use
      vasopressin in kids because there just isn’t enough information on the
      use of this drug in the pediatric population.

   Question: how are these administered? What are they followed with in terms of
   fluid? What about arm position after the drug is given? Answer: these are given
   IV push followed by 20 mL of saline in the adult and elevation of the extremity
   containing a peripheral IV. Please also, after you give one of these medications,
   let the code captain know that assignment is done: “One milligram of
   epinephrine has just been given IV.”

D = Differential Diagnosis (―Why is this human being dying today?‖): 6 H’s
   and 6 T’s— (note that bold items can be assessed with a bedside ABG).

   H: = Hypoxia

   H: = Hydrogen ion (i.e., acidosis)

   H: = Hypovolemia (Hematocrit check; clinical scenario)

   H: = Hyperkalemia or Hypokalemia (severe)


                                     8
                  H: = Hypoglycemia

                  H: = Hypothermia


                  T: = Thrombosis (massive MI)

                  T: = Thrombosis (pulmonary embolism)

                  T: = Tension pneumothorax

                  T: = Tamponade (Cardiac)

                  Trauma: think hypovolemia; worry about mechanical issues too like
                     tension pneumothorax and cardiac tamponade

                  T: = Toxins (including drug overdose)

    E. A “Neurological Primary Survey” in the patient with Altered
       Mentation/Coma (the patient has a pulse and a blood pressure, but we need to
       figure out why their mental status is altered):

         Neck: protect and immobilize the spine in the setting of suspected trauma

         A, B, C’s: airway, breathing, & circulation in the classical fashion

         D: Diabetes (check a fingerstick glucose and correct hypoglycemia)

         E: Epilepsy (consider status epilepticus or that the patient may be post-ictal)

         F: Fever (consider the possibility of a life-threatening infection, including meningitis and/or
             encephalitis – and please remember the entity of Herpes encephalitis)

         G: assess and document the ―Glasgow Coma Score‖ based on eyelids, motor, and mental status

        Eyelid Opening                              Verbal                              Motor Exam

      Spontaneously = 4                          Oriented = 5                      Obeys Commands = 6

         To Speech = 3                          Confused = 4                         Localizes Pain = 5

          To Pain = 2                      Inappropriate Words = 3                 Withdraws to Pain = 4
                                       (I guess I get a 3 for using the
                                              F-word in a class!)

            None = 1                      Nonspecific Sounds = 2                Abnormal Flexion Response =
                                                                                             3

                                                   None = 1                         Abnormal Extension
                                                                                      Response = 2

Score Range is 3-15.                                                                       None = 1
Mild head injury = 13-15
Moderate head injury = 9-12
Severe head injury ≤ 8




                                                        9
     H: Herniation (assess for, treat increased intracranial pressure if suspected with
        the following interventions: head of bed elevation by 30 degrees, blood
        pressure support, gentle hyperventilation to a PaCO2 of about 30-35 mm Hg,
        mannitol (dose: 1 g/kg IV), and emergent Neurosurgery consultation)

     I: Investigate (includes admission labs, blood cultures, tox screens, head CT, ?
          lumbar puncture). Remember that if your working diagnosis is bacterial
          meningitis, then antibiotics should be started immediately—the classic
          antibiotic triad in an adult patient for suspected bacterial meningitis is
          ceftriaxone + vancomycin + ampicillin (this latter is to cover Listeria if the
          patient is elderly, an alcoholic, pregnant, or immunologically suppressed).



III. CLINICAL CASES
  A. ACUTE MYOCARDIAL INFARCTION

     Ms. H is a 62-year-old female who calls the paramedics because of 3 hours of
     moderately severe chest pressure. She is in fair health except for a 28-pack-
     year history of cigarette use. Her only medication is occasional Advil use for
     back pain. She is allergic to penicillin. She has suffered one prior inferior MI
     five years ago.

     Ms. H vomits into a basin while laying semi-recumbent on the examination
     stretcher in the Emergency Department (ED). Her husband is standing nervously
     nearby. The patient appears frightened and in pain. She has drops of
     perspiration across her forehead.

     Initial VITAL SIGNS: P 80 bpm, BP 150/100, RR 16/min, T 37.1 °C.

     1. Outline your initial care of this patient.
         Build our ―three pillars‖:
            O2-IV-monitors,
            Vital signs (already done), and
            Classic A B C D E primary survey.

           Obtain both a bedside ECG and portable CXR. (See the ECG on the next page).

           Send off typical chest pain labs: CBC, Chem panel, PT/aPTT, cardiac enzymes,
            lipid panel, and magnesium level.

           As all of the above is being done, obtain a directed history from the patient,
            especially considering pain history, risk factors, other health problems, etc.
            Some folks would say this is a good ―SAMPLE‖ history:

            S = signs and symptoms
            A = allergies
            M = medications
            P = problem list and risk factors
            L = last time patient had PO intake
            E = event history (if something happened recently to patient)



                                            10
       Generate a differential diagnosis and working diagnosis (ECG on the next page
        shows an acute ST-segment elevation myocardial infarction).

       Activate the cardiac cath lab – patient needs immediate percutaneous coronary
        intervention in the setting of an ST-segment elevation MI or a new LBBB MI.

       Simultaneously with the above, begin therapy with MONAB + H (assuming no
        contraindications). Of these, supporting oxygenation and administering aspirin
        and a beta-blocker are the most essential interventions.




The above ECG shows a normal sinus rhythm and an acute ST-segment elevation
myocardial infarction with prominent ST-segment changes in the antero-lateral leads.

2. What would you do to support her vital signs if her initial blood
   pressure was 80/50 mm Hg?

    Answer: depends on the bedside examination. If the patient is already volume
    overloaded for their given cardiac status on the basis of dyspnea and pulmonary
    crackles on auscultation ½ or more up their posterior pulmonary fields, then we would
    need to support blood pressure with dopamine (start at 5 mcg/kg/min IV and ask the
    nursing staff to titrate to a BP sys of 95-100 mm Hg). If, on the other hand, the lungs
    are clear or we hear only bibasilar crackles, then fluid challenge (boluses of 250 mL
    saline at a time) would be appropriate to support blood pressure.

    (What variables would you check at the bedside to help with that
    decision?)

    Answer: I would listen carefully to the lungs for signs of pulmonary edema (crackles),
    listen to the heart for an S3, look at neck veins for distension, and consider the
    patient’s history (do they have a known problem with congestive heart failure?).




                                        11
3. List the dose & some cautions to the following medications:

   M = Morphine: 2-4 mg IV every 5-15 min titrate to pain. Will decrease blood
   pressure. May cause nausea and itching.

   O = Oxygen: typically start with 2-3 L/min via nasal cannula. We would
   like most ACS patients to have an O2 sat ≥ 98%.

   N = Nitroglycerin: 0.4 mg SL. We can repeat this every 5 min for a total of 3
   doses. Or, alternatively, after the first SL dose we can start an IV NTG
   infusion – beginning dose is 10-20 mcg/min IV, titrated upward in 10 mcg/min
   increments every 5-10 min. Maximum dose is generally considered to be 200
   mcg per min. NTG will drop the blood pressure. It may cause a reactive
   tachycardia. It will compromise pre-load and should not be given in the
   setting of a right-ventricular infarction.

   A = Aspirin: 160-325 mg chewed and swallowed. Do not give if the patient
   is allergic to aspirin or is having their MI in the setting of a large GI
   hemorrhage. If the patient is allergic to aspirin, we should still administer an
   anti-platelet agent. The alternative drug is clopidogrel (Plavix): 300-600 mg
   oral load, followed by 75 mg PO every day.

   B = Beta-blockers (e.g., metoprolol): metoprolol is given in 5 mg
   increments every 3-5 min to a total IV dose over time of 15 mg. Within 15
   min of the last IV dose 25-50 mg of metoprolol should then be given PO.
   Beta blockers will lower blood pressure, exacerbate pulmonary edema,
   activate bronchospasm in patients with reactive airway disease, and will slow
   down the pulse. Do not give if the patient has a pulse < 55 bpm, BP sys <
   100, or has second or third degree heart block.

   H = Heparin: dose is an IV load of 50-60 units per kg (not to exceed 5000
   units; not to exceed 4000 units in the setting of thrombolytic therapy) followed
   by a continuous infusion of 12-15 units/kg/hour (not to exceed 1000 units per
   hour). Do not give if the patient has a history of heparin-induced
   thrombocytopenia or is actively bleeding.

4. How do you emergently decide if a patient is suffering from a right
   ventricular infarction? Why do you care?
   Answer: we ask for a right-sided ECG any time our initial ECG shows an acute ST-
   segment elevation MI in the inferior leads (leads II, III, aVF). When we look at the
   right-sided ECG, we look at only two of the right-sided placed precordial leads (i.e.,
   V3R and V4R). If we see 1-mm or more of ST-segment elevation in either V3R or
   V4R, then we have confirmed a right-ventricular infarction. These folks are very pre-
   load dependent. Avoid giving them NTG, and be ready with normal saline boluses to
   support their blood pressure.




                                      12
  5. The following mnemonic helps to remind us about quality Acute
     Coronary Syndrome (ACS) care over the course of the patient’s
     hospitalization:

      A = antiplatelet drugs (aspirin, clopidogrel, glycoprotein IIb/IIIa
         inhibitors in appropriate candidates) and ACE-inhibitors

      B = beta-blockers and good blood pressure control

      C = cholesterol assessment, statin therapy; cigarette smoking
          cessation counseling
      D = diet (heart healthy) and good diabetes control

      E = exercise prescription and education of patient and family; including
      CPR training for family members

  6. Your brother-in-law has recently had an acute anterior myocardial
     infarction and was released to home yesterday. Your sister calls and
     asks you about his medications. What medications would you expect
     him to be discharged from the hospital on?

       Answer:    aspirin 81-160 mg PO q day
                  clopidogrel: 75 mg PO q day
                  statin (goal LDL cholesterol is < 70-100 mg/dL)
                  beta blocker
                  ACE-inhibitor
                  NTG prn

B. ACUTE CEREBROVASCULAR ACCIDENT

  Mr. CV is an 80-year-old male whose wife calls the paramedics because
  of a sudden inability to speak that started about 1 hour ago. This patient
  has a history of hypertension and benign prostatic hypertrophy. His blood
  pressure has been poorly controlled, with the report of increased degrees
  of hypertension this week in the patient’s primary care clinic. The patient
  was calling unintelligibly to his wife at 6:10 PM—this is why she called the
  Medics. On arrival in the ED the patient is awake, unable to
  communicate, and very frustrated by his sudden language deficits.
  MEDS: ASA, lisinopril, Flomax, nitrofurantoin.

  ALL: meperidine (Demerol)

  EXAM: Gen- WD/WN elderly man sitting semi-upright on an examination stretcher.

  VS: BP 246/126 mm Hg, P 56 bpm, RR 16, T 36.2 °C.
       Patient seems to have difficult understanding all questions. Stammers some short
       words like ―I can’t‖ and ―don’t know.‖ Then shakes his head.




                                         13
1. Outline your initial care of this patient.

      Build our ―three pillars‖:
       a. O2-IV-monitors,
       b. Vital signs (already done), check blood pressure in both arms to confirm the
           present degree of hypertension;
       c. Classic A B C D E primary survey.

      Order a STAT non-contrast Head CT scan and activate the Neurology stroke
       team.

      Obtain both a bedside ECG and portable CXR.

      Send off typical labs: CBC, Chem panel, PT/aPTT, lipid panel, magnesium level,
       ESR, liver enzymes.

      As all of the above is being done, obtain a directed history from the patient and
       family, especially considering neuro symptoms and their exact time onset, risk
       factors, other health problems, etc. Some folks would say this is a good
       SAMPLE history:

       S = signs and symptoms
       A = allergies
       M = medications
       P = problem list and risk factors
       L = last time patient had PO intake
       E = event history (if something happened recently to patient)

      Generate a differential diagnosis and working diagnosis. Our working diagnosis
       is an acute CVA.

      Treat hypoglycemia. Consider thiamine administration. Administer Tylenol (650
       mg PO). Avoid anything by mouth otherwise. Begin IV access with normal
       saline.

2. What are your BP treatment parameters in Acute Stroke? How do those
   parameters change in the following:

   a) Thrombotic stroke (NOT t-PA candidate): avoid emergency treatment
      unless BP sys > 220 mm Hg or BP dias > 120 mm Hg.

   b) Thrombotic stroke (t-PA candidate): we can NOT start t-PA in acute
      stroke through a peripheral IV unless the BP sys < 185 mm Hg and the
      BP dias < 110 mm Hg. So if the patient is a thrombolytic candidate, we
      would need to treat the BP to get it below these numbers. Sample anti-
      hypertensives of use in stroke are IV labetalol or nicardipine IV or even
      sodium nitroprusside IV.

   c) Hemorrhagic stroke: we would like the BP sys < 160 mm Hg and the BP
      dias < 90 mm Hg if the Head CT shows a hemorrhagic stroke.




                                       14
  3. Comment on the following therapeutic considerations in the care
     of the patient with a suspected acute stroke:

     a) Oxygen: not necessary unless the O2 sat < 95%.

     b) IV Fluids: normal saline IV maintenance infusion. If the patient is NPO,
        then D5NS is your maintenance IV. We avoid hypotonic fluids in the
        acute stroke patient.

     c) Fever: fever is hard on infarcting neurons. We put the acute stroke
        patient on PO or PR Tylenol for the first 48 hrs of their hospital stay.

     d) Blood Glucose: we want tight glucose control (would like serum glucose
        to remain in the range of 80-180 mg/dL).

     e) Blood Magnesium Level: keep in the normal range.


C. ACUTE CONGESTIVE HEART FAILURE

  A 62-year-old Russian speaking male with 3 days of increasing dyspnea &
  now orthopnea arrives in the ED. Patient has a history of type II diabetes
  mellitus and HTN.

  MEDS: enalapril, furosemide, metformin
  ALL: NKDA

  VITAL SIGNS: P 120 (irregular), BP 170/105, RR 32, T 36.5 C.

  1. Outline your initial care of this patient.

        Build our ―three pillars‖:
         a. O2-IV-monitors,
         b. Vital signs (already done), and
         c. Classic A B C D E primary survey.

        Obtain both a bedside ECG and portable CXR.

        Send off typical labs: CBC, Chem panel, PT/aPTT, cardiac enzymes, magnesium
         level.

        As all of the above is being done, obtain a directed history from the patient and
         family, risk factors, other health problems, etc. Some folks would say this is a
         good SAMPLE history:

         S = signs and symptoms
         A = allergies
         M = medications
         P = problem list and risk factors
         L = last time patient had PO intake
         E = event history (if something happened recently to patient)




                                         15
        Generate a differential diagnosis and working diagnosis. Our working diagnosis
         is acute pulmonary edema; we will begin treating it as we simultaneously
         consider its causation.

        Begin treatment of acute pulmonary edema with the following:

    L = Lasix (typically start with 20 mg IV). If the patient is already on oral Lasix,
        then whatever their oral dose is give it IV.

    M = morphine: 2-4 mg IV. Vasodilates and helps with the uncomfortable
       sensation of air hunger.

    N =Nitroglycerin = assuming BP is okay, we would start with 0.4 mg SL. We
       could also start an IV NTG drip, beginning at 10-20 mcg/min IV.

         Nesiritide = don’t use this until we know more about this drug. It seems to
         increase mortality in acute congestive heart failure.

    O = Oxygen: supplement as necessary

    P = Positive inotropes; Position (patients do better if they can sit up and
       dangle their legs).

         Dobutamine: dose 2-20 mcg/kg/min IV.

         Dopamine: dose 2-20 mcg/kg/min IV. (inotropic doses begin at 5
         mcg/kg/min IV. At doses above 20 mcg/kg/min more alpha-effects come
         into play).

2. Acute CHF: Questions

    a)   What are the symptoms of Acute CHF?
         Answer:         Exertional fatigue
                         Dyspnea
                         Dyspnea on exertion
                         Orthopnea
                         Paroxysmal nocturnal dyspnea
                         Peripheral Edema (right-sided failure)
                         Right upper quadrant pain from hepatic congestion
                                 (right-sided failure)

    b)   What are the causes of Acute CHF? “ISCHEMIA PA CATHS”

Ischemia                                           Paget’s disease/myeloma
Subacute bacterial endocarditis                    Arterio-venous fistula
Cardiomyopathy                                     Cardiac shunt
Hypertension                                       Anemia
Effusion/Tamponade                                 Thiamine deficiency (beri-beri)
Mitral valve disease                               Hyperthyroidism
Arrhythmia/Aortic valve disease                    Sepsis
The above are causes of low-output failure         The above are causes of high-output
                                                   failure



                                         16
D. ACUTE ALLERGIC REACTION

    A 32-year-old RN arrives emergently from the hospital cafeteria. She is
    allergic to peanuts and inadvertently ate one on her salad.

    Patient presents with lip edema, diffuse pruritis, generalized urticaria, and
    moderate dyspnea with wheezing.

    Vital Signs: P 120, BP 100/70, RR 35, T 37.2 C.

    1. Outline your initial care of this patient.

          Build our ―three pillars‖:
            O2-IV-monitors,
            Vital signs (already done), and
            Classic A B C D E primary survey.

          As all of the above is being done, obtain a directed history from the patient,
           especially considering allergy history, risk factors, other health problems, etc.
           Some folks would say this is a good SAMPLE history:

           S = signs and symptoms
           A = allergies
           M = medications
           P = problem list and risk factors
           L = last time patient had PO intake
           E = event history (if something happened recently to patient)

          Generate a differential diagnosis and working diagnosis. Our working diagnosis
           is an acute anaphylactic reaction.

          Simultaneously with the above, begin therapy for anaphylaxis as follows:

       a) Oxygen: support as necessary to maintain O2 sat > 95%.

       b) IV crystalloid: support volume status with IV normal saline. Remember that
          anaphylaxis may progress to anaphylactic shock, which is a volume & resistance
          issue (recall our discussion in this handout on page 3).
       c) Epinephrine: this is the classic drug of choice in acute anaphylaxis. It is
          usually given SC (subcutaneously) or IM: 0.3-0.5 mg of the 1:1000 dilution
          (meaning 1 mg = 1 mL). We can repeat it every 20 min up to about 3 doses. If
          the patient is going into anaphylactic shock, however, we can give it IV. But then
          the dose is 0.1 mg slow push over about 5 min (when we give it IV we use the
          1:10 000 dilution meaning 1 mg = 10 mL). We could also start an epinephrine
          infusion: dose is 2-10 mcg/min IV.

       d) Albuterol: administer nebulized therapy to treat wheezing/bronchospasm. We
           give 2.5-5 mg nebulized every 20 min for 3 doses, then decrease frequency of
           administration as condition allows.




                                            17
   e) Diphenhydramine: administer 25-50 mg IM or IV. Maximum dose over 24
        hr should not exceed 300 mg.

   f) Prednisone: typical dose is 125 mg of methylprednisolone IV or 60 mg of
        prednisone PO. We can administer every 6 hr if necessary.

   g) OTHERS:

           H2 blockers (e.g., ranitidine): there is evidence that the early use of H2
            blockers may help prevent hemodynamic instability in serious anaphylactic
            reactions. The dose of IV ranitidine is 50 mg IV every 8 hr.

           Racemic epinephrine: this medication comes in a 2.25% solution. It is
            useful for upper airway edema. Take 0.5 mL of this solution, combine it with
            2 mL of saline, and administer it via a nebulizer every 20 min if necessary.

           Glucagon: this is a ―back-up‖ drug in anaphylaxis. If a patient is on a beta-
            blocker, epinephrine may result in significant BP elevations, or the patient’s
            anaphylactic reaction may be unresponsive to epinephrine. Under those
            circumstances, glucagon IV should be used. Typical starting dose is 2-3 mg
            IV.

2. Questions about Anaphylaxis?

   a)   What are the clinical findings of anaphylaxis?
        The life-threatening issues with anaphylaxis are wheezing, airway edema,
        hemodynamic instability, shock, and cardiac arrhythmias from one of these.
        Pruritis and urticaria are also usual findings. If there is some gut edema, nausea
        and vomiting may also be a complaint.

   b)   What is the difference between an anaphylactic reaction and an
        anaphylactoid reaction?
        Anaphylaxis implies an Ig-E mechanism and prior exposure and sensitization to
        the anaphylactic stimulus. Anaphylactoid reactions look like anaphylaxis, but
        they are not Ig-E mediated and require no prior exposure. For example,
        iodinated contrast ―allergy‖ is an anaphylactoid reaction.

   c)   Why is epinephrine the ―drug of choice‖ in the treatment of
        anaphylactic shock?
        Alpha-effects support blood pressure. Beta-effects help treat bronchospasm and
        support cardiac output. In addition, there is general teaching that epinephrine
        helps prevent mast cell degranulation.




                                        18
E. ACUTE ASTHMA EXACERBATION

  This 22-year-old college student has a history of moderately persistent
  asthma. She now presents with an acute asthma attack in the setting of
  an upper respiratory tract infection.

  PE: Awake, alert, wheezing, dyspneic patient sitting on side of exam bed.
     VS P 130, BP 150/100, RR 32, T 37.8 C.

     Lungs with FAIR air flow, prolonged exhalation, and diffuse wheezing.
     Patient is diaphoretic.

  1. Outline your initial care of this patient.
      Build our ―three pillars‖:
         O2-IV-monitors,
         Vital signs (already done), and
         Classic A B C D E primary survey

        As all of the above is being done, obtain a directed history from the patient
         (although, given dyspnea, we may need to delay this to just yes or no answers
         until we have the attack under control) especially considering immediate history,
         risk factors, other health problems, etc. Some folks would say this is a good
         SAMPLE history:

         S = signs and symptoms
         A = allergies
         M = medications
         P = problem list and risk factors
         L = last time patient had PO intake
         E = event history (if something happened recently to patient)

        Generate a differential diagnosis and working diagnosis. Our working diagnosis
         is an acute asthma attack secondary to a viral URI and loss of the patient’s
         metered dose inhaler (MDI).

        Simultaneously with the above, begin therapy:

     a) Beta agonists: 2-5-5 mg nebulized every 20 min initially, trying for 3
        nebulized treatments in the first hour of care. As the patient’s condition
        responds, we will then try to decrease the frequency of administration.
     b) Ipratropium bromide: not sure how often to give this. Some asthma
        patients respond well. The drug has few side effects. Its onset of action is
        slower than with beta agonists. We can nebulize it in the same nebulizer and
        simultaneously with albuterol. Dose of ipratropium is 0.5 mg nebulized every 20
        min for 2-3 doses, then decrease frequency of administration.

     c) Oxygen: : support as necessary to maintain O2 sat > 95%.

     d) Magnesium: most asthma patients won’t need this. Magnesium is a smooth
         muscle relaxer, though. So if patient is not responding to therapy, would give 2
         grams IV over 20-30 min (avoid if patient has renal insufficiency).




                                        19
     e) Epinephrine or Terbutaline: most asthma patients won’t need one of
          these injectable drugs. I prefer terbutaline over epinephrine in this setting.
          Typical dose is 0.25-0.5 mg SC every 6 hr.

     f)   Steroids: if patients don’t respond immediately to albuterol, we should give
          them prednisone or methylprednisolone. The dose of methylprednisolone is
          classically 125 mg IV. The dose of prednisone is 1 mg/kg PO (typically 60 mg
          PO). If necessary, we can repeat steroid administration every 6 hr. If an asthma
          patient requires acute care hospitalization, administer methylprednisolone IV q 6
          hr for the first 3 days.



F. ACUTE ATRIAL FIBRILLATION with a RAPID VENTRICULAR
  RESPONSE (RPR)

  This 70-year-old woman presents to the hospital with mild about 5 days of
  profound fatigue, and one day of mild to moderate dyspnea. Her husband
  felt her pulse today and noted it to be rapid. The patient denies chest
  pain. She has a history of type II diabetes mellitus and hypertension.

  MEDS: metformin, furosemide, lisinopril, Tylenol, MVI

  ALL: Aspirin (stomach upset)

  VS: P 160 (irregular), BP 150/90, RR 20, T 36.5 C.
  Patient is awake, alert, and mildly dyspneic, with dry skin.

  1. Outline your care of this patient:




         Build our ―three pillars‖:
           O2-IV-monitors,
           Vital signs (already done), and
           Classic A B C D E primary survey.

         Obtain a 12-lead ECG (another ―vital sign‖ in an arrhythmia patient) and a
          portable CXR.




                                           20
      As all of the above is being done, obtain a directed history from the patient,
       especially considering immediate history, risk factors, other health problems, etc.
       Some folks would say this is a good SAMPLE history:

       S = signs and symptoms
       A = allergies
       M = medications
       P = problem list and risk factors
       L = last time patient had PO intake
       E = event history (if something happened recently to patient)

      Generate a differential diagnosis and working diagnosis. Our working diagnosis
       is atrial fibrillation with a rapid ventricular response of uncertain duration, perhaps
       as long as 5 days in this patient.

      Simultaneously with the above, begin therapy for rate control with ONE of the
       following. I would personally use diltiazem.

   Diltiazem: dose: begin with 0.25 mg/kg slowly IV and then follow with a continuous
       IV infusion of 5-15 mg/hr. If the patient’s rate does not slow down to a desirable
       90-100 bpm with the initial bolus, 15 min after the first bolus we can give another
       bolus, this time the dose is increased to 0.35 mg/kg.

   Esmolol: dose: begin with 500 mcg/kg/min bolus for 1 min, then start an infusion at
       50 mcg/kg/min. Every 5 min we can re-bolus with another 500 mcg/kg/min IV for
       one minute and increase the infusion by 50 mcg/kg/min. Max infusion dose is
       classically listed as 200 mcg/kg/min IV. The advantage to esmolol is its short
       half-life (about 8 min). So if the patient is not tolerating this drug, we can stop it.

   Digoxin: we tend to not use IV digoxin much these days, probably because of its
       slow onset of action. Dose: begin with 0.5 mg slowly IV if the patient is NOT on
       digoxin. If the patient is on digoxin, then begin with 0.25 mg IV slowly. Maximum
       IV dose over time should not exceed 1-1.25 mg in 24 hr. Make sure to allow one
       hour between IV doses.

   Amiodarone: dose: 150 mg IV over 10 min, followed by 1 mg/min IV for 6 hr, then
       0.5 mg/min IV for 18 hr. This drug will not only control the rate, it may chemically
       cardiovert the patient back into normal sinus rhythm. We don’t want that to
       happen if the patient as been in atrial fibrillation or atrial flutter for > 2 days.

2. Atrial Fibrillation/Flutter Questions & Answers:

   a) Is the patient stable or unstable?
       An unstable arrhythmia patient is defined by any one of the following 5 things:
       hypotension, ischemic chest pain, severe dyspnea, poor perfusion, or altered
       mental status. If a patient is in acute atrial fibrillation with a rapid ventricular
       response (typically a heart rate > 150 bpm) and is unstable, we will prepare for
       emergent sedation and synchronized cardioversion.

   b) How long has the atrial fib/flutter been present?
       We should avoid both electrical and chemical cardioverting atrial fibrillation if it
       has been going on for more than 2 days for fear of causing a CVA secondary to
       clots in the atria (that may form after 2 days) now being squeezed out and
       traveling to the brain. In some centers, however, a transesophageal



                                        21
          echocardiogram will be performed – if no atrial clots are seen – then
          cardioversion will be attempted despite the duration of the atrial fibrillation.

     c)   What is the patient’s ejection fraction?
          Avoid significantly negative inotropic drugs like beta blockers and verapamil if the
          patient’s EF < 40%. Even if the patient doesn’t know their ejection fraction, if they
          are on furosemide, an ACE-inhibitor, and perhaps digoxin and spironolactone,
          the odds are their EF is < 40%.

     d)   Do they have a pre-excitation syndrome?
          These are important because if one is present and the patient is in atrial
          fibrillation or atrial flutter we can NOT use calcium channel blockers, beta
          blockers, or digoxin for rate control – these drugs may paradoxically increase the
          heart rate in the setting of a pre-excitation syndrome and make a bad situation
          critical. If a pre-excitation syndrome is present, the drugs of choice are either
          amiodarone or procainamde. The rhythm strip below shows an example of the
          Wolff-Parkinson-White syndrome with a PR-interval < 0.12 sec and an up-sloping
          delta wave as part of the R wave.


                                                  Delta Wave




G. STATUS EPILEPTICUS

  It is the first day of internship. You are on your clinic block. You walked into the
  room to evaluate Ms. D. This 61-year-old female has a history of an old right
  brain CVA with some residual left sided weakness. She recently was in the
  hospital with an acute pyelonephritis. Her health is otherwise fair, although she
  also has a history of hypertension. You walk into the room to greet her and her
  husband. The patient takes one look at you and begins to suffer a grand mal
  seizure.


  1. Care for this patient now:

         Call for help and Build our ―three pillars‖:
           O2-IV-monitors, (I typically put them on a 100% non-rebreather mask at a
              flow rate of oxygen of 12 L/min).
           Vital signs, and
           Classic A B C D E primary survey. Check a fingerstick glucose. If it is < 60
              mg/dL, then administer one ampule (50 mL) of D50W IV.

         Protect that airway and protect the patient from harm. Have suction ready.

         Generate a differential diagnosis and working diagnosis. Our working diagnosis
          is an acute grand mal seizure in the setting of a prior stroke.




                                           22
      Most seizures will stop on their own after about 2 min, and all we need to do is
       the above. If the seizure persists beyond 2-3 min, then our first line drug is
       lorazepam (Ativan). If the seizure persists despite a full dose of lorazepam
       overtime, then our next line drug is either phenytoin or fosphenytoin.

       Lorazepam: dose is 0.1 mg/kg IV, given in 2 mg increments (each 2 mg given
       slowly over 1 min). If the patient’s seizure stops, stop giving the lorazepam.

       Phenytoin: dose is 15-18 mg/kg IV, give no faster than 50 mg/min

       Fosphenytoin: we can use this instead of phenytoin. The dose is the same as
       with phenytoin, but it can be given faster at the rate of 150 mg/min IV.

       OTHERS:

               Lidocaine: but be careful: remember lidocaine toxicity may RESULT in
               seizures.


               Magnesium: give 2 grams IV over 20-30 min.


               Thiamine: give 100 mg IV or IM.


               Propofol: 2 mg/kg load, followed by 30-250 mcg/kg/min IV




Dear Graduating Seniors (Ahem, I mean ―Doctors‖),

Thank you for the opportunity to be part of your training and to know you.
I am proud of you and your class; I am proud of all that you are and all that
you will be. Remember to be kind to your patients, your colleagues,
everyone throughout the hospital, and last but not least, yourselves.

Sincerely and appreciatively,




Terry J. Mengert, MD




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