Don’t just pre-oxygenate: have an Oxygenation Strategy

A key component in the planning of intubation is pre-oxygenation. Recently apnoeic oxygenation during laryngoscopy has been adopted too. These are just two components of an overall oxygenation strategy to consider when intubating the critically ill. Some patients will require proactive preparation of the components of successful post-intubation oxygenation, especially those with severe lung pathology […]

Mordedura araña de rincón

Comparto este caso realmente impactante y que muestra en toda su magnitud lo grave que puede ser la mordedura por Araña de Rincón
La consulta precoz es siempre recomendable,en este caso la mordedura no generó un cuadro tóxico mayor
Pueden ver la secuencia de las lesiones ,hasta la cirugía realizada
Lo más complejo de este caso que me correspondió atender en varias fases de la enfermedad,fue abordar los aspectos emocionales secundarios en especial al largo periodo en la cual paciente convivió con la lesión necrótica.Un aspecto clave a trabajar en estos casos es hacer entender a paciente que otro desenlace pudo haber sido la muerte,en ese caso una cicatriz se puede entender mejor...

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A 50-something male with Dyspnea

A middle-aged male presented with dyspnea.  An ECG was recorded.
What is going on?  See below.























There is sinus rhythm.  There is notable ST depression in V1-V4, maximal in V2 and V3.  At first glance, it appears to be a posterior STEMI.

But one must always read ST and T-wave abnormalities in the context of the QRS.  There is a large R-wave in V1-V3.  One can see a large R-wave in posterior MI, and so one feels as if one's first impression is confirmed.

However, Right ventricular hypertrophy (RVH) also results in large right precordial R-waves and secondary ST and T-wave abnormalities that mimic ischemia.

One should always look for an S-wave in lead I.  And there it is.   There is right axis deviation.  All this is strongly suggestive of RV hypertrophy.

So a cardiac ultrasound was done:

--Pulmonary hypertension: The estimated pulmonary artery systolic pressure is 72 mmHg + RA pressure.
--Right ventricular enlargement .
--Decreased right ventricular systolic performance .
--Right atrial enlargement but the inferior vena cava is small in size.
--Left ventricular hypertrophy concentric .
--The estimated left ventricular ejection fraction is 75 %

--There is no left ventricular wall motion abnormality identified.


The patient ruled out for MI.


Learning Point:

1.  Abnormal ST elevation and/or depression, and/or T-wave inversion (abnormal repolarization), may be primary (due to ischemia, for instance), or these may be secondary to abnormal depolarization (an abnormal QRS, such as LVH, RVH, LBBB, RBBB, and others).

Thus, one must always closely examine the QRS to be certain that it does not harbor abnormalities that explain the repolarization abnormalities.

2.  Right ventricular hypertrophy often results in right precordial ST depression and T-wave inversion that mimics ischemia.  In particular, it mimics posterior STEMI.

Woke Up with Weak Legs

30 y.o. M PMHx hyperthyrodism, who presents c/o b/l leg weakness since this AM. Pt states he awoke with the symptoms and was unable to stand. Feels that his weakness is located in his thighs. Had similar episode 4 days ago, went to OSH and symptoms had resolved. Denies numbness, other neuro complaints, changes in bowel or bladder, trauma, history IVDU or CA, pain, fever, N, V, SOB.
meds: propylthiouracil, propanolol

Exam is significant for 1/5 strength to BL proximal  LE, with 5/5 strength distally. Sensation grossly intact. Somewhat hyporeflexic to lower extremities.

What tests would you order? What could be in the differential?

CBC wnl
BMP with K of 2.5
TSH low at 0.02
elevated free T4 at 3.69, T4 at 17.08 and T3 at 260.37

After ensuring that other diagnoses (cauda equina, epidural abscess, stroke, MG, etc.) are ruled out, given the above lab results one may entertain the possibility of periodic paralysis (PP). This patient had thyrotoxic PP.

- most common type of periodic paralysis is hypokalemic periodic paralysis. This should be differentiated from thyrotoxic PP (send labs). Less common is hyperkalemic PP.
- hypokalemic PP is a neuromuscular disorder (AD), defect in muscle ion channel
- episodes of painless muscular weakness
- usually affects proximal > distal, legs > arms, with hyporeflexia
- consciousness is preserved
- typically lasts several hours, but can be minutes to days
- may be precipitated by exercise, fasting, high-carb meals
- these activities release of epi or insulin -> K into cells
- K is normal between attacks (mean K 2.4 during attacks)
- replete gradually (10-30 meq/hr PO) and follow K, as there is potential for rebound hyperkalemia. Also, keep pt on monitor

 

Thyrotoxic PP:
- thyrotoxic PP can happen from any etiology of hyperthyroidism including meds
- may have mild myalgias. May have respiratory or bulbar weakness. May have fatal dysrhythmias.
- cases refractory to K may benefit from propanolol
- restoration of euthyroidism prevents/decreases attacks

 

Approccio essenziale all’emogasanalisi (1)

    Il pH   L’organismo deve ‘gestire’ una produzione quotidiana di oltre 15.000 millimoli (mmol) di idrogenioni (H+) prodotti dal metabolismo. Deve perciò trasportarli in maniera protetta,mediante sostanze ‘tampone’, all’esterno sotto forma di CO2 ( acidità volatile) e mediante acificazione delle urine con associato risparmio/rigenerazione di bicarbonati (acidi non volatili). Il range di normalità […]

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