29 1 / 2012

Correct for albumin!

Mild = 10.5-11.9, consider dc if close f/u, pt asymptomatic

  • Oral hydration
  • High-salt diet
  • Avoid meds that cause hyperCa

Moderate = 12-13.9, admit

Severe = >14, admit

  • IVF, Goal UOP = 150ml/hr
  • Consider lasix
  • Consider bisphosphonates:

— zolendronic acid: 4mg IV over 15 minutes, 8mg 2nd dose if required — pamidronate: over 2-24 hours, give 60mg (Ca 12-13.5), give 90mg (Ca > 13.5)

If >18 or >13.5 with AMS, renal failure, CHF, emergent dialysis

28 1 / 2012

  • Triad of bleeding, visual changes, neuro symptoms
  • Get CBCdiff, coags, BMP, peripheral smear for roulette formations, serum and urine electrophoresis
  • Careful hydration and diuresis
  • If extreme WBC, needs leukophoresis
  • If extreme proteinemia, needs plasmapheresis
  • If not immediately available, do 100-200cc phlebotomy

27 1 / 2012

  • Pure Motor
  • Pure Sensory
  • Sensory-Motor
  • Clumsy Hand/Dysarthria

26 1 / 2012

  • Conversion Disorder
  • Delerium
  • Todd’s Paralysis/Postictal
  • Hyperglycemia
  • Hypoglycemia
  • Intracranial Mass
  • Metabolic/Toxic Encephalopathy
  • Complex Migraine

25 1 / 2012

24 1 / 2012

  • Lose 10% of their birth weight by day 3
  • Should be back to birth weight by 1 week
  • Should gain 1 oz per day
  • Fever for every 1deg F > 100.4 can cause 10 bpm of tachycardia

23 1 / 2012

(These totally vary by center.)

  • Level > 25%
  • Level > 15% (if pregnant)
  • Fetal Distress
  • Syncope
  • Coma
  • Acidosis
  • Age > 60
  • Neuro Findings
  • Children
  • Cardiovascular Disease
  • Headache or Chest Pain
  • Maybe Prevents Delayed Neuro Sequelae (Conflicting Data):

  • Numbness

  • Paralysis
  • Paresthesias
  • Basal Ganglia Infarcts
  • And Psych Sequelae:

  • Cloudy thoughts

  • Trouble concentrating
  • Amnesia
  • Depressed Mood
  • Remember, all tubes (foley, eg) must be filled with water, not air!

22 1 / 2012

HbCO levels often do not reflect the clinical picture, yet symptoms typically begin with headaches at levels around 10%. Levels of 50-70% may result in seizure, coma, and fatality.

CO is eliminated through the lungs.

  • Half-life of CO at room air temperature is 3-4 hours.
  • One hundred percent oxygen reduces the half-life to 30-90 minutes;
  • Hyperbaric oxygen at 2.5 atm with 100% oxygen reduces it to 15-23 minutes.

21 1 / 2012

  • For gout and familial mediterranean fever
  • Can have delayed symptoms if patient was given IV colchicine
  • Oral colchicine follows normal toxicity (GI + leukocytosis, then multiorgan failure + pancytopenia, then recovery)
  • 0.5-0.8mg/kg fatal
  • P450 interactions with macrolides, azoles, grapefruit juice
  • Supportive care, charcoal, gastric lavage with EWOL, then multi-dose charcoal
  • Hemodialysis not useful (large volume of distribution)
  • Can cause paralytic ileus making charcoal difficult
  • Consider Granulocyte colony stimulating factor for neutropenia

20 1 / 2012

From one of my favorite sites, HQMedEd.org. Totally worth the hour.

  • Metabolic Acidosis Causes:

    • Impaired contractility
    • Lower Vfib threshold
    • Decreased organ perfusion
    • Inability to respond to catecholamines
    • Vascular collapse
  • Give Bicarb when HCO3 < 6

    • If you give it otherwise, it will make more carbonic acid and more acid and more CO2 (esp if you can’t blow off the CO2)
    • If you give it, causes hypokalemia
    • Shifts Hemoglobin dissociation curve (less offloading of pO2)
    • If low <6, give 2 amps
    • If pCO2 > 1.5(HCO3)+ 8, ventilate more
    • In severe asthma exacerbation, beta agonists don’t work below pH 7.0, so give bicarb to raise pH.
  • Ketones in Urinalysis:

    • Sensitive 99% in ill-appearing patients for ketosis
  • Normal Osmolar Gap = <20

  • Acute Acidosis:

    • 0.1 change in pH causes 0.5 change in [K+]
  • LOW Chloride = Metabolic AlkaLOWsis

    • Na:Cl ratio should be 1.25–1.40
    • If ratio higher, metabolic alkalosis is still present
    • Low chloride can also be from chronic respiratory acidosis (renal compensation)
    • pCO2 = 0.9 * HCO3 + 15
  • Contraction Alkalosis

    • “Contracts” around a fixed amount of bicarb
  • Expansion Acidosis (Hyperchloremic)

    • This is due to a dilution of the preexisting bicarbonate and to decreased renal bicarbonate reabsorption as a result of volume expansion.
  • Albumin Affects the Anion Gap

    • For each 1g drop of albumin, nl anion gap decreases by 2–2.5
  • Delta Ratio: Delta Gap / Delta HCO3

    • Gap – 12 / 24 – HCO3
    • > 1 = Superimposed Alkalosis
    • 0 = Non-Gap Acidosis
    • 0–1 = Both AG and Non-Gap Acidosis
  • Non-Gap Acidosis:

    • Loss of Bicarb (Diarrhea, Acetazolamide)
    • Can’t Excrete H+ (RTA)
  • Metabolic Compensation

    • For Chronic hypercapnia: HCO3 increases 3.5 for each 10 of PCO2 above 40
    • For Chronic hypocapnia: HCO3 decreases by 5 for each 10 of PCO2 less than 40
    • pH changes by 0.08 for every 10 of PCO2
  • Severe Alkalosis: You can give acetazolamide 500mg IV

    • HCl Infusion
  • Metabolic Acidosis Compensation:

    • pCO2 < expected: Respiratory Alkalosis, consider Salicylism, Liver Failure
    • pCO2 > expected: Respiratory Acidosis, consider AMS or fatigue with acidosis