gmergency!

Hypercalcemia of Malignancy

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

Hyperviscosity Syndrome

• 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

Stroke Lacunar Subtypes

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

Stroke Mimics

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

Adult Pressor Dosing

Neonate Growth Pearls

• 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

Carbon Monoxide Hyperbaric Indications

(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!

Carbon Monoxide Half-Life

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.

Colchicine Poisoning

• 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

Stephen Smith’s Acid-Base Tutorial Pearls

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