Want to broaden your differential for hypotension? Do you have a younger patient with hypotension and lab abnormalities? A patient with hypotension refractory to pressers? Think of acute adrenal insufficiency!
I dont have much in the way of additional pearls today - this is pretty self explanatory.
Concerned that your patient ran out of cortisol? Give cortisol (hydrocortisone). You wont diagnose it if you dont suspect it - so keep it on the differential!
Good Monday Morning all!
This one took me all weekend - but I think it will be particularly helpful! I am always looking up how to dress burn wounds and who to give followup to and who to transfer etc, so I think this will be a nice easy reference.
There is just too much info around burns (from cyanide poising which we just reviewed w/Dr. Harmouche to awake nasotracheal intubation) and there are just so many learning points and I could only include so many - so I apologize for having the leave some things out. its already a dense one!
Prepare to zoom in/magnify, and happy learning (:
A couple key take home points that I wasnt able to fit into the graphic:
Burns are dynamic wounds. Burns can deepen over the next few days, and so it is difficult to know the true depth of the wound for at least 48-72 hours. Even burn specialists are only correct about 60% of the time at accurately identifying the depth of the burn on initial assessment. Burns can deepen after the first few hours to days of assessment. This is particularly important when setting expectations with patients and families at the initial visit.
Initial approach to any patient in a fire:
Don’t get distracted by the burns. Perform your primary and secondary survey as you normally would with a trauma patient and address the burns later.
Carbon monoxide (CO) and cyanide poisoning are also associated with burn injuries. Apply 100% O2 to reduce the half-life of carboxyhemoglobin to all patients with a history of exposure to fire in an enclosed space. Assume the pt is both trauma AND tox until proven otherwise.
Many of these pictures and pearls came from this amazing website:
https://emergencymedicinecases.com/burn-inhalation-injuries/
Chapter 1: What dafuq is in an amp of bicarb?
Take a look!
50mL
8.4% NaHCO3 -> 50mEq
The osmolarity of this solution is 2,000mOsm/L - twice that of 3% saline. < (click for emcrit)
Chapter 2: Sodium bicarbonate doesn't just magically raise pH...
Remember this thing?
CO2 + H20 <=> H2CO3 <=> HCO3 + H
It's complicated. Bicarb binds to acid. Then it turns to CO2 and water, so you can breathe it out.
Basically if you're giving bicarb, you can only raise your pH as long as you can breathe off your CO2, increasing your RATE or VOLUME.
**This is particularly a problem in patients who are not in control of their breathing (vented), aren't breathing (arrest), or who have maximized the efficiency of their breathing (Kussmal breathing in DKA).**
That's right - you need to increase your minute ventilation to have a change in pH.
Chapter 3: Sodium bicarb amps can cause harm!
FIRST:
One amp of bicarb is like giving 100cc of 3% hypertonic saline!! But as Josh Farkas points out, we typically have no hesitation giving "a couple of amps of bicarb."
This is a huge osmotic load which can lead to huge fluid shifts - prepare for that amp to increase intravascular fluid by 1/4 liter with every push. (Is this what you want to give to your renal failure pt? Your heart failure pt?)
SECOND:
You are worsening acidosis.
What? Huh? But I thought...
No. Stop. Shush. You're worsening acidosis.
Remember, you're increasing CO2 - whether you can breathe it off or not, this CO2 rises in but blood BUT ALSO rises in the tissues and may worsen acidosis in these tissues. < (click for litfl.com article)
THIRD:
Be ready to cause hypernatremia - expect a rise of 1mEq Na per amp of bicarb.
FOURTH:
Extravasation can cause tissue necrosis.
FIFTH:
CSF acidosis, hypocalcemia. Increased lactate. (Some may argue that's not a bad thing.)
If you do manage to fix the acidosis, you can overshoot and create an alkalosis and even screw up the oxygen dissociation curve (in a bad way).
Chapter 4: It just doesn't f&$%ing work
Cardiac arrest: it doesn't do anything. No increased survival. and AHA says it should not be given routinely.
Lactic acidosis: There's a whole section on UpToDate - there's minimal research for pH < 7.1 so you can consider it at that point... but otherwise, nah.
DKA: Take it from a nephrologist: In ketoacidosis, it is almost never necessary to give bicarbonate even though the patient is bicarbonate deficient unless renal function is permanently impaired. Therapy with fluids and electrolytes restores extracellular volume and renal blood flow, thus enhancing the renal excretion of acid and regenerating bicarbonate.
Hyperkalemia: Amps of bicarb, even in hyperK emergencies, have not been shown to lower potassium. Click that UpToDate link or listen to Scott Weingart talk about it on EMRAP.
Patients with hyperK should be started on isotonic bicarbonate drips for 4-6hours, a treatment that works better in acidotic patients.
CHAPTER 5: Soooo who gets bicarb?
AMPS:
Bicarb ampules in sodium channel blockade (like TCAs) are, as Dr. Bogoch said yesterday, the cornerstone of therapy
Bicarb ampules may be appropriate to alkalinize urine in certain toxicities
Seizing hyponatremic patients
DRIPS:
Appropriate in hyperK patients who can handle fluid
Appropriate in patients with AKI and pH < 7.2 (BICAR-ICU Trial)
May be appropriate for pH < 7.0 or 7.1, depending on who you talk to...
**If the pH is < 7.1 and you wanna give an amp of bicarb, there isn't enough data to say you're wrong. If it's a last-ditch effort, you might as well.
Other references embedded in text.