Med-Peds Pearls

Tidbits for patient care

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SBT Parameters

NIF < -30, RSBI < 100

Respiratory rate RR >38 bpm for 5 minutes or <6bpm

SpO2 < 92%

Tidal volume (TV) < 325 mL

Heart rate: HR > 140 OR 25% above baseline OR HR<60

Blood pressure: SBP 40 mm Hg above baseline

Worsening agitation, anxiety or discomfort despite reassurance

Rapid shallow breathing index (RSBI) = RR/ TV

Most consistent and powerful predictor

RSBI > 105 min/L predicted failure well, but if used rigidly may slow the weaning process

Spontaneous Breathing Trial

Spontaneous breathing trials (SBT) are used to identify patients who are likely to fail liberation from mechanical ventilation

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Pulmonary HTN 2/2 HIV

Pulmonary HTN is part of natural history of HIV

Risk of developing proportional to viral load

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Ganzoni Equation for Iron Deficiency Anemia

Use before dosing iron

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Types of TIRED

-Asthenia: fatigue all the time (medications, malignancy, infections...)

-Fatigue: OK when resting, tired with exertion

-Weakness: true neurologic weakness reproducible on exam

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4Ts of Anterior Mediastinal Masss

-Teratoma

-Thymoma

-Thymus

-Thyroid

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Protein Calorie Malnutrition/Anorexia Nervosa

At risk for SIADH- check urine specific gravity daily

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Heart Murmur

Trill=Palpable Murmur

Fixed Split S2= ASD, pulmonic stenosis, aortic stenosis

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Other Breath Sounds

Wheezing + prolonged expiratory phase (obstructive diseases)- expiratory phase, problem getting air out, DOES NOT CLEAR WITH COUGH

Ronchi (middle chest)- hear with lots of secretions, clears with cough! COPD, CF

Crackles- very end of inspiration, like hair against ear

NO CHARACTERISTIC SOUND FOR ATELECTASIS!

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Stridor

Intrathoracic (trachea)- expiratory stridor

Extrathoracic (larynx, pharynx, oropharynx, above the clavicle)- inspiratory stridor

Acute- aspiration/acute ingestion

Subacute- croup

Chronic- GERD, William's syndrome, masses/lumps/webs, foreign body, vocal cord dysfunction (often misdiagnosed as asthma)

Congenital- laryngomalacia (goes away after 12-18 mo, breathing improves when prone, MOST COMMON CAUSE OF STRIDOR AT BIRTH, usually needs surgical intervention), tracheomalacia (appear 2-6 weeks, goes away 6-12 mo, rarely needs intervention), vascular ring, recurrent laryngeal nerve injury, any congenital cause of hypotonia (listen for hoarse cry/babbling), bronchial webs, Plummer Vinson (webs in oropharynx),

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Pediatric Patient with Persistent Proteinuria

Complement level and ultrasound!

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Warning Signs on Peds KUB

5 air-fluid levels

Air under diaphragm

Air in rectum

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High Pressure Injection Injury

MCC: Industrial painter injecting paint into non-dominant hand

FIRST: soak hand in soapy water, clean paint off skin of hand

EMERGENT CONSULT TO ORTHO

High risk of amputation

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Bradycardia

B- blocks (intrinsic heart blocks)

R- reduced vitals (hypoxia, hypothermia, hypotension)

A- acute coronary syndrome

D- drugs (Beta block, CCB, Digoxin, etc...)

I- increased ICP (Cushing's reflex)

E- endocrine (Myxedema coma) and electrolytes (hypoK+)

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Harlequin Syndrome

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Antidote for Anticoagulation Overdoses

Protamine sulfate- heparin

Kcentra/FFP- warfarin

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Pancreatitis

Most feared outcome of pancreatitis: abdominal compartment syndrome, sepsis, ARDS

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Maintenance Fluids

Unless you're resuscitating hyponatremia-> PICK LR >>> NS

-SMART trial supports it

https://emcrit.org/pulmcrit/smart/