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M&M Tips March 2010

Tips from your diligent peer review committee.
1. When a patient has copious ongoing bleeding, and is hypotensive, consider giving blood. The blood bank can provide un-crossmatched blood very quickly if necessary.
2. When a patient who has a very low blood pressure requires intubation, consider improving the blood pressure prior to performing intubation, as the transition to positive pressure and pharmacologic sympatholysis that accompanies RSI often further depress blood pressure. Intravenous fluids and pressors are two strategies. Phenylephrine 10 mg/1 cc vials, are now available in both the adult and pediatric med rooms at Sinai.
3. In patients who require intubation but cannot be preoxygenated effectively, or in patients who require high minute ventilation to maintain physiologic pH, consider maneuvers to improve oxygenation/ventilation around RSI if an awake approach is not predicted to be successful. These maneuvers include BVM or NIV before, during, and after induction, perhaps using an LMA (after induction). Short laryngoscopy times and first pass success are more important in these patients – choose your approach and intubator accordingly.
Thanks to Dr. Holland Yang for her expertly-presented M&M yesterday.
Key points from the discussion:
* Aortic dissection is an uncommon but lethal, treatable disease associated with a steadily increasing mortality with every hour the diagnosis is delayed.
* Aortic dissection can be very hard to diagnose. 1 out of 3 cases do not have chest pain, and 1 out of 20 cases have no pain anywhere. 1 out 3 cases are first diagnosed on autopsy.
* Key risk factors include abnormalities of the aorta (connective tissue disorders, syphilitic aortitis, Takayasu arteritis) and aortic valve abnormalities (bicuspid aortic valve, valvuloplasty). The disease is also associated with hypertension (especially stimulant use and weightlifting) and pregnancy.
* The most important clinical presentations are pain in the chest and back, migratory chest/back/abdominal pain, and chest pain with a neurological deficit.
* Unusual combinations of symptoms, such as back or abdominal pain with a neurological deficit and symptoms on both sides of the diaphragm, should raise suspicion of the disease. Although not as well described, we have seen several cases at Sinai/Elmhurst where diarrhea (from bowel ischemia) was a prominent component of the presentation.
* In cases where the diagnosis is entertained but not ruled out with a definitive study (usually CT aortography), clinical decision-making to that effect should be documented. Charting a normal neuro exam and peripheral pulse exam implies thoroughness, though absence of findings with these maneuvers does not exclude the diagnosis.

Written by reuben

March 11th, 2010 at 3:12 pm

Posted in Pearls

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