Grand Rounds Recap 6.26.2024

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Global health journal club WITH dr. bryant

  • Organophosphate toxicity is much more common in low- and medium-income countries and carries high mortality

    • Abedin et. al performed an RCT in Bangladesh and investigated standard bolus dosing of atropine compared to frequent push-doses of atropine followed by a drip

    • Incremental boluses plus an infusion of atropine was found to have significantly reduced mortality and less risk of atropine toxicity compared to standard of care

    • Total time to “atropinaztion” (resolution of organophosphate toxicity) was significantly lower in the treatment group than the control group (1 day versus 6 days)

  • Bubble CPAP is a viable option to provide positive pressure ventilation to neonates and children in low- and middle-income countries

    • Bubble CPAP can by built “DIY” for approximately $5 using standard hospital supplies. Commercially-produced bubble CPAP machines are also available and cost approximately $6,000

    • This study by Norgaard et. all was a systematic review. There were some problems with this systemic review; the standard of care group was not standardized and varied from mechanical ventilation to standard low-flow wall oxygen or variable-flow oxygen. Low-income countries were under-represented in this study compared to medium-income countries

    • Bubble CPAP showed promise in terms of reduced mortality for infants and children with respiratory distress. Complications of bubble CPAP include pneumothorax and nasal septal necrosis

    • Oxygen availability is still not a standard resource in low-income countries, which may be a limiting factor even if bubble CPAP devices can be produced

Clinical pathologic case (cpc) with Drs. Vaishnav and Shewakramani

  • The efficacy of treatment for acetaminophen overdose is time dependent, therefore, a high index of suspicion should be present to make the diagnosis in cases where patients are not entirely forthcoming about ingestion history or for patients that are altered and cannot provide a detailed history.

  • The decision to treat depends on the history provided, clinical status and mental status, and acetaminophen levels. Transaminases and other labs may take >24 hours to reflect derangements, therefore normal measurements are not reassuring in acute overdose.

  •  The treatment for acetaminophen overdose is N-Acetylcysteine. If the patient presents within four hours of ingestion, consider activated charcoal. Fomepizole can be used as an adjunct to treatment in severe overdose.

r1 diagnostics and therapeutics: cardiac pacing WITH dr. sookdeo

  • Bradycardia can be caused by structural changes from ischemia and aging, medications, toxins, electrolyte abnormalities, or infection

  • Transvenous and transcutaneous pacing can be utilized in patients with unstable bradycardia that does not respond to medications

  • When using transcutaneous pacing, place pads preferably in anteroposterior orientation

  • Transvenous pacing can be initiated when transcutaneous pacing is ineffective or inadequate

  • When initiating transvenous pacing on a patient that is currently being paced transcutaneously, you can identify capture by setting the transvenous pacer to a higher rate than the transcutaneous pacer, or by stopping transcutaneous pacing while floating the transvenous pacer wire

  • TTE or TEE can be used to evaluate adequate mechanical capture in both TC and TV pacing

r3 taming the sru WITH dr. gobble

  • Pyridium is a (not-so?) rare cause of methemoglobinemia

  • Concern for methemoglobinemia should increase with refractory hypoxia unresponsive to supplemental oxygen

  • Diagnosis made by evaluating the PaO2-saturation gap and formal measurement of methemoglobin levels

  • Treatment centered around methylene blue

  • Methylene blue is a cause of serotonin syndrome, particularly in patients on other serotonergic agents

  • Treatment of serotonin syndrome is largely supportive