(Last Updated On: May 6, 2017)

Crashing GI Bleeder, with Dr. Snow:

  1. Always consider Aortoenteric Fistula in the differential – look for the abdominal scar
  2. ‘Load The Boat’ with the correct consultants very early on
  3. Protect Yourself – always wear face/eye protection
  4. Intubate these patients early – they can decompensate quickly
  5. Place a Nasogastric Tube prior to intubation, to empty the stomach
  6. Use 1:1:1 product transfusion as a guide to resuscitation
  7. Choose the best access for your patient. Remember:
    1. Humeral IO: ~60ml/min (~200ml/min with pressure bag)
    2. Central Line (brown/distal port): ~60ml/min
    3. Cordis: ~120ml/min (~330ml/min with pressure bag)
    4. 16 gauge peripheral IV: ~220ml/min
  8. Consider the following meds:
    1. Vitamin K: In the cirrhotic patient
    2. DDAVP: in the ESRD patient
    3. Vasopressin: For the patient ‘in extremis’
    4. Transexamic Acid: For any unstable patient (without PE history)
  9. Know how to place/set-up a Blakemore/Minnesota tube
  10. Don’t let these patients become hypothermic

Meds for GI Bleeds, with Dr. Scott Heinrich:

  1. PPi’s reduce rates of rebleeding and surgical intervention in bleeding from PUD but do not affect mortality
  2. Erythromycin IV given 30-45 mins prior to endoscopy can decrease endoscopy time, hospital length of stay and increase adequate visualization
  3. Restrictive transfusion strategies to a hemoglobin of <7 and antibiotics (ceftriaxone or fluoroquinolone) for acute variceal bleeding are the only medication interventions that have been shown to decrease mortality

Reading Abdominal CTs for Appendicitis, with Dr. Henry:

  1. Finding the appendix: Look for the proximal portion of the ascending colon (the cecum), then look for anything ‘taking off’ from the cecum (Posterior-medial side of cecum is the usual location of the tubular appendix)
  2. Appendiceal Changes consistent with appendicitis:
    1. Total Thickness/Diameter > 6-10mm
    2. Wall Thickness > 3mm
    3. Wall Hyperenhancement
  3. Appendicolith: present in 1/3 of cases, not diagnostic, but is prognostic as higher risk of perforation when present
  4. Be aware of sterile pyruia. It occurs because of the inflamed appendix causing inflammation in the bladder. Don’t overlook this.
  5. Beware the thin patient, and the young patient – as the classic CT changes can be missed in these patients
  6. Beware the appendix you cannot see! If you cannot see it, and you are concerned about the patient, do not simply discharge and move on…

M&M, with Dr. Daniel Thomas:

  1. Consider DSI (delayed sequence intubation) when you need to optimize oxygenation/intubation environment
  2. Alcohol withdrawal requires aggressive benzodiazepine treatment, with frequent rechecks and adjuncts – consider doubling the dose sequentially if your initial dose does not work…
  3.  Do not anchor on an initial diagnosis when something more serious (eg respiratory distress) is becoming a problem
  4.  Signouts should involve written notes, worst case scenarios, and clear plan for disposition

Trauma Conference, with Dr. Pablo Moreno:

  1. 1. If placing chest tube to drain suspected PTX and unclear whether there may be a chronic process (PNA) which may be causing pleural adhesions please perform imaging (if pt stable) prior to placement to avoid lung injury (Consider the use of Ultrasound to help)
  2. During chest tube placement please confirm soft tissue defect goes into pleural cavity by palpating lung and feel for adhesions by rotating finger 360 degrees. If there are well organized adhesions abort chest tube.
  3. If pt stable, consider conscious sedation and or costal nerve block to minimize pain
  4. Don’t tape the nipples, as it hurts to untape! (Per our CT surgeon)