Conference Summary - February 15th 2018

Conference Summary February 15th 2018


Thank you to Drs. Goldstein, Abraham and Miller and residents Drs. Parmar and Summers for giving lectures and to Drs. Gaines, Hughes, Grosso, Luk, Stull for Tehranisa for attending our conference and guiding our discussions.

And a shoutout to Julieta Lacey for the conference summary.


Angioedema - Dr. Jessica Goldstein

Beta Blocker and Calcium Channel Blocker Toxicity - Dr. Parmar

Anticoagulant Toxicity - Dr. Summers

Vertigo and Dizziness (CME) - Dr. Abraham

Leadership Conference- Dr. Miller


Angioedema - Dr. Jessica Goldstein

- ACE-I induced angioedema can happen at ANY time during treatment, not just after starting the medication

- 4x more likely in AA patients

- may require emergent airway

- treat with epinephrine, H1/H2 blockers, steroids, consider racemic epi

    - most of these do not help with the bradykinin pathway implicated in ACE-I angioedema, but there may be mixed pathology including histamine/allergic reaction

- true angioedema is bradykinin mediated --> icatibant (bradykinin receptor inhibitor) very expensive, currently only approved for ACE-I angioedema, not ARB, though that may change

- FFP 2u - can have some ACE-like activity and may help break down bradykinin to counteract ACE-I effects

Additional Points: 
* If the swelling is isolated to the lips only with no tongue involvement (or with very little tongue involvement), the swelling is unlikely to later spread intra-orally so the patient can be discharged home after some observation
(But remember that "skip lesions" can occur so if there is any sign of deeper swelling such as stridor/voice changes, then you MUST look with an NP scope to rule out laryngeal edema.) 
* If you see any amount of improvement in the swelling before your eyes, they can be discharged home because it will only continue to improve.  
* ALWAYS update the allergy list! These patients should not ever take ACE-i again. About 60% of patient's will have recurrence


B-blocker and Calcium Channel Blocker toxicity - Dr. Nicholas Parmar

B-blocker overdose

-     high dose insulin (1-10u/kg/hr, must give with dextrose gtt)

-     glucagon

-     cardiac pacing if unstable bradycardia or high grade AV block

-     consider lipid emulsion therapy and ECMO for severe cases

CCB overdose

-     (24hr obs if asymptomatic)

-     if symptomatic:

(at high doses, doesn’t matter if dihydropine or not)

-     calcium (up to 6g elemental calcium)

-     high dose insulin

-     pressors (epi vs norepi if cardiogenic vs distributive, dobutamine)

-     atropine


Anticoagulant Toxicity - Dr. Daniel Summers

-     rodenticide overdose often pediatric

-     most pts asymptomatic

-     warfarin absorbed PO/inhalation/skin

-     INR delayed at least 12 hr, but coagulopathy rare/usually requires another trigger and will can be 72hr late (weeks to months for superwarfarins)

-     if bleeding, Vit K (oral preferred for lower risk anaphylaxis, otherwise slow infusion)

-     FFP or 4f-PCC if severe bleeding

-     dabigatran (direct thrombin IIa inhibitor) - only one with antidote (Praxbind)

-     **UH has experimental trial Annexa for other NOAC reversal


Vertigo and Dizziness - Dr. Sean Abraham

-     vertigo vs near-syncope (just add EKG + cardiac monitoring if in doubt)

-     peripheral vs central (ISOLATED - history and neuro exam vs involving cerebellar not just vestibular)

-     HiNTS - head impulse (corrective saccade implies intact cerebellar), nystagmus (unidirectional/horizontal implies peripheral; vertical implies central, rotatory likely PCP), test of skew (inability to keep eye focused concerning for central)

-     labs usually useless (check RPR if suspect posterior column deficit)

-     use imaging to confirm history and physical, esp as MRI can miss posterior circulation stroke in first 6-8hr

-     peripheral - duration imp - BPPV (episodes lasting sec), Meniere’s (hours) or labyrinthitis/vestibular neuritis (days) though pts feel unsettled longer than the spinning feeling

-     BPPV: benign, paroxysmal (lasts only seconds), positional (w/ change in position, often rolling over in bed)

-     Dix-Hallpike will locate the otolith in which semicircular canal (if both sides, in horizontal canal)

-     Epley maneuver - need to know where otolith is

-     save meds for symptom relief (many can cause ototoxicity and persistent vertigo)

-     meclizine

-     valium (ok IV, avoid anticholinergic sx)

-     other options: zofran, haldol/phenergan

-     less effect w/ reglan or scopolamine

-     Vestibular neuritis + hearing loss = labyrinthitis - med taper, f/u ENT

-     (unrelated clinical pearl: if need to needle cric child ie can’t intubate can’t ventilate, instead of trans-tracheal jet ventilator, use ambu-bag connected to top of 7.0ETT connected to 3mL syringe connected to your 14g angiocath in the airway)


Leadership Conference - Dr. Christopher Miller

-     project

-     defining scope & quality

-     time, cost, resources

-     ask yourself - what situation is being addressed? what needs to be done? what will you do? how will you do it? how will you test it? how well did you do?

-     small group session

-     debriefing

-     challenges to success - efficiency in the face of unplanned interruptions, unanticipated issues,

-     PDSA - plan, do, study, act (must find way to analyze issue and success/impact of intervention)

-     Paretian distribution (ie 80/20 rule)

-     projects often fail because all the work falls on one person

-     next session to discuss communication/implementation