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VFlutter

VFlutter

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fma08 said:
Pt. presents with back pain, jaundice and dark orange orange urine. Describe why you already know there is a proportionally elevated direct bilirubin (vs indirect) in the labs and how these signs can focus your differential.
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Conjugated (direct) is water soluble and therefore excreted in the urine whereas uncojugated (indirect) is fat soluble and can not be excreted in urine. The dark orange urine indicates an increase in conjugated bilirubin. Various conditons cause hyperbilirubinemia, both direct and indirect, so we would focus on a DDx that specifically causes an increase in direct. Does our patient like to shoot up with used needles?


What is Tikosyn? How does it work? What is a life threatening side effect?

On a side note: how many of you have actually seen a patient on Tikosyn?
 
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Aprz

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fma08

fma08

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Chase said:
Does our patient like to shoot up with used needles?
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Nah, just an adenocarcinoma of the pancreas impinging on the bile duct. I suppose I could have thrown in greasy, fowl smelling, clay colored stools to point to pancreas involvement too.

Also, fun fact to add on that I found, unconjugated bilirubin once broken down to urobillinogen is colorless when excreted in the urine. The conjugated form gives the color to urine and feces. But you are correct. Due to the jaundice with the dark color urine, we are looking for processes post conjugation (which we all know happens in the liver).

And I've never heard of Tikosyn. I'll be keeping my eye on that one.
 
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Dwindlin

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Chase said:
What is Tikosyn? How does it work? What is a life threatening side effect?

On a side note: how many of you have actually seen a patient on Tikosyn?
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Dofetilide :p

Class III anti-arrhythmic drug, slows potassium flux, thus increasing refractory period. The increased refractory period presents as an increased QTi on ECG . Can progress to Torsades.

And no I haven't, I have seen sotalol used which is also a class III (technically so is amniodarone, though it tough to actually classify).
 
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VFlutter

VFlutter

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Dwindlin said:
Dofetilide :p

Class III anti-arrhythmic drug, slows potassium flux, thus increasing refractory period. The increased refractory period presents as an increased QTi on ECG . Can progress to Torsades.

And no I haven't, I have seen sotalol used which is also a class III (technically so is amniodarone, though it tough to actually classify).
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Correct. I had a patient on it last week but it is pretty rare and I have only seen it a few times. It seems to be used when multiple other drugs and Ablation has failed. We keep them for 3 days and put them on telemetry with continuous QT alarms when starting it for the first time.
 
wyomingearth

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??

...picked that because you said most common...though I would think pseudomonas and clostridium species would be more resistant.
 
Brandon O

Brandon O

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What's the longest vein in the human body?
 
Brandon O

Brandon O

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Nattens said:
Patient does not obey commands but is able to push away your arm with centralised sternal pressure is applied.

aka: Localises to Pain
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Almost. By most interpretations, "localizes" requires you to cross the midline (e.g. to the opposite shoulder). That's one reason some people dislike sternal rubs; the localization you describe could be indistinguishable from other responses, such as flexion.
 
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Nattens

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Brandon Oto said:
Almost. By most interpretations, "localizes" requires you to cross the midline (e.g. to the opposite shoulder). That's one reason some people dislike sternal rubs; the localization you describe could be indistinguishable from other responses, such as flexion.
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I can see why many operators prefer the Trap squeeze to the Sternal Rub then. I should have been more specific, our service's Clinical Work Instruction on taking GCS requires the patient to localise to the sternal pressure with both hands, descerning the different to Flexion in which the pressure is applied to the nail bed.

"If there is no obeying motor response from either limb, apply pressure to mid-sternum as described in '1. Eye Opening'. If both hands move up towards the site of painful stimuli, score '5" for Localised motor response and record as such."

Ambulance Victoria Clinical Work Instructions
 
Brandon O

Brandon O

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Nattens said:
I can see why many operators prefer the Trap squeeze to the Sternal Rub then. I should have been more specific, our service's Clinical Work Instruction on taking GCS requires the patient to localise to the sternal pressure with both hands, descerning the different to Flexion in which the pressure is applied to the nail bed.

"If there is no obeying motor response from either limb, apply pressure to mid-sternum as described in '1. Eye Opening'. If both hands move up towards the site of painful stimuli, score '5" for Localised motor response and record as such."

Ambulance Victoria Clinical Work Instructions
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There are some kinda obscure details behind grading the GCS responses; I don't have all the info here, but I do like the trap pinch (when you can get to a trap). The sternal rub has also been shown in some studies to take an awfully long time to produce a response (up to a minute), and can cause some harm due to all the rubbing. Nothing to move mountains but I usually recommend people choose a different go-to.

It's nice to have an arsenal, though. For instance, I've had drunks who were immune to all pain but woke up when we heaved them onto the stretcher. Nothing like a little (ob)noxious stimuli...
 
Brandon O

Brandon O

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Approximately how long will a D-sized oxygen tank at 2000 PSI last until empty when running at 15 LPM?

How about an M tank at 2000 PSI?
 
JPINFV

JPINFV

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Brandon Oto said:
Approximately how long will a D-sized oxygen tank at 2000 PSI last until empty when running at 15 LPM?

How about an M tank at 2000 PSI?
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About 30 seconds before I change it?

Can I punt to Epocrates?
 
Brandon O

Brandon O

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JPINFV said:
About 30 seconds before I change it?

Can I punt to Epocrates?
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Yeah, I was just hoping you'd have to look up the formula and therefore possibly commit it to memory.

Myself, I look it up about once a year and then promptly forget it. But it actually can come in handy.
 
JPINFV

JPINFV

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Brandon Oto said:
Yeah, I was just hoping you'd have to look up the formula and therefore possibly commit it to memory.

Myself, I look it up about once a year and then promptly forget it. But it actually can come in handy.
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To be fair... the tank my oxygen supply is more often hooked up to is rather large and requires a refrigerated tanker to refill.
 
Brandon O

Brandon O

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JPINFV said:
To be fair... the tank my oxygen supply is more often hooked up to is rather large and requires a refrigerated tanker to refill.
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Well, if you're not careful I'm going to make you calculate gaseous O2 capacity for the liquid reservoir.
 
JPINFV

JPINFV

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Brandon Oto said:
Well, if you're not careful I'm going to make you calculate gaseous O2 capacity for the liquid reservoir.
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Phone... dial zero... ask for transfer to facilities.

...and since I'm currently a traveler in the land of women...

Naegele's rule?
 
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