  Teaching Video: youtu.be/e-83DanOgF8&list=PLOlpsJ0eDlASRw1LywI2iGfzDTqxlAYFJ Increased Intracranial Pressure (ICP) Management
Increased intracranial pressure (ICP) is a serious complication of head injuries and can lead to poor outcomes if not managed appropriately. The Monro-Kellie doctrine states that the skull is a rigid container, and any increase in volume within this container (brain, blood, or CSF) will result in a rise in ICP. Therefore, management of increased ICP focuses on reducing intracranial volume. Hyperventilation, although controversial, can be used in moderation (PaCO2 of 35-40 mmHg) to induce cerebral vasoconstriction and reduce intracranial blood volume acutely. Mannitol, an osmotic diuretic, can be administered to reduce brain edema and lower ICP but should be avoided in hypotensive patients. Neurosurgical consultation is crucial for any patient with signs of increased ICP, as surgical intervention may be necessary to evacuate mass lesions or control bleeding. Teaching Video/Podcast: youtu.be/e-83DanOgF8&list=PLOlpsJ0eDlASRw1LywI2iGfzDTqxlAYFJ The management of elevated ICP is crucial in treating various neurological conditions, such as traumatic brain injury, stroke, and certain types of tumors. Increased ICP can lead to severe complications, including cerebral ischemia, herniation, and permanent neurological damage. Therefore, prompt recognition and appropriate management strategies are essential. Initial Management 1. Raise Head of the Bed: This simple maneuver helps facilitate venous drainage from the head, thereby reducing intracranial venous pressure and potentially lowering ICP. It is a non-invasive and easily implemented initial step in managing increased ICP. 2. Manage Pain and Vomiting: Pain and vomiting can exacerbate ICP by increasing intrathoracic pressure and decreasing venous return from the brain. Adequate analgesia and anti-emetic medications should be administered to alleviate these symptoms and prevent further ICP elevation. Hyperosmolar Therapy The administration of hyperosmolar agents is a cornerstone in managing increased ICP. These agents create an osmotic gradient that draws fluid from the brain parenchyma into the vascular system, thereby reducing cerebral edema and ICP.
Other Interventions
ICP Monitoring In ICP monitoring, ventricular-fluid pressures are recorded from a zero baseline; the normal range is 0 to 15 millimeter mercury. Pressures usually are expressed in millimeter mercury rather than millimeter H2O in order to facilitate comparison with mean systemic arterial pressures. The difference between mean ventricular pressure (ICP) and mean arterial pressure (MAP) indicates the pressure at which the brain is being perfused with blood (CPP).
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    Video lecture link: youtu.be/FcYBts1Wc70 Acute Paracetamol Poisoning
The 150 Rule: Toxic dose is 150 mg/kg Give NAC if level is above 150 mcg/mL four hours post-ingestion Initial loading dose of NAC is 150 mg/kg IV (140 mg/kg PO) Background: Paracetamol (acetaminophen) is commonly used for pain relief and fever reduction in children. It's found in many over-the-counter and prescription products. Paracetamol overdose is the most common toxicological emergency. Screening for paracetamol should occur in all overdose cases. Pathophysiology: Excess paracetamol is metabolized via the cytochrome P-450 pathway in the liver. This produces a toxic metabolite called N-acetyl-p-benzoquinone imine (NAPQI). Glutathione stores in the liver are overwhelmed by excess NAPQI in an overdose. NAPQI leads to centrilobular hepatic necrosis. Clinical Presentation - Stages of Toxicity: Stage I (0-24 hours): Mild symptoms or asymptomatic Stage II (24-72 hours): Right upper quadrant pain, liver enzymes begin to rise Stage III (72-96 hours): Clinical hepatitis, hepatic failure, and coagulopathy manifest Stage IV (beyond 5 days): Resolution of toxicity or progression to multiple organ failure Diagnosis: Obtain serum acetaminophen level as soon as possible in suspected overdose. Use Rumack-Matthew nomogram to determine risk of hepatotoxicity. Order additional tests if poisoning is confirmed: PT, AST, ALT. Consider acetaminophen overdose in all patients, even if accidental ingestion seems unlikely. Management: N-Acetylcysteine (NAC) is the primary antidote for acetaminophen overdose. NAC is most effective when administered within 8 hours of ingestion. NAC can be given orally or intravenously. Start NAC treatment even if degree of toxicity is uncertain. Intravenous NAC Protocol: Loading Dose: 150 mg/kg over 1 hour Second Dose: 50 mg/kg over 4 hours Final Dose: 100 mg/kg over 16 hours Oral NAC Protocol: Loading Dose: 140 mg/kg Maintenance Doses: 70 mg/kg every 4 hours for 17 doses over 72 hours Slide 8: Additional Management Activated charcoal can be given in acute overdose if paracetamol is likely still in the GI tract. Patients with fulminant liver failure may require a liver transplant.  Video Lecture: youtu.be/Y8k3OGXY_Mg   Shock and Serum Lactate
Shock is defined as a life-threatening condition characterized by inadequate oxygen delivery to tissues, which leads to cellular and tissue hypoxia. This state can result from various underlying mechanisms, including reduced blood flow, decreased circulating volume, impaired cardiac function, or vascular dysregulation. Shock is commonly classified into four main types: Hypovolemic Shock: Caused by significant loss of blood volume, such as from hemorrhage or severe dehydration. Cardiogenic Shock: Results from the heart's inability to pump effectively, often due to conditions like myocardial infarction or heart failure. Obstructive Shock: Occurs when blood flow is obstructed, for instance, by cardiac tamponade or pulmonary embolism. Distributive Shock: Characterized by severe vasodilation, leading to inadequate blood flow despite normal or increased blood volume. This includes septic shock (due to infection), anaphylactic shock (due to allergic reactions), and neurogenic shock (due to spinal cord injury) Serum lactate: Serum lactate is a useful marker to assess the adequacy of resuscitation by indirectly indicating the degree of tissue perfusion and oxygenation. Shock, by definition, involves inadequate organ perfusion and tissue oxygenation, leading to a reliance on anaerobic metabolism for energy production. A byproduct of this anaerobic metabolism is lactic acid. Therefore, elevated serum lactate levels indicate that the body has switched to anaerobic metabolism to produce energy, which suggests inadequate tissue perfusion. Successful resuscitation aims to restore adequate blood flow, thus decreasing reliance on anaerobic metabolism and consequently, lowering serum lactate levels. Normal lactate levels are less than two millimoles per liter, with hyperlactatemia defined as lactate levels between 2 millimoles per liter and 4 millimoles per liter. Severe levels of lactate are 4 millimoles per liter or higher. A lactate level of 4.0 mmol/L or higher is considered significantly elevated and requires urgent medical evaluation due to increased risks of morbidity and mortality Serial lactate measurements is helpful during resuscitation. Trending lactate values over time helps clinicians understand: The presence and severity of shock. The patient's response to resuscitation efforts. A downward trend in lactate levels suggests improving tissue perfusion and successful resuscitation, while a static or upward trend warrants further investigation and more aggressive management.  Video lecture: youtube.com/shorts/VsSPZiNp9F4 Pitfall: Hip injury presenting as knee pain!
Referred pain is a critical concept in clinical practice, necessitating a thorough examination to identify the underlying cause. Common areas of referred pain include the hip and knee, where hip conditions can manifest as knee discomfort. In pediatric patients, slipped capital femoral epiphysis (SCFE) often presents with knee pain, making it essential to evaluate the hip. In the elderly, hip fractures can lead to medial knee pain, highlighting the need for careful assessment. Clinical Pearl: Always examine the joints above and below the site of maximal pain. For instance, in older patients with medial knee pain, assess the hip through internal and external rotation. While chronic osteoarthritis may limit hip range of motion, a hip fracture should always be considered.    Delayed sequence intubation (DSI)
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