The Lactate Conspiracy: Part 1
Survive:ED
by Tom
3y ago
What is lactate?  A good medical student will tell you something along the lines of “Lactate is a byproduct of anaerobic respiration that is produced in response to cellular hypoxia secondary to inadequate oxygen delivery.  It is a marker of tissue hypoperfusion and shock” They might go on to say high lactates are correlated with high mortality.  They might colloquially refer to lactate being ‘badness’.  You’d probably look at them moderately stunned, and say they were correct. Oh’s Intensive Care Manual states:  In critically ill patients, lactic acidosis is often due ..read more
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The Lactate Conspiracy: Part 2
Survive:ED
by Tom
3y ago
So in the last post I established: Lactate is a base. Lactate production retards cellular acidosis. Lactate is produced all the time. Lactate is fuel. I have suggested that the traditional lactate hypothesis “Lactate is a byproduct of anaerobic respiration that is produced in response to cellular hypoxia secondary to inadequate oxygen delivery.  It is a marker of tissue hypoperfusion and shock”  Is not correct. However we all see, and all know that when people are sick their lactates go up, and when their lactates go up they become acidotic. Why is this? There are two reasons. The ..read more
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Delirium: the forgotten medical emergency.
Survive:ED
by Tom
3y ago
We have all seen a little old lady crumpled onto a hospital trolley. Referred in eye-rollingly from their family who visited the nursing home and meekly say ‘she is more confused than normal’.  Talking to her you think she’s good value, she thinks she’s on a cruise ship, that you’re a terribly nice young man and that you’d make an excellent match for her daughter. You smile, send off a random panel of blood tests and refer her to care of the elderly. Instruct an exasperated nurse to collect a urine sample (how?!?), maybe you catheterise and cannulate her. No one screams and shouts at you ..read more
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Should we care if Mavis has crackles?
Survive:ED
by Tom
3y ago
Presentations to the ED with acute dyspnoea are a bit of challenge.  History, examination and tests are used to decide if people have heart failure, pneumonia, COPD, or something else.  I think diagnosing heart failure in the ED is a particular challenge, as commonly used ED strategies aren’t particularly good tests for LVF. In a pretty robust study of patients with no cardiovascular disease, normal hearts on ECHO, and normal BNP measurements in 2007 the incidence of bibasal creps in the 80-95 age group was 70%. (CI 58-92% p<0.001).  Incidence increases with age with 11 ..read more
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Crispy…
Survive:ED
by Tom
3y ago
There’s a lady in Resus, she’s 46, she’s got a history of mental health problems.  Her husband tells you she’s been gradually more lethargic over the last few days.  He called the ambulance today because he found her on the sofa in the morning mumbling incoherently.  Her observations are okay.  Her ABC’s are okay, she’s got a normal glucose, but when you go to move her arm to cannulate you notice she’s rigid.  Hypertonic all over.  You do what you can of a neuro exam and find she’s got globally increased reflexes.  Her pupils are fine.  VBG is okay acid ..read more
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Sodium
Survive:ED
by Tom
3y ago
An old man is wheeled into resus.  His GCS hovers around 10.  No carers have come with him, you find out from the paramedics that the care home staff were alerted to a thump as he fell out of bed.  He’s moving all 4 limbs.  His obs are okay.  His CT head is normal.  His VBG shows a Na of 119, but is otherwise okay. This, for me, is a frighteningly common scenario.  It’s also generally managed badly and in variable ways.  Do you give normal saline?  How fast?  What are the risks?  Aren’t you meant to fluid restrict?  What about urine t ..read more
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The Lactate Conspiracy: Part 1
Survive:ED
by Tom
3y ago
What is lactate?  A good medical student will tell you something along the lines of “Lactate is a byproduct of anaerobic respiration that is produced in response to cellular hypoxia secondary to inadequate oxygen delivery.  It is a marker of tissue hypoperfusion and shock” They might go on to say high lactates are correlated with high mortality.  They might colloquially refer to lactate being ‘badness’.  You’d probably look at them moderately stunned, and say they were correct. Oh’s Intensive Care Manual states:  In critically ill patients, lactic acidosis is often due ..read more
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Catheter changes
Survive:ED
by Tom
3y ago
So an elderly gentleman comes into the department.  He lives in a care home, he has a catheter, and he’s got a mild pyrexia, slightly more muddled than normal and some suprapubic tenderness.  After a full assessment you decide he has a Catheter Associated UTI (CA-UTI). Your hospital policy suggests treating based on a previous culture growths and discussion with a microbiologist.  After a short discussion you get a code and prescribe an appropriate antibiotic. You are just preparing to change the catheter when a senior colleague suggests you should also ‘give a shot of ..read more
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The Lactate Conspiracy: Part 2
Survive:ED
by Tom
3y ago
So in the last post I established: Lactate is a base. Lactate production retards cellular acidosis. Lactate is produced all the time. Lactate is fuel. I have suggested that the traditional lactate hypothesis “Lactate is a byproduct of anaerobic respiration that is produced in response to cellular hypoxia secondary to inadequate oxygen delivery.  It is a marker of tissue hypoperfusion and shock”  Is not correct. However we all see, and all know that when people are sick their lactates go up, and when their lactates go up they become acidotic. Why is this? There are two reasons. The ..read more
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Missing things: Addisons
Survive:ED
by Tom
3y ago
Recently missed an Addisonian crisis.  Here’s a brief summary of the case. 61 y o female attended the ED after seeing her GP with vaginal bleeding.  GP sent the patient to the ED for an inappropriate official reason (vaginal bleeding in a post menopausal lady unless torrential should be managed as a two week wait), but the lady looked unwell, and I think that was why the GP fabricated a reason. This lady had a PMH of psychotic illness, rectal prolapse, and that was pretty much it.  She was seen with a family member who looked after her.  The history was vague.  She wou ..read more
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