commit fb8276f2e98006eaa11f4df66bfb0e479054fbb7
parent f3aba1bcf2dfc8462f460e5e50e24aa94cc74da7
Author: Beau <cbeauhilton@gmail.com>
Date: Fri, 1 Oct 2021 08:33:54 -0500
morning MICU
Diffstat:
2 files changed, 96 insertions(+), 0 deletions(-)
diff --git a/medicine/2021-09-16-kennedy-breast-cancer-clinic.md b/medicine/2021-09-16-kennedy-breast-cancer-clinic.md
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+# Laura Kennedy, MD PhD
+
+## 2021-09-16 clinic
+
+### 01
+
+- +FHx breast cancer
+- TLH-BSO 2014
+- colo 2018 w TA, next 2021
+- Cr <1
+- LFTs wnl
+- Ca 9.8
+- Hgb 15.3
+- WBC 6.4
+- Plt 295
+
+- mammo b/l w tomo:
+ - prior 2018, wnl?
+ - density category C: heterogenous
+ - R breast 9 o'clock 7.8cm from nipple, +developing asymmetry
+ - BI-RADS 0 (incomplete)
+
+- US b/l
+ - scattered fibrocystic changes
+ - L axillary lymphadenopathy, ?d/t COVID-19 vax
+ - BI-RADS 3 (probably benign, <2%)
+ - Note: This score of 3 was assigned because the patient had just had her COVID-19 vaccine, and axillary lymphadenopathy is a normal finding in this setting. It would have been BI-RADS 4 otherwise. From an urgency standpoint, the gap between 3 and 4
+
+- LNBx: L axilla
+ - +ER, +PR, E-cadherin mostly -ve (<5%)
+ - pathologist favors mILC
+
+- MRI breast wwo
+ - L scattered enhancement, no definitive masses
+ - L axillary adenopathy -> subpectoral deep nodes and superior mediastinum
+ - BI-RADS 6 (biopsy-proven cancer)
diff --git a/medicine/2021-10-01-micu-morning.md b/medicine/2021-10-01-micu-morning.md
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+# Pre-intubation
+
+Presented with O2 sat 81% to the ED, what's next?
+
+## NC
+
+Max flow through standard NC ~6L/min.
+
+~3-4% increase in FiO2 per L, so 2L/min ~= 30% FiO2.
+
+Minute ventilation ~5L/min if assume 10 breaths per minute,
+~500mL tidal volume,
+but:
+- those are averaged over one minute
+- moment inspiration will exceed that flow rate,
+- the seal isn't perfect,
+
+we're typically putting O2 on dyspneic people,
+so those assumptions typically do not hold.
+
+## Large-bore NC
+
+Bigger tube, up to ~15L/min. Otherwise same as NC.
+
+## Venturi mask
+
+Size of holes determines rough amount of entrainment.
+
+## NRB
+
+One-way exhale valves, bag w 100% O2.
+Still getting some entrainment, but overall higher O2 delivered.
+
+## HFNC
+
+Optiflow, Airvo, etc.
+
+Up to 60L, 100% FiO2.
+Humidified air,
+more complete seal on nose piece.
+Less complications from dry air (massive epistaxis),
+less entrainment (though depends on if their mouth is closed).
+Also provides up to ~5L PEEP.
+
+Blends 100% O2 and medical air to achieve the set FiO2.
+
+[FLORALI trial](https://www.nejm.org/doi/full/10.1056/nejmoa1503326)
+ - intubation rate between HFNC and NIPPV was not different (primary outcome)
+ - ventilator free-days were different (higher in HFNC)
+ - 90d mortality rate better for HFNC than NIPPV
+
+# NIPPV
+
+Pressure increase (mean airway pressure),
+more O2 exchange d/t greater partial pressures of delivered O2
+over more time.
+
+# Invasive ventilation
+
+Next week...
