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shotgun knowledge from emergency geniuses

Posted

Has 1 years experience.

It's been about 4 months or so since i transitioned into ED, and there are things we do routinely but i don't know why we do them. so i am just going to ask any random things I have been curious about here for shotgun answers; it would be nice to know the complete details, but whatever you can afford! For example, I asked surgery residents why they prefer LR over NS, and they basically said it's "voodoo bs"/tradition (lol).

1. Lactic acid: I know it's usually drawn in conjunction with bc, and if it means high, there's some infection going, but can you explain little bit more about that?

2. Why does ammonia and lactic acid have to be on ice (was it prolactin too?)

3. What are they checking when they do US free fluid in traumas? Obviously checking for fluids but where and why?

4. Ammonia induced encephalopathy, what's the pathology and how does it resolve with NG tube?

5. How does physician decide to give fluids to someone? Obviously someone who has CHF or on dialysis won't be getting any, but a healthy adult who came in for nvd, tachy, abd pain would most likely get some fluids, but what's the doc's guidance in who gets fluids?

6. How can you assess for appendicitis and gall stones? our ed doc told me to push on the opposite side of painful abd and if pt has pain, that could be a sign, but really, I'm interested in osteopathic manipulation (something DOs get trained in I hear) to lightly assess for couple important things.

That's all the questions I have so far. Let me know if you got any shotgun answers. Thanks!

Sassy5d

Has 11 years experience.

Lactic doesn't always indicate infection. First draw is your baseline. 2nd draw indicates if your interventions are helping.

If you wait to draw lactic, and say it's 4. That info is more helpful if it's higher or lower than your first draw.

No idea why it's iced. Along with ammonia.

tarotale

Has 1 years experience.

What else is lactic for? Also you mentioned if interventions are helping. What interventions do you refer to by that? Thanks!

Not an emergency genius, sorry, but my thinking on your first question is that the physician is checking for sepsis/septic shock. Lactic acid would indicate anaerobic metabolism, where oxygen delivery to the tissues is inadequate.

With regard to your fourth question, I am thinking that the plan may be to administer Lactulose. I think if you do an internet search, i.e. Medscape, for Hepatic Encephalopathy, you may find the information you are looking for.

In regard to your fifth question, my understanding is that the decision to give fluids, and which ones, is based on a variety of factors, i.e, the patient's chief complaint, medical history, physical exam, changes from baseline usual health, labs. In your example, nausea, vomiting, and diarrhea can lead to dehydration and electrolyte imbalances; my understanding is that if the physician determines these conditions are present, IV fluids will be ordered to help correct this.

tarotale

Has 1 years experience.

Not an emergency genius, sorry, but my thinking on your first question is that the physician is checking for sepsis/septic shock. Lactic acid would indicate anaerobic metabolism, where oxygen delivery to the tissues is inadequate.

With regard to your fourth question, I am thinking that the plan may be to administer Lactulose. I think if you do an internet search, i.e. Medscape, for Hepatic Encephalopathy, you may find the information you are looking for.

In regard to your fifth question, my understanding is that the decision to give fluids, and which ones, is based on a variety of factors, i.e, the patient's chief complaint, medical history, physical exam, changes from baseline usual health, labs. In your example, nausea, vomiting, and diarrhea can lead to dehydration and electrolyte imbalances; my understanding is that if the physician determines these conditions are present, IV fluids will be ordered to help correct this.

plenty help! thanks. I read up on the lactulose a little bit. it seems to work by acidifying the gut flora in colon, which converts the ammonia NH3 (can diffuse back to blood) into ammonium NH4+ (not diffuse-able) and traps it in the gut, which as we all know ends up in patient's buttocks lol, thereby decreasing serum ammonia level. It's also osmotic laxative, so pulls the water and creates that diarrhea yuck. I guess this answers my question as well about NG tube. I had a pt who utterly refused po lactulose, so we ended up NG suctioning, I guess that means ammonia are in the gut as well.

i still do ponder about fluid question. maybe i can ask one of the docs. thank you!

Altra, BSN, RN

Specializes in Emergency & Trauma/Adult ICU.

If you are working in an ED that sees trauma patients (and so performs FAST exams) and is on board with current Surviving Sepsis guidelines, you probably have a nurse educator, or at least some annual ed/orientation resources to help you get up to speed on pathophysiology.

Some suggested key word searches:

sepsis - lactate/lactic acid

focused assessment with sonography for trauma

McBurney's point

rebound tenderness

assessment for appendicitis

abdominal assessment

costovertebral angle tenderness

management of cholelithiasis

fluid balance / fluid requirements daily - adults & peds

assessment for dehydration

ammonia-induced encephalopathy management

And your hospital's lab specimen manual will probably indicate why specimens need to be collected/packaged a certain way.

PS - Please, please don't assume that a patient with a history of renal insufficiency/failure or CHF will not get fluid, or advocate that they shouldn't get fluid based on that history alone.

annie.rn

Has 21 years experience.

Lactic acid levels can give the doctor a lot of information if elevated. Lactic acid levels will rise w/ any condition that lowers the level of oxygen in the body. The reason for this is that in the presence of low oxygen, carbohydrates break down for energy into lactic acid. Under normal oxygen conditions, carbohydrates break down into water and carbon dioxide.

Under normal oxygen conditions, you can still get elevated lactic acid levels if the liver is not functioning at full capacity b/c the liver is responsible for breaking down lactic acid.

Things to consider when lactic acid levels are high:

Recent strenuous exercise? (Remember lactic acid is produced by muscle cells.)

Is the pt. overheated?

Is the pt. dehydrated?

Does the pt. have liver dz.?

Is the pt. in heart failure?

Has the pt. lost a lot of blood? (thereby diminishing oxygen carrying capacity.

Is the pt. anemic? (also diminishing O2 carrying capacity)

Is there a P.E.? (decreasing O2 to body)

Are there clots elsewhere in the body? (causing lack of blood flow to the adjacent tissues)

Severe infection?

Alcohol poisoning?

Use of Metformin by pt.s w/ kidney dz.?

Taking INH?

Was the tourniquet left on too long during blood sampling for the lactic acid level or was the person clenching their fist during sampling? Both can cause falsely high levels secondary to muscle breakdown.

1-http://labtestsonline.org/understanding/analytes/lactate/tab/test/

5- Honestly, pretty random There are obvious clinical indications like actual dehdration (the kind that manifests in labs), tachcardia, npo status, etc. And then there are docs just doing something for the sake of doing it. For the most part, if you have a pt tolerating PO, and there is no indication for a bolus, there probaly isn't a good reason. Any order for 125/hr on a pt who is not to be admitted, is silly. Usually.

wyosamRN

Specializes in ED, OR, Oncology. Has 6 years experience.

Was the tourniquet left on too long during blood sampling for the lactic acid level or was the person clenching their fist during sampling? Both can cause falsely high levels secondary to muscle breakdown.

We always draw lactic without a tourniquet, if we cant get the line that way, then we draw everything else and lab will come draw the lactic.

LakeEmerald

Specializes in Emergency/ICU. Has 4 years experience.

Lactic acid may also be elevated after a grand-mal seizure. If the seizure is prolonged, the pH may be low, anion gap high. It usually resolves soon after the seizure (within an hour unless seizures continue). Some of our docs will order it if they suspect a pseudo-seizure, which typically consists of a lot of "convulsions" (and drama) and no postictal period.

Here's a link to an article about seizures and lactic acidosis: MMS: Article

Enjoy your time in the ED. The learning never ends!

Edited by LakeEmerald
link adjust

CoolDork

Specializes in ED, SICU. Has 5 years experience.

Everyone discussed great points for lactic acid indicators and the pathology of it. For US, it is important for a trauma because it provides information on where there is internal organ trauma especially and where it is.

Also, CO=SVxHR ; SV=preload, contactility and afterload. During hypotension, first thing I see is fluid resuscitation which improves preload. CVP is a diagnostic tool to evaluate preload. Secondly, with lactic acid. CHF,Renal failure and/or cerebral edema MDs use fluid resuscitation cautiously. If preload does not improve, afterload or contractility is what they target...pressors are used. Depending on what type of shock, indicates what pressor is used. MDs USUALLY never Rx pressors without filling the intavascular system d/t greater harm you can do with them.

I hope this helps.

bb007rn

Specializes in Emergency room, Neurosurgery ICU. Has 10 years experience.

some lab work needs to be iced to cool it quickly in order to prevent continued metabolism and therefore false levels.

tarotale

Has 1 years experience.

Everyone discussed great points for lactic acid indicators and the pathology of it. For US, it is important for a trauma because it provides information on where there is internal organ trauma especially and where it is.

Also, CO=SVxHR ; SV=preload, contactility and afterload. During hypotension, first thing I see is fluid resuscitation which improves preload. CVP is a diagnostic tool to evaluate preload. Secondly, with lactic acid. CHF,Renal failure and/or cerebral edema MDs use fluid resuscitation cautiously. If preload does not improve, afterload or contractility is what they target...pressors are used. Depending on what type of shock, indicates what pressor is used. MDs USUALLY never Rx pressors without filling the intavascular system d/t greater harm you can do with them.

I hope this helps.

sure did. makes sense why most of times we rarely see pressors but almost all the time, fluids start first.

PedsED-RN

Specializes in Pediatric ED;previous- adult Ortho/Neuro.

US for trauma, looking for free fluid in abd help identify internal organ damage, as either something is bleeding (and how much based on amt of fluid), or perfed bowel leaking bowel contents into the peritoneum, etc. Gives an idea before something more definitive like a CT, but can be done at the bedside while other interventions are underway. I have read some articles on some docs questioning the true value of FAST exams, but it's non-invasive, no radiation, so why not?

I think the other questions were all pretty thoroughly answered so far, good luck =)