Blood Product Components, Contents, Volume and Shelf Life Whole blood (autologous or directed donations) - RBC and plasma. WBC and platelets not viable after 24 hr. Factors V and VIII significantly decreased after 2 days. Hct 35%. 450mL blood and 63 Ml CPDA-1 anticoagulant Red cells (AS-1) Note: these are not “packed” red cells. Packed red cells have a Hct of 70-80% - RBC with about 25 mL of plasma and 100 mL of saline and additive solution (adenine, mannitol). Hct 60% Platelet concentrate - Platelets (5.5 X 1010); some WBC; 50 mL of plasma, a few RBC (Hct < .005) Platelet pheresis - Platelets (3.5 X 1011); some WBC; 300 mL ofplasma, a few RBC Fresh frozen plasma - Plasma proteins, all coagulation factors, complement. Cryoprecipitate - 150 mg of fibrinogen , at least 80 units of factor VIII, von Willebrand factor, factor XIII, fibronectin, ADAMTS-13 - Dr. Tom DeLoughery @Bloodman #BloodProduct #Components #Contents #Volume #Hematology #Management #Table

Approach to Hemorrhagic Shock PLAN FOR CONTROLLING HEMORRHAGE & ACTIVATE MASSIVE TRANSFUSION PROTOCOL • Activate massive transfusion protocol • Determine how hemorrhage can be controlled (surgical, IR, or GI intervention) and call for help from the appropriate team(s) USE THE RIGHT LINES AND EQUIPMENT • Don't wait for central access to begin resuscitation; often PIVs are superior for resuscitation anyway • Use a pressure infuser/heater to give product faster USE BLOOD PRODUCTS IN A BALANCED RATIO • Initially, perform hemostatic resuscitation with blood products in a fixed ratio, e.g. 1 RBC/1 FFP/1 platelet • Goal is to provide an overall balanced resuscitation (but don't wait for a particular product to resuscitate) • Use hemodynamic stability (not hematocrit) as the resuscitation endpoint. • Can use CBC, coags, or TEG/ROTEM to guide additional resuscitation (see OnePager on TEG) Nick Mark MD @nickmmark #Hemorrhagic #Shock #Management #Summary #CriticalCare #MassiveTransfusion

Guide to Acute Kidney Injury (AKI) What to ask/look for: - HPI, PMH, full ROS - Nephrotoxins (NSAlDs, contrast, OTCs, herbals, abx, illicits, chemo, immunosuppression) - Hx of AKI/CKD - Recent hypo/hypertension? - TTE/liver fxn? - BMP, cap, CBC w/ diff - Urinalysis/microscopy/UOP/weights - Urine Na/K/Cl/urea/protein/Cr - Renal/bladder US w/ PVR - CPK, uric acid (rhabdo/TLS) Causes of Inpatient AKI (Liano 1996) - ATN - 45% - Pre-renal disease — 21% - AKI on CKD— 13% (mostly ATN and pre-renal) - Urinary tract obstruction — 10% (most often prostate related) - Glomerulonephritis or vasculitis — 4% - Atheroemboli — 1% #AcuteKidneyInjury #AKI #Nephrology #Diagnosis #Algorithm #Causes #Differential

# Acute Kidney Injury # AKI #algorithm #differential #nephrology

Typical Withdrawal Characteristics of Various Opiates / Time course of opiate withdrawal. - Half-life - Onset of withdrawal symptoms after Exposure - Typical duration of withdrawal #Opiates #Opioid #Withdrawal #Timecourse #timeline #pharmacology #diagnosis

Emergency Treatment Algorithm for Convulsive Status Epilepticus #Seizure #Management #status #epilepticus #algorithm #neurology

Alcohol Withdrawal Timeline Minor withdrawal (6 to 36 hours) - Tremulousness, mild anxiety, headache, diaphoresis, palpitations, gastrointestinal upset; normal mental status • Seizures (6 to 48 hours) - Single or brief flurry of generalized tonic-clonic seizures, short postictal period; status epilepticus • Alcoholic hallucinosis (12 to 48 hours) - Visual, auditory, and/or tactile hallucinations with intact orientation and normal vital signs • Delirium tremens (48 to 96 hours) - Delirium, agitation, tachycardia, hypertension, fever, diaphoresis BWH Medicine Chiefs @BrighamChiefs #Alcohol #Withdrawal #Timeline #etoh #diagnosis

Guide to Interpretation of Positive Blood Cultures I arrange the potential Gram stain results that one can be called w/ as follows: Gram(+) cocci, Gram(+) rods, Gram(–) rods, Gram(–) cocci, yeast. Gram(+) cocci are grouped by ‘morphology’ since the lab usually tells you this: clusters, pairs, chains, etc. Fill in with orgs. The orgs are deliberately ordered this way: Gram(+) orgs are often [skin] contaminants, Gram(–) orgs & yeast are not. Remember that clinician adjudication is the ‘gold standard’ for deciding what is a contaminant! Now, w/ the bugs organized, when you get that call from the micro lab, here are 3 questions to ask yourself/the lab: 1) Number of positive bottles/cultures and time to positivity? 2) ‘Shape’ of the bacteria? 3) Aerobic or anaerobic bottle? Fewer positive cultures & longer time to positivity suggests a contaminant. Apply Q1) to Gram(+) orgs. Time to positivity tough to interpret unless extreme (ex. 8h v 48h). Can use Number of positive cx fact to your advantage – before abx, obtain more cx & increase the denominator! Apply Q2) to Gram(+) rods since their shapes are so distinct. There are some uniquely shaped Gram(–) rods too, but rare (think Fusobacterium). Here’s a comparative chart of GPRs to illustrate. A great reason to go to micro lab and review the Gram stain! Apply Q3) to Gram(+) rods & perhaps Gram(–) rods too. For GPRs, preferential growth in the aerobic v anaerobic bottle helps organize the ‘shape’ chart. Ex: while you await speciation for that aerobic box car shaped GPR, these clues suggest Bacillus, usually a contaminant! For Gram(–) rods, the pearl is that Pseudomonas is a ‘strict’ aerobe and ought to grow preferentially in the aerobic bottle – thus, a GNR that grows in the anaerobic bottle first is less likely Pseudomonas. Of course, always exceptions to these pearls, so await speciation! Dr. Varun Phadke @ https://twitter.com/VarunPhadke2 #BloodCultures #BCx #Positive #Interpretation #Contaminant #Contamination #Interpretation #Laboratory #Microbiology #Diagnosis

Adrenal Insufficiency Algorithm - Cosyntropin Stimulation Test T-1m: Baseline cortisol drawn T0: 250 µg cosyntropin given IV T30m: Repeat cortisol level drawn T60m: Final cortisol level drawn BCM IM Residency @BCM_InternalMed #Adrenal #Insufficiency #Testing #Algorithm #Cosyntropin #Stimulation #endocrinology

Timing & Intensity of Alcohol Withdrawal Symptoms - Delirium Tremens - Seizures - Hallucinosis - Minor Withdrawal "The Shakes" Dr. Melissa Bregger @MelBreggs #Diagnosis #Alcohol #Withdrawal #Timeline #Symptoms #Seizures #DeliriumTremens #DTs #Timing #Syndromes