Journal Club Articles, Posted 8/18/2014

  • Anaesthesia. 2014 Aug 2. doi: 10.1111/anae.12804. [Epub ahead of print]
    A prospective randomised controlled trial comparing tracheal intubation plus manual in-line stabilisation of the cervical spine using the Macintosh laryngoscope vs the McGrath® Series 5 videolaryngoscope.

    Ilyas S, Symons J, Bradley WP, Segal R, Taylor H, Lee K, Balkin M, Bain C, Ng I.

    [PubMed]
    [Full Text PDF]

  • Ann Surg. 2013 Oct 10. [Epub ahead of print]
    Enteral Contrast in the Computed Tomography Diagnosis of Appendicitis: Comparative Effectiveness in a Prospective Surgical Cohort.

    Drake FT, Alfonso R, Bhargava P, Cuevas C, Dighe MK, Florence MG, Johnson MG, Jurkovich GJ, Steele SR, Symons RG, Thirlby RC, Flum DR; The Writing Group for SCOAP-CERTAIN.

    [PubMed]
    [Full Text PDF]

Tony’s Take Home Memo 8/13

(Notes from Wednesday Lectures, 8/13/2014)

10a Syncope (GJ)

  • “people who wake up & now feel normal”
  • HOCM, longQTc, Brugada, WPW(preexcitation), AVnRT/SVT
  • Life threats in stable asymptomatic pt c transient LoC…
  • QTC >500 concerning: Hypomagnesemia, Hypocalcemia, Hypokalemia, Hypothermia, Congenital, Drugs…
  • Brugada Syndrome is Na Channel Abnormality… unmasked by CCB or NaChBlk…
  • (ST elevation c T wave inversion, nonspecific otherwise?)
  • “S in V1 plus R in V5” total >35? HOCM also may have septal Q waves & nonspecific Twave changes…

1030a Electrolytes (Prasad) Hyper/HypoKalemia

  • Case 1: Dialysis Dependent pt… weak, nausea, malaise, mild BPelevation… crackles on exam… anticipate hyperkalemia! EKG progression from Twave peaking to QRS widening to sine wave/VTach… odd variants include “dumping” & “z wave” patterns.

    Treat c: Calcium gluconate (except c Digoxin tox!), insulin & glucose (K down 0.4 to 0.6), careful c IVF load in dialysis pts!, consider bibcarb & albuterol… lasix or dialysis to remove K.

    Bicarb is still class 1A in hyperkalemic cardiac arrest.

  • Case 2: 20yo college student syncope, hx bulemia… HypoK (<3), flattened Twave & Uwave present, sinus bradycardia (also found in hypoCalcemia)
  • Case 3: ST depression & Twave inversion mimicking ischemia in 30F with negative troponin.

11a Small Groups (Lavoie, Prasad)

  • hyperkalemia (dialysis pts c peaked T…)
  • hypokalemia (bradycardic, longQTc, Uwave, flattened overall)
  • hypercalcemia (short QTc, also found in digoxin toxicity)
  • LVH (axis change & 35mm sV1 plus rV5) plus Twave peaking & nonspecific ST changes common in dialysis dependence.
  • torsades de pointes requires Magnesium (>2g) plus ACLS (prn)… Prasad says usually takes ~6g before conversion.
  • STEMI v nonspecific ST changes: distribution & shape of ST segments (III > II STE or convex up/horizontal shape is MI until proven otherwise!)
  • Pericarditis: diffuse changes, concave up ST (no reciprocal change/ST depression), PR depression common c reciprocal PR elevation, downsloping of the TP segment & PR segment (Spodick sign), can be associated c myocarditis (beware resting teachycardia after treatment, IVF, etc.) & troponin elevation, most often viral illness.

12p Holy Cow Cases (Joslin)

  • (Maley) SCIWORA EtOH pt… beware for revised radiology read!
  • (Ku) RPA with Leukemia! (Eikanella, Strep)

1230p JrSr Sessions (Paolo, Lavoie)

  • EKG Lab!
  • PAILS (Posterior > Anterior > Inferior > Lateral > Septal)
  • Idioventricular Rhythm (reperfusion) is good after thrombolytics
  • RBBB look at slurred Swave in I & V6
  • PE S1 Q3 T3 (also could be L posterior fascicle block)
  • VTach~ish… go to ACLS pathway!
  • PseudoRBBB with downsloping STE! ~ Brugada Syndrome (rare but happens…)
  • Careful c Calcium in dialysis pts? CaCl faster but sclerosing.
  • MAT v PAT (different pwave morphologies)
  • Osborne Waves in hypothermia
  • Sooo many QTc prolonging drugs! Torsades get Magnesium.
    (fluoroquinolones, azith, zofran, reglan, TCAs, antipsychotics, methadone…)
  • LGL short PR preexcitation syndrome
  • Wellan’s Sign associated c ischemia! c CP, goes to cath lab… (biphasic Twave, commonly V2, V3 in multiple vessel disease.)
  • Posterior MI! Tall R wave in V1 with ST depressions in V1, V2… (most common miss!)
  • aVR STEMI!
  • Sgarbossa Criteria for LBBB
  • Spodick sign in Pericarditis c PR depression (aVR PR elevation) & diffuse ST elevations s reciprocal changes.
  • Takotsubo “Octopus Pot” stress induced cardiomyopathy
  • Symmetric Twave inversions can be caused by SAH! (but call ischemia until shown otherwise)

130p STEMI (Joslin)

  • full thickness, sudden occlusion, troponin positive, needs cath, bad hemodynamics…
  • ST elevations, Qwaves…
  • PAILS mnemonic to look for reciprocal changes
  • Progression: hyperactute T (asymmetric), ST elevation, Qwave, ST elevation c Twave inversion…
  • Posterior STEMI needs only 0.5mm depression?!
  • check aVL for Lateral STEMI
  • Know R sided v Posterior EKG…
  • “Old MI”? “Age Indeterminate”? Read it yourself.
  • Acute LAD occlusion ~deWinter morphology, v. Chronic LAD occlusion ~Wellens morphology
  • Pt c shocked resuscitation should go to cath lab.
  • Paced EKG should be compared to prior, & ?consider Sgarbossa criteria.

2p NSTEMI & Ischemia (ERod)

  • Ischemia is dt interruption of optimal blood flow.
  • STEMI has EKG evidence of infarction & biomarker elevation.
  • NSTEMI missing EKG evidence but may have biomarker elevation or Echo evidence.
  • Unstable Angina is without biomarker elevation.
  • Treat ACS c ASA, O2, NTG(prn)
  • NSTEMI can become STEMI!… recheck for progression! ACS is dynamic process.
  • Compare against old EKGs.
  • EKG 1small box amplitude is 0.1mV;  1 small box across is 0.04s (large box is 0.2s)
  • New ST depression threshold is >0.05mV!!!  V2,V3 can be slightly >0.1mV (0.15, 0.2, 0.25 depending on age & gender by 2012 AHA guidelines) & potentially wnl!
  • Most STE cutoffs are 0.1mV though.
  • Twave inversions not always ischemia… can happen in LVH or SAH.
  • Hyperactute Twaves in ischemia have slightly different morphology than hyperkalemia (less symmetric).
  • Be careful c aVL elevations because low amplitude dt isoelectric vector may hide changes.
  • Deep symmetric Twave inversions in anterior leads ~ Wellens, indicates chronic multivessel CAD… Cath only if active Sx.
  • aVR should always be checked, may have apparently isolated mild elevations…
  • New Tall Twave in V1 is marker of ischemia! (“NTTV1” ~Mattu)
  • Inverted Uwaves predictive of L occlusion(s)? (>75%?)
  • Remember ACS is dynamic continuum. Know Wellens.  Careful c aVR &aVL

230p EKG Review (Deepali)

  • HyperK, HypoK…
  • Hypercalcemia potentially short QT (& can also cause Osborn wave, like hypothermia)
  • PE has anterior lead Twave inversion in 85%! (rare pathognomonic S1Q3T3)
  • Consider Thyroid causes of arrhythmia
  • Myxedema Triad ~ Bradycardia, low QRS voltage, Twave flattening & inversion

3p Pediatric Syncope (Thabet)

  • Syncope is loss of consciousness & postural tone with rapid return to baseline.
  • Very common in kids.  Always get EKG, though most is noncardiac.
  • QTc, WPW, Brugada, HOCM…
  • Most common cause of syncope vasovagal or idiopathic.
  • Primary differential vs Seizures! (tongue biting, postictal period, headache, incontinence?)
  • FamHx heart Dsx? Murmur? Orthostatics? (change >20 in HR or SBP?)  Drugs/Meds?
  • Consider Tox!
  • Case 1: QTc prolongation & syncope dt Zofran, Risperdal, Azith… orthostatic? vasovagal? HCG? GLUCOSE? Check for hypertrophic murmur (louder when standing, lower c valsalva).
  • Case 2: Actual longQTc case… check Ca, Mg, TSH… other Tox screen? give Mag…
  • Plus WPW?! ~ given Digoxin dt relative contraindication for Adenosine (in Asthmatic) c syncope & SVT episode during transfer for Appendicitis?!

How to Read a Systematic Review and Meta-analysis and Apply the Results to Patient Care

JAMA. 2014;312(2):171-179. doi:10.1001/jama.2014.5559.

http://jama.jamanetwork.com/article.aspx?articleid=1886196
[Full text PDF]
[PubMed]

Abstract:

“Clinical decisions should be based on the totality of the best evidence and not the results of individual studies. When clinicians apply the results of a systematic review or meta-analysis to patient care, they should start by evaluating the credibility of the methods of the systematic review, ie, the extent to which these methods have likely protected against misleading results. Credibility depends on whether the review addressed a sensible clinical question; included an exhaustive literature search; demonstrated reproducibility of the selection and assessment of studies; and presented results in a useful manner. For reviews that are sufficiently credible, clinicians must decide on the degree of confidence in the estimates that the evidence warrants (quality of evidence). Confidence depends on the risk of bias in the body of evidence; the precision and consistency of the results; whether the results directly apply to the patient of interest; and the likelihood of reporting bias. Shared decision making requires understanding of the estimates of magnitude of beneficial and harmful effects, and confidence in those estimates.”

Conclusions:

“Clinical and policy decisions should be based on the totality of the best evidence and not the results of individual studies. Systematic summaries of the best available evidence are required for optimal clinical decision making. Applying the results of a systematic review and meta-analysis includes a first step in which we judge the credibility of the methods of the systematic review and a second step in which we decide how much confidence we have in the estimates of effect.”

David adds: Please note Box 1. Learn to frame a clinical question using PICO and you’ll get the best possible results while being every medical librarian’s favorite patron.

Pearls From Wednesday Lecture (7/30/2014)

Tony’s Take-Home Memo, Wed Conference 7/30/14, Altered Mental Status

10a – Thyroid Disease (Kruse)
Follicular (T3,T4) & Parafollicular Cells (Calcitonin)… TSH, T3, freeT4 recommended for screening. Thyrotoxicosis ~80% Graves, then toxic multinodular goiter & thyroiditis (subacute, hashimoto, postpartum). Temperature sensation alterations, tachy, wt loss… avoid Iodinated contrast dt Iodine effects on thyroid conditions. Propylthiouracil(PTU) & Methimazole for thyrotoxicosis. Propranolol for Sx Trx. 2 main emergencies: thyroid storm (hyper) & myxedema coma (hypo). Thyroid Storm give: PTU, Lugol’s solution (inorganic Io) or Lithium, steroids, Propranolol, supportive care & search for cause, Adm ICU… Hypothyroid most common dt Hashimotos sp Tx, then treat c Synthroid/Levothyroxine, start 50 to 75 mcg/day. Myxedema hyponatremia can cause Sz! Hypoglycemia & hypothermia also dangerous (passive > active rewarming prn)… check cortisol Lv (steroids prn)… IV synthroid & basic supportive care. Mortality 15 to 30% for myxedema coma! Thyroid nodules can cause mechanical occlusion. Thyroid conditions can mimic multiple other conditions, & often comorbid.

1030a – Bites & Envenomations (Jennings)
especially aquatic animals, hyperbarics context… Surf & Turf (snakes & spiders, then: jellyfish, sea snakes, sting rays, octopus, scorpion fish…) Venom is injected toxin by animal.

Locally, timber rattlesnake (more local) & northern copperhead (NYC area of NYS & south…)

CroFab antitoxin binds venom, but many bites are dry. Most antivenom is horse or sheep serum. Anaphylaxis risk.

Most venomous snakes all Australian.

Brown recluse (violin pattern, woodpiles & dark basements, delayed bite pain, hemolytic toxin causes ischemic necrosis, debridement, tetanus; Dapsone…doesn’t work) centered around Alabama, very far South…

Black Widow is here (N, W, S variants). Hourglass pattern on back in females, much more aggressive! Painful, rigid abdomen mimics Appy, common rxn. Tx c tetanus, CaGluconate? There is antivenom for severe cases. No local antivenom availability. Often, no distinctive bite marks dt small size.

Jellyfish, ManOWar, Anemones, Corals (Cnidarians) have stinging barbs (nematocysts from cnidocytes). Toxins have mixed effects, catecholamines & multiple toxicity, sometimes continuous release after sting! (Vinegar ~acid may help c some?). Remove source! Analgesics & Antihistamines…

True jellyfish (Scyphozoans) rarely lethal, but can cause recurrent dermatitis.

Blue Bottle/Portuguese ManOWar is a colony of smaller organisms that look like a Jellyfish bubble, potentially very deadly! StringofPearls rash.

Box Jellyfish is MOST POISONOUS venom known. Usually in shallow waters (mostly Asian Pacific, but also California occasionally). Sheepbased antivenom… Vinegar ok, may help.

Stingrays physically dangerous, but also toxic…
Sea snakes have paddle shaped tail & normally NOT aggressive, but ALL venomous, small mouths normally can’t penetrate wetsuit. Cholinomimetic toxin c ascending paralysis & myoglobinuria.

Scorpion Fish ~ Stone Fish on bottom, stepped on 13 spines (most toxic scorpionfish), Lion Fish

Octopus ~ Blue Ringed Octopus Dangerous! Tetrodotoxin deadly. “Never give an Octopus a ride”.

11a – Small Groups (ERod, Sarsfield)
*Sim Case1: AMS… Septic in Pregnancy c Diarrhea, febrile, tachy, HTN, 29F… hallucinating… Pheochromocytoma? Sympathomimetic Toxidrome? Cocaine? Thyroid Storm: TSH abnormality, Fever & AMS! (Mortality up to 30% if untreated). Formal scoring system in Tintinalli, somewhat coomplicated & sensitive, but not superspecific… Beta blockers give, c consideration of hydralazine for alpha block, PTU given to prevent T3 conversion… SSKI (super saturated Potassium Iodide), steroids also block conversion of T4 to T3. APAP good antipyretic, but no ASA (may exacerbate hyperthyroid?). Fever & AMS, consider LP & urgent Abx! Vanc, Ceftri, Acyclovir… Pregnancy as trigger? HCG in molar pregnancy can trigger TSH release; additional stressors can trigger hormone release… Off/stopped Methimazole in pregnancy…

*Case2 (Haldipur, 1130a): 56M confusion & weak 2 days, L face & extrem twitching (synchronous), EMS arrival… lethargic, arousable to pain stimulus, suspected Sz… Glucose high, other VSS except HR 110… Sepsis? DKA? Sz? Syncope workup… CThead (wnl), IVF bolus, Labs, EKG, VBG lactate (.03 to .04 pH difference from ABG?)… Pt has glucose 1100, but no Anion gap, HHS (no longer HHNK dt small ketosis likely). Na corrected from 137, plus (1100 minus 100 eq 1000, div by 100 is 10)x1.5, plus15, gives corrected Na of 142. Check Ammonia? TSH? “MI until proven otherwise”…

12:30p – J/Sr Sessions, Head CT Reading (Paolo)
*Schwartz’s Radiology Textbook, recommended. Online?

*Artifacts & Anatomy: beam hardening artifact adjacent to dense bone; streak artifact from fillings, density scatter or motion; partial volume (averaging) artifact dt avg volume of structures causing intermediate signals (less with subdural window view). Anatomy orientation of slice is ANGLED lower in posterior, higher anterior. Temporal horns of lateral ventricles important; Cisterns (interpeducular[between cerebellar peduncles], quadrigeminal[smiley face], & supracellar[pentagonal, circle of Willis]) also important. “Dense MCA sign” [obvious CVA] in hyperacute stroke, as well as loss of gray & white matter differentiation [“effacement of sulci”]…

*SAH: 4th ventricle open in SAH, communicating hydrocephalus (Juan Valdez mustache, not good <http://www.juanvaldez.com/splash.jpg&gt;), found with dilation of temporal horns. Look at interhemispheric fissure to confirm blood away from hardening artifacts anterior & posterior. Pineal gland looks calcified, wnl, not blood…

*VThromb: young females who smoke on BCP with coagulopathy…& Clinton… Look for hyperattenuation, but can be wnl in up to 60% of ppl! …but with clinical suspicion, follow c CTv or MRv… Not usually b/L, usually unilateral. “Empty Delta sign” is clot in sinus confluence.

*Hydrocephalus & LP: know the ventricles… most hydrocephalus not suble, but know communicating v noncommunicating… & old ppl hydrocephalus “ex vacuo” ~ brain loss. 4th ventricle loss in NC~hydrocephalus! …means compression somewhere (could be in 3rd ventricle). Meningitis & SAH most common causes for communicating hydroccephalus, failure of reabsorption. *Focal Neuro exam, papilledema, Sz, & immune compromise are reasons to confirm CThead prior to LP. No LP if midline shift, obstructive hydrocephalus, compressed cisterns or compressed 4th ventricle.
1) Symmetry/Midline Shift?
2) SAH?
3) Ventricles Enlarged? Small or wnl ventricles? (communicating?)
4) Brain Parenchymal Lesions…

1:30p – Meningitis/Encephalitis (Johnson)
CSF studies: Culture, Gram Stain, Cell Count (1&3, 1&4, 2&4), Protein, Glucose

…Viral PCR, HSV, Antigen tests

Abx: Gent/Cefotax/Ceftri (GramNEG), Vanco (GramPOS), Acyclovir (HSV)

*Amp (Listeria) for Neonates & Elderly…

IV, O2, Monitor, H&P, Abx&Cxs with Steroids!!! …better CSF penetration & outcomes, VBGlactate, Labs… CT?&LP… CT first if Focal Neuro deficits, Papilledema, Seizures, or Immune Compromise. Then LP! If NEG, aseptic meningitis still require hospitalization!

*Meningitis Risks: Immunosuppression, Uncooked food, College & EtOH…, DM2, ENT/nasal dsx

*Encephalitis can be very complex. Recognize HSV (treatable), but EEE, WNV, enterovirus, other arboviruses supportive care. Ceftriaxone 2g (>1g) normal dose. Acyclovir 10mg/kg. Amphotericin for Fungal?! DON’T FORGET AMPICILLIN & DEXAMETHASONE!!!

*Consider Fungus & Tuberculosis!

*Cryptococcal Ag >> India Ink stain for Cryptococcus in Immune compromised pt.

>5WBCs in tap (no more than 1WBC:1000RBC) is bad.

ICU brain support, glucose & fever monitoring.

PPx for meningococcemia: Rifampin &…

10 to 20% of bacterial meningitis may have Leukocytic predominance!

Encephalitis needs Acyclovir, Steroids, IgG?

2:00p – Adrenal Dsx (Siegler)
Epinephrine (Adrenal) Gland Disorders

Cortex 3 zones: Salt(Aldosterone), Sugars(CCS), & Sex(DHEA) from ACTH(Ant.Pit)…
& Medulla(Epi, NorEpi)

HPA Axis c stress response… Primary(Adrenal), Secondary(Ant.Pit, ACTH), Tertiary(Hypothal)

*Primary: severe electrolyte abnormalities…high K, low Na…

*Secondary: dt exogenous CCS, drugs, Sheehans syndrome (pituitary infarct)…

*Tertiary: exogenous CCS, brain tumors… similar to 2* Adrenal failure… hypotension, shock, may be refractory to pressors.

*Pheochromocytoma: Rule of 10s: 10% bilateral, 10% Malignant, 10% extraadrenal, 10% familial. Weight Loss, fever, arrhythmia & tachycardia, seizure, tremors, NET syndromes… Dx c plasma metanephrin testing or 24hr urine collection(cortisol). AbdCT, MRI both good for localization… Treat c alpha/beta blockers, CCB, angiotensinRBs, Magnesium? (preoperatively). For incidentalomas, followup c PCP is usually adequate, for repeat CT in [time]…

2:30p – Exposures (Joslin) “Heat & Photography”
Alaska chasing grizzly bears last week 🙂 Approach bears slowly & predictably…Wilderness Med.

*Case: No air connditioner, obese 24yoF at 42*C, AMS, heat stroke, done?

Delirium, disoriented, confused, decreased mentation…

HR not predictive in BetaBlocked pts. (May be tachy otherwise?)

BP LOW! (vasodilation peripherally in skin, flushed).

Temp:HeatStroke::BP:HTN Emergency… #, itself does not define automatic pathology.

Labs: BMP, CK [likely wnl], EKG, UA, CBC/infxn?, Coags, LFTs, Troponin, CXR, Lactate/VBG…

Abx not unreasonable dt gut bacterial translocation…

Ice Bath in Body Bag, Cool/Cold water immersion… Arctic Sun, Shower, Mist & Fan [easiest]…

*Case2: <http://www.mountaingoatrun.com/&gt; Mountain Goat Race May3rd: Awake & speaking pig latin only[AMS], HR 121, oral 39*C, glucose & Na wnl. No med hx, still sweating. …still heat stroke! (mental status change in context of heat stress). “Brain boils first.” Heat stroke needs admission. Discharge instructions must include special precautionary instructions.

Heat stroke DOES NOT MEAN pt is necessarily dehydrated.

Correct pt down ~0.1*C per minute, goal.

*Heat cramps/syncope/exhausion “fake terms” (v exercise associated collapse, heat intolerance…)

3p – Pediatric AMS (KNacca)
12moM P2, AMS… slow to wake… “lethargic” is BAD ~ think “unresponsive”.

Neuro, Tox, Intuss(GI), Infxn, …

*Modified GCS in children… APVU?

ABC Dextrose! & FULLY EXPOSE KIDS! (bruises, patches, rashes…)

Moro reflex up to 9mo… infant sucking reflex…

Peds milestones, know: 2mo support head, 4mo flips over, 7mo sits, 1yr walk & one word, 18mo stiff running…

GLUCOSE, GLUCOSE, GLUCOSE. Neonates need >40.

Rule of 50s: [glucose bolus]
*5cc/kg of D10 is 50…[neonate]
*2cc/kg of D25 is 50…[infant]
*1cc/kg of D50 is 50…[can use in child/adolescent]

Ask how formula is prepared. Pure water is not for infants. HypoNatremia can be Sz problem!

TOX! <http://www.upstate.edu/poison/&gt; Call PCC 1 800 222 1222.

UDS can be used in undifferentiated peds OD. Comprehensive screens need drug specific tests as sendouts. Flumazenil may be used in naiive Benzo ODs, such as Peds Tox!

Suspect Abuse! Low threshold for LP! Consider Intussusception!

Random Tumors & Intracranial bleeds do happen too… consider CT if necessary.