Journal Club Articles

http://www.nejm.org/doi/full/10.1056/NEJMoa1411587
A Randomized Trial of Intraarterial Treatment for Acute Ischemic Stroke
Olvert A. Berkhemer, M.D. et al
N Engl J Med 2015; 372:11-20January 1, 2015DOI: 10.1056/NEJMoa1411587

http://www.nejm.org/doi/full/10.1056/NEJMoa1404380
Goal-Directed Resuscitation for Patients with Early Septic Shock
The ARISE Investigators and the ANZICS Clinical Trials Group
N Engl J Med 2014; 371:1496-1506October 16, 2014DOI: 10.1056/NEJMoa1404380

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Wednesday Lectures, 2/18/2015

TTHM 9.2 (2/18) Diabetes Day (Tint. 137, 139, 218-220, 222)

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10a ~ Behavioral Issues in Peds (Hanley)
Mental Health disorders on the rise, one of the top few thousand “Top 5” causes of morbidity & mortality… our role in the ED is to involve the multidisciplinary team, including psychiatry, social work.  Document more details of SocHx where appropriate! FamHx of Psych illness…
“HEADS FIRST”… Home, Education, Abuse, Drugs, Safety, Friends, Image, Recreation, Sexuality, Threats…
SI: 4Q: (NIMH Horowitz, 2013)
*past few weeks, felt you or family better off if you are dead?
*past few weeks, wished you were dead?
*past week thoughts about killing self?
*ever tried to kill self?
Chemical or Physical Restraint?
Be sensitive for Autism, Abuse
Child Life available 11a~11p
Breath~Holding spells! (hx! hx! hx!) further workup rarely needed if exam wnl on presentation.
Precipitating emotional events, without prolonged post~ictal type period.

1030 ~ Oral Hypoglycemics (Maraffa)
15yM Glyburide OD… got D50, more D50 & Octreotide (Somatostatin blocks Ca influx to decrease insulin release, which relates directly to sulfonylurea mechanism)
*Consider Octreotide when giving 2nd bolus D50! esp when unknown OD…
Prandin & Starlix ~ “sulfonylurea~like drugs”, consider also.
Octreotide may only need a dose or two, no gtt needed.
C~peptide & insulin levels both elevated means increased insulin release (i.e. not Lantus or exogenous insulin OD)
***Chlorpropramide, Diabinase, Glimepiride Amaryl, Glipizide Glucotrol, Glyburide Micronase/Diabeta… names to know… SULFONYLUREAS & GLITINIDES ~ “one pill kills” in Peds.
Chlorpropramide can urinary alkalinize out c Bicarb.
*Metformin OD CAN cause severe Lactic Acidosis, but usually not hypoglycemia.
Not always occurring, but “MALA” is bad when it happens!
MALA only ~4% in acute OD, but very common in chronic OD!  Mitochondrial toxicity?
Acute role for Dialysis? …Probably.  Poor prognosis with acute Lactate >10.  Repeat BMP & Lactate over 6hrs important for prognosis.
***OTHERS: TZDs (glitizones), alphaGlucosidase inhibitors (Acarbose & Miglitol), Gliptins (Januvia, Onglyza, Tradjenta)DPP4 Ag~?pancreatitis, Canagliflozins (Invokana, Farxiga) ~UTIs? NEW DRUG, NO OD CASE REPORTS!
*Glucagon doesn’t seem to work all that well & very ex$pen$ive!

11a ~ Small Groups (Prasad & K.Nacs)
Whipple’s Triad c Insulinoma…
*Emergency Peds Abd Pain: Intussusception(most common Peds obstruction, intermittent somnolence, Air enema gold for Dx/Tx), Appy, Volvulus/Malro (1mo to 1yr c bilious emesis ~GI contrast upper GI series as Gold standard, “Ladd’s Bands”), Pyloric Stenosis
Hawaii Radiology Website good for Peds.  Pancreatitis can happen in kids! Ov Torsion can happen before puberty if focal exam!

1230 ~ Jr/Sr (Laporte & Lavoie)
Organophosphate Poisoning ~ used in Nazi & Russian warfare (TABUN, SARIN, SOMAN, VE, VG, VM, VX, Novichok), currently used as pesticide agents, but often used in suicide/homicide events in india >> U.S.!  Pts present c muscarinic & nicotinic effects ~ SLUDGEM… or DUMBELS…  After initial ICU hospitalization, delayed “Intermediate Syndrome” can decompensate up to 2 or 3 days later!
Cholinesterase assays check for activity (should be >30% for fxn).
Tx c prompt anticholinergic (Atropine, Glycopyrrolate) c appropriate Airway protection…
Pralidoxime (Tupam) used as acetylcholinesterase reactivators.
Cochrane of Atropine continuous incremental dosing v prn bolus dosing showed benefit, also >glycopyrrolate. Pralidoxime also improved outcomes despite poor levels of evidence.  Oximes become temporally less effective dt “aging” irreversible bond phenomenon.
Oximes not effective on carbamates.

130 ~ DKA (Joslin) a.k.a. “The Joslin Center”
CAN be euglycemic, bc defined by Diabetes, Ketosis, Acidosis.
DKA is an insulin problem, NOT a glucose problem!
Ketones & Ketone bodies… betahydroxybutyrate, acetoacetate, acetone
1) Hydrate
2) Insulin
3) Mind the K… Watch ABCs, dysrhythmia? obtundation, aspiration, edema…
Other ketosis (starvation, EtOH) & Other Acidosis (MUDPILES)…
Osmolality & Betahydroxybutyrate Lv may correlate with illness, but not necessarily

2p ~ HHS (Pryor) (Semi-Annual Eval Day)

230p ~Hypoglycemia (Martini)
Rule of 50s for dextrose bolus:
D50 (0.5g/mL) 1mL/kg
D25 x2cc/kg
D10 x5cc/kg
D5  x10cc/kg
ABCs of pediatric resuscitation.  PICU mortality much higher with episodes of hypoglycemia!!!
Avoid unnecessary intubations.  Glucagon? Octreotide for Sulfonylureas…
In the US ~1/13 ppl is Diabetic!
Can hypoglycemic pt go home?
…if baseline mental status, no concurrent medical issues, & glucose normalized… so…No…
Jan 1st hypoglycemic kids… think EtOH!
Liver failure also have no glycogen stores or gluconeogenesis capacity.

3p ~ Peds Diabetes (Jones)
Type1 ~ Destruction of Pancreatic Islet Cells
Type2 ~ Relative Insulin Deficiency
New Dx in ED c glucose >250…
Minorities & lower socioeconomic? more associated c T2DM, but can happen to anyone.
…usually go to PICU for acute glucose & electrolyte management c frequent checks.
Remember rapid IVF repletion can cause edema!  q1H neuro checks for cerebral edema exclusion… Cerebral Edema <1%, consider mannitol, hyperventilation, 3% saline…

Wednesday Lectures, 2/11/2015

TTHM 9.1 (2/11/15) Kidney Day (Tint. Ch. 91~98, 128)

10a ~ AKI & Renal Dysfunction (Prince)

Prerenal, Intrinsic, PostRenal

Community Acquired (mostly prerenal, dehydration, sepsis)

Hospital Acquired (mostly intrinsic, AKI, meds)

Know the pt’s Potassium, BUN/Cr Ratio (>15 or 20 suggests prerenal), fluid status, Toxic drug levels, consider GFR (esp for contrast studies); Urine Na (FeNa) may be useful for hypovolemia mechanism… EKG!

Digoxin Toxicity: DigiBind & Dialysis…

Foley in? Nephrology Consult?

Rhabdo: IVF.

Emergent Dialysis: Lithium, ASA, Methanol, EtGlycol, Theophylline, Uremic Pericarditis, Refractory Hyperkalemia.

Contrast Induced Nephropathy ~ often have significant comorbid Dsx… (MRI GFR needs >30) (CT recommendation GFR > 60 & IVF bolus)

Don’t give Demerol to CKD, stays around forever!

ESRD pts have 6x higher CVA, 10x higher SDH, 10to30x higher CAD!

 

1030a ~ Urolithiasis & Renal Colic (LaVoie)

Pain Control (Toradol, Opioids), Nausea Control (Zofran), Single dose NSAIDS are safe despite AKI, US to r/o hydronephrosis, UA to r/o concurrent infxn!

IVF ~ help or harm? …Cochrane 2009 says nbd either way.  Manage pt’s volume status.

Keep in mind DDx: Infection/Pyelo/Divertic/Appy, Ao Dissection, Mesenteric/Renal Ischemia, Ectopic/Gyn!

*AAA commonly misdiagnosed as renal colic! (Nearly 20%!) Most will have hematuria!

STONE score 2014: attempting to exclude 2* diagnosis via clinical decision rule, misses 0.3 to 3%…

Hematuria absent in up to 25% of Urolithiasis.

Is imaging standard of care?  “1st time stone” guideline useful c Dx uncertainty…

& useful c suspicion for proximal infection (r/o hydronephrosis)

CT most sensitive, possibly consider

 

11a ~ Small Groups (Prasad & Paolo)

12p ~ Holy Cow (Rossettie, Schenker, Joslin)

1230 ~ Jr/Sr (Cantor, Lavoie)

130p ~ Nephrotic Syndrome (Cantor)

2p ~ UTI (MacConaghy)

230p ~ Dialysis (Prasad)

3p ~ Male GU (Mann)