Wednesday Lectures, 9/9/2015

TTHM a3.3 PDR (9.9.15), TQM, TLLT

10a ~ PDR (Paolo) ~ HIV Emergencies & AIDS ~
Must know, despite uncommon emergencies now…
Pulmonary & CNS Disease greatest specific manifestations.
AIDS now fairly well controlled, better compliance.
Acute Retroviral Syndrome looks like Mono… Fever & Lymphadenopathy 2-6wks postexposure, common in IVDU with other IVDU complications (i.e. endocarditis)
Once it gets to lymph nodes pretty much chronic
Risk Stratify CD4 counts come back ~ LATE.
Last CD4 within 4-6wks pretty accurate. Ever had AIDS (<200) or had AIDS defining illness?
Candida Esophagitis? Cryptococcus? Many Fungal Dsxs… opportunistic infections…
Viral Load less important, but CD4 count go well with certain Dsxs <500, <200, <50…
CD4 Estimate = ALC2000 is low risk; ALC 1000-2000 indeterminate.
Physical Exam ~ Skin & Mouth matter! ~ Crackles in lungs not there bc no inflammation!
Dermatology & Neuro deficits! & meds have common rxns too!
Not all fever is sepsis! Rheumatology, Oncology, Pharmacology common too!
Sinusitis in HIV is BAD. MAC, Lymphoma, PCP/PCJ…
high rates of NMS in HIV! (Abacavir)
PNA the most common, despite PCP ppx… S.pneumo still most common! (Bactrim misses!)
HIV pts on ppx still get PCP PNA too! Pulse Ox gradient better indicator c walk desat… v A-a…
LDH not great for Dx in ED but ID docs may trend
PCP diffuse infiltrate on exam, but anything in real life!
Steroids not good in TB, but otherwise helpful c PNA with poor sats. TB has many coinfections. Treatment in ED, consider Rifampin?…
Toxoplasmosis associated c depression (3-10%), Cryptococcal meningitis (10%), Lymphoma, TB, other CNS manifestations… Toxo typical CD4 <400, fever, headaches, AMS, Sz, or WNL!!! Image ANY AIDS pt c ANY CNS-related Symptoms! Contrast usually no more helpful than NC-CT, & can always be added later. Never LP AIDS pt without CT! Ring enhancing ~ Abscess/Toxo v Lymphoma… Typical Acute Sepsis Abx still most important to cover common acute bugs first! Cryptococcus gets Ampho, prolonged fluconazole… Meningeal signs unreliable, less than usual. Crypto antigen in CSF > india ink… NonFocal CNS still needs head CT.

11a ~ PSQ (Rossettie) *Confidential
12p ~ RPL (Sheikh)

1230 ~ Journal Club (Kinariwala)
*REVERT trial showed Trendelenburg positioning with Valsalva Maneuver improved SVT conversion from ~17% to ~43% (~214 pts ea group), p<0.001, so probably relatively useful. *Kidney Stones given Tamsulosin or CCB(nifedipine) for follow up outcome improvement? …Not so much. Medical Expulsive Therapy has no role or not an established one at least. & Drugs not cheap. Tamsulosin can cause orthostatic hypotension in elderly… Paolo doesn’t want it. Get up slowly. 130 ~ Ultrasound Review (Nicholas) ~ Jeopardy 230 ~ TLLT & Clinical Controversy (Cohen) *Controversy of Abx for URI? …ok for specific indications like Strep Pharyngitis, AOM, but probably not even necessary… we likely overtreat & may do more harm than good despite current standards of care… More pharyngitis & even PNA is viral > bacterial etiology
EB Medicine Pharyngitis only recommends Abx c Strep. AOM with effusion or severe inflammation…
*Contraception in the ED ~ OCP complications, IUDs, vaginal bleeding & emergency contraception… Role of SANE vs ED physician? Most OCPs are combined vs progestin-only “mini-pills”…

Journal Club Articles for 9/8/2015

Full texts are available on BlackBoard.

  • Medical expulsive therapy in adults with ureteric colic: a multicentre, randomised, placebo-controlled trial
    Prof Robert Pickard, MD et al
    The Lancet
    Volume 386, No. 9991, p341–349, 25 July 2015
  • Postural modification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): a randomised controlled trial
    Andrew Appelboam et al
    The Lancet
    Published online August 25, 2015

Wednesday Lectures, 9/2/2015: Arrhythmia Day

TTHM a3.2 Arrhythmia Day 9/2/15 (Tintinalli 12, 13, 22, 23, 35, 36, 122, 140)

10a ~ Peds Arrhythmias (Jones)
Tachy >> Brady, & MANY causes, consider congenital issues, postop issues, cardiomyopathy, fever, emotional agitation. FamHx: Brugada, longQT, HOCM…
Neonates: 10yo/Adult: 60-100 HR awake

1030 ~ Tachycardia (Rossettie) ~ see my lecture…

11a ~ Small Groups (Prasad, Lavoie)
CHF, Ao Stenosis, Aflutter, refractory until digoxin?!
Sinus Tachycardia… SVT, Tox? Onset sudden? Sudden resolution? (>Variability with sinus tach vs SVT very regular!) Rate 150? think of flutter!

1230 ~ Jr/Sr Session (Sarsfield/Lavoie)
Ventricular Tachycardia? Yes, but DDx SVT with aberrancy?
Capture beat is a pwave that captures to transiently interrupt VTach
Fusion beats are partially conducted, in between VTach & capture beat… no specific leads
Precordial Concordance rather than progression cw VTach
RBBB R’>R; while VTach R>R’.
Brugada Criteria & Josephson Signs ~ Tertiary Notch in VTach > LBBB, but CANNOT r/o VTach.
Old & heart disease likely VTach.
Young without prior heart disease unless known arrhythmia hx likely SVT…
Why differentiate? SVT with aberrancy +Adenosine may work… VTach +Adenosine less likely…
Shock if unstable, medication first if relatively stable…
Avoid Adenosine in WPW?! Cardiovert. Then consult for antidysrhythmic…
Cardioversion is always an appropriate option for unstable pt.
2010 guidelines recommend: Procainamide (2a, 75% conversion), Amiodarone (2b, 30% conversion), & Lidocaine (2b, 35% conversion) for chemical cardioversion of monomorphic VTach.
“Slow VTach” ~ Drugs/Tox, Cocaine, TCA, hyperKalemia, Digoxin Tox Accelerated Jct rhythm, CAREFUL c DRUGS! ~ can cause asystole… Na Bicarb may help c Na channel block…
Versed before shock? Fentanyl? Etomidate?(half RSI dose) …then shock…

130 ~ Atrial Fibrillation/Flutter (Silaban)
Flutter “sawtooth” pattern is classic/characteristic, various ratios

2p ~ Pacemakers/AICDs & PreExcitation (GJ)
WPW accessory pathways preexcitation & tachydysrhythmia,
V6 appearance with/without pacing & ischemia,
analogous to Sgarbossa’s criteria for ischemia in LBBB,
TC/TV Pacing: Buttons: On/Off, Rate, Output (mA), Amplitude (mV sense), via cordis catheter
R IJ or L subclav, down ~15 to 20cm to RV, & defib pads >10cm from AICD…
Paced & capture beats on EKG, Magnets in the trauma bay.
Paced, sense, & action of pacemaker (Atrial, Ventricular, Dual, Inhibit, Trigger)
(VVI vs DDD ~ Vent paced, Vent sense, Inhibit action… VS Dual paced, Dual sense, Dual Action) VVI can cause pacemaker syndrome, atrial contraction against closed mitral & tricuspid valves, so DDD generally preferred.
Magnet over pacer induces asynchronous pacing, over AICD deactivates sensing & shocking.
*Orthodromic (narrow), Antidromic (wide), & AF are ~ 3 different versions of preexcitation dysrhythmia.
Ao stenosis: syncope, angina, failure.
Procainamide ok for wide complex stable-ish tachycardia.

3p ~ Bradycardia (ERod)
Pacing, Cases…
*SA node dysfunction & blocks… PR interval can be delayed especial by Na channel block…
Bradycardia has problems with impulse formation & impulse conduction…
Formation: sinus dysrhythmia (ie. resp variation), sinus bradycardia, sick sinus syndrome
*AV nodal dysfunction… Junctional escape (40-60 typical)
*Ventricular… escape & AIVR (20-40 typical)
*1st degree ~ PR prolongation
*2nd degree ~ type 1 Wenckebach & type 2 Mobitz II. Mobitz II
*3rd degree ~ Complete Heart block (& Acc Jct Rhythm of Ventricular overdrive?)
Atropine & pacing 1st line
HyperKalemia can cause bradycardia
HypoThyroid? CCB/BB OD?
Sick Sinus Syndrome Spectrum… (TachyBrady is a subtype) ~ needs Cardiology for Pacer.