Article pertaining to PD rounds today

Tighter Patent Rules Could Help Lower Drug Prices, Study Shows
August 23, 201611:14 AM ET



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.

Wednesday Lectures, 8/26/2015 – ENT

TTHM a3.1 HEENT Day (8/26)

10a ~ Dental (Biondich) ~ 32 teeth, good to know terminology for consultants
Temperature sensitivity often precedes pain in dental caries
Pulpitis ~ infection to pulp chamber can precipitate rapid septicemia
Periapical abscess can be drained to relieve, associated c tooth injury or decay
Different kinds of abscesses… Gingival, Periodontal, Pericoronal (wisdom tooth), Combined…
Dental Blocks helpful for drainage ~ see Roberts & Hedges (or Google/YouTube)
Have suction going… they smell/taste bad & bleed some, don’t torture them.
Rinse well & home with mouthwash, consider Abx, depending on severity & tooth involvement…
Deep space infections ~ periapical infections can spread along maxilla or mandible, especially in immunocompromised hosts.
Ludwigs Angina ~ sublingual infection c tongue elevation ~ dangerous infection! can involve epiglottis, can be associated c trismus.
Vincent’s Disease/”Trench Mouth” ~ Pain to gums/Ulcerated dental papillae/Bleeding of gums, can become septic, not well understood, but opportunistic infxn common in WW1? Mainly anaerobic bacteria
Traumatic Dental injuries ~ 70% are maxillary central incisors: Ellis 1,2,3 & Alveolar Frxs
Ellis Class III should consider oral Abx, especially if capped with dental cement.
Dental box has dental cement, or even consider *dermabond & N95 mask wire splint!
Avulsion ~ tooth is out. Can potentially be reimplanted & splinted to next teeth?
!!! missing teeth can be subluxed into gums or aspirated or swallowed…
Baby teeth mixed from 6-12 yo, don’t reimplant dt risk to permanent teeth.

1030 ~ Acute Vision Loss (Prince)
Good eye exam: Funduscopic exam, Tetracaine & Fluorescein/Woods, Acuity Chart,
Visual Fields!, Slit Lamp, IOP Tonopen, perilimbic sparing?
*Acute Closed Angle Glaucoma ~ Fixed midposition pupil c conjunctival injection, treat c timolol, acetazolamide, pilocarpine… & Ophtho consult! CRAO v CRVO are emergencies ~ Stroke Code. Flashers & floaters c vision loss can be vitreous or retinal detachment (avg age 55)
Vitreous Hemorrhage, GCA/Temporal Arteritis, Venous Sinus Thrombosis, blurry vision occipital tract CVA…

11a ~ Small Groups (Lavoie)
Epistaxis & rhino rockets, LET…

1130 ~ Small Groups 2 (Rodney)
Epiglottitis Cric Case ~ tends to be fulminant
Lateral XR concerns, thumbprint sign, HFlu & SPneumo cover c Abx!
Airway Anticipation!!! Consider Atropine for secretions if using Ketamine…
While watching the airway, also consider the sats & pulse.

1230 ~ ICARE (Vince Calleo)
Review & Remind, keep expectations low & performance high (overshoot not undershoot)

1p ~ Jr/Sr Session (Lavoie)
Ear Hematomas get drained, elliptical, then packed & ENT follow-up
Ear Block is approximate diamond field block. Center is innervated separately by vagus.
Which NOT to fix? lid edge or medial canthus possibly involving canaliculi/ducts. leave the lid?
Risky wounds need Ophtho follow-up & repair… Home c erythromycin.
Parotitis ~ stensons gland, vs submandibular whartons duct… often a stone.
Lemon drops ~ sialogogue. Abx if fever or purulent, for oral flora… Augmentin/Clinda…
PCN great for strep, but not great anaerobic coverage… warm compresses & followup.
Dental Blocks ~ Infraorbital (Maxillary anterior) & Superior Alveolar branches (local, Maxillary posterior), Inferior Alveolar (Mandible) & Mental (Anterior Mandible)
If it goes to the neck, strongly consider imaging!

130 ~ Nose (Lavoie) ~ Epistaxis
Sphenopalatine Artery is potential more brisk posterior source
Posterior bleed avg age ~67 yo.
>90% anterior, Silver nitrate cautery can help but never do both sides at once!
LET & rhino rockets handy.
Surgicel handy for those pts who may be anticoagulated (hemostatic pad).
Take out within 3 days, & consider Abx for extended course dt TSS risk!?!
Foley for posterior packing needs ADM dt risks for complications.

2p ~ Ears (Pipas)
Anatomy: Tragus & Helix
Cerumen Removal ~ Cerumenolytics at home, Irrigation in ED c VasCath, or direct manual removal. potentially c eardrops for after…
Staph > Pseudomonas for Otitis Externa… CiproDex
Malignant Otitis Externa 98% Pseudomonas, mostly in immunocompromised.

230 ~ Eyes (Rodriguez)
DDx Red Eye… many things.
Anatomy & Terms: Blepharitis, Episcleritis, Keratitis, Uveitis, Endophthalmitis…
Vital Sign of the Eye: Visual Acuity
Limbic involvement is concerning for uveal involvement!
EOM important for limitation of movement or pain!
Hypopion = Bad. ~Uveitis
Dacrocystitis ~ Duct obstruction. ~ Abx & warm compresses.
Blepharitis ~ leads to hordoleum, chalazion… inflammation of sebaceous gland of eyelid
Chalazion ~ Chronic, Hordoleum/Stye ~ Acute.
Lid involved in Hordeolum, vs chalazion usually noninfectious, less painful, can become infected.
Viral Conjunctivitis ~ Incubation ~9 days, Infection for 2 weeks…
Bacterial Conjunctivitis ~ best treated c PolyTrim (vs Gent has more side effects). Polymixin actually does have some Pseudomonal coverage.
Cells & Flare ~ as sunlight angled through a window slat courses through dust.
~Dr. Cherrington, class poet
Periorbital Cellulitis usually appear nontoxic, still get Abx for cellulitis.
CT if in doubt for Orbital Cellulitis, which would need IV Abx & ADM.
HSV ~ Vesicles around the eye ~ keratitis c fluorescein ~ dendrites c terminal bulbs
VZV ~ Ramsey Hunt & Hutchinsons ~ pseudodendrites by fluorescein
Topical & Oral Antivirals, cycloplegics, ophtho consult & pain ctrl! …No steroids.
Both can have post herpetic neuralgia!

3p ~ Sinusitis (Rossettie) ~ see my presentation 😉

Wednesday Lectures – 8/19/2015 (Alternate Week)

10a ~ PDR (Paolo)
*CTAs for PE ~ false positives? ~25%! but outcomes not improving with enhanced diagnostics.
*Low risk chest pain ~ Newman @ NY ACEP, “low risk to patient, high risk to provider”… HEART score, TIMI… Medicolegal concerns lead to admissions in 30% of CP admits.
*CAP in VA patients get Abx but rarely bacterial etiology. What is PNA gold standard? CXR? uncertain… Staph PNA tends to follow influenza PNA. Rhino, Influenza, metapneumovirus most common causes > bacteria. …but CXR not useful in immunocompromised, AIDS, etc.
*Abx for URIs ~ why? because it’s easy.
Nasopharyngitis, pharyngitis, sinusitis, acute bronchitis, URI, laryngitis, tonsillitis… …NONBACTERIAL & DON’T NEED ABX.
*Contrast Allergy reduced by 13,7,1 hour steroid course!?

11a ~ PSQ (Haswell/Shaw)
Fishbone Diagrams…
Syncope, ‘98% benign, 2% fatal’
NYS is highly litigious & M&M type discussion poorly protected, although limited QI protections.
We do have SANE order set at UH, but may be more limited resources in community hospitals.
PEP has potential kidney & liver side effects (~2%) & pts get 5 day supply to follow-up CARE clinic.

1pm ~ Jeopardy of Ultrasound (Nicholas)

2pm ~ Low Risk CP, Journal Club (Walker)
*CP dispo largely dependent on follow-up availability (i.e: better at St. Joes)
*Blunt trauma US/exam vs CT? reevaluation can be as good, roughly? Sensitivity much less with CUST Clinical/US tracking compared to CT (77% v 97% Sn?!)

3pm ~ TLLT Clinical Controversy (Finch)
“Backboards are useful to stabilize vertebral fractures”? 1966 Geisler et al. 2 pts set protocol, dt 2 bad paralysis outcomes! Bad outcomes c backboards? Yes ~ pain, can be caused by backboard, leading to additional tests?! Unnecessary CTs?! 97% of cspine XR are negative… can cause airway compromise & ETT difficulties! Supine restrained positioning causes reduced tidal volume, increases aspiration risks… Pressure sores more likely… ICP concerns with collar, flat supine, maybe backboard association? On scene delays? c bleeds needing SG.
*”NO ROLE” for Cspine immobilization in penetrating trauma…
Backboards no longer for “spinal immobilization”. They are extrication devices, not transport devices!? Backboards NOT to be used for transfers!
New NYS Protocol Update!!! Oct 31…
Ccollars still in place, but backboards minimized now.

330p ~ TLLT Topic Marathon Medicine (Finch)
2014 there were >1200 US marathons c >550,000 finishers.
Knee injuries greater in road races, Ankle injuries more common in track
Cramps & pain ~ single muscle ~ assisted walking…
Repeat cramping ~ electrolyte problem ~ hypokalemia, dyshydration ~ IVF, benzos, Mag???
Chafing & blistering not uncommon.
GI complaints in >50% of runners… often artificially guiac positive dt demand ischemia?
Case reports of cecal volvulus in marathon runners, 25-35yo?
Troponins will likely be artificially elevated dt physiologic muscle breakdown.
Sudden drop, check pulse as per BLS, ACLS…
Get glucose & core temp! Then EKG & electrolytes!

Program Director’s Rounds: Articles for 8/19/2015

Community-Acquired Pneumonia Requiring Hospitalization among U.S. Adults
Seema Jain, M.D.,et al
N Engl J Med 2015; 373:415-427
July 30, 2015
DOI: 10.1056/NEJMoa1500245
Full text at NEJM

Risk for Clinically Relevant Adverse Cardiac Events in Patients With Chest Pain at Hospital Admission.

Weinstock MB et al
JAMA Intern Med.
2015 Jul 1;175(7):1207-12.
doi: 10.1001/jamainternmed.2015.1674.
Full text at JAMA

The Association Between Medicolegal and Professional Concerns and Chest Pain Admission Rates.

Brooker JA et al
Acad Emerg Med.
2015 Jul;22(7):883-6.
doi: 10.1111/acem.12708.
Epub 2015 Jun 26.
Full text through Upstate library

Overdiagnosis of Pulmonary Embolism by Pulmonary CT Angiography.
Hutchinson BD et al
AJR Am J Roentgenol.
2015 Aug;205(2):271-7.
doi: 10.2214/AJR.14.13938.
Full text through library at AJR Online

Variation in Outpatient Antibiotic Prescribing for Acute Respiratory Infections in the Veteran Population: A Cross-sectional Study.
Jones BE et al
Ann Intern Med.
2015 Jul 21;163(2):73-80.
doi: 10.7326/M14-1933.
Full text through library at Annals of Internal Medicine

Rates of Breakthrough Reactions in Inpatients at High Risk Receiving Premedication Before Contrast-Enhanced CT.

Mervak BM et al
AJR Am J Roentgenol.
2015 Jul;205(1):77-84.
doi: 10.2214/AJR.14.13810.
Full text through library at AJR Online