Keywords: electrocardiography, EKG, cardiogenic shock, acute myocardial infarction (PubMed Search)
Here's a nice, simple pearl for cardiogenic shock:
"A normal ECG virtually rules out shock due to myocardial infarction."
Essentially, even though MI may be associated with a normal ECG in approximately 5-8% of cases, if a patient has cardiogenic shock due to MI, the ECG will ALWAYS be abnormal.
Gowda RM, Fox JT, Khan IA. Cardiogenic shock: basics and clinical considerations. Int J Cardiol 2008;123:221-228.
Diarrhea and the Petting Zoo
Now that it is Spring Time, trips to the Zoo and to Pools will become more frequent… consider them as potential environmental exposure sites.
Petting Zoos, Farmers Markets and Fairs, and Swimming Pools (especially kiddie swimming pools) are known sources of enteropathogens that can cause diarrhea (sometimes bloody).
Consider these on your DDx of vomiting/diarrhea.
Ask about these possible exposure sites along with Travel History and Nontraditional Pets.
Keywords: heparin, chondroitin, toxicity (PubMed Search)
Heparin FDA Alert
In case you had not heard, there was a major recall of Baxter's Heparin. It was responsible for dozens of deaths in the USA and an investigation was launched. It has been found that the contaminant comes from manufacturing plants in China. The most concerning part is that it looks like it was chemically synthesized sulfated chondroitin. This brings the suspicion of intentional adulteration. First lead in toys now cartilage in our heparin - what's next?
Some fascinomas of Heparin:
News link for FDA Heparin Alert:
Keywords: tPA, stroke, intracerebral hemorrhage (PubMed Search)
Category: Critical Care
Keywords: phosphate, hypotension, hypomagnesemia (PubMed Search)
Potassium Phosphate ("K-phos")
Over the weekend, I had a patient with Dr. Scott that had a phosphate of 0.8 mmol/L. Phosphate < 1.0 mmol/L is an indication for IV repletion. IV repletion involves giving potassium phosphate. An important clinical question, therefore, is how much potassium does the patient actually get?
Keywords: cardiogenic shock, hypertrophic cardiomyopathy (PubMed Search)
Cardiogenic shock associated with LV outflow obstruction is managed best without the use of vasoconstrictive agents and vasopressors. Ideally, patients should be treated with IVF and beta blockade. Alpha agonists (e.g. ISO) can also be added.
Typical vasopressors may actually worsen LV outflow obstruction in these patients.
Keywords: Avulsed Tooth, hanks solution, dental emergencies (PubMed Search)
Dental Emergency -- Avulsed Tooth
Keywords: Gonorrhea, Chlamydia, Syphilis, Sexual Abuse, Trichomonas (PubMed Search)
Keywords: sumatriptan, myocardial infarction, migraine (PubMed Search)
Keywords: benign paroxsymal positional vertigo, vertigo, bppv, dix hallpike maneuver, dizziness (PubMed Search)
Keywords: Variceal Bleed (PubMed Search)
Medical Regimen for Suspected Variceal Bleed
To review what Dr. Bond and Dr. Winters have already posted:
Three medical therapies have been shown to be effective in patients with severe upper GI bleed thought to be due to esophageal varices:
Most of our gastroenterologists recommend this regimen (all three therapies)
Other things to consider:
Category: Critical Care
Keywords: fresh frozen plasma, coagulopathy, PRBC (PubMed Search)
Coagulopathy and Trauma
Keywords: MI, Cardiogenic Sock (PubMed Search)
Post-MI cardiogenic shock, while traditionally thought to carry a mortality > 80%, actually has perhaps half that mortality when patients are treated aggressively with prompt invasive therapy (PCI, possibly CABG). Fibrinolytics have traditionally been discouraged, but authors now indicate that they should be given if all of the following three conditions are present:
Sent on behalf of Dr. Amal Mattu
[adapted from: Reynolds HR, Hochman JS. Cardiogenic shock: current concepts and improving outcomes. Circulation 2008;117:686-697.]
Keywords: Trigeminal Neuralgia, Microvascular decompression, treatment (PubMed Search)
Keywords: Appendicitis, Delayed Surgical intervention, Perforation (PubMed Search)
Acute Appendicitis – Delayed Surgery option?
Keywords: amiodarone, torsades, hypothyroidism, toxicity, adverse effects, medication induced (PubMed Search)
Did you know how many toxicities and adverse effects amiodarone has? Many are severe, and many VERY common.
1. CARDIAC: hypotension with rapid infusion, prolonged QT, torsades
2. NEUROLOGIC problems occur in 20-40%, including malaise, ataxia, and peripheral neuropathies
3. ENDOCRINE: hypothyroidism and hyperthyroidism
4. GI problems occur in 25%
5. OPHTHALMOLOGIC disturbances include optic neuropathy, papilledema, and photosensitivity
6. SKIN: blue grey pigmentation
7. PULMONARY: pulmonary fibrosis
Keywords: nystagmus, cerebellar dysfunction (PubMed Search)
Category: Critical Care
Keywords: aspiration pneumonitis (PubMed Search)
Keywords: Oncologic, Emergency, SVC Syndrome (PubMed Search)
Clinical Presentation of SVC Syndrome
SVC syndrome (caused either by tumor or thrombosis of the SVC) classically presents with facial swelling, arm swelling, and dilated chest wall veins. The problem in the real world is that often times the manifestaions are a bit more subtle.
Some SVC syndrome pearls:
Keywords: cardiogenic shock, right ventricular failure, myocardial infarction (PubMed Search)
Right ventricular (RV) dysfunction in the setting of acute MI accounts for only 5% of cases of cardiogenic shock but carries nearly the same mortality as LV shock. Shock due to RV dysfunction is usually treated by aggressive volume loading with IVF. However...
In some cases of RV dysfunction, RV end-diastolic pressure can be very high, resulting in shiftng of the invterventricular septum into the LV cavity, which in turn decreases LV filling and cardiac output. Aggressive fluid resuscitation in these patients may actually further worsen RV pressures, leading to further reductions in cardiac output. These patients should instead be treated early with vasopressors.
How do you tell if your patient needs aggressive fluid resuscitation or early vasopressors? Bedside ultrasound can be the answer...if you find marked distension of the RV, go with early vasopressors. If the RV appears normal in size (smaller than LV), go with the IVF.
And of course early revascularization is critical as well.
(adapted from: Reynolds HR, Hochman JS. Cardiogenic shock: current concepts and improving outcomes. Circulation 2008;117:686-697.)