Podcast #267: Causes of Very High Lactate

Author: Dylan Luyten, M.D.

Educational Pearls

  • Lactate is a byproduct of anaerobic metabolism, a sign of dying tissue. Dangerous causes of high lactates will not normalize with repeat labs.
  • Crush injuries, seizures, bowel necrosis,  end-stage liver disease, and metformin toxicity are common causes of highly elevated lactate.

References: https://lifeinthefastlane.com/ccc/lactic-acidosis/

Podcast #165: TTP

fafc49c3-5bf2-4289-bf57-a58c8cfd5ac6Run Time: 5 minutes

Author: Eric Miller M.D.

Educational Pearls:

  • TTP stands for thrombotic thrombocytopenic purpura.
  • TTP patients usually have renal failure, bruising or petechia, anemia, confusion, and other neurologic changes, which distinguishes itself from ITP which is mostly characterized by just low platelets and petechia.
  • Both TTP and ITP are thought to be autoimmune diseases where the body produces antibodies that attack your own platelets or blood clotting mechanisms, preventing blood from clotting. In the case of TTP – antibodies attack a protein called ADAM TS-13, which cleaves Von Willibrand Factor.
  • Without treatment TTP has a 95% mortality rate, but with treatment patients have a 5-10% mortality rate.
  • Patients with TTP are admitted to the ICU and receive complete plasma transfusions daily – which takes out the antibodies that prevent clotting, dialysis for kidney failure, and steroids – because the majority of autoimmune diseases respond to steroids.
  • Causes of TTP can be infectious, chemotherapy, or common medications. However, only about 4 out of 1 million people get TTP yearly.
  • Pediatric patients who have hemolytic uremic syndrome have similar symptoms, and usually have a bacterial gastorintestinal infection from E.coli or Shigella toxin.

Link to Podcast: http://medicalminute.madewithopinion.com/ttp/

References: https://www.nhlbi.nih.gov/health/health-topics/topics/ttp

Podcast #80: Superior Vena Cava Syndrome

54294690-8008-447e-97fd-b6ca71e93bd3Run Time: 4 minutes

Author: Dr. David Rosenberg

Educational Pearls:   

  • A patient presented with left arm swelling with a history of a right pneumonectomy due to lung cancer. The patient received a NIVA of the arm and was discharged upon normal interpretation of the exam.
  • The patient returned the next day with worsened arm swelling with discoloration, shortness of breath, and posterior pharyngeal swelling.
  • The patient was diagnosed via CT with Superior Vena Cava Syndrome where the superior vena cava becomes occluded. It is usually caused (about 90% of the time) by cancer, specifically bronchogenic carcinoma.
  • Treatment is emergent radiation to eradicate the cancer as soon as possible. In the emergency room, steroids and Lasix can be used to help reduce the swelling and inflammation. There is also an option to have IR stent open the SVC.
  • About 90% of patients with this diagnosis die within a year.

Link to Podcast: http://medicalminute.madewithopinion.com/superior-vena-cava-syndrome/

References: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2728369/


Podcast #35: Coumadin Reversal

dpt01721Run Time: 3 minute

Author: Dr. Samuel Killian

Educational Pearls:

  • 5 million people are on Coumadin. Coumadin is in the top 5 of most adverse events.
  • 2 options for reversal in the ER: Vitamin K and FFP or vitamin K and 4 factor PCC.
  • FFP is cheap but harder to use and takes longer – 18-20 hours. Also there are several complications such as: AVO compatibility, volume of medication, and transfusion injuries.
  • PCC is expensive, easier to use, and takes less time – 15 minutes. PCC has less adverse effects and reactions.
  • Study showed that 14 patients given FFP had complications (7%), and 14 patients given PCC had complications – mortality rate was the same.
  • PCC has rapidly become preferred method for reversing Coumadin coagulopathy for sick patients – head bleeds, gi bleeding, etc.

Link to Podcast:  http://medicalminute.madewithopinion.com/coumadin-reversal/

References:  http://www.annemergmed.com/article/S0196-0644(15)00387-X/fulltext


Podcast #12: TXA in the ED

Run Time: 3 minutestraneamic-new

Author: Dr. Nicholas Hatch

Educational Pearls:

  • TXA is short for tranexamic acid.
  • Most often use in the ED is with severe bleeding or problematic bleeding associated with trauma.
  • Crash II trial determined the benefit of TXA is only applicable for about three hours after a trauma.
  • Typical dosing is 1 gram in the first ten minutes and 1 gram over the next eight hours.

Link to Podcast: http://medicalminute.madewithopinion.com/txa-in-the-ed/