Podcast # 331: Oral Rehydration Therapy (ORT)

Author: Nick Hatch, MD

Educational Pearls:

  • The sodium-glucose cotransporter in the gut is essential for rehydration.
  • Oral rehydration therapies require an equimolar concentration of glucose and sodium to be effective.
  • ORT has saved millions of lives globally.
  • Consider using ORT in patients with dehydration. Especially useful in resource limited settings.

References:

Victora CG, Bryce J, Fontaine O, Monasch R. Reducing deaths from diarrhoea through oral rehydration therapy. Bull World Health Organ. 2000; 78:1246.

Santillanes G, Rose E. Evaluation and Management of Dehydration in Children. Emerg Med Clin North Am. 2018. 36(2):259-273. doi: 10.1016/j.emc.2017.12.004.

Podcast # 329: Hypokalemic Periodic Paralysis

Author: Dylan Luyten , MD

Educational Pearls:

  • Rare autosomal dominant condition that is often misdiagnosed as a psychiatric illness.
  • Presents as profound muscle weakness with frank paralysis that is often precipitated by vigorous exercise, high carb diet, high sodium load, or by high temperatures.
  • Supplemental potassium can rapidly reverse symptoms.
  • Important to rule out thyrotoxicosis (get a TSH!).
  • Prevention is key: adhering to a low carb and low sodium diet with supplemental potassium can help prevent episodes.

 

References:

Vicart S, Sternberg D, Arzel-Hézode M, et al. Hypokalemic Periodic Paralysis. 2002 Apr 30 [Updated 2014 Jul 31]. In: Adam MP, Ardinger HH, Pagon RA, et al., editors. GeneReviews® [Internet]. Seattle (WA): University of Washington, Seattle; 1993-2018. Available from: https://www.ncbi.nlm.nih.gov/books/NBK1338/?report=classic

Statland JM, Fontaine B, Hanna MG, et al. Review of the Diagnosis and Treatment of Periodic Paralysis. Muscle & Nerve. 2018;57(4):522-530. doi:10.1002/mus.26009.

Podcast # 327: No More Hemoccults

Author: Don Stader, MD

Educational Pearls:

  • The use of fecal occult blood tests is falling out of favor in emergency departments.
  • In the ED, small amounts of bleeding are often not clinically significant and can lead to harms and costs of over-testing.
  • They have relatively high false positive and false negative rates.
  • Fecal occult blood tests have strong evidence suggesting their efficacy in cancer screening.

References:

Cuthbert JA, Hashim IA. Diagnostic Fecal Occult Blood Testing in Hospitalized and Emergency Department Patients: Time for Change? Laboratory Medicine. 2018. doi:10.1093/labmed/lmy010.

Podcast #324: Superwarfarin

Author: Rachel Beham, PharmD

Educational Pearls:

  • Some synthetic cannabinoids have been contaminated with Brodifacoum. Brodifacoum is a Vitamin K antagonist and can present with a severe coagulopathy.
  • Brodifacoum is commonly known as “superwarfarin” and has a very long half life of 120+ days.
  • Check PT/INR in patients with a bleeding diathesis in setting of synthetic cannabinoid use.
  • Treatment is activated charcoal and large doses of Vitamin K (10mg Q6H for months).

References:

Lipton R.A.; Klass E.M. (1984). “Human ingestion of a ‘superwarfarin’ rodenticide resulting in a prolonged anticoagulant effect”. JAMA. 252: 3004?3005.

La Rosa F; Clarke S; Lefkowitz J. B. (1997). “Brodifacoum intoxication with marijuana smoking”. Archives of Pathology & Laboratory Medicine. 121: 67?69

Podcast #323: Calcium Channel Toxicity

Author: Jared Scott, M.D.

Educational Pearls:

  • Cardiac myocytes and vascular smooth muscle are dependent on an intracellular calcium influx for contraction. Pancreatic beta cells rely on calcium to release insulin.
  • Calcium channel blockers will decrease cardiac contractility and heart rate, but will also cause vascular smooth muscle relaxation with a subsequent decrease in systemic vascular resistance.
  • Resultant cardiac depression and hypotension.
  • Pancreatic beta cells also use calcium to release insulin, so calcium channel blockade can cause hyperglycemia.
  • Treatment for calcium channel toxicity include: fluid resuscitation, calcium gluconate, vasopressors, and high dose insulin.
  • Dosing for insulin therapy is usually 1-5 Units/kg/hr. Make sure to add dextrose!

 

References:

Boyer EW, Shannon M. (2001).Treatment of calcium-channel-blocker intoxication with insulin infusion. New England Journal of Medicine. 344:1721.

Proano L, Chiang WK, Wang RY. (1995).Calcium channel blocker overdose. American Journal of Emergency Medicine. 13:444.

St-Onge M, Dubé PA, Gosselin S, et al. (2014). Treatment for calcium channel blocker poisoning: a systematic review. Clinical Toxicology. 52:926.

Podcast #322: Methemoglobinemia

Author: Nick Hatch, M.D.

Educational Pearls:

  • Methemoglobinemia is when the iron in hemoglobin is in the Fe3+ (ferric) state rather than the normal Fe2+  (ferrous) state. Methemoglobin cannot release oxygen at the tissues.
  • Symptoms include cyanosis, headache, tachycardia, dyspnea, and lethargy.
  • Suspect in setting of hypoxia that does not improve with oxygenation, and clinical cyanosis with a normal PaO2 on ABG.
  • Treatment is methylene blue which reduces the iron back to the ferrous state.
  • Causes can be Dapsone, Lidocaine, Benzocaine.

 

References:

Agarwal N, Nagel RL, Prchal JT. Dyshemoglobinemias. In: Disorders of Hemoglobin: Genetics, Pathophysiology, and Clinical Management, 2nd ed, Steinberg M (Ed), 2009. P.607

Cortazzo JA, Lichtman AD. (2014). Methemoglobinemia: a review and recommendations for management. Journal of Cardiothoracic and Vascular Anesthesia. 28:1043.

Darling R, Roughton F. (1942). The effect of methemoglobin on the equilibrium between oxygen and hemoglobin. American Journal of Physiology. 137:56.

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/

http://emedicine.medscape.com/article/460865-overview

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