Sepsis: The Golden Hours

- Early fluid resuscitation, broad spectrum antibiotics (after cultures x2) and source control makes a difference in sepsis! 

- There is a survival benefit with early goal directed therapy (EGDT), based on a single-centre randomized trial. Check out these 2008 Surviving Sepsis Campaign guidelines for the targets of EGDT and other recommendations for the treatment of severe sepsis and septic shock

- A large NIH-funded multi-centre RCT trial is underway to confirm the findings of the landmark 2001 Rivers trial. This study will compare the original EGDT protocol against two separate arms: a structured resuscitation arm without routine central venous catheters, or usual care. The expected completion date of the ProCESS study is December 2013

Churg-Strauss Vasculitis

- Churg-Strauss vasculitis has recently been renamed as 'eosinophilic granulomatosis with polyangiitis' or EGPA. It is a vasculitis involving small and medium-sized blood vessels

- The American College of Rheumatology diagnostic criteria for EGPA includes 4 or more of:
1) Asthma - often precedes the vasculitis, and may be difficult to control
2) Eosinophilia >10%
3) Neuropathy - most common is mononeuritis multiplex
4) Migratory pulmonary opacities on CXR
5) Paranasal sinus disease - allergic rhinitis, sinusitis, nasal polyposis possible
6) Biopsy confirming eosinophilic accumulation

- Other organ involvement (ie. GN) is also possible

- Yesterday we talked about the DDx of dyspnea in a patient with EGPA vasculitis. This includes an asthma exacerbation, pulmonary hemorrhage/vasculitis, cardiac involvement, or infection in a patient on immunosuppressants. Patients with EGPA may also be at an increased risk of DVT/PE

DKA: Mind the Gap

- Check out our past blog posts on DKA management!

- The most reliable measure to diagnose DKA is the anion gap. Acidemia, ketonemia or hyperglycemia may be absent because of:
        - Mixed acid-base disturbance from vomiting or dehydration
        - Negative ketones: our lab measures acetoacetate and acetone, not B-hydroxybutyrate 
        - Normal blood glucose on presentation if partially treated with home sc insulin

A review of other common pitfalls and challenges of DKA management is found here

Mumps

- This week we talked about a case of parotitis secondary to mumps, the most common presentation of the mumps virus. Parotitis is caused by direct viral infection and associated inflammation of the parotid glands. Amylase, secreted from the parotids, is commonly elevated. This may be accompanied by a prodromal fever, headache, myalgias or malaise

- Other presentations include orchitis, oopheritis, aseptic meningitis or pancreatitis. More serious presentations, like encephalitis or cardiac involvement, are rare but possible

- Treatment is supportive. Because the virus is highly transmissible, patients should be placed on droplet and contact precautions if they are admitted to hospital

Upper GI Bleed

Upper GI Bleeding: What changes mortality?

- The most important take-home point: 2 large bore IVs. RESUSCITATION.

- A recent RCT NEJM article showed that a restrictive transfusion strategy (Hb < 70) had a survival benefit. There was a significant decrease in rebleeding, rescue procedures, transfusion reactions and mortality compared to a liberal (Hb < 90) strategy
However, patients with massive bleeding or cardiac disease were excluded, and the protocol was violated to transfuse for symptomatic or worsening bleeding (this happened in <10% of patients)

- In patients with cirrhosis and GI bleeding, don't forget the Ceftriaxone! Even if a patient has no ascites or infectious symptoms, there is still a mortality benefit with Abx


GI Bleeding and Dabigatran

Without an antidote, time and supportive treatment is the recommended management strategy. For life-threatening bleeds not amenable to intervention, involving specialists to consider options like dialysis or activated prothrombin complex (FEIBA) may be warranted. There is little to no evidence in this area

Acute Ischemic Stroke

When was the patient last seen normal?

What are the patient's symptoms? Hemiparesis, aphasia, visual field deficits?

What is the patient's baseline function (including occupation & important hobbies)?

Any contraindication to thrombolytics?

- These important questions, along with the CT head and score on this NIH stroke protocol, will help guide whether a patient is a candidate for thrombolytic therapy

- Systemic tPA provides the most benefit early (< 3 hours) but can be used up to 4.5 hours in certain cases. The major benefit is reduced disability at 3 months (NNT 8), at the risk of increased intracranial bleeding (NNT 17). Check out these two landmark trials to see the difference in outcome and exclusion criteria based on the different time cut-offs (NINDS and ECASS-III). Every minute counts!

 

 - Malignant MCA syndrome is the consequence of increased cerebral edema with large MCA strokes. In younger patients there is evidence that a hemicraniectomy performed early significantly improves mortality and disability

Here is a great review article on acute ischemic stroke!

Hypothermia

- Patients with moderate (temp <32 C) or severe hypothermia (temp <28 C) are at risk for fatal arrhythmias, which may be precipitated by sudden movements or invasive procedures

- The classic EKG finding is an Osborn wave (J wave). Other common EKG findings are atrial fibrillation, bradycardia, a prolonged PR or QT interval, or motion artefact from shivering

- Worsening hypotension and hypothermia may occur if extremities are rewarmed and vasodilate before the core body temperature rises

- If the patient arrests, don't stop resuscitation until the temperature has normalized!

Here is a fantastic review article for the DDx and step-wise treatment of hypothermia 

Status Epilepticus

Today we discussed the management of status. Some learning points:

- With a mortality of 20% always remember to start with ABCs, and don't forget to check the glucose!

- Why is lorazepam first line? Check out this RCT and ACP summary article for the evidence behind lorazepam

- Phenytoin is dosed per weight (20mg/kg IV infusion), 1 gram does not fit all. Patients should be on a cardiac monitor during the infusion due to the risk of hypotension and arrhythmias (MAX rate 50 mg/min)

We also reviewed phenytoin toxicity. Here is a great review article on the side effect profiles of other seizure medications

Clinical Pearls

Welcome back Western residents and clerks,

I’ll be starting up our morning report blog again. I look forward to sharing some great articles to complement each morning report topic. I’ll try and share some clinical pearls along the way too!

To get started, here is a fantastic (and free) Canadian resource: http://medicalpearls.com/

Until next week,

Your friendly CMR