Cardiac temponade after myocardial biopsy

Posted 24 June, 2011 - 13:38 by steve

She is a 86 year old lady with recent admissions of recurrent pulmonary oedema.

This time again she was transferred to acute coronary unit as she needed CPAP for her type 1 respiratory failure.

When I checked her background history

 

  • 1. Myelofibrosis under haematologist (regular transfusions)
  • 2. Recent Echo: Mildly impaired LV function, not explaining her recurrent pulmonary oedema
  • 3. Cardica MRI: not conclusive regarding cardiomyopathy, recommended cardiac biopsy.

 

 

She had been on CPAP, IV furosemide and daily U&E/ body weight/ fluid chart.

Her condition was improving slowly and respiratory weaned off to high flow and low flow oxygen. She was booked for cardiac biopsy. Informed consent and family meeting as usual stuffs.

In the afternoon after she came back from cardiac lab for procedure, nursing staff informed me that her blood pressure had been going down to 88/48.

I reviewed and give 250 ml of Gelofusin. Urgent echo was requested, which showed pericardial effusion.

The consultant cardiologist was informed straight way and patient was sent back to cath lab for drain. Critical out reach team involved.

Patient’s BP picked up gradually in next 12 hours. But , from next day, her renal function deteriorated. I rang renal team. They kindly came and saw patient.

After 2 weeks, her general condition improved back to her normal. Myocardial biopsy result came back as insignificant minor fibrotic changes.

We still cannot find the cause of her recurrent pulmonary oedema. It could be multifactorial.

Anyway, we will see her in clinic. Haematologist is also planning to see for her haematology problem.

Unconscious after VF arrest

Posted 24 June, 2011 - 13:01 by steve

This 79 year old gentleman, normally fit and well apart from deafness, was broght in by ambulance after community  VF arrest. He received one shock before emergency department, which was followed by a long pause before an episode of sinus tachycardia.

On arrival, GCS was 8. ABC was maintained. Anaesthetist on-call intubated. My role was to asses patient and to start initial management. I was no so sure the cause of cardiac arrest. CXR NAD. Electrolytes were normal. ECG showed sunus tachy and ? high take off or ST elevation. After discussed with cardiologist on-call, we agreed to start ACS protocol, but not for urgent PCI in view of time lapse.

He was in ICU for a few days. Echo was moderate LV impairment. Respiratory weaned off . The cardiologsit reviewed hima agian and suggested that no clear evidence of acute MI in repeat ECG and enzyme test. (Trop I already high since admitted) , but agreed to do cardiac catheter in view of unexplained cardiac arrest.

 

Angiography showed triple vessel disease. Clearly, he was a candidate for CABG.

He had opeartion 2 weeks later. He was well when discharged.

 

 

 

 

 

 

 

Grentamycin dosing

Posted 16 May, 2011 - 19:38 by steve

Gentamicin assays for once daily dosing (5mg/kg) in adults: Target range and results interpretation

  • The target range for the "Pre-dose" is <1.0 mg/L.

    Normal pre-dose level:

    • The regimen of 5 mg/kg once daily can be continued.
    • A further "pre-dose" level should be performed following 3-4 more doses so long as renal function is stable.

  • Pre-dose level is between 1-2 mg/L (and renal function unchanged)
    • Review if gentamicin still required
    • If still indicated, reduce the dose:

    Current Regimen New regimen
    5mg/kg 3mg/kg
    3mg/kg 2mg/kg
    2mg/kg omit dose and repeat the level the following day

  • Pre-dose level is >2 mg/L or renal function deteriorated

    • Gentamicin assays for patients on conventional divided doses (tds or bd) or other regimens: Target range and Results interpretation

    Pre-dose level

    • The pre-dose level must be low to minimise toxicity
    • The target range is <2 mg/L
    • Remember that apparently high levels may be due to mistiming of the samples

    Normal pre-dose level:

    • The regimen can be continued
    • Further "pre-dose" level should be monitored twice weekly  so long as renal function is stable
    • Pre-dose level is between 2-3 mg/L (and renal function unchanged)
      • Increase the dosing interval e.g. from tds to bd
    • Pre-dose level is >3 mg/L
      • Further Gentamicin doses should be withheld until discussed with Microbiology
      • The need for Gentamicin therapy should be reviewed

    Post-dose level

    • The post-dose level must be adequate to ensure efficacy
    • For most infections the target range is 5-10 mg/L
    • For serious pseudomonas infections the target range is 7-10 mg/L
    • For streptococcal or enterococcal infections eg endocarditis the target range is 3-5 mg/L
    • If post dose level is below the target range
      • Gentamicin is sub-therapeutic
      • The dose must be increased

    Pre- and post-dose levels

    • Post-dose level is above the target range; pre-dose is normal
      • Reduce the dose
    • Both the post-dose and pre-dose levels are above the target range
      • The  next dose(s) should be omitted
      • The need for further gentamicin should be reviewed
      • For further gentamicin therapy the interval between doses must be increased after discussion with Microbiology.

    LAD Syndrome

    Posted 4 November, 2010 - 10:31 by steve

    It is also known as Wellens syndrome.

    Critical proximl LAD artery stenosis in patients with unstable angina.

    Syndrome criteria include

    • characteristic T-wave changes; ( 76%: is deep inversion of the T-wave segment in the precordial leads.; 24% of patients: biphasic T waves, most commonly in leads V2 and V3 but also can include V1- V5/V6 )
    • normal or minimally elevated cardiac enzyme levels
    • No Q waves, No significant ST elevation
    • normal precordial R-wave progression.

    Clinical signigicance

    • A very high risk of developing myocardial infarction.
    • ETT can be fatal due to the severe stenosis that might lead to infarction at the time
    • Angiographyhas demonstrated that 100% of patients with this syndrome will have greater than 50% stenosis of proximal LAD. More specifically, 83% will have the lesion proximal to the second septal perforator.

    Ref:

    Emedicine

    ISPUB

     

     

    Clopidogrel Vs Prasugrel

    Posted 2 November, 2010 - 13:24 by steve

    TRITON-TIMI 38 ,which was a study on 13,608 patients with acute coronary syndromes,  has revealed that in patients with STEMI undergoing PCI, prasugrel is more effective than clopidogrel for prevention of ischaemic events, without an apparent excess in bleeding. (Lancet)

    NICE guidance

    Prasugrel for the treatment of acute coronary syndromes with percutaneous coronary intervention (October 2009)

    Prasugrel, in combination with aspirin, is an option for the prevention of atherothrombotic events in patients with acute coronary syndromes undergoing percutaneous coronary intervention, only when:

    • immediate primary percutaneous coronary intervention is necessary for ST-segment elevation myocardial infarction, or

    • stent thrombosis occurred during treatment with clopidogrel, or

    • the patient has diabetes mellitus.

    (BNF)

    Prasugrel is a third generation thienopyridine while Colpidogrel is 2nd generation.

     

     We can see Acute coronary syndrome - prasugrel: final appraisal determination here last updated in March 2010.

    Unstable angina and NSTEMI 2010 guide line

    Posted 2 November, 2010 - 12:32 by steve

    Just sharing new NICE guide line

     

    Key points

    • As soon as the diagnosis of unstable angina or NSTEMI is made, and aspirin and antithrombin
      therapy have been offered, formally assess individual risk of future adverse cardiovascular events
      using an established risk scoring system that predicts 6-month mortality (for example, Global
      Registry of Acute Cardiac Events [GRACE]).
    • Consider intravenous eptifibatide or tirofiban1 as part of the early management for patients who
      have an intermediate or higher risk of adverse cardiovascular events (predicted 6-month mortality
      above 3.0%), and who are scheduled to undergo angiography within 96 hours of hospital
      admission.
    • Offer coronary angiography (with follow-on PCI if indicated) within 96 hours of first admission
      to hospital to patients who have an intermediate or higher risk of adverse cardiovascular events
      (predicted 6-month mortality above 3.0%) if they have no contraindications to angiography
      (such as active bleeding or comorbidity). Perform angiography as soon as possible for patients
      who are clinically unstable or at high ischaemic risk.
    • When the role of revascularisation or the revascularisation strategy is unclear, resolve this by
      discussion involving an interventional cardiologist, cardiac surgeon and other healthcare
      professionals relevant to the needs of the patient. Discuss the choice of the revascularisation
      strategy with the patient.
    • To detect and quantify inducible ischaemia, consider ischaemia testing before discharge for
      patients whose condition has been managed conservatively and who have not had coronary
      angiography.
    • Before discharge offer patients advice and information about:
      – their diagnosis and arrangements for follow-up (in line with ‘MI: secondary prevention’,
      NICE clinical guideline 48)
      – cardiac rehabilitation (in line with ‘MI: secondary prevention’, NICE clinical guideline 48)
      – management of cardiovascular risk factors and drug therapy for secondary prevention
      (in line with ‘MI: secondary prevention’, NICE clinical guideline 48 and ‘Lipid modification’,
      NICE clinical guideline 67)
      – lifestyle changes (in line with ‘MI: secondary prevention’, NICE clinical guideline 48).

    Here is NICE for more

    Next,

     The GRACE ACS Risk model has been replacing TIMI risk score.

    The use of RSs developed from databases of clinical trials (PURSUIT and TIMI) or registries (GRACE) in the risk stratification of patients with NSTE?ACS revealed a fair to good discriminatory accuracy in predicting major adverse cardiac events at both 30 days and 1 year.

    The GRACE RS was the best for predicting the risk of death or MI at 1 year after admission.(European Heart Journal)

    Common dermatology applications

    Posted 5 October, 2010 - 09:13 by steve

    Well known name

    Indication

    Dose

    Aveeno

    colloidal oatmeal, white oat fraction in emollient basis

    for endogenous and exogenous eczema, xeroderma, ichthyosis, and senile pruritus (pruritus of the elderly) associated with dry skin,

    10 × 50-g sachets

    add 50 g/bath

    Betnovate cream /Ointment

    betamethasone 0.1%

    1. severe inflammatory skin disorders such as eczemas unresponsive to less potent corticosteroids;

    2. psoriasis

    30g/100g

    Apply thinly OD-BD daily

    Cocois

    see Sebco

    See Sebco

    40/100g

    Dermovate cream/ Ointment/ Scalp application

    Clobetasol propionate 0.05%,

    1. short-term treatment only of severe resistant inflammatory skin disorders such as recalcitrant eczemas unresponsive to less potent corticosteroids;

    2. psoriasis

    30g/ 100g

    Apply thinly 1–2 times daily for up to 4 weeks

    DiproSalic

    0.05% Betamethasone 3% Salicylic acid

    30g/100g

    apply thinly 1–2 times daily

    Dithro cream

    Dovonex

    Calcipotrol

    Plaque psoriasis

    60g/ 120g

    apply cream or ointment once or twice daily

    Dovonex scalp solution

    Scalp psoriasis

    Scalp solution 60 mL

    apply scalp solution twice daily

    Driclor

    Aluminium chloride

    Hyperhidrosis

    To control minor bleeding after skin scraping

    Elidel cream

    Pimecrolimus 1%

    30/60/100g

    Elocon cream

    Cream, mometasone furoate 0.1%, Ointment 0.1%, Scalp lotion 0.1%

    severe inflammatory skin disorders such as eczemas

    30g/100g

    30ml

    Apply thinly once daily

    Eumovate cream/ ointment

    clobetasone butyrate 0.05%

    Can be used on face:

    eczemas and dermatitis of all types; maintenance between courses of more potent corticosteroids

    30g/100g

    Apply thinly 1–2 times daily

    Hydrocortisone ointment

    1%

    Mild steroid. so can be used on face, flexure area and genital area

    Hydromol ointment

    125g

    Locoid Lipocream

    Hydrocortisone bytyrate

    Micanol

    Dithranol 1%

    50g

    Modrasone Ointment

    0.05% alclometasone

    50g

    Protopic ointment

    Tarcrolimus 0.03%

    30/60g

    Sebco

    Coconut oil compound: Coal tar 12%, Salicylic acid 2%, Sulphur 4%

    scaly scalp disorders including psoriasis, eczema, seborrhoeic dermatitis and dandruff

    40g/ 100g

    apply to scalp as necessary

    shampoo off after 1 hour

    Silkis ointment

    Calcitriol 3mcg/g

    mild to moderate plaque psoriasis

    100g

    Trimovate cream

    Clobetasone butyrate 0.05% and Nystatin

    Infected eczema and eczema at genital area

    Apply thinly 1–2 times daily

    PERC rule

    Posted 4 October, 2010 - 15:41 by steve

    Some time, it is a difficult to decide if this patient is for further investigation for PE or to be discharged without any further intervention.

    This PERC rule would be a useful tool to rule out PE, based on 8 questions

    1. Age <50? 
    2. HR <100?
    3. O2 Sat on Room Air >94%? 
    4. No Prior History of DVT/PE? 
    5. No Recent Trauma or Surgery?
    6. No Hemoptysis? 
    7. No Exogenous Estrogen? 
    8. No Clinical Signs Suggesting DVT? 
    According to the PERC Study, there is less than 2% risk of PE in the patient with 8 points
    Here is the calculator

     

    Atrial flutter cardioverted electrically

    Posted 4 October, 2010 - 15:23 by steve

    I saw 57 year old lady during my night on-call. She has ablation well over 10 years ago for her SVT. Since then, no problem.

    This time she was on holiday in our area. Presented with chest pain and palpitation. ED  (Emergency department ) ECG showed narrow complexed SVT with some flutter waves. They had tried Adenosine 6 and 12 mg. No rhythm changed. Flecainide was given. Not cardioverted. Anti-coagulated with LMWH.

    Haemodynamically stable. But on-going chest pain off and on. Onset was less then 48 hrs. After discussing with cardiology team, it was decided to do electro cardioviersion. Patient was also keen to go with that plan.

    It was done in theature under GA of course. I warned, I charged I shocked at synchronised 50 J. Wonderfully, back to normal sinus rhythm.

    Last time, I tried to cardiovert on a young chap with fast AF. Not successful. He has several episodes of such attempts in the past. That would be the reason his AF had been stubborn to go back to sinus. ( chamber wall thickness also determines ) On the other hand, in this lady, it was easy.

    This is our protocol for synchronous cardioversion of tachycaridias

    Using the Biphasic PhysioControl Lifepak 20e

    Remember to use Syn button!

    If 'T' wave is being sensed, adjust

    • Gain
    • Lead setting (to I or III)
    • Electrode postion/spacing
    • Consider Hyperkalaemia

    Atrial fibrillation and Broad complec tachycarida

    200J* >>> 300J >>> 360 J**

    Atrial Flutter and Paroxymal SVT

    50 J >> 200J >>> 360 J **

    * Use lower initial energy if patient is taking Digoxin.

    ** Also consider anterior/ posterior placement , if safe to move patient.

    Leg swelling in the pateint with a history of IVDU

    Posted 4 October, 2010 - 15:03 by steve

    Normally, those patients referred by GP with leg swelling would be straight forward DVT cases  for out-patient management. If cellulitis is going on, it is for initial IV antibiotics and discharge them once changed to oral ones.

    I saw this 42 years old lady with previous IVDU, insisting now that she had not used hard drugs in last 2 years, presented with swelling in lt legs. my first thought was to give one shot of therapeutic clexane and DVT clinic referral as out-patient for further scan and management.

    But when I review her history in details, her right leg got swollen up 2 weeks prior to left leg started to be afftected. No history or examination suggested of cellulitis. The left leg circumference was 2 cm bigger than its counter part.

    I did check with Well's criteria, indicating the high risk group.

    But in view of bilateral swelling in history, I think we need to rule out something obstrcting at higher level. So I admitted that patient for scan as in-patient.

     

     

     

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