Grand Rounds Recap - 7/16/14

Oral Boards Case with Dr. Blomkalns

The pt is a 70 yo M who presents with AMS, weakness and nausea for 1-2 days. He complains of diffuse weakness and feeling "sick". His hx is significant for HTN, HLD, CHF and he takes digoxin. Vital signs on arrival are BP 90/60 with HR 47. There is concern for digoxin toxicity, so dig level is obtained and is 2.4

(normal is less than 1.2).

His K is 6 and Cr is 1.9. EKG shows LBBB.

Learning points on dig toxicity:

• Can be acute or chronic
• Acute presentation: unstable hypotension and bradycardia. PAT with slow ventricular rate is a common EKG finding.
• Chronic presentation: AMS, fatigue, nausea
• Common lab abnormalities: hyperkalemia, AKI
• Treatment is digibind
• Not all digoxin toxic patients get digibind. Be careful giving digibind to A.fib patients as this may put them in A.fib with RVR and make their hemodynamics worse.
• Patients should be treated based on their K (> 5.5), EKG and symptoms. Do not treat based on dig level alone.
• Stone heart phenomenon: in the past, folks used to be afraid of giving Ca to dig-toxic patients. This has been disproved and Ca is safe in these patients, though it will not work as digoxin binds to Na/K ATPase and does not work on Ca channels.
• Dose of digibind (given in vials): 100/weight in kg
• Dialysis does not work, however it does clear digoxin-digibind complex and is helpful in pt's with renal failure
• Do not get repeat digoxin level after giving digibind as it is useless.

Tox to know for oral boards:

• Tylenol and NAC
• Aspirin and alkalization
• Toxic alcohols: ethylene glycol, methanol
• Digoxin
• Pediatric Fe ingestion
• TCA
• Beta blockers and Ca channel blockers

General tips for oral boards:

• Updating family and calling PCP gives you extra points!

Oral Boards Case with Dr. Stettler

84 yo F with AMS

. Presents hypotensive, tachycardic, febrile. Has a sacral decubitus with crepitus. Concern for necrotizing fasciitis. Pt should get aggressive fluid rescuscitation, at least 2 L. She then requires pressors for management of her septic shock, NE and vasopressin. Needs a surgery consult for debridement.

27 day old F that is "not acting right".

 Has had decreased PO, lethargy for 1 day. Presents hypotensive, tachycardic, tachypneic, with temp 100.2. Has 2 seizures in the ED. Has hypoglycemia on labs as well as leukocytosis in CSF concerning for sepsis. Treat hypoglycemia and seizure aggresively as well as give antibiotics early. Do not delay for LP. Always consider nonaccidental trauma.

Sim Cases with Drs. Fernandez and Hill

Male with chest pain, shortness of breath and fatigue

. Presents with HR in the 30s and BP 95/62. Has 3rd degree heart block on EKG. Troponin is 0.89 and BNP is 1008. You can give atropine, but this will not work. DDx is likely ischemia, so the pt likely needs the cath lab. The pt gets put on transcutaneous pacer, but that does not capture, so he needs a transvenous pacer. The line for this is similar to a trauma cath (dilator is already in the line) and then the pacer threads through the line. The control box for the pacer is precet for HR at 80 and current of 10. If you forget what settings to use, hit the red button and it gives you automatic settings. Thread the pacer to 15 cm and then inflate the balloon until you get capture. Deflate the balloon and then decrease current to the lowest value that gets capture.

Young male with racing heart rate

. He drinks a lot of caffeine and has HR in 170s-180s on presentation with normal BP and mental status. EKG shows SVT. Try vagal maneuvers, which have success rate of 25%. If this doesn't work, give adenosine 6 mg, followed by 12 mg x2 prn. Adenosine has to be given fast as it has a very short half life - consider stopcock method for administration or drawing the med up in the flush (ala ALIEM and Bryan Haynes). If adenosine doesn't work, consider synchronized cardioversion or other medications: verapamil, BB, procainamide. It is ok to discharge these patients if they are healthy and remain in NSR.

Update on Drugs of Abuse with Dr. Mel Otten

• Overdoses kill more people than MVCs
• Heroin overdoses are increasing in number while cocaine overdoses are decreasing
• Prescription drug abuse: clonazepam is the most abused, followed by xanax/oxycodone/hydrocodone.
• Cocaine is very frequently adulterated
  • Levamisole: antihelminth used in horses and used to adulterate cocaine
    • Metabolized to a stimulant (Aminorex)
      • Causes agranulocytosis (low WBC and increased infection risk) and necrotozing vasculitis
• Synthetic Drugs
  • Most act on cannabinoid and/or amphetamine receptors
  • Bath salts: synthetic KHAT, mephedrone
    • Addictive, easily available
    • Aka "plant food"
      • Similar in structure to methamphetamine
      • Stimulant with serotonin and NE activity
      • Toxicity: tissue injury if injected, tachyarrhythmia, MI, stroke, myocarditis
  • NBOME: causes hallucinations, seizures, AKI
  • Geranium: stimulant that causes HTN, MI, cerebral hemorrhage
  • Spice: super THC that acts on cannabinoid receptors
    • Desired effects: euphoria, anxiolysis, antidepressant
    • Side effects: paranoia, seizures, HA, agitation, hyperthermia, arrhythmia
  • Inhalants: can cause sudden death due to V.Fib
  • Krokodil: desomorphine - causes skin and soft tissue damage

Intralipid with Dr. Mel Otten

• Is this the tox magic bullet?
• First used in anesthesia to reverse local anesthetic cardiotoxicity
• Reported in animal studies to reverse lipid soluble drugs
• Mechanism of action: no one knows but there are a few theories:
  • Lipid sink: sequestration of toxins from tissue
  • Hemodilution
  • Cardiotonic: rapid inotropic effects
  • Metabolic: provides lipid substrate for metabolism
  • If it is going to work, it works very fast, within minutes
  • Adult dosing: 200 mL bolus of 20% lipid emulsion followed by infusion of 0.25 ml/kg/min
  • Current indications: overdose of local anesthetic, haldol, TCA, beta blocker, Ca channel blocker

Financial Planning with Dr. Shaw

640px-Piggybank

"The power of compound interest the most powerful force in the universe"

- Albert Einstein (supposedly)

Investment options for college: education IRA, 529 plan, UGM

• Education IRA
  • 2000/year with income qualifications
  • No restrictions on investments
  • Must be used by age 30
  • Only educational expenses allowed
  • Not tax deductible, so funded with post-tax dollars
• 529 plan: prepaid tuition/savings
  • Educational expenses only
  • Can be transferrable
  • Contribution considered as gift, so there is an overall dollar limit
  • Tax treatment: investment earnings are not subject to tax but contribution is taxed
• UGMA = trust
  • Legally belongs to the child
  • No tax advantage to the contributor
  • No restrictions on investments or spending
  • Child gets control at 21 years of age
  • Tax treatment: can count against your child for FAFSA purposes
  • Can't be accessed if you get sued as it is in your child's name

Retirement options: pension, social security, IRA, Roth IRA, 401k/403B

• Pensions: these are exceedingly rare
  • You receive X dollars/years worked
  • Now you can have a defined contribution, meaning that you and your company put in X/year and get it when you retire
• Social security: 2642/mo maximal benefit if you retire at full retirement age
• IRA: can contribute up to 5500/year
  • Set up with variety of institutions
  • If retirement option available at work, can only tax deduct if AGI < 69,000
• Roth IRA: 5500/year max
  • Eligible only if income is less than 129,000
  • Contribution is not tax deductible but there is no tax on investment EVER
• 401k/403B
  • Set up by employer
  • You pick contribution amount and investment
  • Employer can match contribution
  • Contribution is tax deferred
  • Current limit is 17,500/year

Investment options: stocks vs bonds

• Stocks: unit of ownership in a company
  • Make money from appreciation and/or dividends
  • Foreign stocks are useful as their market does not always correlate with US market
  • Over long haul, usually increase in value
• Bonds = IOUs
  • You lend me 100,000 over 10 years and I will pay you 400/month and then return 100,000 at the end of 10 years
  • Safer than stocks
  • Sources of risk
    • Inflation
    • Interest rate
    • Credit risk: issuer goes bankrupt

How to buy stocks/bonds: individually through a broker or through a mutual fund

• 2 types of mutual funds:
  • Actively managed: fund hires a manager
    • Costly, 1-2%/year
  • Passively managed: index fund
    • Fund duplicates return on index
    • Index fund outperforms actively managed fund 75% of the time
• Market crashes are terrifying. Do not sell your stocks. Sit and do nothing and stick to your plan
  • Upside of market crash is that stocks are on sale!

Alternative minimum tax: applies if you have lots of kids, high medical/dental expenses and high state and federal tax

     - not indexed for inflation

     - if you make > 100 K/year, you need to check if you have to do this

Bottom line: start investing now as every dollar you invest will compound over 20-30 years