When it is about the heart, it is all about relationships

Let us start our tale with little Ms. P who has a relationship with the broad shouldered Mr. QRS. In a normal stable relationship (NSR), Ms. P is always accompanied by Mr. QRS. They plan to go to weekly dance classes with some other partnered friends, but it's difficult with the sometimes early and other times late Sinus Arrhythmia. The Sinus Exit Block couple are always punctual when they make it, but sometimes skip a dance class or two with no warning, only to be there punctually next time. The hardest folks to do any planning with is the Sinus Arrest couple, they not only miss classes they never get the time right on the next one, arriving early or late.

Relationships can be challenging, like when Ms. P's ex-boyfriend Pac (Premature Atrial Contraction) drops in. He wants to hang out with P and reminisce about old times, messing up the lovebirds orderly schedule. The same thing happens when one of Mr. QRS' old frat brothers from the PVC (Premature Ventricular Contraction) house crashes their place for the weekend.

However relationships can also have more serious discord or blocks between them:

• A first degree block places some distance between the two lovers, but still they remain together.



• A second degree type I block is demonstrated by P and QRS Wenkebach who grow steadily further apart until QRS cheats and P dumps the bum, but she forgives him and takes him back only for the cycle to repeat.



• The more dastardly second degree type II occurs in the relationship between P and QRS Mobitz II, where despite the illusion of a stable relationship, QRS gets drunk, cheats, and they break up. P is still a forgiving lady and takes him back, but the scalawag QRS will do it again.



• Divorce, or the third degree block, has complete disassociation between P and QRS

The thin and rhythmless rapper A fib has so many ladies (his P's) that he is only erratically spotted. He is not to be confused with the equally anorexic hip hop artist A flutter who usually dates only twins and triplets. Neither one of these artists jams should be confused with the sudden vibrant beat of the techno SVT, he brings a rapid rhythm that looks almost sinus. Rumor has he too has an eating disorder. Everyone knows a player like their friend Mat (Multifocal Atrial Tachycardia), he's got a different P every week.

Not so for the amphetamine and steroid abusing loner V Tach, no Ps for him in his destructive quest. He used to be a founding member of the all male deathmetal band V Fib, but they were too chaotic even for him.

Four Rs of fluids

Resuscitation	Rehydration	Rectification	Regular (Maintenance)
Situation
Shock Decreased blood pressure Increased lactic acid Decreased urine output	Hypovolemia +/- electrolyte abnormalities "Pre-shock" (downtrends in blood pressure or urine output, increasing tachycardia) Diabetic ketoacidosis Rhabdomyolysis Post-obstructive diuresis Hypovolemic acute prerenal failure Pancreatitis	Electrolyte abnormalities +/- hypovolemia Hypovolemic hyponatremia Hypernatremia Hypokalemia Hyperchloremic acidosis	NPO
Choice of fluids
NS LR Albumin Hespan (but numerous contraindications)	Typically composition is directed by published guidelines (as in DKA) or fluids can be formulated by the considerations for maintenance fluids given in the column furthest to the right. Remember that 40 mEq of potassium in a peripheral line has a maximal infusion rate of 125 mL/hr	Hypovolemic hyponatremia 0.9% saline ("NS", 154 mEq Na/L) 3% saline (513 mEq Na/L) Hypernatremia 0.45% saline ("1/2 NS", 77 mEq Na/L) D5 (0 mEq Na/L) Hypokalemia Given normal renal function, assume 20 mEq of potassium increases serum potassium 0.25 mEq/L Hyperchloremic acidosis Assuming mild hyponatremia or normal sodium consider 150 mEq NaHCO3 in 1000 mL of D5 or free water (1)	Based on electrolytes, specifically: sodium, potassium, chloride, bicarbonate, and glucose (and occasionally phosphate) as well as blood pressure. If they are hypertensive consider hypotonic (1/2 NS) rather than isotonic (NS, LR) solutions even if they are mildly hyponatremic. If Na is within normal limits < 140 use NS, > 140 use 1/2 NS If K is within normal limits < 4 add 20 mEq KCl If hypoglycemic or marginally hyperglycemic use the D5 variant of the 1/2 NS or NS chosen above
Rate
20 mL/kg of crystalloid (NS or LR) over 15-20 minutes (thus a pressure bag is needed)	100-1000 mL/hr titrated to whatever volume deficit you are correcting	Hypovolemic hyponatremia The initial rate to correct by 10 mEq/L in 24 hours with NS is by rough calculation 1.35 x wgt [kg] for the rate in mL/hr. If using 3% saline multiply by 0.3 (2) Titrate the rate to serial BMP, if life threatening hyponatremia (e.g. seizures) correction may be more rapid for the first few hours but still < 10-12 mEq/L over 24 hours Hypernatremia The initial rate to correct by 10 mEq/L in 24 hours with D5 is by rough calculation 1.35 x wgt [kg] for the rate in mL/hr. If using 0.45% saline multiply by 2. Titrate the rate to serial BMP, such that the rate of correction < 10-12 mEq/L over 24 hours Hypokalemia Maximal correction via peripheral line is 40 mEq/L in 500 mL NS over four hours or 125 mL/hr Hyperchloremic acidosis As per "rehydration" rates	40-20-10 "rule" (for patients with normal electrolyte hemostatic mechanisms) 40 mL/hr for the first 10 kg 20 mL/hr for the second 10 kg 10 mL/hr for each additional 10 kg
How do you know it's working
Blood pressure increases Lactic acid decreases Urine output increases	Blood pressure, heart rate, and urine output improve ("preshock") Anion gap decreases (diabetic ketoacidosis) CK and renal function improve (rhabdomyolysis) Replace 50% of urine output per hour (post-obstructive diuresis) Urine output increases and renal function improves (hypovolemic acute prerenal failure) Amylase and lipase improve (pancreatitis)	Hypovolemic hyponatremia Sodium corrects by < 2 mEq/L every 4 hours, thus check BMP or I-STAT every 2-4 hours and titrate rate and composition of fluids appropriately Hypernatremia Sodium corrects by < 2 mEq/L every 4 hours, thus check BMP or I-STAT every 2-4 hours and titrate rate and composition of fluids appropriately Hypokalemia Electrolyte correction monitoring at most Q8H Hyperchloremic acidosis Electrolyte correction monitoring at most Q8H	The patient remains hemodynamically stable without electrolyte abnormalities or worsening renal function

1. Assuming NaHCO3 comes in a stock solution of 1 mEq/mL, then [C] = solute osmolarity / solution volume

   = solute osmolarity / (solute volume + solvent volume)

   = 150 mEq / (0.150 L + 1 L) = 130 mEq NaHCO3/L

   In 850 mL of solvent, then [C] = 150 / 1000 = 150 mEq Na HCO3/L

2. Assuming total body water [L] = 0.5 x wgt [kg] (acutally TBW fraction varies between 0.45 and 0.6 depending on gender and age). We want to change the current plasma sodium by 10 mEq/L/24 hours (i.e. the maximum safe change in serum sodium that will not precipitate central pontine myelinolysis) and recall that the concentration of sodium in 0.9% saline or NS is 154 mEq/L, then:

   infusion rate = 0.5 x wgt [kg] x 10 / 154 (L x mEq/L/24 hr) / (mEq/L)

   = 5 x 1000 x wgt [kg] / (154 x 24) mL/hr

   = 1.35 x wgt [kg] mL/hr for NS

   If we are using 3% saline, multiply by 0.9/3 (0.9% / 3%) or 0.3

   In the case of hypernatremia, we know that 1/2 NS is half the concentration of NS, such that if we did a similar infusion rate calculation the denominator would be half what is above, or simply multiplying by 2.

Encephalopathy in a nutshell

Although not the definitive, all encompassing, reasons for encephalopathy/delirium/altered mental status, this short list certainly covers many of the most prevalent causes.

Etiology	Physical Exam	Bedside Diagnostic Tests	History	STAT Diagnostic Tests
"Bugs" Infection	Temperature SpO2 Meningeal signs Lines (vascular, GI, GU)		Headache Aspiration Productive cough Vomiting / Diarrhea Urinary changes	CXR UA and urine c/s Blood c/s Sputum c/s C. difficile toxin
"Drugs" Side effects of and withdrawal from drugs		Naloxone trial	MAR (narcotics, corticosteroids, CNS agents) Review home medications Alcohol/substance abuse
"Lytes" Electrolyte abnormalities particularly hypo- and hyperosmolar states		I-STAT	Ins/Outs	BMP Serum osmolarity
"Plights" Inadequate pain control	Pain scale Abdominal examination	Bladder scan
"Beating" Cardiac arrhythmia and ischemia	Heart rate Blood pressure Jugular venous pulsation Heart murmurs and additional sounds	Telemetry I-STAT Troponin		EKG Cardiac markers BNP
"Bleeding" Acute blood loss	Scleral pallor Rectal exam	Fecal occult blood test I-STAT (ABG also has an H&H)	Recent surgery Anticoagulation	CBC
"Gases" Hypoxemia or hypercarbia Acidosis or alkalosis	Respiratory rate SpO2	ABG	History of hypercarbia Previous ABG
"Glucose" Hypo- and hyperglycemia		Accu-check I-STAT	Diabetes mellitus Insulin or oral antihyperglycemic medications
"Gourd" Intracranial pathology (i.e. stroke, mass effect, traumatic brain injury) Seizure	Neurological examination		Documentation of seizure-like activity without formal history of seizure Trauma History of dementia or seizure	CT head without contrast

CDC Warns of Zombiepocalypse

SHM 2010 Day #2 "Hospitalists...the 2010 National Champions"

Plenary Session
The plenary session started with the winners of the abstracts for this year, that asked the following questions:
Does hospitalist care change one year post discharge increase readmission or use of health care resources? Actually decrease in any emergency department visits but not frequency, if they start going to the emergency department they keep going. Also decreases MD office visits, but no difference in post-discharge hospitalization. The researchers hypothesized that hospitalists have an increased use of home health

What does disclosure do to liability? i.e. what is the effect of transparency?
Yes it improves (decreases) claims, time to resolution with a 53% decrease in liability costs

The final presentation was an innovation in health care, in this case ensuring safe discharge of homeless patients using a respite program. Which of course begs the question if respite programs might be used for patients with homes to decrease readmissions.

NIPPV in acute respiratory failure
Inspiration actually places inward pressure on external airways while internal airways expand. Examining the hysteresis curve at the ends where maximal changes in pressure have minimal changes in volume is comparable to filling a balloon, the most difficulty is at the beginning and end of filling of the balloon.

Positive pressure ventilation

• Decreases venous return
  
• Decreases RV stroke volume and increases LV filling volume
  
• Decreases work of breathing
  
• Improves gas exchange
  
• Unloads heart
  

CPAP improves oxygenation
PSV improves ventilation
BiPAP = CPAP + PSV

Entry criteria

• Able to protect airway (anatomic + neurologic)
  
• Stable hemodynamics
  
• Absence of MSOF
  
• Cooperate with NIPPV
  
• Compatable facial anatomy
  
• Can tolerate insuflation
  

NPPV Predictor of Success

• Youth
  
• Low APACHE score
  
• Cooperative
  
• Moderate hypercarbia, PaCO2 > 45 mmHg
  
• Mild acidosis
  

NPPV in COPD (Cochrane Database Syst Rev. 2004;(3):CD004104)

• PaCO2 > 45 mmHg
  
• Decreased mortality and LOS
  
• Works well for modern COPD exacerbations
  

NPPV in decompensated left heart failure

• Decreased ICU admissions, if started in ED
  
• 50% reduction in need to intubate
  
• Widely accepted for ADHF
  
• If PaCO2 normal use CPAP not BiPAP
  

Other indications of NPPV

• Immune compromised patients (Intensive Care Med. 2002 Sep;28(9):1233-8)
  
• Hypoxemic respiratory failure (Crit Care Med. 2004 Dec;32(12):2516-23)
  
• Pneumonia with manageable secretions
  
• Asthma exacerbation (Cochrane Database Syst Rev. 2005 Jan 25;(1):CD004360)
  

Clinical pearl: Status asthmaticus with normal ABG is either not that sick or about to crash.

Preoxygenation before intubation
Am J Respir Crit Care Med. 2006 Jul 15;174(2):171-7
Critically ill patients have ~30 seconds before they become hypoxic versus nearly 5 minutes in healthy adults. Effective bag mask ventilation is difficult, thus BiPAP studied before intubation: higher preintubation SpO2, smaller dip in SpO2, fewer severe desaturations.

Postextubation Respiratory Failure
N Engl J Med. 2004 Jun 10;350(24):2452-60
NPPV is an effective bridge post extubation far longer before reintubation. NPPV prevented reintubation only if instituted BEFORE the onset of respiratory failure.

Airway Obstruction?
Sometimes if rapidly reversible cause NPPV can "stent" open an airway

Initiation

• Early is Better (Intensive Care Med. 2002 Dec;28(12):1701-7)
  
• Moderate severe respiratory distress
  
• pH < 7.35 and PaCO2 > 45 mmHg
  
• RR > 25
  

How do I know if it's working?
Chest. 2000 Mar;117(3):828-33

• pH, PaCO2, and LOC if these do not improve in 1-2 hours, it will probably not improve
  
• 48-72 hours total trial
  

Mask Type

• Face mask is more effective
  
• Nasal mask/pillows are more comfortable
  

Complications

• Discomfort
  
• assure: rjuy to nose, the. eye
  
• sinus pain/congestion
  
• mild gastric distortion
  
• Barotrauma is uncommon
  
• Adverse hemodynamic reactions uncommon
  

Common Hematologic Emergencies and Consults
Thrombocytopenia, defined as platelets < 150000

Causes

• Artefact
  
• Dilution
  
• Sequestration
  
• Decreased production
  
• Increased consumption
  

Essentials of work-up

• Review blood smear
  
• History of blood transfusions
  
• Hypersplenism
  
• Bone marrow biopsy
  

"Washout phenomenon"
Platelet count < 50000 would be equivalent to about 15 units transfused

Congenital hereditary thrombocytopenia
Bleeding out of proportion to platelet count and often associated with platelet function deficit (gray platelets, Bernard-Soullier, vWF deficiency Type 2B)

May Hegglin Anamoly
Diagnosed by peripheral smear and associated with MYH9 mutation

Other causes of thrombocytopenia

• B-12 deficiency
  
• Alcohol abuse
  
• Leukemia
  
• DIC
  
• ITP
  
• TTP/HUS
  

Drug-induced thrombocytopenia
Heparin-induced thrombocytopenia (Chest. 2005 Feb;127(2 Suppl):35S-45S)
Diagnostic gold standard: Serotonin platelet loaded assay, however platelet factor 4 assay more commonly available. Hospitalist should support and promote efforts to eliminate heparin flushes. HIT can cause both arterial and venous thrombosis. Fondaparinux can be used to treat (unlabelled use).

Platelet GP IIb-IIIa inhibitors may cause sudden severe drop in platelets (N Engl J Med. 2004 Jan 15;350(3):232-8)

Idiopathic Thrombocytopenic Purpura
Increased bone marrow megakaryocytes. Thrombocytopenia + mucosal based bleeding have increased chance of intracerebral hemorrhage. RFVIIa limits ICH volume in ITP.
Treatment

• 2/3 corticosteroids
  
• 2/3 IV Ig
  
• 2/3 anti-D immunoglobulin (may cause DIC in elderly patients)
  
• 2/3 splenectomy
  
• 2/3 danazol (associated with some virilization and increased hepatic dysfunction
  
• TPO mimetics increase megakaryocyte production of platelets

?H. pylori positive associated with ITP more true in Asia than the US

Thrombotic Thrombocytopenic Purpura
The classic pentad of microangiopathic hemolytic amenia, neurological abnormalities, fever, renal failure and thrombocytopenia is nearly useless clinically. Instead:

• Schistocytes
  
• Elevated LDH
  
• ADAMTS13 inhibitor
  
• vWF multimers
  
• No anticoagulation abnormalities and negative D-dimer
  

Treatment is plasma exchange and corticosteroids

Disseminated intravascular coagulation
Too much thrombin generation or too little down regulation in thrombin or points along the cascade. Induced by sources of tissue factor and is an acquired syndrome characterized by intravascular activation of coagulation leading to end organ damage. Associated with sepsis, trauma, malignancy, obstetric complications, vascular disorders, toxins (snake bite), and immune disorders (severe allergic reactions or transplant rejection). Treatment:

• Treat the underling cause
  
• Heparin anticoagulation
  
• Platelet transfer after anticoagulation
  
•  FFP/cryoprecipitate
  
• ATIII concentrate
  
• Activated protein C concentrate
  

Antiphospholipid Ab syndrome
J Thromb Haemost. 2006 Feb;4(2):295-306
Think of this diagnosis in a pregnant woman presenting with stroke and has a history of recurrent spontaneous abortions. These patients must be anticoagulated, bridge with heparin, eventually target INR > 2.5 with warfarin. If recurrent thrombosis add aspirin.

VTE and postthrombotic syndrome
Deep vein thrombosis is 15-25% associated with cancer and carries 7% mortality. Thrombolytic therapy has not been shown to improve overall mortality.

SHM 2010 Day#1 "It is NOT Rocket Medicine"

SHM Exhibit Hall
I'm attending the Society of Hospital Medicine's 2010 meeting in Washington, D.C. This morning I toured the Exhibit Hall over a tasty (free) breakfast of fruit and pastry products. I saw the GE Vscan which is a PDA sized ultrasound device that would allow nonradiologist physicians to do simple imaging as an adjunct to physical exam. It does not allow for ultrasound guidance of central line placement but it does allow visualization of the heart (i.e. to look for wall motion abnormalities and pericardial effusions), aorta, liver, kidney and gall bladder. The cost is in the $8000 range for a unit one could slip in a pocket. Later in the day (again over free munchies), I was able to contrast the Vscan with the SonoSite M-Turbo which is about the size of a laptop and with a heftier price tag starting $30000. It appears to be able to do anything that is worth doing with ultrasound.
I also checked out the documentation solutions from Shareable Ink which uses Livescribe technology and custom forms to allow handwritten documentation to be immediately available in an electronic medical record. It also has applications for billing. I got to drive the "robohospitalist" or InTouch Health RP-7 Robot. In addition I spoke to the representatives for PNA FISH which offers rapid identification of certain species of bacteria in particular MRSA and VRE as well as candida differentiation within 90 minutes rather than waiting for 2 days for culture results. This begs the question will the Surviving Sepsis Campaign guidelines change in the future? Also I picked up some articles regarding hyponatremia management using vasopressin antagonists as an adjunct in patients resistant to conventional hyponatremia management.
Of course no conference trip for me is complete without a little bit of shopping so I picked up some books (Evidence-Based Medicine: In Sherlock Holmes' Footsteps by Jörgen Nordenström, The 10-minute Clinical Assessment by Knut Schroeder, and ICU Chest Radiology by Harold Moskowitz) at the Wiley Interscience booth and ordered custom heavy weight cotton lab coats with chef's buttons in orange and blue respectively from On Call Medical Coats.

Plenary Session: Hospitalists are Becoming Influencers of Healthcare Policy
The plenary session began with a panel discussion regarding healthcare reform. The idea of the CMS Development Center whose goal is to decrease cost while increasing quality was applauded warily as a great idea already hamstrung by limited vision. One key area of praise was that it would be allowed to independently contract with companies to decrease costs, i.e. rewarding those whose systems work. Meanwhile, terms like "Super-MedPAC", "bundle payments", "medical homes", and "accountable care organization" flew. I'm not entirely clear on what they all meant (nor do I think any of us are) but these are the tools to provide that higher quality of care at less cost. The models of these are places like Mayo and Geysinger, qualifications for accountable care organizations are in the pipe. The argument was made that hospitals, like major academic centers, are actually potential lobbying groups and need to do so to compete with special interest groups.
The bottom line was that "fee for service" will disappear and in its void remains opportunities and challenges for providing as well as reimbursing healthcare. There will be a change from "profit" centers to "cost" centers that create value in non-value based ways. This was summarized best as we need to limit healthcare, not because we don't care but because rising costs do not provide more care. Medicare the "big dumb payer" sends 33% of it's money to hospitals and another 20% to physicians. By stopping paying for readmits, theoretical we increase a hospital's responsibility for readmissions.
Despite the disagreement with "cook book medicine" the use of "comparative effectiveness" will mandate the usage of evidence-based medicine in healthcare. There was some discussion regarding patient autonomy and the entitlement society, particularly in discussion of patient accountability for their own healthcare. One example of how less insurance drove down costs was in Lasix surgery, since it is mostly out of pocket and not covered demand drove down the price.

Plenary Session: Paul Levy
Paul Levy is CEO of Beth Deacon Isreal hospital and runs a blog called Running a Hospital. He presented a paradox: Doctors are dedicated to alleviating suffering but are the 4th leading cause of death in the U.S. In fact the chance of patients being killed in American hospitals each year was greater than the chance of American soldiers in Iraq during the height of the Gulf War being killed.
Doctors like to finish tasks so they often resort to "work arounds" that transiently solve a single problem and not the systemic issue. Mr. Levy discussed the work of Steve Spear examining the the lean approach to production as applied to healthcare. The lean approach as optimized by Toyota up until recently states that when a worker identifies a problem they call the supervisor who initiates a team to work on it, i.e. "root cause analysis".
Mr. Levy also discussed "transparency" as a management tool, stating that after releasing numbers on central line infection and VAP this helped to decrease these complications without more costs. He also noted that leadership takes audacious statements that cannot be scientifically met.

How To Eyeball A Patient

Gestalt View

As you walk into the room is the patient appear sick or not sick? Distressed? Obtunded? Comatose?

ABCs

Does the patient oxygenate and perfuse?

Vital signs

What are the specific numbers, how was it assessed, and does it correlate with the picture above?

Diagnostics

Find abnormalities. That's really what you are paid for. Some people always have high creatinine or low hemoglobin or whatever, so don't focus on the population mean abnormalities, focus on the patient's abnormalities.

Medications

Will tell you a lot about the protoplasmic substrate (except cancer as chemotherapeutic agents generally don't show up on medication reconciliations) and look out for side effects of therapeutic intervention