Month: March 2017

March 23, 2017

Bedside Ultrasound Quiz Part 2: A 50 yr old man with dyspnea, acidosis, hepatitis and leg edema. #FOAMed, #FOAMer, #FOAMus

So I was glad to see some great answers on twitter about this case, so let me fill you guys in on the management and the details.

So my diagnosis was of a (likely viral) myocarditis as a subacute process over the last weeks, with a superimposed pneumonia causing the acute deterioration and presentation to ED.  I didn’t think that his elevated lactate represented shock, but rather a reflection of adrenergic activation and reduced hepatic clearance due to congestive hepatitis.  He also had congestive renal failure. Of course, the LV had a 4 x 2 cm apical thrombus, which is likely secondary to the dilated cardiomyopathy.

So the management was diuretics, antibiotics, and anticoagulation, which resulted in a gradual improvement of the respiratory status and renal/hepatic dysfunction. He had a coronary angiogram the day following admission which showed two 50% stenoses deemed to be innocent bystanders.

Bottom Line:

I think the learning point in this case is that, without POCUS, this could easily have been treated as severe sepsis with multiple organ failure (potentially rationalizing away the BP of 140 as a “relatively low” BP due to untreated hypertension), and as such, may have received fluids… Especially south of the border where they are mandated to give 30 cc/kg to anything deemed “septic.”  This would have been the polar opposite of the necessary treatment.

The scarier thought is that he may have then progressed to “ARDS,” been intubated and then the debate between keeping him dry and giving fluids for the kidneys may have ensued.  Though a formal echo likely would have been done, it may not have happened in the first 24-48 hours… If MSOF progressed and he succumbed, the rational may have been that he was “so sick,” and died despite “best care…”

The reality is that he is not yet out of the woods today, with an EF of 15% and afib, but he is off O2 and sitting up in a chair. Fingers crossed he falls in the group of those with myocarditis who improve…

Love to hear anyone’s thoughts!

 

Cheers

Philippe

March 21, 2017

Bedside Ultrasound Quiz Part 1: a 50 yr old man with dyspnea, acidosis, hepatitis and leg edema. #FOAMed, #FOAMer, #FOAMus

So last night, an interesting call from the ED about a 50 year old man who presented with a 3 week history of increasing dyspnea, leg edema, temp of 39,  a lactate of 3.9, an INR of 1.7, elevated LFTs and a WBC of 18, but a BP of 130/75.

Fortunately, I was dealing with a saavy ER doc with some POCUS capabilities, so he also told me he saw a pretty big IVC and he was a bit leery about giving fluids, though this looked like pretty severe sepsis with 3 or 4 affected organ systems…

So I asked him to hold fluids until I got there. Here is what POCUS found:

He revealed a past history of untreated hypertention, and a flu-like illness 3-4weeks ago.

What’s the diagnosis (-es) and management?

Answers & Clinical evolution in part 2 tomorrow!

 

cheers

 

Philippe

 

 

 

 

 

 

 

 

March 17, 2017

Bedside Ultrasound Clip Quiz! A 72 year old man with fever, weight loss and tachycardia. #FOAMed, #FOAMcc, #FOAMer

So a 72 year old man is brought to the ER after collapsing at home. His family had noted weight loss in the last months, and recently some fever and general weakness.  His HR is 108, T 38.8, BP 80/40, GCS 14 – somnolent – he is in lactic acidosis (4.5) and renal failure (cr 180 – baseline 120), with some vague abdominal pain, a clear chest and warm extremities.

POCUS shows a normal IVC, normal RV/LV, A profile lungs, no ascites, and this on the left flank:

 

What is the main diagnosis?

Scroll below for the answer:

 

 

 

 

 

 

 

 

 

So the clip shows fairly severe hydronephrosis, the “bear paw” with very dilated calyces.  The patient was suffering from obstructed pyelonephritis due to massive retroperitoneal adenopathy later found to be lymphoma.  A couple of hours later he got a nephrostomy tube to take care of the septic source (double J could not pass) and his sepsis resolved within a few days, and he headed off to chemo for the NHL.

The advantage of POCUS here is. once again, the speed of diagnosis. He went straight from CT to the readied urologists and source control happened within a couple of hours. His relatively benign abdomen may not have prompted a rapid CT otherwise.

See here for more POCUS!

cheers!

 

 

Philippe

March 12, 2017

Genomics & Preventive Medicine: The Next Level. #FOAMed

So, on a totally different note that has little to do with my usual rants about bedside ultrasound, resuscitation and critical care, I wanted to share with everyone an interesting project I’m involved in which really applies not only to prevention and early diagnosis, but even to the care of the acutely ill, and this is genomics.

To us physicians in the trenches, mutations are generally clinically relevant in certain limited settings, such as thrombosis (factor V et al, ), cancers (BRCA1, etc), but not really in our day-to-day. However, in the next decade, this will probably change quite a bit. The human genome project not turbocharged by crisper technology has resulted in an exponential increase in research and discovery of genetic mutations, disorders and, around the corner, gene therapy.

 

So in the last year we’ve put together a team, developed and designed a process by which an individual can get his entire genome sequenced, then ran against the current crop of known and significant mutations. We have a team of genetic counselors that will ensure follow-up of anything found. Additionally, genomes will be re-run on a yearly basis against any newly discovered significances.

So, what does this mean clinically? Well, I won’t bore everyone with a mutation-by-mutation breakdown of what could be done, but I think everyone understands the advantage of knowing specific disease propensity and having a heads-up for the development of certain associated pathologies. If I had factor V leiden, I might be tempted to take a couple aspirins before boarding and make sure I walk the aisles regularly in my trans-pacific flight, or if I have the philadelphia chromosome, I might get a cbc when my cold/flu lasts more than a couple days…

To get a little more perspective, here is a recent article by the American College of Medical Genetics that may help see the possibilities:

ACMG Article

So I’m really quite excited by this development, and I think it can have quite an impact. For the moment, there are costs involved, but as we are clinician group and not a corporate machine, we are keeping these as low as possible. For anyone interested, for themselves, their practice or their patients, or just have some questions, please get in touch! We have just opened up the “door” in Montreal and are starting up in Toronto shortly.

The real value to this organization is a turn-key solution to genetic testing and follow-up, unlike any other out there, none of which are MD-run nor involve genetic counselors and association to specific clinics and medical follow-up, in addition to the updating of the patient’s variants against new discoveries and treatments.

This is the cutting edge. That’s why I like it!

See below for some more details:

cheers

 

Philippe

March 1, 2017

Great things to come at TheRounds! Webminar Series 2017

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Just to let everyone out there know about a cool thing coming up on TheRounds (www.therounds.ca), which is a professional network for medical students and physicians, permitting an exchange of ideas and knowledge between peers in a secure network (verifiable credentials needed, but free to join).

So we are starting up what should be a pretty cool series of webminars in the next couple of months, and I’ve been asked to chair the scientific committee, so we’ll be drawing up the programme in the next month or so, so needless to say we should have some familiar FOAMed names in the fields of ED/CC and probably hospital medicine contributing.

We’ll be sure to cover interesting topics, controversial ideas, groundbreaking studies and set it all in  physiology, with the philosophy of individualized care. I’m happy to entertain ideas and requests from the FOAMed world, and highly encourage everyone to join and contribute. You won’t find any “industry” talks here, I guarantee it.

So great topics and speakers aside, this will be a great CME opportunity, as the formula will include the faculty remaining active answering questions for a couple of weeks after each webminar, which will likely feature 2-3 talks on a given topic. Even better, TheRounds also has a system that keeps a log of your CME (including browsing time) so it will be really simple to tally every year.

So looking forward to this new venture, and hope to see a slew of the FOAMers join in!

 

cheers

 

Philippe