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Medical Cases Podcast

Medical Cases Podcast is a medical variety show whose target audience includes Internal Medicine and Emergency Medicine residents, medical students and foreign medical graduates. Podcasts will be 1 of 4 types: knowledge pearls (KP), clinical pearls (CP), board review (BR) and cases.
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Now displaying: August, 2016

Medical Cases Podcast - EM/IM/Critical Care

Aug 29, 2016

Show notes at www.medicalcasespodcast.libsyn.com

 

Remember in medical school when you were taught to treat the patient and not the numbers? It sounded so good, right? So why are we so aggressive with treating fever in patients with sepsis? This episode reviews the article "Acetaminophen for Fever in Critically Ill Patients with Suspected Infection".

 

Bottom line: for septic patients with fever, you can use acetaminophen to treat symptoms but there is no mortality benefit.

Furthermore, if patients are persistently tachycardic despite adequate resuscitation and all other causes of tachycardia have been ruled out there is no harm in giving acetaminophen to control fever/ tachycardia. 

Background: acetaminophen is often used to control fever in patients with suspected infection in the ICU - there is little data to suggest that this is beneficial. 

Population: 700 ICU patients with fever (temp ≥38°C) and suspected source of infection

Design: Multi-center, prospective, parallel-group, blinded, randomized, controlled trial.

Intervention: 1 gm IV acetaminophen Q6H until  1) ICU discharge, 2) Resolution of fever, 3) Cessation of antimicrobial therapy OR 4) Death

Control: Placebo Q6H

Results: Primary Outcome - No difference in ICU free days to day 28. 

Secondary Outcome - No significant differences between the acetaminophen group and the placebo group with respect to mortality at day 28 or at day 90

 

It should be noted that acetaminophen WAS associated with a shorter ICU stay among survivors but a LONGER stay among non-survivors. 

 

 

Acetaminophen has a low chance of harming your patient but it is clear that there is no pressing medical indication (other than discomfort) to treat mild fever in sepsis.

 

Keep in mind that we are talking about fever in suspected infection. There are many other cases where temperature management of some sort IS indicated. This is often acheived through medications or external cooling.

Examples include:

  1. Neuroleptic malignant syndrome 
  2. Serotonin syndrome
  3. Environmental exposure like heat exhaustion and heat stroke
  4. Post cardiac arrest - 33℃ vs 36℃
  5. Malignant hyperthermia
  6. Anticholinergic toxidrome
  7. Brain trauma.
  8. Premies with Hypoxic-Ischemic Encephalopathy 

 

From the article - Young, Paul, Manoj Saxena, and Rinaldo Bellomo. "Acetaminophen for Fever in Critically Ill Patients with Suspected Infection." New England Journal of Medicine N Engl J Med 373.23 (2015): 2215-224. 

 

Aug 20, 2016

 

The topic of this lecture is how to approach a Rapid Response in the hospital. The website has a PDF version of the RAPID RESPONSE CHECKLIST that you can download/print/laminate. There are three sections:

  1. Information
  2. Actions
  3. Differential Dx

 

While the topic is short, the general theme is one that I will continue to expound upon throughout the podcast: you need to be prepared to perform during variant or labile situations in the hospital. A systematic approach is one of keys to being ready.

Caveats to the list: You don't need to check of every item of the checklist but it can be useful to go back to basics if the situation becomes chaotic. Furthermore, no specific order is implied in the checklist. The information gathering and actions can often be done in tandem. The action section may have lab tests not available at your hospital but the general concepts apply. 

 

This episode was inspired by a lecture entitled "Chaos" given by one of our best senior residents. You may notice thematic similarities to Emcrit Podcast 118 - "EMCrit Book Club - On Combat by Dave Grossman"; I recommend listening to that episode as well. 

 

PDF LINK IS BELOW

 

Aug 15, 2016

Episode #2

A knowledge pearl episode with a short case seen during intern year of residency. These three clinical entities all share a common theme; they develop quickly and need definitive management within minutes. 

 

Fentanyl rigid chest syndrome: chest wall/abdominal/masseter rigidity following the administration of fentanyl. More commonly seen with doses >4mcg/kg but can be with ANY dose. 

Risk factors: higher doses, fast push rate, extremities of age, critical illness and use of medications that alter dopamine levels.

Treatment:

  1. Double check your mask seal.
  2. Recognize what is going on.
  3. Give naloxone.
  4. If still unable to ventilate- paralyze with Succinylcholine. 

 

Succinylcholine masseter muscle rigidity (MMR): whereas mild masseter rigidity and jaw stiffness is common up to a minute after giving succinylcholine, MMR presents with severe prolonged jaw stiffness after giving sux. Some of these patients will progress to outright malignant hyperthermia (MH) and management should proceed accordingly. 

Risk factors: inadequate dosing of sux (<1mg/kg), children, myotonia congenita, duchenne muscular dystrophy. 

Treatment:

  1. Double check your ventilations
  2. Recognize what is going on.
  3. Consider propofol for further sedation.
  4. Administer a non-depolarizing agent such as rocuronium or vecuronium.
  5. Expectant management for MH - monitor vitals, EtCO2 (>55 mmHg is bad), urine, cpk, abg.
  6. Give dantrolene 2.5mg/kg if MH. 

 

Ketamine Induced Laryngospasm: laryngospasm seen after giving ketamine. Results in difficult ventilation. Can often be managed with CPAP or positive pressure ventilation using a BVM. 

Risk factors: children <3 mo, pts with active URTI or asthma, larger doses, rapid push rate. 

Treatment:

  1. Double check your mask seal
  2. Recognize what is going on/ call for help.
  3. Give 100% FiO2 through tight mask sealed BVM with positive pressure or CPAP.
  4. Attempt pressure at "Larson's Point" (may or may not work).
  5. Consider propofol for further sedation
  6. Give succinylcholine (4 mg/kg IM or 1.5 mg/kg IV) for paralysis - this is very rarely needed for isolated ketamine induced laryngospasm. Use Broselow tape to determine dosages in children. 

 

 

Aug 15, 2016

Motivated by the podcast greats in the EM world; the very first episode of MCP. 

What inspired this podcast was a month long elective ER/ICU rotation during my second year of residency. In preparation for rounding and doing H/P's in Spanish I wanted to improve my medical vocabulary. I listened to a lot of medical podcasts in Spanish. What I wanted at that time was a podcast with variety, excitement and that fit my interests of EM/IM/critical care. There was nothing that fit that description perfectly - that is what this podcast will intend to be. While I did learn Spanish, episodes will be in English. 

The goal of the podcast is to provide interesting and clinically useful medical pearls, management strategies and case presentations to med students, EM/IM residents and foreign medical graduates. 

I suspect that the podcast will evolve as time goes on. 

Initially, lectures will be one of 4 types: 1) Knowledge Pearls (KP), 2) Clinical Pearls (CP), 3) Cases, 4) Board Review (BR)

 

 

 

Disclaimer: This is educational material much like any lecture that you would hear. Use your own judgement and know that every clinician including myself can be flawed in their teachings. Medicine changes, research changes and so should your opinions as time goes on.  

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