Tasty Morsels of EM 054 – Paeds Cardiology: Long QT

As always, this is from the ever expanding google doc on bits and bobs I read and learn from and transfer here for all our learning pleasure.

Today we have some notes from a lecture by a paeds cardiologist at a recent national EM training day.

The first is on long QT

  • the Schwartz score can be useful for diagnosis of long QT syndrome. Now a bit old and superseded by genetics but important to know that it is not all about the QT on the ECG – it’s a syndrome with various factors.
  • T wave alternans is a marker of ventricular instability
  • 3 main provocations of arrhythmia
    • swimming
    • arguing
    • alarm clocks
  • long QT in the first 2 weeks of life will usually be normal
  • like many folk he emphasised the importance of manual measurement of QT
  • beta blockers really good for this disease. Only if you have an event on a beta blocker do you get an ICD implanted
  • there are the Bethseda guidelines on exercise which tend to be very conservative. There are some recent moves to relax this
  • if you find someone with syncope and a long QT then they probably don’t need admitted but this totally depends on the paeds cardiology service you have – they need to have a planned follow up and in my opinion if you’re in a system where you can’t get that then maybe admitting them is the way to go

 

Tasty Morsels of EM 053 – Use of Naloxone

As always, this is from the ever expanding google doc on bits and bobs I read and learn from and transfer here for all our learning pleasure.

Today it comes from a paper I found via the Poison Review from two well known names in Toxicology, Hong Kim [here him speak on MarylandCC Project] and Lewis Nelson.

For those that work with me naloxone is a bit of a personal hobby horse of mine. I think it gets overused and poorly used and we seem to take perverse pleasure and moral superiority in acutely and totally reversing someone’s “high”.

Below are some of the pearls and learning points I got from it..

  • despite popular opinion, if you can’t reverse a clearly opioid toxicity then it may well be buprenorphine you’re dealing with. (due to the complex chemical bit that I don’t really follow…)
  • 0.04mg (a tenth of the dose found in most amps in the UK/Ireland) is probably the starting dose of choice (probably, not great science behind this but it’s what all the smart people say) in the opioid dependant person and titrate up. You can titrate up to 10mg or maybe even more.
  • However if they have respiratory depression from opiates you have given the patient then feel free to give the whole  amp (in our case 0.4mg)
  • naloxone is short acting as it is very lipophilic and redistributes very quickly (possibly quicker than the opiate you were reversing) therefore patients can rebound into opiate toxicity (possibly after absconding from your ED…)
  • if the patient is profoundly bradypneoic or apnoeic then it might be better to bag them first prior to reversal. The theory is that if they have a high pCO2 when you reverse them it may cause an increased catecholamine response with the reversal (this is animal data but it’s a nice pearl)
  • therefore they suggest against use of o2 for patients with respiratory depression without CO2 monitoring. This is probably the right thing to do despite the routine practice of people slumped in wheelchairs with a face mask on and sats of 100% and a CO2 of dear knows what…
  • they recommend the widely known infusion of 2/3 of the reversal dose over an hour
  • they warn of the dangers of acute reversal (something many people seem quite satisfied with)

Check out the paper [if you can get access] and remember to watch my favourite scene of naloxone in popular culture.

Kim HK, Nelson LS. Reducing the harm of opioid overdose with the safe use of naloxone: a pharmacologic review. Expert Opinion on Drug Safety. Informa UK, Ltd; 2015;14 (07 ):000–0.

 

Featured image via “M” on flickr CC license

Tasty Morsels of EM 052 – Rheumatic Fever and the Jones Criteria

As always, this is from the ever expanding google doc on bits and bobs I read and learn from and transfer here for all our learning pleasure.

This is something you’re very unlikely to diagnose in Ireland. The real reason for including this is it seems to be a favourite exam question and I put it here in the hope that I’ll remember it. I did look after a couple of kids with ARF when I was in NZ in 2007 but that’s it.

As an acute illness you’re hoping to see

  • kid aged 5-15
  • Migratory Arthritis
    • usually the earliest manifestation
    • usually large joints
    • one joint just settling while another one flares up. Usually over a 2 week period or so
  • Carditis (a poker overuse syndrome?)
    • usually called a pancarditis cause it can affect everything from valves to myocardium
  • Sydenham chorea (nothing to do with the Sydenham bypass apparently…)
    • sometimes called St Vitus’s dance. See this video.
  • Rash
    • Erythema marginatum
    • serpinginous (what a word!) bright pink macules
    • apparently hot water (bath or shower) could make the rash worse
  • Subcutaneous nodules
    • small round and painless over the joints

These are summarised in the Jones criteria:

  • Major
    • Arthritis
    • Carditis
    • Chorea
    • Rash
    • Nodules
  • Minor
    • Fever >38
    • Arthralgia
    • ESR/CRP rise
    • Prolonged PR interval (without other carditis)

Two major criteria nails it or one major and two minor.

More FOAMed Resources:

Featured Image:

  • Painting by Pieter Brueghel the Younger on Wikipedia CC License. Of note it comes from a wonderful article called ‘dancing mania’.

Tasty Morsels of EM 051 – Spondyloarthropathy

As always, this is from the ever expanding google doc on bits and bobs I read and learn from and transfer here for all our learning pleasure. This one from a recent training day with a rheumatologist. Some is literature based some his good old fashioned doctoring and experience.

  • can be axial (think ank spond) or peripheral (think psoriatic)
  • most important ones
    • ankylosing spondylitis
    • reactive arthritis (formerly Reiter’s)
    • arthritis of inflammatory bowel disease (enteropathic arthritis)
    • psoriatic
  • enthesitis (tendons or ligs into bone) and dactylitis are distinctive features
  • lots of systemic features/associations
    • uveitis
    • skin rash
  • For ank spond MRI will show the SI joint changes so much earlier than plain films and you’re likely wasting your time with plain films (my own opinion on that one)
  • NICE Guidelines suggest diagnosis of ank spond based on radiological and clinical evidence. Beware of unilateral sacroilitis as it’s often infective (esp IDU)
  • Psoriatic
    • nail disease v common
    • back pain, dactylitis and enthesitis all common
    • psoriatic skin changes prior to the arthritis in 60%

 

References:

  • Excellent rheumatology lecture somewhere in the midlands of Ireland Spring 2015
  • Rosen’s 8th Edition Chap 115

 

Featured image:

Tasty Morsels of EM 049 – Gout

As always, this is from the ever expanding google doc on bits and bobs I read and learn from and transfer here for all our learning pleasure. This one from a recent training day with a rheumatologist. Some is literature based some his good old fashioned doctoring and experience.

  • 10-40% have a normal urate during flares
  • the red hot shiny joint is rarely rheumatoid, much more suggestive of gout
  • 95% of nodules are gout or rheumatoid. If you want a really easy diagnosis then crystals of gout are present in huge numbers in a gouty tophus and if you can read or find someone to read a microscope then it might get you out of needling a joint
  • wine less gout forming than beer or spirit
  • coffee protective against gout
  • intense exercise and micro trauma at 1st MTP can precipitate gout
  • podagra was the old school term for classic 1st MTP disease. Knee disease rejoices in the term gonagra

Acute treatment pearls:

  • NSAIDs, if contraindications then topical still great for single joint
  • Colchicine (1.8mg a day) at a low dose, can be used chronically. Remember SEs (sepsis, home marrow suppression. Mostly D&V)
  • Steroids (personally i use steroids a lot for gout in the older folk with comorbidities and a few joints involved)

Chronic treatment pearls:

  • Colchincine can be used
  • Allopurinol: usually wait 6 weeks but can start immediately as long as they get some steroid cover which was news to me

References:

  • Excellent rheumatology lecture somewhere in the midlands of Ireland Spring 2015
  • Featured Image: Nick Gorton, CC License, Wikipedia

Other FOAMed sources