Tasty Morsels of EM 037 – Heart Transplants

I keep a little, ever-expanding note on my phone where I jot down little morsels of goodness that I pick up while listening to or reading one of the many excellent sites/podcasts in the useful resource section. They’re useful in a kind of “board review” way. I tend to skip the really basic stuff and try and focus on what I didn’t know.

I’ll try and transfer them here for your enlightenment.

  • 5 year survival about 75%
  • most common ED complaints are fever, SOB, GI probs, chest pain
  • baseline tachycardia is normal as no vagus innervation to the transplanted heart
  • patient has no pericardium but due to scarring clinical tamponade can still develop
  • chest pain is rarely related to ischaemia as heart is denervated (most anginal pain is probably sympathetically mediated and the sympathetic plexi around the heart would have been disconnected at transplant)
  • however ischaemia is common as atherosclerosis is accelerated in the graft. Often presents as CHF or arrhythmia.
  • CMV is a risk factor for accelerated atherosclerosis.
  • ECG Often demonstrates two p waves. One is from native sinus node (which is often left in place as it lies in the post RA) and the other is from the donor SA node. The donor p wave is the one that should conduct.
Via Wikipedia

Via Wikipedia

  • rarely a heterotropic transplant is done where the the native heart remains in entirety in the chest. The ECG in this scenario is understandably bizarre.

Reference:

Rosen 7th Edition p2369-70

Tasty Morsels of EM 036 – Serotonin Syndrome

I keep a little, ever-expanding note on my phone where I jot down little morsels of goodness that I pick up while listening to or reading one of the many excellent sites/podcasts in the useful resource section. They’re useful in a kind of “board review” way. I tend to skip the really basic stuff and try and focus on what I didn’t know.

I’ll try and transfer them here for your enlightenment.

  • ‘CAN’

    • C: Cental Nervous Syndrome

      • Altered Mental State

      • Seizures

    • A: Autonomic Nervous System

      • BP High or Low

      • HR High or Low

      • Mydriasis

      • Flushing, sweating

      • Hyperthermia

    • N: Neuromuscular dysfunction

      • Rigidity

      • Hyperreflexia

      • Clonus, inc ocular) If spontaneous then highly suspicious

      • Tremor

  • Comes from

    • serotonergic drugs, in OD or combination

  • Treat with

    • the usual (and probably the most important) supportive care

    • cyproheptadine (anti-histamine and anti-serotonergic) the one to remember

References:

  • Serotonin Syndrome NEJM [via Salim Rezaie]
  • Critical Care Compendium LITFL and Conundrum

Featured Image: Wikimedia Commons

Tasty Morsels of EM 035 – Erythema Multiforme

I keep a little, ever-expanding note on my phone where I jot down little morsels of goodness that I pick up while listening to or reading one of the many excellent sites/podcasts in the useful resource section. They’re useful in a kind of “board review” way. I tend to skip the really basic stuff and try and focus on what I didn’t know.

I’ll try and transfer them here for your enlightenment.

Multiforme

  • Target lesions

  • Usually symmetrical and involves hands and feet

  • Frequent mucous membrane erosions (called EM major if mucous membrane involved. This is the SJS/TEN spectrum)

  • Common Associations

    • HSV

    • Mycoplasma

    • Drugs only about 10% overall, with NSAIDs and sulphonamides commonest causes

 

 

Tasty Morsels of EM 034 – HIV Emergencies

I keep a little, ever-expanding note on my phone where I jot down little morsels of goodness that I pick up while listening to or reading one of the many excellent sites/podcasts in the useful resource section. They’re useful in a kind of “board review” way. I tend to skip the really basic stuff and try and focus on what I didn’t know.

I’ll try and transfer them here for your enlightenment.

From the AFJEM series on HIV emergencies. Well worth a read [Free Full Text]:

  • Acute HIV usually within 3 weeks. No antibodies as yet therefore antibody tests will be negative. Viral loads however will be very high for the same reason

  • Recurrent severe bacterial pneumonia (>2 in 12 mths) is a who stage four diagnosis (what you could call AIDS defining)

  • TB may present as lobar pneumonia esp in lower lobes

  • LDH greater than 500 supports diagnosis of PCP

  • Commonest HIV associated neurological conditions

    • Cryptococcal meningitis

    • Toxoplasmosis

    • TB

    • Lymphoma

  • In cryptococcal meningitis the opening pressure is usually raised. A key treatment goal is reduction of that pressure by CSF drainage

  • People with HIV have four times risk of DVT. Reason unclear.

  • The major AIDS defining malignancies are all virally mediated

  • Acute red eye means two things

    • CMV retinitis

    • Zoster Ophthalmicus

  • Diarrhoea is common and may be acute infection, HAART related or due to HIV itself

  • HIV medications are complex with a bewildering range of them with unpronounceable names and a cornucopia of side effects. The good news is they work

  • IRIS = immune reconstitution inflammatory syndrome

    • Following initiation of HAART CD4 improves and viral loads fall

    • Paradoxically there can be a worsening of condition typically manifested by an opportunistic infection

References:

Chandra, Amit, Jacqueline Firth, Abid Sheikh, and Premal Patel. “Emergencies Related to HIV Infection and Treatment (Part 1)” African Journal of Emergency Medicine 3, no. 3 (September 1, 2013): 142–149. doi:10.1016/j.afjem.2013.03.005. [Free Full Text]

Chandra, Amit, Jacqueline Firth, Abid Sheikh, and Premal Patel. “Emergencies Related to HIV Infection and Treatment (Part 2)” African Journal of Emergency Medicine (May 30, 2013): 1–6. doi:10.1016/j.afjem.2013.04.001. [Free Full Text]

 

Tasty Morsels of EM 033 – Melanoma recognition

I keep a little, ever-expanding note on my phone where I jot down little morsels of goodness that I pick up while listening to or reading one of the many excellent sites/podcasts in the useful resource section. They’re useful in a kind of “board review” way. I tend to skip the really basic stuff and try and focus on what I didn’t know.

I’ll try and transfer them here for your enlightenment.

I ended up browsing this on uptodate one day. Still not sure why…

ABCDE for melanoma

  • Asymmetry (if a lesion is bisected, one half is not identical to the other half)

  • Border irregularities

  • Color variegation (brown, red, black or blue/gray, and white)

  • Diameter ≥6 mm

  • Evolving: a lesion that is changing in size, shape, or color, or a new lesion

Prognosis is linked to thickness of tumour. Stage 1 has a great 92% 10yr survival

The ugly duckling sign

  • Most naevi share characteristics that make them look like other nearby naevi. If there’s one that really stands out then think melanoma