UTSW physicians, residents and interns are always on the look-out for continuous improvement of their hospitals and patient care. Out of several months discussions, Parkland Hospital is implementing a new policy: Tele Monitor Tech will call Code Blue and then call the Telemetry hotline for these lethal rhythms:
Bradycardia 30bmp or less
Sustained VT for > 30 seconds
Great example of team work amongst physicians, residents, nurses and techs. Focusing on effective and safe patient-centered care!
But what do YOU think? For our HouseStaff:
What do you look at if called about possible NSVT and/or VT?
2. You see this rhythm on a telemetry strip:
and after urgent cardioversion, you see that the QT is normal:
Today one of our superstar attendings joined us for lecture. Dr. Sambandam, nephrologist extraordinaire.
The topic was Diuretics Resistance. He went over basic pharmacology of diuretics, mechanisms of resistance, clinical syndromes of resistance and management of diuretic resistance.
Just a few highlights with the powerpoint below:
– Bioavailibilty of torsemide and bumetanide >> furosemide
– Mechanism of diuretic resistance? Excess Na intake, ineffective dosing frequency, increased distal nephron transport
– Resistance but thinking noncompliance? signs include requirement for large doses of diuretic for GFR, requirement for large K replacement
– Renal insufficiency? Will need higher dose of diuretic as tub secretion is diminished and renal mass is reduced
– Natriuresis is directly proportional to GFR
– And so much more! Including slides like this:
A recent Wall Street Journal article highlighted the importance for trainees – both interns and residents to know when to call their Attending for guidance and help. The article describes how 4 hospitals developed guidelines to improve communications and decreased their proportion of critical events that weren’t conveyed to an attending from 33% to just 2%.
At UTSW Internal Medicine program, we support our trainees and remind them that Interns and Residents are encouraged and expected to inform their Faculty members in these following situations:
Events that require prior notification to attending physicians
Dr. Biff Palmer,nephrologist and clinician researcher extraordinaire has published a great piece in NEJM about renal autoregulation, creatinine, anti-HTN agents and renal dysfunction. Fantastic read!
Just a few points:
– with chronic HTN and chronic renal disease, the intraglomerular to MAP (or renal perfusion) curve becomes more linear – and anti-HTN therapy can lead to decreases in intraglomerular pressure for chronic renal disease patient that would not affect a normal person. See Figure 1.
– Chronic renal failure, even small declines in the glomerular filtration rate will lead to an increase in the serum creatinine concentration
– In many patients, this initial decline in renal function will either improve or resolve with long-term control of the blood pressure.
– Allowing blood-pressure control to deteriorate in order to prevent a rise in the creatinine concentration can harm the very patients who benefit most from tight blood-pressure control, which has bee proved to slow the progression of chronic renal failure.
ANSWER:You were correct! The thrombus is in the RA. There is a large free floating thrombus in Right Atrium. Left ventricle ejection fraction is 202-25% with severely depressed RV function. Bi-atrial enlargement with RV dilation. Example apical 4 chamber view on TTE shown below.
Quick Learning Points:
Right sided heart thrombi (RHTh) in 2 types:
– Type A thrombi: worm-like shape, extremely mobile and likely arising from lower-limb veins–> mortality of 28-44%
– Type B thrombi attach to the atrial or ventricular wall indicating that they are probably of local origin. –> mortality of 4% (lower risk than Type A)
* Either can obstruct Right Ventricle filling + emptying or migrate to pulmonary arteries.
Surgical thromboembolectomy has been the treatment of choice in the past, however with RCT lacking – many have presented prospective studies showing good outcome + rapid improvement with t-PA (classically indicated for proven PE w/ cardiogenic shock). Heparin alone may not be adequate as some studies have shown. Catheter-based interventions also an option for those unable to undergo surgery or t-PA.
Our own phenomenal Dr. Brad Cutrell, UTSW ID faculty extraordinaire joined us for our Back-2-Basics series and delivered a lecture to remember! And refer to over-and-over again. Antibiotic Strategies + Pearls!
Only just a few highlights:
– HAP and VAP considered separate entities in new guidelines; removal of HCAP
– Consider PseA in patients w/ Bronchiectasis or COPD + frequent steroids/antibiotics, chronic alcoholism, recent hospitalization in last 90 days
– MDR risk factor: IV Abx use in prior 3 months!
– Anti-Psa for HAP: 2 drug coverage if prior IV abx last 90 day, structural lung dz (e.g. CF), septic shock or MV need
– colony threshold (≥ 105 cfu/mL) is NOT an indication for treatment of asymptomatic bacteriuria
#Answer: You were correct! Atelectasis from mucus plugging of R mainstem bronchus. This patient had severe oropharyngeal dysphagia. The position of the trachea is crucial in formulating a differential for a unilateral lung white-out. Here it is pulled towards the white out, indicating a resorptive atelectasis (also with pulmonary hypoplasia and intubation of bronchus). A pleural space process (effusion, hemothorax) will push the trachea away, while it will remain largely central in a primarily parenchymal (pneumonia, edema) and pleural/chest wall (mesothelioma, tumor) pathology.
Image and write-up credit: Arjun Gupta
A man in his 60’s admitted for myeloma chemotherapy develops acute onset shortness of breath. CXR 12 hours prior (Fig 1) and now (Fig 2) are presented.
Good luck to those applying for fellowships today!
Try to certify/submit your applications today (July 15) – even if all your uploaded LOR from your letter writers have not been yet released by ERAS-EFDO. You can assign those letters once they’ve been released.
Remember you have to pay the fees and only then will your application be released. Confirm this under the “Programs Applied to” tab.
Let the Chiefs know when your interview dates will be – we can help!