Unusual condition discussed today - spontaneous dissection of the carotid artery resulting in stroke in a young patient. Often precipitated by an innocuous trauma such as turning the head rapidly, painting a ceiling, extending the neck during hair care at a beauty shop, and chriopractic manipulation (risk probably less than 1 in 40,000 encounters).
Collagen vascular disease present in ~ 1/4 as a predisposing cause.
This article from NEJM is a comprehensive review of the topic and covers vertebrobasilar (which has a similar pathogenesis and treatment) dissection as well.
Treatment is anticoagulation with heparin followed by warfarin, and interventions such as stenting is generally reserved for those with unresolving neuro deficits or significant hemodynamic cerebral blood flow impairments.
Review of topics covered in morning report, M&m, and core conferences with links to supplemental reading material.
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Wednesday, October 5, 2011
Tuesday, October 4, 2011
Sep 30 MR - Hyperglycemia Potpourri
Hyperglycemic Crises in Diabetes - review article from the ADA with great references and resources, covers the topics discussed today. Read this and you will know enough for boards and most patient care scenarios. Read and know the rest and you will be an internist.
Two contrasting cases of significant hyperglycemia - classic DKA and hyperglycemic hyperosmolar nonketotic state (HHNS) also formerly known as hyperglycemic nonketotic coma and many other names.
HHNS is a condition seen in type 2 diabetics with uncontrolled disease that lose access to free water due to debility, restraints, or acute illness. Things rapidly spiral out of control as they lose fluids from osmotic diuresis and develope more and more concentrated serum.
This AFP article is a good review of the condition and its treatment. Primary focus should be on volume resuscitation as it is not a pure insulin deficiency state. Administering insulin before fluid resuscitation could precipitate hypotension.
Also, keep in mind that this syndrome can precipitate central pontine myelinolysis, even in the absence of hyponatremia, as this article and several other reports have demonstrated.
As for DKA this is a condition that some patients have so often it often breeds complacency in physicians caring for them. It is a life threatening emergency and bad management decisions can make things worse. Overcorrection of glucose, inadequate volume resuscitation, or mismanagement of electrolyte problems are all potential pitfalls. It is easy to get lost in the data and a flowchart is essential to ensure good management. This article from a pediatric diabetes journal summarizes concensus guidelines and includes tons of useful calculations and fomulas for various fluid and insulin regimens. Most of this generalizes to care of adult DKA patients.
Two contrasting cases of significant hyperglycemia - classic DKA and hyperglycemic hyperosmolar nonketotic state (HHNS) also formerly known as hyperglycemic nonketotic coma and many other names.
HHNS is a condition seen in type 2 diabetics with uncontrolled disease that lose access to free water due to debility, restraints, or acute illness. Things rapidly spiral out of control as they lose fluids from osmotic diuresis and develope more and more concentrated serum.
This AFP article is a good review of the condition and its treatment. Primary focus should be on volume resuscitation as it is not a pure insulin deficiency state. Administering insulin before fluid resuscitation could precipitate hypotension.
Also, keep in mind that this syndrome can precipitate central pontine myelinolysis, even in the absence of hyponatremia, as this article and several other reports have demonstrated.
As for DKA this is a condition that some patients have so often it often breeds complacency in physicians caring for them. It is a life threatening emergency and bad management decisions can make things worse. Overcorrection of glucose, inadequate volume resuscitation, or mismanagement of electrolyte problems are all potential pitfalls. It is easy to get lost in the data and a flowchart is essential to ensure good management. This article from a pediatric diabetes journal summarizes concensus guidelines and includes tons of useful calculations and fomulas for various fluid and insulin regimens. Most of this generalizes to care of adult DKA patients.
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