Sep 30 Update

Batch of updates today - MR back on schedule after month of CPC, inservice, etc.

Today's topic:  gastrointestinal hemorrhage in an anticoagulated patient.

First:  guidelines for management of peptic ulcer bleeds from the American College of Gastroenterology:  Their 30 key recommendations available here, also has link to full text of their guideline for additional reading.

Contrast those recommendations with the ones provided for management of variceal hemorrhage. Key differences in variceal hemorrhage:
 - Octreotide and prophylactic antibiotics indicated for variceal bleed
 - All variceal bleeds require ICU admission, whereas only the high risk subset of ulcer bleeds even require hospitalization.

As for reversal of anticoagulants, this handy pocket card from the American Society of Hematology covers dosing as well as reversal of multiple anticoagulant and antiplatelet medications.  Their guidelines are available as an app as well.

Cardiogenic Shock 

Also from noon conference - make sure you know your mechanical complications of acute myocardial infarction well.  This topic is all over the boards and in training examinations.

Also, remember that right ventricular infarction is something of a unique clinical syndrome.  Nitrates can do great harm, and large amounts of volume resuscitation are often required to overcome RV dysfunction,  Diagnosis in the setting of IWMI requires a R sided ECG, with lead V4r being the highest yield lead for diagnosis.

August 29 WeeklyUpdate

Not as much content this week due to quiz bowl and ethics case rounds, but the following articles are very good reading:

From Monday's noon conference on endocarditis, I recommend this condensed article from NEJM that covers what you need to know about endocarditis for board purposes.

Friday morning report covered management of acute ischemic stroke, as well as measures to prevent recurrences.  Good articles covering the topic are below:

Acute Ischemic Stroke (NEJM Clinical Practice)

Secondary Prevention After Ischemic Stroke (NEJM Clinical Practice)

On a related note, the question often arises - should we heparin bridge A-fib patients on warfarin therapy when their medication is held for surgical procedures.  The answer, according to a study in this week's NEJM, is no.  Stroke events are not reduced, and bleeding is increased if heparin is used during the time warfarin is held.  Always pay attention to exclusion criteria, as this trial excluded anyone who had experienced stroke or TIA symptoms within 12 weeks.

Resuscitated

After a long hiatus, the IM blog is back in action.  I will make weekly posts with links for additional reading to follow up discussions form conferences.

On the topic of resuscitation:  The AHA has specific guidelines for resuscitation in certain unique situations, such as severe asthma, pregnancy, etc.  I will develop a simulation center scenario for one of these for use in a future SimMan session.  The material in this article goes far beyond the material covered in standard ACLS provider courses, and should be reviewed before taking on code team leader responsibilities.  There are separate articles that describe ACLS in the setting of recent cardiac surgery.  These are not currently part of official AHA ACLS guidelines but have been adopted by some institutions.

On the topic of appropriate use of the thrombophilia panel - the BJH has a nice summary of the topic.  In general, these workups are most appropriate for the outpatient follow up setting in select cases only.  Their utility in guiding the inpatient management of most patients is questionable.