Day #194 - Stroke in the Young

A link to an approach to stroke in the young is here.

An article on PFO and stroke (and the treatment thereof) is here.

Day # 193 - Hyponatremia

Approach to hyponatremia, including references available here.

The study, highlighted by the discussant, on marathon induced hyponatremia is available here.

Remember -- the doctor may be the most dangerous factor in the treatment of hyponatremia. Overcorrection can lead to severe consequences.

Day #187 - Intracranial Hemmorhage

Today we discussed a case of intracranial hemorrhage presenting as a stroke like syndrome with confusion, aphasia and neglect.

I have previously blogged about acute confusion and aphasia here.

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Intracerebral Hemorrhage:

• Second most common cause of stroke syndrome
• Mortality -- ICH Score
• GCS 3-4 (=2 pts) 5-12 (=1 pt)
• ICH greater than 30cm2 = 1 pt
• Intraventricular extension (spills into ventricles) = 1 pt
• Infratentorial =1
• Age greater than 80 =1

ICH scores of 1, 2, 3, 4, and 5 were 13, 26, 72, 97, and 100 percent mortality

The key aspects to management of ICH include:

• Reverse coagulopathies
• Reduce blood pressure (goal generally 160-180 systolic) to minimize further bleeding and maximize cerebral perfusion

Reduce risk of progression:

• Stop ASA/plavix -- can consider restarting day 10
  
• Reverse anticoagulation from warfarin -- Prothrombin Complex Concentrate and Vitamin K or FFP
  
  • Can consider restarting @ 2 weeks (tight monitoring) and usually only for hard indications like mechanical heart valves.
    
• Reverse heparin -- protamine sulfate
• Initial excitement about rFVIIa -- now in question.
  

Treat increased ICP:

• Head of bed at 30 degrees
• Analgesia
• Mannitol, surgery if profound increase

Blood Pressure Control:

• Greater than 200 systolic or MAP 150 -- reduce to 160-180
• 160-180 and increased ICP -- consider ICP monitoring and aim for CPP (MAP-ICP) of 60-80
• 160-180 no increased ICP -- goal 160 MAP 110

Surgery has a limited role but can be life saving.

Day #186 - PCP/HIV

I wasn't there (post-call) but I've blogged about this before and I encourage you to read that here.

Day #183 - Severe Influenza Redux

Previously presented this 'classic' case here.

Dr. Allison McGeer, the director of infection control and an infectious diseases physician here at MSH has recently published an article discussing the use of empiric influenza treatment in hospitalized patients here.

You can look up the current level of influenza across Canada here.

Day #182 - Tylenol Overdose

I have previously blogged about hepatitis and tylenol overdose here and here.

The article the discussant mentioned on alcohol and tylenol overdose is available here. There is a newer publication that looks retrospectively at 20 years of ingestion data and adjusts the classic Rumack-Matthew nomogram for chronic alcohol use (without simultaneous co-ingestion).

A similar study proposes to predict the risk of hepatotoxicity using a combination of the tylenol level, the time since ingestion, and the time N-AC is started.

There is some evidence that simultaneous co-ingestion may be protective. This effect, and the effect of alcohol are quantified in the table here (based on the above nomogram)

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A good review article on alcoholic hepatitis is available here.

Other groups have suggested that the glascow alcoholic hepatitis score >=9 is more useful in predicting benefit from corticosteroids than the DF.

Day #181 - Pulmonary Embolism

Today was a case of pulmonary embolism in a patient with advanced malignancy.

We didn't really talk about PE -- but the discussant talked about very relevant issues including end of life care, diagnostic reasoning and clinical decision making.

For your information, I have previously blogged about DVT/PE here and thrombophilia here.

Addendum: NEJM article from Jan 2009 on PE.