Variceal Hemorrhage

Today we discussed the case of an elderly man who presented with an upper GI bleed in the setting of known cirrhosis. A variceal bleed was suspected.

Management of an upper GI bleed is a common scenario faced in our hospital's Emergency Department. Keep the following questions in mind:

1) Is my patient stable (ABCs, IV access -large bore, and on the monitor)?
2) Do they need fluid?
3) Do they need blood?
4) Are they coagulopathic?
5) What management can I initiate now (acid suppression, octreotide)?
6) Do I need to call Gastroenterology now?

Here is a link to a recent review on the management of variceal bleeds in the setting of cirrhosis.

Finally, here is a link for a review on the natural history and consequences of Hepatitis B.

Atrial Fibrillation

Today we discussed a case of a critically ill patient who had atrial fibrillation with rapid ventricular response and hypotension.

From a management perspective, this can be a difficult situation as many of the agents we use to rate control patients (beta-blockers and CCBs) also have a negative inotropic effect. Amiodarone can be used intravenously but also drops blood pressure in this formulation. Alternative therapies (digoxin) may avoid this, but also seem to be less effective. D/C cardioversion may bring the patient back to sinus rhythm, but will not keep them there if the underlying issue has not been assessed.

Remember that if critical illness is driving the rhythm, aggressive therapy to the underlying cause is what counts.

If you are looking for some light reading, here are the AHA guidelines on atrial fibrillation.

Finally, this is the link for the article I mentioned comparing diltiazem to digoxin or amiodarone for rate control in atrial fibrillation.

Aortic Stenosis

Today in Morning report we discussed a case of chest pain was attributed to aortic stenosis. Much of our discussion centred on the physical exam findings.

Here is a link to a previous posting that summarizes this for you.

Medical management of aortic stenosis is limited as no drug has been shown to significantly change outcomes. If the stenotic lesion is severe enough, and the patient is symptomatic, valve replacement procedures should be considered (open vs. percutaneous). Read a NEJM review here, that summarizes surgical indications.

Find the JAMA rationale clinical exam article on systolic murmurs here, and review a bedside prediction rule here.

Fever after International Travel

Yesterday we discussed the classic case of fever in a returning traveler.

There are many diagnostic approaches to take in this situation but a careful travel history is often the key to the diagnosis. Never forget that when people travel, the may do riskier things then is typical for them (or that they may care to admit) both in the environment or with other people. Point is: you need to ask and you need to look.

Inquire about chemoprophylaxis, vaccines and sick contacts and take a minute to check out the country's information on the CDC website.

An oldie but goodie review from NEJM can be found here and does a nice job with the differential diagnosis.

Rashes and bleeds

In Morning Report today, we ran through a number of cases. I wanted to highlight a couple of points:

Upper GI Bleeding

Discussion surrounding the medical management of upper GI bleeding focused on the role and dose of acid suppression medication. Specifically, does intravenous pantoprazole change outcomes as compared to an oral equivalent. The administration of high-dose intravenous proton-pump inhibitors while the patient is awaiting endoscopy does not appear to have an effect on the outcome, even though its use may be associated with a significant down-staging of endoscopic lesions. Whether this is cost-effective is still controversial. There is a recent NEJM review on the topic that I would encourage you to read.

Rash

Our case of the night focused on an approach to a patient with a rash involving the palms and soles. Involvement of the palms and soles minimizes the differential and includes syphilis, rocky mountain spotted fever, Enteroviral infections including Coxsackievirus and Echovirus, drug reactions and contact dermatitis. You MUST rule out syphilis in this context. Here is a BMJ review on syphilis. Check out some pictures here in CMAJ.