BNP: Data, Diagnosis and Applications

Cardiology, CCU Rotation, Respiratory, Why We Do What We Do
BNP: Data, Diagnosis and Applications M Lamberta PGY-3   What are the Biomarkers? [caption id="attachment_3101" align="alignright" width="559"] ACEP Clinical Policy[/caption] Natriuretic Peptide (NP) assays gained approval by the FDA around the year 2000 for the evaluation of undifferentiated dyspnea and suspected ADHF.  The first commercially available test detected the biologically active hormone BNP, but many more recent assays also detect the inert Amino-terminal cleavage product of the BNP prohormone: N-Terminal proBNP (NT-proBNP). (Table 1)  Both biomarkers are comparable in their diagnostic accuracy demonstrated by Receiver Operating Characteristic (ROC) curves.    From 1999 to 2000, Maisel et al. recruited 1,586 participants in the first large multinational randomized control trial (RCT) to evaluate BNP for the diagnosis of heart failure in ED patients presenting with acute dyspnea.[1].  The Breathing Not Properly (BNP)…
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SEATTLE II

Cardiology, CCU Rotation, Respiratory, Why We Do What We Do
Stephanie Haimowitz, PGY3   AS is a 43 yo F, on OCPs for menorrhagia, h/o recent left ACL tear and as a result decreased ambulation x3 weeks, p/w SOB, worse on exertion x2 weeks but acutely worsening on the day of presentation. On the day of presentation, the patient complained of an episode of acutely worsening dyspnea, now occurring at rest and associated with lightheadedness, chest pressure, and diaphoresis. On Exam, the patient was mildly tachycardic with an O2 sat of 98% on RA at rest. She appeared to be breathing comfortably, although at times noted to take shallow breaths, and the remainder of her exam was unremarkable. Labs were notable for an elevated troponin of 0.302. EKG showed sinus tach with a ventricular rate of 106 and an incomplete…
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A Discussion of the Effects of Succinylcholine on Intracranial Pressure in Patients with Acute Brain Injury Requiring Rapid Sequence Intubation with or without Pretreatment with a Neuromuscular Blocking Agent- Dr. Alexander Le

Respiratory
Acute brain injuries (whether due to traumatic brain injury (TBI), spontaneous hemorrhage, or other cause) are a significant public health concern and major cause of morbidity and mortality worldwide. Patients with acute brain injuries frequently require mechanical ventilation, and emergent control of the airway is a time-sensitive, paramount step in management. Rapid sequence intubation (RSI) offers timely control of the airway while maintaining oxygenation and minimizing the risks of aspiration and hypercapnea. Of the choices of paralyzing agents used for RSI, succinylcholine (SCH) is widely favored due to its rapid onset and offset and consistency in achieving excellent intubating conditions.(10) In cases of acute brain injury, the use of SCH has been controversial as it has been implicated as a potential cause of increased intracranial pressure (ICP). This paper will…
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Why We Do What We Do: Limitations of the PERC Score in PE – Dr. Jason West

Respiratory, Why We Do What We Do
When the PERC Rule Fails         Kline et al (1) developed a clinical decision tool based on parameters that could be obtained from a brief initial assessment to reasonably exclude the diagnosis of pulmonary embolism (PE) without the use of D-dimer in order to prevent unnecessary cost and the use of medical resources.  Even our interns have used the PERC rule by now, but we should be clear on what it includes: The PERC rule includes age < 50, HR < 100, oxygen saturation on RA > 94%, no prior history of DVT or PE, no recent trauma or surgery, no hemoptysis, no exogenous estrogen, and no clinical signs suggestive of DVT.   A review and meta-analysis published in the Annals in 2012 (2) found 12 qualifying studies evaluating the PERC rule…
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Why We Do What We Do: Cuffed Tubes versus Uncuffed Tubes in Pediatrics

Respiratory, Why We Do What We Do
In choosing the tube size, one must consider choosing between cuffed and uncuffed tubes. For many years, uncuffed tubes have been recommended for children under 8 yrs of age. The uncuffed tube is to be positioned to form a seal at the cricoid ring; the narrowest portion of the child’s airway. However, a great debate has developed in the world of anesthesia when choosing between a cuffed tube and uncuffed tube. Those who are against cuffed tubes note the paucity of randomized control trials justifying their use. In a pro-con paper discussing the issue, Weber (2009) noted the internal diameter of the cuffed tube will inevitably be smaller due to its thicker wall coupled by the diameter that the cuff adds to create the seal within the trachea. Further, the…
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Why We Do What We Do: HELIOX

Respiratory, Why We Do What We Do
A young child comes to the ED with diffuse wheezing and retractions. You diagnose the patient with RSV bronchiolitis. The child’s oxygen saturation is in the low 90’s and is working very hard to breath. You have tried albuterol but the patient’s symptoms aren’t getting much better. You are concerned you might have intubate this patient if you do not find another solution quickly. Check out the article attached and the thoughts below to offer a possible solution. Noninvasive ventilation with helium-oxygen in children - J of Critical Care 2012 HELIOX is a combination of both Oxygen and Helium. Helium being an inert gas with a low molecular weight has a low density (7x less density). Nitrogen on the other hand has a higher molecular weight and higher density. By…
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