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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Why Not Dobutamine?

Cardiology, CCU Rotation, EBM, Why We Do What We Do
Why Not Dobutamine? PGY3 Neil McCormack   A patient rolls into the emergency room. You don’t need this. You’ve got a lot of other patients. This patient however is in shock. They are hypotensive and with a decreased mental status. You need to give them something and the attending asks what vasopressors you would like. “Why not dobutamine” the intern asks. With a sigh and a heavy eye roll you turn away. But… Why not dobutamine?                 Dobutamine is a synthetic catecholamine used primarily for cardiac stress testing outside of the hypotensive patient (8). This is due to the positive inotropic effects it plays on the heart. Dobutamine acts via a 3:1 selective agonist effect on β1 and β2 receptors respectively. This causes…
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Dilt v. Metoprolol in Afib/RVR

Cardiology, EBM, Journal Club, Why We Do What We Do
by Najm Haque, PGY2   Atrial fibrillation with rapid ventricular response is a common emergency room problem. Patient with stable blood pressure who present in Afib with RVR need medications to control their heart rate (unstable patients require more cardioversion). Traditionally, these patients receive beta blockers or calcium channel blockers in IV form for rate control. The most common medications used in the US are metoprolol and diltiazem, but it is unclear which is superior. Fromm et al Diltiazem vs. Metoprolol in the Management of Atrial Fibrillation or Flutter with Rapid Ventricular Rate in the Emergency Department This study was published in the Journal of Emergency Medicine in April 2015 and compared how fast rate control was achieved in diltiazem vs metoprolol. This was a prospective, double-blind study which compared…
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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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Goodbye MONA? Oxygen in AMI

Cardiology, CCU Rotation, Journal Club, Why We Do What We Do
Goodbye MONA? [caption id="" align="alignnone" width="291"] From: Best Mona Lisa Parodies @ http://beforeitsnews.com/fun-news/2011/09/the-best-mona-lisa-parodies-1167194.html[/caption] Dr. Mayuri Patel PGY3 CC: Chest pain and Shortness of breath HPI: 72F w/ PMHx of Rheumatic fever (s/p AVR repair 9 years prior), pHTN, hFrEF (EF 30%), HLD, DVT (on coumadin) s/p IVC filter BIBEMS for progressive DOE over 1 month. Prior to arrival to ED, pt developed substernal chest pain radiating to jaw associated with diaphoresis and nausea. EMS placed patient on NRB. Triage VS afebrile BP 129/85 HR 74 RR 24 02 96%RA General: awake, mild distress, oriented to person, place and time CVS: RRR Pulm: CTA – b/l Abd: +bs, soft, nt/nd Ext: 2+ pulses, no cyanosis or edema EKG – Sinus rhythm, HR 74, STE II, III, aVF with reciprocal changes Troponin…
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Why We Do What We Do Critical Care Edition: Is there an Echo? What is all This I Keep Hearing About ECMO?

Why We Do What We Do
By: Moses Washington, MD Figure 1: Central ECMO cannulation, image courtesy of google images, N Engl J Med 2011; 365:1905-1914 Extracorporeal Membrane Oxygenation (ECMO) is a procedure that over the past several years has seen a tremendous resurgence in its use in adults. ECMO is effectively a type of mechanical cardiopulmonary bypass that temporarily (days to weeks) supports the cardiovascular and/or respiratory system in severe illnesses. It has often been used as a last ditch effort in treating refractory illnesses such as ARDS (most commonly), peri-transplant, cardiogenic shock, and post-cardiac arrest. The original technology has been in existence since early 1970s, but very small trials showed its poor outcome resulted in its abandonment in adult population. ECMO only recently saw a resurgence beyond the cardio-thoracic operating rooms in adults during…
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Why We Do What We Do: Do We Really Need Contrast CT Scan for Acute Appendicitis?

Why We Do What We Do
Surgical Validation of Unenhanced Helical Computed Tomography In Acute Appendicitis.     Image courtesy of google images: funnyand.com    by: Sarah Goldman, MD, PGY-2 Bottom Line:   Plain helical CT (without PO or IV contrast) has a sensitivity of 95.4% and specificity of 100% in diagnosis of acute appendicitis.   Major points: Appendicitis carries a lifetime risk of 8.6% for males and 6.7 for females. Currently the diagnosis of appendicitis is aided by the use of helical CT; however, necessity of oral and/or IV contrast is controversial.  In this study, “Surgical validation of unenhanced helical computed tomography in acute appendicitis” 103 patients diagnosed clinically with appendicitis underwent an unenhanced CT scan of the abdomen and pelvis followed by emergency laparoscopy.  CT scan diagnosed appendicitis in 83 patients (80·6 per cent);…
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How We Do What We Do: Regular Delivery

Lectures, Why We Do What We Do
  Below are the steps that you need to know in order to facilitate getting baby out safely as well as protecting mom’s perineum from lacerations (namely 3rd and 4th degree tears).  This will be particularly helpful when you are working at a facility that doesn't provide OB service.  Print out this post and have it next to you during the delivery.  Enjoy! 2nd stage of Delivery Establish IV access and start IV fluids – increased fluids decreases the length of time for labor. Place mom on Nasal Cannula as it is associated with a decreased incidence of low cord pH (350% actually)   Perform your focused H&P: which includes Gestational age, timing and regularity of contractions, rupture of membranes. Cervical exam should be done to ascertain the stage of…
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