Preoperative Patients on Coumadin

If you work in surgery or with the elderly - anticoagulation is an every day part of life. INRs, PTs, PTTs, etc... it is important to know what measures what and what reversal agents (if any) are available. Let's talk about Coumadin today.

Scenario: 79 yo patient is coming in for a surgical procedure, but he is on Coumadin. You did your due diligence and had them stop it about 5 days pre-op, but their INR is still 1.6 on preoperative blood work. What are your next steps?

Generally if you are going to bring someone to the OR you'd like their INR to be less than 1.5. If it is higher, you would consider a reversal agent.

Your 1st option for reversal is Vit K. 

• PO is most predictable and is preferred to IV if rapid reversal is not needed. PO Vit K lowers INR in about 24-48 hours. 
• IV works in approximately 12-24 hrs, but you run a greater risk of anaphylaxis and it must be administered over a longer period of time (approx 20 minutes). 

Your 2nd option for reversal is Fresh Frozen Plasma (FFP).

• FFP is more expensive than Vit K, but works within 12 hrs. FFP replaces clotting factors.

So, even though you did your due diligence, why was the INR still high? There are several reasons that can delay the drop of a patient's INR:

1. Age - Elderly pts
2. Malignancy (active)
3. Liver disease
4. CHF, unstable
5. Meds that keep Coumadin around in the blood (check their med list)

Sources:

Ansell, J, Hirsh, J, Poller, L, et al. The pharmacology and management of the vitamin K antagonists: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004; 126:204S. 

Normalization of INR After Stopping Coumadin: http://www.fpnotebook.com/mobile/HemeOnc/Surgery/PrprtvAntcgltn.htm

Atrial Fibrillation

AFib, The Basics

Characteristics

1. irregularly iregular
2. irregular RR intervals
3. not a P wave in front of every QRS
4. atrial rate = 400-600bpm, ventricular rate = 80-160bpm

Etiologies = PIRATES

P = pulmonary (COPD, PE)/pheo/pericarditis

I = ischemic heart dz +/- HTN

R = rheumatic heart dz

A= anemia/atrial myxoma

T = throtoxicosis

E = ethanol ("holiday heart)/cocaine

S = sepsis (post-operative)

Signs/Symptoms

1. fatigue (most common)
2. tachypnea
3. palpitations
4. lightheaded

Work Up

(Test yourself... why would you order each of these? what are you looking for?) - answers below

1. EKG
2. ECHO
3. TSH (?)
4. Baseline coags

1. EKG = narrow complex QRS (<120msec), variable RR, irregular or absent P waves
2. ECHO = maybe thrombi, maybe dilated L atrium
3. TSH (?) = hyperthyroidism can cause AF
4. Baseline coags = getting baseline prior to starting anticoagulation

Of note: if you are looking for THROMBI..."normal" ECHOs (transthoracic) has low sensitivity - transesophageal ECHOs allow for better visualization of L atrial appendage (location where most thrombi form) 

source: First Aid for the Wards by Le, Bhushan, Skapik

pic source: http://www.saintvincenthealth.com/Services/Heart/Heart-Resource-Library/Atrial-Fibrillation/default.aspx

Heart Failure

Quick study material on heart failure:

LEFT SIDED

• dyspnea
• wheezing
• orthopnea
• S3/S4 gallop
• puLsus alternans

RIGHT

• peripheral edema
• nocturia
• JVD
• hepato/spleno-megaly

FUNCTIONAL CLASSES (1 = best, 4 = worst)

Pic source: http://www.remodulin.com/patient/diagnosing-pah.aspx
Source: Medical Boards Step 2 - Made Ridiculously Simple (Andreas Carl, MD)

Cardiac Surgery Made Ridiculously Simple

Cardiac Surgery Made Ridiculously Simple is a good resource if you are heading into a Cardiac rotation. Below are some additional resources listed on this site:

A good reference is: Cardiac Surgery in the Adult 

by L. Henry Edmunds, Jr., MD which is available online http://www.ctsnet.org/book/

An online reference text “Cardiothoracic Surgery Notes” for residents 

is available at http://www.ctsnet.org/residents/ctsn/

An online Johns Hopkins Cardiac Intern Survival Guide is available at http://www.ctsnet.org/doc/2695

http://www.nhrmc.org/heartsurgery

PANCE REVIEW: Jones Criteria

Is it rheumatic fever or not? You need to know the Jones Criteria to make the determination.

Source: AAPA/PAEA Exam Review Book, PANCE review lecture by Janice Herbert-Carter, MD, MGA, FACP

CT Surgery Starter Resource

This is an excellent starting resource for PAs starting out in CT surgery or PA students rotating in CT surgery. It is designed for CT surg residents starting out - but I have found it very helpful.

CTSWOT

PANCE REVIEW: Ischemic Heart Dz

Angina

1-Stable = < 3min during activity, better with rest

2-Unstable = > 30 min at rest

3-Prinzmetal = vasospasm at rest

Risk Factors (10):

-male
-increased age
-decreased estrogen state
-smoking
-fam hx
-HTN
-DM
-obesity
-dyslipidemia
-inactivity

Tests/Labs:

-EKG: horizontal or downslopping  ST seg (depression)
-Exercise Test: good non-invasive test
*Pimping Question: What signifies a positive exercise test? (Answer below)
-ECHO: prognostic indicator

Tx:

-sublingual nitro is the primary pharm tx
-chronic angina = beta blockers (prolong life)
-CCB decrease cardiac muscle O2 demand
-Platelet inhibition agent (aspirin, clopidogrel, ticlopidine)
-NOTE: Nitro and CCB only for Prinzmetal! Beta-blockers can provoke a spasm!





Answer: ST segment depression of 1mm


Source: AAPA and PAEA Exam Review Book

PANCE REVIEW: Urgency vs Emergency

HTN, both primary and secondary, are fair game for the PANCE - but HTN in general is a huge topic. So in the interest of keeping these entries short and sweet, I went with the niche topic of urgency vs. emergency.

Hypertensive Urgency	Hypertensive Emergency
Systolic > 220, Diastolic >125	Diastolic > 130
Lower in HOURS	Lower within 1 HOUR
Complications: optic disc edema, end organ complications	Complications: hypertensive encephalopathy, IC hemorrhage, aortic dissection, pulm edema

Tests/Possible results:
1-EKG: heart failure/LVH
2-CXR: ventricular hypertrophy
3-Labs: decrease in Hbg/Hct, increase in BUN/Cr/Glucose - renal dz? DM? end organ damage?

Treatments:
Parenteral agents
-sodium nitroprusside
-if MI present, nitro or Beta-blocker
-if aortic dissection present, nitroprusside + beta blocker (Labetalol)





Source: AAPA and PAEA Exam Review Book

PANCE REVIEW: Congenital Heart Dz

According to the NCCPA site - the following congenital heart dz are fair game on the the PANCE. I have listed them with some key buzz words:

Red = non-cyanotic

Blue = cyanotic

Ventricular septal defect

-MOST COMMON

-systolic murmur, LLSB

-sx are size dependent (range from asymptomatic to CHF)

-"Outlet VSD" - most common in Chinese and Japanese

Atrial septal defect

-2nd most common

-systolic ejection murmur, 2nd LICS

-failure to thrive

-RV heave

-wide fixed S2 split 

 (If you can remember ASD is #2 - then you can remember 2nd LICS and fixed S2 split!)

*septal defects are #1 and #2 most common 

Coarctation of the aorta

-systolic, LUSB (may be Continuous)

-infants may present with CHF

-older kids may present with systolic HTN +/- murmur

Patent ductus arteriosus (PDA)

-continuous machinery murmur (I remember it has a PDA- like a phone- is a machine.)

-Wide pulse pressure (machine = "wide" screen TV)

-hyperdynamic apical pulse

Tetralogy of fallot

-crescendo-decrescendo

-HOLOsystolic at LSB 

-cyanosis, clubbing

-increased RV impulse at LLB

-Loud S2

-Associated things: polycythemia vera + hypercyanotic spells (Med Emergency!)







Source: AAPA and PAEA Exam Review Book
Image: http://www.healthofchildren.com/C/Congenital-Heart-Disease.html

PANCE Review: Postual HypOtension (aka Orthostasis)

I have slowly begun to start studying for my boards... well at least organized my thoughts around studying for the PANCE... so many of my next posts will be dedicated to PANCE topics. I highly recommend visiting the official NCCPA site to get a list of the covered topics so help focus your studying. If it isn't on the Blueprint list, it isn't going to be on the exam. PANCE Blueprint site

Let's start simple:
Postual HypOtension (aka Orthostasis)

Def: A >20mmHg drop in SYSTOLIC BP between Supine and Sitting and/or Standing positions

If accompanied by an INCREASE in pulse by 15bpm = likely cause is DECREASE in BLOOD VOL (bleeding, dehydration, etc)

If is not accompanied by an increase in pulse = likely causes are meds or peripheral neuropathies

Tx: treatment is directed at the cause!



Source: AAPA/PAEA Exam Review Book

EKG Quizzes

I am currently in emergency medicine and LOVING it. I can go from seeing a 2 yo with croup to an 85 yo with syncope. I've sutured ear lobes, faces, legs, and arms as well as seen a good amount of ortho and dermatology. It is just so diverse and exciting day in and day out. One of the most important things that I wanted to get out of this rotation of EKG interpretation. I had had a little bit in my other rotations, but not much.... I knew I would see a ton in the ED and I have. One of the docs in particular has been great about teaching me stuff and then making sure I see almost every EKG for that shift and then we discuss it. I went searching for a site to practice interpretations and came across EKG Quizzes and Lessons. It is basic but helpful. They only way to get good at them is to keep practicing!

DrawMD, Free iPad App (Patient Education)

One of my favorite parts of my jobs is educating patients about their medical troubles. Sometimes it is difficult to get the patient to visualize a specific surgery or procedure that you are about to perform. You end up drawing on a piece of paper or a white board (and it never really looks quite right!) DrawMD came out with an incredible app for the iPad. There are several different apps for different specialties such as ortho, OB/GYN, cardiology, general surgery, etc. You can sit with a patient with great pictures... explain the procedure, draw on the picture or add your own notes, and then send a copy to the patient or save it if you often explain the same procedure. The best part about this app is that it is FREE! See below for examples from the DrawMD - Cardiology.

There is a menu of different pics/procedures that are available.

Once you pick a general picture, there are picture "stamps" that you can add to describe procedures or anatomy.

You can draw on the pics for effect.

You can either write or type information on the picture.  Then select the "SEND" key on the bottom right.

Options for sending the image.

You may save the final product to your library for future use.

Cardiothoracic Imaging Resource

Yale's Introduction to Cardiothoracic Imaging. It includes cardiothoracic anatomy, imagining, case, and reference resource. Very high quality.

Critical Care

I recently found a great Critical Care Tutorial website. If you are interested in critical care - it is definitely worth a browse.

Ambulatory Topic #3: QT Intervals

Ambulatory Topic #3: QT Intervals

Normal QT Interval:
less than 1/2 of the R-R interval (approx <0.42s)


Causes of Prolonged QT:
1-Meds:
2-Electrodisturbances (hypOCa+ and hypOK+)
3-Congenital
4-Ischemia
5-CNS lesion
6-Bradyarrhythmia

How to get the corrected QT interval (QTc):

What is it "correcting" for? The heart rate. The length of the QT interval is obviously dependent on the rate the heart is pumping so the QTc adjusts for this.



Pic: http://www.mayoclinic.com/health/medical/IM02677
Pic: http://heart.bmj.com/content/93/9/1051.abstract

Unique Cardiac Sound App for iPhone

Cardiac sounds.... as I've said before... not my strong suit... so I have been on the hunt for some great iPhone apps to help me pass the time and learn a bit in the process. After all, you can't become good at murmur auscultation by reading a book. I was recently introduced to the Blaufuss Sound Builder. This app is has some great features. I found myself playing with it for hours (rather than studying!).

1. It allows you to listen to a murmur on a patient and then listen to the app and customize the app's sounds to match that of the patient's. Not sure if it is systolic or diastolic? Click on each and then ask yourself which one sounds like your patient. As advertised, you can "You can also compare/contrast sounds that are easily confused: holosystolic vs mid systolic, murmurs, and extra sounds near the 1st and 2nd heart sounds."

2. As I show in the screen shots below, once you find the combo of heart sounds that you are looking for you can hit Dx for the predicted diagnosis or a differential list (super helpful)!

3. If you need some extra information... you can select the side arrow in blue and more information is available (screen shot below).

4. The initial download of the app is free - but you get only a few of the sounds included. For full use of the application it is $9.99 - but honestly worth it. I've downloaded and tried 10-15 heart sound apps and ended up deleting them 2 days later because they weren't very helpful. This is definitely a keeper. 

You can select any combination of heart sounds to hear together. By adding them 1 at a time I found it MUCH easier to pick them out.

You can see how the "Early diastolic" tab is selected because it is yellow. Then select the blue Dx circle  to  get the differential diagnosis list.

The differential list of Early systolic murmurs. (There is more if you scroll.)

More information on Aortic Regurgitation 

Disclaimer: I received this app for free as a tester, but do not receive any compensation for future purchases.

Cardiac Auscultation

Michael Chizner, MD wrote a great article in July 2008 on the lost art of listening to the heart called: Cardiac Auscultation: Rediscovering the Lost Art - It is great. Listening for murmurs is a difficult skill to master. I have worked with several seasoned PAs and MDs that still claim that they don't have a good handle on murmurs. Personally, I am terrible at it. I can tell you it is abnormal and I can tell you what the text book systolic or diastolic murmurs should sound like.... but hearing a heart beating at 80 bpm and picking out and correctly naming a murmur.... I'm definitely not there yet.

If you have access to your school's library- you should have access to free journal articles. Just do a quick search for the title and author. Below is a snippet from the article.

TABLE 1. Proper cardiac auscultatory technique

● Room should be quiet

● Time heart sounds and murmurs by “inching” technique (or by palpation of carotid artery

or apical impulse)

● The bell of the stethoscope is best for low-frequency sounds and murmurs (eg, S4 and S3

gallops, diastolic rumbles)

● The diaphragm of the stethoscope is best for high-frequency sounds and murmurs (eg,

aortic regurgitation)

● Listen with bell lightly applied at cardiac apex, with patient turned to left lateral decubitus

position, for S4and S3 gallops and/or diastolic rumble of mitral stenosis

● Listen with diaphragm firmly applied over the left sternal border with patient sitting

forward, during held expiration for diastolic blowing murmur of aortic regurgitation and/or

pericardial friction rub

● Listen individually to S1 and S2

— Are both S1 and S2 present?

— Is either sound loud, normal, or faint? Does splitting of S2 widen, remain “fixed,” or

reverse with inspiration?

● Listen for extra sounds in systole (eg, mitral clicks, aortic or pulmonic ejection sounds)

or diastole (eg, S4 and S3 gallops, pericardial knock sound, mitral opening snap, “tumor

plop”)

● Listen for murmurs

— Systolic (early, mid, late, holosystolic)

— Diastolic

— Continuous

— Where is the murmur heard and radiate?

— Does the murmur change with body position, respiration, certain maneuvers (eg,

Valsalva)

Listen for pericardial friction rubs or prosthetic valve sounds

(Reproduced with permission from Chizner MA. Clinical Cardiology Made Ridiculously Simple, 2nd edition. Miami, FL: MedMaster, Inc., 2007.) 






Picture: http://www.medcomrn.com/cgi-bin/mc/sectionpreview?8a9dQUaN;VIDM259B-T;620