Monthly Archives: April 2016

Medical Musing of The Week: DIC

Overview

  • Disseminated Intravascular Coagulation
  • Can be acute or chronic subclinical presentation

Etiology/Pathophysiology

  • Mechanisms and feedback loops of clotting and fibrinolysis function inappropriately.
  • Clotting can occur for too long or without presence of vessel injury.
  • Presence of lipopolysaccharides
  • Tissue Factor (a procoagulant)can be present Meningococcal sepsis
  • Trauma can damage the endothelium triggering the release of procoagulants
  • Protein C deficiency
  • Fibrin Degradation Products can interfere with fibrin clot formation and platelet aggregation
  • Delay of procoagulant factors being removed from the site of damage (endothelial) may result in prolonging the process of coagulation
  • Acute:
    • Sepsis
    • Trauma
    • Acute Promyelocytic Leukemia
    • Prolonged clotting times and thrombocytopenia
    • OB complications (pre-eclampsia, retained products and fatty liver of pregnancy)
  • Chronic
    •  Advanced Malignancy (pancreatic, gastric, ovarian and brain)
    • Normal clotting times and platelet counts may be normal (the body has learned how to compensate
  • Less common but possible:
    • Heat stroke
    • Crush injuries
    • Amphetamine OD
    • Fat Embolism
    • Snake bite
    • Organ transplant rejection

Clinical Manifestations and Diagnosis

  • Acute:
    • Prolonged PT, aPTT
    • Elevated Fibrin Degradation products & D-Dimer
    • Reduced Platelets, Factor V & Factor VIII
    • Bleeding
    • Renal Dysfunction
    • Shock
    • Thromboembolism
    • Liver Dysfunction, jaundice
    • Pulmonary hemorrhage w hemoptysis, dyspnea, may progress to ARDS
    • Coma, delirium, transient neurological changes
    • Purpura Fulminans (purpuric lesions caused from hemorrhagic skin necrosis—very rare and can also occur in some variants of protein C deficiency)
  • Chronic
    • Platelet count is variable
    • Fibrin and Dimer also elevated as in acute
    • Other lab findings WNL (PT, aPTT, platelets )
    • History of malignancy
    • Thromboembolism without other clear etiology
  • Evidence of end organ damage including but not limited to low urine output, hypotension, bradycardia, elevated LFT’s etc.

Treatment

  • Generally until patients show signs of bleeding or clotting they are not treated prophylactically–management is usually focused on reversing the underlying cause
  • Based on evidence platelets are not administered until <10,000
  • Prolonged PT or aPTT with significantly low fibrinogen level w/ serious bleeding should receive factor replacement or FFP
  • Fibrinogen <100 give cryoprecipitate (goal of Fibrinogen >100; if >100 and PT or aPTT significantly prolonged)
  • Antithrombin is NEVER used for treatment

Complications & Prognosis

  • Ensure patient is able to support their airway depending on their respiratory status
  • Prognosis depends on how severe their clotting/bleeding abnormalities are and the ability to reverse the underlying condition pushing the pt into DIC
  • Mortality rate ranges 40-80%

 

Sugar and Sleep

I’ve always been a relatively healthy eater in my adult life.  This of course was after a long phase in high school of eating Entenmann’s chocolate donuts for breakfast and sometimes lunch (seriously ask my best friend Melanie I ate them for basically 50% of my meals). I’ve also always been very active and athletic.  However, I’ve never really followed a particular way of eating…paleo, zone, etc.  I’ve just always kind of followed what I called a strict 85-90% clean and 10-15% stuff I wanted.

Recently a lot of my friends have tried out the Renaissance Periodization Diet.  They’ve all made tremendous gains on their lifts and tell me they feel amazing–not to mention they’ve cut their body fat percent and leaned out.  So–I decided to give this it a try, I bought the templates for my weight and gender.

I’ve been doing it only about a week and a half and I decided to have some cake at dinner and “cheat”(I have a serious sweet tooth) I immediately felt awful.  What was more troubling to me was that when I woke up the next morning I felt like I had a hangover.  I had slept a solid 9 hours and only woke up once because of my dog barking. I couldn’t believe how great I had been feeling when I woke up on the RP diet and how shitty I felt this morning when I woke up. I’ve always been a good sleeper–head hits pillow I’m out.  I’m blessed in this respect I realize.

I’m wondering if anyone else out there has had this experience when they strictly cleaned up their diet that sugar made them feel like shit?  I’ve heard people talk about it and how when they then have sugar their body is basically rejecting it.  I’ve honestly always kind of thought “yea ok whatever”.  But now I’m wondering if there is something to it?

 

Medical Musing of The Week: Malignant Otitis Externa

Overview

  • Begins as simple otitis externa and extends to the bony ear canal and the soft tissues deep of ear canal
  • Older adults and Diabetes are risk factors (also patients who are immunocompromised in anyway)

Etiology/Pathogenesis/Risk Factors

  • Causative Organism: Pseudomonas aeruginosa 
  • Almost always have glucose intolerance
  • The degree of glucose intolerance does not correlate with development of malignant otitis externa or the severity of the disease that develops
  • Water contaminated with P. Aeruginosa
  • Earbuds, hearing aids and swim caps (anything that occludes the ear)
  • Prior radiation therapy

Clinical Manifestations

  • Otalgia (likely occurring at night)
  • Otorrhea (foul smelling)
  • Fever
  • Facial weakness
  • Pain in TMJ when chewing
  • Obvious infection in the external auditory canal
  • Granulated tissue on floor of ear canal

Diagnosis

  • Clinical based on history and physical exam
  • Prolonged exposure to water
  • Elevated ESR & CRP
  • Gram Stain

Treatment

  • Ciprofloxacin: 400 mg intravenously [IV] every 8 hours or 750 mg orally every 12 hours
  • Levofloxacin 750mg daily (every 48 hours if significant renal impairment)
  • Patients generally need IV therapy until a clinical improvement is observed
  • Duration of therapy is usually at least 6 weeks
  • If resistant to fluroquinolone, admit for biopsy and debridement to determine sensitivity to other antibiotics. (ie: piperacillin-tazobactam, ceftazidime, cefepime)

Complications & Prognosis

  • Watch out for resistance to Ciprofloxacin in patients aren’t responding
  • Potential for Osteomyelitis in base of the skull
  • Cranial nerve involvement