HIV

I hope everybody had a restful and relaxful Labor Day. Today's POTD comes straight from the horses mouth, AKA our fearless admin leader REUBEN "I'M NOT THE GUY FROM CASH CAB " STRAYER.  

He posed a question to me. "Josh, I want to diagnose more people with HIV in our ER, how would I go about doing it???"

Well thankfully for Reuben, and all our new HIV positive folks, we as doctors can order the screening test in HMED. It used to be controlled by nursing, but now we have the power. FIRST, lets talk about how to order it.

-Go into PHYSICIAN tab --> CDS forms --> HIV testing (it's ~10th on the list, just below EBOLA screening). From there it's just a single button in the HIV testing page.

NOW lets talk about what the hell you're ordering. It comes up as "HIV AB, HIV 1/2, EIA, WITH RFLX". HUH???

So, what this means.

1. The first test that the blood is run through is a HIV 1/2 antibody test with ELISA (enzyme-linked immunosorbent assay, or EIA as in the order). This is a quick test, where they dilute the serum and apply it to a plate with HIV antigens attached. If it sticks, it's positive (it's more complicated than just PRESTO, but for our simple ER minds I'll leave it at that). Sensitivity AND Specificity of this assay are >99% according to multiple studies. However the RFLX at the end of the order means that if it's positive, they will reflexively do a western blot to confirm.

-The ELISA is ready fast, a few hours at the most.

2. Western Blot. That's the fancy thing with gel electrophoresis and stuff. Who cares. It's pretty good. They will run it only if the EIA is positive. And if you positive you positive dawg.

-This can take days. Patient needs to be given good follow-up and someone to follow up this blot.

Now go out there and diagnose some people with HIV!

THURSDAY POTD, ALL TREMOR BEFORE ITS MIGHT

AMIODARONE: THROW IT IN THE TRASH!  

At least, that's what I'm going to try to convince you of today.

Recently there was a patient in stable VTach, awake alert normotensive.

Get 150/300 mg bolus of amio right? That's what everyone goes for. It's familiar, it's comfortable, it's oh so sexy (ok maybe not that one). But they probably shouldn't.

THE BASICS

Amio is typically used in 3 indications in the ED.

1. Afib for cardioversion
2. VTach for cardioversion
3. Refractory VF or pulseless VT

WHY I WON'T BE USING IT IN ANY OF THESE THINGS

1. AFIB
   1.  shown to be no more effective than flecainide/propafenone at 24 hours("pill-in-pocket"), and no more effective than placebo in first 1-2 hours. (https://www.ncbi.nlm.nih.gov/pubmed/12535819)
   2. Procainamide had a better conversion rate with mean time of 55 minutes, with lower incidence of SE (https://www.ncbi.nlm.nih.gov/pubmed/18045891)
   3. Electrical Cardioversion has a conversion rate of >90% with 1 shock, approaching 100% if 2 shocks delivered.
2. VTach (Stable)
   1. PROCAMIO TRIAL: read it, love it, admire it. Use it over and over and over again. (https://www.ncbi.nlm.nih.gov/pubmed/27354046). Basically it says that procainamide is safer and more effective than amio.
3. Refractory VF/Pulseless VT
   1. Multiple studies showing increase of ROSC, but no increase in neurological outcomes. Does it really do anything?

NOTES: Procainamide dosing for VT is 10 mg/kg run over 20 minutes. Dosing for AF is 1 gm over 60 minutes. The AF dosing is in the computer under COMMON MED DRIPS. The major side effect of procainamide is HYPOTENSION, so be care with already hypotensive patients, and have them on a monitor. (but amio also causes hypotension so who really cares???)

SO. I don't know if this changes your practice or not. Definitely read the studies, do your own due diligence. We often reach for amio because it's familiar, but often it can cause more harm than good. I know Jason and the Argonauts, sorry, Pharmacists, support using PROCAINAMIDE in most situations.

Disclaimer: I wish I was getting paid by the makers of procainamide.

Subdued POTD Weds

Today there will be no caps lock, no colors, no pizzazz. Just down to brass tax. That patient that we didn't give Apneic Oxygenation to the other day, coded. Boom. Dead. Asystole. Hasta la vista baby. Now we're coding him.

Epi, push push push, epi, push push push.

PULSE CHECK (sorry that called for all caps). Check the monitor, feel for pulse....get the ultrasound?

Maybe we shouldn't be getting the ultrasound routinely. A recent study showed pretty much what we all know. It showed that pauses in ACLS using POCUS echo were significantly longer than those without. While they didn't study patient mortality/mobility or outcomes, the results speak for themselves. We are taught longer the pause in CPR the lower the mean cardiac arterial pressure.

RESULTS Duration of Pulse Check: Without POCUS: 13.0 seconds (95% CI of 12-15) With POCUS: 21.0 seconds (95% CI of 18-24) p <0.001

Study was done prospectively with videos being reviewed of the cardiac arrests by a 3rd party. It wasn't controlled for POCUS user training (intern vs 3rd year vs attending).

Whether this changes your practice or not (I think this is pretty intuitive and not hugely practice changing), but maybe it serves to remind you that if you take a pause to take a look at the heart, don't spend to long trying to get a perfect picture. Maybe only take a look in the beginning of a code (rule out tamponade or R heart dilation, both problems that need to be fixed), or at the end of a code (to confirm cardiac standstill)

https://www.ncbi.nlm.nih.gov/pubmed/28754527 http://rebelem.com/impact-pocus-cardiac-arrest-resuscitation-compression-pauses/