Acute coronary syndrome – 11/20/17

Unstable angina = symptoms with negative biomarkers and EKG
NSTEMI or STEMI = symptoms with positive biomarkers and EKG

Types of stress

  • Exercise
  • Dobutamine (works by increasing contractility)
  • Vasodilators – lexiscan or adenosine (not a true “stress” but causes vasodilation of the vessels and if there is an occlusion in one, then more blood will be shunted to the other ones leading to the “steal” phenomenon)

Types of imaging

  • EKG
  • Echo
  • Nuclear medicine study

When deciding what kind of stress and what kind of imaging to use you must take a few things into consideration:

  • If possible, always try to stress a patient with exercise as that gives you information about their exercise tolerance and functional capacity
    • Exercise can be paired with an EKG, echo, or nuclear medicine study
  • If a patient cannot exercise, consider dobutamine or a vasodilator
  • Dobutamine is best to use when a patient has a contraindication to a vasodilator e.g. a patient cannot use adenosine because they have bronchospastic airway disease (COPD or asthma)
    • Dobutamine can be paired with an echo or a nuclear medicine study
  • Vasodilators are ideal if a patient has a LBBB because it is not affected by the fact that in a LBBB you have a delayed contraction of the septum which can cause a false positive for obstruction if done with exercise or dobutamine
    • Vasodilators can only be paired with a nuclear study

Contraindications to using an EKG as your form of imaging are:

  • LBBB
  • Ventricular paced rhythm
  • ST changes > 1 mm

Anti-anginal medications:

  • BB
  • Nitrate (give a medication free period at night to avoid tachyphylaxis)
  • CCB
  • Ranolazine (4th line medication if the others have failed)

Myxedema Coma – 12/12/17

What is it?

  • Severe hypothyroidism leading to AMS and hypothermia
  • Can have other symptoms related to the slowing down of organs

Who gets it?

  • Usually older females with long standing hypothyroidism triggered by a precipitating event

How does it present?

  • Change in mental status (rarely presents as true overt coma)
  • Hypothermia
  • Hypotension
  • Bradycardia
  • Hyponatremia
  • Hypoglycemia
  • Hypoventilation

What labs should you check?

  • TSH, FT4
  • Cortisol (to rule out concurrent adrenal insufficiency)

What is the treatment?

  • IV T3 and/or T4 – data is mixed
    • Use IV because patient likely has gut edema so PO form may have decreased absorption
    • T3 has better bioavailability and is the active form
    • In acute illness, body’s normal conversion of T4 to T3 is impaired
    • Monitor patients on telemetry because biggest concern is arrhythmias
    • Use lower dosing in elderly patients or those with cardiac disease
    • Recheck TSH in one week – goal is drop by > 50%
  • Stress dose steroids (hydrocortisone 100 mg every 8 hours)
    • Until you rule out concomitant adrenal insufficiency
  • Supportive measures
    • Avoid dilute fluids which can worsen hyponatremia
    • Use passive rewarming
    • Pressors if needed

APML – 12/5/17

  • Makes 5-20% of AML cases and accounts for 600-800 cases per year in the US
  • Higher incidence in people from Mexico, Central America, South America, Italy, and Spain
  • Uncommon < 10 years old and > 60 years old
  • Considered a medical emergency due to a high rate of mortality from hemorrhage

Labs will show:

  • Pancyctopenia (one of the few leukemias that classically can present with a low WBC)
  • Peripheral smear with promyelocytes and high nucleus to cytoplasm ratio with granules
  • Coagulopathy (frequently with DIC)
  • FISH with t(15:17) translocation


  • ATRA – start immediately even before diagnosis is confirmed given high rate of mortality without treatment

Consequences of ATRA

  • ATRA differentiation syndrome – presents with SOB and volume overload – can occur at week 1 of treatment or up to 3-4 weeks after – treatment is dexamethasone and patient can be continued on ATRA
  • Pseduotumor cerebri – look for in patients with high ICP – pathophysiology due to ATRA causing a hypervitaminosis A type syndrome – do LP to check ICP

Platelet transfusion goals

  • > 100 for NSG procedure
  • > 50 for bedside procedure or surgery
  • >10 for anyone without bleeding to prevent spontaneous bleeding