Primary Care RAP August 2018 Written Summary Editor-in-Chief: Neda Frayha MD ​ Associate Editor: Kenji Taylor MD, MSc ​ Intro - Good Samaritan Laws Brandon Grove MD, Neda Frayha MD Pearls: ● Good Samaritan Laws provide guidance on medical liability for medical and non-medical providers who offer care as bystanders or “samaritans”. They vary by state and country but generally protect medical providers from medical liability assuming the provider is practicing within their scope. ● Good Samaritan Laws: ○ General laws that deal with medical liability and obligation to provide care in the case of a medical provider as a bystander (ie: airplane, baseball field, walking down the street) ○ Differ by state, country and even airline ■ US, Canada and Britain are similar ■ France, Germany and other countries actually obligate aid and if not offered may result in fines or imprisonment ■ States vary: some protect medical providers from legal suits while others protect all samaritans ○ US law does not obligate us to act while our ethical duty would suggest we do ■ The Aviation Medical Assistance Act of 1998 was put into place to: ● 1. Protect the airline and “samaritan” if: ○ The samaritan is medically qualified (ie: a psychiatrist treating an MI may or may not be covered) ○ The samaritan needs to act voluntarily ○ The samaritan acts in good faith ○ The samaritan does not engage in gross negligence or willful misconduct ○ The samaritan does not receive compensation, though travel vouchers and upgrades do not count ● 2. Required standardization of medical supplies on an airplane ○ General tips before providing medical care as a samaritan: ​ Primary Care RAP August 2018 Written Summary | hippoed.com/pc ​ ■ 1. Assess your own state of mind. If you’ve had something to drink or an ativan before getting on a plane, you may not be able to provide care. ■ 2. If possible, obtain verbal consent from the person ■ 3. Use an interpreter if available ■ 4. Utilize ground-based medical services as they are often available ■ 5. If you think diversion is medically indicated, it is your call to make. ■ 6. Document what happened ■ 7. Don’t practice outside your scope of medicine Interstitial Lung Disease Made Simple Nirav Shah MD, Neda Frayha MD Pearls: ● Interstitial lung diseases are a large and diverse group of ailments that can be divided into four main groups: smoking-related, steroid-responsive, connective tissue-related and exposure-related. ● Diagnosis includes pulmonary function tests and high resolution CT. ● Treatment is dependent on the type. Do not start steroids until you know what you’re dealing with because it may cause further complications and muddy the diagnostic window. ● Interstitial Lung Disease (aka: diffuse parenchymal lung disease): diverse and large group ​ of lung diseases (more than 140 different ones) that can be thought of as follows: ○ 1. Smoking-related ○ 2. Steroid-responsive ○ 3. Connective tissue-related ○ 4. Exposure-related ● Clinical presentation concerning for ILD ○ Shortness of breath or dyspnea: may initially be with exertion and then progress to be even at rest. ○ Cough ○ Headache given chronic hypoxia ○ Back tightness and back pain ○ Crackles on lung exam (velcro-like or dry crackles) ○ Non-acute, insidious process ● Smoking-related ILD: ​ ○ Types: ■ Desquamative interstitial pneumonia (DIP) ■ Respiratory bronchiolitis interstitial lung disease (RBILD) ■ Pulmonary Langerhans cell histiocytosis (PLCH) Primary Care RAP August 2018 Written Summary | hippoed.com/pc 2 ​ ​ ■ Idiopathic pulmonary fibrosis (IPF): whole upcoming episode on this diseases ○ Thought of as a continuum of diseases in all people who smoke but not all progress to interstitial lung disease ○ Counseling: STOP SMOKING. Definitive treatment for PLCH is smoking cessation. ● Steroid-responsive ILD: ○ Types: ■ Sarcoidosis ● Thought to be genetic predisposition plus environmental trigger but exact cause is unknown ● 6-9 months of early prednisone taper results in symptoms improvement and resolution of abnormalities found on imaging ■ Organizing pneumonia - if no cause is found it is called cryptogenic organizing pneumonia ● Lung heals itself from the outside in, so you get peripheral sparing on CT scan ● Pearl: Often these patients have presented with fever, cough and ​ consolidation on imaging. They are treated with antibiotics and their symptoms don’t resolve. They then have a biopsy or further imaging for diagnosis and treatment with steroids. ■ Eosinophilic pneumonia ● Steroids dampen the eosinophilic response ■ Hypersensitivity pneumonia ● Needs to remove the trigger and treat with steroids ● Connective tissue-related: ○ Types: ■ Rheumatoid arthritis: often times presents with RA symptoms first or the lung disease is caught first while on hindsight they had typical RA symptoms all along ■ Lupus ■ Scleroderma ■ Polymyositis ■ Dermatomyositis ○ Treatment: if you treat the underlying connective tissue disease you also treat the lung disease; hence, serologies to identify the underlying disease is really important. ■ Often times steroid-sparing agents like methotrexate ● Exposure-related: ​ ○ Types: ■ Asbestos: huge latency between exposure and disease onset ■ Amiodarone ■ Coal ■ Silica Primary Care RAP August 2018 Written Summary | hippoed.com/pc 3 ​ ​ ■ Beryllium ○ Treatment: remove the exposure and protect against future exposure ● Focus of history: ​ ○ Characterize dyspnea severity (flight of stairs, walk to mailbox), duration and compensation ○ Characterize cough ■ Sputum color ■ Chronic ■ Worse at night, humid or dry settings, laying flat, taking a shower ● Physical exam: ○ General breathing pattern at rest and with conversation ○ Ambulatory oxygenation ○ Thorough skin exam ○ Lung and cardiac exam ● Work-up: ○ Full set of pulmonary function tests looking for restrictive lung pattern → ​ ​ ■ Decreased forced expiratory volume in one second (FEV1), forced vital capacity (FVC) and decrease in total lung capacity (TLC). Normal or even elevated ratio of FEV1 to FVC. ■ May also see decrease in diffusion lung capacity (DLCO) ○ Often will order inspiratory and expiratory mouth pressures because it tells whether or not they are having any weakness associated with the ILD ○ High resolution CT scan ○ May also do inspiratory/expiratory or prone/supine films to see how much air trapping there is ● Treatment: ○ If hypoxic, give them oxygen for at rest or with exertion ○ Don’t start steroids unless you know you have a steroid-responsive interstitial lung disease ○ Referral to pulmonology ○ Health maintenance: flu and pneumonia vaccine Primary Care RAP August 2018 Written Summary | hippoed.com/pc 4 ​ ​ Post Syncope ECG Red Flags Malcolm Thaler MD, Matthew Delaney MD Pearls: ● The ECG is a simple and cost effective tool to use in the evaluation of syncope. ● The red flags patterns (and details below) to look for in an ECG are: ○ 1. Hypertrophic cardiomyopathy ○ 2. Long QT syndrome ○ 3. Wolff-Parkinson-White ○ 4. Brugada’s ○ 5. Arrhythmogenic right ventricular cardiomyopathy ● Clinical Case: 35 year-old healthy male training for a half marathon, runs three times per ​ week. When he’s running halfway through his 4 or 5 miles, he feels like he is going to pass out. This has happened twice and a third time he actually passed out while running. Physical exam is normal. ECG is normal. What else about the ECG should really get us concerned? ● ECG red flags in syncopal-related events: ​ ○ 1. Hypertrophic cardiomyopathy ○ 2. Long QT syndrome ○ 3. Wolff-Parkinson-White ○ 4. Brugada’s ○ 5. Arrhythmogenic right ventricular cardiomyopathy ● 1. Hypertrophic cardiomyopathy: hypertrophy of the left ventricle and particularly the ​ left ventricular septum that leads to obstruction of the outflow tract, impaired ventricular filling which is a set up for arrhythmias that generate themselves and cause problems. ○ Common - the leading cause of sudden cardiac death in young people ○ Autosomal dominant with high penetrance ○ Caused by disorganized muscle fibers that leads to hypertrophy ○ Diagnostic criteria on ECG: ​ ■ Left ventricular hypertrophy ■ Sharp, narrow and deep Q waves in the lateral and inferior leads ○ Treatment: ​ ■ Beta blockers and calcium channel blockers to reduce the excitability of the heart muscle and reduce contraction ■ If the patient has come in with a prior episode of syncope or sudden cardiac death from which they were resuscitated, you’ll want to put in an implantable cardiac defibrillator ○ Pearl: ​ ■ Get a good family history because a history of other families with syncope or sudden cardiac death may support the diagnosis. You may also consider screening other family members with serial ECGs and echos Primary Care RAP August 2018 Written Summary | hippoed.com/pc 5 ​ ​ ■ The hypertrophy and disease can evolve over time so screening family members every couple of years is a good idea ■ Ask about drowning: there is thought to be an association between drowning and several congenital arrhythmias ● 2. Long QT syndrome (congenital): ​ ○ Definition: ■ Men - 0.45 seconds ■ Women - 0.47 seconds ■ Pearl: cardiologist don’t worry about it until >0.5 seconds. Also, 10% of ​ patients with long QT syndrome will have a normal QT on resting ECG. ○ Many causes: ■ Drugs: antiarrhythmics, macrolides, quinolone antibiotics, non-sedating ​ antihistamines, antifungal drugs, psychotropics, tricyclics, SSRIs) that can lead to a lethal torsades de pointes. ■ Electrolytes: low K, low Ca, low Mg ​ ■ Congenital: common in both men and women ​ ○ Management of congenital: ■ Treated