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We had a resident feedback session today after conference that was constructive. I discussed most of the issues that came up with the residency leadership and will provide updates as they are available. For more information, see my email from this date as I don’t want to post that information online.

That’s it. No clinical review this week. See you in 2 weeks for our first conference of the academic year.

Thanks to everyone who stuck it out through conference today with us running late and starving because the food was delayed. I’m glad that we had time to get all the talks in, especially the seniors who provided some useful insights about our IRB. I wanted to follow up on some points that came up today in conference:

Use of cholestyramine in decontamination after digoxin overdose: Cholestyramine does have an effect on reducing absorption of digoxin from the gut but its role has largely been limited by the overwhelmingly more effective activated charcoal so it has been relegated to being used as an adjunct. (As with almost all tox, the studies are old, small, or just case reports: PMID 3358884, 3341874, 1841076) Bottom line: reach for the activated charcoal first.

Insulin and glucose in treatment of bradycardia: Insulin is well known to help shift potassium into cells for temporary treatment of hyperkalemia. Recent data would suggest that high-dose insulin can be therapeutic in both calcium-channel and beta-blocker overdose. The evidence (again, case reports and animal studies: PMID 11386285, 10465243, 8246150, 16990629 — interestingly, almost all the data comes from the same people at Harvard and Carolinas) is stronger for CCBs than for BBs and suggest that insulin is useful in critically-ill patients in whom the suggested first-line therapies have been ineffective (atropine, glucagon, and — for calcium channel blockers — calcium chloride infusion). Bottom line: use insulin for CCB or BB toxicity if your the patient is crumping and nothing else works.

Digoxin: So we heard the sad story of digoxin as is went from the pinnacle of medicine in the 18th century to the low position that it holds in medicine today. So much that Circulation saw fit to publish and article entitled “Contemporary Use of Digoxin in the Management of Cardiovascular Disorders” in 2006 to clarify when this drug should be used. Further, we as new physicians don’t really know how to use this drug at all (and maybe we shouldn’t). In any case, the only time that I ever consider using it is when I want to be elegant in treating patients who present with CHF exacerbation, abysmally low EF, and Afib with RVR. In that case, you want to avoid a BB and CCB for rate control due to the negative inotropy but dig may just be a good choice with some AV refractoriness and a little inotropy in addition to the standard nitrates and diuretics. It takes time, and you definitely don’t want to give it to anyone with renal failure. There are no studies to back this up, but a few review articles that suggest it (PMID: 16735690, 1352657). For what it’s worth, I ran this approach by Dr. Rubinstein who thought it was a waste of time, and instead suggested using amio (although this will depress EF). Bottom line: don’t use dig often, if at all. Always check a dig level on patients taking digoxin.

That’s it for now. See everyone next week.