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The Paper Chase:TTP Update 2013

Sanjay Arora, MD and Mel Herbert, MD MBBS FAAEM
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No me gusta!

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Sanjay and Mel kick off the March episode with a conversation on the latest TTP literature.

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Salim R. -

Great Topic. Some other populations to think about as well in this ddx is pregnant Pts (HELLPs) and Septic patients (DIC). Both can also have schistocytes on their smears as well.

@srrezaie (twitter)

Ian M. -

Mel,
Love the review questions! Thank you from a lowly intern.

Frank D. -

Bonus session is really helpful thanks Mel,

Sean G., M.D. -

Review section....awesome! I remember less during my first go round then our pts do of their dc instructions.

Andrew M., M.D. -

Like the review section and enjoyed the musical interludes. And, always appreciate the banter. Keep up the excellent work.

Paula C., MD -

You guys are hysterical. So real! So just like me!

Benjamin M. S., M.D. -

Sanjay, I don't get it. Apparently we will piss off the hematologist if we call with a case that has borderline thrombocytopenia, in a disease that has 10% - 20% mortality even when treated, and near 100% mortality if untreated. They must have "significant" (not defined), "real" (not defined) or even "profound" (also not defined) thrombocytopenia. If platelet count of 150K doesn't cut it, what number does?

And what do we do with the patient with 150K or 141K platelets? Do we withhold treatment till we are sure they fall in the 100% untreated mortality category? Do we wait 2 days for the ADAMTS13 tests come back? I presume not. At what point, what platelet count, do we start presumptive treatment with steroids and plasma? Is it 139 K platelets? 120K? 100K? Do we admit borderline cases to watch if the platelets drop further?

Jose C. -

Great Review!!!!

robert b., jr -

great review. quick question. my ICU doctor states I'd be hard pressed to find any literature that did not support starting insulin concurrently with IV fluid rehydration in the treatment of dka in adults. my practice has been to give three liters of normal saline initially, reassess, do another accu check, then start an insulin drip. the intensivist stated there was no reason not to start an insulin drip from the start, assuming the patient has a normal potassium. thoughts?

robert b., jr -

sorry. wrong section. great review anyway.

Sean G., M.D. -

Awesome piece!!!!!!! This is Emrap at its finest! Mel Sanjay, Australian accents, bunt cake goodness, 1 Adam 12 pure genius! That's one board question I will for sure answer correctly. You guys took a perplexing disease, explained it, busted up yet another Med School/Residency myth, this is what I buy Emrap for, Mel u remain a god like figure in my eyes, one deserving at least of a national Holiday....I propose February God knows this country needs more February holidays....

Jeffrey S., D.O. -

Mel and Sanjay,
Does the patient have to anemic to have TTP? I had a patient a few days after listening to this section and thought of TTP (thanks to EMRAP). The patient was altered, had low platelets, renal failure (also CPK 5400), schistocytes on CBC, temp. 99.9F, but the HgB was 14.4. Everything fit, except the HgB, and the patient was treated for TTP. Are schistocytes enough to call MAHA?
Thanks,
Jeff

Jacques R. P., M.D. -

The piece on the couple on vacation in Europe is a prime example of the woes of socialized medicine. Maybe we should prepare for this type of treatment within the next few years. You get what you pay for.

Jacques R. P., M.D. -

Sorry about posting in the incorrect section for the PE pt interview. The TTP article was great, especially the memory aides (Adam West, Adam 13). I can still remember the pathophysiology from the discussion. I would add that the RBCs have to put on their helmets to go through the tangle.

Colin Kaide, M.D. -

I teach my residents to remember it this way: TTP/HUS Pentad is FAT RN! Never say this in the ED or you will be beaten!
F Fever (rare)
A Anemic (MAHA -- always present)
T Thromobcytopenia (always present)
R Renal failure (HUS>>TTP)
N Neuro symptoms (present in most TTP)

When you see schistocytes, you should make a little schistocyte in your pants...these are NEVER normal at > 1%. When the "schistocytes" hit the fan, they get fragmented, except for those who wear helmets...and all the platelets pile into their VW Buses and they all get stuck in traffic. ADAM12* (Officers Reed and Malloy) are out getting doughnuts and can't break up the traffic jam. ADAMTS13* (A Disintegrin And Metalloproteinase with a ThromboSpondin type 1 motif, member 13...for the UberNerds)!
The treatment is Really Friggin Painful (RFP): Roids, FFP, PLEX

Allyson W., M.D. -

I just identified a case of TTP that I may have missed if it were not for your review. I was able to transfer her to a tertiary care center immediately and she has been on plasmapheresis now for over one week and improving. Thanks for the great review.

William G., M.D. -

I recently had a case of TTP in an IV drug abuser. The hematologist suspects that her case is due to IV abuse of opana. See this link:

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6201a1.htm

This report strongly suggests IV opana abuse as a risk for getting TTP.

david h. -

as a bleeder i appreciate your comments i have 52000 platelets

but every single one of them is a winner !

Kirt W., M.D. -

Question 8 asks abut patients over 60 days, which technically includes older kids, but the paper is about the 60 to 90 day old babies.

I have an anecdotal bias in my career- early on a mother leaped out of a car and handed me a limp baby, previously beautiful and healthy as I was checking the weather on the ambulance bay. Resusitation never regained a rhythm. It was meningococcus dx on post-mortem LP. There was no rash. It gave me a keen interest in this, fortunately rare problem.

About 15 years ago I saw a healthy 3 and 1/2 month old beautiful child with a rash. The triage nurse pounced and we had the child cultured and tapped and on appropriate antibiotic doses within 20 min of hitting the door. As I did all of this I could not help noting that she still looked great except for the rash. She was clearly in the age range where, in theory, the EP could base treatment on an appearance of toxicity. Despite very aggressive treatment by the pediatrician she progressed despite everything and died within six hours.

What this anecdote told me loud and clear was that this child looked great despite having meningicoccal sepsis and was clearly outside the 60 day limit being promoted by the paper in question and many others. In my career, subsequently, I was happy to tap babies up to 3 months or more and to treat with antibiotics to catch the one early enough for antibiotics to work. This patient had been seen by a partner nine hours earlier for fever, looked great, and the very experienced EP was talked out of giving antibiotics then after talking to the pediatrician, consistent with this belief that you can judge clinically at that age.

I have watched these papers with keen interest because in my mind, 1% is not small enough given the severe consequences and the assumption that early antibiotics are better than later in improving outcome for the ones with meningococcus.

Just my experience with 30 years full time as a denominator, to think about.

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Episode 138 Full episode audio for MD edition 246:41 min - 103 MB - M4AResumen Marzo 2013 en español Español 72:06 min - 25 MB - MP3EM:RAP 2013 March MP3 80 MB - ZIPEM:RAP March 2013 Written Summmary 2 MB - PDFNew Feature: EM:RAP March 2013 Board Review Questions 1 MB - PDFNew Feature: EM:RAP March 2013 Board Review Questions: Answer Sheet 654 KB - PDF

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