3.28.19 Conference Summary

Morbidity and Mortality Conference

Dr. Lauren McCafferty

  • Case 1: 90 yo M presenting with CC of dizziness

    • VS unremarkable

    • PMH: atrial fibrillation (recently stopped his warfarin for hernia repair), HTN

    • Dizziness was intermittent in nature, he described his symptoms as “my eyes can’t focus”

    • Exam: CN 2-12 intact, strength and sensation intact; rest of PE normal

    • EKG: afib with single PVC, no signs of acute ischemia

    • Labs: CBC, CMP, troponin unremarkable; no INR ordered

    • CT head: no evidence of acute abnormality

    • MDM: asymptomatic at presentation so DC’d home with follow up visit at PCP

    • Follow up visit 2 days later at PCP complaining of confusion and visual changes

      • MRI ordered that showed acute/subacute temporal and occipital stroke

    • Repeat visit at OSH ED: CTA showed complete occlusion of L posterior cerebral artery; transferred to 2nd OSH; patient refused aspirin during visit

    • Inpatient stay: R sided visual deficits noted by neurology, recommended heparin drip and monitoring

      • HD 2: CT head showing evolution of stroke

      • HD 6: discharged to SNF for rehab

  • Posterior Circulation Stroke

    • Main vessels involved are 2 vertebral arteries that forms basilar artery

    • Accounts for 20% of all ischemic strokes

    • Embolic is MCC, followed by vasculitis and dissection; small vessel disease is much less common (as compared to anterior or middle cerebral artery strokes, where small vessel disease accounts for majority of pathology)

    • Most commonly missed stroke (>1/3 missed)

    • Highly variable clinical presentation because of varying lesion locations

    • Tend to affect younger population

    • Presentation:

      • Facial weakness, hemiparesis, ocular symptoms, locked in syndrome

    • Question 1: What is the most common presenting symptoms of posterior circulation CVA?

      • Dizziness and vertigo

      • These patients are more likely to report pain than anterior or middle circulation stroke

    • Question 2: What are the predictors of mortality for posterior CVA?

      • Embolic etiology, distal territory, multiple territory infract, complete basilar artery occlusion

    • Question 3: How frequently are posterior stroke missed?

      • Up to 25%

    • Question 4: Best way to evaluate for posterior stroke?

      • MRI misses up to 20%

      • CTA or MRA is more sensitive than non angiographed MRI

      • HINTS exam is more sensitive than MRI in first 48 hours

        • Head impulse: jerk head side to side to look for corrective saccades; positive finding in which patient has corrective saccade indicates peripheral cause

        • Nystagmus: looking for vertical, rotary, or multidirectional

        • Test of Skew: eyes deviate to correct to center when one eye is covered indicates a positive test

        • Good test to differentiate central and peripheral

        • Only useful if patient has active, continuous symptoms

        • Central cause will showed normal head impulse test (can fixate eyes), vertical or multidirectional nystagmus, and positive skew test

        • Pitfalls of HINTS: not studied in ED, need all 3 components to apply, requires continuous and ongoing symptoms

    • Management: similar to other strokes; consider discharge only if patient can ambulate with negative HINTS exam; need close follow up

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  • Case 2: 52 yo F presenting with R sided neck pain, worsened with movement and swallowing; no sore throat

    • PMH: connective tissue disorder

    • VS unremarkable

    • PE: tenderness over R SCM, worsened with movement of head

    • MDM: provider believed symptoms were related to torticollis and dc’d home

    • 2nd visit: worsening neck pain, difficulty opening mouth, difficulty chewing

    • PE: Tachycardia with difficulty turning head to left

    • Labs: WBC 14k and elevated ESR and CRP

    • CT neck w/ contrast: mild to moderate retropharyngeal thickening and possible abscess

    • Given IV abx and dexamethasone

    • Transferred to tertiary hospital for ENT eval

    • ENT performed awake nasopharyngoscopy at bedside and unremarkable

    • Sent to observation unit; blood cultures returned positive so admitted to floor

    • Repeat cultures negative, dc’d on HD 6 ultimately with dx of retropharyngeal cellulitis and phlegmon (not abscess)

  • Retropharyngeal abscess/cellulitis

    • Anatomically close to danger space of neck and can spread to mediastinum

    • Primarily occurs in children <5 yo because this space is larger and is filled with lymph nodes

    • Very rare in adults as this is a potential space in adulthood

    • Symptoms: fever, sore throat, neck pain, drooling, difficulty swallowing and bending neck

    • Signs: stridor, trismus, torticollis, dysphagia; often appear toxic

    • Complications: airway obstruction, septic shock, mediastinitis

    • Diagnosis:

      • lateral neck X-ray: obtain in hyperextension and inspiration

        • Look for prevertebral space widening

          • >6 mm at C2 and >14 mm at C6 (22 in adults) is considered widened

          • High false positive rate, however

      • CT neck with contrast is gold standard

    • Treatment: airway management, antibiotics (clindamycin or ampicillin/sulbactam), and admission with ENT evaluation

    • Question 1: Does initial presentation etiology differ between kids and adults?

      • Children often present with feeding difficulties, drooling, stridor, and fever

      • Adult: sore throat, dysphagia, neck pain, posterior edema, trauma

        • Stridor much less common

    • Question 2: Surgical vs medical management?

      • Medical treatment is preferred unless abscess is >2 cm

      • Surgical management preferred in adults with evidence of abscess

    • Question 3: role of steroids?

      • Mildly improves symptoms, but does not shorten duration of disease nor complication rate

  • Case 3: 31 yo AA female presents with SOB and wheezing

    • Initial presentation: VS show tachycardia

    • PMH: asthma

    • PE: tahcycardic, end expiratory wheezing bilaterally, uncomfortable appearing

    • CXR: unremarkable

    • MDM: given oral prednisonse, 3 duonebs, and toradol; felt improved, patient requesting to be discharged home; discharged on 4 days of prednisone

      • DC dx: asthma exacerbation, URI vs influenza

    • Presentation on day 2

      • Worsening shortness of breath

      • VS: tachycardic to 145 and hypoxic to 93%

      • HPI: worsening cough and SOB

      • PE: severe distress, tripoding, severe wheezing

      • Labs: respiratory acidosis with pH 7.25 and CO2 65, lactate 3.2

      • Treatments: IV solumedrol and duonebs x3

      • Hypoxia improved after treatments, but remained tachycardic to 140s

      • Admitted to family medicine; influenza returned positive 2 hours later

      • Code white called for work of breathing and worsening hypoxia

      • Transferred to MICU and intubated with some difficulty (requiring “code intubate”)

        • Received tamiflu and given paralytics for better ventilator synchrony

      • HD1: developed AKI, transaminitis, leukocytosis to 21K

      • HD 9: HD initiated for worsening renal function

      • HD 11: extubated; now noted to have L sided weakness

      • HD 12: transfer to floor

      • HD 13: neurology consulted, MRI brain showed bilateral ACA infarcts L>R, ASA given

      • HD 20: discharged to rehab with persistent R foot drop

  • Influenza:

    • 3 different types

      • Influenza A: most prevalent with most severe morbidity

        • Only type that can cause pandemic

        • Cause of swine flu in 2009-10

      • Influenza B: less common and less severe

      • Influenza C: rare

    • Transmitted by respiratory secretions

    • Incubation periods is 18-72 hours

    • Viral shedding peaks at 1-2 days of symptoms

    • Clinical presentation

      • Adults: abrupt onset of fever, cough, myalgia, nasal congestion, malaise, headache

      • Children: atypical with higher fevers

    • Cold vs flu?

      • Influenza has more abrupt onset, worse myalgia, and higher fevers

    • Question1 : What is the most accurate way to diagnose influenza?

      • Rapid antigen testing has 40-80% sensitivity

      • No significant different between rapid flu test and clinical judgment

      • Influenza PCR has highest sensitivity and higher specificity

      • Viral culture most specific but takes 3 days for confirmation so less helpful in ED environment

      • Consider testing in patients with exacerbation of chronic cardiopulmonary disease

    • Question 2: What is the benefit of antivirals for the flu?

      • Symptomatic relief if oseltamivir given within 48 hours of symptom onset

        • Adults 16 hours faster to resolution

        • Peds: 29 hours faster to resolution

      • NO significant reduction in morbidity or mortality

      • Adverse effects of oseltamivir: nausea, vomiting, particularly in adults

        • Number needed to harm with Tamiflu is 7 (nausea) and 37 (vomiting), which is similar to number needed to treat (20) to prevent one positive culture

    • Question 3: Who to treat?

      • Hospitalized patients

      • High risk of complications

      • Have sever, complicated, or progressive illness

      • Dosing: 75 mg BID adults (QD for prophylaxis) for 5 days

    • Question 4: Complications?

      • Sinusitis, OM, Pneumonia, sepsis, myocarditis, stroke (very rare), renal failure

      • Who is at greatest risk?

        • Pregnancy, extreme obesity, hx of cardiopulmonary disease

    • Question 5: Why are asthmatics at higher risk?

      • Poor compensatory function

      • Increased risk for PNA, resp failure, hospitalization

Influenza Virus

Influenza Virus

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“One Pill Can Kill”: Pediatric Toxic Ingestions

Dr. Brendan Kilbane

  • Epidemiology

    • >1 million pediatric exposures/year

    • Most exposures are not toxic

  • Cosmetics and personal care account for most substances that children come in contact with (14.5%)

  • Substances that cause pediatric fatalities

    • Analgesics

    • Cleaning products

    • Pesticides

    • Antidepressants like TCA

    • Iron

  • Toddlers are….

    • Small, curious, like to put things in their mouth, low to the ground, unaware of safe vs unsafe, imitators of big people, exhausting to supervise

  • Typical exposures…

    • Occur at home, involve things within reach, involves medication of relative, often occurs at time of distraction event (new sibling, recent move)

  • Home vs. ED management

    • 80-90% of ingestions reported to poison control centers are handled successfully by phone/home observation

  • Poison Control: 1-800-222-1222

  • Toxic ingestion treatment paradigm

    • Decontamination, elimination, antidote

  • Substances not absorbed by activated charcoal

    • Metals (Fe, Pb)

    • Electrolytes

    • Mineral acids and alkalies

    • Alcohol

    • Cyanide

    • Most solvents

    • Lithium

  • Calcium channel blockers

    • Older non dihydropyridine are most dangerous

      • i.e verapamil or nefidipine

    • Onset of action typically 30 min with half life varying from 3-7 hours

    • No QRS prolongation

    • Hyperglycemia and hypocalcemia are common electrolyte abnormalities

    • Treatment:

      • ABCs

      • IV calcium

      • Vasopressors

      • Glucagon (maybe)

      • High dose insulin euglycemia therapy (HIE)

    • All symptomatic children should be admitted to PICU

    • Even if asympomatic, consider admission for observation as delayed release is possible

  • Tricyclic antidepressants

    • Inhibit re-uptake of NE and serotonin

    • Significant Na channel blockade

    • Major associated toxidromes

      • Tremors/seizures

      • Cardiovascular

        • Sinus tachycardia with prolonged QRS, PR, or QT interval

        • Hypotension

    • Treatment:

      • ABCs

      • Bicarbonate indicated for QRS>100

      • Early IV fluids, plus pressors if necessary

      • Benzos for seizures and agitation

    • Diposition

      • All children with symptoms -> PICU

      • Asymptomatic: observe for at least 6-8 hours

  • Narcotic medications

    • Codeine (one 30 mg tablet), hydrocodone (5 mL of elixir), methadone (one 10 mg tablet) can all cause opiate toxicity in pediatric toxicity

  • Sulfonylureas

    • Multiple episodes of hypoglycemia

      • Results in hypotension, tremor, tachycardia

    • Treatment:

      • ABCs

      • If awake and alert -> feed them

      • IV dextrose or glucose +- fluids

      • Glucagon 1-2 mg IM or IV

      • Octreotide 50 mg SC q12H

    • Disposition

      • “Toxic time bomb” = hypoglycemia may be delayed up to 8-20 hours

      • All patients with possible sulfonylurea shoulder be admitted for observation (12-24 hours)

  • Loperimide

    • Combo anticholinergic and opiate agonist

    • Bradycardia, resp depression, drowsniness, convulstions, coma, miosis

    • Treatment:

      • Narcan may be helpful

      • Symptomatic care

  • Toxidromes

    • Sympathomimetic

      • HTN, tachycardia, hyperthermia, agitation, diaphoresis, mydriasis

      • Resembles anticholinergic but with diaphoresis

      • Treatment: benzos

    • Anticholingeric:

      • TCAs, benadryl, dextromethorphan, scopolamine, Jimson weed, antispasmodics

      • Presents similarly to sympathomimetic toxidrome but with dry skin

      • Treatment: supportive, may consider physostigmine in consultation with poison control

    • Cholingeric

      • Consider in mass exposure

      • Presentation: Diarrhea, diaphoresis, rhinorrhea, salivation, bradycardia, hypotension, urination, lacrimation

      • Treatment: atropine +- 2-PAM

    • Opiate

      • Presentation: Lethargy, coma, obtundation, respiratory depression, miosis

        • Relatively normal VS

    • Benzodiazepines

      • Presentation: lethargy, hypotension, bradycardia, respiratory depression

      • Treatment: supportive

        • Flumazenil is reasonable only if certain that patient had single large ingestion with no history of chronic ingestion, as intractable seizures can occur that are resistant to benzo treatment after flumazenil treatment

  • Salicylates

    • Vomiting and hyperventilation with tinnitus, lethargy, coma, seizures, hypoglycemia, hyperthermia

    • Mixed resp alkalosis and metabolic acidosis

    • Start worrying fi you see resp acidosis as this is a sign of fatigue and impending respiratory failure and need for intubation

    • Treatment: Activated charcoal, Bicarbonate is mainstay, HD

      • Avoid intubation if possible as this can worsen treatment course

      • If intubation necessary, keep minute ventilation rate high

  • Camphor (Vick’s vaporub)

    • 15 mL Vicks in 3 yo is toxic

    • Causes direct CNS stimulation but underlying mechanism is unkonwn

    • Causes intractable seizures

    • Must decontaminate patient (i.e. wash off all skin with soap and water to stop absorption)

    • Treatment: benzos

  • Toxic alcohols (methanol, ethylene glycol, isopropyl alcohol)

    • Isopropyl alcohol causes intoxication with a negative ETOH level; also causes ketosis without acidosis (because isopropyl alcohol is metabolized to acetone and not acetic acid)

    • 4 mL of methanol or 60 mL (2 oz.) antifreeze is toxic

    • Can cause ATN and CNS depression

    • Treatment: IV ethanol or fomepizole

  • Methemoglobinemia

    • Orajel (benzocaine) classically causes this in children

    • Presentation: pallor, cyanosis, fatigue, lethargy, headache

    • Hypoxia that minimally improves with supplemental O2

    • Treatment: methylene blue

      • Avoid with known or suspected G6PD deficiency

  • Caustic ingestions

    • Alkalotic ingestions (ie. drain cleaner, oven cleaner, toliet bowl cleaner) are worse as they cause early liquefactive necrosis

    • Treatment: emergent consultation with GI for endoscopy to eval for injury and decide plan of care

  • Antimalarials

  • Antiarrhythmics

  • Clonidine

    • single 0.1 mg tablet in toddler can cause respiratory depression

    • Opiate like effects

    • Treament

      • ABCs, naloxone

EBM: Targeted Temperature Management in Post Cardiac Arrest

Dr. Victoria Mason

ttm.jpg
  • Evidence for TTM

    • Bernard Study

      • 77 patients in Australia

      • Inclusion criteria: Vfib/Vtach presenting rhythm with ROSC not following commands

      • Cooled to 33 degrees for 18 hours using ice packs vs normothermia vs 37, randomized by days of the week

      • Outcomes: Good neurologic outcome with odds ratio of 5/2

    • Europe Study

      • 273 patients in Europe with Vfib/Vtach with ROSC

      • Cooled to 33 degrees C within 4 hours vs normothermia

      • Outcomes: NNT 6 for good neurologic outcome and NNT 7 for prevention of 1 death

    • TTM study

      • 950 patients in Scandinavia, Europe, Australia in any rhythm with ROSC

      • Cooled within 4 hours to 33 degrees C vs 36 degress for 28 hours

      • Found no difference in death or neurologic outcomes in 33 degree or 36 degree group

    • Bernard study, before and after cohort study

      • 77 shockable rhythm patients

      • Only 70% in 36 degree group received active cooling

      • 1 in 5 had fevers in 36 degree group

      • Patients spent less time at target temperature

  • Goal Temperature?

    • Evidence unclear

    • American Heart Association recommends range between 32-36 degrees

    • Casamento 2016 looked at TTM protocol in a cohort study with 138 patients in Australia

      • Found no difference at time spent at target temerpature

    • Salter 2018 cohort study evaluating TTM before and after study

      • 36 degree group have 4% more fevers than 33 degree group

    • 35-36 may be a more reasonable goal range

    • Pregnant patients or patients with active bleeding have worse outcomes when cooled to 33 degrees

  • Candidates for TTM

    • There is no absolute contraindication for TTM with goal 36 degrees Celsius

    • Pregnant patients or patients with active bleeding (even intracranially) have worse outcomes

  • Other post- cardiac arrest considerations

    • Foley catheter probe should be used to monitor temperature, or esophageal probe if low UOP

    • Use arctic sun if available

    • Scheduled Tylenol and buspirone for prevention of shivering

    • Use adequate sedation for RASS -4 to -5

    • Paralyze if uncontrolled shivering

    • If patient is >32 or <36, passive rewarming only

    • Record temperatures every hour

    • Maintain the above interventions for full 24 hours

    • Early consultation with a cardiologist to consider coronary angiography should be performed as >50% of patients will have a culprit lesion

    • Avoid neuro-prognostication in first 72 hours after cardiac arrest

    • Obtain a CT head w/o contrast early after ROSC to evaluate for ICH or loss of gray/white matter

    • Maintain a low threshold for antibiotics as 38% of cardiac arrest patients will have bacteremia on HD1 in ICU

    • Maintain eucapnia with arterial CO2 35-45

    • O2 goal 93-98%

    • Avoid hyperglycemia

    • Consider ECMO if refractory shock