5.23.19 Conference Summary

Morbidity and Mortality: Dr. Lauren McCafferty

Case #1: 34 yo male who presented with sinus congestion, confusion, blurred vision. Sent in from work who stated that he was having trouble walking and reading

  • PMH: IBS, HLD, fatty liver

  • Social: Denies tobacco, 1-2 ETOH daily

  • Exam: Neuro- wide based gait, can’t heel to toe walk, repetitive speech, + Romberg

  • Labs: ALT 121, AST 130s

  • CT head: No acute findings

  • LP: Unremarkable, opening pressure is 20

  • Final diagnosis: Wernicke Encephalopathy

320px-Thiamine_structure.svg.png

Wernicke Encephalopathy

  • Encepholapthy secondary to thiamine deficiency

  • Thiamine: co-enzyme in carb metabolism = decreased ATP = CNS/cardiac events

  • Who is at risk?

    • Chronic alcoholics most common

    • If not alcohol- AIDS, BMT, bariatric surgery, malignancy (most common in kids), hyperemesis, eating disorders

  • Clinical findings: AMS/confusion. ophthalmoplegia (lateral gaze palsy), ataxia, nystagmus

    • Classic triad present about 10-16% of the time

    • AMS is most common followed by ocular findings

    • 80% of patients diagnosed with autopsy were misdiagnosed as something else

  • Treatment:

    • Check glucose

    • Give Thiamine!

      • Dose is not exact but current thought is 500 mg IV every 8 hours x3 days, then 250 mg after that

      • Prolonged glucose alone can be a risk factor for Wernicke’s but the evidence is unclear

Case #2: 30 yo male with stage IV recurrent Nonhodgkins lymphoma, chemo last two days before coming in. complaint of cough, diarrhea, congestion

  • Febrile, tachy, hypotensive

  • EKG: Sinus tachy

  • Labs: WBC 0.7, platelets 49, bands 6%, ANC 300, Na 124 (new), creatinine 1.46

  • CXR: bilateral opacities concerning for pneumonia

  • Treatment: 30 cc/kg fluids, zosyn

  • Course: code white called almost immediately on arrival to the floor for hypotension -> given an additional 2L NS and transferred to MICU. Blood cultures with +MSSA. Transferred back to the floor on day 2.

240px-Blausen_0676_Neutrophil.png

Neutropenic Fever

  • ANC <500

  • Neutropenic fever = neutropenia (or expected neutropenia is 48 hours) + temp of 38.5C or sustained 38 for one hour

  • Mortality 90% if left untreated

  • Predisposing factors for neutropenia: sepsis, malignancy, drug induced, malnutrition, myelodysplastic syndrome, infection

  • What affects outcomes?

    • Antibiotics- one study with ever hour delay increasing mortality by 18%

      • Single broad spectrum agent (anti-pseudomonal)

      • Add vanc with indwelling catheter, if on gram negative prophylaxis, prior MRSA infection, SSTI

      • Antifungal/antiviral not started routinely

    • Higher MASCC score, delay in abx = prolonged hospital stay, bacterima/bandemia = increased mortality

Case #3: 46 yo with congestion, not sleeping well, wife passed away early in the week. H/O BKA, HTN, kidney transplant January 2019.

  • Exam: Dry appearing, lethargy

  • Labs: pH 7.11, pCO2 49, potassium 7.4, bicarb 14, BUN 77, creatinine 4.31 (baseline 2s)

  • CXR: concern for pneumonia on the right

  • EKG: stable from old

  • Treatment: albuterol, calcium, dextrose, insulin, bicarb, ceftriaxone (cefazolin allergy listed- patient stated diarrhea)

  • Transplant surgery: vanc, zosyn, bactrim, lasix, renal ultrasound

  • 6 hour repeat labs: K 5.8, pH 7.11.

  • 12 hours after arrival- periorbital edema, stridor, mouth/tongue swelling = epi, steroids, benadryl, ENT consulted- significant edema = nasotracheal intubation

  • 2330 ceftriaxone/azitho, 0500 zosyn/vanc/bactrim, 1230- angioedema

PenNandCephC-1.gif

Penicillin/Cephalosporin Allergy:

  • Most commonly reported allergy but only 5% actually IgE mediated reaction

  • Cross-reactivity between PCN/cephalosporins

    • penicillin allergy most associated with 1st generation cephalosporins and almost non in other generations

    • Actual crossreactivity in people with confirmed PCN allergy = 2.5%

    • Matters because people get a suboptimal therapy = higher rates of C. diff, AKI, MDR, adverse side effects, higher costs

Neonatal Resuscitation: Dr. Megan Evers

Fetal transitional circulation: With first breath, PFO closes and pulmonary resistance decreases = blood flow goes to lungs

  • Ductus arteriosus- usually closes in a few hours

  • Signs of abnormal transition (should take about 10 minutes to get to SpO2 100%)- irregular or absent respiratory effort, apnea, or tachypnea

    • bradycardia/tachycardia, low sat, poor perfusion = concerning, but always focus on respiratory first

Delivery in the ED:

  • Is the baby full term?

  • Is the baby breathing?

  • Do they have good tone?

  • Steps:

    • Step 1:

      • place baby under radiant heat, if <32 weeks you can wrap in plastic, dry baby and then remove wet blanket

      • Depress bulb syringe and clear out mouth

      • Look for meconium staining- only intubate after working on airway first

        • Meconium aspirator

    • Step 2:

      • Heart rate: at least 100 bpm

        • Feel pulse at the base of the umbilical cord and tap it out for the rest of the team

      • pulse ox and ECG monitors are heart in a wet child

        • If you place it, must be on right for preductal baby

    • Step 3: Not doing well

      • PIP 20-25, PEEP 5

      • Breath 40-60 breaths per minute

      • Most important indicator for success is increase in heart rate

        • If baby still needs a little more help, you can do blow by oxygen

        • If baby has increased work of breathing, consider CPAP

        • If heart rate is still below 100….

    • Step 4: After 30 seconds of PPV

      • Heart rate > or = to 100 = success!

      • Heart rate between 60-100 = positive pressure

      • Heart rate <60 seconds = adjust technique (will start compressions after 60 seconds)

    • STep 5: Intubation

      • Blade: 00, 0, 1

      • Depth roughly 3x size of tube itself

      • GA <28 = 2.5, 28-35 = 3, full term = 3.5

      • Can use an LMA if congenital abnormalities make airway difficult= but smallest size is a 1

    • Step 6: CPR

      • 90 compressions per minute

      • Sternum, right at nipple line

      • Compress with thumbs

      • Medications

        • Epinephrine: only the 1:10,000 concentration

          • IV/IO- 0.1-0.3 mg/kg

        • Fluid- NS 10 cc/kg

        • Blood- 10 cc/kg

      • Umbilical line:

      • 3.5 or 5F single lumen catheter filled with NS

        • 2-4 cm at first- wait for blood flow

      • Tie cord at the bottom to cut off blood flow for a minute and then cut the cord. The vein is the largest, compressible vessel

      • OG tube

        • Consider if proving CPAP or PPV for several minutes and having trouble aerating

        • 8F

    • When do you stop?

      • 10 minutes without heart rate is a good predictor or mortality

      • Always have the discussion in the setting of congenital abnormalities

Pitfalls in the Initial Evaluation of the Burn Patient: Dr. Charles Yowler

Burn injury:

  • Burn injuries about 2 million per year

  • 700,000 ER visits

  • Hospitalizations = 45,000

  • Mortality of patient’s who get admitted to burn unit: 6%

Airway

  • Inhalation injury

    • Anoxic injury: oxygen content of closed room with fire may be as low as 10% = anoxic injury within minutes

      • Kills even in the setting of small burns/no burns

    • Carbon monoxide/cyanide: systemic poisons absorbed through the lungs

      • Often from upholstered furniture- worsened if found down in living rooms or bedrooms

    • Smoke inhalation: chemical byproducts of combustion that create chemical burns to the airway

      • No heat goes below the glottis until steam heat but smoke does = chemical burn to lung

    • All victims of closed space fires should be placed on 100% oxygen by mask until an arterial blood gals with carboxyhemoglobin is obtained

    • Carbonaceous sputum, soot in the nasopharyngeal cavity, and facial burns are signs of inhalation injury but are not absolute indications for intubation

      • 70% of patient with inhalation injury have mild/moderate inhalation injury and do not require intubated (ie, blood gas normal, no hoarseness, mentating well, and soot in mouth but not nose)

    • Who do you intubate?

      • Respiratory distress, unresponsiveness, hoarseness (remember that this is a sign of airway edema and he will get lots of fluid for burns, worsening the edema), stridor, dyspnea (ARDS can happen in burn), third degree facial burns, CO poisoning

      • Wheezing- does not indicate laryngeal edema. Bronchospasm is common after smoke inhalation and usually responds to bronchodilators/asthma protocols

      • Pearls: scald and grease burns to face never require intubation

  • Carbon Monoxide- burn patients should NOT be unconscious

    • Consider CO poisoning, closed head injury

    • By product of combustion, usually in patients exposed to closed space fires

    • signs: decreased alertness

    • Remember that these people will be 100% on a pulse ox

    • Half life: room air- 240 minutes, 100% oxygen 30-45 minutes, hyperbaric oxygen 15-20 minutes

    • Pathophysiology- impaired oxygen delivery, impaired oxygen utilization

    • Levels:

      • Intubate/100% oxygen- COHgb > 20 if symptomatic, >30 always

      • Wean oxygen when COHgb >10 and serum bicarb >20 = resolution of metabolic acidosis signifies CO has cleared the mitochondrial cytochrome oxidase system

    • Pearl: Hyperbaric oxygen use in carbon monoxide poisoning remains controversial

      • Burn society does NOT like it- 100% oxygen already decreases the half life and putting a severe burn/sick patient in HBO is dangerous

      • Intensive Care Medicine (2011)- groups were transient loss of consciousness vs coma- not receiving HBO had similar outcomes between groups and people who “dove” more often did worse

        • Hyperbaric chambers will increase free radicals and worsen anoxic injury

  • Smoke inhalation injury

    • Determinants of mortality: age, burn size, presence of inhalation injury

      • 85% of people who survive for the first two days and then die will die of infection- usually pneumonia (pseudomonas) in people with inhalation injuries

Rule of Nines: use patient’s hand size, counts second degree burns and above

  • Torso includes groin and buttocks- it’s 15% to belt line

  • Red burns that do not blanch are 3rd degree burns

  • 2nd degree burns are often pink

Fluid Resuscitation:

  • 2-4 cc/kg per % burned for adults

  • Children <14 = 3 cc/kg per % burned

  • Children <2 = D5LR at maintenance rate (don’t start if less than one hour transport but otherwise they get severely hypophostemic)

  • 1/2 is given over 8 hours post-burn and half is over next 16 hours

  • Prefer to resuscitate with LR because of amount of fluid- WILL develop hyperchloremic acidosis

  • IV access may be through burn but should not be distal to circumferential burns

  • Bolusing can create a problem- there is a capillary leak syndrome so you will loose the fluid from the skin quickly

    • Bolus for hypotension, not for UOP

  • Some people need more fluid

    • Inhalation injuries, delay in resuscitation/associated injury, pre-existing dehydration, hyperglycemia, alcohol intoxication, chronic diuretic therapy

  • Under-resuscitation results in hypoperfusion or organ and the burn wound = can convert partial thickness burns for full thickness

  • Over-resuscitation exacerbates co-existing pulmonary injury and increases edema

  • Goal urine output of 0.5 cc/kg/hr (1.0 cc/kg/hr in infants)

    • Urine outputs greater than 1.0 cc/kg should be avoided

  • They will have an elevated lactate that persists with severe burns- don’t necessarily try to clear it

Monitoring

  • Myocardial depression occurs in patients >20% burns and persists for 24-36 hours

Wound care

  • Immediate transfer: clean/dry/lubricated dressing, tetanus

  • No systemic antibiotics

  • Transfer delay > 6 hours: Topical agents

Topical Agents:

  • Systemic antibiotics do not penetrate the dead surface tissue of the burn wound and cannot prevent infection of the necrotic tissue

  • Topical antibiotics decrease surface colonization

  • Silver sulfadiazine

    • poor penetration

    • sulfa drug

    • Can cause transient neutropenia

    • Inhibits healing and increased scarring in 20 degree burns

      • Don’t use on burn going home

    • Can use it on third degree burns if you need to or areas with high infective risk (ie diabetic foot)

    • Advantage: soothing, overall excellent coverage

Adjuncts:

  • NG tube for burns >20%- gastric ileus is common

  • Tetanus

  • Fluorescein eyes if facial burns are present

  • Avoid hypothermia

  • Beware associated injuries- remember to do a full trauma survey

    • Found down = hit their head

Electrical Injury

  • Low voltage = <1000 volts: Everything inside your house and does not cause tissue damage. Can cause arrhythmia acutely but will not cause permanent cardiac injury

    • History of unconsciousness = need admitted because likely had an arrhythmia

  • High voltage: May result in injury to conduction system of the heart and persistent arrhythmias. Signifcant soft tissue injury with 25% requiring major amputation

    • Tetany- worry about compartment syndrome

    • Current goes in straight line- will jump parts of body

    • Cardiac injury can cause an arrest 30-45 minutes or later after event

    • Rhabdomyolysis -> kidney failure

    • Nerve injuries often occur

  • Initial evaluation

    • ABCs, rule of 9s does not work

    • Pearl: If urine is clear, you do not have enough rhabdo to cause kidney failure

    • Red urine = 2L of fluid + 2L bicarb fast

      • Output >100 cc/hr

    • Tetanus + topical agents to areas of cutaneous burns

    • Serial exams- will develop compartment syndrome

    • Contact point so trunk may be associated with internal injuries (ie liver lac, pneumothorax, subdurals)

Lightning

  • Voltage in millions

    • direct hit will kill you

  • Direct current flow often minimal

  • Dendritic fern like erythematous pattern

  • Can have a cardiac arrest

Pediatric Aspects

  • low voltage: does not need admission until there is a history of LOC or abnormal EKG

  • Oral burns: no debridement, await final demarcation, hemorrhage from labial artery

Toxicology: Diabetic Medications: Dr. Zac Rasmussen

Sulfonylureas

  • Activates potassium channel in beta cell and forces it to make insulin even if there is not any glucose there

  • Duration of action- 6-60 hours

    • Most commonly used medications have a duration of action of 24 hours

  • Acute overdose:

    • Onset of action in 6 hours = can observe for 8 hours and if not hypoglycemia, can medically clear

  • Chronic overdose: usually get hypoglycemic in 3-4 days

  • Treatment of overdose:

    • Maintain euglycemia

    • Octreotide

    • Glucagon not recommended

Megitinides

  • Works similarly to a sulfonylurea

  • Onset of action is 4 hours so only need to observe that long

  • Treatment: maintain euglycemia, think about octreotide

Metformin

  • Decreased glucose from liver, increases skeletal muscle utilization, and decreased GI absorption of glucose

  • Metformin associated lactic acidosis

    • blocks pathway distal to the krebs cycle to substrates are pushed into the lactic acid pathway

    • Renal injury increases risk

  • Treatment of overdose:

    • normalize pH with bicarb/dialysis

    • Do not do anything to cause a kidney injury

Insulin

  • Recognize long vs short acting insulin

  • Treatment: Euglycemia, massive overdose - consider adding a steroid to increase insulin resistance

Alcohol Withdrawal Treatment: Dr. Sean Mayerik

AWS:

  • approximately 600,000 cases a year

  • Can be fatal in up to 15% of cases

  • Tremendous burden on healthcare system

Risk factors:

  • Chronic use

  • History of withdrawal

  • Every time you are sober -> chronic use-> sobriety attempt = each additional withdrawal is worse

  • Signs/symptoms:

    • Starts after about 6 hours from last drink, do not need to be sober

    • 12-24 hours mild symptoms, 24-36 hours moderate, 36-48 hours = DTs

  • CIWA protocol

    • Medications: benzos, benzos, benzos

What about phenobarbital?

  • Works on gaba receptors + stops hyperactive NMDA receptors

  • 1/2 life up to 5 days

  • Can’t use in severe liver disease, pregnancy

  • Rosenson 2013

    • started patients on CIWA with or without phenobarbital

    • Less benzo use with equal amount of side effects, including respiratory compromise

  • Oks et al, 2018

    • Observational study: 86 patients

    • phenobarbital 130 mg q15 hours til RASS 0 to -1

    • No intubations

  • Tidwell et al, 2018

    • Exluded anyone with benzos over the last 24 hours

    • Looked at groups: active DT, history of DT, and no history of DT at a flat dose

      • Doses varied by group/active DTs

    • People had 2 less ICU days, overall less days in the hospital

Proposed protocol:

  • Initial CIWA score ->

    • <10 = start oral taper and consider d/c if reliable

    • CIWA >10 and <20 = 130 mg IV x1 dose

    • CIWA > 20 = 260 mg IV x1 -> 130 mg IV x1 dose

  • After 130 mg IV dose

    • 130 mg IV x15 minutes for RASS 0 to -1 -> 2 hours -> dispo

      • <8 doses = floor with taper

      • > 8 doses = ICU