11.29.18 Conference Summary

Morbidity & Mortality Conference - Dr. Lauren McCafferty

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Necrotizing Fasciitis

  • Rapidly spreading deep soft tissue infection with high mortality

  • Surgical emergency — needs rapid debridement in the OR

  • Risk factors

    • Poor vasculature/wound healing

    • Immunocompromise

    • Trauma to skin or mucosa

  • Most common symptoms: soft tissue edema, erythema, pain out of proportion*, fever, crepitus, bullae/necrosis*

    *favors nec fasc over cellulitis (in addition to hypotension or recent surgery)

  • Classification:

    • Type I: polymicrobial

    • Type II: monomicrobial (MRSA vs Group A strep)

    • Type III: Vibrio vulnificus

    • Type IV: Fungal

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  • LRINIC Score (see Table 1)

    • Risk/Score/Probability of necrotizing infection

      • Low: ≤ 5 <50%

      • Intermediate: 6-7 50-75%

      • High ≥ 8 >75%

    • Poor sensitivity when used in isolation… clinical suspicion is key. Use LRINIC as adjunct.

  • Predictors of mortality

    • WBC>30k, creatinine >2.0, heart disease, clostridial infx

  • Management/practice guidelines

    • Prompt surgical debridement (<24 hrs improves outcomes, <6 hrs is optimal)

    • Broad spectrum antibiotics (IDSA)

      • Vancomycin (or linezolid) PLUS zosyn or ceftriaxone+flagyl or carbapenum

      • Penicillin + clindamycin covers group A strep and clostridium

Sepsis in Hemodialysis Patients

  • Annual % mortality from sepsis is 100-300x higher in dialysis-dependent patients compared to general population

  • Septic dialysis patients significantly under-resuscitated due to concern for fluid overload

  • Need aggressive fluid resuscitation! Can always dialyze off or intubate if pulm edema/respiratory compromise ensues.

  • Bottom line: mortality in septic dialysis patients is far too high to be too cautious with fluids. Adequately resuscitate!

Ascending Cholangitis

  • Biliary obstruction (stones, stricture, malignancy, iatrogenic) + infection

  • Mortality previously up to 50%, improved to 7% with improvements in biliary drainage

  • Usually polymicrobial (GN, GP, anaerobes)

  • Classic presentation:

    • Charcot’s Triad = abdominal pain, jaundice, fever — low sensitivity, good specificity (good rule-in, .poor rule-out test)

    • In more severe cases…. Reynold’s Pentad = triad + hypotension + AMS

  • Diagnostic criteria: Tokyo Criteria 2013/2018

    • A: Signs/sx of systemic inflammation, WBC, CRP

    • B: Cholestasis - jaundice, LFTs

    • C: Imaging showing obstruction

    —> 1 in each category = definite diagnosis; 1 in A and 1 in B or = suspected diagnosis

  • Predictors of mortality include end-organ dysfunction, bacteremia, high fever, comorbidities, elderly

  • Management guided by severity but generally;

    • Resuscitation and broad spectrum antibiotics (duration 4-7 days once obstruction resolved)

    • Urgent decompression (especially in moderate to severe cases)

Table 2. Antibiotics for Cholangitis (Tokyo Guidelines 2013/2018)

Table 2. Antibiotics for Cholangitis (Tokyo Guidelines 2013/2018)

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Subarachnoid Hemorrhage (spontaneous)

  • Pathophysiology

    • Rupture of intracranial vessels resulting in blood accumulating in subarachnoid space, mixing with CSF

    • Most commonly due to aneurysm rupture

  • Risk factors:

    • Tobacco/EtOH/sympathomimetic use

    • Family hx of aneurysm

    • Hypertension

  • Clinical presentation

    • Headache most common

      • abrupt onset at maximal intensity

      • ‘thunderclap’ headache, ‘worst headache of my life’

    • +/- Syncope, nausea/vomiting, meningismus

    • Seizures rare but predict poor outcome 

    • Death may occur

  • Complications

    • Rebleeding - highest risk in first 6 hrs

      • Risk factors include: SBP > 160mmHg (higher risk than >140mmHg), higher Hunt/Hess score, posterior circulation aneurysm, aneurysm size >10mm

    • Delayed cerebral ischemia - avoid hypotension

    • Vasospasm

    • Seizure - AED prophylaxis not routinely recommended (especially phenytoin)

    • Increased ICP - may require EVD to decompress

    • Non-neurologic sequelae:

      • Cardiac dysfunction - related to sympathomimetic stimulating. catecholamine surge

      • Hyponatremia (cerebral salt wasting), hyperglycemia, fever

  • Workup

    • Noncontrast CT head; if negative, perform LP

    • LP—> +xanthochromia and significant RBCs (no clear cutoff) concerning for SAH

      • Study by Perry J, et al. showed 100% sensitivity for absence of xanthochromia AND RBC <2000 in excluding SAH

  • Management

    • Goal blood pressure <140 vs <160 mmHg

    • Early intervention (coiling vs clipping) is better

    • Oral nifepidine shown to improve outcomes (Class 1 Level A) - 60mg q4h x 21 days

    • Close monitoring for re-bleeding and other complications


Mass Casualty Incidents/Disaster Medicine 101 - Dr. Jason Zeller, Dr. Jeff Luk

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  • Mass casualty = incident in which casualties exceed the resources of emergency medical services resources available

  • Based on number and severity of injuries and availability of resources (personnel and equipment)

  • Medical evaluation and treatment are needed as part of the response to essentially any disaster scenario but the type/extent of medical services needed is situation-dependent

  • Essential to mobilize personnel and supplies and designate leader who has ‘big picture’ view

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  • START Triage (Simple Treatment and Rapid Treatment)

    • Very brief assessment of breathing, respirations, perfusion, mental status used to assign a patient a ‘tag’ indicating one of the following categories; a way to clearly identify acuity and prioritize patients

    • Only perform the most basic intervention (head tilt if not breathing, bleeding control) before moving on to the next person; not practical/efficient to try to treat each patient in normal fashion

    • Categories:

      • Black = deceased or expectant

        • Absent vitals or severe injuries such that death is imminent

        • If no respirations after head tilt, move on to the next patient; further treating these patients is futile and poor use of resources

      • Red = Immediate

        • First Priority

        • At risk for imminent death and need stabilization immediately

      • Yellow = Delayed

        • Second Priority

        • Injuries that may be serious but breathing, mentation, perfusion relatively stable

        • Need reevaluation

      • Green = Minor

        • Third priority

        • Minor injuries that may still need care but not urgently

        • Provide reassurance and move to designated area to wait until further care can be provided

      ***if patient’s status changes, they should be reassigned a different tag and treated appropriately


Power (Half) Hour - Dr. Lauren McCafferty

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Case #1

65 yoF presented for a few hours of painless unilateral vision changes, slightly blurry and seeing ‘floaters’. Visual acuity intact, visual fields full, grossly normal external exam, limited fundoscopy but ocular ultrasound showing this….

Ophtho consulted and subsequently took patient to the OR

Retinal Detachment

  • Retinal tear-> fluid accumulation-> ‘detachment’ of retina from posterior eye

  • Painless, flashes of light, floaters, curtain over visual field

  • Ultrasound findings

    • Hyperechoic linear structure in vitreous body,

    • Tethered to optic nerve posteriorly (vs vitreous detachment which ‘floats’ in vitreous body)

    • Moves in ‘wave’ with eye movement 

    • ‘Mac-on’ (still attached to macula just lateral to the optic nerve; vs ‘mac-off’ (detached from macula, only attached to optic nerve)

  • Ocular emergency (especially mac-on) !!!

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Case #2:

68yo M presenting s/p trip and fall onto outstretched hand. C/o elbow pain. ROM intact but eliciting pain. X-ray shown here.

Pt diagnosed with elbow effusion (suspected radial head fracture), placed in long arm splint to follow up with ortho,

Sail Sign

  • Crescenteric lucency adjacent to distal humerus on lateral xray

  • Anterior fat pad

    • Normal: thin and ventral to joint 

    • Abnormal: larger, more elevated

  • Posterior fat pad always pathologic

  • Seen in intra-articular fractures of elbow, often occult

    • Kids: supracondylar fracture

    • Adults: radial head fracture

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Case #3

21yo M history of IVDU presented for progressive back pain and lower extremity weakness, slightly altered. Found to have diffuse miliary-like lung nodularities, large prevertebral and psoas abscess, multiple cerebral/cerebellar lesions w/ ring enhancement… ultimately diagnosed with miliary TB

Miliary TB

  • Hematogenous dissemination of Mycobacterium tuberculosis from lungs

  • Sx often subacute to chronic and dependent on organ involved

  • Diagnosis: clinical + testing including

    • Acid fast bacilli smear/cultures

    • Nucleic acid amplification testing (NAAT)

  • Treatment

    • Similar to primary TB (4-drug regimen RIPE 1st line)

    • Disease/site-specific treatment (this pt underwent IR drainage of abscess)

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Case #4

80yo F presented by EMS after suddenly becoming short of breath then collapsed. Arrived to ED obtunded, hypoxic not protecting airway, only moving one arm. HDS. Patient intubated while POCUS showing signs of right heart strain and this….

Mobile clot in IVC… IVC filter ‘holding it back’. Patient taken immediately for CT head to r/o bleed as well as CTA which showed submassive bilateral PE and occlusive MCA thrombus. Patient given TPA.