1 / 47

CASE PRESENTATION

CASE PRESENTATION. July 7, 2005 Trevor Langhan PGY-3. OUTLINE. Case seen while on plastic surgery this spring Brief case presentation As interactive as possible, ask some questions if you like, and I may ask one or two of you! Diagnosis Review of current literature. CASE. May 17, 19:20

dalton
Download Presentation

CASE PRESENTATION

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. CASE PRESENTATION July 7, 2005 Trevor Langhan PGY-3

  2. OUTLINE • Case seen while on plastic surgery this spring • Brief case presentation • As interactive as possible, ask some questions if you like, and I may ask one or two of you! • Diagnosis • Review of current literature

  3. CASE • May 17, 19:20 • 43 year female unrestrained driver in MVC at 60 km/h • Frontal collision with no airbags • Steering wheel deformity • Extracted by fire/EMS at scene • C-spine protected in collar • Talking at scene • Copious oral/pharyngeal blood from facial smash • Multiple EMS attempts to intubate – 3rd attempt successful • Transported to RGH for treatment

  4. CASE • Arrival at RGH in C- spine collar and intubated • Vitals on arrival to trauma bay • HR 110 • BP 124/70 • Sats 99% (intubated) • Temp 37.0 • GCS – 11 (E4,V1,M6) • Primary survey adjuncts?

  5. PRIMARY SURVEY Airway Breathing Circulation Disability Exposure Full Vitals ADJUNCTS CXR, PXR, C-spine NG, foley, ECG Monitors, trauma panel FAST if needed SECONDARY AMPLE hx Full head-to-toe ADJUNCTS CT, FAST, DPL Extremity Xrays Angiography Endoscopy Contrast studies CASE

  6. CASE • Secondary survey • Start at head and work down • Ears/nose/eyes/dentition/scalp etc… • Complicated facial laceration extending from mid-brow toward nose • ? Medial canthus involvement • Tarsal plate OK • Appears to have full EOM and pupils are equal and reactive

  7. CASE • Lab work – all normal • Injuries include: • Right rib fractures • Complex facial laceration • Complex nasal bone #’s • ? Aspiration • Blood in and around oral pharynx • Superficial lip laceration

  8. CASE • May 18, 7 am (approx 16 hours post MVC) • Was kept intubated overnight as C-spines not cleared radiographically • On monitor in ICU: • ? ST changes • 12 lead EKG • Troponin 0.3 • Talk to the husband – only CAD risk factor is smoking

  9. CASE • 43 year lady: • BP 125/65 HR 80 • Intubated, ventilating OK • New EKG changes, +ve troponin • What now? • Would you heparinize this lady? • CT head/chest/abdo/pelvis – normal • Hemoglobin this am 110 (down from 140 on admit)

  10. CASE • CCU consulted • Troponin 0.05 • ASA, IV heparin and Beta blocker • Echo: • Apex and Anterior wall severely hypokinetic • ? Aneurysmal formation at heart apex • No pericardial effusion • DDx: • Coronary dissection • Myocardial stunning due to contusion • Ischemic heart disease • Left ventricular aneurysm

  11. Normal coronary arteries

  12. Normal coronary arteries

  13. diastole systole

  14. Tako-tsubocardiomyopathy

  15. Tako-tsubo • Takotsubo: a Japanese pot for fishing for octopus • Tako – octopus • Tsubo - pot

  16. Tako-tsubo cardiomyopathy • First described by Satoh et al. in 1990 • Recently recognized reversible form of heart failure • Clinically resembles acute myocardial infarction but normal coronary arteries • Characterized by: • transient left ventricular dysfunction with chest pain • electrocardiographic changes • minimal release of myocardial enzymes

  17. Tako-tsubo • 250 cases have been reported in Japan since 1990 • Defined as: • Occurrence of heart failure similar to acute myocardial infarction • Takotsuboshaped hypokinesis of left ventricle on echo/ventriculography • Normal coronary arteries despite continued ST segment abnormalities • Complete normalization of LV dysfunction in a few weeks

  18. Tako-tsubo • More prevalent among women than men (7 : 1) • Average age mid 60’s • 68.6±12.2 in women and 65.9±9.1 years in men • Women are 6–12 times more likely to be affected than men • Clinical features derived from case reports: • Symptoms at onset mimic MI • Ventricular dysfunction looks like a takotsubo • Coronary arteries are disease free • Dysfunction improves rapidly over few weeks • Mean time to resolution 17.4 days in one study (N=7) • Data on recurrence rate is unknown

  19. Tako-tsubo • Most common presenting symptom is chest pain • Often acute pulmonary edema from decreased left ventricular systolic function • Dyspnea, shock may also be presenting complaints • May have associated tachy or brady dysrhythmias • EKG findings classically ST elevation in V3 and V4 • ST depression • T wave inversion • Abnormal Q waves • Small or moderate elevation of cardiac enzymes (large elevations unusual)

  20. Tako-tsubo • Most case reports (some case series): • elderly women over 60 years of age • some physical or mental stress precedes the onset of thesymptom • associated with several clinical events: • Myocardial stunning • Pneumothorax • Trauma • subarachnoid haemorrhage • Phaeochromocytoma • Guillain-Barré syndrome • Emotional stress (death of loved one, panic d/o)

  21. Tako-tsubo • Onset is associated with: • Acute medical illness • Emotional or physical stress • Animal models support idea that it is likely the result of catecholamine induced microvascular spasm • Also supported by elevated serum norepinephrine levels in patients with disease • Myocardial perfusion studies support this theory

  22. Tako-tsubo • Many authors debate the actual pathophysiology • Primarily argue vasospasm vs. a less well known effect of elevated catecholamines • Provocative testing using ergonovine • Did not show coronary spasm • 0 out of 20 cases in one study • Ergonovine testing proved positive in some series’ • 21% of cases in one series • 30% of cases in a second series

  23. Tako-tsubo • Akashi et al. The clinical features of takotsubo cardiomyopathy. Q J Med. 2003: 96:563-573 • 472 patients with sudden onset of heart failure, acute MI like abnormal Q wave and ST changes admitted • 463 with acute MI from CAD, 2 viral myocarditis • 7 (1.5%) with takotsubo defined as: • Acute heart failure similar to MI • Boat shaped hypokinesis on echo and LV ventriculograph • Normal coronary angio with continuous ST changes • Normalization of LV function in 3 weeks

  24. Tako-tsubo • Akashi et al. The clinical features of takotsubo cardiomyopathy. Q J Med. 2003: 96:563-573 • 5 had Hx of HTN, none had CAD Hx • Possible triggers included • Pneumothorax • Common cold (2) • Idiopathic ventricular fibrillation • Exercise • Emotional care giver stress • ST elevation in 6 of 7 persisted for 1 week • Plasma norepinephrine level elevated in 4 of 7 • Serial levels showed highest value in first sample • 1 – 4 year follow up - 6 had no further cardiac illnesses, 1 died of non-cardiac cause

  25. Tako-tsubo • Seth et al. A syndrome of Transient Left Ventricular Apical Wall Motion Abnormality in the Absence of Coronary Disease: A perspective from the the United States. Cardiology 2003;100:61-66. • Over 2 ½ year period 12 (11 women) patients presented with chest pain, ECG changes, abnormal cardiac enzymes, echo findings of apical wall motion abnormality • All inverted T waves in precordium, 1/3 had ST elevation • 10 had angiography (all had non-critical lesions) • All 12 had a definitive precipitating ‘trigger’ • 5 emotional, 5 resp distress, 2 post-op • Follow up echocardiography revealed normalization of LV function • Concluded that Takotsubo phenomenon described in Japan occurs in the U.S. • Increasing use of echo will result in more frequent diagnosis

  26. Tako-tsubo • In-hospital mortality rate is less than 1% • Fatality rate Takotsubo less than acute myocardial infarction • 10 of 250 patients in one study • 1 of 88 patients in another • 0 of 7 in a third • The 2-year recurrence rate is less than 3% • reversible left ventricular dysfunction

  27. Questions raised by case? • Another cause of non-ischemic ST elevation to add to the list? • Role of troponins and/or EKG in setting of blunt thorax injury? • Anti-coagulation of a trauma patient? • Angiography of a trauma patient +/- stenting?

  28. References • Sato H, Tateishi H, Uchida T, Dote K, Ishihara M. Tako-tsubo-like left ventricular dysfunction due to multivessel coronary spasm. in: Clinical Aspect of Myocardial Injury: From Ischemia to Heart Failure. Kodama K, Haze K, Hori M, Eds. Kagakuhyoronsha Publishing Co., Tokyo, 1990: 56–64 (in Japanese). • Kawai S, Suzuki H, Yamaguchi H, et al. Ampulla cardiomyopathy ('Takotsubo' cardiomyopathy). −Reversible left ventricular dysfunction with ST segment elevation. Jpn Circ J 64: 156–159, 2000 (Erratum in Jpn Circ J 64: 237, 2000). • Kawai S. Ampulla-shaped ventricular dysfunction or ampulla cardiomyopathy? Respiration and Circulation 48: 1237–1248, 2000 (in Japanese). • Ogura R, Hiasa Y, Takahashi T, et al. Specific findings of the standard 12-lead ECG in patients with 'Takotsubo' cardiomyopathy. −Comparison with the findings of acute anterior myocardial infarction. Circ J 67: 687–690, 2003. • Kawabata M, Kubo I, Suzuki K, et al. 'Tako-tsubo cardiomyopathy' associated with syndrome malin. −Reversible left ventricular dysfunction. Circ J 67: 721–724, 2003.) • Kurisu S, Inoue I, Kawagoe T, et al. Myocardial perfusion and fatty acid metabolism in patients with Tako-tsubo-like left ventricular dysfunction. J Am Coll Cardiol 41: 743–748, 2003. • Abe Y, Kondo M, Matsuoka R, et al. Assessment of clinical features in transient left ventricular apical ballooning. J Am Coll Cardiol 41: 737–742, 2003. • Amaya K, Shirai T, Kodama T, et al. Ampulla cardiomyopathy with delayed recovery of microvascular stunning: a case report. J Cardiol 42: 183–188, 2003 (in Japanese).

  29. References • Osa S, Abe M, Ueyama N, et al. A case of ampulla cardiomyopathy caused by dysfunction of coronary microcirculation. Heart 35: 117–123, 2003 (in Japanese).Yamashita E, Numata Y, Sakamoto K, et al. Clinical analysis of 21 patients so-called tako-tsubo like cardiomyopathy. Heart 35: 379–385, 2003 (in Japanese). • Tsuchihashi K, Ueshima K, Uchida T, et al. Transient left ventricular apical ballooning without coronary artery stenosis: a novel heart syndrome mimicking acute myocardial infarction. J Am Coll Cardiol 38: 11–18, 2001. • Ishihara M, Sato H, Tateishi H, et al. "Takotsubo"-like cardiomyopathy. Respiration and Circulation 45: 879–885, 1997 (in Japanese). • Kono T, Morita H, Kuroiwa T, et al. Left ventricular wall motion abnormalities in patients with subarachnoid hemorrhage: neurogenic stunned myocardium. J Am Coll Cardiol 24: 636–640, 1994. • Dote K, Sato H, Tateishi H, et al. Myocardial stunning due to simultaneous multivessel coronary spasms: a review of 5 cases. J Cardiol 21: 203–214, 1991 (in Japanese). • Tokioka M, Miura H, Masaoka Y, et al. Transient appearance of asynergy on the echocardiogram and electrocardiographic changes simulating acute myocardial infarction following non-cardiac surgery. J Cardiograph 15: 639–653, 1985 (in Japanese). • Sassa H, Tsuboi H, Sone T, et al. Clinical significance of transitory myocardial infarction-like ECG pattern in postoperative patients. Heart 15: 669–678, 1983. • Kuramoto K, Matsushita S, Murakami M. Acute reversible myocardial infarction after blood transfusion in the aged. Jpn Heart J 18: 191–201, 1977.

  30. Blunt Cardiac Injury • Definition is heterogeneous in various specialties • Encompasses mild cardiac bruise to cardiac rupture and death • Due to difficulty defining injury incidence can range from 19% - 75% in blunt chest trauma • No gold standard • Practical diagnosis is by good mechanism and altered cardiac function (wall motion or arhyth)

  31. Blunt Cardiac Injury • Nagy KK, Krosner SM, Roberts RR, et al (Cook County Hospital, Chicago, IL; Rush University, Chicago, IL) World J Surg. 2001;25:108-111 • Patients at risk for BCI admitted to ICU for serial ECGs, monitoring, serial enzymes and Echo. N= 171 (group 1). • Group 2 = no risk factors and hemodynamically stable. • Results: • normal ECG, normotensive and no dysrhythmias on admission had benign outcomes. • Those with ST segment changes, dysrhythmias, or hypotension after blunt chest trauma need to be monitored for 24 hours; they occasionally need further treatment for complications of BCI. • No additional information was gained by using ECHO for screening

  32. Blunt Cardiac Injury • Meta analysis of BCI literature by Maenza et al. • 25 prospective (2210 pts), 16 retrospective • Cardiac complications requiring treatment in 2.6% of patients – dysrhythmias • Abnormal ER EKG and +ve CK-MB correlated with developing BCI related complications • 100% sensitive if use any and all dysrhythmias (including sinus tach, a fib, conduction delays) • Normal EKG and –ve troponin on admit and at 6 and 12 hours, very low probability of clinically significant BCI

  33. Prospective and consecutive major blunt chest patients. N=333. • All had serial ECGs and TnI • Echo prn • Outcome = sigBCI = heterogeneous definition • Hypotension presumed to be cardiogenic in origin • Arrhythmia • abnormal post-traumatic TTE with low Cardiac Index

  34. Myocardial Contusion • Results • 44 (13%) significant BCI • Admission ECG or TnI was abnormal in 43 of 44 patients with SigBCI • 80 patients with abnormal ECG and TnI • 27 (34%) developed SigBCI • 131 with normal serial ECG and TnI • none developed SigBCI • Abnormal ECG only or TnI only, 22% and 7%, respectively, developed SigBCI • one patient had initially normal ECG and TnI and developed abnormalities 8 hours after admission • Concluded: • PPV and NPV 29%/98% for ECG • 21% and 94% for TnI • 34% and 100% for the combination

  35. Rajan GP, Zellweger R.Cardiac troponin I as a predictor of arrhythmia and ventricular dysfunction in trauma patients with myocardial contusion.J Trauma. 2004 Oct; 57(4):801-8; discussion 808. 187 pts TnI below 1.05 [mu]g/L in asymptomatic patients at within the first 6 hours rule out myocardial injury Tn levels above 1.05 [mu]g/L mandate further cardiologic workup 63 (34%) +ve TnI 124 (–ve TnI) All had –ve echos and EKG’s 47 (25%) Abnormalities Echo/ecg 16 (9%) no other abnormality TnI levels: Lower on admit Lower peak Resolved sooner

  36. My Take home points • ECG is the best screening test • Optimal period of observation is unknown • Enzymes have no role alone, but in conjunction with EKG can improve negative predictive value • not predictive of disease or absence of disease • Echo is not a screening test • Positive echo does not predict clinical complications • Use echo to r/o tamponade or cardiac rupture or to aid in diagnosis of unexplained hypotension

More Related