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Follow up rounds

Follow up rounds. Andrew Yoon, MD Rhonda Forest, MD 8/12/11. Case 1. Montefiore ED 7/29/11 Patient H.M. 01355124 CC: 89yo F BIBA from home for change of mental status as per home health aide. Case 1. EMS gave 1 amp of D50 Triage assessment: AAO X 1

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Follow up rounds

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  1. Follow up rounds Andrew Yoon, MD Rhonda Forest, MD 8/12/11

  2. Case 1 • Montefiore ED 7/29/11 • Patient H.M. 01355124 • CC: 89yo F BIBA from home for change of mental status as per home health aide

  3. Case 1 • EMS gave 1 amp of D50 • Triage assessment: AAO X 1 • Vitals in ED: T 99.8F (rectal), P 38-45, RR 14, BP 138/30, O2 99% on RA, Pain 0/10 • PMH: DM, HLD, Depression, colostomy from colon ca, chronic kidney disease (not on dialysis) • Meds: Citalopram, Glyburide, Zocor • All: NKDA

  4. History of Present Illness • HHA reports patient was in her wheelchair eating when she suddenly leaned backwards and became unresponsive. HHA checked patient who was breathing. She tried to wake her up but no response. Patient continued to slouch in her wheelchair for ~20 minutes before she vomited then awoke. Patient recalls eating dinner then waking up to her HHA and EMS surrounding her.

  5. Review of Systems • ROS: (-) fever, chills, malaise, CP, SOB, cough, difficulty swallowing, decreased PO intake, nausea, diarrhea, constipation, hematochezia, melena, dysuria, hematuria, increased urinary frequency, vag bleeding, abnormal speech, HA, seizure like activity, blurry vision, new focal weakness • ROS: (+) vomiting x1, NBNB

  6. Physical Exam • General: NAD • Skin: WNL • Scalp/face: WNL • Neck: WNL • Heart: bradycardic, regular otherwise • Lungs: clear, equal b/l • Abd: WNL, colostomy bag in LLQ with healthy pink appearing colonic tissue. Minimal amount of brown liquid in ostomy bag. • Back: No CVA tenderness • Ext: WNL • Neuro: Alert, AAO x2 (self, location), speech WNL, CNS 2-12 intact, sensation intact throughout body, motor WNL except 2/5 strength b/l LE, gait untested

  7. EKG

  8. Differential Diagnosis • Syncope • Vasovagal • Myocardial Infarction • Long QT syndrome • Brugada • Arrythmia • Neurologic • CVA • Seizure • Apnea/Hypoxia • Aspiration Pneumonia • Intracranial hemorrhage • Hypovolemia • Pulmonary Embolism • Electrolyte Imbalance • Hypoglycemia • Deep Sleep • Medication Induced • Unexplained

  9. Causes of Bradycardia • Can be normal, especially in sleep and athletes • Sick Sinus Syndrome • Vagal activity • Increased ICP • Acute MI • Heart block • Obstructive sleep apnea • Drugs (cholinergic drugs ie neostigmine, physostigmine, beta blockers, reseperine, guanethidine, methyldopa, clonidine, cimetidine, digitalis, calcium channel blockers, amiodaroneand lithium) • Other (hypothyroid, hyper/hypoK, hypothermia, prolonged hypoxia, strange infections iebabesiosas, Q fever, dengue fever, yellow fever, RMSF)

  10. Labs • Blood work resulted at 1835 • Wbc 8.4, Hgb 12.1, Hct 36.1, Plts 254 • Na 124, K hemo, Cl 94, CO2 15, BUN 80, Cr 3.2, Glu 211 • Trop 0.07, CPK 144, CPK MB 1.7% • Free T4 1.06 (No TSH sent) • Repeat BMP resulted at 2000 • Na 128, K 6.3, Cl 99, CO2 15, BUN 78, Cr 3.2, Glu 180

  11. Imaging • CXR: clear lungs, heart enlarged but is an AP view. • Head CT: chronic ischemic changes. No acute findings.

  12. Treatment • Calcium gluconate 1 amp IV • Kayexelate 30g PO • Bicarb 1 amp IV • Insulin 10U IV, D50 1 amp • NS 2L IV

  13. Result • Within 1 hour of administration of medications patient’s heart rate increased to 50s, which is patient’s baseline heart rate based on previous two admissions. • No repeat EKG was done as patient was being prepared for transport to inpatient telemetry bed.

  14. After Treatment of Hyperkalemia

  15. Hyperkalemia- EKG Changes • First changes: • Peaked T waves • Shortened QT interval • Then: • Lengthening of PR interval • Widening of QRS complex • Disappearance of P waves • Finally: • Sine wave pattern • Asystole

  16. Peaked T waves

  17. QRS Widening

  18. Sine Wave

  19. Hyperkalemia- Cardiac Membrane Stabilization • Calcium gluconate or chloride if QRS widening or loss of P waves • Calcium chloride has 3x concentration of calcium as calcium gluconate • Calcium gluconate: 1g or 10ml of 10% solution • Calcium chloride: 500mg to 1g or 5 to 10ml of 10% solution • Give calcium chloride through central line • In patients taking Digitalis still can give Ca

  20. Temporary Treatment • Insulin 10U IV, D50 1 amp • Drives K intracellularly • Peak effect at 30-60 minutes • Drop K by 0.5-1.2 meq/L • Albuterol 10-20mg Nebulized • Drives K intracellularly • 4-8x concentration used for asthma • Peak effect 90 minutes • Drop K by 0.5-1.5 meq/L • Bicarb • Drives K intracellularly • Effects controversial even in setting of acidosis • If given recommended to be given as infusion over 2-4 hours

  21. Potassium Removal • Loop or thiazide diuretics • Increase K loss through urine • No data showing short term benefit • Kayexelate • 1 dose is ineffective • Requires at least TID for 1-5 days • No short term benefit • Intestinal necrosis believed to be due to sorbitol, which SPS contains, but Kayexelate does not • Dialysis • When above treatments are ineffective • When hyperK is “severe” • When expected to have continued release of K ierhabdomyolysis or tumor lysis syndrome

  22. Case 2 • Jacobi ED 8/10/10 • Patient T.K. 2154687 • CC: 21yo F 17 weeks pregnant with diffuse lower quadrant abdominal pain

  23. Case 2 • Vitals T 100.1 F, BP 129/79, HR 94, RR 16, O2 100%, Pain 10/10 • PMH: G2P1001, C-section 4/2010 • Meds: None • All: NKDA

  24. History of Present Illness • 21yo F 17 weeks by LMP p/w lower abdominal pain since this morning associated with N/V. Pain started off in RLQ and is now also suprapubicarea. No vag bleeding/discharge.

  25. Review of Systems • ROS: (-) HEENT, cough, CP, SOB, diarrhea/constipation, dysuria, vag bleeding/discharge, HA, blurry vision • ROS: (+) fevers, chills, nausea, vomiting (non-bloody, +bilious),

  26. Physical Exam • HEENT: NCAT • CV: RRR, No m/r/g • Lungs: clear b/l • Abd: soft, non-distended, TTP suprapubic region, (+/-) RLQ TTP, (+/-) guarding, no rebound, +BS • GYN: Normal external genitalia, white discharge in vault, os closed, no blood, no lesions/masses, no CMT, no adnexal tenderness b/l • Back: No CVA tenderness b/l • Ext: No c/c/e • Neuro: AAOX3, normal gait

  27. Labs • WBC 14.9, Hgb 12.0, Hct 35.2, Plt 268, 0.2% bands • Na 140, K 4.1, Cl 109, CO2 22, BUN 6, Cr 0.5, Glu 77, T bili 0.3, ALKP 83, SGOT 20, SGPT 14 • Hcg 23,436 • Lipase 20 • UA: blood neg, LE neg, Nit neg, WBC 5/hpf, Epi 3-4/hpf, Bact trace

  28. Imaging • Bedside TVUS: +IUP w/ FHR 150s, no free fluid in cul-de-sac, b/l ovaries small 2.5 x 3 x 3 cm with no adenexal masses.

  29. Ovary

  30. IUP

  31. Ultrasound Appendicitis

  32. Further Imaging • MRI abd/pelvis: limited study, no evidence of free fluid, gravid uterus, appendix cannot be identified therefore appendicitis cannot be excluded

  33. MRI

  34. Even More Money for the Radiology Department • CT abd/pelvis: normal appendix visualized, no free fluid, single intrauterine gestation

  35. CT Normal appendix Appendicitis

  36. Results • Admitted to Gen Surg s/p MRI results, but discharged from ED after CT results • May 16, 2011 had C-section at 42 weeks gestational age. Healthy male infant with Apgar scores of 8 & 9. Male infant circumcised, tolerating breast and bottle.

  37. Clinical Assessment of Appendicitis • Most widely used is the modified Alvarado scale • Migratory right iliac fossa pain (1 point) • Anorexia (1 point) • Nausea/vomiting (1 point) • Tenderness in the right iliac fossa (2 points) • Rebound tenderness in the right iliac fossa (1 point) • Fever >37.5 degrees C (1 point) • Leukocytosis (2 points) • Score <3 home, 4-6 admit for observation, >7 OR (male) • Sensitivity 95%, Specificity 83% • Much less reliable in women

  38. Imaging Modalities for Diagnosing Appendicitis • Ultrasound • Sensitivity 86%, Specificity 81% • MRI • Sensitivity 91%, Specificity 98% • CT w/ IV and PO contrast • Sensitivity 91-98%, Specificity 93% • CT w/ rectal contrast only • Sensitivity 98%, Specificity 98% • CT w/ no contrast • Sensitivity 88-96%, Specificity 91-98%

  39. Radiation to Fetus • < 5 rads • NO increased risk of fetal anomalies or pregnancy loss • CXR < 1mrad, Abdxray 2-3 rads, CT abd 2-3 rads • 5-10 rads • Inconclusive data • IV pyelogram 4-9 rads, L-spine xray 4-6 rads • > 10 rads • Increased risk of fetal anomalies and pregnancy loss • Barium enema 7-16 rads

  40. Bathe in Radiation • Round trip flight from NY to LA • 3 mrem • CXR • 10 mrem • Natural radiation from living on Earth for 1 year • 300 mrem • Blaming Mother Earth for child’s MR • Priceless

  41. Fetal Periods of Vulnerability • First 2 weeks after conception • “All or none” • 100 rads will kill 50% of embryos • 2-16 weeks after conception • Death is rare • Anomalies occur with 10-20 rads • 20-25 weeks and beyond after conception • Relatively resistant to teratogenic effects of radiation

  42. References • Hong JJ, Cohn SM, Ekeh AP, et al. A prospective randomized study of clinical assessment versus computed tomography for the diagnosis of acute appendicitis. Surg Infect (Larchmt). 2003;4(3):231. • Denizbasi A, Unluer EE. The role of the emergency medicine resident using the Alvarado score in the diagnosis of acute appendicitis compared with the general surgery resident. Eur J Emerg Med. 2003;10(4):296. • Lee SL, Walsh AJ, Ho HS. Computed tomography and ultrasonography do not improve and may delay the diagnosis and treatment of acute appendicitis. Arch Surg. 2001;136(5):556. • CeydeliA, Lavotshkin S, Yu J, Wise L. When should we order a CT scan and when should we rely on the results to diagnose an acute appendicitis? Curr Surg. 2006;63(6):464. • Gaitini D, Beck-Razi N, Mor-Yosef D, et al. Diagnosing acute appendicitis in adults: accuracy of color Doppler sonography and MDCT compared with surgery and clinical follow-up. AJR Am J Roentgenol. 2008;190(5):1300. • TerasawaT, Blackmore CC, Bent S, Kohlwes RJ. Systematic review: computed tomography and ultrasonography to detect acute appendicitis in adults and adolescents. Ann Intern Med. 2004;141(7):537. • RaoPM, Rhea JT, Novelline RA, et al. Helical CT combined with contrast material administered only through the colon for imaging of suspected appendicitis. AJR Am J Roentgenol. 1997;169(5):1275. • Bentur, Y. Ionizing and nonionizing radiation in pregnancy. In: Maternal-fetal toxicology, 2nd ed, Koren, G (Ed), Marcel Dekker, New York, 1994, p. 515. • ACOG Committee Opinion. Number 299, September 2004. Guidelines for diagnostic imaging during pregnancy. Obstet Gynecol. 2004;104(3):647. • CDC. http://www.bt.cdc.gov/radiation/pdf/measurement.pdf

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