Morbidity and Mortality Conference

1. Morbidity and Mortality Conference Garrett Feddersen 11/27/13

2. Case:Brief Admission HPI • New pt into the ER, nurse comes out of the room and tells you that ”you need to evaluate this kid now, he’s sick.” • Come into the room and find the pt on the bed, his father and mother are in the room with him.

4. HPI, continued… • 14 YOM • Presenting with 2 days of neck pain. The day before the pain started he was helping his father unload hay bales. Next day the pain started and has continually gotten worse since. Pain is most severe in his neck but now his whole body hurts, worse in neck and back. • 10/10 pain, can’t hardly talk

5. Case: • PMH – Healthy, no hx • PSH - none • FH – nothing pertinent • SH – Lives with parents, no T/A/D • Medications - none • Allergies - none

6. Case: • Physical exam • Vitals BP129/87, P109, R16, 100% ra • Decorticate-like posturing (arms flexed in and held tight) • Jaw clenched tight, able to talk around it but not well • Muscle spasticity head to toe • Writhing in the bed in pain • Labs

8. Ddx • Tetanus!! • Drug induced (phenothiazines – phenergan, thorazine) • Dental infection trismus • Strychnine poisoning • Malignant neuroleptic syndrome • Meningitis

9. Further exam • Crush injury to right great toe • Very small circular scab on bottom of left foot (“cut himself” while picking vegetables in the garden) • HEENT otherwise nml, CV – RRR, Lungs – CTAB, Abd – rigid, but no pain with palpation and NABS

10. Timeline of Events

11. Adverse events/outcomes triggering case presentation

12. Tetanus Sir Charles Bell

13. Nervous system disorder caused by the toxin produced by clostridium tetani • Worldwide approx. 1 million cases/year with 30-50% mortality • In the US, averages 29 cases per year with mortality at 13% • Only 2 cases of neonatal tetanus since 1989 • Heroin users, unimmunized at higher risks, though only 72% of those vaccinated at protected *CDC

14. Diagnosis • Purely clinical dx • No labs that can help • Tongue depressor test

15. QUIZ! • Trismus • Opisthotonus • Risus Sardonicus

16. General Tetanus Clinical Sx • 50% present with trismus • Irritability, restlessness, diaphoresis, tachycardia • Intensely painful tonic contractions – jaw, back, fists, neck, abdomen • Fever often present, can develop cardiac arrhythmias • Respiratory arrest • Fully concious

17. Treatment • Supportive – PROTECT AIRWAY • Stop toxin production – 1. Metronidazole 500 mg IV Q6 or 2. PCN G 4 million units Q4 • Neutralize toxin 3-6k units of TIG

18. Rest of the story • Pt remained intubated for 3 ½ weeks. Was given TIG and IV antibiotics (Flagyl and Ampicillin) • Around 2 weeks started doing wean trials, backing off sedatives/paralytics, if spasm present went right back on. • Extubated and did well per IC

19. Room for improvement • Only one of the ER docs had ever seen a clinically advanced case (in Africa). • Heparin drip was ordered by IC ER • Anesthesia placed ET 6.5 • Needed to start ABX immediately • TIG administration

20. Factors contributing to adverse outcome

21. Comments &Discussion

22. References • http://www.cdc.gov/vaccines/pubs/pinkbook/tetanus.html#epi • UpToDate - Tetanus

24. Case #2 • 45 YOM brought into the ED for seizure • Hx of seizures seemingly related to his alcohol abuse, also questionable “epilepsy” hx. • Significant EtOH abuse hx, has reportedly “cut back” • Witnessed by daughter, full tonic/clonic with post ictal period after

25. HPI, continued… • In ED A&O x 3, recovering well • Hgb 7.2 in ED, rest of CBC and BMP normal. Hypotensive (sys in 60’s) • Admitted to ICU for alcohol detox and hypotension • Recent admission for similar seizure episode, had 15 L removed via paracentesis for ascites during that admission

26. PMH: HTN, PAD, alcoholic hepatitis, ascites, seizures, anemia, epilepsy • PSH – none • Fam – alcoholism • Soc – still smokes, still drinks, no drugs. • Meds: Lasix, pentoxyfylline, Flagyl, spironalactone, metoprolol

27. When he gets to the ICU, he is A&O x 3, BP’s still in the 60’s. • PE – tachy, hypotensive, fast respirations. Big abdomen with significant ascites, mild tenderness, no RRG. Lungs were clear. • Felt “OK”

28. A/P • Seizure – start Keppra, CT when stable • Shock/anemia – hypovolemic/blood loss. FOBT ordered, guiacc of emesis, 2 units of PRBCs to be transfused immediately. PT/INR ordered • EtOH – CIWA, CD and psych • Ascites – LFTs nml, schedule tap when stable

29. Course: • Levofed started shortly after arrival to ICU for pressure support • 1.5-2 hrs after arrival to ICU has 2nd seizure, immediately following has massive BRBPR. BP crashes to 50’s and 30’s, pt unresponsive. IVF immediately opened up along with blood products. Levofed maxed out and dopamine started.

30. As pressures came back up into the 80s, became responsive, discussed with him the need to intubate him and provide pressure support. • Massive blood loss protocol initiated • Pt intubated with rocuronium and atomidate by anesthesia d/t concerns with sedatives further lowering pressures • After tube placed, pt was noted to have blood in oropharynx, presumably coming from esophagus.

31. 2 units FFP given along with 10 units vit K, fluid boluses, and more blood. • Femoral line placed by Dr. Visokey • Levofed, dopamine, and vassopressin all at max. PT/INR – 22.7/2.07 • Discussion with family about futility of treatment at this point as the majority of family was now present. Decision made to discontinue resucitation. • Arrived at ICU at around 1100, TOD 1820. Received 7 units PRBCs and 2 units FFP.

32. Conclusions • Massive GI Bleed • Ruptured esophageal varices • Mallory-Weiss tear • Perforated ulcer • By the time we saw the blood it was most likely too late • Rectal exam

33. Factors contributing to adverse outcome

34. Questions and comments

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