Download - Morbidity and Mortality rounds July 2001
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Morbidity and Mortality rounds July 2001
Arun Abbi M.D.
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Peter Lougheed Centre5 deathsAll classified as class 12 cardiac arrests1 case of ischemic bowel1 ruptured AAA in a patient who was a
no code1 case of a Patient who died of a
Pulmonary embolus
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Rockeyview Hospital6 deathsAll classified as class 12 cardiac arrests1 drug overdose who arrested1 respiratory failure2 pneumonia and sepsis
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Foothills Hospital17 deaths All classified as class 18 cardiac arrests3 trauma arrests3 Intracranial hemorrhages of which one
was post TPA1 was pneumonia/sepsis
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Foothills Hospital cont’d1 was a pulmonary embolus1 was respiratory failure and cardiac
arrest secondary to pulmonary hypertension in a 31 yr old female
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Case 150 yr old female who collapsed at homeThe patient was short of breath and was
found to be hypotensive on scene with a systolic blood pressure of 70
Her pulse was 150 – 160She complained of chest pain going into
her back
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Case 1 cont’d The patient was assessed at a rural hospital Her physical exam was unremarkable except
for her hypotension She was given fluids but remained
hypotensive An EKG was done at the scene and showed
atrial fibrillation with nonspecific ST changes The chest X-Ray was unremarkable
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Case 1 cont’dThe patient was intubated and
transported by Stars to the PLC with the concern being of a possible aortic dissection
She arrived at 03:45V/S BP 65/35 P 90 Pt was intubated with a FiO2 of 100%
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Case 1 con’tABG Ph - 7.01
Co2 – 43Po2 – 134HbG – 79HCo3 15
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Case 1 cont’dCXR: was read as normalEKG atrial fibrillationLytes were normal
What is your differential diagnosis?
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Think of the differential diagnosis of shock Hypovolemic: aortic dissection, ruptured
abdominal aneurym,GI bleeding Obstructive: pulmonary embolus, cardiac
tamponade (from proximal dissection) Distributive: sepsis, anaphylaxis (both
umlikely) Cardiac : EKG was unremarkable
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The patient was assessed by the vascular surgeon
Both he and the ER doctor wanted to obtain a CT scan of her chest, however it was going to be 30 – 40 minutes (as the tech was at home) and it was felt she was too unstable
She was given blood in the ER She was taken to the OR
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The aorta was normalThe retroperitoneum was edematousThe Bowel was edematousShe was given 4 units of blood in the
OR and a repeat gas showed a HgB of 120 but she remained hypotensive
She arrested on the table
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Autopsy: Large pulmonary embolusHemorragic gastritis The edema was thought to be
secondary to hypoxia and elevated portal pressures
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Things to think about
1. It would have been nice to have an initial O2 sat prior to intubation
2. The hemorrhagic gastritis which lead to the anemia took us down the hypovolemic shock picture
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On the initial blood gas in the ER; her Po2 was 134. If someone is intubated on 100% O2 her Po2 should be:
1.0 X (660 – 47) - 43/0.8 = 559We would expect some V/Q mismatch
with someone in shock but not such a profound difference if her CXR was clear
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Note that this patient probably going to die even if a PE was diagnosed as she probably would have bled out if she was given TPA (Due to her gastritis)
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Case 2 53 yr old female who was from the States and
was visiting in Fernie A boat got detached from a car that was
heading in the opposite direction and went across the highway and cut her car in half
The patient had a head injury. She also had an amputation of her left leg with an open fracture of her right leg
She was profoundly hypotensive
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The accident happed at 18:30 The patient was given multiple units of
blood and a tourniquet was placed over her left leg.
The helicopter was down for repairsFixed wing was sent and landed in
Cranbrook
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The patient was felt to be too unstable to be transported to Cranbrook by ground
The helicopter was repaired and was able to leave Calgary and go directly to Fernie
The patient arrested at 23:25, 10 minutes prior to landing
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The only concern here was that it was 5 hours for this patient to get to a tertiary care centre
Also Sparwood had an airport where the plane could have landed
This case was review by the prehospital organizations
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Case 377 yr old male who has a history of
prostate cancer with metastasesThe patient developed acute onset of
dyspnea with syncopeO2 sat on scene was 70 % with a BP of
60/34
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Patient arrived to ER at 10:40V/S BP 78/50 P 54 EKG showed RBBBABG : PH - 7.45 done on NRB
PO2 – 206PCo2 – 19HCo3 - 13
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Pt’s HgB was 82
The concern was that of a Pulmonary Embolus
The patient was heperanized within 25 minutes (which was excellent)
A central line was placed and the patient was started on levophed
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A CXR was unremarkableAn Echo was done which showed RV
strain and moderate amount of TRA CT scan was performed which
showed an obtructing thrombus involving both main pulmonary arteries that straddled the bifurcation
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The CT scan also involved the legs and showed and occlusive thrombus in the left popliteal region
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What would you do?
Would you give this person TPA
Would you place an IVC filter in this patient?
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The patient was taken to the ICU at 15:00 and it was elected not to give this person TPA nor place an IVC filter
The patient arrested at 15:23
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ECHO findings for PE Most of the time they do not see the clot They look for indirect evidence of a
pulmonary embolus such as RV strain 1. RV dilation (usually > 0.6 the size of the
LV) 2. Tricuspid Regugitation – moderate to
severe 3. Septal shift 4. RV strain – poor contractility
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Thrombolytics in PEEveryone quotes the study by jerjes-
sanchez et al.They had 8 patients who were all
hypotensive. 4 were randomized to thrombolytics and 4 were given heparin.
The 4 who received thrombolytics all survived while those that received heparin all died.
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There have been studies that looked at RV strain and found that it improves if patients are given TPA.
However there has not been any studies showing reduced mortality in patients who have RV strain and receive thrombolytics
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In this case the argument could be made for giving this patient TPA as he was on levophed.
He did however have metastic prostate cancer and may have hemorraged as a result.
The dose of TPA would be 100 mg/2hours
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Case 431 yr old patient visiting from Japan and
had flown to Canada 3 days agoShe developed left sided chest pain
going into her backHer Sat was 80% in BanffThe patient has a history of SLE and
was on prednisone 15 mg/day and vitamin D and E
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The patient was given Dalteparin sc and was sent to the FHH
She complained of SOB on exertion and of chest pain
She felt diaphoretic and feverishShe had a nonproductive cough earlierShe denied any leg pain nor swelling
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PMHx: lupus for 18 yearsRaynauds phenomenomNephritis
No cardiac history,no history of PE nor DVT
No history of asthma
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V/S BP - 114/80 P 120 RR 34 T 38.6 Sat 94% on 4 litres
The patient looked unwell and was in moderate distress
she had good air entry and her chest was clear
CVS - pulses were equal, she had normal heart sounds and she had peripheral cynaosis due to Raynauds
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Abdomen was soft and nontender
Labs INR 1.1 PTT 46.3WBC 21.4 (18.6 neuts)EKG - sinus tachycardia
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CXR showed pulmonary hypertension
CT scan - no evidence of PE, pulmonary hypertension, and patchy infiltrate
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The differential was that of lupus induced ARDS and secondary pulmonary hypertension versus pneumonia
The patient received antibiotics and was admitted to the floor
The next morning she became short of breath and arrested about ½ hour later
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An autopsy was not done as per the families request
The coroner stated the patient died of cardiorespiratory failure secondary to pulmonary hypertension
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Systemic Lupus Erythematosus 4 out of 11 features 1. Malar rash 7.Neurologic Disorder 2. Discoid rash 8. Hematologic Disorder 3. Photosensitivity 9. Oral Ulcers 4. Arthritis 10. Immunologic Disorder 5. Serositis 11. Antinuclear Antibody 6. Renal Disorder
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Complications1. Nephritis/Renal Failure2. Infections3. Thrombosis –1.(LA) Lupus
Anticoagulant (present from 30% – 40 %)
2.(ACA) Anticardiolipin Antibody
Present in 40% – 50 %
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It is recommended to test patients for these antibodies if they have lupus.
However it is not recommended to anticoagulate these patients prophylactically
If a patient has a DVT/PE and has one of these antibodies then they require life long anticoagulation
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It is felt that these patients who are positive for LA or ACA have a shortened lifespan
The Pulmonary Hypertension that they develop is from microvascular thrombosis secondary to the SLE
We do not know if life long anticoagulation prevents this
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These patients should be followed for the development of Pulmonary hypertension as they may be a candidate for lung transplant
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ConclusionWe do a good job.
Sick people die
Beware of Pulmonary Emboli