Saving Lives - capanet.org · 2019-11-22 · – No external signs of trauma. Case # 3: Tequila Jane • Initial management? – Airway management (suction) – Check fingerstick

John Beuerle, M.D.

Saving Lives !!!

California Emergency

Physicians

I wonder what’s for

lunch.

I’m here for knee pain.

Now what ?Now what ?Now what ?Now what ?

Saving Lives!!

Case #1: Dysuria Blues

• 40 y.o. female

• Dysuria x 2 days


Physical Exam:

• Mild lower abdominal discomfort

• Left CVAT


• Work-up?– CBC, CMP, HCG, UA, possible CT abd/pelvis

• UA: Urinary Tract Infection • CBC: mild leukocytosis

• Diagnosis– UTI, mild pyelonephritis

• Treatment?– Abx, Pyridium, education, timely follow-up


Lesson #1:

The diagnosis and treatment of many diseases are simple and easy, but our patients will be appreciative anyway.

That’s what makes our

jobs so satisfying.

Case #2: Daze of Thunder

• 52 y.o. diabetic schizophrenic female– Arrives via EMS

– “Hearing voices and crashing sounds of thunder.”

“Hello . . .?”

History

• HPI: – Not suicidal, just hearin’ voices

– Abdominal pain, nausea and vomiting

• PMHx– Schizophrenia

– Diabetes

– Hypertension

– Atrial fibrillation

• Rx: – Zyprexa, Abilify

– HCTZ, Lisinopril, Coumadin, Metformin, Amiodarone, Lipitor

• Allergies:– APMED

Physical Exam

• Physical exam (psych version):– Patient breathing

– Most likely has a pulse

• Physical Exam (paying attention this time):– BP: 180/92, Heart rate: 140 BPM, RR 22, Temp 101 F

– Accucheck 462

– Alert and oriented x 3 with auditory hallucinations

– A little shaky (possibly alcohol withdrawal?)

– Abdominal exam: mild generalized tenderness

– Otherwise normal

Medically cleared!

• Treatment? • Work-up?

Labs

8.214.3

43.7211

140

4.1

110

16

28

0.8498

13.1

64.22.6

28

40

56

0.8

7.2

4.4

UA: nml Tox screen: negative

Lipase: 110 BAL < 10 mg/dL

Normal

Hyperglycemia

Acidemia

Dehydration


• Treatment:

– IVFs, Insulin drip

– Serial BMPs, (watch that K!!)

– Tylenol for fever

– Look for infectious etiologies

• What about the abdominal pain?

– CT abd/pelvis (with or without contrast?)

– BUN = 28; creat = 0.8


• Patient returns from CT:

– HR 160, Temp 100.6, BP 206/110

• CT results: normal

• CXR: normal

• LP?

– Consent?

– CSF normal

• What now?

“Hello, Intensivist?”


• Admit to the ICU

• No ICU beds. Patient boarding in the ER.

• Getting worse!!

– More confused

– More tachycardic

– Still febrile

– Alcohol withdrawal?

– Septic shock?!!

• What’s going on??

“Hello, Bed Control?”

“Hello, Stanford?”

“Hello, morgue?”Diagnosis??


• Thyroid Storm

– With DKA?! What are the chances of that?!

• Good. Metabolic emergencies such as Storm are often

precipitated by other emergent medical conditions.

– DKA, pneumonia, sepsis, heat stroke, surgery, trauma

– Mortality: 20-75%

– Other precipitating factors:

• Drugs: amiodarone, ASA, sympathomimetics,

IV contrast

– What about the abdominal pain?

• Nonspecific abdominal pain is common with Thyroid Storm.

• 20% will have a surgical emergency

• Avoid IV contrast with CT


• Treatment:

– Most importantly, you must identify it.

• There are several diseases that are rapidly fatal if they are

not quickly identified.

– T hyroid Storm

– A ortic dissection

– M assive pulmonary embolism; Meningitis; Meningococcemia

– I schemic bowel; Intracranial hemorrhage

– Ph eochromocytoma

– L ife-threatening toxicities (CO, tylenol, etc.)

– U ndiagnosed esophageal rupture (Boerrhave’s)

• They will only be identified if they are part of your differential

diagnosis.

• They all require specific tests to make the diagnosis.

– You are unlikely to stumble across the diagnosis.


• Treatment of Thyroid Storm– Supportive measures:

• Airway management, oxygen, cardiac monitor

• Cooling (avoid ASA)

• Aggressive IV hydration

– B-blockers

• Propranolol 1-2 mg IV Q10min PRN

– Inhibit T4 synthesis• Methimazole (PTU can be hepatotoxic) 20 mg PO Q4H

• SSKI

– 1-5 gttp PO Q8H

– Delay 1 hour after administration of methimazole

– May substitute Lithium for patients with an allergy to iodine

– Inhibit conversion of T4 to T3

• Dexamethasone 2 mg PO/IV Q6H


(Bounce-back)

• 40 y.o. female

• Dysuria x 2 days

• UTI, early pyelo

• Abx, Pyridium,

timely follow-up


• Returns via EMS six hours later

• SOB, profoundly cyanotic


• Treatment?• O2 via NRB @ 15 LPM

• No change

• Work-up?• ABG

• CXR• EKG

• Labs

• CTA chest r/o PE



• pH: 7.29 / pO2: 238 / pCO2: 32 / HCO3: 18

• Labs

• CBC, CMP, PT/PTT, cardiac enzymes, d-dimer

• Normal

• EKG

• CXR

• CTA chest r/o PE

Normal

Diagnosis??


• Diagnosis: Methemoglobinemia– Cyanosis that does not respond to oxygen

• Shunt vs. abnormal hemoglobin

– Arterial blood looks venous– Pulse oximetry is unreliable

– Patient looks sicker than they actually are

• What is it?– Oxidized iron on hemoglobin– Can’t bind oxygen

– Unable to release oxygen at the tissue level

– Becomes ineffective as an oxygen-carrier molecule


• Caused by:– Hurricane spray or injectable lidocaine– Topical benzocaine (teething remedies)

– Pyridium (UTI’s)

– Dapsone (HIV, leprosy, PJP, toxoplasmosis)

– Many other agents . . .

• Treatment: – Methylene blue 1-2 mg/kg IV

– Will cause pulse-ox to plummet (warn nurse!)

– Turns urine blue or green for a few hours (warn pt.!)


Lesson #1:

The diagnosis and treatment of many diseases are simple and easy, but our patients will be appreciative anyway.

That’s what makes our

jobs so satisfying.


Lesson #1:

Medicine is seldom simple or easy.

There are almost as many ways to make our patients

worse as there are to make them better.

Being aware of potential

complications is critical

to managing them

appropriately should

they arise.

Case # 3: Tequila Jane

• 16 y.o. female, arrives by EMS

• HPI:

– Found unresponsive at home.

– Empty bottle of tequila in room.

– Family reports patient

“may have been drinking.”

– Family called 911.

• PMHx: none

• SocHx: Nonsmoker, occasional EtOH,

No illicit drug use

• FmHx: HTN, asthma, hyperlipidemia


• Physical Exam:

– Strong odor of alcohol to breath.

– Moans / withdraws to deep painful stimuli

– BP 96/68, HR 56, RR 12, Temp 98 F, 96% on room air

– PERRL

– Small amount of emesis in oropharynx.

– No external signs of trauma.


• Initial management?

– Airway management (suction)

– Check fingerstick glucose !!!

– Drop patient off in the ER for 6-12 hours until she sobers up.

211 211 211 211

Case # 4: Whiskey Joe

• 54 y.o. self-proclaimed concert

pianist

• Wife called 911 because patient was “drunker than usual”.

• PMHx: HTN, DM, a-fib, and . . .

wife reports:

“He’s a pathological liar.”

• “He can’t even play a kazoo.”

?


• Physical Exam

– Dissheveled.

– Strong odor of alcohol

. . . and feet.

– No external signs of trauma.

– Mutters incoherently.

– Kazoo found in back pocket.


• Initial management?

– Airway management

– Check fingerstick glucose !!!

– Rule-out pregnancy

– Drop patient off in the ER for 6-12

hours until he sobers up.

82828282


10.411.4

34.8298

137

6.2

98

25

13

0.9118

96

32

42

0.6

6.7

3.6UA: nml

Tox screen: negativeBAL 210

54 y.o. male with altered mental status

Vitals: 82/54, HR 50, RR 12, Temp 98.7 F

Urine hcg: positive !!!

2.423.2

45.6

• 62 y.o. female pig

• Brought to ED by ambulance.

• Found down in trough.

• Suicide note paper-clipped to her tail.

Case # 5: The Actress Swine Formerly

Known as Miss Piggy

Kermit,

You never loved me.

Goodbye,

Piggy

Case # 5: The Actress Swine Formerly

Known as Miss Piggy

8.210.4

32.7289

134

4.3

97

25

18

0.8108

26

38

42

0.6

6.8

4.1

Tox screen: BAL 82

HCG: neg

62 y.o. suicidal pig with altered mental status

Vitals: 70/42, HR 160, RR 14, Temp 99 F

Lightweight !!

(Even for a pig.)

Positive for bacon !!

We need you at Hallway

Bed 8!!

STAT !!!


10.212.4

36.7301

136

4.2

97

25

11

0.8211

26

38

42

0.6

6.8

4.1UA: nml

Tox screen: negativeBAL 154

HCG: neg

16 y.o. female with altered mental status

Vitals: 68/36, HR 38, RR 14, Temp 98 F

Accucheck: 211


• Vitals: 54/32, HR 32, RR 12, Temp 98 F

• Repeat EKG

We need you in Room 4!!

STAT !!!


I wanna sandwich.

Vitals: 74/50, HR 48

What’s wrong with these patients?!!

• Just plain drunk

• Faking it

• Minding their own business . . .

when all of a sudden . . .

TWO DUDES jumped out of the bushes and gave them

hypotension and cardiac arrhythmias!!

• Could they have overdosed?!!

• If so, on what?!!

• What commonly prescribed medications

are cardiotoxic?

– Digoxin

– β-blockers

– Calcium channel blockers

– Clonidine

Salvador Dali Sign

• Symptoms of acute toxicity:

– First 6 hours: GI symptoms

– At 3-4 hours: cardiac effects

• Bradycardia, PVCs

• AV node effects:

– atrial fibrillation / flutter

– high degree AV blocks

Digoxin

How can we tell the difference?

Digoxin

β-blockers

Calcium channel blockers

Clonidine

bradycardia + Salvador Dali sign

Cardiotoxic Drug Overdose

β-blocker sites of action

blockade of pulmonary beta 2 receptors

causes

bronchoconstriction

blockade of renal beta 1 receptors blocks

release of renin

causes decreased blood pressure

Blockade of beta receptors in the CNS reduces performance anxiety

blockade of smooth muscle beta 2 receptors causes

vasoconstriction and GI effects

blockade of beta receptors impairs glycogenolysis and

gluconeogenesis, causing

hypoglycemia


Digoxin

β-blockers

Calcium channel blockers

Clonidine

bradycardia +

bradycardia + Glucose


Calcium Channel Blocker sites of action

Peripheral vasodilatation

• Decreased chronotropy (rate)

• Decreased dromotropy (conduction)

• Decreased inotropy (squeeze)

• Decreased FFA utilization

Decreased insulin release

from the pancreas, causing

hyperglycemia


Digoxin

β-blockers

Ca++-channel blockers

Clonidine

bradycardia +




Clonidine

• Centrally acting

• Alpha-2 agonist– Decreased HR

– Decreased BP

– Decreased RR

– Vasodilatation

• No heart blocks

• Opioid-like effects– Altered Mental Status

– Pinpoint pupils

• May be reversed with naloxone

Inhibits sympathetic outflow


Digoxin

β-blockers


Clonidine

bradycardia +




bradycardia +

But what about the pig?!

Kermit,

You never loved me.

Goodbye,

Piggy

Digoxin

β-blockers


Clonidine

bradycardia +




bradycardia +

Tachycardia

Widened QRS complexes

I

aVF

Right axis deviation

Large R wave in aVR

TCA Overdose

Tachycardia

Right axis deviation

Large R wave in aVR

Widened QRS complexes

Tricyclic Antidepressant Overdose

•

QRS widening• associated with development of seizures and

arrhythmias• can be used to assess severity of TCA toxicity• QRS < 100 ms: unlikely to develop seizures and

arrhythmias• QRS > 100 ms:

• 34% of patients develop seizures• 14% of patients develop serious arrhythmias

• QRS > 160 ms: 50% of patients develop ventricular arrhythmias


A large R wave in aVR is a highly sensitive screening tool for TCA toxicity.


• Airway management

• Activated charcoal

• Sodium bicarbonate

• Treat seizures with benzodiazepines

• Treat hypotension with IV fluids

• Lidocaine for ventricular arrhythmias

Digoxin

β-blockers


Clonidine

bradycardia +




bradycardia +

Why do we care?

• “We don’t. It’s Miller time!!”

• The treatment is different !!!

How is the treatment the same?

• ABC’s

• Gather information at the scene.

• Activated charcoal in conscious patients.

• Transport to the ED.

• Search patient’s pockets for insurance card.

How is the treatment different?

• Clonidine Naloxone

• Digoxin toxicity Digibind

• Beta-blockers Glucagon, Calcium, Atropine


– β-blocker toxicity

– Atropine, cardiac pacing

– Glucagon (5 mg IV, then 5 mg/hour IV)

– Calcium

– Ca-gluconate 3 amps IV or CaCl 1 amp via central line

Ca++





• Calcium channel blockers


• Ca++-channel blocker toxicity

– High mortality !!! Why??

Atropine

Ca++

Is there no hope??!

Calcium Channel Blocker sites of action

Peripheral vasodilatation

• Decreased chronotropy (rate)

• Decreased dromotropy (conduction)

• Decreased inotropy (squeeze)

• Decreased FFA utilization

Decreased insulin release

from the pancreas, causing

hyperglycemia

Treatment: Calcium Channel

Blocker Toxicity

• High-dose insulin therapy

– 1 unit/kg IV, then 0.5 units/kg/hour IV

– Ten-fold higher dose than used for DKA !!

– Restores insulin supply to the body.

– Provides glucose to starved myocardial cells.

– Reduces lactic acidosis.

– Insulin itself has inotropic properties.

• Intralipid IV infusion





• Calcium channel blockers

GlucagonCalcium

AtropineHigh-Dose Insulin

Intralipid infusions

35 y.o. Cambodian male with palpitations after a nightmare

(He now feels better . . . but is afraid to go to sleep.)A few more cases . . .

Brugada syndrome

Brugada Syndrome

• 1992, Brugada & Brugada– Subgroup of patients with

unexplained VT/VF

– EKG consistent with RBBB with ST-segment elevation in V1 and V2

– Genetic myocyte mutation that mostly affects males

– Clinical presentation

• Sudden cardiac arrest or syncope

• Usually at rest

RBBB pattern and ST elevations in V1 and V2

Brugada Syndrome

• Mortality:– 11-38% risk of dying from sudden VT/VF

per year !!!

• Treatment:– AICD � normal life expectancy

According to Wes Craven, his idea for A Nightmare on Elm

Street was sparked by news of a group of young Cambodian men who reported such horrible dreams that

they were afraid to go to sleep. Several of the men died in

their sleep soon after, and the mysterious disease was

termed Asian Death Syndrome.

It was later thought that the men suffered from Brugada

syndrome.

19 y.o. swimsuit model develops chest pain, shortness of

breath, and is freaking out after getting bit by a dolphin

The dolphin is rushed to the hospital!!

Flippered T waves!!

The human’s EKG

Arrhythmogenic Right Ventricular Dysplasia (ARVD)

Epsilon wave

Arrhythmogenic Right Ventricular Dysplasia (ARVD)

• Epsilon waves: sharp

deflections at

terminal portion of

QRS in V1 or V2

• Inverted T waves in

the anterior leads

• Incomplete or

complete RBBB

Arrhythmogenic Right Ventricular Dysplasia

(ARVD)Fibrofatty replacement of the right ventricle

Right Ventricular Hypertrophy

Fibrofatty Replacement of the Right Ventricle

Arrhythmogenic Right Ventricular Dysplasia

(ARVD)

• Patients are at high risk for ventricular tachyarrhythmias

and sudden death, particularly during exertional activity.

• Management

– AICD placement

– Avoidance of sports and exertional activity

– Heart transplantation for patients who develop intractable arrhythmias or heart failure

44 y.o. male w/ chest pain


EKG


• Prior EKG (6 months ago)


Today’s EKG


• Chest pain with new deep T wave inversions in the

anteroseptal and inferior leads.

• These are ischemic EKG changes due to Acute Coronary

Syndrome.

• Right?!!!


Wrong.


Rightward axis


Inferior T wave inversions

Anteroseptal T wave inversions


This . . . is a pulmonary embolism.


• Classic EKG findings in PE:

– Most common finding:

– Rightward axis

– SIQIIITIII (10-15% of cases)

– New or incomplete RBBB

– Supraventricular tachydysrhythmias (30-50% of cases)

– Ventricular dysrhythmias

– ST-segment elevations / depressions

– T wave inversions, especially in the anteroseptal

and inferior leads

NSR

(highly specific for large PE’s)


– Kosuge, et. al. (2007; Am J Cardiol)

• 99% predictive for PE !!

– Witting, et. al. (December 2011; J Emerg Med)

• Seen in 11% of cases of PE

• When seen, however, findings were 75% predictive for PE.

More examples: 33 y.o. obese male w/ CP and SOB

Diagnosis: Large Pulmonary Embolism

18 y.o. pregnant female w/ SOB & palpitations

Diagnosis: Pulmonary Embolism

That’s it. That’s all you’s need ta know.

What did we learn?

• Medicine is neither simple nor easy.

• Every treatment carries potential complications.

• Being aware of potential

complications is critical

to managing them

appropriately should

they arise.

What did we learn?

• The diagnostic box is not closed after the first diagnosis.

• Rare but rapidly fatal diseases should always be considered within the differential diagnosis.

What did we learn?

• The opportunity to save a life comes in many

forms.

• Be prepared to encounter all of them.

Thanks to:

Saving Lives - capanet.org · 2019-11-22 · – No external signs of trauma. Case # 3: Tequila Jane • Initial management? – Airway management (suction) – Check fingerstick

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