Grand Rounds Recap 1.29.20
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Morbidity and Mortality WITH Dr. Klaszky
Hypothermia
Mild: 32-25 degrees C
Moderate: 28-32 degrees C
Severe < 28 degrees C
Profound: cardiac arrest
Temperature Measurement
Oral thermometer will only register above 34 degrees C
Temperature sensing Foley can be used for continuous temperature monitoring
Cannot use temperature sensing Foley for bladder rewarming given the fluid temp
Central monitoring with either rectal or esophageal probe
Of note, both of these methods will lag behind core temperature
Cardiovascular Changes
Initial phase: vasoconstriction, tachycardia, hypertension
Second phase: bradycardia, hypotension, myocardial irritability
There is a decreased refractory period and delayed conduction through the heart which can cause malignant ventricular arrhythmias
Consider gently transferring patients from the stretcher to the bed
Resuscitation
ACLS medications do not work at extremely low temperatures and are not metabolized as quickly giving a theoretical risk of worsening myocardial irritability once the patient is warmed
AHA recommends to attempt 3 rounds of ACLS, but if unsuccessful focus efforts on warming patient instead
Consider femoral central access to avoid additional irritation to the heart as well as gently moving the patient
Thoracic Lavage
Consider right sided thoracic lavage first as this is further away from the heart
Can use percutaneous chest tubes up high and standard large bore down low, but consider placing large bore first as to not placed the percutaneous chest tubes into the lung parenchyma
Please see Dr. Connelly and Dr. Urbanowicz’s QIKT presentation for more information here
Hypokalemia
The total body deficit of potassium is often much greater than is initially anticipated
For a serum potassium of 3, total body deficit is 100-200 mEQ
For a serum potassium of 2, total body deficit is 400-600 mEQ
Medications causing hypokalemia
Medications causing intracellular shift: such as insulin, beta agonists
Renal loss: such as steroids and diuretics
Approach to the patient with prolonged QTc
Check QTC
If less than 500, standard of care
If greater than 500:
Check K: replete to 3.5 prior to administering any medications that can cause K shifts
Check Mg: target Mg>2
do not administer QTc prolonging medications
Alcohol Withdrawal
Symptom onset: 6-24 hours
Humans metabolize alcohol at a rate of 20 mg/dl per hour, meaning depending on what the initial blood alcohol level was you can begin seeing effects of alcohol withdrawal while the blood alcohol level is still elevated
Symptoms
Intention tremors:
Onset: 6-36 hours; Resolution: 24-48 hours
Important to note that tremors are not present at rest and seen with movement
Can look for tongue fasciculations if trouble discerning if tremor is true or not
Seizure
Onset: 6-48 hours; Resolution: 48 hours
Hallucinations:
Onset: 12-48 hours, Resolution: 24-48 hours
Delirium Tremens:
Onset: 72-96 hours
Incidence: 1-4%
Mortality: 1-4%
causes of death include hyperthermia, cardiac arrhythmias likely due to severe electrolyte and metabolic derangements, seizure complications or worsening of concomitant medical disorders
Risk Factors: prior DTs, cirrhosis, CIWA>15, withdrawal with elevated BAL
Treatment
Please see protocol here
Refractory Ventricular Fibrillation
There are 400,000 out of hospital cardiac arrests per year. Of those, 130,000 have shockable rhythms. And of those 65,000 are in a refractory shockable rhythm.
Treatment options
Esmolol
Small paper in Resusciation with 25 patients in control arm and 16 in esmolol group
ROSC achieved 56% in esmolol group vs 16% in control group
Because of such small sample size, differences in favorable neurologic outcomes could not be detected
Lidocaine vs Amiodarone
2016 pre-hospital article showed 5.4% achievement of ROSC in pre-hospital group vs 1.4% in amiodarone group, but no statistically significant in difference for survival to hospital discharge
ALPS trial in 2016 show lidocaine, amiodarone or placebo for survival to hospital discharge
Thrombolytics
2001 study looked at all comers with medical cardiac arrest, including nonshockable rhythm, which showed increased rates of ROSC for tPA (68%) compared to control (44%). This led to increased rates of hospitalizations with tPA (58%) compared to control (30%). No statistical difference in 24 hour survival or discharge.
2019 meta-analysis showed no statistical significance and as of now AHA does not recommend thrombolytics in undifferentiated cardiac arrest
ECLS
Minneapolis Protocol:
Inclusion criteria: age 18-75, presumed cardiac etiology, initial rhythm VT or VF, 3 defibrillation attempts, 300 mg Amiodarone, mechanical CPR, <30 min transport time, favorable labs (EtCO2 >10, PaO2 > 50, lactate <18), downtime < 90 min
Of the 100 patients who were transported for ECLS:
17 did not meet inclusion criteria based on labs
37 patients died on circuit (most common cause of death anoxic brain injury)
6 patients survived but with severe neurologic deficits
40 patients discharged with good neurologic outcomes
These group published additional data in January 2020 with additional 60 patients that showed slightly more modest neurologically intact survival rate of 33%.
Imaging in Seizure Patients
In 2007, American Academy of Neurology looked at the use of imaging in seizure patients and found that it changed management 9-17% of the time in new onset seizure and 7-21% of time in chronic seizures
There was a large selection bias for the chronic seizure cohort as these are not patients routinely imaged
ACEP guidelines recommends imaging if there is any of the following: trauma, immunocompromised state, history of malignancy, anticoagulation, new pattern or type of seizure, new focal neurologic findings
Proposed Algorithm:
New onset seizure:
Normal exam, normal baseline: outpatient MRI preferred, although CT if unable to assure follow up
Prolonged postictal state, focal neuro deficit, focal or partial onset: CT followed by MRI
Chronic seizures:
Normal exam, baseline mental status, no trauma: no imaging
Prolonged postictal state, focal neurologic deficit, increased seizure frequency, acute head injury: CT
Cerebral Cavernoma
Less than 1% of the population
Immature blood vessels often located in the temporal lobe that often have thin walls and are at increased risk of repeat hemorrhages
4-6% of patients will develop seizure
Surgical resection reserved for refractory epilepsy
Bacteremia in Cardiac Arrest
Noncardiac causes make up half of the causes of sudden cardiac death, and of those about 9% are attributed to infection
Initial presenting rhythm is most commonly asystole (67%), followed by PEA (19%) and then VF/VT (14%)
1/3 of these patients with ROSC had positive blood cultures
Predictors of bacteremia in cardiac arrest include: high lactate, low pH amnd higher base deficit
ATHARTIC trial in 2019 included 194 patients randomized to receive Unasyn or placebo for aspiration prophylaxis
showed decrease in incidence of ventilator associated pnuemonia, but no difference in 28 day mortality or ventilator free days
Have a low threshold to start antibiotics on post-cardiac arrest patients
Severe Malaria
Treatment: IV artesunate for severe malaria
Indications for Artesunate: altered mental status, seizures, shock, Hgb < 7, renal failure, pulmonary edema, DIC, >5% parasitemia WITH a positive blood smear
Call CDC to receive medication:
M-F 8:00-4:30: 770-488-7788
All other times: 770-488-7100
Global Health Grand Rounds: Misnomers of TB WITH Dr. Owens
TB is the leading cause of death in adults worldwide from an infectious disease
In 2018, US saw the lowest number of TB cases worldwide with 2.8 per 100,000 cases
Ohio had 171 cases reported in 2018
1 in 3 people worldwide are infected with TB and approximately 10% of those infected develop active disease
Have to have a high level of suspicion for these cases because if relying on risk factors alone, will still miss many cases
Testing
If concerned about active TB, need to order sputum AFB culture
This can be suboptimal in the immunocompromised or those with difficulty making sputum
PPD and quantiferon gold testing is often thought to be used to test for active TB but neither can determine between current disease vs previous disease or active TB vs latent TB. Goal of these tests is to identify people with latent TB who would benefit from treatment.
Quantiferon Gold measures peptide Ab to TB; T cells secrete IFN-gamma in response to stimulation by peptides from TB
These peptides are absent from the BCG vaccine
There is a high likelihood that quantiferon gold will be negative if active disease due to IFN-gamma suppression
PPD is a mix of peptides and fragments, few are unique to TB thus the test can cross-react with many types of infections, also including the BCG vaccine
Urine LAM testing for those with CD4 under 100 who are ill and hospitalized: simple, cheap, fast, noninvasive
used more globally; not currently available in Cincinnati
studies have shown mortality benefit for testing in this population, but not the general population
Pediatric TB
Very different presentation than adults
70% of cases are missed due to nonspecific presentation
Can be as subtle as falling off the growth curve
Chronic cough for >2 weeks is most common presenting symptom
Children do not necessarily have a latent period
If under 5, more likely to have progressive disease as well as extrapulmonary disease
Of note, children under 5 cannot be considered the source as they cannot generate a cough strong enough to aerosolize
There is a gastric aspiration for diagnosis for those who cannot produce sputum which if done correctly has high sensitivity and specificity compared to adult sputum test
Vaccines for children given in areas with high incidence and children at high risk
decreases risk by 30% and can deliver herd immunity to adults in some areas
BCG protects children from severe and disseminated disease, specifically meningitis
imaging
Not all cases of TB present with typical apical cavitary lesion
most common xray finding for TB is normal or mild atelectasis
any new effusion in the right patient should be concerning for TB
patients can still have TB with normal CXR, specifically with extrapulmonary TB
Treatment
Multi-drug resistant (MDR) TB: isoniazid resistant
a fluoroquinolone should be added to the antimicrobial regimen
Extensively drug resistant (XDR) TB: isoniazid and rifampin resistant
new development with bedaquinline and delamind: novel drugs both recommended by WHO
R1 Clinical Diagnostics: Brain MRI WITH Dr. Zalesky
Please see Dr. Zalesky’s post for further details about Brain MRI
Case 1
Elderly man is brought to the emergency department by his daughter who states that it sounds like he has been slurring his words occasionally over the last few hours. She states that an hour ago, she could hardly understand him. Presently, he is speaking clearly. When asked about the episodes, the patient chuckles and says, “I guess, if she says so.” The patient denies having any recent falls, weakness, or loss of sensation.
PMH: HTN, DM, BPH
Meds: Lisinopril, metformin, tamsulosin
Exam: BP 186/104, HR 62, RR 16, SpO2 99% on RA, T 98.6 Normal exam. Normal neurologic function.
Testing: Glucose 126. Laboratory workup and EKG are unremarkable. CT head is normal.
What would you expect the MRI to show?
Right occipital lobe hyperintensity, best seen on DWI sequence concerning for possible ischemic lesion
Case 2
34-year-old man is involved in a frontal-collision MVC at highway speeds, in which he was the restrained driver and airbags deployed. He complains of left-sided neck pain and dizziness. He reports that he feels like the room is spinning and he has almost fallen over twice. He does not have weakness or loss of sensation.
Exam: Vitals are normal. Exam is notable for non-extinguishing horizontal nystagmus and truncal ataxia when he walks. He is in a cervical collar because of his neck pain so you cannot do a proper HINTS exam.
Testing: CT head is normal. CT angiogram reveals a possible filling defect in the left vertebral artery. CT c-spine is read as normal.
What would you expect the MRI to show?
Hyperintensity in the left hemisphere of the cerebellum on T2 sequence; concern for ischemic infarct in setting of vertebral dissection
Case 3
36-year-old female presents to the emergency department complaining of double vision and headache. She has no other complaints. Has never had these symptoms before. No past medical history.
Exam: Vitals are normal. Exam is notable for internuclear ophthalmoplegia. Rest of her exam is normal
Testing: CT head is normal
What would you expect the MRI to show?
Multiple periventricular hyperintensities seen on FLAIR sequence consistent with multiple sclerosis
CPC WITH Dr. Leech vs Dr. Goel
Case: Young female with PMHx of ALS, Crohn’s presenting with SOB and dysphagia. Family brought her in due to concern for dehydration. Patient complains of progressive SOB for one month in addition to leg swelling in lower extremities. Also been evaluated for a PEG tube as an outpatient. Has been unable to swallow solids and now liquids for the past one week. Feels as if she is unable to get “enough air in”.
Exam: Tachycardic, but otherwise hemodynamically stable. Anxious, but in no acute distress. Crackles in bilateral bases. Dysarthric, increased tone L>R, fasciculation seeing R forearm, 2+ strength in upper extremities and normal strength in lower extremities.
Test of choice: CTPA that showed R segmental PE
Amyotrophic Lateral Sclerosis (ALS)
Progressive neurodegenerative disease with steady decline, no remissions or exacerbations
1-2 cases per 100,000
Most commonly occurs in 7th-8th decade of life, but can be seen in younger patients as well
No clinical test, but often defined by both upper mother signs (weakness with hyperreflexia, spasticity, +babinski) and lower motor signs (atrophy, fasciculations)
Presentation
80% of patients will present with asymmetric limb weakness
20% will have bulbar weakness
psedobulbar affect: inappropriate laughing, crying or yawning
1-3% with respiratory symptoms
Natural progression is incredibly variable, but the mean survival is 3-5 years but many people will go on to live 10 years longer or more
Patients that tend to do worse include older age at onset, bulbar-type ALS, early progression rate, decline in functional status
respiratory symptoms
Non-linear respiratory decline; when bulbar weakness develops patients often become dependent on NIMV
NIMV is started when symptoms of SOB start, frequent nocturnal desalts, CO2 retention, FVC < 50%
Half to these patients cannot tolerate NIMV, but can help with survival 7-14 months
Signs and symptoms include tachypnea, voice changes, reduced vocal volume, frequent pauses in speech, use of accessory muscles
Sleep disordered breathing: 1) obstructive sleep apnea: similar rate as the general population; 2) sleep related hypoventilation: progressive weakness of the diaphragm that leads to sleep fragmentation, non-restorative sleep, daytime fatigue and excessive sleepiness
Respiratory causes of death include respiratory failure, pneumonia, asphyxiation, PE
ALS puts patients at higher risk for blood clots due to decreased mobility
CONCLUSION: Patient’s symptoms likely a combination of PE in addition to worsening muscular weakness and the progression of her ALS
