Grand Rounds Recap 6.28.2017

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Mortality and Morbidity with Dr. Betham

Case #1: Male in his 60s with chest pain, significant family history of CAD, normal vitals. EKG: RBBB, initial trop negative. Repeat EKG shows a posterior STEMI, pt taken to the cath lab. 

RBBB

  • Diagnostic Criteria
    • Wide QRS > 120ms
    • RSR' in V1-V3 ("rabbit ears")
    • Wide, slurred S wave in lateral leads I, aVL, V5-V6
  • In BBB, the T wave is opposite the direction of the QRS slurring

Posterior MI (check out Annals of B-pod March 2016 EKG Corner) 

  • Accounts for 15-20% of STEMI
    • Usually with lateral or inferior infarct as well
    • 3-11% isolated posterior
  • Frequently missed due to positioning of the EKG
    • Consider getting a posterior EKG with V7-9
  • Often L circumflex disease
    • Can be RCA if right dominant

Case #2: Male in his 60s with history of coronary disease with stent placement 1 year ago who presents with chest pain.  EKG: ST depression V3-V6, I & aVL, and ST elevation in aVR. Cath lab activated and ends up with lesion in circumflex. 

aVR

  • Mirror of the lateral leads
  • Reflects changes in the R upper portion of the heart
  • Useful in its own right
    • PR elevation in pericarditis
    • R' in TCA overdose
    • ST elevation in AV nodal re-entrant tachycardia
  • How is ST elevation in aVR used in MI
    • Reciprocal change from ST depression in the lateral leads
    • Often indicates severe disease
    • Prognosticate in the hospital
      • ST elevation in aVR associated with older age, increased number of risk factors, 
      • OR if in-hospital mortality with aVR elevation
        • Minor OR 4
        • Major OR 6
    • A single culprit lesion is often not found
  • Isolated ST elevation in aVR is not a STEMI
  • Recommend emergent consultation of the interventional cardiology
  • Treat as NSTEMI

Case #3: Female in her 30s who presents with weakness and inability to perform ADLs who fasted earlier for religious reasons. LE>UE weakness, vertical & horizontal nystagmus, doesn't follow commands, sleepy, temporal wasting. MRI shows abnormal signal in mammillary bodies, thiamine deficiency, diagnosis of Wernicke's Encephalopathy

Wernicke's Encephalopathy

  • Results from critical vitamin B1 deficiency
    • Alcoholism 
    • Bariatric surgery
      • 4-12 weeks post-op
    • Hyperemesis
    • Chronic illnesses
    • Anorexia
    • Fasting/unbalanced diet
    • Staple diet of polished rice
  • Develops in 2-3 weeks 
  • Prevalence in the US 0-2.2%
  • Estimated mortality 17%
  • Men > Women
  • Triad of symptoms
    • Ophthalmoparesis
      • Nystagmus
        • Horizontal & vertical
        • Evoked by gaze
      • Lateral rectus weakness
      • Loss of conjugate gaze
    • Ataxia
    • Altered Mental status 
      • apathy and confusion
      • progresses to coma and death in weeks if untreated
  • Diagnosis
    • MRI shows abnormal enhancement
    • Vitamin B1 levels
  • Treatment
    • Admit
    • Vitamin B1 IV then home on PO

Case #4: Young man with inability to use his bilateral upper extremities, septic, multisystem organ failure, + rhabdomyolysis with compartment syndrome of his BUE. Lost use of bilateral hands. 

Compartment syndrome

  • Increased pressure within a muscular compartment resulting in compromised perfusion, tissue necrosis
  • Causes
    • External compression
    • Hemorrhage into a compartment
    • Reperfusion injury 
  • Five "P"s
    • Most sensitive: pain with passive flexion/extension
    • Other early findings: parasthesias and loss of 2-point discrimination
    • Paralysis is a late finding
      • Frequently irreversible (~13% recover function)
    • Pallor/Pulselessness? Unlikely
  • Clinical exam pitfalls:
    • Depressed GCS
    • Simultaneous nerve injury
    • Sensitivity of palpation of the compartment is about 50%
  • Whats an abnormal pressure? (Check out our video on how to use an a-line set-up to check compartment pressures) 
    • Normal is less than 10 mmHg
    • Greater than 30mmHg is generally diagnostic
    • Delta pressure= DBP - compartment pressure
      • 20-30mmHg or less is diagnostic
      • Sometimes felt to be better than absolute pressure in decision-making for fasciotomy

Case #5: Male in his 40s with DM who presents with penile swelling, septic shock, EKG with STEMI, sent to cath lab with clean coronaries. EF 20-25% thought to be secondary to his sepsis. EF recovers before discharge. 

Cardiomyopathy in Sepsis

  • Global LV hypokinesis in ~60% of septic shock patients
  • Increasingly recognized as Takotsubo phenomenon
  • ST segment elevation common
  • Normal LHC
  • Recovers at 10-14 days with appropriate treatment
  • Likely multifactorial
    • Catecholamines (endogenous and exogenous)
    • Inflammatory cytokines
    • ?perfusion mismatch in the myocardium

Case #6: Young woman with rectal prolapse and incarcerated, prolapsed, internal hemorrhoids which required operative intervention. 

Hemorrhoids

  • Incidence unreported: 4-40%
  • Most common cause of rectal bleeding
  • Vascular cushions that become enlarged and displaced distally
    • Pregnancy 
    • Portal HTN
    • Constipation or straining
    • Internal or External 
  • Internal Hemorrhoids
    • First Degree: No prolapse
      • Warm baths
    • 2nd Degree: Spontaneous prolapse and reduction
      • Manual reduction with TID warm baths and after every bowel movement
    • 3rd degree: digital reduction
    • 4th degree: unable to reduce
  • Consult surgery
    • Severe bleeding
    • Severe pain
    • Incarcerated or strangulated internal hemorrhoids
  • Topical Agents
    • Preparation H 
    • 1.5% topical lidocaine
    • 0.3% topical nifedipine
  • Excision of the clot?
    • Thrombosis >48h, then likely unhelpful

Updates in Global Health with Dr. Deborah Gerdes MD, MSc, DTH&H

Malaria

  • 3.2 billion people are at risk of infection globally
  • Since 2000 great progress in reducing mortality related to infection- 66% in WHO Africa region and 60% worldwide
  • In 2015 still 438,000 malaria deaths -- 90% in Africa
  • Majority of deaths are in children under 5
  • High burden of disease in Africa
    • High prevelance
  • Caused by infection with parasites of the genus Plasmodium
    • P falciparum (most deadly and common)
  • Parasite & Life Cycle
  • Clinical course varies with different host factors- age, prior exposure/immunity, pregnancy
  • Severe disease is most common in children and travelers
  • Milder symptoms: fevers, malaise, headaches
  • Severe Malaria: cerebral malaria, severe anemia, acidosis, hypoglycemia, AKI, ARDS, bleeding, and shock
    • Cerebral malaria and severe anemia are more common in African children
    • Organ failure more common in adults without prior exposure
  • Accurate and rapid diagnosis is essential
  • WHO recommends rapid diagnostic testing (RDT) for anyone suspected of malaria before beginning treatment
  • From 2005 to 2014 use of RDTs increased in WHO Africa from 36% to 6%%
  • Some limitations-- including underlying parasitemia in highly malaria-endemic areas
  • Thick and thin blood films are also still available and the test of choice in the US
  • WHO Principles: early diagnosis, effective treatment, treat only confirmed cases
  • Treatment:
    • 3 days of artemisinin combination therapy (ACT) for P falciparum 
  • ACT use increased from 11 million to 2005 to 337 million in 2014
  • Severe disease: IV artesunate in Africa; quinine + ?artesunate in US
  • First true concerns about ACT resistance noted in Thailand in 2003- along Cambodian border
  • Studies in Cambodia during the same time period found reduction in parasitological response
  • In 2007, parasite clearance times were found to be significanly longer in Palin than in Wang Pha and decrease in ART susceptibility from Bangladesh through Thailand
  • WHO and international community working together to contain resistance
  • Increasing resistance to partner drugs-- leading to full treatment failur
  • Other areas of focus
    • Vector control
    • Vaccines
    • Malaria Examination

Traveler's Diarrhea

  • Most common illness to travelers to lower income
  • Represents 1/3 of returning travelers
  • Risk highest in 1 k week of travel then declines

Strongyloidiasis hyperinfection 

  • Strongyloides stercoralis- nematode (roundworm)
  • Widespread in tropics and subtropics also reported in more temperate climates
  • Larva currens (creeping eruption)
    • Caused by migrating larvae during autoinfection
  • Hyperinfection
    • Complication of the chronic form of the disease
    • when host immune system is abruptly reduced-- steroids, DKA, malignancy-- leukemia/lymphoma, immunosuppressive tx
    • Steroid use is most common
    • Likely under recognized
    • Symptoms:
      • Severe bloody diarrhea
        • Bowel inflammation with microperforations
        • Peritonitis
      • GN sepsis
      • Pulmonary infiltrates, hemopytsis, pleural effusion
    • Diagnosis:
      • Stool microscopy
      • Duodenal biopsy
      • microscopy of duodenal juice
      • Serologic tests-- ELISA
      • Stool culture
      • Hairy string test.
      • Much easier to diagnose in hyperinfection 

Taming the SRU with Dr. Titone

The Case: Older male found down outside on a hot August day, temp was 105.9 and tachycardic, actively seizing on arrival. Final Diagnosis: Heat Stroke

Fever v Hyperthermia

  • Fever
    • Elevation in temp that occurs with an increase in the hypothalamic set point
    • Vasoconstriction commences
    • Body is hot and it likes it
  • Hyperthermia
    • Something external is heating the body
    • Compensatory mechanisms overwhelmed
    • Body is hot and can't fix it

Regulatory Mechanisms in Hyperthermia

  • Evaporation
  • Radiation
  • Conduction
  • Convection

Hyperthermia Spectrum

  • Heat Edema
    • Mild Swelling
    • Cutaneous vasodilation
    • Increased ADH
  • Heat Syncope
    • Volume depletion and low vasomotor tone
    • Decreased venous return
    • Postural hypotension
  • Heat Cramps
    • Salt depletion 
    • spasm of voluntary muscles
    • fasciculations
    • salt tabs
  • Heat Exhaustion
    • Regulation and CNS function is intact
    • <105 F
    • Can be hypo or hypernatremia, or eunatremic
  • Heat Stroke
    • Loss of consciousness
    • Cardiovascular collapse
    • Severe dehydration --> vasoconstriction to maintain mAP--> cessation of heat loss
      • Classic:
        • Older patient who is out in a heat wave
        • mild lactatic acidosis, mild CK elevation, normoglycemia
      • Exertional
        • Younger patient who is running a marathon
        • High lactic acidosis
    • "End Stage" Heat Stroke
      • Above 107.6F
        • Enzymes become non-functional

Resuscitation of Heat Stroke

  • Check a glucose
  • Think about taking airway early 
  • Rectal vs bladder continuous monitor
  • Ativan (primarily renally cleared) works for shivering and seizures
  • Pressor of choice is dobutamine
    • Avoid vasoconstriction because the patients are trying to get rid of heat
  • Fluids: Classic be judicious, Exertional types should get a lot of fluid
  • Cooling Techniques
    • Ice packing
      • Least effective
      • .05 F per min
    • Convection Air Cooling
      • .07F per min
    • Radiation
      • 32F surroundings --> .07F per min
      • 0F surroundings --> 1F per min
    • Evaporative Cooling
      • .09F-.015F per min
    • Ice Water Immersion
      • Most efficient
      • Logistically difficult
      • .27F-.63F per min

A quick line of respect for our chief residents Drs Dan Axelson (@axelsontweets), Brittany Betham (@BethamMD), Riley Grosso (@grossoriley), and Jon McKean for a phenomenal year summarizing, addending and connecting our Grand Rounds via these Recaps and engaging our online community - thank you immensely and good luck next year!