Grand Rounds Recap 1.3.17

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R4 SIMULATION:  SALICYLATE TOXICITY WITH DRS. PLASH, SHAH, THOMPSON, AND TITONE

HISTORY:  74 Year old female brought in by EMS for shortness of breath and altered mental status.  Daughter provides history.  States her mom had been complaining of headaches and body aches earlier this week.  Recently she has been complaining of shortness of breath, and has become altered/confused per daughter.  On further questioning, she has been taking OTC medications for her headache, including "Goody's Powder".  ROS otherwise positive for tinnitus.

PMHx:  HTN

Meds:  Lisinopril, Aspirin 81 mg

VITALS:  T:  99.4F   HR:  105    BP:  155/80   RR:  26   O2%:  100% on RA

EXAM: 

  • HEENT:  Clear
  • CV:  RRR, No rubs, murmurs, gallops
  • Pulm:  CTAB
  • Abd:  Soft
  • Neuro:  AO X 1, Moves all 4 extremities equally.  Sensation intact.  

EKG:  Sinus Tach

CXR:  Clear

Labs:  

  • Fingerstick: 175
  • VBG: pH 7.50/ CO2 24/ PO2 55/ Base excess -9/ Lactate 4
  • Renal panel 146/3.3/108/15/45/2.0/118
  • CBC: 15/12/45/184
  • Acetaminophen: <3
  • Salicylate: 110

DIAGNOSIS:  Acute Salicylate Toxicity

Discussion:

Background:  

  • Often occurs as accidental ingestion in children or elderly
  • Ingredient in over the counter medications.
    • Goody's
    • Oil of Wintergreen (Think mint flavor)

Complications of Severe Ingestion

  • Combined respiratory alkylosis / Metabolic Acidosis
    • Direct stimulation of respiratory center => Tachypneic with respiratory alkalosis
    • Disruption of oxidative phosphorylation => Metabolic acidosis
    • Balance often differs by age
      • Pediatrics:  Metabolic acidosis > Respiratory alkalosis
      • Adults:  Respiratory alkalosis > Metabolic Acidosis
  • Kidney Injury + Electrolyte Abnormalities
    • Increased fluid loss (GI losses, insensible loss)
    • Decreased renal blood flow 2/2 prostaglandin inhibition
  • Encephalopathy / AMS
  • Pulmonary Edema

Approach to Management:

  • Minimize Ingestion
    • Activated Charcoal
      • Thought to be beneficial within 1 hour of ingestion (Though evidence is debated)
      • Aspirin forms concretions in stomach.  Charcoal thought to decrease continued absorption
      • Dose may be repeated hourly X 4 doses
      • Airway should be protected
  • Increase Excretion
    • Alkalanization of urine: traps salicylates in renal tubules, increases salicylate excretion 10-20 fold. 
    • Sodium bicarbonate
      • Administered as a drip, often 2X maintenance rate
      • Mix Drip:  3 Amps of NaHCO3 in 1 Liter of Fluid (usually D5)
  • Supportive Care
    • Airway / Respiratory Management
      • Multiple reasons for possible respiratory compromise
        • Pulmonary edema
        • AMS/Encephelopathy and inability to protect airway
      • Ventilator Management
        • Patient's usually tachypneic => Partially compensates for metabolic acidosis
        • IMPORTANT TO MATCH PATIENT'S RESPIRATORY RATE to prevent worsening acidosis
    • Fluid / Electrolyte replacement
      • Likely need to supplement potassium
      • Will likely need fluid replacement due to GI, insensible losses, increased urinary excretion with bicarbonate
  • Elimination
    • Dialysis:  Effective in decreasing serum salicylate levels
    • Indications for dialysis
      • AMS
      • Pulmonary edema with respiratory distress or oxygen requirement
      • Cerebral Edema
      • AKI or CKD→ Cr >2.0 or 1.5 in elderly patient will low muscle mass
      • Fluid overloaded that prevents sodium bicarb administration
      • Markedly elevated salicylate level (>90)
      • pH <7.20
      • Clinical deterioration despite appropriate care

For more information, a few resources

WELLNESS AND MINDFULNESS WITH DR. RICHARD SEARS

Defining Wellness and Mindfulness:

Wellness:  5 Components of Well Being

  • Connection:  People, community, cause
  • Activity:  Physical activity
  • Taking notice:  Be present in the moment, notice what is going on around you
  • Ongoing learning
  • Sense of Giving

Mindfulness: “[Mindfulness] is the awareness that emerges through paying attention, on purpose, in the present moment, and nonjudgmentally to the unfolding of experience moment to moment”  (Kabat-Zinn, 2003, p. 145)

  • Awareness:  Paying attention, be present in the moment
  • Purpose:  Selecting what you think about as opposed to automatic thinking
  • Decision:  Choosing to focus on what’s useful in the moment
  • Non-Judgmental:  Accept what you are feeling without guilt for feeling that way

Minimizing Worry and Rumination

Congnitive / Behavioral Techniques:  Methods have been shown to decrease worry, improve management of worry in the future

  • Exposure Therapy:  "Swimming Pool Analogy".  Involves trying to focus on and experience the worry in full to then help get past it.  In place of letting it ruminate over time, which leads to negative reinforcement.  
  • Decentering / Defusing:  "Noticing thoughts, but not getting caught up in them"  Step back outside of the situation and look at situation and how it is making you feel.  "I'm having these feelings, I'm probably very stressed out."
  • Filling Attention:  Teach to prevent avoidance
  • Self Compassion:  Teach ability to understand and forgive self

Mindfulness in the Workplace

Mindfulness in the workplace has been shown help with the following:

  • Significant declines in stress, negative affect, rumination state and trait anxiety
  • Significant increases in positive affect and self-compassion
  • Shown to increase provider effectiveness and patient mental health

METHODS

3 Minute Breathing Exercise

  • Minute 1:  Noticing the moment  (Body, feelings, thoughts)
  • Minute 2:  Breathe  (OK for mind to wander, try to bring it back by focusing on breathing)
  • Minute 3:  Be in your body

Resetting:  Between each patient, reset.  Notice where you are.  Think about what you are doing in that moment. 

CLINICAL DIAGNOSTICS:  SICKLE CELL ANEMIA LABS WITH Dr. EILEEN HALL

See Dr Hall's Post for a primer on SCD Labs here

Sickle Cell Disease:  Background

  • Most common genetic disease in the US
  • Hemoglobin S causes RBCs to sickle
  • Can lead to vaso-occlusion / Vaso-occlusive crisis
  • Crises are extremely painful
  • Associated with myriad sequelae
    • Neurologic (Stroke, Retinopathy, Neuropathy)
    • Pulm (Acute Chest, Pulm HTN, Pneumonia)
    • Cardiac (Cardiomyopathy)
    • GI (Hepatic Sequestration, Cholelithiasis, Jaundice)
    • GU (Papillary Necrosis, CKD, Priapism)
    • Splenic (Sequestration, Functional Asplenia / Autoinfarction => Immunocompromise against encapsulated organisms)

Laboratory Evaluation in Sickle Cell Disease

  • Reticulocyte Count:  Immature RBC, serves as a marker of bone marrow function.   Mild elevation at baseline in sickle cell anemia due to more rapid RBC turnover
    • HIGH reticulocyte count:  
      • Splenic sequestration
      • Hepatic sequestration
      • Hemolysis (Transfusion reactions, etc)
      • Blood Loss
    • LOW reticulocyte count:
      • May signal aplastic crisis
    • Clinical Utility
      • May help to diagnose processes mentioned above
      • However, little utility as a screening tool in asymptomatic patients
        • Large study showed reticulocyte count was not helpful in screening for occult disease in patients who did not meet certain criteria (fever, hypotensive, hypoxic, pregnant, AMS/neuro symptoms, new CXR infiltrate)
  • Lactate Dehydrogenase (LDH):  Present in most cells.  Released as a result of hemolysis and tissue damage.  Elevated at baseline due to intravascular hemolysis, tissue necrosis, ischemia-reperfusion.  
    • HIGH LDH
      • Chronic elevation in LDH:  Associated with increased chronic complications
        • Increased pulmonary hypertension
        • Higher LV mass index
        • Abnormal cerebral velocities by transcranial doppler
        • Higher rates of priapism
        • Higher rates of leg ulcerations
        • Increased rates of death 
      • Acutely elevated LDH: 
        • Will likely elevate even with mild vaso-occlusive crisis
        • Greater increases in serum LDH level on admission associated with more severe outcomes
    • NORMAL LDH
      • Can be used in conjunction with haptoglobin > 25mg/dL to rule out hemolysis
  • Hemolysis Labs
    • Haptoglobin:  Scavenger protein.  In setting of hemolysis, binds free hemoglobin.  Will decrease in the setting of hemolysis.
    • Bilirubin:  Product of the breakdown of heme, which is released in hemolysis.  Will increase in the setting of hemolysis.

Summary:

  •  Stable patients with typical pain crisis likely do not require laboratory evaluation
  • Patients who are having an atypical crisis, have vital sign abnormalities, will likely benefit from laboratory evaluation
    • CBC to check for anemia/worsening anemia
    • Reticulocyte count:  Rule out aplastic crisis
    • LDH:  May serve as marker of severity
    • Hemolysis Labs:  Haptoglobin and bilirubin to assess for level of hemolysis, transfusion reaction, etc.  
  • If patient is being admitted for pain crisis, may facilitate admission / help admitting service to collect labs

CPC WITH DR. KLASZKY and DR. POWELL

Middle aged man with history significant for HTN, hypoplastic aortic arch, aortic pseudoaneurysm s/p repair in 2009, chronic back pain who presents with pain in his back and bilateral knees.  2 hours prior to presentation, the patient was standing from a seated position when he felt severe pain in his back which caused him to fall to his knees.  The patient now presents with primary complaint of bilateral knee pain, however, he also mentions continued back pain as well as diffuse abdominal pain.

PMHx:  HTN

Meds:  Antihypertensives, Neurpathic pain meds, Pain meds for chronic back pain

Vital Signs:  T 102.8   HR 151   RR 28   BP 200/78   O2 98% on RA

Exam:

  • General:  Appears to be in acute distress
  • Cardiac:  Tachycardic, RRR, no rubs, murmurs, or gallops
  • Pulm:  CTAB
  • Abdomen:  Soft, non distended, endorses diffuse tenderness to palpation
  • MSK:  Bilateral knee effusions.  L Knee and calf warm compared to right side.  Bilateral leg swelling, L>R.  ROM limited 2/2 pain.

Initial Diagnostics:

  • EKG:  Sinus tachycardia
  • Labs
    • Renal:  Within normal limits, creatinine baseline
    • CBC:  Normal
    • LFT/Lipase:  Normal
    • Troponin:  Normal
    • UA:  Normal
    • ESR and CRP:  Elevated
    • BILATERAL KNEE ARTHROCENTESIS
      • No signs of septic arthritis
  • Imaging
    • CT Angiogram of chest, abdomen, and pelvis:  No acute abnormalities
    • X-Ray Bilateral Knees:  No acute fracture or mal-alignment.  Diffuse soft tissue swelling noted, particularly over left proximal tibia

Faculty Discussion

Summary:  Patient is a young male, though he has a significant and complex medical history.  He presents with primary complaint of acute knee pain.  He also has complaints of abdominal and back pain, however those seem largely chronic and he has had negative cross sectional imaging of his chest, abdomen and pelvis during this visit.

As the patient is decently febrile, concern is for likely infectious etiology.  Vasculitis and autoimmune etiologies were considered, however appear to be less likely given history and workup thus far.  Question is, where is the source.

Differential Includes:

  • Neuro:  Less likely meningitis/encephalitis.   AO X 3
  • ENT: No complaints of sore throat, stridor.  PTA, RPA, less likely.  
  • Pulm:  No SOB, no hypoxia, no evidence of infection on chest CT
  • Cardiac:  Endocarditis, myocarditis less likely as he has no Hx of IVDU, otherwise immunocompetent, normal cardiac function without signs of acute failure
  • GI:  Has belly pain, but normal labs and normal CT.  Less likely hepatobiliary infection, bowel necrosis, etc.  
  • Vascular:  Hx of previous pseudoaneurysm repair.  Possible aneurysm, mycotic aneurysm, etc.  Negative CT makes this less likely
  • MSK:  Negative bilateral knee aspirate for septic knees.  However, septic bursitis is possible.  
  • Back:  Patient has no history of IVDU.  NO mid-line back pain.  No neurologic deficits.  Less likely epidural abscess, spinal infection
  • Skin:  Possible.  There is redness over the left knee

Final Diagnosis:  Given focal swelling on exam and on X-Ray of left knee, redness and swelling, fever, likely septic bursitis.  Diagnostic test = Bursal aspiration.  

Septic Bursitis

Physiology

  • Bursa are sacs of synovial fluid located around bony joints that help to decrease friction and provide a cushion
  • >150 Bursa exist in the human body
  • The knee has 6 bursa, categorized into 2 groups: superficial and deep
    • Group 1:  Superficial Bursa
      • Prepatellar
      • Infrapatellar
      • Pes-Anserine Bursa
      • Semi-Membrinosis Bursa
    • Group 2:  Deep Bursa
      • Deep Infrapatellar
      • Suprapatellar

Pathology

  • Bursitis:  Aseptic inflammation within the bursa.
    • Causes
      • Trauma
      • Overuse
      • Prolonged Pressure
    • Management
      • Conservative
      • RICE
      • NSAIDs
  • Septic Bursitis:  Inflammation due to bacterial infection
    • Causes
      • Superficial Bursa:  Usually seeded by direct trauma / innoculation
      • Deep Bursa:  Usually hematogenous spread.
      • Prepatellar bursa most commonly affected (Roughly 50% of septic bursitis)
    • Diagnosis
      • Bursal fluid aspiration
        • Commonly performed on superficial bursa with exception of suprapatellar bursa
        • US can be useful in locating bursa
        • Procedure similar to arthrocentesis
          • Sterilize skin
          • Local Anesthetic
          • Sterile technique
          • 18 gauge needle (Bursa are usually fairly superficial, no need for spinal needle)
          • Approach laterally
          • Procedural video
      • Bursal fluid analysis
        • Appearance:  Assess for puruluence, etc
        • Cell count:  Cutoff for septic bursitis is less than septic joint.  > 2-3000 WBC considered positive.  Neutrophils > 50%
        • Glucose:  Bursa to serum glucose ration <50% concerning for infection
        • Gram Stain + Culture
    • Management:
      • Uncomplicated:  (Well appearing, afebrile, normal vitals)
        • Oral antibiotics covering MRSA (Clinda, Bactrim, or Doxy)
        • Discharge with PCP follow up
      • Complicated:  (Febrile, abdnormal vitals, diffuse swelling)
        • Aspirate as much fluid as possible
        • IV antibiotics (Vancomycin for gram + coverage.  Consider pseudomonal coverage in immunocompromised patients)
        • Admit to hospital
      • Indications for orthopedic surgery involvement
        • Excessive cellulitis over joint => Inability to aspirate
        • Critically ill and need source control
        • Concern for deep bursal infection (Usually associated with concomitant septic arthtritis)
        • Recurrent infection