Grand Rounds Recap 2.21.18
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Morbidity and mortality conference WITH DR. Lagasse
CASE 1: Carbon Monoxide Poisoning
Background:
- Carbon Monoxide poisoning responsible for >50,000 ED visits annually in the US
- It is the #1 cause of poisoning death in the US
- Physiology review
- CO is a colorless, odorless, tasteless gas
- It has 200 times greater binding affinity to hemoglobin than oxygen
- Displacement of O2 leads to tissue hypoxia
Symptoms and sequelae:
- Symptoms: Often non-specific. Can include headache, dizziness, weakness, upset stomach, vomiting, chest pain, confusion, muscle aches
- Sequelae: There are many, but the major systems affected are those with high metabolic/oxygen demands. Can both persistent or delayed.
- Neuro-psychiatric
- Memory loss/difficulty (Primarily short term)
- Ataxia
- Vestibular disturbances
- Dementia
- Psychosis
- Cardiac
- Global LV dysfunction
- Regional wall motion abnormalities can also be seen
- This is more common in elderly patients with underlying CAD
- Poorly perfused regions more greatly affected by global hypoxia in CO poisoning (Essentially like a failed stress test)
- General
- Patients with history of CO poisoning have been found to have reduced life expectancy. Reason is unclear, but may be as a result of myocardial damage and predisposition to arrhythmia
- Neuro-psychiatric
Assessment:
- Carboxyhemoglobin level
- Value is a function of both concentration and time of exposure
- Level in ED may not correlate with amount of exposure
- Interpretation may change with smoking history
- Non-smoker: >3% abnormal
- Smoker: >10% abdmormal
Management
- Remove from area of exposure
- High oxygen therapy is mainstay of treatment
- Half life of CO on room air: 6 hours
- Half life of CO on non-rebreather mask: 90 minutes
- Half life of CO in hyperbaric chamber: 30 minutes
- Hyperbaric therapy (Chamber with 100% O2 and 1.4 atm absolute pressure)
- Shown to more rapidly displace CO from hemoglobin/tissue
- Actual utility in clinical management of CO poisoning is still debated
- Review of current literature:
- Weaver et al, NEJM 2002
- Study evaluated the neuro-psychologic effects in patients following either hyperbaric O2 vs. O2 at normal atmospheric pressure
- Found that patients who received hyperbaric oxygen had better neuropsychologic testing outcomes at 6 and 12 months
- 2011 Cochrane review
- Analyzed existing literature around hyperbaric oxygen for CO poisoning
- Conclusion: Not enough data to support routine use of hyperbarics
- Weaver et al, NEJM 2002
- Current guidelines
- Hyperbaric medical society recommends hyperbaric use in "Severe Poisoning," defined as one of the following:
- Carboxyhemoglobin > 25%
- Age > 36
- AMS
- Cardiac dysfunction
- Severe acidosis
- ACEP
- Does not routinely recommend use of hyperbaric oxygen
- Non Rebreather mask remains mainstay of treatment
- Hyperbaric medical society recommends hyperbaric use in "Severe Poisoning," defined as one of the following:
- General recommendation
- Non rebreather is probably sufficient for most cases
- Consider hyperbaric chamber/transfer for hyperbarics if:
- Pregnant
- Significant neurologic sequelae
- Consider discharge in the following patients
- Has received high flow oxygen on non-rebreather mask for 4-6 hours
- No evidence of sequelae
- The patient's social situation is appropriate (Has alternative place to stay / CO source has been eliminate)
Arrest from Carbon Monoxide Poisoning
- Prognosis is dismal
- Consider other poisoning (eg. cyanide in house fires)
CASE 2: Medication Induced Hyperkalemia
Background:
- Drug induced hyperkalemia is common, and is responsible for many the cases of hyperkalemia in hospitalized patients
- Mortality of hyperkalemia in hospitalized patients is 1 per 1,000 patients
High Risk Patients
- Moderate-Severe chronic renal insufficiency
- History of HIV/AIDS
- History of Rheumatologic disease
- Hypo-aldosteronism
- Elderly/polypharmacy
High Risk Medications
- Beta Blockers: Decrease activity of Na+/K+-ATPase pump and renin release
- Digoxin: Inhibition of Na+/K+-ATPase pump activity
- NSAIDS: Decrease of prostaglandin-mediated renin release, renal blood flow and glomerular filtration rate
- Heparin: Inhibits aldosterone synthesis
- Bactrim: Blockade of luminal sodium channels causing less of a gradient for potassium
- ACE Inhibitors: Inhibits aldosterone production leading to decreased renal potassium excretion
ACE Inhibitor and Bactrim Combination
- 7 Fold increase in risk of hospitalization
- Common combination in elderly patients with UTI
- Increased risk of death in same population, likely due to hyper K+ and subsequent arrhythmia
CASE 3: Spontaneous Heterotopic Pregnancy
Background
- Heterotopic pregnancy is a multiple pregnancy with one embryo implanted in the uterus and another at an ectopic site
- "Spontaneous" refers to this event occurring without fertility treatments or medications to induce ovulation
- Rare, occurring in 1 in 30,000 cases
- Usually diagnosed before 11 weeks gestation
Risk factors
- Same as ectopic pregnancy
CASE 4: Evaluation of the Suicidal Patient
Background:
- Studies have shown that 6-10% of ED patients have had or currently have thoughts of suicide
- JCAHO has mandated that all patients with psychiatric symptoms should be screened for suicidality/homicidality
- Our ED's current practice is universal screening
Risk Factors for suicide:
- Male sex
- Older age (>44)
- Sexual orientation
- History of self harm
- No history of outpatient psychiatric care
- Education (High school or less)
- Alcohol or substance abuse disorders
- Specific occupations
- Physician
- Lawyer
- Veteranarian
High risk time periods:
- Interpersonal stress
- Loss of a family member
- Financial or legal difficulties
- Physical illness
Protective factors:
- Well developed social support network
- Strong reasons for living
- Responsibility for young children
- Religiosity
- Extroversion and optimism
- Effective coping and problem solving
Approach in the ED:
- Assess decision making capacity
- Information gathering
- Take history, assess risk and protective factors
- Obtain collateral information from family/friends/other
- Assess their access to lethal means
- Firearms
- Medications
- Chemicals, etc
- Use decision support tool / Screening tool
- Several exist: Columbia, U Mass, etc
- ex: Patient Safety Screener
- Use SAFE-T Tool to determine level of risk
- Disposition
- Low risk patient: Consider discharging if the following are met:
- You can assure outpatient follow up
- You are able to explain and distribute information on warning signs, crisis line
- Involve the patient's family
- Document risk level and rationale
- Document a plan to reduce risk (Safe place to stay, reduce access to firearms, etc)
- Moderate to high risk: Transfer to psychiatric emergency services or admit for psychiatric evaluation
- Low risk patient: Consider discharging if the following are met:
AIr care grand rounds organized by Dr. Dang and Dr. Renne
Balloon Pump Transfers:
Basic principles of balloon pump
- Designed to augment cardiac output and diastolic pressure
- Inflates during diastole => Increasing aortic pressure during diastole, leading to increased coronary perfusion
- Deflates during systole => Creates vacuum in aorta helping to augment cardiac output (CO)
- Positioning
- Balloon should be situated between the left subclavian artery and the renal arteries within the aorta
- Balloon is filled with helium
- Less likely to form air embolus if balloon ruptures (Though still possible)
- Better laminar flow
- Contraindications
- Aortic regurgitation
- Severe peripheral vascular disease
Assessing the balloon pump patient
- Review patients X-Ray if possible to assess for correct placement
- Check pulses to make sure balloon is not occluding major artery
- Best to check left radial pulse
- Place pulse ox on left hand
- Should have foley. Monitor UOP to make sure not obstructing renal arteries
Transferring the balloon pump patient
- Bring the pump in to the patient's bedside to make sure all equipment is compatible/present
- Copy the hospital's settings for the balloon pump onto out machine
- Best to keep on AUTO setting
- Set augmentation alarm to 10mmHg below the augmented pressure
- Transfer the balloon pump after organizing drips (Last thing along with vent)
- Attach ECG cords
- Attach pressure monitor (Fiber optic)
- Transfer helium balloon
- Keep lines together
- Best to dedicate someone to moving the pump
- Fasten in helicopter with holder (pilot will help install)
- Have machine facing seats and not rear facing
Monitoring and troubleshooting
- Power
- Replacement batteries in the backpack
- Plug in during flight
- Batteries last 45 minutes each
- Waveform
- Waveform will be present on the screen
- Will essentially look like A-line tracing when balloon not inflating
- Will have an additional bulge upward when balloon inflated
- Balloon can be set to inflate 1:1, 1:2, or 1:3
- Helium
- Helium level shown on the screen (Refilled by maintenance)
- Waveform should look like a chair
- Most common failure is a purge failure, which means helium us unable to empty from the balloon. Usually caused from a kinked line
- Solved by laying the patient flat
- Balloon
- Rust coloring in line suggests balloon leak
- Turn off pump to avoid air embolus
- Will need to re-inflate every 4-5 minutes to prevent clot
- Timing
- Common errors
- Early inflation: DANGEROUS. Means it's inflating against an open aortic valve
- Late inflation: Fine, but means it's not optimized
- Late deflation: DANGEROUS. Heart pumping against inflated balloon
- Common errors
Cardiac Arrest with Balloon Pump:
- If patient is pulseless, balloon will default to pressure mode
- IF PEA, balloon will still trigger. Will need to switch it to pressure mode
- If arrhythmia or fast heart rate => Switch to pressure mode
- Can perform CPR in pressure mode
Impella Transfers
Device:
- Different sizes (2.5 and 5), with 2.5 and 5L of CO augmentation respectively
- Percutaneous line, usually through femoral artery (axillary also possible)
- Parts
- Pigtail catheter helps pump sit in ventricle
- Pump portion in ventricle
- Marking should be at level of valve
- Outflow port in aorta
- Lubricant / D5 flow at outflow port
- Catheter through aorta out of groin. Connects to control module
- Control module is portable. Weighs roughly 25 pounds
Transfer
- Drive line attached to monitoring unit
- Will also require several drips
- D5 lubricant
- Heparin
- MUST BE MAINTAINED
- Need to ensure that catheter protection sheath (Swandom) is secured
Monitoring
- Monitor should show two lines
- Aortic wave form: Should mimic A-Line, should not look ventricular
- Pump/Power wave form: Should also look pulsatile as ventricle assists pump
- Suction alarm
- Common causes
- May be due to placement
- Low preload
- RH failure
- Solutions
- Drop power
- Give fluid
- Keep CVP > 10 if monitored
- Common causes
Cardiac arrest with Impella
- If CPR, turn down power/flow
EKOS Catheter
Device:
- Dual purpose catheter
- High frequency, low energy US helps break up clot
- Catheter allows localized delivery of thrombolytics
- Uses
- Sub-Massive PE
- Peripheral DVT
Transfer:
- Control box does not transfer with patient
- Curl up wires
- Place in glove to keep dry
- Things to consider
- TPA must be maintained on pump
- Coolant must be maintained on pump as well
- Will need to be on heparin
- The catheter itself is difficult to suture in because it can occlude TPA
- Be careful when moving the patient
Left Ventricular Assist Device (LVAD)
Types of VADs
- Axial flow pump
- Heartmate II (Most common at UC)
- Centrifugal flow pump
- Heartware
- Heartmate III
Basic mechanics
- Inflow catheter from ventricle
- Pump sucks blood from ventricle
- Outflow catheter anastomosed into aorta
- Right heart VADs also exist from RV to PA
Monitoring
- LVAD creates continuous flow
- BP needs to be obtained by doppler
- Pulse ox not reliable for pulse
- EKG should not be greatly affected by VAD
Common complications
- Suction event
- Give bolus
- Decrease speed
- SHOULD AUTOCORRECT
- Thrombus
- Spike in power
- Decreased flow
- Loss of flow
- Low power / Loss of power
- Batteries last 12 hours
- Should have a line from each battery going into controller module
- Drive line
- Check and make sure connected
- Low power / Loss of power
Cardiac arrest with VAD
- Check device
- Drive line plugged in
- Batteries attached
- Assess power, speed for signs of suction or thrombus
- Depending on local protocol, may begin CPR, follow ACLS
- Know that CPR has theoretical risk of dislodging VAD
Determining transfer location
- Ideally transfer to medical home (Implanting facility)
- Will have LVAD monitor/docking station/extra batteries
- If unstable, closest ED