Grand Rounds Recap 8.9.17

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QUARTERLY SIM WITH DRS. LAFOLLETTE, HILL & CURRY

Oral Boards Case #1 (Triple Encounter)
Patient 1
HPI: 35 y/o M found 30 yards from his motorcycle
Vitals: Tachycardic to 130, BP 105/75, Tachypneic, O2 100% on 4L NC
PE: Covered in abrasions, moaning and opening his eyes, moving all fours, localizes pain, clear breath sounds bilaterally, pulses present but faint, GCS 10-11, pelvis is unstable and tender, right leg externally rotated
Work up: FAST, CXR, Pelvis X-Ray, blood glucose, CBC, type and screen, BMP, EtOH, PT/INR, LFTs
PMH: Unknown
Therapeutics: Placed pelvic binder, GCS worsens and tachycardia increases so given 1 PRBC and 1 FFP and TXA with improvement in vital signs
Pelvis film showed open book pelvis, hemodynamics worsen again and massive transfusion started
Critical Actions: Hemodynamic stabilization prior to leaving the department, utilizing IR for pelvic embolization, placement of pelvic binder, evaluation of urethral injury

Patient 2

HPI: 14 month old F, playing with change and the started coughing and choking, now seems irritated
PMH: None
PE: Drooling, not tolerating secretions which are pooled in back of mouth, moderate distress, lungs sounds normal
Vitals: O2 sat 100% on RA but tachypneic
Interventions: placed in a position of comfort and IV placed
Diagnostics: CXR and Airway films show FB on AP view 

  • If it looks like a coin on AP view and a slip on lateral view, it's likely in the esophagus
  • If it looks like a slip on AP view and a coin on the lateral view it's likely in the trachea

Critical Actions: Obtain airway films, speak with surgical specialty

Patient 3

HPI: 52 y/o M with abdominal pain that started three hours ago suddenly, epigastric, has had similar intermittent pain in past but worse now and constant
Vitals: Tachycardic but hemodynamically stable
PMH: HLD and HTN on enalapril and atorvastatin
SH: Significant EtOH use
Workup: CBC, renal, LFTS, lipase, VBG, lactate and type and screen
Exam: Decreased bowel sounds with diffuse tenderness, rebound and guarding
Diagnostics: Acute abdominal series with free air under the diaphragm
Diagnosis: Perforated viscous
Given pipericillin-tazobactam and transferred to OR
Critical Actions: Obtaining plain film prior to CT, surgical consult and antibiotics 

 

Oral Boards Case #2

HPI: 45 y/o F with agitation, palpitations and nervousness
Vitals: Tachycardic to 140s and hypertensive, saturating well, temp 102.6
PE: agitated with dry mucous membranes, exophthalmos, thyroidmegaly, EOMI, no stridor, irregularly irregular rhythm, mild diffuse abdominal tenderness, flushed/moist skin
PMH: "Gland problem with her neck" on no medication
SH: Cocaine use daily
Diagnostics: CBC, EKG, BMP, TSH, T3 and Free T4, UA, Urine HCG and UDS, LFTs, Lipase and blood cultures
Labs: Mild AKI with hypercalcemia and hyperglycemia, WBC 13, TSH 0.1, Free T4 1000, UDS positive cocaine
EKG: atrial fibrillation with RVR
Diagnosis: Thyroid Storm

  • Possible causes: Iodine exposure (shellfish, contrast or amiodarone), pregnancy, infection/illness, DKA, drugs of abuse (cocaine)

Management:

  • Consider avoiding beta blockers in cocaine induced thyroid storm (data is questionable on this, but be conservative when dealing with known dogmas on oral boards) (usual dose of propanolol is 1-2mg q 15minutes)
  • Consider CCB (diltiazem)
  • Dexamethasone or hydrocortisone to prevent peripheral conversion
  • PTU: 600mg PO loading then 200 q 4-6 hours or Methimazole 20mg PO q 4-6 hours to stop production
  • Iodine at least one hour after PTU/Methimazole treatment

Simulation

HPI: Middle aged female with right sided chest pain x 2 days with SOB, hurts to breath, getting worse, constant, worse on the right side, no fever or cough. Actively undergoing chemo for breast cancer
VS: 115, 121/79, 92% on RA, RR 27, Temp 98.0
PMH: laryngeal cancer, CABG, breast cancer
PE: tachypneic, diminished lung sounds without focality, trace bilateral pitting edema, port looks ok, skin ok, 
Labs: VBG, lactate, CBC, BMP, troponin, BNP, UA, urine preg
CXR:  Not impressive EKG: Sinus tach
DDx: ACS, CHF, PE, infection, obstruction with history of laryngeal cancer, effusion
Cardiac ultrasound performed showed globally poor squeeze with no effusion, or D-sign
Patient worsens with Temp 101 and BP 86/49
WBC count returns at 0.7, 1L bolus given, blood cultures obtained and cefepime/ vancomycin/ azithromycin started
Hemodynamics remain poor, levophed, vaso and epi added
Learning points

  • Using ultrasound to guide resuscitation  
     
    • Hyperdynamic LV can help confirm suspected sepsis (33% sensitive, 94% specific) but does not rule it out. Her poor EF still helped guide our diagnosis from PE to sepsis and heart failure
    • Can push you to move to ionotropes early and also guide pressor management (ie this patient needed more beta agonism)
  • Reasons for low cardiac output: chemo induced, sepsis induced, baseline CHF from previous CABG, PE, etc
  • High suspicion and source control in neutropenic fever: consider CT scan of chest/abdomen/pelvis if negative labs, good skin exam, consider indwelling lines

Pediatric DKA with dr. Wurster ovalle

The Case
3 y/o M with vomiting and diarrhea, "not acting right"
Temp 39, HR 190, RR 30, 98% with no BP
KUB ordered and 20 cc/kg push pull NS bolus
VBG: 7.08/18.9/-24    Glucose 458     K 5.3
Dx: DKA in a new-onset diabetic

Pediatric DKA
25-67% of type 1 diabetics will initially present in DKA
DKA is more common if age <5, they do not have first degree relative with diabetes, lower socioeconomic status or on high risk medications (steroids, atypical antipsychotics)
Present with non-specific symptoms more often (abdominal pain, n/v, headache)

Cerebral Edema
Most common in 4-12 hours and almost always within the first day. Can happen at anytime before, during or after treatment.
Risk factors: New onset, younger age, severity of dehydration/acidosis, treatment with bicarb
Symptomatic CE: 1% of all kinds in DKA but deadly (mortality rate around 40%) with 25-35% of cases having neurologic sequelae 

  • Symptoms: HA, confusion, decreased LOC, seizures, slurred speech, pupillary changes, Cushing's triad

Subclinical CE: common, asymptotic or minor mental status changes

Pathophysiology Theories: 

  1. Hypersomsolar state: kids have a bigger brain relative to body size and they are susceptible to more rapid changes in plasma osmolarity leading to larger fluid shifts. 
  2. Hypoxia and ischemia: high volumes of fluids at fast rates can cause reperfusion injury and ischemia

Diagnostic tool for CE 
NEJM landmark paper 

Recommended labs
Anti-islet cell antibody screen
TTG/IGA
Hemoglobin A1c

Fluid resuscitation

10-20 ml/kg until adequate perfusion if unstable (hypovolemia or poor peripheral pulses)
Once stable try to stay under 40000 ml/m2/day for the first 24 hours to reduce risk of CE (includes bolus and maintenance gtts)
Consensus is to start with 10 mg/kg over 30 minutes then can repeat or start 1.5-2x MIVF
Based on three studies: Kids who died/herniated received  >4000 ml/m2/day  or > 50 ml/kg during the first 4h

2-Bag System 

Benefits: Decreases duration of insulin therapy, decreases adjustments needed to insulin rate, decreases wasted IVF bags
Concept: Equal amounts of saline and electrolytes in both bags but one bags has 10% dextrose

  • Start adding in dextrose when glucose <300

At CCHMC: Go to flow sheets, search DKA and enter height in cm and weight in kg --> will give you BSA and total fluid rate which can then be used in the ED DKA order set
Insulin gtt can be y-ed in @ 0.1 U/kg/hr without bolus

  • Discontinue when gap is closed

Consider PICU when: AMS, pH 7.1, age <2 especially if new onset, glucose >1000 or corrected Na >155