FOLLOW UP ROUNDSAndrew Yoon, MD

Rhonda Forest, MD8/12/11

Case 1 Montefiore ED 7/29/11 Patient H.M. 01355124

CC: 89yo F BIBA from home for change of mental status as per home health aide

Case 1 EMS gave 1 amp of D50 Triage assessment: AAO X 1 Vitals in ED: T 99.8F (rectal), P 38-45, RR

14, BP 138/30, O2 99% on RA, Pain 0/10 PMH: DM, HLD, Depression, colostomy

from colon ca, chronic kidney disease (not on dialysis)

Meds: Citalopram, Glyburide, Zocor All: NKDA

History of Present Illness HHA reports patient was in her

wheelchair eating when she suddenly leaned backwards and became unresponsive. HHA checked patient who was breathing. She tried to wake her up but no response. Patient continued to slouch in her wheelchair for ~20 minutes before she vomited then awoke. Patient recalls eating dinner then waking up to her HHA and EMS surrounding her.

Review of Systems ROS: (-) fever, chills, malaise, CP, SOB,

cough, difficulty swallowing, decreased PO intake, nausea, diarrhea, constipation, hematochezia, melena, dysuria, hematuria, increased urinary frequency, vag bleeding, abnormal speech, HA, seizure like activity, blurry vision, new focal weakness

ROS: (+) vomiting x1, NBNB

Physical Exam General: NAD Skin: WNL Scalp/face: WNL Neck: WNL Heart: bradycardic, regular otherwise Lungs: clear, equal b/l Abd: WNL, colostomy bag in LLQ with healthy pink appearing

colonic tissue. Minimal amount of brown liquid in ostomy bag.

Back: No CVA tenderness Ext: WNL Neuro: Alert, AAO x2 (self, location), speech WNL, CNS 2-12

intact, sensation intact throughout body, motor WNL except 2/5 strength b/l LE, gait untested

EKG

Differential Diagnosis Syncope Vasovagal Myocardial Infarction Long QT syndrome Brugada Arrythmia Neurologic CVA Seizure Apnea/Hypoxia Aspiration Pneumonia Intracranial hemorrhage Hypovolemia Pulmonary Embolism Electrolyte Imbalance Hypoglycemia Deep Sleep Medication Induced Unexplained

Causes of Bradycardia Can be normal, especially in sleep and athletes Sick Sinus Syndrome Vagal activity Increased ICP Acute MI Heart block Obstructive sleep apnea Drugs (cholinergic drugs ie neostigmine, physostigmine,

beta blockers, reseperine, guanethidine, methyldopa, clonidine, cimetidine, digitalis, calcium channel blockers, amiodarone and lithium)

Other (hypothyroid, hyper/hypoK, hypothermia, prolonged hypoxia, strange infections ie babesiosas, Q fever, dengue fever, yellow fever, RMSF)

Labs Blood work resulted at 1835 Wbc 8.4, Hgb 12.1, Hct 36.1, Plts 254 Na 124, K hemo, Cl 94, CO2 15, BUN 80, Cr

3.2, Glu 211 Trop 0.07, CPK 144, CPK MB 1.7% Free T4 1.06 (No TSH sent)

Repeat BMP resulted at 2000 Na 128, K 6.3, Cl 99, CO2 15, BUN 78, Cr

3.2, Glu 180

Imaging CXR: clear lungs, heart enlarged but is an

AP view.

Head CT: chronic ischemic changes. No acute findings.

Treatment Calcium gluconate 1 amp IV Kayexelate 30g PO Bicarb 1 amp IV Insulin 10U IV, D50 1 amp NS 2L IV

Result Within 1 hour of administration of

medications patient’s heart rate increased to 50s, which is patient’s baseline heart rate based on previous two admissions.

No repeat EKG was done as patient was being prepared for transport to inpatient telemetry bed.

After Treatment of Hyperkalemia

Hyperkalemia- EKG Changes

First changes: Peaked T waves Shortened QT interval

Then: Lengthening of PR interval Widening of QRS complex Disappearance of P waves

Finally: Sine wave pattern Asystole

Peaked T waves

QRS Widening

Sine Wave

Hyperkalemia- Cardiac Membrane Stabilization

Calcium gluconate or chloride if QRS widening or loss of P waves Calcium chloride has 3x concentration of

calcium as calcium gluconate Calcium gluconate: 1g or 10ml of 10% solution Calcium chloride: 500mg to 1g or 5 to 10ml of

10% solution Give calcium chloride through central line In patients taking Digitalis still can give Ca

Temporary Treatment Insulin 10U IV, D50 1 amp

Drives K intracellularly Peak effect at 30-60 minutes Drop K by 0.5-1.2 meq/L

Albuterol 10-20mg Nebulized Drives K intracellularly 4-8x concentration used for asthma Peak effect 90 minutes Drop K by 0.5-1.5 meq/L

Bicarb Drives K intracellularly Effects controversial even in setting of acidosis If given recommended to be given as infusion over 2-4 hours

Potassium Removal Loop or thiazide diuretics

Increase K loss through urine No data showing short term benefit

Kayexelate 1 dose is ineffective Requires at least TID for 1-5 days No short term benefit Intestinal necrosis believed to be due to sorbitol, which SPS

contains, but Kayexelate does not Dialysis

When above treatments are ineffective When hyperK is “severe” When expected to have continued release of K ie

rhabdomyolysis or tumor lysis syndrome

Case 2 Jacobi ED 8/10/10 Patient T.K. 2154687

CC: 21yo F 17 weeks pregnant with diffuse lower quadrant abdominal pain

Case 2 Vitals T 100.1 F, BP 129/79, HR 94, RR 16,

O2 100%, Pain 10/10 PMH: G2P1001, C-section 4/2010 Meds: None All: NKDA

History of Present Illness 21yo F 17 weeks by LMP p/w lower

abdominal pain since this morning associated with N/V. Pain started off in RLQ and is now also suprapubic area. No vag bleeding/discharge.

Review of Systems ROS: (-) HEENT, cough, CP, SOB,

diarrhea/constipation, dysuria, vag bleeding/discharge, HA, blurry vision

ROS: (+) fevers, chills, nausea, vomiting (non-bloody, +bilious),

Physical Exam HEENT: NCAT CV: RRR, No m/r/g Lungs: clear b/l Abd: soft, non-distended, TTP suprapubic region,

(+/-) RLQ TTP, (+/-) guarding, no rebound, +BS GYN: Normal external genitalia, white discharge

in vault, os closed, no blood, no lesions/masses, no CMT, no adnexal tenderness b/l

Back: No CVA tenderness b/l Ext: No c/c/e Neuro: AAOX3, normal gait

Labs WBC 14.9, Hgb 12.0, Hct 35.2, Plt 268,

0.2% bands Na 140, K 4.1, Cl 109, CO2 22, BUN 6, Cr

0.5, Glu 77, T bili 0.3, ALKP 83, SGOT 20, SGPT 14

Hcg 23,436 Lipase 20 UA: blood neg, LE neg, Nit neg, WBC

5/hpf, Epi 3-4/hpf, Bact trace

Imaging Bedside TVUS: +IUP w/ FHR 150s, no free

fluid in cul-de-sac, b/l ovaries small 2.5 x 3 x 3 cm with no adenexal masses.

Ovary

IUP

UltrasoundAppendicitis

Further Imaging MRI abd/pelvis: limited study, no

evidence of free fluid, gravid uterus, appendix cannot be identified therefore appendicitis cannot be excluded

MRI

Even More Money for the Radiology Department

CT abd/pelvis: normal appendix visualized, no free fluid, single intrauterine gestation

CT

Normal appendix Appendicitis

Results Admitted to Gen Surg s/p MRI results, but

discharged from ED after CT results

May 16, 2011 had C-section at 42 weeks gestational age. Healthy male infant with Apgar scores of 8 & 9. Male infant circumcised, tolerating breast and bottle.

Clinical Assessment of Appendicitis

Most widely used is the modified Alvarado scale Migratory right iliac fossa pain (1 point) Anorexia (1 point) Nausea/vomiting (1 point) Tenderness in the right iliac fossa (2 points) Rebound tenderness in the right iliac fossa (1 point) Fever >37.5 degrees C (1 point) Leukocytosis (2 points) Score <3 home, 4-6 admit for observation, >7 OR

(male) Sensitivity 95%, Specificity 83% Much less reliable in women

Imaging Modalities for Diagnosing Appendicitis

Ultrasound Sensitivity 86%, Specificity 81%

MRI Sensitivity 91%, Specificity 98%

CT w/ IV and PO contrast Sensitivity 91-98%, Specificity 93%

CT w/ rectal contrast only Sensitivity 98%, Specificity 98%

CT w/ no contrast Sensitivity 88-96%, Specificity 91-98%

Radiation to Fetus < 5 rads

NO increased risk of fetal anomalies or pregnancy loss

CXR < 1mrad, Abd xray 2-3 rads, CT abd 2-3 rads

5-10 rads Inconclusive data IV pyelogram 4-9 rads, L-spine xray 4-6 rads

> 10 rads Increased risk of fetal anomalies and

pregnancy loss Barium enema 7-16 rads

Bathe in Radiation Round trip flight from NY to LA

3 mrem CXR

10 mrem Natural radiation from living on Earth for

1 year 300 mrem

Blaming Mother Earth for child’s MR Priceless

Fetal Periods of Vulnerability

First 2 weeks after conception “All or none” 100 rads will kill 50% of embryos

2-16 weeks after conception Death is rare Anomalies occur with 10-20 rads

20-25 weeks and beyond after conception Relatively resistant to teratogenic effects of

radiation

References1. Hong JJ, Cohn SM, Ekeh AP, et al. A prospective randomized study of clinical assessment versus

computed tomography for the diagnosis of acute appendicitis. Surg Infect (Larchmt). 2003;4(3):231.

2. Denizbasi A, Unluer EE. The role of the emergency medicine resident using the Alvarado score in the diagnosis of acute appendicitis compared with the general surgery resident. Eur J Emerg Med. 2003;10(4):296.

3. Lee SL, Walsh AJ, Ho HS. Computed tomography and ultrasonography do not improve and may delay the diagnosis and treatment of acute appendicitis. Arch Surg. 2001;136(5):556.

4. Ceydeli A, Lavotshkin S, Yu J, Wise L. When should we order a CT scan and when should we rely on the results to diagnose an acute appendicitis? Curr Surg. 2006;63(6):464.

5. Gaitini D, Beck-Razi N, Mor-Yosef D, et al. Diagnosing acute appendicitis in adults: accuracy of color Doppler sonography and MDCT compared with surgery and clinical follow-up. AJR Am J Roentgenol. 2008;190(5):1300.

6. Terasawa T, Blackmore CC, Bent S, Kohlwes RJ. Systematic review: computed tomography and ultrasonography to detect acute appendicitis in adults and adolescents. Ann Intern Med. 2004;141(7):537.

7. Rao PM, Rhea JT, Novelline RA, et al. Helical CT combined with contrast material administered only through the colon for imaging of suspected appendicitis. AJR Am J Roentgenol. 1997;169(5):1275.

8. Bentur, Y. Ionizing and nonionizing radiation in pregnancy. In: Maternal-fetal toxicology, 2nd ed, Koren, G (Ed), Marcel Dekker, New York, 1994, p. 515.

9. ACOG Committee Opinion. Number 299, September 2004. Guidelines for diagnostic imaging during pregnancy. Obstet Gynecol. 2004;104(3):647.

10. CDC. http://www.bt.cdc.gov/radiation/pdf/measurement.pdf