Morbidity and Mortality Conference

Garrett Feddersen11/27/13

Case:Brief Admission HPI

New pt into the ER, nurse comes out of the room and tells you that ”you need to evaluate this kid now, he’s sick.”

Come into the room and find the pt on the bed, his father and mother are in the room with him.

HPI, continued…

14 YOM Presenting with 2 days of neck pain. The

day before the pain started he was helping his father unload hay bales. Next day the pain started and has continually gotten worse since. Pain is most severe in his neck but now his whole body hurts, worse in neck and back.

10/10 pain, can’t hardly talk

Case:

PMH – Healthy, no hx PSH - none FH – nothing pertinent SH – Lives with parents, no T/A/D Medications - none Allergies - none

Case:

Physical examVitals BP129/87, P109, R16, 100% raDecorticate-like posturing (arms flexed in

and held tight)Jaw clenched tight, able to talk around it

but not wellMuscle spasticity head to toeWrithing in the bed in painLabs

Ddx

Tetanus!! Drug induced (phenothiazines –

phenergan, thorazine) Dental infection trismus Strychnine poisoning Malignant neuroleptic syndrome Meningitis

Further exam

Crush injury to right great toe Very small circular scab on bottom of

left foot (“cut himself” while picking vegetables in the garden)

HEENT otherwise nml, CV – RRR, Lungs – CTAB, Abd – rigid, but no pain with palpation and NABS

Timeline of EventsDate/Time Clinical Status/ change in status

1707 Examined by me in the ED

1730 Given morphine and valium

1745 Decision made to transfer to University of Iowa by helicopter

1820 Pt intubated by anesthesiology with vecuronium and versed. Initially a 6.5 MM ET tube placed.

1833 U of I requesting we start Tetanus IG 3k-5k units…. CMC only has 1k units on hand. None given.

1840 Heparin drip ordered by U of I started.

1850 Pt flown to U of Iowa

Adverse events/outcomes triggering case presentation

Case Yes No

Unexpected death x

Medical or surgical complication x

Delay in care x

Delay in Diagnosis x

Prolonged medical care in setting of poor prognosis x

Other x

Tetanus

Sir Charles Bell

Nervous system disorder caused by the toxin produced by clostridium tetani

Worldwide approx. 1 million cases/year with 30-50% mortality

In the US, averages 29 cases per year with mortality at 13%

Only 2 cases of neonatal tetanus since 1989

Heroin users, unimmunized at higher risks, though only 72% of those vaccinated at protected

*CDC

Diagnosis

Purely clinical dx No labs that can help Tongue depressor test

QUIZ!

Trismus Opisthotonus Risus Sardonicus

General Tetanus Clinical Sx

50% present with trismus Irritability, restlessness, diaphoresis,

tachycardia Intensely painful tonic contractions – jaw,

back, fists, neck, abdomen Fever often present, can develop cardiac

arrhythmias Respiratory arrest Fully concious

Treatment

Supportive – PROTECT AIRWAY Stop toxin production –

1. Metronidazole 500 mg IV Q6 or

2. PCN G 4 million units Q4 Neutralize toxin 3-6k units of TIG

Rest of the story

Pt remained intubated for 3 ½ weeks. Was given TIG and IV antibiotics (Flagyl and Ampicillin)

Around 2 weeks started doing wean trials, backing off sedatives/paralytics, if spasm present went right back on.

Extubated and did well per IC

Room for improvement

Only one of the ER docs had ever seen a clinically advanced case (in Africa).

Heparin drip was ordered by IC ER Anesthesia placed ET 6.5 Needed to start ABX immediately TIG administration

Factors contributing to adverse outcome

Factor Y N

Communication: e.g., inadequate handoffs; incomplete clinical informationx

Coordination of care: e.g., involving multiple services and/or care sitesx

Volume of activity/workload: e.g., increased clinical volume and /or perception of workload x

Escalation of care: e.g., delay or failure to involve more senior physician or nurse x

Recognition of change in clinical status: e.g., delay or failure to recognize changing clinical signs +/or symptoms x

Other factors:x

Comments &Discussion

Referenceshttp://www.cdc.gov/vaccines/pubs/pink

book/tetanus.html#epiUpToDate - Tetanus

Case #2 45 YOM brought into the ED for seizure Hx of seizures seemingly related to his

alcohol abuse, also questionable “epilepsy” hx.

Significant EtOH abuse hx, has reportedly “cut back”

Witnessed by daughter, full tonic/clonic with post ictal period after

HPI, continued…

In ED A&O x 3, recovering well Hgb 7.2 in ED, rest of CBC and BMP

normal. Hypotensive (sys in 60’s) Admitted to ICU for alcohol detox and

hypotension Recent admission for similar seizure

episode, had 15 L removed via paracentesis for ascites during that admission

PMH: HTN, PAD, alcoholic hepatitis, ascites, seizures, anemia, epilepsy

PSH – none Fam – alcoholism Soc – still smokes, still drinks, no

drugs. Meds: Lasix, pentoxyfylline, Flagyl,

spironalactone, metoprolol

When he gets to the ICU, he is A&O x 3, BP’s still in the 60’s.

PE – tachy, hypotensive, fast respirations. Big abdomen with significant ascites, mild tenderness, no RRG. Lungs were clear.

Felt “OK”

A/P

1. Seizure – start Keppra, CT when stable

2. Shock/anemia – hypovolemic/blood loss. FOBT ordered, guiacc of emesis, 2 units of PRBCs to be transfused immediately. PT/INR ordered

3. EtOH – CIWA, CD and psych

4. Ascites – LFTs nml, schedule tap when stable

Course:

Levofed started shortly after arrival to ICU for pressure support

1.5-2 hrs after arrival to ICU has 2nd seizure, immediately following has massive BRBPR. BP crashes to 50’s and 30’s, pt unresponsive. IVF immediately opened up along with blood products. Levofed maxed out and dopamine started.

As pressures came back up into the 80s, became responsive, discussed with him the need to intubate him and provide pressure support.

Massive blood loss protocol initiated Pt intubated with rocuronium and

atomidate by anesthesia d/t concerns with sedatives further lowering pressures

After tube placed, pt was noted to have blood in oropharynx, presumably coming from esophagus.

2 units FFP given along with 10 units vit K, fluid boluses, and more blood.

Femoral line placed by Dr. Visokey Levofed, dopamine, and vassopressin all

at max. PT/INR – 22.7/2.07 Discussion with family about futility of

treatment at this point as the majority of family was now present. Decision made to discontinue resucitation.

Arrived at ICU at around 1100, TOD 1820. Received 7 units PRBCs and 2 units FFP.

Conclusions

Massive GI BleedRuptured esophageal varicesMallory-Weiss tearPerforated ulcer

By the time we saw the blood it was most likely too late

Rectal exam

Factors contributing to adverse outcome

Factor Y N

Communication: e.g., inadequate handoffs; incomplete clinical informationx

Coordination of care: e.g., involving multiple services and/or care sitesx

Volume of activity/workload: e.g., increased clinical volume and /or perception of workload x

Escalation of care: e.g., delay or failure to involve more senior physician or nurse x

Recognition of change in clinical status: e.g., delay or failure to recognize changing clinical signs +/or symptoms - -

Other factors:x

Questions and comments

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