Theyll Be Dead Before Morning

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Theyll Be Dead Before Morning
Things That Kill you in 12 Hours! James Hunt,
MD Richard Fuquay, MD UCDHSC Chief Medical
Residents
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Objectives

• Identify life threatening medical and surgical
  conditions
• Discuss diagnosis of such conditions
• Management basics
• Who to ask for help

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Things that kill you in the.

• Head
• Head bleeds
• Meningitis
• Chest
• Respiratory failure
• Acute MI
• PE
• Aortic Dissection
• Pneumothorax
• Tamponade

• Abdomen
• GI Bleed
• Ischemic Gut
• Perforated Viscous
• Other
• Sepsis
• DKA, HHS
• Hyperkalemia

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Subdural Hematoma

• Definition Acute SDH is usually caused by
  tearing of the bridging veins that drain the
  surface of the brain into the dural sinuses
• Can also be arterial though
• Etiology Most commonly trauma (falls, etc)
• Three varieties
• Acute dont miss these!
• Subacute
• Chronic

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Acute Subdural Hematoma Presentation

• Approximately 25-33 of patients have a transient
  "lucid interval" after the acute injury that is
  followed by a progressive neurologic decline to
  coma
• May have focal neuro findings or relatively nl
  exam depending on severity
• Symptoms and signs of elevated intracranial
  pressure
• Always check a glasgow coma scale (prognosis)

Harrisons Online
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Diagnosis and Management

• Dx Non contrast head CT picks up most
• Management
• Check coags and correct if out
• Manage BP and ICP
• Manage A/B/Cs
• Call neurosurgery for possible surgical
  intervention

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Which is a subdural hematoma?
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Epidural Hematoma

• Classic lucid interval
• Pt should be on a trauma service

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Subarachnoid Hemorrhage

• Bleeding into the cerebrospinal fluid within the
  subarachnoid space that surrounds the brain
• Arterial aneurysms or vascular malformations
• Aneurysmal bleeds releases blood under arterial
  pressure which rapidly increases intracranial
  pressure
• Death or deep coma ensues if the bleeding
  continues

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Symptoms of SAH

• Begin abruptly (thunderclap)
• Headache is an invariable symptom and is
  typically instantly severe and widespread
• Grade 1 Asymptomatic or mild headache and slight
  nuchal rigidity
• Grade 2 Moderate to severe headache, stiff neck,
  no neurologic deficit except cranial nerve palsy
• Grade 3 Drowsy or confused, mild focal
  neurologic deficit
• Grade 4 Stupor, moderate or severe hemiparesis
• Grade 5 Deep coma, decerebrate posturing

UpToDate Online
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DX and Management of SAH

• DX Non contrast head CT (sensitivity 90-95,
  decreases with time)
• Lumbar puncture if high clinical suspicion after
  negative scan
• RX ICU monitoring
• Allow blood pressure to run high (CPP ICP
  MAP)
• Consults Neurosurgery and/or Interventional
  Radiology
• Clip or coil aneurysm

Emergency Medicine Journal 200118271-273
Suarez JI, Tarr RW, Selman WR. Aneurysmal
subarachnoid hemorrhage.  N Engl J Med. Jan
26 2006354(4)387-96
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Pearls

• Worst headache of my life
• Warning Leak / Sentinel headache
• Thunderclap headache
• Mortality rate 50

Harrisons Online
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Bacterial Meningitis

• Infection of the arachnoid mater and the CSF in
  both the subarachnoid space and ventricles
• Fever, nuchal rigidity and AMS Triad of sxs
• Other symptoms
• Headache
• Photophobia
• Seizure

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Very poor tests!
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DX and Management

• Eval
• Fundoscopy and then tap
• CT scan for focal neuro signs, immunosuppressed,
  recent seizure
• What about a delay in LP?
• Steroids for certain populations
• Antibiotics (acyclovir?)
• Blood cultures
• Call Infectious Disease Consult

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Acute Myocardial Infarction

• Acute closure of a coronary vessel causing tissue
  death to the supplied area

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Symptoms of AMI

• Classic symptoms
• diaphoresis, substernal chest pressure or pain,
  radiation to the left arm, neck and, most
  specifically, the jaw
• Less classic symptoms (women, diabetics)
• Nothing
• funny taste in mouth, generalized weakness or
  fatigue, shortness of breath, pain with palpation

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DX and Management of AMI

• ( MONA 2 LBS )
• M - morphine (only for dyspnea relief or pain
  that cannot be controlled with nitro
• O - oxygen (good for everybody)
• N - nitroglycerine (drip, titrate up till pain is
  gone)
• A - aspirin (325 mg chewable)

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DX and Management of AMI

• II - IIB/IIIA inhibitor (useful on the way to the
  cath lab, call cards before starting)
• L - lovenox (for all patients with high risk of
  CAD but not going immediately to cath
• B - beta blocker (stops the arrhythmias)
• S - statin (MIRACLE trial done at CU, better
  outcomes with high-dose statin at the door in MI

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Pearls

• Dont be fooled by a bad story
• 2-3 miss rate in US emergency rooms, 6 in UK
  emergency rooms
• Low threshold to get someone else to look at the
  EKG with you

Annals of Emergency MedicineVolume 48, Issue 6,
December 2006, Pages 647-655
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Respiratory Failure

• 67 yo man with CAP admitted 2 days prior is
  having increased WOB, increasing oxygen
  requirement on your cross cover night
• Whats the most important part of your eval?
• ABG
• CXR
• New CBC
• Bedside assessment

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Pulmonary Embolus

• 75 y/o woman, hospitalized for a hip fracture,
  becomes acutely short of breath without any
  antecedent symptoms and begins to get confused.
• - PE!

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Classic Clinical Signs

• Increased A-a gradient
• requires you get an ABG if youre concerneddont
  be shy
• present in gt 90 of PEswhich means it wont be
  there in 10
• Hypoxia - same rule as above
• ECG with S1, Q3, T3 patternseen in less than 5
  of pulmonary emboli

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Symptoms of PE
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DX and Management of PE

• Who gets lytics?
• Shock or substantial hemodynamic compromise
• Anticoagulation
• Heparin, either LMWH or unfractionated
• LMHW easier to dose and faster to achieve goal
  anticoagulation
• Doesnt dissolve clot, just stabilizes things

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DX and Management of PE

• Coumadin?
• Yesstart coumadin immediately assuming no other
  contraindications
• keep LMWH on board for at least 48 hrs after the
  INR becomes therapeutic

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Pearls

• You dont have to be hypoxic to have a large PE
• Pathophysiology is multifactorial and requires
  high clinical suspicion

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Tension Pneumothorax

• Classically seen following blunt force trauma,
  penetrating trauma or as a result of a medical
  procedure.
• Death results from ventilatory failure as the
  check valve mechanism allows more and more air
  to build up outside the lung, compressing the
  normal tissue

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Symptoms of PTX
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Signs/Symptoms of PTX

• Acute onset shortness of breath
• Loss of breath sounds on one side with increased
  tympany with percussion
• Mediastinal shift AWAY from the affected side
• though this is late in the game and hopefully you
  already made your diagnosis

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DX and Management of PTX

• Needle thoracostomy
• insertion of an angiocath into the 2nd
  intercostal space in the mid-clavicular line
• if the patient is dying in front of you, this is
  a lifesaving maneuverdont go looking for a
  Netter to find the 2nd intercostal spaceact!
• Chest tube placement
• better if there is time or performed after the
  needle thoracostomy has alleviated the emergency

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Symptoms of Aortic Dissection

• As described previously
• tearing pain
• radiates to the back
• moves, often down the back as the tear increases
• BP different between the two arms (sensitivity lt
  50)
• can present with syncope, heart failure, even
  vague neurologic complaints

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Types of Aortic Dissection

• DeBakey Classification
• Type I - involves the proximal aorta and often
  the valve itself going to at least the aortic
  archbe very afraid
• Type II - confined to the ascending aorta
• Type III - originates in the descending aorta and
  runs distally

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DX and Management of AD

• CXR will give you a clue if the mediastinum is
  widened (sensitivity low)
• ECHO can be done quickly at the bedside and will
  show aortic valve dysfunction if a Type I
  dissection and/or the tear itself
• CT with AD protocol should detect all three types
  of dissection

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Management of AD

• Four important things to do
• call surgery immediately
• call surgery
• did I mention call surgery
• lower the BP using labetalol or nitroprusside to
  a systolic of 100-120gotta stop that tear while
  you wait for the surgeons

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Pericardial Tamponade

• Defined as an accumulation of pericardial fluid
  under pressure leading to impaired cardiac
  filling and hemodynamic compromise.

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Symptoms of Tamponade

• Acute onset
• chest pain
• dyspnea and resultant tachypnea
• syncope

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Diagnosis of Tamponade

• Sinus tachycardia
• Elevated JVP
• Muted heart sounds, /- pericardial rub
• Pulsus paradoxus
• what is this?

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Management of Tamponade

• ICU transfer
• Emergent pericardiocentesis
• Discuss with cardiology the need for continued
  drainage or possibly surgical window

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A 49-yr-old male is admitted after bloody emesis.
He has a history of heavy alcohol use.
Blood pressure 90/40 mm Hg Heart rate 116
beats/min Hematocrit 24 He is confused and
diaphoretic.
GI Bleed
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Etiology of GI Bleed

• Upper
• Peptic Ulcer Disease
• Gastric
• Duodenal
• Variceal
• Esophagitis/Gastritis
• Mallory Weiss
• Tumor

• Lower
• Diverticular
• AVM
• Tumor
• Hemorrhoid
• Ischemic
• Inflammatory

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Severe GI Hemorrhage Initial Management

• A/B/Cs
• Intravenous access At least two large bore IVs
• Prompt initial fluid resuscitation
• Blood
• Fluid
• Place nasogastric tube, lavage
• Arrange for endoscopy

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Severe Upper GI Hemorrhage

• Endoscopy after lavage to establish diagnosis
• Endoscopic therapy
• Variceal bleeding
• Endoscopic therapy
• Vasopressin
• Octreotide

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Severe Lower GI Bleeding

• Rectal examination
• Consider upper GI source
• Endoscopy
• Angiography embolization
• Surgery

SPC 47

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Acute mesenteric ischemia

• The clinical consequences can be catastrophic
• Sepsis
• Bowel infarction
• Death
• Rapid diagnosis and treatment are imperative

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Etiology

• Superior mesenteric artery embolism (50)
• Superior mesenteric artery thrombosis (15 to 25)
  
• Mesenteric venous thrombosis (5)
• Nonocclusive ischemia (20 to 30)

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Clinical Signs and Symptoms

• Classically described as having rapid onset of
  severe abdominal pain, which is often out of
  proportion to findings on physical examination
• Nausea and vomiting are also common
• Pain more insidious with subacute / chronic
  presentations

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Dx and Management

• Clinical suspicion
• Resuscitation and A/B/Cs
• Labs Metabolic acidosis, CBC, Lactate
• Plain film to r/o perf, consider CT-angio or MRA
• Call surgery to discuss anticoagulation

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Perforated Viscous

• Perforation from esophagus to colon
• Usually secondary to a perforated ulcer
• A true surgical emergency
• Severe onset of diffuse abdominal pain
• External material reaches an internal location
• Abdominal exam with peritoneal signs

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DX and Management

• Death likely if dx delayed gt 12 hours
• Free air on xray ? Definitive dx
• May need CT scan to detect free fluid or small
  amount of air
• Fluid resuscitation
• Antibiotics
• Call your surgeon quickly

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Sepsis

• SimpleSIRS infection
• What is SIRS?
• WBC lt4k or gt12k, or gt 10 bands
• T lt 36 C or gt 38 C
• P gt 90 bpm
• R gt 20
• Whats this early goal directed therapy I keep
  hearing so much about?

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What Do All The Other Terms Mean??

• SIRS - as before
• Sepsis - SIRS with infectious source
• Severe sepsis - sepsis with evidence of some end
  organ dysfunction (elevated creatinine, AMS,
  increasing lactate, etc)
• Septic shock - severe sepsis which is not
  responsive to adequate fluid resuscitation

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EGDT
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Pearls

• Sepsis requires a quick and aggressive response
  1-2 liters is not the answer
• Dont be shy about central lines
• If the question is sepsis, the answer is fluids,
  fluids, fluids, fluids and fluids
• A very small amount of those fluids, given
  early, should be antibiotics

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DKA

• Diabetes (glu elevated but not sky high,
  typically 300-800 mg/dl)
• Ketosis (measured in serum or urine, but can be
  falsely negative by missing beta-hydroxybutyrate)
• Acidosis (on ABG)

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Management

• Volume, volume, volume
• Insulin (initial bolus 10-25 units IV, then start
  drip at 5-10 units per hr)
• Replete potassium as it will inevitably drop
• Follow phosphorus
• If glu drops, dont stop all of the above switch
  to D5 as your fluid

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Hyperkalemia
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Hyperkalemia Emergent Management

• Bad looking EKG gets
• Calcium (gluconate vs chloride?)
• Insulin and D50
• Beta agonists
• Call renal
• Not bad looking EKG gets
• Calcium
• Kayexalate

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Conclusions

• You know a lot at this point so listen to your
  gut if someone looks sick
• Go see the patient
• Doing nothing is not acceptable, so call for help
• To save someone from an acute emergency requires
  a high level of suspicion dont be embarrassed
  by negative workups