Morbidity and Mortality rounds July 2001

1. Morbidity and Mortality rounds July 2001 Arun Abbi M.D.

2. Peter Lougheed Centre • 5 deaths • All classified as class 1 • 2 cardiac arrests • 1 case of ischemic bowel • 1 ruptured AAA in a patient who was a no code • 1 case of a Patient who died of a Pulmonary embolus

3. Rockeyview Hospital • 6 deaths • All classified as class 1 • 2 cardiac arrests • 1 drug overdose who arrested • 1 respiratory failure • 2 pneumonia and sepsis

4. Foothills Hospital • 17 deaths • All classified as class 1 • 8 cardiac arrests • 3 trauma arrests • 3 Intracranial hemorrhages of which one was post TPA • 1 was pneumonia/sepsis

5. Foothills Hospital cont’d • 1 was a pulmonary embolus • 1 was respiratory failure and cardiac arrest secondary to pulmonary hypertension in a 31 yr old female

6. Case 1 • 50 yr old female who collapsed at home • The patient was short of breath and was found to be hypotensive on scene with a systolic blood pressure of 70 • Her pulse was 150 – 160 • She complained of chest pain going into her back

7. Case 1 cont’d • The patient was assessed at a rural hospital • Her physical exam was unremarkable except for her hypotension • She was given fluids but remained hypotensive • An EKG was done at the scene and showed atrial fibrillation with nonspecific ST changes • The chest X-Ray was unremarkable

8. Case 1 cont’d • The patient was intubated and transported by Stars to the PLC with the concern being of a possible aortic dissection • She arrived at 03:45 • V/S BP 65/35 P 90 • Pt was intubated with a FiO2 of 100%

9. Case 1 con’t • ABG Ph - 7.01 • Co2 – 43 • Po2 – 134 • HbG – 79 • HCo3 15

10. Case 1 cont’d • CXR: was read as normal • EKG atrial fibrillation • Lytes were normal • What is your differential diagnosis?

11. Think of the differential diagnosis of shock • Hypovolemic: aortic dissection, ruptured abdominal aneurym,GI bleeding • Obstructive: pulmonary embolus, cardiac tamponade (from proximal dissection) • Distributive: sepsis, anaphylaxis (both umlikely) • Cardiac : EKG was unremarkable

12. The patient was assessed by the vascular surgeon • Both he and the ER doctor wanted to obtain a CT scan of her chest, however it was going to be 30 – 40 minutes (as the tech was at home) and it was felt she was too unstable • She was given blood in the ER • She was taken to the OR

13. The aorta was normal • The retroperitoneum was edematous • The Bowel was edematous • She was given 4 units of blood in the OR and a repeat gas showed a HgB of 120 but she remained hypotensive • She arrested on the table

14. Autopsy: Large pulmonary embolus • Hemorragic gastritis • The edema was thought to be secondary to hypoxia and elevated portal pressures

15. Things to think about • 1. It would have been nice to have an initial O2 sat prior to intubation • 2. The hemorrhagic gastritis which lead to the anemia took us down the hypovolemic shock picture

16. On the initial blood gas in the ER; her Po2 was 134. If someone is intubated on 100% O2 her Po2 should be: • 1.0 X (660 – 47) - 43/0.8 = 559 • We would expect some V/Q mismatch with someone in shock but not such a profound difference if her CXR was clear

17. Note that this patient probably going to die even if a PE was diagnosed as she probably would have bled out if she was given TPA (Due to her gastritis)

18. Case 2 • 53 yr old female who was from the States and was visiting in Fernie • A boat got detached from a car that was heading in the opposite direction and went across the highway and cut her car in half • The patient had a head injury. She also had an amputation of her left leg with an open fracture of her right leg • She was profoundly hypotensive

19. The accident happed at 18:30 • The patient was given multiple units of blood and a tourniquet was placed over her left leg. • The helicopter was down for repairs • Fixed wing was sent and landed in Cranbrook

20. The patient was felt to be too unstable to be transported to Cranbrook by ground • The helicopter was repaired and was able to leave Calgary and go directly to Fernie • The patient arrested at 23:25, 10 minutes prior to landing

21. The only concern here was that it was 5 hours for this patient to get to a tertiary care centre • Also Sparwood had an airport where the plane could have landed • This case was review by the prehospital organizations

22. Case 3 • 77 yr old male who has a history of prostate cancer with metastases • The patient developed acute onset of dyspnea with syncope • O2 sat on scene was 70 % with a BP of 60/34

23. Patient arrived to ER at 10:40 • V/S BP 78/50 P 54 • EKG showed RBBB • ABG : PH - 7.45 done on NRB • PO2 – 206 • PCo2 – 19 • HCo3 - 13

24. Pt’s HgB was 82 • The concern was that of a Pulmonary Embolus • The patient was heperanized within 25 minutes (which was excellent) • A central line was placed and the patient was started on levophed

25. A CXR was unremarkable • An Echo was done which showed RV strain and moderate amount of TR • A CT scan was performed which showed an obtructing thrombus involving both main pulmonary arteries that straddled the bifurcation

26. The CT scan also involved the legs and showed and occlusive thrombus in the left popliteal region

27. What would you do? • Would you give this person TPA • Would you place an IVC filter in this patient?

28. The patient was taken to the ICU at 15:00 and it was elected not to give this person TPA nor place an IVC filter • The patient arrested at 15:23

29. ECHO findings for PE • Most of the time they do not see the clot • They look for indirect evidence of a pulmonary embolus such as RV strain • 1. RV dilation (usually > 0.6 the size of the LV) • 2. Tricuspid Regugitation – moderate to severe • 3. Septal shift • 4. RV strain – poor contractility

30. Thrombolytics in PE • Everyone quotes the study by jerjes-sanchez et al. • They had 8 patients who were all hypotensive. 4 were randomized to thrombolytics and 4 were given heparin. • The 4 who received thrombolytics all survived while those that received heparin all died.

31. There have been studies that looked at RV strain and found that it improves if patients are given TPA. • However there has not been any studies showing reduced mortality in patients who have RV strain and receive thrombolytics

32. In this case the argument could be made for giving this patient TPA as he was on levophed. • He did however have metastic prostate cancer and may have hemorraged as a result. • The dose of TPA would be 100 mg/2hours

33. Case 4 • 31 yr old patient visiting from Japan and had flown to Canada 3 days ago • She developed left sided chest pain going into her back • Her Sat was 80% in Banff • The patient has a history of SLE and was on prednisone 15 mg/day and vitamin D and E

34. The patient was given Dalteparin sc and was sent to the FHH • She complained of SOB on exertion and of chest pain • She felt diaphoretic and feverish • She had a nonproductive cough earlier • She denied any leg pain nor swelling

35. PMHx: lupus for 18 years Raynauds phenomenom Nephritis No cardiac history,no history of PE nor DVT No history of asthma

36. V/S BP - 114/80 P 120 RR 34 T 38.6 Sat 94% on 4 litres • The patient looked unwell and was in moderate distress • she had good air entry and her chest was clear • CVS - pulses were equal, she had normal heart sounds and she had peripheral cynaosis due to Raynauds

37. Abdomen was soft and nontender • Labs INR 1.1 • PTT 46.3 • WBC 21.4 (18.6 neuts) • EKG - sinus tachycardia

38. CXR showed pulmonary hypertension • CT scan - no evidence of PE, pulmonary hypertension, and patchy infiltrate

39. The differential was that of lupus induced ARDS and secondary pulmonary hypertension versus pneumonia • The patient received antibiotics and was admitted to the floor • The next morning she became short of breath and arrested about ½ hour later

40. An autopsy was not done as per the families request • The coroner stated the patient died of cardiorespiratory failure secondary to pulmonary hypertension

41. Systemic Lupus Erythematosus • 4 out of 11 features • 1. Malar rash 7.Neurologic Disorder • 2. Discoid rash 8. Hematologic Disorder • 3. Photosensitivity 9. Oral Ulcers • 4. Arthritis 10. Immunologic Disorder • 5. Serositis 11. Antinuclear Antibody • 6. Renal Disorder

42. Complications • 1. Nephritis/Renal Failure • 2. Infections • 3. Thrombosis –1.(LA) Lupus Anticoagulant (present from 30% – 40 %) • 2.(ACA) Anticardiolipin Antibody • Present in 40% – 50 %

43. It is recommended to test patients for these antibodies if they have lupus. • However it is not recommended to anticoagulate these patients prophylactically • If a patient has a DVT/PE and has one of these antibodies then they require life long anticoagulation

44. It is felt that these patients who are positive for LA or ACA have a shortened lifespan • The Pulmonary Hypertension that they develop is from microvascular thrombosis secondary to the SLE • We do not know if life long anticoagulation prevents this

45. These patients should be followed for the development of Pulmonary hypertension as they may be a candidate for lung transplant

46. Conclusion • We do a good job. • Sick people die • Beware of Pulmonary Emboli