Morbidity and Mortality rounds July 2001

Arun Abbi M.D.

Peter Lougheed Centre5 deathsAll classified as class 12 cardiac arrests1 case of ischemic bowel1 ruptured AAA in a patient who was a

no code1 case of a Patient who died of a

Pulmonary embolus

Rockeyview Hospital6 deathsAll classified as class 12 cardiac arrests1 drug overdose who arrested1 respiratory failure2 pneumonia and sepsis

Foothills Hospital17 deaths All classified as class 18 cardiac arrests3 trauma arrests3 Intracranial hemorrhages of which one

was post TPA1 was pneumonia/sepsis

Foothills Hospital cont’d1 was a pulmonary embolus1 was respiratory failure and cardiac

arrest secondary to pulmonary hypertension in a 31 yr old female

Case 150 yr old female who collapsed at homeThe patient was short of breath and was

found to be hypotensive on scene with a systolic blood pressure of 70

Her pulse was 150 – 160She complained of chest pain going into

her back

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

Case 1 cont’dThe patient was intubated and

transported by Stars to the PLC with the concern being of a possible aortic dissection

She arrived at 03:45V/S BP 65/35 P 90 Pt was intubated with a FiO2 of 100%

Case 1 con’tABG Ph - 7.01

Co2 – 43Po2 – 134HbG – 79HCo3 15

Case 1 cont’dCXR: was read as normalEKG atrial fibrillationLytes were normal

What is your differential diagnosis?

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

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

The aorta was normalThe retroperitoneum was edematousThe Bowel was edematousShe 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

Autopsy: Large pulmonary embolusHemorragic gastritis The edema was thought to be

secondary to hypoxia and elevated portal pressures

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

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 = 559We would expect some V/Q mismatch

with someone in shock but not such a profound difference if her CXR was clear

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)

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

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 repairsFixed wing was sent and landed in

Cranbrook

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

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

Case 377 yr old male who has a history of

prostate cancer with metastasesThe patient developed acute onset of

dyspnea with syncopeO2 sat on scene was 70 % with a BP of

60/34

Patient arrived to ER at 10:40V/S BP 78/50 P 54 EKG showed RBBBABG : PH - 7.45 done on NRB

PO2 – 206PCo2 – 19HCo3 - 13

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

A CXR was unremarkableAn Echo was done which showed RV

strain and moderate amount of TRA CT scan was performed which

showed an obtructing thrombus involving both main pulmonary arteries that straddled the bifurcation

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

What would you do?

Would you give this person TPA

Would you place an IVC filter in this patient?

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

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

Thrombolytics in PEEveryone 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.

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

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

Case 431 yr old patient visiting from Japan and

had flown to Canada 3 days agoShe developed left sided chest pain

going into her backHer Sat was 80% in BanffThe patient has a history of SLE and

was on prednisone 15 mg/day and vitamin D and E

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 feverishShe had a nonproductive cough earlierShe denied any leg pain nor swelling

PMHx: lupus for 18 yearsRaynauds phenomenomNephritis

No cardiac history,no history of PE nor DVT

No history of asthma

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

Abdomen was soft and nontender

Labs INR 1.1 PTT 46.3WBC 21.4 (18.6 neuts)EKG - sinus tachycardia

CXR showed pulmonary hypertension

CT scan - no evidence of PE, pulmonary hypertension, and patchy infiltrate

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

An autopsy was not done as per the families request

The coroner stated the patient died of cardiorespiratory failure secondary to pulmonary hypertension

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

Complications1. Nephritis/Renal Failure2. Infections3. Thrombosis –1.(LA) Lupus

Anticoagulant (present from 30% – 40 %)

2.(ACA) Anticardiolipin Antibody

Present in 40% – 50 %

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

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

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

ConclusionWe do a good job.

Sick people die

Beware of Pulmonary Emboli