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Multiple Small Feedings of the Mind a.k.a. 28 days on Gmed1 Ward Attending, Feb 18 – Mar 16, 2008 Norm Jensen MD MS Professor (emeritus) CHS Intended Learning Outcomes Tell ‘em what yer gonna tell ‘em Overview of a month on Gmed 1 4 selected cases – “Internal medicine trauma” (2) – “Drug Rash” reconsidered – Pneumonia that won’t go away Case inventory with pearls Feb 17 – March 16, 2008 Patients admitted 4 inherited 47 new admissions 7 TLC transfers Average LoS = 6.7 days (2-38) Case 1 64 y/o homeless man, verbally aggressive, labile mood, old MI, LE arterial insufficiency, heavy tobacco use; transferred after 5 days in a Rockford hospital for care of foot injury of ~ 2 week duration. Surgery refused to take him in ER. Case 1 Not Case 1 Case two 49 y/o man referred from Beaver Dam hospital for hypothermia and frostbite after out drinking with a friend. Stopped by police on way home, ran from car in light clothing, lay in field near farm house in 10° F weather, fell asleep ~ 6.5 hours, awoke unable to walk. Crawled to house where residents called 911. Hx of AODA, Reynaud’s ?, and hep C. Case two, cont. Beaver Dam ER: Core temp 89.9°, combative, foam around mouth, CK 719, Troponin 0.7 , atrial fibrillation RVR. Rx: rapid external warming of body and extremities, transfer to UWH UWH: Cooperative, throbbing pain in fingers, temp 97.5°, NSR 102, erythema abdomen, mottled cyanosis anterior knees, fingers, toes and heels, CK max 2724, troponin 0.4, urine tox. cocaine +, alcohol -. Case two, cont. Photos not case 2 Not case 2 photo Literature search = frostbite, human, english, adults > 19, core clinical journals Mesh 1449 Major Mesh 1180 RCTs = 0 Clinical trials = 1 Meta-analysis = 0 Reviews = 2 89.6 82.4 Local cold-induced injuries Axonal degeneration = Numbness, dysesthesia, cutaneous vasomotor instability; sensitivity to cold may persist for years Chilblains (pernio) = Pruritic patches of erythema and cyanosis, especially on hands and feet, that may blister, ulcerate, scar or atrophy Cold-contact adhesion = Erosion or ulcer on forcible separation Frostbite = Superficial Pallor, edema, blistering, desquamation, deep hemorrhagic blisters and anesthesia, followed later by hyperesthesia, ulceration and gangrene Frostnip = Transient numbness and tingling without residual tissue damage Immersion syndrome (trench foot) = Alternating vasoconstriction (cold, pallor, cyanosis and pulselessness) and vasodilatation (warmth, erythema and edema), ecchymosis, blistering, lymphangitis, cellulitis, thrombophlebitis, gangrene Frostbite Only one RCT in Medline Twomey JA, Peltier GL, Zera RT. J Trauma. 2005 Dec;59(6):1350-4; discussion 1354-5. – An open-label prospective case series to evaluate the safety and efficacy of tissue plasminogen activator (tPA) in treatment of severe frostbite. – Hennepin County Hospital, MPLS, MN Methods Historical controls – Consecutive trauma center patients with severe frostbite, 1985-1989 – N = 16, 1 woman, age 26 – 60 – 22 foot injuries, 14 hand injuries – All imaged with Tc-99m for arterial flow – Blinded review of nuclear vascular scans by 3 radiologists J Trauma. 2005 Dec;59(6):1350-4 Methods Intervention patients – Consecutive patients considered 19892003 – Severe frostbite – Age 18 - 75 J Trauma. 2005 Dec;59(6):1350-4 Methods Inclusion – No improvement on rapid rewarming in tepid water (38-42° C) for 15-20 min. – Absent Doppler pulses in limbs and/or digits – No perfusion on Tc-99mm 3-phase scan J Trauma. 2005 Dec;59(6):1350-4 Methods Exlusion – – – – – – – Severe hypertension Recent trauma, stroke or bleeding disorder Pregnancy Mental incapacity Drug or alcohol intoxication Repeated freeze-thaw cycles > 48 hours of cold exposure J Trauma. 2005 Dec;59(6):1350-4 Methods Treatment group 1 n = 6 – 0.075 mg/kg/hr intra-arterially x 6 hours – Flow scanned again after treatment – If no flow, treatment repeated Treatment group 2 n=7 – After recognizing benefits in untreated limbs – Trial & error varying IV doses seeking optimal J Trauma. 2005 Dec;59(6):1350-4 Methods Treatment group 3 n=6 – 0.15 mg/kg IV bolus, then 0.15 mg/kg/hr x 6 hrs up to 100 mg total All started on IV heparin immediately after tPA to PTTx2, + warfarin 2-5 d after tPA x 4 wks. J Trauma. 2005 Dec;59(6):1350-4 Results, controls Historical controls, n = 16 – Generalized or focal hyperemia present in all on scintiscan – 7 had little or no perfusion distal to a “cutoff” point on scintiscan – All 7 needed amputation – “Cutoff” level predicted amputation level and standard care didn’t modify that. J Trauma. 2005 Dec;59(6):1350-4 Pre-treatment “typical” Results of tPA Treatment groups 1, 2, & 3 lumped for data reporting. N = 19 174 digits at risk for amputation 2 tPA complications required d/c tPA – Both having intra-arterial tPA – 1 bleeding from arterial puncture sites – 1 hematuria, rx held until resolved J Trauma. 2005 Dec;59(6):1350-4 Results of tPA Treatment groups 1, 2, & 3 lumped for data reporting. N = 19 16 / 19 “responded” to tPA 33 / 174 digits required some amputation – Including 10 digits from one with 60 hours exposure who secondarily clotted both limbs after tPA – 1 other “complete failure” attributed to prolonged exposure – NNT 1/1-0.19 = 1.2 J Trauma. 2005 Dec;59(6):1350-4 Results of tPA Before tPA J Trauma. 2005 Dec;59(6):1350-4 After tPA Frostbite Rx standard Rapid re-warming Assess appearance & Doppler pulses Early phase Tc-99m scintiscan (or arteriography) tPA 0.15 mg/kg IV bolus, then 0.15 mg/kg/hr to 100 mg total over 4-6 hrs. Heparin 3-5 days Warfarin INR 2 for 4 weeks Opioids for pain / ibuprofen 400-600 q.i.d. Light dressings with topical antimicrobials No ambulation on frostbitten feet Case 3 42 y/o man previously healthy except for depression was referred from Monroe Clinic for abdominal pain, non-itchy rash (face → trunk) fever 100.4 max, abnormal liver tests beginning one day after beginning new antidepressant, duloxetine. Rx vancomycin, acyclovir and ceftriaxone, and transferred. Alk Phos 168, AST 90, ALT 155 Not Case 3 photos Not case 3 photo Varicella in adults Highly contagious: respiratory droplets, vesicle fluid direct contact Incubation 14 – 16 (10 – 21) days Vesicles in crops over <4 days Vesicles → pustules → crusts Contagious 48 hr before rash until all lesions fully crusted (~=< 6 days). >90% adults “immune”, ? Reinfection? Immunization kids since 1995 > age 20 = < 5% cases & 55% deaths Varicella in adults Complications – Pneumonia 1:400, 1-6 days after rash, most hospitalizations, 10-30% mortality, 50% if ventilation needed. – Encephalitis 1:4,000, diffuse, 10% die, 15% permanent deficits. – Hepatitis, uncommon if immune competent often fatal if immune incompetent – IF immune compromised, everything is worse Case 4 38 y/o woman, mother of 2 with concurrent respiratory illness, accountant, on OCP 3 wk ill, burning anterior low neck, and DOE “like something sitting on chest”, chills, anorexia, sudden onset after snow shovelling 1 week fever, dry cough, and pleurisy on admission First treated with PPI, then Azithromycin Case 4 PE = healthy appearing, good color, no distress, 124/80, HR 128 reg., RR 22 easy, 96% RA, fine râles bases, P2 LAB = WBC 8,500 nl. ESR 81, CRP 3, dDimer 0.6, Alk Phos 354 (<131), GGT 221 (<40), AST 58 (<41), ALT 115 (<66), Lipase 327 (<286), ANA + >1:640, +anti HBC, low iron and ferritin, and slightly increased ceruloplasmin 71 (17-54), haptoglobin, C3, and 3x increase in IGM. ECG = right heart strain pattern Case 4 CXR bilat airspace disease lower lobes CT ANGIO CHEST-PE PROTOCOL = Extensive bilateral patchy airspace disease with a basilar and peripheral predominance. No emboli. Case 4 chest xray Case 4 lung CT, PE protocol Case 4 lung CT, PE protocol Case 4 lung CT, PE protocol Case 4 lung CT, PE protocol Case 4 lung CT, PE protocol Case 4 lung CT, PE protocol Case 4 LE dopplers negative for DVT Bronchoscopy = normal appearance of airways BAL = 2000 cells / uL, 80% monos BX = Organizing pneumonia. RSV+ DFA Case 4: Rx and Hospital course RX: – Fractionated heparin – ABX for complex CAP = Amp / sulbactam, vancomycon, moxifloxacin narrowed to moxifloxacin after 3 days. Daily improvement. DC’d on day 5, 50% improved by symptoms on 40 mg prednisone / day + TMP/SMZ prophylaxis Case 4 Adult RSV pneumonia Typical chest imaging CONCLUSION: The most common highresolution CT findings in patients with respiratory syncytial virus pneumonia after bone marrow transplantation consist of small centrilobular nodules and multifocal areas of consolidation and ground-glass opacities in a bilateral asymmetric distribution. AJR Am J Roentgenol. 2004 May;182(5):1133-7. Case 4 Adult RSV pneumonia 5 year case series teaching hospital Barcelona 338 consecutive patients with CAP 61 (18%) viruses detected – 30 (9%) virus with other organisms – 31 (9%) only viruses 16 Influenza A 7 Influenza B 2 Parainfluenza 1, 2, or 3 4 R S V (1% all) 2 Adenovirus CHEST 2004;125:1343-51 Case 4 Adult RSV pneumonia 4 year case series at Rochester (NY) General 2,514 respiratory infections 1,148 prospective: 608 healthy, 540 high risk 1,388 hospitalized agreed – RSV 244: 102 prospective, 142 hospitalized – vs Influenza A in 198 RSV 3 – 7 % healthy / year, 4-10 high risk RSV admissions = 11% pneumonia, 11% COPD, 5% CHF, and 7% asthma Death rate for hospitalized patients with RSV = 8% NEJM 2005;352:1749-59 CDC: USA Influenza & RSV Mortality, modeled mathematically JAMA 2008;289:179-185. Season 1990-1 91-2 92-3 93-4 94-5 95-6 96-7 97-8 98-9 Mean H1N1 1988 6518 1190 173 572 14727 0 66 293 2,836 H3N2 6033 45928 19892 48923 33767 23605 55937 70701 55367 40,017 B 17549 566 19030 404 7129 7509 12609 649 9698 8,349 Tot Flu 25570 53012 40112 49500 41468 45841 68546 71416 65358 51,203 RSV 16947 17825 15464 17581 18312 19262 17100 16461 17273 17,358 Pneumonia & Abn. Liver tests Sarcoid Viruses – – – – – EBV Q Fever CMV Adenovirus Varicella Bacteria – Legionella – Strep milleri Mycoplasma BOOP / COP ? RSV not yet reported Slowly or non-resolving pneumonia Failure to resolve 50% in 2 weeks or fully in 4 weeks Nonresolving Pneumonia and mimics of pneumonia. Med Clin N America 2001;85(6) November. Host factors – Age – Loss of lung elasticity – Increase in FRC – Flattening diaphragms – ↓T cell function – ↓ IL1, IL2, IgM – Impaired mucociliary clearance Co-morbid factors – – – – – – – – – CHF DM COPD Renal failure Cerebrovascular Disease Ethanol abuse Corticosteroids Immunosuppression Malignancy Slowly or non-resolving pneumonia Failure to resolve 50% in 2 weeks or fully in 4 weeks Nonresolving Pneumonia and mimics of pneumonia. Med Clin N America 2001;85(6) November. Infectious agent – Pneumococcal = 6 wks in healthy adult, 1-4 months – Legionella = 2-6 months – Mycoplasma = < 4 wks – TB – Fungal Histo, Blasto, Ciccidio, Aspergillus, actinomycosis, nocardia – Viral Influenze A & B, Parainfluenze, RSV, adenovirus – Pneumocystis Pneumonia Mimics – – – – – – – – – – – – BOOP / COP Carcinoma / lymphoma Eosinophilic pneumonia Vasculitis, Wegener’s, Churgg-Stauss Lupus pneumonitis Acute alveolar hemorrhage Pulm alveolar proteinosis Drug-induced infiltrates Aspiration, lipoid SS chest syndrome Occupational inflitrates Radiation pneumonitis Slowly or non-resolving pneumonia COP → BOOP → COP & OP The organizing pneumonias. Current Opinion in Pulm Medicine 2005;11:422-430 Clinical picture of COP – “heterogeneous disease with insidious onset, non-specific physiologic findings, and variable radiographic patters, and TYPICAL histopathology.” – 2-10 week prodrome, cough, dyspnea, abrupt onset – PE = fine râles – CXR & CT patchy alveolar opacities, nodular, mostly lower lobes, often sub-pleural and variable ground glass opacity. – DX: biopsy = granulation tissue in lumen of bronchioles and alveolar ducts with interstitial and air-space infiltration with mononuclear cells and macrophages – Clinical course highly variable – RX underlying cause; 70-80% clear with steroids, 10-15% progressive Slowly or non-resolving pneumonia COP → BOOP → COP & SOP The organizing pneumonias. Current Opinion in Pulmonary Medicine 2005;11:422-430 31-44 % associated with other diseases (SOP) Drug reactions Cocaine abuse Collagen vascular diseases Extrinsic alleric alveolitis Bacterial infection HIV Mycoplasma Viral Malignancy Transplantation Adjacent to infarcts, tumors, granulomas, pneumonia Radiation Fume / smoke inhalation Anthrax vaccination (new) bronchiolitis obliterans: granulation plug (Masson body) is present within a bronchiolar lumen. The organizing pneumonias. Current Opinion in Pulmonary Medicine 2005;11:425 F6/5 Feb 17 – March 16, 2008 Medical diagnoses Major GI Bleed 4 (gastritis, AVM, esophageal varices, colitis?) COPD 3 Olecranon bursitis 3 Asthma 3 End stage liver disease 3 – – – Pneumonia, community acquired 3, nosocomial 2 SBO 2 – – Internal hernia of splenic flexure Uterine CA stage 4, post RRx, adhesions, s/post SB resection & bypass Acute gout 2 inadequate uric acid control Volume depletion & diarrhea, nursing home 2 Peritoneal carcinomatosis 2 Bariatric surgery complications 2 – – Methotrexate cirrhosis Alcoholic liver disease, encephalopathy Hemophilia, HIV, HepC, encephalopathy Severe iron deficiency Hypokalemia & volume depletion Frost bite 2 Severe dementia, recurrent aspiration pneumonia 2 DKA 2 F6/5 Feb 17 – March 16, 2008 Medical diagnoses Acute on chronic ventillatory respiratory failure – Prader-Willie, aspiration, hypoventillation, hypoxia, body wall pain – Surgical hypopituitary, morbid obesity, OSA, rhabdomyolysis Breast CA, metastasis to femur, high risk fracture Urosepsis, self-cath on Rehab Medicinee Fat emboli after femur fracture rod fixation Cellulitis Leaking common iliac artery anneurysm Varicella Hyperkalemia of 6.0 without signs toxicity Sertraline OD, depression, personality disorder Hypoglycemia ( glucose 28) syncope Surgical injury to pancreas, acute pancreatic ascites IBS syndrome → Amyloid colon Fall, head trauma Post laryngectomy, hypothyroid, hypoparathyroid Myositis, hepatitis, ?MCTD, parvovirus 19? Thrombosis of portal vein, unknown cause Intended Learning Outcomes Tell ‘em what you told ‘em Overview of a month on Gmed 1 4 selected cases – – – – Frostbite, trauma for internists Chicken pox in adults RSV pneumonia BOOP / COP Peals Bariatric surgery follow up is important Searching for GI bleeding source Prevent gout by keeping uric acid < 6 Olecranon bursitis needs needle drainage