Download Follow_up_rounds-Yoon-8_12_11

Andrew Yoon, MD
Rhonda Forest, MD
8/12/11
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Montefiore ED 7/29/11
Patient H.M. 01355124
CC: 89yo F BIBA from home for change of
mental status as per home health aide
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EMS gave 1 amp of D50
Triage assessment: AAO X 1
Vitals in ED: T 99.8F (rectal), P 38-45, RR 14, BP
138/30, O2 99% on RA, Pain 0/10
PMH: DM, HLD, Depression, colostomy from
colon ca, chronic kidney disease (not on
dialysis)
Meds: Citalopram, Glyburide, Zocor
All: NKDA
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HHA reports patient was in her wheelchair
eating when she suddenly leaned backwards
and became unresponsive. HHA checked
patient who was breathing. She tried to wake
her up but no response. Patient continued to
slouch in her wheelchair for ~20 minutes before
she vomited then awoke. Patient recalls eating
dinner then waking up to her HHA and EMS
surrounding her.
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ROS: (-) fever, chills, malaise, CP, SOB, cough,
difficulty swallowing, decreased PO intake,
nausea, diarrhea, constipation, hematochezia,
melena, dysuria, hematuria, increased urinary
frequency, vag bleeding, abnormal speech, HA,
seizure like activity, blurry vision, new focal
weakness
ROS: (+) vomiting x1, NBNB
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General: NAD
Skin: WNL
Scalp/face: WNL
Neck: WNL
Heart: bradycardic, regular otherwise
Lungs: clear, equal b/l
Abd: WNL, colostomy bag in LLQ with healthy pink
appearing colonic tissue. Minimal amount of brown liquid
in ostomy bag.
Back: No CVA tenderness
Ext: WNL
Neuro: Alert, AAO x2 (self, location), speech WNL, CNS 212 intact, sensation intact throughout body, motor WNL
except 2/5 strength b/l LE, gait untested
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Syncope
Vasovagal
Myocardial Infarction
Long QT syndrome
Brugada
Arrythmia
Neurologic
CVA
Seizure
Apnea/Hypoxia
Aspiration Pneumonia
Intracranial hemorrhage
Hypovolemia
Pulmonary Embolism
Electrolyte Imbalance
Hypoglycemia
Deep Sleep
Medication Induced
Unexplained
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Can be normal, especially in sleep and athletes
Sick Sinus Syndrome
Vagal activity
Increased ICP
Acute MI
Heart block
Obstructive sleep apnea
Drugs (cholinergic drugs ie neostigmine, physostigmine,
beta blockers, reseperine, guanethidine, methyldopa,
clonidine, cimetidine, digitalis, calcium channel blockers,
amiodarone and lithium)
Other (hypothyroid, hyper/hypoK, hypothermia, prolonged
hypoxia, strange infections ie babesiosas, Q fever, dengue
fever, yellow fever, RMSF)
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Blood work resulted at 1835
Wbc 8.4, Hgb 12.1, Hct 36.1, Plts 254
Na 124, K hemo, Cl 94, CO2 15, BUN 80, Cr 3.2,
Glu 211
Trop 0.07, CPK 144, CPK MB 1.7%
Free T4 1.06 (No TSH sent)
Repeat BMP resulted at 2000
Na 128, K 6.3, Cl 99, CO2 15, BUN 78, Cr 3.2,
Glu 180
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CXR: clear lungs, heart enlarged but is an AP
view.
Head CT: chronic ischemic changes. No acute
findings.
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Calcium gluconate 1 amp IV
Kayexelate 30g PO
Bicarb 1 amp IV
Insulin 10U IV, D50 1 amp
NS 2L IV
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Within 1 hour of administration of medications
patient’s heart rate increased to 50s, which is
patient’s baseline heart rate based on previous
two admissions.
No repeat EKG was done as patient was being
prepared for transport to inpatient telemetry
bed.
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First changes:
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Then:
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Peaked T waves
Shortened QT interval
Lengthening of PR interval
Widening of QRS complex
Disappearance of P waves
Finally:
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Sine wave pattern
Asystole
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Calcium gluconate or chloride if QRS widening
or loss of P waves
Calcium chloride has 3x concentration of calcium as
calcium gluconate
 Calcium gluconate: 1g or 10ml of 10% solution
 Calcium chloride: 500mg to 1g or 5 to 10ml of 10%
solution
 Give calcium chloride through central line
 In patients taking Digitalis still can give Ca
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Insulin 10U IV, D50 1 amp
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Albuterol 10-20mg Nebulized
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Drives K intracellularly
Peak effect at 30-60 minutes
Drop K by 0.5-1.2 meq/L
Drives K intracellularly
4-8x concentration used for asthma
Peak effect 90 minutes
Drop K by 0.5-1.5 meq/L
Bicarb
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Drives K intracellularly
Effects controversial even in setting of acidosis
If given recommended to be given as infusion over 2-4 hours
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Loop or thiazide diuretics
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Kayexelate
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Increase K loss through urine
No data showing short term benefit
1 dose is ineffective
Requires at least TID for 1-5 days
No short term benefit
Intestinal necrosis believed to be due to sorbitol, which SPS
contains, but Kayexelate does not
Dialysis
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When above treatments are ineffective
When hyperK is “severe”
When expected to have continued release of K ie
rhabdomyolysis or tumor lysis syndrome
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Jacobi ED 8/10/10
Patient T.K. 2154687
CC: 21yo F 17 weeks pregnant with diffuse
lower quadrant abdominal pain
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Vitals T 100.1 F, BP 129/79, HR 94, RR 16, O2
100%, Pain 10/10
PMH: G2P1001, C-section 4/2010
Meds: None
All: NKDA
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21yo F 17 weeks by LMP p/w lower
abdominal pain since this morning associated
with N/V. Pain started off in RLQ and is now
also suprapubic area. No vag
bleeding/discharge.
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ROS: (-) HEENT, cough, CP, SOB,
diarrhea/constipation, dysuria, vag
bleeding/discharge, HA, blurry vision
ROS: (+) fevers, chills, nausea, vomiting (nonbloody, +bilious),
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HEENT: NCAT
CV: RRR, No m/r/g
Lungs: clear b/l
Abd: soft, non-distended, TTP suprapubic region,
(+/-) RLQ TTP, (+/-) guarding, no rebound, +BS
GYN: Normal external genitalia, white discharge
in vault, os closed, no blood, no lesions/masses, no
CMT, no adnexal tenderness b/l
Back: No CVA tenderness b/l
Ext: No c/c/e
Neuro: AAOX3, normal gait
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WBC 14.9, Hgb 12.0, Hct 35.2, Plt 268, 0.2%
bands
Na 140, K 4.1, Cl 109, CO2 22, BUN 6, Cr 0.5,
Glu 77, T bili 0.3, ALKP 83, SGOT 20, SGPT 14
Hcg 23,436
Lipase 20
UA: blood neg, LE neg, Nit neg, WBC 5/hpf,
Epi 3-4/hpf, Bact trace
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Bedside TVUS: +IUP w/ FHR 150s, no free
fluid in cul-de-sac, b/l ovaries small 2.5 x 3 x 3
cm with no adenexal masses.
Appendicitis
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MRI abd/pelvis: limited study, no evidence of
free fluid, gravid uterus, appendix cannot be
identified therefore appendicitis cannot be
excluded
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CT abd/pelvis: normal appendix visualized, no
free fluid, single intrauterine gestation
Normal appendix
Appendicitis
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Admitted to Gen Surg s/p MRI results, but
discharged from ED after CT results
May 16, 2011 had C-section at 42 weeks
gestational age. Healthy male infant with
Apgar scores of 8 & 9. Male infant circumcised,
tolerating breast and bottle.
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Most widely used is the modified Alvarado scale
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Migratory right iliac fossa pain (1 point)
Anorexia (1 point)
Nausea/vomiting (1 point)
Tenderness in the right iliac fossa (2 points)
Rebound tenderness in the right iliac fossa (1 point)
Fever >37.5 degrees C (1 point)
Leukocytosis (2 points)
Score <3 home, 4-6 admit for observation, >7 OR (male)
Sensitivity 95%, Specificity 83%
Much less reliable in women
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Ultrasound
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MRI
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Sensitivity 91-98%, Specificity 93%
CT w/ rectal contrast only
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Sensitivity 91%, Specificity 98%
CT w/ IV and PO contrast
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Sensitivity 86%, Specificity 81%
Sensitivity 98%, Specificity 98%
CT w/ no contrast
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Sensitivity 88-96%, Specificity 91-98%
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< 5 rads
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5-10 rads
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NO increased risk of fetal anomalies or pregnancy
loss
CXR < 1mrad, Abd xray 2-3 rads, CT abd 2-3 rads
Inconclusive data
IV pyelogram 4-9 rads, L-spine xray 4-6 rads
> 10 rads
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Increased risk of fetal anomalies and pregnancy loss
Barium enema 7-16 rads
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Round trip flight from NY to LA
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CXR
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10 mrem
Natural radiation from living on Earth for 1
year
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3 mrem
300 mrem
Blaming Mother Earth for child’s MR
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Priceless
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First 2 weeks after conception
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2-16 weeks after conception
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“All or none”
100 rads will kill 50% of embryos
Death is rare
Anomalies occur with 10-20 rads
20-25 weeks and beyond after conception
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Relatively resistant to teratogenic effects of radiation
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Hong JJ, Cohn SM, Ekeh AP, et al. A prospective randomized study of clinical assessment versus
computed tomography for the diagnosis of acute appendicitis. Surg Infect (Larchmt). 2003;4(3):231.
Denizbasi A, Unluer EE. The role of the emergency medicine resident using the Alvarado score in
the diagnosis of acute appendicitis compared with the general surgery resident. Eur J Emerg Med.
2003;10(4):296.
Lee SL, Walsh AJ, Ho HS. Computed tomography and ultrasonography do not improve and may
delay the diagnosis and treatment of acute appendicitis. Arch Surg. 2001;136(5):556.
Ceydeli A, Lavotshkin S, Yu J, Wise L. When should we order a CT scan and when should we rely
on the results to diagnose an acute appendicitis? Curr Surg. 2006;63(6):464.
Gaitini D, Beck-Razi N, Mor-Yosef D, et al. Diagnosing acute appendicitis in adults: accuracy of
color Doppler sonography and MDCT compared with surgery and clinical follow-up. AJR Am J
Roentgenol. 2008;190(5):1300.
Terasawa T, Blackmore CC, Bent S, Kohlwes RJ. Systematic review: computed tomography and
ultrasonography to detect acute appendicitis in adults and adolescents. Ann Intern Med.
2004;141(7):537.
Rao PM, Rhea JT, Novelline RA, et al. Helical CT combined with contrast material administered only
through the colon for imaging of suspected appendicitis. AJR Am J Roentgenol. 1997;169(5):1275.
Bentur, Y. Ionizing and nonionizing radiation in pregnancy. In: Maternal-fetal toxicology, 2nd ed,
Koren, G (Ed), Marcel Dekker, New York, 1994, p. 515.
ACOG Committee Opinion. Number 299, September 2004. Guidelines for diagnostic imaging during
pregnancy. Obstet Gynecol. 2004;104(3):647.
CDC. http://www.bt.cdc.gov/radiation/pdf/measurement.pdf