Morbidity and Mortality Conference
Garrett Feddersen11/27/13
Case:Brief Admission HPI
New pt into the ER, nurse comes out of the room and tells you that ”you need to evaluate this kid now, he’s sick.”
Come into the room and find the pt on the bed, his father and mother are in the room with him.
HPI, continued…
14 YOM Presenting with 2 days of neck pain. The
day before the pain started he was helping his father unload hay bales. Next day the pain started and has continually gotten worse since. Pain is most severe in his neck but now his whole body hurts, worse in neck and back.
10/10 pain, can’t hardly talk
Case:
PMH – Healthy, no hx PSH - none FH – nothing pertinent SH – Lives with parents, no T/A/D Medications - none Allergies - none
Case:
Physical examVitals BP129/87, P109, R16, 100% raDecorticate-like posturing (arms flexed in
and held tight)Jaw clenched tight, able to talk around it
but not wellMuscle spasticity head to toeWrithing in the bed in painLabs
Ddx
Tetanus!! Drug induced (phenothiazines –
phenergan, thorazine) Dental infection trismus Strychnine poisoning Malignant neuroleptic syndrome Meningitis
Further exam
Crush injury to right great toe Very small circular scab on bottom of
left foot (“cut himself” while picking vegetables in the garden)
HEENT otherwise nml, CV – RRR, Lungs – CTAB, Abd – rigid, but no pain with palpation and NABS
Timeline of EventsDate/Time Clinical Status/ change in status
1707 Examined by me in the ED
1730 Given morphine and valium
1745 Decision made to transfer to University of Iowa by helicopter
1820 Pt intubated by anesthesiology with vecuronium and versed. Initially a 6.5 MM ET tube placed.
1833 U of I requesting we start Tetanus IG 3k-5k units…. CMC only has 1k units on hand. None given.
1840 Heparin drip ordered by U of I started.
1850 Pt flown to U of Iowa
Adverse events/outcomes triggering case presentation
Case Yes No
Unexpected death x
Medical or surgical complication x
Delay in care x
Delay in Diagnosis x
Prolonged medical care in setting of poor prognosis x
Other x
Tetanus
Sir Charles Bell
Nervous system disorder caused by the toxin produced by clostridium tetani
Worldwide approx. 1 million cases/year with 30-50% mortality
In the US, averages 29 cases per year with mortality at 13%
Only 2 cases of neonatal tetanus since 1989
Heroin users, unimmunized at higher risks, though only 72% of those vaccinated at protected
*CDC
Diagnosis
Purely clinical dx No labs that can help Tongue depressor test
QUIZ!
Trismus Opisthotonus Risus Sardonicus
General Tetanus Clinical Sx
50% present with trismus Irritability, restlessness, diaphoresis,
tachycardia Intensely painful tonic contractions – jaw,
back, fists, neck, abdomen Fever often present, can develop cardiac
arrhythmias Respiratory arrest Fully concious
Treatment
Supportive – PROTECT AIRWAY Stop toxin production –
1. Metronidazole 500 mg IV Q6 or
2. PCN G 4 million units Q4 Neutralize toxin 3-6k units of TIG
Rest of the story
Pt remained intubated for 3 ½ weeks. Was given TIG and IV antibiotics (Flagyl and Ampicillin)
Around 2 weeks started doing wean trials, backing off sedatives/paralytics, if spasm present went right back on.
Extubated and did well per IC
Room for improvement
Only one of the ER docs had ever seen a clinically advanced case (in Africa).
Heparin drip was ordered by IC ER Anesthesia placed ET 6.5 Needed to start ABX immediately TIG administration
Factors contributing to adverse outcome
Factor Y N
Communication: e.g., inadequate handoffs; incomplete clinical informationx
Coordination of care: e.g., involving multiple services and/or care sitesx
Volume of activity/workload: e.g., increased clinical volume and /or perception of workload x
Escalation of care: e.g., delay or failure to involve more senior physician or nurse x
Recognition of change in clinical status: e.g., delay or failure to recognize changing clinical signs +/or symptoms x
Other factors:x
Comments &Discussion
Referenceshttp://www.cdc.gov/vaccines/pubs/pink
book/tetanus.html#epiUpToDate - Tetanus
Case #2 45 YOM brought into the ED for seizure Hx of seizures seemingly related to his
alcohol abuse, also questionable “epilepsy” hx.
Significant EtOH abuse hx, has reportedly “cut back”
Witnessed by daughter, full tonic/clonic with post ictal period after
HPI, continued…
In ED A&O x 3, recovering well Hgb 7.2 in ED, rest of CBC and BMP
normal. Hypotensive (sys in 60’s) Admitted to ICU for alcohol detox and
hypotension Recent admission for similar seizure
episode, had 15 L removed via paracentesis for ascites during that admission
PMH: HTN, PAD, alcoholic hepatitis, ascites, seizures, anemia, epilepsy
PSH – none Fam – alcoholism Soc – still smokes, still drinks, no
drugs. Meds: Lasix, pentoxyfylline, Flagyl,
spironalactone, metoprolol
When he gets to the ICU, he is A&O x 3, BP’s still in the 60’s.
PE – tachy, hypotensive, fast respirations. Big abdomen with significant ascites, mild tenderness, no RRG. Lungs were clear.
Felt “OK”
A/P
1. Seizure – start Keppra, CT when stable
2. Shock/anemia – hypovolemic/blood loss. FOBT ordered, guiacc of emesis, 2 units of PRBCs to be transfused immediately. PT/INR ordered
3. EtOH – CIWA, CD and psych
4. Ascites – LFTs nml, schedule tap when stable
Course:
Levofed started shortly after arrival to ICU for pressure support
1.5-2 hrs after arrival to ICU has 2nd seizure, immediately following has massive BRBPR. BP crashes to 50’s and 30’s, pt unresponsive. IVF immediately opened up along with blood products. Levofed maxed out and dopamine started.
As pressures came back up into the 80s, became responsive, discussed with him the need to intubate him and provide pressure support.
Massive blood loss protocol initiated Pt intubated with rocuronium and
atomidate by anesthesia d/t concerns with sedatives further lowering pressures
After tube placed, pt was noted to have blood in oropharynx, presumably coming from esophagus.
2 units FFP given along with 10 units vit K, fluid boluses, and more blood.
Femoral line placed by Dr. Visokey Levofed, dopamine, and vassopressin all
at max. PT/INR – 22.7/2.07 Discussion with family about futility of
treatment at this point as the majority of family was now present. Decision made to discontinue resucitation.
Arrived at ICU at around 1100, TOD 1820. Received 7 units PRBCs and 2 units FFP.
Conclusions
Massive GI BleedRuptured esophageal varicesMallory-Weiss tearPerforated ulcer
By the time we saw the blood it was most likely too late
Rectal exam
Factors contributing to adverse outcome
Factor Y N
Communication: e.g., inadequate handoffs; incomplete clinical informationx
Coordination of care: e.g., involving multiple services and/or care sitesx
Volume of activity/workload: e.g., increased clinical volume and /or perception of workload x
Escalation of care: e.g., delay or failure to involve more senior physician or nurse x
Recognition of change in clinical status: e.g., delay or failure to recognize changing clinical signs +/or symptoms - -
Other factors:x
Questions and comments
IF YOU’RE COMING TO THANKSGIVING LET ME KNOW!
Top Related