Transcript Multiple Small Feedings of the Mind

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
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– “Internal medicine trauma” (2)
– “Drug Rash” reconsidered
– Pneumonia that won’t go away
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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)
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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
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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.
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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
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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
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89.6
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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.
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– 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
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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
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Intervention patients
– Consecutive patients considered 19892003
– Severe frostbite
– Age 18 - 75
J Trauma. 2005 Dec;59(6):1350-4
Methods
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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
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Exlusion
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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
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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
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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
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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
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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
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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
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– 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
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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
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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
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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
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Highly contagious: respiratory droplets,
vesicle fluid direct contact
Incubation 14 – 16 (10 – 21) days
Vesicles in crops over <4 days
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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
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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
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often fatal if immune incompetent
– IF immune compromised, everything is worse
Case 4
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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
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PE = healthy appearing, good color, no
distress, 124/80, HR 128 reg., RR 22 easy,
96% RA, fine râles bases,  P2
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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.
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ECG = right heart strain pattern
Case 4
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CXR bilat airspace disease lower lobes
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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
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LE dopplers negative for DVT
Bronchoscopy = normal appearance of
airways
 BAL = 2000 cells / uL, 80% monos
 BX = Organizing pneumonia. RSV+
DFA
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Case 4: Rx and Hospital course
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RX:
– Fractionated heparin
– ABX for complex CAP = Amp /
sulbactam, vancomycon, moxifloxacin
narrowed to moxifloxacin after 3 days.
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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
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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
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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
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4 year case series at Rochester (NY)
General
2,514 respiratory infections
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1,148 prospective: 608 healthy, 540 high risk
1,388 hospitalized agreed
– RSV 244: 102 prospective, 142 hospitalized
– vs Influenza A in 198
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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
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Sarcoid
Viruses
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EBV
Q Fever
CMV
Adenovirus
Varicella
Bacteria
– Legionella
– Strep milleri
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Mycoplasma
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BOOP / COP
? RSV not yet
reported
Slowly or non-resolving pneumonia
Failure to resolve 50% in 2 weeks or fully in 4 weeks
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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
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Co-morbid factors
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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
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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
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Histo, Blasto, Ciccidio,
Aspergillus,
actinomycosis, nocardia
– Viral
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Influenze A & B,
Parainfluenze, RSV,
adenovirus
– Pneumocystis
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Pneumonia Mimics
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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
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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
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The organizing pneumonias. Current Opinion in Pulmonary Medicine
2005;11:422-430
31-44 % associated with other diseases (SOP)
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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)
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bronchiolitis obliterans: granulation plug
(Masson body) is present within a
bronchiolar lumen.
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The organizing pneumonias. Current Opinion in Pulmonary
Medicine 2005;11:425
F6/5 Feb 17 – March 16, 2008
Medical diagnoses
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Major GI Bleed 4 (gastritis, AVM, esophageal varices, colitis?)
COPD 3
Olecranon bursitis 3
Asthma 3
End stage liver disease 3
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Pneumonia, community acquired 3, nosocomial 2
SBO 2
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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
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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
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Acute on chronic ventillatory respiratory failure
– Prader-Willie, aspiration, hypoventillation, hypoxia, body wall pain
– Surgical hypopituitary, morbid obesity, OSA, rhabdomyolysis
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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
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Frostbite, trauma for internists
Chicken pox in adults
RSV pneumonia
BOOP / COP
Peals
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Bariatric surgery follow up is important
Searching for GI bleeding source
Prevent gout by keeping uric acid < 6
Olecranon bursitis needs needle drainage