SKH ED Mortality Conference Oct' 2002

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SKH ED Mortality Conference Oct. 2002

• Presenter ??? Instructor???
• Nov. 11, 2002

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Statistics

• Oct. 2002
• DOA patient number 24 persons
• DOA with initially successfully resuscitated 14
  persons, Percentage 58
• AICU mortality 9 patients

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Case Discussion

• 16-year-old boy presented with conscious change
  and shock after chest compression
• 86-year-old man complained of lower legs weakness
  for 2 days and dyspnea for 1 day

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Case 1

• 16-year-old boy fell down and was being
  compressed over anterior chest by the falling
  door while he was hanging over the hand-ball
  gate.
• Severe dyspnea and chest discomfort were
  complained.
• He was sent by 119 to Tai-An Hospital and walked
  into the ER.

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Case 1

• Initial PE and CXR revealed no significant
  findings.
• He was placed in the observation unit.
• Conscious change with undetectable BP noted 1
  hour or more later. CPCR was initiated and his BP
  regained soon.
• He received intubation and mechanical
  ventilation. Blood sampling was taken.

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Case 1

• Lab. Findings CPK 707, CK-MB 53.1 TnI 6.26, No
  PE findings were noticed.
• Chest CT was then arranged and revealed massive
  pericardial effusion.
• Pericardiocentesis was performed and some 300ml
  bloody discharge was drained.
• Due to no CVS available, he was transferred to
  our hospital for further management.

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Case 1

• He was sent by a ambulance with Tai-Ans doctor
  accompanied. He complained that his vital signs
  were stable on the way to our hospital. However,
  there was no any monitoring tool.
• DOA was noted on the arrival at our ED. CPCR was
  initiated and thoracotomy was performed by the
  CVS doctor. The patient passed away despite over
  2 hours of resuscitation effort.

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Discussion

• 1. Detection of cardiac contusion and the
  disastrous cardiac tamponade.
• 2. Transferring a patient with unstable condition

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Assessment of myocardial contusion

• ECG (sensitivity 96, specificity 47)
• Arrhythmia observed are sinus tachycardia and
  extrasystoles.
• CK, CK-MB
• Troponin I
• Cardiac echo
• TTE
• TEE
• CXR
• PE thrill, JVP, murmur, friction rub

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Algorithm for assessmentof the heart in blunt
chest trauma.Richard B. Weiskopf,
M.D.,Anesthesiology 2001 955448
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Routine work-up for blunt cardiac injuryPretre,
NEJM 336(9), Feb. 197 p626 - 632

• Base-line chest radiography, ECG, and measurement
  of cardiac-enzyme levels.
• If details of the accident and signs of thoracic
  trauma suggest particularly severe impact to the
  chest, monitor the patient closely for several
  hours
• Angina-like chest pain, raised enzyme levels or
  minor arrhythmias, monitor patient in an
  intermediate care unit and evaluate with
  echocardiography if these symptoms persist longer
  than 12 hours.

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Incidence of injury
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Cardiac tamponade can be delayed after blunt
chest trauma

• slow bleeding into the pericardial space
• displacement of thrombus that hadtemporarily
  closed the cardiac wound
• Adhesion that formed at the time of injury was
  torn
• PE has gradually developed and that haemolysis of
  anearlier pericardial haematoma is responsible
  for accumulation of additional fluid in the
  pericardial space
• exudative non-haemorrhagic pericardial effusions
  caused by postcardiac injury syndrome and is then
  attributed toautoantibodies against the
  pericardium or myocardium
• Herbots Heart, Volume 86(5).November 1, 2001.e12

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Case 2

• ? X X 86 y/o male
• Date of admission Oct 30, 2002
• Sent in by 119 Ambulance
• Cons Alert, T 34.8C PR 118/min BP
  101/65mmHg SpO2 89
• Triage 2 by nurse

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Chief complaint

• General weakness for 2 days and dyspnea since
  today

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Past history

• Hypertension
• Cardiac arrhythmia
• NKDA
• Old CVA

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Present Illness

• Cough with productive sputum noted for over one
  week
• Confused consciousness and dyspnea noted by his
  family on the day of admission
• His appetite was poor. He denied of chest
  tightness, abdominal pain, nor fever / chills at
  home.
• PND, DOE were denied. Weakness of bilateral lower
  legs were told by the patient in recent days.

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Physical examination

• Cons confused
• HEENT JVP not elevated
  Conjunctiva slightly pale Sclera
  not icteric
• Chest Heart sound RHB Breath sound
  diffuse coarse crackles
• Abdomen soft, no tenderness
• Extremities freely, skin turgor decreased
• Muscle powers 4/4 simmetric

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Impression

• R/O pneumonia
• R/O electrolyte imbalance

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Orders -1

• O2 mask 6L/min
• CBC/DC
• Biochemistry
• ABG
• Blood culture x 2
• N/S KVO
• CXR
• EKG
• ???? OBN

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ABG

• Under FiO2
• pH 7.42 pCO2 32 pO2 137.3 HCO3- 21.4O2 Sat
  99.2

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(No Transcript)
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At the OBN

• Patient was coughing and had difficulty in
  coughing out the sputum. Suddenly, conscious
  changed.
• GCS E1M4V1, BP104/86 HR 82
• ETT/MV was given. NG tube / Foley catheter were
  then placed.
• Waveform of the ECG monitor changed noted by
  nurse and the BP was undectable. PEA was
  impressed. CPCR was started.

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Lab

• Hb 12.2 WBC 17800 S92.8 Plt 106K
• Glu 194, GOT 25 BUN/CR 31/1.6Na 143 K 4.6
  CRP 10.10
• CPK 98, CK 26 TnI lt0.1
• Chest X-ray
• D-Dimer drawn after CPR 17.4

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ECG after CPCR
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ECG in Nov, 2000
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At AICU

• Recurrent PEA attacks noted. The family finally
  wished no further resuscitation and went AAD.
• CV CR visit Heart echo LV global hypokinesia
  septal wall akinesisRV preserved
  contractility, moderate TR

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Cause of death

• AMI?
• Major pulmonary embolism?
• Other cause?

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PEA

• Hypovolemia
• Hypoxia
• Acidosis
• Hyper/hypo kalemia
• Hypothermia

• Tablets
• Tamponade, cardiac
• Tension pneumothrorax
• Thrombosis, coronary
• Thrombosis, pulmonary embolism

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PEPulmonary Embolism as Cause of Cardiac Arrest
Presentation and OutcomeArchives of Internal
Medicine 20001601529-1535

• In fulminant PE, up to 90 of cardiac arrests
  occur within 1 to 2 hours after the onset of
  symptoms.
• The mechanism of cardiac arrest caused by PE
• pulmonary mainstream obstruction and liberation
  of vasoconstrictive mediators from the thrombi,
  leading to increased RV afterload.
• Overload of the RV results in a leftward shift of
  the ventricular septum, leading to decreased LV
  diastolic filling and EDV

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PE
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PE

• 55 had lost consciousness suddenly, either as
  the initial symptom itself without any prodromal
  signs or almost immediately after onset of
  symptoms
• 45 developed cardiac arrest after sustained
  acute cardiogenic shock associated with
  pronounced bradycardia and hypotension.

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PE - prodromes
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PE

• Echocardiographic capability was available in 24
  patients (57), either transthoracic
  echocardiography (n6) or transesophageal
  echocardiography (n18).
• In 12 of those patients, emboli were present in
  proximal pulmonary arteries, while in other
  patients, indirect signs highly suggestive for
  PE, such as RV dilatation, IVS bulging, and TR,
  were detected.

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PE

• ECG RBBB (70), S1Q3 pattern (8), T-wave
  inversion in V1 to V5 (5), and complete
  atrioventricular block (2).
• 87 of patients, central pulmonary emboli could
  be detected in 22 of them emboli were detected
  in segmental regions as well, while 13 emboli
  were found only in segmental regions. DVT was
  found ante mortem or postmortem in 85 patients,
  but only 3 patients showed clinical signs of DVT.

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PE intervention
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PE intervention (-)
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PE