Transcript Slide 1

Morbidity and Mortality
Conference
Garrett Feddersen
11/27/13
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 exam
Vitals BP129/87, P109, R16, 100% ra
 Decorticate-like posturing (arms flexed
in and held tight)
 Jaw clenched tight, able to talk around
it but not well
 Muscle spasticity head to toe
 Writhing in the bed in pain
 Labs

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 Events
Date/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
Unexpected death
Medical or surgical complication
Delay in care
Delay in Diagnosis
Prolonged medical care in setting of poor prognosis
Other
Yes
No
x
x
x
x
x
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 information
Coordination of care: e.g., involving multiple services and/or care sites
x
x
Volume of activity/workload: e.g., increased clinical volume and /or perception
of workload
x
x
x
Escalation of care: e.g., delay or failure to involve more senior physician or
nurse
Recognition of change in clinical status: e.g., delay or failure to recognize
changing clinical signs +/or symptoms
Other factors:
x
Comments &
Discussion
References
 http://www.cdc.gov/vaccines/pubs/pin
kbook/tetanus.html#epi
 UpToDate - 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.
2.
3.
4.
Seizure – start Keppra, CT when stable
Shock/anemia – hypovolemic/blood loss.
FOBT ordered, guiacc of emesis, 2 units
of PRBCs to be transfused immediately.
PT/INR ordered
EtOH – CIWA, CD and psych
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 Bleed
Ruptured esophageal varices
 Mallory-Weiss tear
 Perforated ulcer

By the time we saw the blood it was
most likely too late
 Rectal exam

Factors contributing to adverse outcome
Factor
Communication: e.g., inadequate handoffs; incomplete clinical information
Coordination of care: e.g., involving multiple services and/or care sites
Volume of activity/workload: e.g., increased clinical volume and /or perception
of workload
Escalation of care: e.g., delay or failure to involve more senior physician or
nurse
Recognition of change in clinical status: e.g., delay or failure to recognize
changing clinical signs +/or symptoms
Other factors:
Y N
x
x
x
x
-x
Questions and comments
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