Best Cases Ever

Dr. David Carr Assistant Director Of Risk Management and Faulty

Development University Health Network

A career in cases

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10 mg phenyl in 100ml!1ml = 100 ug

10 % Anaphylactic Shock is Epi Resistant

Vasopressin to the rescue?

BEWARE 35% BV can go IS

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113/80 38.7 C

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Abdo pain & menstrual cramps

•  +++ VB x 4 days ++ clots •  headache, nx, abdo cramps •  PMHX anemia MEDS Fe Unwell Chest, cvs, abo, heent N Pelvic ++ clots no cmt or adnexal tenderness BHCG-

Management and Work Up

•  Thoughts……

NSAIDS decrease menstrual blood loss by 25-50%

Interrogate your fevers!

The Labs calls: Now what?

HB 135 WBC 2.5 PLT 8 AST 159 ALT 97 BR 8 Cr 56 Lytes N Extended N Caogs N

Dengue Hemorrhagic Fever

•  “Break bone fever” 3-14 days after bite •  Its everywhere >110 countries

–  FL AZ, TX, NC, SC OK TN AL, GA, NM, MI, KY

•  Criteria: Hx of Fx 2-7D hemorrhagic events Inc vasc permeability and decreased PLT’s

DHF 3-7d post onset ! often no fever

20 year old multiple “seizures”

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Neuro exam: • Drowsy, GCS 13 (E3V4M6) • CN II-XII normal • Pupils 3mm bilat, PEARL • Power, Sens, Tone, Neck Normal • Reflex N Toes DG Remainder Exam WNL Tests…….

Labs: •  CBC •  Lytes •  Cr, urea •  TSH •  Urinalysis

Urine tox screen EtOH Acetaminophen Salicylates

NORMAL

Clinical Course

•  Intubated for 3 days •  LP: 7 WBC CSF studies N •  MRI and EEG N àNeuro “Not Sz D/o” •  D4: Choreiform movements and oral dyskinesia •  Psych “not likely pseudo seizuresàneuro” •  Day 10: IVIG and Steroids???

WHY?

Young Encephalitis = Anti NMDA

4X > HSV VZV WNV IN <30

Median age 21 Only 5% > 45 4:1 F:M

Four clinical phases: 1.  Prodromal phase (60-80%)

­  Headache, fever, URTI sx

2.  Psychotic/seizure phase 2-14 d later ­  Concentration difficulties, behavioral changes, paranoia,

hallucinations (77%), delusions

3.  Unresponsive phase ­  Catatonia, choreiform movements, orofacial dyskinesias

4.  Hyperkinetic phase ­  Autonomic instability, cardiac/resp collapse

Peery HE, Day GS, Dunn S, et al. Anti-NMDA receptor encephalitis. The disorder, the diagnosis and the immunobiology. Autoimmun Rev 2012;11:863-72c

IVIG + Steroids Substantial neurological improvement >80%

Treatment

•  Timely diagnosis & treatment saves lives •  Consider in:

–  Young patients with altered mental status, “first presentation” psychosis, seizures

•  AMS +AI +Movement d/o= NMS, SS, MH and… •  Discuss role for empiric IVIG with consultant

PLANT THE SEED

Anti- NMDA Receptor Encephalitis

1st Night Back Home

•  61 y.o male brought in by car decreased loc •  D/C rehab 1 day ago after 3/12 •  PMHX: VF arrest Dec 25th, NIDDM, glaucoma •  Meds: metformin, ASA, plavix, metoprolol �  just started celexa, trazadone and aricept in past

2/52

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155/74 36.3 C

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First Night Back Home � GCS b/w 3-5 occasional sounds and facial grimaces �  155/74 69R 36.3C 16 99% ORA BS 7.2 � Chest, CVS, Derm, Abdo N � Neuro: PERLA, Tone, Reflexes N

Management? Investigations? Thoughts?

NCSE

•  “Seizure activity > 30 minutes without motor signs but change in behaviour or cognition”

•  Can occur before or after convulsion •  Under diagnosed and frequently missed

–  13% of ER pt’s correctly dx

•  Often misdiagnosed as psychiatric •  Seen in up to 50% COMA or CSE PT’s •  14% CS on EEG à NCSE

NCSE: When to be suspicious

•  Seizure and prolonged post ictal state •  AMS with twitching, blinking, jerks, eye

deviations or fluctuating mental status •  AMS with a history of seizures •  Stupor in elderly on meds i.e bzd or neuroleptics •  Stroke patients worse than you expect

COMA + Suspicion = BZD

B4

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147/76 36.6 C

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Returning Traveler

•  75 y.o female returned home yesterday •  c/o 2d hx SOB, cx, cold, dizziness, nx •  Hypotensive on scene 65/45 •  No leg pain, cp or hemoptysis or fever •  PMHX: HTN CHOL OP DEPRESSION •  MEDS: Fosomax Crestor •  Thoughts?? Concerns ??

Traveler Work up

•  CXR N •  Lactate 5.9 •  Trop 1.12 •  WBC 13 •  Cr 138 •  AST 661 ALT 321 BR 25 ALP 54

BP 65/40 AFTER 3L

IVC< 2cm with Insp collapse >

50%! CVP <10

Before sniff After sniff

Lower CVP

Before sniff After sniff

Higher CVP

CONCLUSIONS

•  WHEN IVF DUMPS BP THINK PE

•  RUSH EXAM FOR A LL SHOCKY PTS

•  NOT EVERY LACTATE IS INFECTIOUS

•  TREAT HIGH PRE-TEST RISK PE

5 Cases

•  Anaphylaxis: Think IVF

•  Interrogate ALL Fevers

•  Young Encephalitis think IVIG

•  Unusual COMA think BZD Trial

•  RUSH EXAM