LGH April QI 2020

Overview

• 10 deaths
• Some quick morbidity

63 M

• Woman asking for help on 13th st
• Likely 20' of no CPR
• PEA, BVM>intubated (switched out supraglottic device)
• 4x Epi, CaCl
• POCUS - no PCE, FF.
• "Lightening" pain in the back while playing table tennis, radiation to L leg with numbness.
• Coroner case
• No issues

86 M

• Retired MD
• Recent long admission 6 weeks w C Diff, sepsis, retroperitoneal hematoma (apixiban), ICD, R CEA, SBO.
• Resp distress-BiPAP prehospital. Intubated in field w sedation only.
• ROSC in ED, no BP. POCUS good slide, SpO2 100%, CXR unremarkable
• ph 7.2 HCO3 17 lactate 3.8 WBC 17.7
• Family brought in home DNR, requested cessation of resuscitation

76 M

• pacer, AF, DM, MIBI day prior (RV dilation w R apical ischemia)
• Collapse at home with immediate bystander CPR
• 1 shock, then PEA, intubated in field. PACING attempted.

cont'd

• ERP meeting w wife-wished for no aggressive measures
• Lytic given
• pH 7.05 lactate 5.6
• Morphine given by second MD x 2 (20 mg IV*)
• Pt. had known metastatic prostate CA w lytic mets
• No issues

85 F

• PMhx: CKD, HTN
• woke w L sided CP 0420, associated nausea. Developed back pain during transfer. ALS>prehospital EKG.
• Known thoracic aneurysm 7 CM, followed by Vascular at VGH.
• Recent workup for Lung CA with + PET for lung mass recurrence.

code blue CT

@CT

• patient confused, awake
• Palpable femoral pulse, no BP
• intubated (K/R). CPR commenced for pulselessness.
• PEA, no PCE.
• EPIx2, 2 U PRBC
• CT-rupture of aneurysm into L pleural space
• Recent treatment 10/7 ago for PNA
• Good documentation

68 F

• PMhx: compression #s, remote leukaemia, dysphagia, GVHD.
• cc-abdominal pain w CGE.
• EHS-no pulse, non shockable rhythm, in ED, HAD pulse and BP.
• Massive transfusion protocol commenced in the ED. 3 IOs placed.
• FAST -
• Intubated, N ETCO2, blood in tube
• CXR small R PTX, 14g angiocath (due to CPR?).

case cont'd

• ICU consulted.
• Free air on CXR
• Discharged the day before from H service.
• URI tx with inh steroids and clarithromycin.
• On Imatinib for remote leukemia (GVHD+). Query drug interaction?
• Endo-mild diffuse gastropathy
• Die of PUD perforation???

97 M

• PMhx: AFib, APR for villous adenoma
• One day hx of pain around stoma site.
• Seen at 1200 by ERP 1, 1900 by ERP 2
• GS consult at bedside 1939
• CT-equivoval for LBO
• Deemed to be non-surgical-@ under hospitalist service

77 M

• PMhx: colitis, VTE, anticoagulation for prosthetic valve.
• Last seen 0530 by spouse, found down at 1610
• ERP 17:36
• Intubated with R/E. Given IV labetolol
• CT-catastrophic ICH R temp lobe w + shift
• GCS 3/fixed pupils/gag present/INR 3.3

95 F

• PMhx: remote BRca, CKD, DM2. Summerhill.
• @ w hemoptysis-recently started on Moxi for URI
• on ASA
• CXR/CT=pulm hemorrhage, LUL consolidation
• WBC 20.7, HGB 114, d dimer 1738
• Decompensated 24 h later due to hypoxia

66 F

• Known met breast CA
• Found down at home by family with glucose 1.7, BP 60/40
• Actively dying in ED
• Insulin had stopped 2/52 ago
• on PC program locally

75 M

• pancreatic and colon ca w liver mets
• suddenly unwell that day with abdominal distension
• found to be in AF-cardioversion attempted w 200J
• Given Ketamine, IV fluids
• No PCE on POCUS
• Xray-large perforation

morbidity

61 F

• local MD
• playing hockey, sudden onset of HA, dizziness, falling to L. HA peak intensity at 5'. Emesis x1.
• Tried to keep playing, difficulty getting up.
• Recent doubling of Wellbutrin dose in addition to Fluoxetine

In ED

• GCS 15 161/91 76 @2145
• Essentially N exam-noted to have hoarse voice and ha. No meningismus.
• Code 77 activated and discussed with Neurologist (did not come in).
• CT/CTa read as N

Re-Exam at 0100

• Patient wanted to go home
• Still listing to L
• Admitted under IM (1045) with another Neurologist immediately seeing
• Patient severely symptomatic with vertigo to the point where she could not open eyes
• ERP noted-med interaction/SE? (Wellbutrin)

Neurologist exam

• L ptosis
• L dysmetria w heel-shin
• L limb hemiataxia
• Clinical diagnosis: L medullary infarct-aka Wallenberg Syndrome due to PICA blockage
• MRI confirms L medullary infarct
• ECHO w bubble study N
• 5 day admission w good prognosis

Wallenberg Syndrome

• due to schema of lateral medulla oblongata
• most commonly due to vertebral artery block or PICA
• aka PICA syndrome, vertebral artery syndrome
• Contralateral trunk and extremity sensory findings, ipsilateral facial and CN deficit (crossover).
• Ataxia, vertigo, dysphagia, dysarthria, hoarseness, nausea, differential body temperature sensation, bradycardia
• Decent prognosis depending on size of infarct and co-morbidities.
• Consider this diagnosis in Horner's Syndrome (Annals Vol. 62, No. 5, November 2013)

More brains

March 14

• 74 M w/ AF on Xarelto, Prostate CA, HTN
• Got up at 0600, went for drive
• Spouse became worried when at 0900 he was confused, w speech difficulty, R sided facial droop.
• Refused to go to ED all day
• Presented and seen by ERP at 2200 that evening

CT/CTA
Subacute L frontal lobe infarct w petechial hemorrhage

Admit March 14-17

April 3

woke from sleep w profound diaphoresis and nausea

Course

• CT/CTA subacute infarct again seen, *new R vertebral artery dissection*
• Neurologist refused to 'hear story' from ERP and suspicious of dissection-rather Hypertensive Emergency.
• Remained under IM
• Follow up CT demonstrated R cerebellar infarct
• Commenced dual anti platelet therapy

April 5 0100

Code Blue

• CT-acute hydrocephalus
• decreased LOC, bradycardia, brief PEA arrest
• Intubated
• Re-arrested briefly after
• Given Amiodarone and Dex
• Immediate OR for decompressive craniotomy and drain
• ICU now, guarded prognosis

Issues

• what could have been done differently?
• etiquette of Neurology?
• difficult case (anticoagulation decisions, anchoring bias)

quick snapper

67 F working out

• sudden onset of chest pain while working out w associated diaphoresis and emesis
• Prehospital STEMI suspected by ALS
• Told by SPH cath lab that they were not accepting CODE Stemi
• LGH ERP contacted, recommended that the patient come in for assessment after review of strip

IN ED

• STEMI suspected on repeat EKG
• reviewed with ERP 2 and faxed to local cardiologist
• Code STEMI initiated
• Accepted to SPH Cath Lab
• D1 stent placed, LVEF 45%
• Discharged home 2 days later

issues

• this could have gone poorly
• should the EHS crew just proceed to other cath lab?
• who makes this decision?
• sometimes cath labs cannot accept in real time (IABP, back up of sick patients)