LGH QI Rounds Dec 2022

Outline

• 7 deaths
• 6+ morbidities

83 F 111666437

• EHS-slurred speech-q 77
• Awake at triage, crumped
• Pulseless-coded 30 min
• ph 7.07 lactate 10 trop n
• TNK, magnesium IV
• Not coroner
• Cause of death?
• Past hx: HTN, hypothyroid, DDD

64 M 113393941

• Transfer from WHCC, intubated
• 16 year hx of muscular dystrophy. On CPAP. Depression, HTN, 4 WW.
• Had discussed MAiD in past, not applied
• Up in Whistler for son's wedding
• ETOH that evening

Muscular Dystrophy cont'd

• first time seizure, repeated in ED
• hypotensive (75 P), levophed
• intubated (propofol*)
• CT head, cxr N
• Transfer to higher level of care

Muscular Dystrophy

• CAi 2.03, given calcium chloride during code in our ED, run largely by ICU
• GOC-not for further resuscitation, per son
• Died in ED
• Stopped antidepressants months ago, not telling wife
• Intentional? Overdose?

Can you die of hypercalcemia?

31 M 200404999

• Jumped 16 stories
• Weak pulses after landing, lost VS just prior to ED>CPR>CODE 99
• HOTT in ED/intubated
• MTP/TXA
• Taken to pan scan>eFAST neg

Untitled Slide

Pan Scan

• C456 #
• R sided ribs, scapula #s
• pneumobilia
• pelvic #
• Died in CT
• Coroner case
• No issues-good team work
• patient-MDD/ADHD

96 F 110027875

• Past hx HTN, DM, CHF, CVA, PMR/TA, pancreatitis
• Witness collapse at home, bystander CPR (son)
• 1325-droopy face, 911
• 1337-cardiac arrest-no shock advised
• 1355-ROSC after EPI x 2

in ED

• Intubated in field, good ET CO2
• One hour total CPR
• Mottled in ED, no POCUS cardiac activity
• Reviewed w coroner-not a case
• no issues

58 M 110073930

• 0915-crushing chest pain
• 911-BLS, LOC, CPR
• Aystole, PEA
• EPI x 7 (!)
• ETT, ETCO2 45

in ED

• Calcium/bicarb/ket
• pH 7.08/lactate 11.8
• ECMO not initiated due to 'lack of CNS signs during CPR'
• Total of 12 mg EPI/TNK given
• Reviewed w coroner-no case
• total 1:45 CPR**

in retrospect

• ECMO (direct to SPH?)
• 'he abused his heart'
• syncope in 2010 in ortho office-sinus brady, normal holter
• likely cardiac thrombosis
• medical pause?

73 F 110737350

• Pre hospital cardiac arrest, likely 5 min no CPR? PEA/tube/EPI 1mg
• Discharged 10 d prior (PNA)
• MOST 3 upon DC
• Past history: COPD, AUD, Afib, hemorrhagic CVA, PVD
• Care reviewed in ED with family-comfort
• Died next day under PC. No issues

91 M 112491432

• brought in by family with general decline/FTT/not eating nor drinking
• requesting comfort care

MAiD

• wife had MAiD earlier in year
• he requested MAiD but denied due to cognitive impairment
• @ under PC, died next day
• AKI/WBC up on basic workup
• no issues (access to home care?)

morbidities

Bleeding

• 59 F cc BRBPR
• hx of same, @ to outside hospital and transfused-source?
• Pelvic in ED-massive pool of blood on bed
• Sent for CT angio
• HGB 120

Not GI

• Grade 1 endometrial CA
• TLH BSO
• DC for MONC follow up

12 M groin pain

• 1350 L groin pain at school
• 1519 triage-L groin pain, 6 x emesis. No trauma
• CTAS 3 to intake

EDMD 1925

• Abdo N, no CVT
• L scrotal edema w no cremasteric reflex
• UA neg/WBC 13.9
• US: "no vascularity identified throughout L testicle"

Urology

• 8 h since symptom onset
• 360 degree torsion
• no perfusion recovery after 20' of warming
• orchiectomy

issues?

• triage
• time to MD
• ED de-torsion attempt?

80 M

• PO ~ 3 weeks minimally invasive esophagectomy, lap J tube w esophagogastric conduit
• presents to LGH ED with SBP in shock (SBP 60/P)

6 d prior

• CT AP to assess for retained J tube
• "fluid distension in distal esophagus. Small bilateral pleural effusions. Small volume bilateral subcutaneous emphysema in both chest walls/posterolateral abdominal walls"
• No documentation. Apparently seen in ED, sent home

LGH ED

• moved to resus
• push dose EPI/levophed/BS abx
• CT head/chest/abdo/pelvis

CT

• complete disruption of anastomosis with ++ leak
• transferred stat to VGH Thoracics

OR

• VATS
• Stented esophagus
• 2 chest tubes
• eventual stent change
• new J tube

course

• decline
• mets to colon
• GI/Palliative Care
• Nov 26 died with comfort care measures for delirium

issues

• missing documentation
• missed earlier dehis?
• mets on initial CT (colon)
• GOC (PCP=Pall care doc)

weak!!!

• Oct 24/22 syncope
• EHS hypotension 80 syst
• ED 119/67 sit 116/65 standing
• N labs/EKG
• N CTA
• DC home

weak(er)

• Nov 8
• resting hypotension at home (tells me 60 SBP)
• No fever, bleeding, sob, chest pain/palpitations.
• Feels pre-syncopal
• PMHX: psoriatic arthritis, retinal detachment, COVID in July

VS repeated

• postural drop (more than 40 mmHG)
• random cortisol 119
• ACTH stim confirms adrenal insufficiency
• CT no adrenal masses

Primary Adrenal Insufficiency

• no hx of exogenous steroids
• DC home with hydrocortisone/fludrocortisone
• ENDO follow up

80 M post op hip pain

• POD 13 from THR
• ++ pain (mis-step in house?)
• no fever
• XR, duplex N, labs N
• better with analgesia in hallway

Labs

• Na 114 (135-145)
• remainder of labs N
• pharmanet-no culprits
• PMHX-CABG w AVR, HTN, DM, Migraine

"He always has low sodium doc"

Hyponatremia

• estimated him to be euvolemic (SIADH)?
• urine sodium ordered
• IM consulted-"Poor PO intake. I see it all the time with these old guys"
• 'tricked ortho in to being MRP'

SMS-sellar mass!

Course

• 500 cc NS>NA 112
• Fluid restriction, salt tabs
• Nov 25 (day 3 admission) CODE 77>slurred speech, R arm weak> Na 120
• Nov 27 DC home Na 129
• Neurosurgery follow up

Some good news

Sept 11 2020

• 45 F seizure and fall
• GCS 6
• Breast CA tx
• Na 117
• intubated, hypertonic saline

Course

• CT CTA=acute carotid dissection, no brain mets nor bleeding
• GOC=full code
• ICU=did well, no need for anticonvulsants. DC Na 139
• ASA upon DC
• SIM Case BC EMN

Nov 22/22

chest pain

• ongoing cancer treatments
• R sided chest pain
• CT PE neg
• normal workup
• cancer free!

Tamiflu?