RN GRAND ROUNDSMay 16th, 2012

Thursday, May 17, 12

CASE 1

22 yo M , college student

CC: Nausea / Vomiting

PMH: ADHD/ Anxiety

Meds: Adderall

HPI: 3 day hx of N/V, this is his third visit for same

Thursday, May 17, 12

CASE 1- N/V

Vitals: 152/81, P 103, RR 16, T 97.5, Sat 100% RA

Pt seen two other times for same and sent home

IVF, Zofran IV, Compazine PR, CT head neg, K+ was 3.0

Rash on back noted by RN, did not look like Erythema chronicum migrans “bullseye”

Maybe there for several months according to the ID consult

Lyme titer added to labs

Thursday, May 17, 12

WORKUP

Admitted to medicine for workup

CT abdomen was neg

ID consulted for positive Lyme titer ( ELISA)

Western blot added (confirmatory test)

Thursday, May 17, 12

ECM RASH

Note “bullseye pattern” typical for Lyme Disease

Thursday, May 17, 12

LAB TESTS

Laboratory blood tests are helpful if used correctly and performed with validated methods. Laboratory tests are not recommended for patients who do not have symptoms typical of Lyme disease. Just as it is important to correctly diagnose Lyme disease when a patient has it, it is important to avoid misdiagnosis and treatment of Lyme disease when the true cause of the illness is something else.

Source: cdc.gov

Thursday, May 17, 12

LYME TITER

http://www.cdc.gov/lyme/diagnosistreatment/LabTest/TwoStep/

Thursday, May 17, 12

WESTERN BLOT

The confirmatory test for a positive Lyme titer

Many false positives occur with with the Lyme titer

This clarifies equivocal or positive tests

Western Blot sub-fractionates the IgG and IgM

Thursday, May 17, 12

WESTERN BLOT

For Positive Results you must have:

An lgG Western Blot must have five or more of these bands: 18, 21,28, 30, 39, 41,,45, 58, 66 and 93 kDa.

An lgM Western Blot must have two or more these three bands: 23, 39, 41

Source: www.whatislyme.com

Thursday, May 17, 12

OUR PATIENT’S WB

IgG - Negative overallonly 2 bands posProb no chronic infection

IgM- 2 of 3 are positivepresumes acute infection

Thursday, May 17, 12

WB DISCLAIMER

Thursday, May 17, 12

SUMMARY

False positives on the initial Lyme titer and Western blot can occur

Routine testing without actual symptoms causes unnecessary concern, further testing and treatments

Much controversy exists on the actual interpretation of Western blot

Thursday, May 17, 12

WESTERN BLOT

False-positive reactions may occur with patients with other spirochetal diseases (syphilis, yaws, pinta, relapsing fever, or leptospirosis), influenza, autoimmune disorders, multiple sclerosis, or amyotrophic lateral sclerosis.

http://www.mayomedicallaboratories.com/interpretive-guide

Thursday, May 17, 12

CASE 2

22yo F Status post delivery of twins 6 days ago

CC: Headache/ HTN since yesterday

Pain 6/10

PMH: Asthma, Migraine, Pre ecclampsia (RN note)

Arrival 1414hrs, PA time 1448 hrs in FT

BP:144/69 in triage

Thursday, May 17, 12

MD NOTE

2 days of HA

Hx migraines, this was “more severe”

BP running high, repeat in ER at 1651 hrs at 175/99, 1705 hrs Gyn consulted

1739hrs at 189/114

1740 hrs Labetalol 10mg IV

1849hrs Hydralazine ordered IV ? in MD note, not RN

1911 Magnesium IV ordered 4 grams over 15 mins

Thursday, May 17, 12

POST-PARTUM HA/ HTN

Thursday, May 17, 12

HTN IN PREGNANCY

Gestational HTN: found late in pregnancy, no other findings for preeclampsia, “transient” , clears by post partum week 12

Chronic HTN Preceding Pregnancy- ≥140/90, before 20 wks, persists beyond 12 weeks

Chronic HTN with PIH ( preeclamsia or eclampsia) highest risk

Thursday, May 17, 12

PREGNANCY INDUCED HTN

Preeclampsia- mild/ BP ≥ 140/90, > 20 wks gestation, no end organ damage, >300mg protein/ 24hrs.

Severe Preeclampsia- SBP ≥160/110, proteinuria > 5gr/ 24hr, Headache, Epigastric pain, Low PLT, Oligouria < 400mg/ 24hr, Pulmonary edema

Thursday, May 17, 12

PREECLAMPSIA RISK FACTORS

Nulliparity

Previous gestational hypertensive disorders

Diabetes

Malnutrition

Hydatiform mole

Low social status

Chronic Nephritis

Thursday, May 17, 12

PREECLAMPSIA SIGNS & SYMPTOMS

CNS: Headache, visual disturbances, altered mental status, blindness, weakness & malaise

Edema

Epigastric Pain

Dyspnea

Seizures- on top of the criteria for preeclampsia define Eclampsia

Thursday, May 17, 12

MANAGEMENT

Delivery is the only “cure”

HTN management

Hydralazine/ Labetalol IV/ Sodium nitroprusside

IV Magnesium - seizure prevention “eclampsia”

IV Fluids, patients are intravascularly depleted

Thursday, May 17, 12

HELLP SYNDROME

H- Hemolysis

EL- Elevated Liver Enzymes

LP- Low platelets

Occurs in 10-20% of women with Preeclampsia or Ecclampsia

Women usually have HTN/ Preeclampsia before HELLP syndrome is noted.

Thursday, May 17, 12

HELLP SYNDROME

Fatigue

Headache

N/V

Blurry vision

RUQ pain

Fluid retention/ edema

Thursday, May 17, 12

LABS

All women with new onset HTN: CBC, AST/ALT, BMP, Uric acid, LDH, Indirect Bilirubin, PT/PTT

HELLP: check Spot Protein (prot/creat ratio) > 0.3, Proteinuria > 300mg/ 24hr, Uric Acid> 5.6, Creat> 1.2

Also for HELLP: PLT < 100k, Elevated PT/ PTT, Decreased Fibrinogen, Hemolysis markers ( peripheral smear, Indirect Bili > 1.2, LDH>600)

Thursday, May 17, 12

OUR CASE

Pt was seen in triage. BP was144/69, RN noted home BP of 170/110

Pt had Headache, got Reglan (no note of vomiting on chart), had leg edema

Sent to Fast Track

MD involved after PA presentation

Thursday, May 17, 12

PREECLAMPSIA

Lessons learned.......

Thursday, May 17, 12

LACTIC ACIDOSIS

The product of anaerobic metabolism

Number one cause of metabolic acidosis

Causes anion gap

AG= Na⁺ - (Cl⁻ + HCO3⁻)

Bicarb (HCO3⁻) will be low

Lactate above 4meq/L is abnormal

Thursday, May 17, 12

LACTIC ACIDOSIS

Thursday, May 17, 12

METABOLIC ACIDOSIS

MUDPILES Methanol- metabolized to Formic Acid via liver enzymes, cellular hypoxia, blindness

Uremia- increased bicarb wasting leads to acidosis

DKA- ketone formation in the absence of insulin from fatty acid breakdown

Paraldehyde- sedative no longer in use

INH- inhibits lactate dehydrogenase

Lactic Acidosis- type A ( hypoperfusion) and type B ( DM, toxins,

Ethylene glycol- antifreeze degradation produces glycolic acid and oxalate

Salicylates- ie ASA overdose

Thursday, May 17, 12

METABOLIC ACIDOSIS

Anion gap- associated with an unmeasured anion produced or gained

Thursday, May 17, 12

TYPES OF LACTIC ACIDOSIS

Type A: from tissue hypoperfusion/ hypoxia

Type B- Drugs, DM, Liver disease, malignancy, inborn errors of metabolism

Thursday, May 17, 12

LACTIC ACIDOSIS

When to order?

Think of the situation.

Hypoxia- asthma, COPD, CHF

Increased Metabolic Activity- seizure, exercise, shivering ( doesn’t change management)

Sepsis- dead bowel, overwhelming infection, fever

Thursday, May 17, 12

SEPSIS

SIRS definition- Systemic Inflammatory Response Syndrome

Essentially a cytokine storm with abnormal

Thursday, May 17, 12

SEPSIS

SIRS due to an infection is SEPSIS

Non Sepsis Causes- trauma, burns, pancreatitis, ischemia and hemorrhage

Also- anaphylaxis, tamponade, PE, Adrenal insuff., complications of surgery, Overdoses

Complications- organ failure

Thursday, May 17, 12