Rn grand rounds may 2012

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


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


WORKUP

Admitted to medicine for workup

CT abdomen was neg

ID consulted for positive Lyme titer ( ELISA)

Western blot added (confirmatory test)


ECM RASH

Note “bullseye pattern” typical for Lyme Disease


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


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

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

http://www.cdc.gov/lyme/signs_symptoms/index.html

http://www.cdc.gov/lyme/signs_symptoms/index.html

http://www.cdc.gov/lyme/diagnosistreatment/Treatment/

http://www.cdc.gov/lyme/diagnosistreatment/Treatment/

LYME TITER

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






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


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


http://www.whatislyme.com

http://www.whatislyme.com

OUR PATIENT’S WB

IgG - Negative overallonly 2 bands posProb no chronic infection

IgM- 2 of 3 are positivepresumes acute infection


WB DISCLAIMER


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


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






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


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


POST-PARTUM HA/ HTN


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


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


PREECLAMPSIA RISK FACTORS

Nulliparity

Previous gestational hypertensive disorders

Diabetes

Malnutrition

Hydatiform mole

Low social status

Chronic Nephritis


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


MANAGEMENT

Delivery is the only “cure”

HTN management

Hydralazine/ Labetalol IV/ Sodium nitroprusside

IV Magnesium - seizure prevention “eclampsia”

IV Fluids, patients are intravascularly depleted


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.


HELLP SYNDROME

Fatigue

Headache

N/V

Blurry vision

RUQ pain

Fluid retention/ edema


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)


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


PREECLAMPSIA

Lessons learned.......


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


LACTIC ACIDOSIS


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


METABOLIC ACIDOSIS

Anion gap- associated with an unmeasured anion produced or gained


TYPES OF LACTIC ACIDOSIS

Type A: from tissue hypoperfusion/ hypoxia

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


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


SEPSIS

SIRS definition- Systemic Inflammatory Response Syndrome

Essentially a cytokine storm with abnormal


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


Rn grand rounds may 2012

Health & Medicine

Transcript of Rn grand rounds may 2012