ED/ICU mortality and morbidity

1. ED/ICU mortality and morbidity A 55 year old female suffered from hypertension and altered mental status 報告者：急診醫學科R4 劉書君 報告日期：2013-10-02 指導醫師：石啓仲醫師 主持：邱德發醫師

2. 2013/09/23 08:15(00:00) • 55 year old • Female • 163cm, 55kg • T:35.7 P:108 R:22 SBP:221 DBP:119 E:2 V:2 M:5 • 檢傷二級 • 檢傷主訴:病患來診為意識程度改變,血行動力循環不足

3. 2013/09/23 08:15(00:00) • Chief complaint: altered mental status with agitation, duration unknown • Present illness: • HTN history, found faint at the bathroom, time unknown
No limbs twitching, no eyeball deviation; • No vomitus, no wound or bleeding • Susp. onset at 03:30; Sent to LMD around 4:00 • Hypoxia ? • LMD: brain CT: Brian stem tumor ? • Past history: Hypertension • No liver disease, no cirrhosis, no heart disease

4. 2013/09/23 08:15(00:00) • T:35.7 P:108R:22 SBP:221 DBP:119 • Physical examination • Patient has no evidence of pain
GCS: E1V2M4
HEENT: Pale conjunctiva, Pupil: 2+/2+
       doll eye sign (-)
CHEST: Bil. coarse breathing sound; crackle (+)
       No wheezing, no stridor
Abd: soft, no distended, no tenderness
Ext: freely movable, no edema

5. BRAIN CT (C-)

6. MORE HISTORY?MORE PE?FIRST IMPRESSION?INITIAL ORDER? 你還想問什麼？ 你心中有哪些differentialdiagnosis？ 想讓病人做什麼檢查？

7. More History • Allergy • Medication • Past history • Last period/ Last meal • Event/ environment

8. More PE • Neurologic examination • Cranial nerve, facial palsy, muscle power • Meningismus • barbinski sign • gait • Special odor • Needle puncture • Skin rash, skin turgor

9. Hypertensive emergency • Hypertensive urgencyis a clinical presentation associated with severe elevations in blood pressure without progressive target organ dysfunction. • Hypertensive emergencyis an acute elevation of blood pressure (180/120 mm Hg) associated with end-organ damage, specifically, acute effects on the brain, heart, aorta, kidneys, and/or eyes • The majority of patients who present with a hypertensive emergency have a history of hypertension (84% to 93%) Tintinalli’s emergency medicine, 7ed, Ch 61

10. Tintinalli’s emergency medicine, 7ed, Ch 61

11. Acute neurologic symptoms and severe hypertension • Intracranial hemorrhage • Subarachnoid bleeding • Acute stroke • Hypertensive encephalopathy • Hypertensive encephalopathy is characterized by insidious onset of headache, nausea and vomiting, followed by non-localizing neurologic symptoms such as restlessness, confusion, seizure or coma. • UptoDate 2012 Tintinalli’s emergency medicine, 7ed, Ch 61

12. Hypertensive encephalopathy • Hypertensive encephalopathy is (1) acute in onset and (2) reversible. • Hypertensive encephalopathy is an uncommon syndrome resulting from an abrupt, sustained rise of BP that exceeds the limits of cerebral autoregulation of the small resistance arteries in the brain. (MAP >160 mmHg) Tintinalli’s emergency medicine, 7ed, Ch 61 Rosen’s emergency medicine, Ch83 hypertension

13. 2013/09/23 08:27(00:12) • Impression: • Malignant neoplasm of brain stem • Hypertension • General weakness • Shortness of breath

14. 2013/09/23 08:27(00:12) • CBC/DC, PT, APTT • BUN, CR, NA, K, CA, BILIRUBIN(T), AST, ALT, SUGAR, ALBUMIN,AMMONIA, TROPONIN I, ABG • U/A, ICON • EKG, CXR • 備血：一般用血 血品 :PRB 2U,FFP 2U,PC 12U • RECHECK BP 30 mins later   • O2 2L/min   • Hydralazine 20mg 0.5amp IV stat  

15. Medication choice?Target BP? 如果是你，你會用什麼藥物降血壓？ 你想要把血壓控制在多少？

16. Blood pressure reduction • Blood pressure reduction in the setting of neurologic emergencies typically requires emergency CT scanning to determine diagnosis, treatment thresholds, and priorities. • Hypertensive encephalopathy is the clearest indication for blood pressure reduction • Blood pressure reduction is controversial in the setting of acute vascular lesions, subarachnoid hemorrhage, intracranial hemorrhage, and ischemic stroke. Tintinalli’s emergency medicine, 7ed, Ch 61

17. Hypertensive encephalopathy • Hypertensive encephalopathy is a true medical emergency, rapid measured reduction of BP is mandatory • Excessive reduction of BP must be avoided to prevent increasing cerebral ischemia. • The standard treatment regimen is intravenous (IV) nitroprusside with a careful reduction of the MAP by 25% or to a minimum diastolic pressure of 110 mm Hg over an hour. Rosen’s emergency medicine, Ch83 hypertension

18. Tintinalli’s emergency medicine, 7ed, Ch 61

19. Goal of hypertension control • Hypertensive encephalopathy • Decrease MAP 15%–20% • Subarachnoid hemorrhage • SBP< 160mmHg or MAP < 130mmHg • Intracranial hemorrhage • P’t with suspicion of elevated ICP: MAP <130mmHg • P’t without suspicion of elevated ICP: MAP < 110mmHg or SBP < 160mmHg • Acute ischemic stroke • If fibrinolytic therapy planned, treat if >185/110 mm Hg. • Treat if >220/120 mm Hg on third of three measurements, spaced 15 min apart

20. Lab data

21. Lab data

23. 2013/09/23 09:05 (00:50) • T:36 P:98SBP:220 DBP:108 • CT.MRI Indication: conscious disturbance • Midazolan 5mg 1amp IV stat • BRAIN CT (C+/-) • ETHYL ALCOHOL (B) • AMPHETAMINE (U) • On foley catheter

24. 2013/09/23 10:02 (01:38) • P:98SBP:217 DBP:110 • HTN history • No use anti HTN for at least 5 days • 四肢保護性約束 • NICARDIPINE LINE: 5 AMPS IN N/S 100ML RUN 3ML/HR; ↑↓2ML/HR; KEEP SBP < 160MMHG • Morphine 5mg IM stat

25. NEXT STEP? 你覺得這個病人是怎麼了？ 接下來你想要做什麼？

26. Sympathetic crisis • Pheochromocytoma • Headache, alternating periods of normal and elevated blood pressure, tachycardia, and flushed skin, punctuated by asymptomatic periods • 24-h urine test for catecholamines and metanephrine • Sympathomimetic drug use • Tachycardia, diaphoresis, and hypertension, with or without mental status changes. • cocaine, amphetamine; positive urine drug screen result

27. Acute sympathetic crisis • The preferred initial treatment : IV benzodiazepine, such as lorazepam or diazepam • If first-line treatment is not successful •  nitroglycerin, phentolamine, or CCB (Nicardipine) may be used

28. Acute sympathetic crisis • The use of b-blockers is not recommendedbecause unopposed b-blockade can cause alpha storm and increase cocaine toxicity • Most hypertension will resolve with time and benzodiazepines. • Watch respiratory rate.

29. Brain Ct (C+/-)

30. What is your interpretation? 這個檢查有改變你的想法嗎？

31. 2013/09/23 10:32 (02:17) • T:36 P:89SBP:179 DBP:98 • Friends suggest without using of anti-hypertensive for five days • SBP: > 220mmHg at ER • CONSULT Dept 心臟內一科 Tm. 102/09/23 10:31 • Midazolan 5mg IV stat 

32. 2013/09/23 11:57 CV consult sheet • Assessment:
1.Consciousness disturbance, cause? illicit-drug related?
2.HTN urgency
3.Hypokalemia • Plan:
1.Please rule out other possible etiologies of consciousness disturbance.
2.Control HTN with IV drugs if NO contraindications
3.Survey the etiology of hypokalemia
4.CCU admission if NO active CNS lesion; not suitable for ordinary ward.

33. 2013/09/23 11:59 (03:44) • Admission to MICU2 2013/09/23 12:23 (04:08) • Acute respiratory failure • Midazolan 5mg IV stat • Rocuronium 50mg IV stat • On ETT 7.5 fix 22 with ventilator • On NG • CXR (B)

34. MICU2 admission course • Midazolan line • Nicardipine line • NTG line • Consult NS • 9/25 Operation NS consult sheet: Acute hydrocephalus, rule out recent SAH/IVH, or infection related

35. OP finding • 2013-09-25 EVD and ICP monitor • Right frontal EVD insertion • Initial ICP>20mmHg with yellow to pink CSF gushed out • 2013-09-26 • Right ICA injection: a Pcom A aneurysm was noted 0.6 x 3.6 (NECKX DOME) ; volume: 13 mm3 • Left ICA injection: left Pcom A favor infundibular dilatation • 2013-9-26 • TAE of right Pcom aneurysm

36. Final diagnosis • Subarachnoid hemorrhage • 9-25 EVD and ICP monitor • 9-26 TAE of right P-com aneurysm • Hypertension • Amphetamine abuse • Current status: • Extubation on 9-27 • E4V4M6 • NS ward admission and post OP care

37. Discussion Hydrocephalus

38. Hydrocephalus • Obstruction (most common): non-communicating • foramen of Monro, at the aqueduct of Sylvius, or at the fourth ventricle and its outlets • Impaired absorption (less common): communicating • Inflammation • Excessive production (rare)

39. Hydrocephalus • Congenital hydrocephalus • Acquired hydrocephalus • Infection and tumor • Infection: bacterial/viral meningitis • Tumor: Posterior fossa medulloblastomas, astrocytomas, and ependymomas • Post-hemorrhagic • hemorrhage into the subarachnoid space or, less commonly, into the ventricular system • Low pressure hydrocephalus • Uncommon, extremely challenging to manage • result from tumors, chronic hydrocephalus, subarachnoid hemorrhage, and infections

40. Post hemorrhagic hydrocephalus • The main mechanism for hydrocephalus is impaired absorption of CSF (communicating hydrocephalus) • CT demonstrated acute hydrocephalus less than or equal to 72 hours after SAH in 24 (23%) of 104 patients. • International Study on the Timing of Aneurysm Surgery. • 3521 patients • Hydrocephalus was diagnosed on admission computed tomographic (CT) scans in 15% of patients and was thought to be clinically symptomatic in 13.2% of patients. There was a 5.9% overlap between these groups.  Hasan, D., Lindsay, K. W., & Vermeulen, M. (1991). Treatment of acute hydrocephalus after subarachnoid hemorrhage with serial lumbar puncture. Stroke, 22(2), 190–194. doi:10.1161/01.STR.22.2.190 Graff-Radford NR, Torner J, Adams HP, Jr, & Kassell NF. (1989). Factors associated with hydrocephalus after subarachnoid hemorrhage: A report of the cooperative aneurysm study. Archives of Neurology, 46(7), 744–752. doi:10.1001/archneur.1989.00520430038014

41. Subarachnoid hemorrhage • Hydrocephalus is a common complication of SAH • Drainage should be considered for patients who have a deteriorating level of consciousness and for those in whom no improvement in hydrocephalus occurs within 24 hours • Earlier reports suggested that the frequency of rebleeding was increased with external ventricular drainage for acute hydrocephalus after aneurysmal SAH • these studies had methodologic limitations, and later reports have found no association of external drainage with the risk of rebleeding

42. Take home message • Acute Hydrocephalus is an indirect sign of SAH • Diagnosis of hypertensive encephalopathy shall be made after excluding intracranial lesion • Seek second opinion of image study