ALTERED MENTAL STATUS IN A 36 Y/O FJonathan B Wilfong, MD

January 31, 2014

Fletcher Allen Health Care

Admission

36 y/o F is transported to FAHC after being found in bed with altered mental status, responsive only to pain. Per EMS report, two men, one being her husband, were found deceased at the scene with drug paraphernalia scattered close-by. There was no evidence of trauma.

Prior to arrival she was treated with Flumazenil 0.5 mg x2, Naloxone 2 mg IV x4 at a local hospital. She briefly regained consciousness following Flumazenil administration but mental status declined rapidly again. She arrives intubated, off sedation, and is admitted to the MICU for management of hypoxemic respiratory failure.

History

PMH•Substance abuse (benzos, barbituates, IV heroin)•Depression w suicide attempt (overdose, laceration)•Victim of domestic violence•History of imprisonment•Multiple psychiatric (MDD, BPD1, PTSD, ADHD)•Recent aspiration pneumonia in the setting of recent drug overdose

FHx •Unknown

HistoryMedications•busPIRone (BUSPAR) 10 mg tablet •clonAZEPAM (KLONOPIN) 0.5 mg tablet •fluvoxaMINE (LUVOX) 50 mg tablet •montelukast (SINGULAIR) 10 mg tablet •pantoprazole (PROTONIX) 40 mg tablet •Prazosin (MINIPRESS) 2 mg capsule •risperiDONE (RISPERDAL) 1 mg tablet •topiramate (TOPAMAX) 100 mg tablet •albuterol (VENTOLIN HFA) 90 mcg/actuation inhaler •fluticasone-salmeterol (ADVAIR HFA) 45-21 mcg/Actuation inhaler

Allergies•NKDA

Social History• Born in New York, NY• Married, Living in Plattsburg• Married, 3 teenage children in NYC• Known hx of long-standing illicit and Rx drug use

Objective

In the field [AM, Day 1]•62/45•106•20•79% SpO2 on RA

Following intubation, I/O line x2, 2L NS [18:00, Day 1]•105/71•115•29•100% SpO2 on 0.70 FiO2

Initial Evaluation and Work-up

Initial Evaluation and Work-up

142

4.8

97

19

26

1.26130 5.4

11.9

36.8254

AST 87ALT 40tBili 0.3tPro 6.7

24

UASpecGrav 1.02LeukEst negNitrite neg3+ blood

pH 6.0

7.34 / 35 / 94 / 24 on 0.70( PaO2:FiO2 134 )

UTox+ Barbituate+ Benzodiazepine+ Amphetamine

Phenobarbital level 85.5 (15-40) Lactate 3.4

Troponin < 0.034CK 1860

Management• 33.7C , 83/51, 96, 22, GCS 8, ventilated [0:00, Day 2]• Aspiration in the setting of poly-substance use was

suspected.• Pulm: Levofloxacin, Vanc, tapering off ventilator• Cor: IV fluid resuscitation, serial lactate, serial EKG• RenalL: Foley catheter, monitor UOP• Neuro: Head CT negative, Serial neuro exams• GI: NPO• ID: Sputum, Blood, Urine Cx. Abx as above• PPx: PPI, SQ Heparin, SCD

Day of Hospitalization #2• 7.38 / 30 / 60 / 18 on 0.55 (PaO2:FiO2 109) [05:00, Day 2] • Improving mental status, responding to commands

but…• Systolic pressure continued to drop despite 4L IVf

78/46, 138, 33, 98% on 0.60• Levophederine gtt started

The patient was declining despite aggressive supportive care.

Day of Hospitalization #2• Bedside Echocardiogram was performed suggesting RV

ballooning with septal flattening• A STAT CT PE protocol of chest was obtained• A STAT echocardiogram was obtained

CT PE Protocol

CT CHEST W CONTRAST (PE) PROTOCOL 11/1/2013 1:01 PM

Findings: Opacification of the pulmonary vasculature is good. There is a saddle embolus with clot extending predominantly into the lower lobe pulmonary arteries, with the most significant clot burden in the left lower lung. Additional regions of emboli are seen in the right middle lobe There is evidence of right heart strain with a right ventricle to left ventricular ratio of greater than 1.

Echocardiogram

Impressions: Cor pulmonale. Summary: 1. Left ventricle: The cavity size was below normal. … Systolic function was hyperdynamic. The estimated ejection fraction was 65-70%. Wall motion was normal; there were no regional wall motion abnormalities. 2. Ventricular septum: The contour showed diastolic flattening and systolic flattening. 3. Right ventricle: The cavity size was severely dilated. Systolic function was severely reduced. 4. Pulmonary arteries: Pulmonary systolic pressure was moderately increased, estimated to 50mm Hg.

BP 62/45 HR 106RR 20 Found w AMS, Intubated

BP 105/71 HR 115RR 29Stable,Arrives at FAHC

BP 83/51 HR 96RR 22MICU, Improving mental status

BP 78/46 HR 138RR 33Declining mental status

IntubatedIV access2L NS

FlumazenilNaloxone

2L NSCentral lineLevofloxacin

LevophedVancomycin

Bedside echo

CTangio TPA

0:0012:00 12:00

Echo

Transfer

Phenylepherine added

0:00

BP 86/47 HR 128RR 26Unresponsive

CT Head

PULMONARY EMBOLISM IN THE SETTING OF CRITICAL ILLNESS

Overview

• Incidence• Pathophysiology• Diagnosis• Treatment• Outcomes

Incidence• “Obstruction of the pulmonary artery or one of its

branches by material (eg, thrombus, tumor, air, or fat) that originated elsewhere”• Massive = sustained hypotension

• 112.3 per 100,000• Mortality estimated 30% if untreated• Risk factors

• Immobilization• Obesity, Heart Disease• Malignancy, Autoimmune• Central venous instrumentation, Surgery• Smoking, Medications

Pathophysiology• 50-80% from below popliteal vein• Severe acute VQ mismatch• Death is by R heart failure, acute cardiogenic shock• Increase in mortality from PE and overall

• RV strain • Mural thrombus• DVT

• Associated w increased mortality• BNP• Troponin• Hyponatremia• Lactate

Diagnosis• Clinical findings nonspecific

• DVT signs (47%)

• Diagnostic studies• S1Q3T3 on ECG suggestive of cor pulmonale• Lower extremity US for risk reduction – not diagnosis• VQ scan 15-86% diagnostic accuracy• D-Dimer high negative predictive value• CT angiogram, 53-98% diagnostic accuracy

• Echocardiogram• Increased RV size• TR• Mural thrombus• McConnell sign (hypokinesis w apical sparing)

Echocardiogram• http://www.youtube.com/watch?v=x4bVhnL3Ix8

Treatment: A Simplified Algorithm

1. Stabilize

2. Anticoagulate

3. Unstable? Thrombolysis

4. Unimproved? Consider Embolectomy

Treatment of Acute Massive PE• Correction of hypoxemia• Hemodynamic Support

• IV fluids, 500-1000 mL• Pressors: NorEpi/Epi/Dobutamine

• Empiric Anticoagulation within 24hr• Weigh against risk of acute bleed (recurrent PE 25% > Bleed 3%)• LMWH as tx in uncomplicated cases• IV UFH if massive PE, risk of bleed, or considering lysis, thrombectomy

Dosing IV UFH• Bolus 80 mg/kg• Infusion 18 mg/hr• Titrate to institution protocol goal aPTT• If abnormal PTT response

• Follow anti-Xa

• When to consider thrombolysis?

Thrombolysis• Indication:

• persisting SHOCK• Isolated RV dysfunction..?

• Outcomes:• Early hemodynamic improvement• No proven mortality benefit

• (3.5 vs 6.1 percent, relative risk 0.7, 95% CI 0.37-1.31)

• Increased risk of major bleeding• (9.0 vs 5.7 percent, relative risk 1.63, 95% CI 1.00-2.68)• Risks for bleeding not well characterized• Intracranial hemorrhage rate ~3%

Contraindications• Surgery in last 10 days• Bleeding diathesis• Intracranial neoplasm• Severe HTN (>200)• Ischemic stroke within 2 months• Past hemorrhagic stroke• Intracranial trauma/surgery in last 6 months• Thrombocytopenia (<100k)

tPA Dosing• Binds Fibrin affinity for Plasminogin activation• Administration

• Stop Heparin• tPA 100 mg IV infusion over 2 hr• Re-check aPTT• Restart anticoagulation

• Reassess hemodynamics routinely

Thrombectomy• Catheter

• Interventional Radiology• Limited data• Requires vascular access with chance of bleeding• High intraoperative mortality

• Open Surgical• High mortality• Requires cardiopulmonary bypass• High rate of intraoperative myocardial infarction• No evidence of better outcomes than repeat tPA

• Lower risk of severe bleeding?

Our patient• tPA was administered with little to no benefit at four hours• Surgical thrombectomy not available at FAHC• Urgently transferred by air to Brigham and Womens • Repeat CT showed migration of thrombus• Supportive care continued in MICU

Bedside echo

Take Away• Think PE on the DDx for cardiogenic shock• Bedside US can aid in diagnosis• Urgent anticoagulation with IV UFH• There are 8 strict contraindications to tPA• No evidence of improved mortality w tPA• Surgical thrombectomy as a last resort