Dr Alby Maria Mathews JR3 M4 unit CLINICAL PRESENTATION 58 year old male diabetic and hypertensive not on medication Presented to ER at 12 am on 1872022 ID: 1035953
Download Presentation The PPT/PDF document "MORTALITY CLUB" is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
1. MORTALITY CLUB Dr. Alby Maria Mathews JR3 M4 unit
2. CLINICAL PRESENTATION58 year old male diabetic and hypertensive not on medicationPresented to ER at 12 am on 18/7/2022Recent h/o travel to Chennai 1 week back.Had one episode of fever 1 week back.He had history of loose stools 10 to 15 episodes per day for the past 5 days.Had diffuse abdominal pain for the past 5 days.
3. Associated with blood in stools for the past two days.Four episodes of vomiting past 2 daysDiffuse abdominal pain
4. He was a known diabetic and hypertensive not on medicationHad no other significant past medical or surgical historyNo h/o any trauma He was a chronic smoker , non-alcoholic
5. On examination,Patient was conscious orientedGeneral examination NADPR 110/min regularBP 190/90 right arm supine position; spo2 96%RaAfebrile
6. System examinationGIT: oral cavity NADPer abdomen diffuse tenderness was presentNo guarding or rigidityNo hepatosplenomegalyNo shifting dullness
7. Nervous system : no signs of any focal neurological deficitRespiratory system: normal vesicular breath sounds heard bilaterally equal in all areasCVS: S1 S2 heard; no added sounds
8. Surgery opinion was sought from the casualtyPer rectal examination was done :hemorrhoids at 3 and 5 O clock position with active bleeding
9. Provisional diagnosisAcute gastroenteritisInvasive diarrhea Bleeding hemorrhoids
10. Initial managementPatient was managed in the casualty observation roomHad stable vitalsSymptomatic care was given with iv fluids , PPIs ,antiemetics and antispasmodic agents.Later admitted in view of persisting symptoms.
11. Two hours later, patient developed worsening of abdominal pain while in ward.Patient was given analgesics and antispasmodic agents.Emergency x rays were ordered.
12. 8.30 am during ward rounds, patient complained of a new onset weakness of right lower limb and inability to stand and walk for the past two hours.Bloody diarrhea was persisting.Abdominal pain was persisting.Now he gave a history of pain and numbness over the right lower limb for the past one week, which worsened while walking and was relieved at rest. He had consulted a local hospital and had taken i v analgesics for the same
13. Reassessed Patient was conscious, oriented and restless.Bilateral lower extremities were cold,Tachypneic RR 45/min; PR 12O/min regular ; bilateral lower limb pulses were absent up to the femoral level. BP: 230/110 right upper limb supine position; spo2 98% ra
14. Cranial nerves WNLBilateral lower limbs hypotonicRight LL grade 0 power ; left LL grade 3DTRs absent bilateral lower limbsBilateral plantar reflex muteComplete sensory loss right lower limb up to the level of inguinal ligament.Left lower limb sensations preserved.
15. P/A guarding presentNo local rise in temperatureNo organomegalyShifting dullness not assessed
16. Respiratory system: NADCVS: NAD
17. InvestigationsHb: 16mg/dl ; PCV 54TC: 7600: N66 L28 Platelet 1.78 lakhsBU 38; S. Cr 1.0 Na 133; k 4.6; LFT: WNLaPTT 34 sec INR 0.98
18. ECG : sinus tachycardia; VR 120/minChest x ray: NADXray abdomen: mild dilatation of small bowel and large bowel loops.
19.
20.
21.
22. Discussion In view of the asymmetry in pulses in the upper and lower extremities, a provisional diagnosis of aortic dissection was made.
23. Provisional diagnosisProbable Abdominal aortic dissection Complicated with acute mesenteric ischemia , spinal ischemia and limb ischemia.
24. Intravenous labetalol was given for BP control.Started on iv fluids.Blood sample was sent for crossmatching.Case discussed with radiology department.Planned for emergency CT aortogram.
25. Sustained cardiac arrest while being shifted for CT at 10.30 am.Patient expired despite resuscitative measures.
26. AORTIC DISSECTIONAortic dissection is defined as separation of the layers within the aortic wall.Tears in the intimal layer result in the propagation of dissection (proximally or distally) secondary to blood entering the intima-media space.
27.
28.
29. Hospital-based mortality for aortic dissection is approximately 30%.Patients with type A aortic dissection who undergo surgical treatment have a 30% mortality; patients who receive medical treatment have a 60% mortalityMedically treated patients with type B dissection have a 10% mortality; surgically treated patients with type B dissection have a 30% mortality.Acute aortic dissection (< 2 weeks) - 1% to 2% of patients with aortic dissection die per hour for the first 24-48 hours
30. Clinical manifestations include the following:Sudden onset of severe chest pain that often has a tearing or ripping quality (classic symptom)Chest pain may be mildAnterior chest pain: Usually associated with anterior arch or aortic root dissectionNeck or jaw pain: With aortic arch involvement and extension into the great vesselsTearing or ripping intrascapular pain: May indicate dissection involving the descending aortaNo pain in about 10% of patients
31. SyncopeCerebrovascular accident (CVA) symptoms (e g, hemianesthesia, and hemiparesis, hemiplegia)Altered mental statusNumbness and tingling, pain, or weakness in the extremitiesHorner syndrome (i e, ptosis, miosis, anhidrosis)
32. DyspnoeaHaemoptysis DysphagiaFlank pain (with renal artery involvementAbdominal pain (with abdominal aorta involvement)FeverAnxiety and premonitions of death
33. Possible physical examination findings include :HypertensionHypotensionInterarm blood pressure differential greater than 20 mm HgSigns of aortic regurgitation (e g, bounding pulses, wide pulse pressure, diastolic murmurs)Findings suggestive of cardiac tamponade (e g, muffled heart sounds, hypotension, pulsus paradoxus, jugular venous distention, Kussmaul sign)
34. Neurologic deficits (eg, syncope, altered mental status)Peripheral paresthesiasHorner syndromeNew diastolic murmurAsymmetrical pulses (eg, carotid, brachial, femoral)Progression or development of bruits
35. Possible lab findings includeLeucocytosis - due to stress stateDecrease in Hemoglobin and Hematocrit values.Elevated BUN and S creatinine values- due to prerenal azotemia
36. Elevation of the myocardial muscle creatine kinase isoenzyme, myoglobin, and troponin I and T levels: Myocardial ischemia from coronary artery involvementLactate dehydrogenase elevation: Haemolysis in the false lumenSmooth muscle myosin heavy-chain assay: Increased levels in the first 24 hours are 90% sensitive and 97% specific for aortic dissectionFibrin degradation product (FDP) elevation
37. IMAGINGChest x ray may show widening of the mediastinum and hemothorax if it is ruptured.TEEComputed tomographyMRIAortogram
38. ABDOMINAL AORTIC DISSECTIONIsolated dissecting AAAs are often evident clinically, although the symptoms are nonspecific. The fast expansion of the false lumen of the aneurysm produces early clinical symptoms, such as back pain, peripheral ischemia, distal embolization, and an easily detectable pulsatile abdominal mass.
39. In a review of 47 cases of abdominal aortic dissection, approximately 33% presented with lower limb ischemia, 30% with abdominal pain, and 20% with back or flank pain.More recent clinical series, confirm that dissecting AAAs, although associated with heterogeneous clinical features, are rarely asymptomatic
40. Transient or permanent neurological symptoms at onset of AD are often dramatic and may mask the underlying condition especially in pain-free dissection.They are usually caused by either dissection / occlusion of one or more aortic side branches supplying brain, spinal cord, or peripheral nerves or hypoperfusionSCI on the basis of AD is a rare syndrome and more common with distal Ads.
41. The symptoms are almost bilaterally symmetrical since both halves of the anterior spinal cord are supplied from one anterior midline spinal artery.ASCS with unilateral symptomatology has rarely been reported due to occlusion of unilateral sulcal arteries or collateralization from one posterior spinal artery.This could explain our case with asymmetrical incomplete paraparesis with loss of sensation on right LL till T12-L1 level.
42. If the location of infarction involves the lateral horns within levels T11-L2, it will cause autonomic dysfunction, including neurogenic bowel/bladder.
43. Acute mesenteric ischemiaThe clinical scenario of a patient complaining of excruciating abdominal pain with an unrevealing abdominal exam is classic for early AMI.Abdominal pain 95%, nausea 44%, vomiting 35%, 35% with diarrhoea and 16% with blood per rectum.Clinical signs of peritonitis may be subtle.
44. More than 90% will have an abnormally elevated leucocyte count.88% metabolic acidosis with elevated lactate level.There are no laboratory studies that are sufficiently accurate to identify the presence or absence of ischemic or necrotic bowel, although L-lactate and D dimer may assist.
45. Computed tomography angiography should be performed as soon as possible for any patient with suspicion of AMI, despite the presence of renal failure.When the diagnosis is made, fluid resuscitation , nasogastric decompression and electrolyte abnormalities should be corrected.Anticoagulation and iv antibiotics must be started.
46. Conclusion Aortic dissection can have varied presentation in the emergency department.For any patient with symptoms abdominal pain or a sharp tearing type of chest pain a possibility of aortic dissection should be considered.Patients with symptoms suggestive of mesenteric ischemia may have AD in the background.Palpation of peripheral pulses are of utmost importance!
47. THANK YOU