1C Craig Destree State ACP 2015 Vignette...1C_Craig_Destree_State_ACP_2015_Vignette.pptx Author...
Transcript of 1C Craig Destree State ACP 2015 Vignette...1C_Craig_Destree_State_ACP_2015_Vignette.pptx Author...
![Page 1: 1C Craig Destree State ACP 2015 Vignette...1C_Craig_Destree_State_ACP_2015_Vignette.pptx Author Scott Mattson Created Date 9/18/2015 8:10:21 PM ...](https://reader030.fdocuments.net/reader030/viewer/2022041001/5ea2e45f531082621d56cbd4/html5/thumbnails/1.jpg)
9/18/15
1
The Pressures of Non-‐Compliance
Craig Destree, MD
Rachel Hawker, MD, FACP
2015 State ACP Conference September 11, 2015
Emergency Department
• A 49 female presented with lower extremity weakness. – Progressive worsening over 4 weeks – Unsteady balance – Recurrent falls – Swelling in hands, calves and feet
![Page 2: 1C Craig Destree State ACP 2015 Vignette...1C_Craig_Destree_State_ACP_2015_Vignette.pptx Author Scott Mattson Created Date 9/18/2015 8:10:21 PM ...](https://reader030.fdocuments.net/reader030/viewer/2022041001/5ea2e45f531082621d56cbd4/html5/thumbnails/2.jpg)
9/18/15
2
Medical History
• Hypertension – Metoprolol tartrate, 150mg daily – Hydrochlorothiazide, 25mg daily
• SedaRves – Hydroxyzine, 50mg TID prn – Mirtazapine, 30mg at bedRme – Hydrocodone-‐acetaminophen, 5-‐325mg q6h prn – Methocarbamol, 750mg TID
• Hypothyroidism – Levothyroxine 175mcg daily; endorsed compliance – Last TSH 1.5 years ago was normal
Vitals and Physical Exam
• T 36.4 HR 71 BP 135/99 RR 14 SaO2 98% • Heart: irregularly irregular rhythm • Respiratory: notably hoarse voice • HEENT: puffy face • Skin: – Dry, coarse – Diffuse alopecia
![Page 3: 1C Craig Destree State ACP 2015 Vignette...1C_Craig_Destree_State_ACP_2015_Vignette.pptx Author Scott Mattson Created Date 9/18/2015 8:10:21 PM ...](https://reader030.fdocuments.net/reader030/viewer/2022041001/5ea2e45f531082621d56cbd4/html5/thumbnails/3.jpg)
9/18/15
3
Lower ExtremiRes
• Non-‐pi`ng edema • Absent DP and PT pulses • Lea leg tenderness • Right leg – Foot drop – Diminished sensaRon
IniRal InvesRgaRons
• Blood Work (Abnormal only) – CPK > 20,000 (upper limit of assay) – AST 510 – Na 110
• Urinalysis – 3+ Occult Blood – 0 RBCs
![Page 4: 1C Craig Destree State ACP 2015 Vignette...1C_Craig_Destree_State_ACP_2015_Vignette.pptx Author Scott Mattson Created Date 9/18/2015 8:10:21 PM ...](https://reader030.fdocuments.net/reader030/viewer/2022041001/5ea2e45f531082621d56cbd4/html5/thumbnails/4.jpg)
9/18/15
4
Compartment Pressures
• Acute compartment syndrome definiRon: – Compartment pressure > 20mmHg – Delta Pressure < 30mmHg
• Right leg calf compartment pressure: – Compartment pressure 103 mmHg – Delta pressure 0 mmHg
• Lea leg calf compartment pressure: – Compartment pressure 60 mmHg – Delta pressure 43 mmHg
CT Tibia and Fibula
![Page 5: 1C Craig Destree State ACP 2015 Vignette...1C_Craig_Destree_State_ACP_2015_Vignette.pptx Author Scott Mattson Created Date 9/18/2015 8:10:21 PM ...](https://reader030.fdocuments.net/reader030/viewer/2022041001/5ea2e45f531082621d56cbd4/html5/thumbnails/5.jpg)
9/18/15
5
Fasciotomies
Severely Hypothyroid
TSH >100 Free T4 < 0.10
![Page 6: 1C Craig Destree State ACP 2015 Vignette...1C_Craig_Destree_State_ACP_2015_Vignette.pptx Author Scott Mattson Created Date 9/18/2015 8:10:21 PM ...](https://reader030.fdocuments.net/reader030/viewer/2022041001/5ea2e45f531082621d56cbd4/html5/thumbnails/6.jpg)
9/18/15
6
Severely Hypothyroid
TSH >100 T4 < 0.10
Non-‐compliant with levothyroxine
AtraumaRc Compartment Syndrome
• Reperfusion Injury • Bleeding Disorders • Vascular Disease • Animal Venom • ExtravasaRon of IV Fluids • OsteomyeliRs • Burns • Prolonged lying • Viral MyosiRs
• IV Drug Use • Exercise • StaRn-‐induced • Intramuscular hemorrhage (anR-‐coagulaRon)
• Methanol • Sapheneous vein harvesRng • Phlegmasia cerulea dolens • Hypothyroidism
![Page 7: 1C Craig Destree State ACP 2015 Vignette...1C_Craig_Destree_State_ACP_2015_Vignette.pptx Author Scott Mattson Created Date 9/18/2015 8:10:21 PM ...](https://reader030.fdocuments.net/reader030/viewer/2022041001/5ea2e45f531082621d56cbd4/html5/thumbnails/7.jpg)
9/18/15
7
100
105
110
115
120
125
130
135
140
0 2 4 6 8 10 12 14 16 18 20
Serum Na
0
0.2
0.4
0.6
0.8
1
1.2
0 2 4 6 8 10 12 14 16 18 20
Free T4 (Ref 0.90 -‐ 1.70)
Treatment
• Liothyronine (T3) -‐5mcg BID
• Levothyroxine (T4) -‐100mcg IV Daily
• ±HydrocorRsone
R² = 0.94
R² = 0.96
![Page 8: 1C Craig Destree State ACP 2015 Vignette...1C_Craig_Destree_State_ACP_2015_Vignette.pptx Author Scott Mattson Created Date 9/18/2015 8:10:21 PM ...](https://reader030.fdocuments.net/reader030/viewer/2022041001/5ea2e45f531082621d56cbd4/html5/thumbnails/8.jpg)
9/18/15
8
Mechanism
• Anatomical predisposiRon • Muscle Pseudo-‐hypertrophy – Remodeling • Loss of atrophic fast-‐twitch fibers • Gain of hypertrophic slow-‐twitch fibers
– Glycogen deposiRon
Mechanism
• Glycosaminoglycan deposiRon – Extracellular matrix expansion – Fluid retenRon
• Increased capillary permeability – Capillary leak of plasma fluid – ExtravasaRon of plasma protein
![Page 9: 1C Craig Destree State ACP 2015 Vignette...1C_Craig_Destree_State_ACP_2015_Vignette.pptx Author Scott Mattson Created Date 9/18/2015 8:10:21 PM ...](https://reader030.fdocuments.net/reader030/viewer/2022041001/5ea2e45f531082621d56cbd4/html5/thumbnails/9.jpg)
9/18/15
9
Summary
• Hypothyroidism can cause compartment syndrome.
Summary
• Hypothyroidism can cause compartment syndrome.
• Trust but verify (your paRent history)
![Page 10: 1C Craig Destree State ACP 2015 Vignette...1C_Craig_Destree_State_ACP_2015_Vignette.pptx Author Scott Mattson Created Date 9/18/2015 8:10:21 PM ...](https://reader030.fdocuments.net/reader030/viewer/2022041001/5ea2e45f531082621d56cbd4/html5/thumbnails/10.jpg)
9/18/15
10
Summary
• Hypothyroidism can cause compartment syndrome.
• Trust but verify • QuesRons?