M&M - Dr. Bronner

Case 1 - Lower extremity weakness

• Generalized pain and BLE pain > numbness> weakness as well as urinary retention and epigastric pain; 2 weeks prior had vaginal hysterectomy with BSO.
• Physical Exam - LLE objective wekaness
  

DDX - Transverse myelitis, EDH abscess, viral myeltitis, trauma ,degerenative, vascular, toxic metabllites

• Admitted for MRI but, while admitted complained of chest pain > trop bumped, CTA showed aortic dissection

     > Learning points - DDimer cannot be used as a screening tool to rule out dissection
     > Stanford classification - A involves the aortic root, B is limited to the descending aorta
     > Prsenting sx of type B dissections- chest or back pain, abrupt onset of pain
     > Imaging - CXR - 56,5% are nl, TTE - usef for aortic root, CT best sensitivity and specificity

Therapy

• BP/HR control - reduce shear stress:  SBP < 100 is goal, HR < 60;   beta blockers are first line
• Type A = needs surgery, Typer B attempt medica control l
• Before initial beta blocker, listen for aortic insufficiency and use ultrasound to evaluate for pericardial tamponade as these patients don't do well on beta blocker
  

Case 2 - Fatigue - dyspnea

• Initially seeen in ambulatory area. Developed distress and moved to Major area. Called out as code sepsis.

a. Patient with worsening resp status and was started on heparin drip for possible PE.     
b. Admitted to hospital - heparin drip stopped and echo gotten - shows right heart strain
c. CTA showed massive Bilateral PEs

Predictors of Complications from PE

• Troponin
• Pulse ox
• BNP
• Echo findings
  

Massive PE = Unstable, sustained BP < 90 (for HTN and BP < 100)

Submassive PE - Rigth ventricle with dilitation and systolic dysfunction, CT - RV dysfunction, elevated BNP or troponin

---