Unspoken and lesser known topics in A&E.pptx

Sympathetic crashing acute pulmonary oedema, Thyrotoxic crisis, SCAPE, Thyroid storm, Hyperthyroidism, FOSPE, Fluid overload, Hypertensive heart failure

1. Unspoken and lesser known topics in A&E Dr Varun Patel

2. Case 1 A 20yr old young male presented to A&E blue lighted with history of sudden onset severe shortness of breath that worsened within hours since early morning. He was absolutely normal last night. He was known to have incidental detection of High blood pressure on his last visit to his GP which was 160/94mmHg and was advised to keep a record of blood pressure for a week. He also had a prolonged prior history of Headache. No PMH. No medications. No Allergies. Non-smoker, No alcohol or recreational drug use. On arrival his observations were as follows- P – 136/min BP- 216/120mmHg RR – 44/min SPO2 – 64% on RA – 92% on 15l/min O2 via NRBM GCS – 15/15 Chest – Coarse crackles all over both lungs. He is seen to cough up pink frothy sputum. Using all accessory muscles and looks exhausted and sweaty. CVS – S3 gallop heard, No murmurs noted

3. Case 1 Bedside Lung Ultrasound of this patient shows this picture -

4. Diagnosis? Management plan?

5. Hint - Later on, MR Angiography showed Bilateral Renal Artery stenosis

6. Sympathetic Crashing Acute Pulmonary Edema (SCAPE)

7. Pathophysiology (A Vicious spiral) The central, defining pathophysiological feature of SCAPE is pathologically elevated afterload due to systemic vasoconstriction and hypertension. SCAPE patients may be Euvolaemic or Hypovolaemic , the problem here is the shift of fluid into the lungs rather than Hypervolaemia .

8. A Spectrum of Pulmonary Oedema

9. SCAPE vs FOSPE SCAPE and FOSPE aren't mutually exclusive. For example, some patients can have SCAPE superimposed upon FOSPE (i.e., gradual volume accumulation over time, which eventually reaches a tipping point and triggers an acute episode of SCAPE). Some authors have proposed that SCAPE and FOSPE represent two extreme forms of pulmonary edema, with some patients lying in between. Differentiating SCAPE vs. FOSPE is clinically important, because the treatment is different.

10. Clinical Features:

11. POCUS in SCAPE:

12. Diagnosis

13. Pitfalls

14. SCAPE triggers

15. Diagnosis of the case: PICKERING SYNDROME – SCAPE in Undiagnosed Renal Artery Stenosis (Usually noted in Young adults or Adolescents)

16. Why is it necessary to differentiate FOSPE vs SCAPE?

17. Emergency Management

18. BiPAP / CPAP

19. Emergency Management

20. Using Nitroglycerin

21. Using Nitroglycerin

22. Using Nitroglycerin **You should not leave the patient’s bedside till the SCAPE episode breaks**

23. Refractory Hypertension Half life of Clevidipine – 1 minute (Terminal phase at 15 min) Half life of Nicardipine – 8.5 hours

24. Beta-Blockers? No, Contraindicated

25. Opioids? YES, Fentanyl is the drug of Choice

26. Fentanyl

27. End of SCAPE **Invasive BP Monitoring with an Arterial line is Essential to known when SCAPE breaks**

28. Pitfalls in SCAPE

29. Case 2 A 44-year-old Caucasian woman with a history of metastatic melanoma presented blue lighted to the emergency department, with a 3-day history of intractable nausea, vomiting and anxiety. She had been initiated on dual nivolumab and ipilimumab therapy 1 month prior and received two courses of therapy thus far. Her last dose was 1 week prior to presentation. She had previously completed 1 year of high-dose interferon therapy. Surgical history included right video-assisted thoracoscopic surgery with right lower lobe wedge resection due to metastasis 6 weeks prior and right cheek melanoma resection 2 years prior. PMH included depression and anxiety. The patient's medications included atenolol, citalopram and alprazolam. She denied alcohol or illicit drug use.

30. Case 2 On presentation, her observations were as follows- Temp - 40.3°C (104.5° Fahrenheit), HR - 146  bpm (Sinus Tachycardia on Monitor) BP- 138/87mmHg GCS 15/15 On examination, the patient was agitated and acutely anxious but still awake, alert but confused to time and place. She was diaphoretic and flushed with no jugular venous distention, no peripheral oedema , and with regular rate and rhythm on cardiac examination, and clear breath sounds on lung examination. The rest of the physical examination was unremarkable.

31. Diagnosis? Management plan?

32. Hint -

33. Diagnosis of the case – Thyroid Storm caused by Immunosuppressive Chemotherapy

34. Thyroid Storm ( Thyrotoxic Crisis)

35. Pathophysiology

36. Pathophysiology

37. Pathophysiology

38. Pathophysiology

39. Pathophysiology

40. Nomenclature

41. Diagnosis

42. Diagnosis

43. Management

44. 4 blocks for Thyroid storm

45. Management

46. Management

47. Few important aspects to remember in management If Thyroid Storm is associated with AF on ECG, do not ever give Amiodarone to treat it. It will further precipitate Thyroid storm. If patient is alcoholic presenting with Hypoglycaemia in Thyroid storm, always give Thiamine before giving Glucose / Dextrose. Always stop release of Thyroid hormones using PTU or Methimazole first before stopping production with help of Lugol’s Iodine

48. THANK YOU!