Crazy Consult!!!

[347932]

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I get called relatively frequently to the rehab floor at the teaching hospital where I do all my cases to bust on some nails. I never mind doing this because the hospital is literally walking distance to one of my offices and most of these patients end up making their way to my office eventually and end up sending their family blah, blah, blah.

One of those cases turned out to be one of the most unique I've ever seen in my career so far.

I got called to see a rehab patient so I brought along my nail busters and almost dropped them when I walked in to see this patient.

Here's the story:

This poor guy came in from the UK for a meeting with some mutual clients and decided to have a little too much to drink the first night he was in town. The next day he has extreme abdominal pain and ends in the ED of this hospital I work out of. The ED Docs call in the Surgeon on call as this patient has acute peritonitis. They then do an emergency lap, which they convert over to an open abdominal lavage and drain ONE LITER of purulence from this gentleman's belly. The patient goes into acute septic shock, and ends up intubated in the ICU. Cultures grew out Strep Pyogenes beta hemolytic.

While in septic shock clinging to life, he develops such severe hypotension, that he develops acute distal ischemia to all of his digits of his hands and feet. He also goes into acute renal failure and is slowly being weaned off of dialysis.

He now has dry gangrene of all of his fingers and half (dorsal and palmar) of his right hand and all of his toes and dorsally just proximal to his MPJs. Plantar feet from tip of the toes to the heel also show dry gangrene with a circular area of fresh healthy tissue in his midarch.

I thought he had developed frostbite, but nope. He has been inhouse for two months now and will likely be sent home by next week on a commercial airline.

At the moment, I was not able to find any literature after about 2 hours on Pubmed about similar documented cases.

Has anyone ever seen anything like this?

 

[jonwill]

I've seen a couple cases of pressor induced ischemia where the hands and feet ended up like that.

 

[PADPM]

No, but I once spend a night at a Holiday Inn.

Do you think he needs a pair of orthotics before he flies home

Sorry, couldn't resist. There's a local young doctor (not very well trained) who makes or tries to make EVERY new patient a pair of orthoses on the first visit, no matter what the ailment. I'm very confident that this patient in the hospital would be leaving on a jet plane with a new pair of orthoses if he was her patient!

I had 3 new patients in my office this week with various ailments, and each patient was seen in this other doctor's office within the last month. Within the first 2 minutes of the visit, the doctor told each patient that it was "impertive" they needed custom orthotics for their problems to avoid signficant complications now and in the future.

Needless to say, in my opinion, none of the patients needed orthoses at the present time.

 

[Feli]

I've seen a couple cases of pressor induced ischemia where the hands and feet ended up like that.

Yep, I've seen about a half dozen of these types of consults also. End organ perfusion is the name of the game, but the distal extremities suffer the consequences of the pressors.

Most of the pts never made it out of the ICU, but sometimes they do. I'd just paint the gangrene digits with beatdine and let it demarcate. If it turns to wet gangrene or he has intractable pain and he's stable enough, you could try TMA or other amp that might heal, but definitely get a vasc consult and/or noninvasive bloodflow studies first.

 

[347932]

Yep, I've seen about a half dozen of these types of consults also. End organ perfusion is the name of the game, but the distal extremities suffer the consequences of the pressors.

Most of the pts never made it out of the ICU, but sometimes they do. I'd just paint the gangrene digits with beatdine and let it demarcate. If it turns to wet gangrene or he has intractable pain and he's stable enough, you could try TMA or other amp that might heal, but definitely get a vasc consult and/or noninvasive bloodflow studies first.

I think I was consulted CYA because the patient was complaining about his feet after being in house for 2 months. He's leaving in less than a week, so not much involvement on my part.

Why is there no literature about this?

 

[podpal]

I think I was consulted CYA because the patient was complaining about his feet after being in house for 2 months. He's leaving in less than a week, so not much involvement on my part.

Why is there no literature about this?

Compounding pharmacies MAY have a suggestion for revascularization. These types of medications would likely be topical and OFF LABEL, ie, no literature available. It is possible to create a Nifedipine Paste to aid in revascularization, to be applied at the site of decreased flow. Another suggestion is Nitroglycerin paste or patches to assist in generating flow to the area. Since the poorly vascular region has poor exchange of blood flow, it may be necessary to use a high dose, ie compounded, for an effect. The "normal" distribution of the drug will not occur since it would rely on healthy blood flow to be absorbed and carried throughout the vascular system. The advantage of this is that if a "relative" contraindication exists to nifedipine or NTG, it may not matter as absorption and distribution outside of the immediate site is much less likely. While something like this is unlikely to "save" the nonvascular distal end, it may help to make the line of demarcation/autoamputation more distal.

 

[krabmas]

Has anyone ever seen anything like this?

yup. about hte same as feli and jonwill 1/2 dozen or so. mostly ICU patients on pressors.

The most impressive case I saw was purple blistering edematous skin to the distal 1/3 of the leg. He feet remained soft and non-infected and over time and weening of pressors total perfusion returned all the way to the digits. no vascular intervention required, no amputations needed. but these pt do require vigilence from the pod or physiatrist for off-loading and advoidance of achilles contracture. The nurses never seem to realize how big a deal it is if the feet are pressing on the end of the bed 24hrs a day.

I agree with Feli that a vascular consult and demarcation is a must prior to attempting amputation/surgical intervention.

 

[347932]

yup. about hte same as feli and jonwill 1/2 dozen or so. mostly ICU patients on pressors.

The most impressive case I saw was purple blistering edematous skin to the distal 1/3 of the leg. He feet remained soft and non-infected and over time and weening of pressors total perfusion returned all the way to the digits. no vascular intervention required, no amputations needed. but these pt do require vigilence from the pod or physiatrist for off-loading and advoidance of achilles contracture. The nurses never seem to realize how big a deal it is if the feet are pressing on the end of the bed 24hrs a day.

I agree with Feli that a vascular consult and demarcation is a must prior to attempting amputation/surgical intervention.

Interesting you mention the Achilles, as about a month ago they were doing aggressive PT with him and he partially ruptured his Achilles. The area now has a large ulceration and I'm concerned that his tendon will become exposed.

He's leaving back to the UK next week and already has a bed at a hospital there in Manchester. I gave him my e-mail address and took some pictures, so hopefully he will keep me abreast of his progress.

 

[krabmas]

he needs aggressive wound care over the achilles wound to prevent exposure. agressive offloading and possibly wound vac to keep it covered - hard to say since I know nothing of what the wound looks like.

 

[Black Surgeon]

No, but I once spend a night at a Holiday Inn.

Was that before or after you saved some money on your car insurance by switching to geico?

 

[347932]

he needs aggressive wound care over the achilles wound to prevent exposure. agressive offloading and possibly wound vac to keep it covered - hard to say since I know nothing of what the wound looks like.

Agreed 1000%. I gave him my e-mail address and I'm hoping he keeps me up to date so I can make some across the ocean recommendations. As I said, I was consulted more as a CYA before he left, so I only had a very short amount of time to give my recommendations.

 

[Sig Savant]

How interesting. I was reading this thread today, and just a few minutes ago I was watching E, a show about bizarre and mysterious celebrity deaths. They presented a case about Mariana Bridi da Costa - before dying in 2009 she had to have her hands and feet amputated. Is this similar to the initial case presented?

http://www.huffingtonpost.com/2009/01/22/mariana-bridi-da-costa-mi_n_160055.html

 

[krabmas]

How interesting. I was reading this thread today, and just a few minutes ago I was watching E, a show about bizarre and mysterious celebrity deaths. They presented a case about Mariana Bridi da Costa - before dying in 2009 she had to have her hands and feet amputated. Is this similar to the initial case presented?

http://www.huffingtonpost.com/2009/01/22/mariana-bridi-da-costa-mi_n_160055.html

It is difficult to tell since the media does not present the best medical information.


This can happen from pressors which typically causes end organ ischemia. The end organs here are the feet, sometimes it happens to the hands as well but not as common as the feet. The blood vessels to the feet are smaller in diameter relative to the organ compared to the vessels of the hand and their organ. If the patient is on pressors long enough and gangrene develops this becomes an irreversible ischemia. Gangrene does not always result, and the condition can be reversible.

The model developed septicemia which on its own can cause ischemia of the limbs without the pt being on pressors. So, the model could have had the same pathology, but maybe not, but definitely similar.

 

[347932]

Update on his situation.

He's decided to delay his return home and have his fingers on both hands amputated and revascularized by implantation into his vastus muscles for a short time.

Time to get a Vac on his Achilles wound and also to talk to Vascular and Plastics about amputation level. Since his plantar tissue is involved it would be hard to do a TMA and we can't do Chopart's in our state =(. We can do ankle fusions though. Weird huh?

We'll see how this plays out.

 

[GiftedPoster22]

plenty of articles out there. Not sure what serarch terms you were using.

here's one.
http://www.ncbi.nlm.nih.gov/pubmed/20828758

In the old days fluoracine dye was used to assess the tissues. Today other methods include assessing the microvascular tissues o2 content.

Hope this helps