Author: Nisha Crouser, MS4 // Editor: Michael Barrie, OSU EM Attending
One of the first questions Emergency Medicine physicians have to ask themselves is “Do I think this patient is sick or not sick?” A simple question, that takes years of practice and experience to answer. Once a patient is deemed “sick” the questions to follow become more difficult, “How sick?” “What should we do next?” The following case presentation helps elucidate some of the difficulties faced in the ED when sick patients arrive and how to act on the dangerous diagnosis of septic shock.
A 58-year-old patient with several past medical problems including hypertension, hyperlipidemia, and heart disease; presents to the ED with a fever and back pain. Upon arrival the patient is a diaphoretic and ill-appearing obese female who is able to follow commands and answer a few questions. It is difficult to obtain a history from the patient and there is no family present to contribute any information. She is tachycardic and hypotensive when placed on the monitor. Given these vitals in combination with her fever, a Septic Shock alert is initiated. The ED is very busy and there is another severely ill patient that the physician is also covering. Several tests are ordered and fluids are started, there is no obvious source of infection. Over the course of the next half an hour, the internal medicine doctors lay eyes on the patient who has now become more unresponsive. As another half an hour goes by, the patient’s skin become extremely mottled and blue. Her oxygen saturation and blood pressure drop precipitously and she goes into asystole.
Author: Hiro Miyagi OSU MS4 // Editor: Michael Barrie OSU EM Attending
Medical Student Corner – When do kidney stone patients need immediate intervention?
A 51yo female presents with an acute episode of severe right sided back pain with nausea and vomiting. Patient has a past medical history of HTN and chronic back pain. The pain is intermittent, described as sharp and stabbing 10/10 pain. She has not been able to tolerate any liquids since the onset of pain. The patient denies fevers or chills, with no recent infections or illnesses. No dysuria, but with mild urinary frequency. She has a past surgical history of appendectomy 30 years ago.
Dr. Kaide’s Airway “tip of the month”
There was this hypothetical patient…who was being intubated. As soon as the patient was paralyzed dark blood came pouring out into the mouth from an upper GI bleed. The resident immediately suctioned a continuous flow of blood from the airway. She could not see any airway structures because of the bleeding. Now what?
Authors: Kenneth Akapo, OSU MS4 // Dr. Michael Barrie, OSU EM Attending
A 24 year old female with history of sickle cell disease presents with a 6 hours history of widespread pain. The pain is in her lower back but also present within the lower and upper extremities. She also endorses mild shortness of breath although she attributes this to her pain episode. She mentions being seen a week ago due to a similar episode during which she also had new onset headaches associated with blurry vision. During that episode, CT scan was unremarkable. During the current encounter, there was low concern for ischemic stroke. The headaches have persisted until now, however, she no longer endorses changes in vision. She also denies any other focal neurologic symptoms.
Upon initial examination, the patient appeared to be in mild distress. She was mentating well and exhibited no focal neurologic symptoms. She was diffusely tender to palpation although she seemed to exhibit more pain when palpating the lower extremities and back. Breath sounds were clear to auscultation bilaterally, and cardiovascular exam was normal.
Before presenting the case to the senior resident, you consider your differential diagnosis – sickle cell pain crisis, acute chest syndrome (ACS), ischemic stroke, acute coronary syndrome (the other ACS), and heart failure among others.
But what findings would help support or refute a diagnosis of acute chest syndrome? And what is the plan to manage the initial diagnosis and treatment of possible acute chest syndrome?
Learn, Evaluate, Adopt…Right Now!
Colin G. Kaide, MD, FACEP, FAAEM // Editor Michael G. Barrie MD
LEARN airway word document version of this resource
This patient was an obese male in his 50’s who developed respiratory failure in the ED. Intubation by a senior resident and a very experienced attending using first GlideScope® (GS) then direct laryngoscopy (DL) were unsuccessful. They placed a size 5 LMA and were able to successfully oxygenate the patient. I was called to assist with the airway. They said they could visualize the cords with DL and with the GS. They were unable to guide the ETT into position because of what was described as a large amount of “redundant tissue” and some anatomic issue that prevented 2 experienced doctors from guiding the ETT thru the cords.
Leslie Adrian, MD, OSU EM PGY-1 // Michael Barrie, MD OSU EM
You get a call from triage, a 34 year old female is in the waiting room, presenting to ED with chief complaint of intentional ingestion. You briefly examine her; she is well appearing but tearful with a HR of 70 and BP 120/79 and is alert and oriented. She admits to taking thirty of her friend’s blood pressure medication one hour ago, she does not know what it was called, but thinks it ended with an “-olol.” You put her on the monitor, order ingestion labs and then receive a call that a level 1 stroke patient has arrived and needs to be intubated.
15 minutes later, you get a frantic call from the psychiatric nurse stating that your patient’s HR is 30 her blood pressure is 70/40, and she is altered but protecting her airway. You put the patient on oxygen and start fluids immediately, but what do you do next?
Thanks Dr. Sam Basu for creating these conference reviews on Acid-Base disorders, UTI/Pyelonephritis, and EMTALA!