Case Study

  1. 0 A few months ago we had a case study presentation of a cardiac episode in the ER and I was wondering if anyone was interested in another one? I'll try to present this one as best I can (I've never done this before) and I'm sure you smart cookies will figure this out pretty quick.

    A 64 y.o. male admitted with acute mental status change and fever. His vitals are:
    HR 127 intermittent a-fib/sinus tach
    BP 146/62
    RR 28
    SpO2 94% on 5L/NC

    He is restless and confused. The neurologist was unsuccessful at obtaining an LP so he was started on Acyclovir empirically. After several days, you notice his urine output is markedly decreased (+2L I&O). His heart rate has been controlled with Metoprolol and Diltiazem and he has been NPO, receiving Heparin,Travasol and lipids through a central line. He is becoming dyspneic on 35% venturi mask and developing peripheral edema. SpO2 has dropped to the mid 80s.

    What would you want ordered? What do you think are the best actions to manage him?
  2. Visit  getoverit profile page

    About getoverit

    getoverit has '18' year(s) of experience and specializes in 'ER/ICU/Flight'. From 'NC'; 45 Years Old; Joined Dec '07; Posts: 435; Likes: 752.

    15 Comments so far...

  3. Visit  student00 profile page
    0
    I would order labs, and give him lasix.
  4. Visit  CaseManager1947 profile page
    0
    I'm guessing he's in trouble due to the Travasol and reduced kidney function. I suspect he's overloaded. Renal consult ? You don't mention BUN or Cr levels, but I suspect they're up. Aluminum accumulation and toxicity a possibility. I'd consult renal, Blood gas, and 2D Echo.
  5. Visit  blondy2061h profile page
    0
    I'd think he'd need to be intubated in the near future. I'd also think he'd need diuresing- Lasix or bumex.
  6. Visit  HonestRN profile page
    0
    I would want a BNP, BMP, CBC & ABG's ordered, lasix ordered, renal consult, pulmonary consult. How high is his fever? High enough to order blood cultures? Has cardiology been consulted? I suspect so due to the metoprolol and diltiaziem orders.
  7. Visit  MN BigJ profile page
    0
    I'm still trying to figure out how he is in A-fib and Sinus tach at the same time.

    I'm sure he needs some lasix, a chest Xray, bipap, possible intubation.

    And depending on labs he could also be in early sepsis so some antibiotics to start while we are waiting for the labs. Probably has more than one problem, CHF- secondary to his HR and a-fib along with pneuomia.
  8. Visit  getoverit profile page
    0
    Good calls. I forgot to mention, he had a head CT wtih contrast showing encephalopathy which prompted the anti-virals/abx.
    His cxr shows left lower lobe infiltrate/atelactasis. Pertinant labs are
    Cr 4.37
    BUN 42
    BNP 307
    WBC 13.8
    H&H 8.1/25.2
    Plt 136
    pH 7.27
    pCO2 53.1
    pO2 60.4
    HCO3 22.9
    BE -2.5

    MNBigJ, he's in intermittent a-fib and sinus tach, which means he alternates between the two rhythms.
    So the patient is intubated and placed on a mechanical ventilator. Aggressively diuresed and after 160mg Lasix he has put 25 cc out over 12 hours.
    What next?
  9. Visit  MN BigJ profile page
    0
    I was just giving you crap about the afib sinus tach at the same time thing.

    Besides his renal failure and possible pneuomia/chf (though the BNP isn't real high) and possible meningitis and anemia I'm starting to lose track of it all without seeing the guy and being there. He is trying to compensate though. What's his K+? Seems almost like he has gone to far and it's time for a preist if the dialysis doesn't help much and we don't get a LP to r/o meningitis (which he is being covered for). Of course I could be missing something here and could be way off.
  10. Visit  meandragonbrett profile page
    0
    What's his serum lactate? What's his BMP? Are we monitoring CVP? Has blood, urine, and a BAL been sent yet? Sounds like we need an ASAP nephrology consult. What was the admission CBC compared to the most recent? Despite having the AMS, what is his neuro exam like?
  11. Visit  CaseManager1947 profile page
    0
    TRAVASOL and DECREASED renal function.... he's also got a line..... what about line sepsis... this or a drug interaction....
  12. Visit  getoverit profile page
    1
    Quote from MN BigJ
    I was just giving you crap about the afib sinus tach at the same time thing.

    Besides his renal failure and possible pneuomia/chf (though the BNP isn't real high) and possible meningitis and anemia I'm starting to lose track of it all without seeing the guy and being there. He is trying to compensate though. What's his K+? Seems almost like he has gone to far and it's time for a preist if the dialysis doesn't help much and we don't get a LP to r/o meningitis (which he is being covered for). Of course I could be missing something here and could be way off.
    That's cool. And it is tough to lose track without being there and seeing it. You're right he's trying to compensate. His K+ is 4.4
    Once he's sedated and tolerating the vent an LP is obtained and the HSV PCR is sent off. Also the nephrologist requests emergent placement of dialysis catheter, which is accessed in his RIJ.

    What's his serum lactate? 1.0
    What's his BMP? all abnormal values are listed BUN, Cr, eGFR is 12. Ca++ is a little low but not major.
    Are we monitoring CVP? yes, central line in and CVP is around 24-26
    Has blood, urine, and a BAL been sent yet? yes, blood cxs reveal no growth. UA has high WBCs and RBCs. no BAL.
    What was the admission CBC compared to the most recent? his Hgb has dropped 2 grams to 8.4, other than that it's essentially unchanged
    Despite having the AMS, what is his neuro exam like? off the diprivan he's extremely sluggish. before being sedated he was confused, restless, combative at times.

    hemodialysis pulls off 5.2L of fluid. He is still anasarcous with 2-3+ pitting edema. His urine output markedly improves.
    You've mentioned CHF, a-fib (which he's being anticoagulated and diuresed) and pneumonia (which he did not have). What do you think is going on with his kidneys?
    CaseManager1947 likes this.
  13. Visit  getoverit profile page
    0
    Quote from CaseManager1947
    TRAVASOL and DECREASED renal function.... he's also got a line..... what about line sepsis... this or a drug interaction....
    Very good thought process, What else has he received that could cause this problem?
    And good thinking about the line sepsis, but cultures reveal no growth. He's not septic.
  14. Visit  blondy2061h profile page
    0
    Quote from getoverit
    He's not septic.
    You can be septic with no growth with viral or fungal infection.


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