I'm wondering if there would be any interest in a "case study" that would take a patient from presentation and through treatment. There would not be any right/wrong - just an exchange and hopefully an opportunity to improve all of our abilities to critically think and be able to work through patient complaints, history and interpret the data. Also, we can look at treatment - so anyone up for it??
Brief example:
You are working in adult ED triage 74 year old female patient presents ambulatory with minimal assistance to the ED at 1500 c/o fever and feeling bad. Patient has 2 very concerned daughters and this is the 4th ED visit this week - (the other visits were at other ER's - but, the family volunteers that they were idiots working in the other ED's --- so we came here instead). Pt does not appear in acute distress.
Patient is alert but confused. (Family states this is near normal for her).
Vital Signs:
BP 104/64 HR 104 RR 22 SaO2 95% on RA Oral Temp 100.6F
History:
Hypertension
AMI 3 years earlier - placed 2 stents.
GI bleed 5 years ago -required 6 unit transfusion
NIDDM
GERD
Osteo-Arthritis/Chronic Pain
Hysterectomy at age 43
Basal cell carcinoma removed 2 years ago
Medications:
NKDA (does "break out" from adhesive tape)
Lisinopril
Atenolol
Prilosec
Plavix
Baby ASA
Duragesic Patch
Metformin
Now what? How do you proceed? Questions?
Anyone interested in participating in case studies?
One thing about EKG's, often they don't give enough time to make an accurate diagnosis. I see where Torsades could be possible, especially with the pt. background. I'm still going for V-tac at this time. I can live without giving amnioderone, so long as we give lido, however, if I'm going to stick with my original feeling, I'll also stick with amnioderone.
This certainly is NOT a cut and dried case, especially because it seems like the OP has forgotten to get back to us.
At this point, a couple of us could be correct, and we could be wrong. We do need more input from the OP.
I think this type of thread is a great idea, but I am anxious to get on with it.
In any case, this thread has certainly piqued my interest, and others too. It's great to see such interest, and having new ideas brought in is also great. Keep em coming
Specializes in Flight, ER, Transport, ICU/Critical Care.
Great discussion on the case.
Most all are right to some degree.
I have been tied up with a sorta (thankfully, not bad, bad sick) but sick hubby for the past 3 days - with 250 mile round trip to MD for care/testing - I had not forgotten - but - I could not get enough blackberrry bw to even try and catch up. Sorry.
I will wrap the case up and give all the rationales and outcomes. It was a major learning experience for me and I hope to share some of the lessons learned.
Thanks Guys -
Keep up the great discussion and I promise it will be worth it!
Babs0512, loricatus and HonestRN - You guys are rocking the case!
I'll be back - ASAP. (Need a nap, as it has been since 0345 for the 3rd day rolling). And I don't want to leave out anything in the case -
I think she has metabolic alkalosis from the diarrhea and vomiting. I think her BP is decreased from loss of body fluids. Her temp d/t UTI, slight tachycardia from increased temp, low BP, and probably dehydration. The metabolic alkalosis could cause the arrhythmia. Think she should be getting hydrated with lactated ringers. Treat the cause of the alkalosis and treat the UTI. The vomiting could be cause by the oral potassium. I think the albumin should be checked for nutritional status.
Like the way you think. Sorry I didn't notice your post earlier.
You bring up the UTI, which is the most common cause of sepsis in the elderly. Much of those symptoms can also be d/t sepsis & if that is the case, we would also have to have a cortisol level and vbg (might as well throw in some blood cultures), as the alkalosis would be countered by lactic acidosis.
Seems like we have one sick puppy presented to us-those labs are really the key to this. Or we could just do what I have seen some ER docs do-----throw the kitchen sink at them and pray for the best
I know I'm late, but the EKG does not look like V-tach to me. It actually looks like a SINE wave with short runs of V-tach. The OP mentions that the potassium bottle has less pills than it should and the patient we are assuming has impaired kidney function. My line of thought is that the patient inadvertenly took an overdose or that the doting daughters incorrectly dosed mom.
This EKG is typical of someone with extreme hyperkalemia, and my guess is that her impaired renal function prevented outright cardiac arrest since she is used to a higher K+ level.
I think she needs immediate calcium, insulin and D50 IV. She should also get a dose of kayexalate, if she won't drink it, drop a NGT (If worried about NPO status, can be given rectally but it has to be retained for at least 30min). I would review her BUN/Creatinine, if they are elevated above her normal, call nephrology for emergent vascath placement and dialysis. Go ahead and consult MICU you are going to need a unit bed. Line her up. Her ABG may show acidosis from increased CO2 if her respiratory drive is depressed, but I would postpone intubation unless she is hypoxic. I think she may just have muscle weakness from hyperkalemia, and that will resolve with lowering her K+.
The code cart should absolutely be nearby, with the ability to emergently transcutaneously pace. Bradycardia should be closely watched for.
RNREMT- take it easy, don't put the cart before the horse. She has been talking and walking - yes she has been "a little confused", feels weak, etc... if she has a pulse and a BP, you don't need to "knock down" her resp. drive and intubate her. Treat the patient, not the monitor.
Assuming nothing has changed since the OP's last update, then we need to move fast, but she is "tolerating" this V-tac. I've seen it a few times in my carreer, I know a man who lived 2 days in v-tac while having a pulse, and decent pressure - before we were able to break it (this was 13 years ago).
A loading dose of Amnioderone, followed by a drip - if that does't work, we always have the old standby lido. Have the crash cart at the ready, move fast. Get runs of K+ ready too. Needs to have AT LEAST two IV sites, AT LEAST 20's, 18's would be better. If you can't get an IV, the doc should start a central line and/or art line. In a pinch, you can give meds through the Art Line, time to move fast.:heartbeat That rapid HR is my adrenaline charged pulse! lol
babs0512
I don't treat the monitor instead of the patient and if you'll read my posting, I didn't say anything about knocking down her respiratory drive and intubating her. I was referring to being cautious about the respiratory depressant properties of IV mg++, because at that point we hadn't got a chemistry panel yet and it appeared she was in torsades. She would need mg++ if that was the case and I've seen it many times. People get anxious over respiratory depression but that's a very late effect in IV magnesium.
I do appreciate people responding to my thoughts, but I would ask you to comprehensively read what I've written before jumping on me to "take it easy" and "treat the patient not the monitor" when you didn't understand what I was talking about.
You do make good points about the meds, labs and electrical therapy. As soon as we get a full panel of labs we'll have a better place to stand on this one.
nremt-p/rn
hope your husband is feeling better and I'm interested to hear what you learned from this case!
What I want is an answer to our queries. I find it odd that the originator has left us high and dry. I do hope that her personal problems are resolving. Much luck to her and her family.
Babs0512
846 Posts
One thing about EKG's, often they don't give enough time to make an accurate diagnosis. I see where Torsades could be possible, especially with the pt. background. I'm still going for V-tac at this time. I can live without giving amnioderone, so long as we give lido, however, if I'm going to stick with my original feeling, I'll also stick with amnioderone.
This certainly is NOT a cut and dried case, especially because it seems like the OP has forgotten to get back to us.
At this point, a couple of us could be correct, and we could be wrong. We do need more input from the OP.
I think this type of thread is a great idea, but I am anxious to get on with it.
In any case, this thread has certainly piqued my interest, and others too. It's great to see such interest, and having new ideas brought in is also great. Keep em coming
Blessings