Case study - what would you do?

AJJKRN · Jul 1, 2015

At this point I would be following ACS protocol and getting an ABG on this guy and then thinking maybe a chest CT to r/o PE...wouldn't hurt to draw a drug panel either. It's just me but I'm leaning towards PE...

AJJKRN · Jul 1, 2015

Ohhh ohhh, maybe some morphine too to calm his happy ass down! :nono:

blondy2061h, MSN, RN · Jul 1, 2015

He needs an EKG, line placed (sorry dude, not optional), labs drawn, ntg, ASA if no contraindications, and yes, morphine if no relief with the ntg. With an O2 sat of 99% the 15 lpm of O2 is not doing any good, but if he's in that much respiratory distress, I guess leave it for now, but he might benefit more from the pressure support of bipap more than just pure oxygen since he's no hypoxic. And yes, he'd likely buy himself a CTA as well, especially if the EKG normal.

icuRNmaggie, BSN, RN · Jul 1, 2015

Could be a pneumothorax, PE or an MI. High index of suspicion for drug use since the family feels he is not his usual self. A good history is so important.

The worst case scenario is an aortic dissection which is a surgical emergency. CXR would show a wide mediastinum. Monitor BP and he may need metoprolol. Assess distal pulses. Anticipate transfer no thoracic surgeon available.

The pain of a ruptured spleen radiates to the left shoulder. Ask about falls or any other trauma, check for bruising, front and back. FAST scan should be done if indicated.

Dranger · Jul 1, 2015

C-xray, basic labs, EKG and ABG to start. Won't know if intubation/CPAP/BIPAP will be effective till I get some underlying data. Usual CP meds. CTA wouldn't be out of the question with smoking history (also at risk for pneumothorax), but I want respiratory data first. I will defer to results and physical exam

The fact he is acting strange per family is odd too, perhaps drug screen and CT head when available.

Bruh I am going to scan the crap out of you, too bad.

emtb2rn, BSN, RN, EMT-B · Jul 1, 2015

Chest pain start mid-sternal & go to shoulder?

Go w/dranger's plan & add pericarditis to differential. What's the ekg look like?

MunoRN, RN · Jul 1, 2015

He needs an EKG, line placed (sorry dude, not optional), labs drawn, ntg, ASA if no contraindications, and yes, morphine if no relief with the ntg. With an O2 sat of 99% the 15 lpm of O2 is not doing any good, but if he's in that much respiratory distress, I guess leave it for now, but he might benefit more from the pressure support of bipap more than just pure oxygen since he's no hypoxic. And yes, he'd likely buy himself a CTA as well, especially if the EKG normal.

Not optional... based on?

blondy2061h, MSN, RN · Jul 1, 2015

Not optional... based on?

Obviously if he is capable of refusing treatment (which is questionable since his family says he's acting odd- with just the details provided here, hard to say how meaningful that is), he can refuse anything and everything. However, given that he's in the ED I would imagine he DOES want some treatment, and given the severity of and numerous possible life threatening diagnoses that his symptoms could represent, to get anywhere with work up and treatment he'll need an IV and labs. If he needs a CT scan, he can't have dye without labs and he can't get dye without an IV. If he needs morphine, IV morphine will be most effective. If he's having a hypertensive crisis, he'll need IV cardiac meds. If it's a STEMI, cath lab isn't going to take him without a line and just the work up for it requires enzymes. God forbid his aorta is dissecting- I hope he has IV access before he's really bleeding and losing his pressure. On and on and on.

So yes, if he's alert and oriented and capable of making an informed decision he CAN refuse labs and an IV. If he wants anything more than oxygen and an EKG then for the staff to sit back and watch him die, he's going to need those things.

MunoRN, RN · Jul 1, 2015

Obviously if he is capable of refusing treatment (which is questionable since his family says he's acting odd- with just the details provided here, hard to say how meaningful that is), he can refuse anything and everything. However, given that he's in the ED I would imagine he DOES want some treatment, and given the severity of and numerous possible life threatening diagnoses that his symptoms could represent, to get anywhere with work up and treatment he'll need an IV and labs. If he needs a CT scan, he can't have dye without labs and he can't get dye without an IV. If he needs morphine, IV morphine will be most effective. If he's having a hypertensive crisis, he'll need IV cardiac meds. If it's a STEMI, cath lab isn't going to take him without a line and just the work up for it requires enzymes. God forbid his aorta is dissecting- I hope he has IV access before he's really bleeding and losing his pressure. On and on and on.
So yes, if he's alert and oriented and capable of making an informed decision he CAN refuse labs and an IV. If he wants anything more than oxygen and an EKG then for the staff to sit back and watch him die, he's going to need those things.

He's not currently meeting the requirements to be able to refuse, although clearing that up should be high up on the list since legally and ethically you're going to be somewhat limited until you do. In order to refuse treatment the patient has to express an understanding of what could result from them refusing, which is in this case could certainly include death. Since he isn't expressing an accurate understanding of what the consequences of refusal could be then he isn't able to refuse, but that lack of understanding would have to persist even after the risks of refusal have been explained in order to perform treatments against his will.

His reluctance certainly isn't unusual, particularly for youngish men, and our usual routine is to get the 12 lead first and if it shows STEMI then you've got some ammunition to try and convince them to consent to a heart cath (other option=death), we still have patients that clearly refuse a heart cath even after everything's been explained, in which case we shift to other treatments they do consent to, which may be nothing more than comfort care, which is completely within their rights.

blondy2061h, MSN, RN · Jul 1, 2015

He's not currently meeting the requirements to be able to refuse, although clearing that up should be high up on the list since legally and ethically you're going to be somewhat limited until you do. In order to refuse treatment the patient has to express an understanding of what could result from them refusing, which is in this case could certainly include death. Since he isn't expressing an accurate understanding of what the consequences of refusal could be then he isn't able to refuse, but that lack of understanding would have to persist even after the risks of refusal have been explained in order to perform treatments against his will.
His reluctance certainly isn't unusual, particularly for youngish men, and our usual routine is to get the 12 lead first and if it shows STEMI then you've got some ammunition to try and convince them to consent to a heart cath (other option=death), we still have patients that clearly refuse a heart cath even after everything's been explained, in which case we shift to other treatments they do consent to, which may be nothing more than comfort care, which is completely within their rights.

Right, my comment that it wasn't a choice was more along the lines of it wasn't a choice if he wanted his issues addressed in a meaningful way. I can almost understand refusing a cath. But refusing a peripheral IV when you're having 10/10 chest pain? C'mon. That really makes me wonder what his deal is. Is he truly confused? Worried about a drug screen? Irrationally needlephobic?

twinmommy+2, ADN, BSN, MSN · Jul 1, 2015

I want one person getting an EKG, another person getting the IV and labs (two or three IV's please, larger bore if possible with one being anticubital). Labs should include CBC, CMP, Coags, Ddimer, ABG, Troponin. Assessment, is there pneumothorax, is the trach midline, JVD? Morphine 4mg IVP. Quick portable chest. See if we need to titrate down on the O2. Be ready to roll for CT angio.

I think this person may be altered mentally due to respiratory distress. I don't see yet an indication for UDS but if a urine is obtained that can be ruled out.

Mr. Jones is a 42 year old male who arrived via EMS to your hospital's ER with complaints of sudden shortness of breath and sharp 10/10 chest pain radiating to his left shoulder and back. Vital signs on arrival to the room are BP 138/65 HR 127 BPM, RR 36, and SpO2 is 99% on 15L of oxygen via a non rebreather mask. Mr. Jones has no underlying health conditions. He has a slim build and smokes 3/4 pack of cigarettes per day. The MD arrives to the room as the patient rolls in and respiratory therapy is called to the bedside. Mr. Jones in is visible respiratory distress and is using accessory muscles to breath. Mr. Jones is very agitated and states in full sentences that all he needs is some oxygen and insists that he will be fine without having labs drawn or an IV inserted. His family is very surprised at how he is acting. As this patient's nurse, what are your next steps?[/quote']