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Case 1: Should we?

An 81 year old woman is brought in by ambulance from a nursing home, with a two day history of worsening shortness of breath and increasing confusion.

Her vital signs on arrival are:

GCS 14 (E4 M6 V4)
BP 105/60 mmHg
HR 62 /min
RR 22 /min
SpO2 95% on NRM
Temp 37.1 °C
BGL 13 mmol/l

Please describe and interpret.

 

The letter from the nursing home states that your patient has moderate dementia, but she is independently mobile and able to feed and dress herself. She is a former smoker and has a history of COPD, hypertension, ischaemic heart disease, congestive heart failure, hypercholesterolaemia, osteoarthritis, and polymyalgia rheumatica.

Outline the priorities and challenges in the first 10 minutes of your assessment and management of this patient.

 

List a structured differential diagnosis.

 

What investigations would you undertake at this point? Justify each test.

 

Her ECG looks as follows:
case1 ecg

Source: Dr Ed Burns, Life in the Fast Lane (with permission)  LINK

Please describe and interpret.

 

A CXR is taken in the resus room.
case1 cxr

Source: Dr Sean Scott, EM-Masterclass.

Please describe and interpret. Include relevant negatives.

 

Your resident takes an arterial blood gas (ABG).

      Reference range
pH 7.28   (7.35−7.45)
pCO2 30 mmHg (35-45)
HCO3- 12.0 mmol/l (21-28)
BE -13 mmol/l (-2 - 2)
pO2 124 mmHg (75-100)
Na+ 130 mmol/l (135-145)
K+ 3.4 mmol/l (3.5-5.0)
Cl- 95 mmol/l (95-110)
Glucose 12.5 mmol/l (3.0-6.0)
Lactate 5.1 mmol/l (<2.0)

Please describe and interpret.

 

During your initial assessment, the patient becomes increasingly drowsy.
Her BP drops to 85/50 mmHg and her saturation is 89% on the NRM.

What methods could you use to improve her perfusion?
What are the advantages and disadvantages of your proposed interventions for this patient?

 

How might you improve her oxygenation?
What are the advantages and disadvantages of your proposed intervention for this patient?

 

Outline your specific management for this patient.

 

Despite your interventions, your patient’s vital signs are not improving, and she becomes difficult to rouse. Her daughter arrives, and she is very distressed to see her mother in this state. She insists you have to do everything possible to save her mother.

How do you approach this situation?

 

Does the uncertainty of diagnosis change how aggressively you manage this patient?

Suggested resources

Basic sciences

  • Long N. Frank Starling Curve. LITFL. 2014.  Link
  • Neeland IJ, Kontos MC, De Lemos JA. Evolving considerations in the management of patients with left bundle branch block and suspected myocardial infarction. J Am Coll Cardiol. 2012; 60(2): 96-105.  Link

Fluids

  • Durairaj L, Schmidt GA. Fluid therapy in resuscitated sepsis: less is more. Chest. 2008; 133(1): 252-63.  Link
  • Myburgh JA, Mythen MG. Resuscitation Fluids. N Engl J Med. 2013; 369: 1243-1251.  Link
  • Myburgh JA. Fluid Resuscitation - Which, When, and How Much? Lecture, SMACC 2013.  Link
  • Marik PE, Lemson J. Fluid responsiveness: an evolution of our understanding. Br J Anaesth. 2014; 112(4): 617-20.  Link

Vasopressors & inotropes

  • Kellum JA, Pinsky MR. Use of vasopressor agents in critically ill patients. Curr Opin Crit Care. 2002; 8(3): 236-41. Link
  • Myburgh JA, Higgins A, Jovanovska A, et al. A comparison of epinephrine and norepinephrine in critically ill patients. Intens Care Med 2008; 34(12): 2226-34. Link
  • De Backer D, Biston P, Devriendt J, et al. Comparison of Dopamine and Norepinephrine in the Treatment of Shock. N Engl J Med. 2010; 362: 779-789.  Link
  • Levy B, Perez P, Perny J, Thivilier C, Gerard A. Comparison of norepinephrine-dobutamine to epinephrine for hemodynamics, lactate metabolism, and organ function variables in cardiogenic shock. A prospective, randomized pilot study. Crit Care Med. 2011; 39(3): 450-5.  Link
  • Myburgh JA. Catecholamines, Resuscitation and Resurrection: Fact or Fiction? Video. SMACC. 2013.  Link
  • Other resources on Life in the Fast Lane:

 

 

 

  • Noradrenaline  Link
  • Phenylephrine  Link
  • Vasopressin  Link

End-of-life decision making

  • Nederlandse Vereniging voor Intensive Care (NVIC). Richtlijn nalaten en staken van behandeling en palliatieve zorg na het staken van behandeling bij volwassen IC patiënten. 2013. [Dutch ICU ‘end-of-life’ guideline; includes sections on legal and ethical issues.]  Link
  • Ashby M. Caring for dying patients is not about prolonging life at all costs. BMJ 2013; 346: f3027.  Link
  • Thomas RL, Zubair MY, Hayes B, Ashby MA. Goals of care: a clinical framework for limitation of medical treatment. Med J Aust. 2014; 201(8): 452-455.  Link
  • Brimblecombe C, Crosbie D, Lim WK, Hayes B. The Goals of Patient Care project: implementing a proactive approach to patient-centred decision making. Intern Med J. 2014; 44(10): 961-6.  Link
  • What is possible, what is reasonable, what is best? Panel discussion. SMACC Gold 2014. Video.  Link
  • Australian Commission on Safety and Quality in Health Care. National consensus statement: essential elements for safe and high-quality end-of-life-care. 2015.  Link

 

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