EMCC's What's Your Diagnosis?

Managing Multiple Injuries In High-Speed MVC…

ebmedicine — Mon, 26 Sep 2011 19:53:24 +0000

You are on duty at a community hospital ED when 2 patients arrive simultaneously after a high-speed crash between a pickup truck and a small sedan. Both patients were unrestrained. With the assistance of a partner and the on-call general surgeon, your ED team performs rapid assessments of both patients, with the following initial findings:

Patient 1 is the 33-year-old male driver of the pickup truck. The patient indicates that his chest struck the steering wheel, and he reports chest and back pain. He is restless and diaphoretic, his blood pressure reading is 95/72 mm Hg, and his pulse rate is 115 bpm. Upon examination, scattered contusions are observed on his chest and abdomen. The patient’s breath sounds are equal, and his abdomen is diffusely tender but not distended. He has no long bone fractures and no neurologic deficit. A supine chest x-ray reveals a wide mediastinum. (See Figure 1.) A pelvic x-ray shows no fractures; however, a FAST examination reveals free fluid in the Morison pouch and around the spleen. As a result of his persistent agitation, the patient is intubated.

Patient 2 is the 26-year-old male driver of the small sedan. He reports severe lower abdominal and pelvic pain and screams out with any movement of the backboard splint. His blood pressure reading is 84/60 mm Hg, and his pulse rate is 109 bpm. An examination reveals that the patient’s lungs are clear, his abdomen is diffusely tender, there is severe pain on pelvic compression, and he has an obvious closed fracture of the right tibia/fibula with preserved distal pulses and neurologic function. The results of a supine chest radiograph are normal, and a pelvic x-ray reveals an obvious fracture. (See Figure 2.) Results of a FAST examination are negative for free fluid in the peritoneum and pericardium. Your facility has limited resources, and rapid decisions need to be made regarding stabilization and transfer.

The team gathers to answer several important questions, including the following:

Is additional ED testing needed?
What are the essentials of ED stabilization?
How should these 2 patients be prioritized for interfacility transfer?

Submit your answers to the questions above by entering your response in the comments box.

“Noninvasive Ventilation” … Case Conclusion

ebmedicine — Fri, 05 Aug 2011 13:27:43 +0000

The respiratory therapist recommended CPAP at 10 cm H2O. The oxygen saturation rose from the high 60s to the high 80s, and the patient was no longer diaphoretic. A large bore peripheral IV was placed, blood was collected, and IV furosemide and nitroglycerin were administered. A venous blood gas to follow the pH and PCO2 were sent. These returned as pH = 7.20 and PCO2 = 60. Based on the landmark studies by Kelly and colleagues – having kept in mind that they studied patients with acute COPD – the venous blood gas was repeated and it was noted that the pH had risen by 0.10 to 7.30, and the PCO2 had dropped to 50. While the venous PCO2 result may not have correlated well with arterial PCO2, the pH appeared to be going in the right direction. The patient was no longer diaphoretic and even smiled for the first time. Chest radiograph confirmed acutely decompensated heart failure, and it was decided that this patient would not need tracheal intubation. At least not for now…

For an examination of the evidence and various recommendations for the use of NIV in a variety of patient presentations, read the latest issue of EMCC, “Noninvasive Ventilation: Update On Uses For The Critically Ill Patient.”

Noninvasive Ventilation…

ebmedicine — Wed, 20 Jul 2011 22:04:14 +0000

The triage nurse calls you to the resuscitation room where you find a morbidly obese male who is gasping for air and is cool, pale, and diaphoretic. He is seated in the tripod position with nasal flaring, pursed-lip breathing, and rales to the apices, and he is speaking in 1-2 word sentences. His blood pressure is 240/160. EMS providers have given sublingual nitroglycerin but were unable to obtain IV access and have therefore not given furosemide. You realize that attempting tracheal intubation on this patient is a recipe for disaster. You have used NIV for patients with COPD, but you haven’t tried it in patients with ACPE. You page the respiratory therapist to bring the noninvasive ventilator, hoping that NIV will help the patient avoid the need for a difficult intubation. The respiratory therapist asks whether you want bi-level NIV or CPAP, what pressure to deliver, and whether you prefer a nasal mask, a face mask, or a helmet.

What is your reply, and what are your next steps after initiating NIV?

Submit your answer by entering your response in the comments box.

Intubation…

ebmedicine — Wed, 25 May 2011 21:48:42 +0000

Your asthmatic patient has become so exhausted that she is barely moving any air. She will not tolerate noninvasive ventilation, and it’s obvious that she needs to be intubated. You hand the laryngoscope to a trusted fourth-year resident. He proceeds to place the tube and states that he saw it pass through the cords. A few seconds later, the pulse oximeter reading drops to 40%. You shake your head and grab the laryngoscope. Your resident points out the yellow color change of the ETCO₂ detector, but you now notice the pulse oximeter is reading 36%.

What do you do?

Submit your answer by entering your response in the comments box.

Delayed Sequence Intubation (DSI)…

ebmedicine — Fri, 15 Apr 2011 16:38:21 +0000

You have a 50 y/o male with bad bilateral pneumonia. BP 108/70, HR 96, RR 28. He is delirious, agitated, and looks sick, sick, sick! Saturation is 70% on a nasal cannula; when you try to place the patient on a non-rebreather (NRB) he just swats your hand away and rips off the mask. It is obvious to everyone in the room that this patient needs intubation, but the question is how are you going to do it? Your first impulse may be to perform RSI, maybe with some bagging during the paralysis period. This is essentially a gamble. If you have first pass success, you (and your patient) may just luck out, allowing you to get the tube in and start ventilation before critical desaturation and the resultant hemodynamic instability. However, the odds are against you: bagging during RSI predisposes to aspiration, conventional BVM without a PEEP valve is unlikely to raise the saturation in this shunted patient, and if there is any difficulty in first-pass tube placement your patient will be in a very bad place.

What do you do?

Submit your answer by entering your response in the comments box.

Used with permission from the EMCrit Blog.

Welcome to EMCC’s What’s Your Diagnosis? blog!

ebmedicine — Fri, 15 Apr 2011 15:59:37 +0000

Welcome to EMCC’s What’s Your Diagnosis? blog! This blog was created by EB Medicine, the publisher of EM Critical Care (EMCC), to be a fun way for emergency clinicians to test their knowledge of challenging emergency medicine critical care cases. One patient presentation to the ED will be posted each month, with the case conclusion posted one week later including a link to a full text article on the topic. Post your guess to the diagnosis before we share the conclusion, and then see if you got it right!