Heavy Lies the Helmet Episode #30 Case Studies

Scenario 1 65-year-old male who presented to the emergency department today at the outside hospital complaining of some diffuse abdominal pain, General malaise, nausea and vomiting and subjective fever. He has a history of coronary artery disease, type II diabetes and moderate COPD. The patient is a one pack per day smoker and reports some alcohol use.

He was hypotensive on his presentation in the ED and has received 1 L of NS in the ED. The chest x-ray shows bilateral consolidation in the bases unclear for infiltrate vs atelectasis, (clinical correlation recommended). CT imaging has been deferred secondary to the serum creatinine. EKG LBBB—Ventricular rate 48

Vital Signs: HR: 48 BP: 70/30 RR:26 T: 101.6 SpO2: 95% General malaise. Skin: Cool, pale Lungs: Scattered wheezes bilaterally, Diminished airflow in the bases and scattered petechia on the anterior chest ABD: Diffusely tender, firm and distended there is some mild guarding in the upper right quadrant. It is difficult to appreciate bowel sounds, no Cullens sign, no Grey turners sign

9.0 126 116 55 21.2 35 88 28 7.1 10 3.3 Neutrophils 88 % Monos 8% Bands 35% Eosonophils 3% Lymphs 18% Basophils 2% 26 75 Mg 2.3 AST 1122 Amylase 140 Phos 4.0 ALT 1804 Lipase 500 Ca++ 7.8 Alk Phos 580 Lactate 7.4 T Bili 6.2 Troponin 0.33 D Bili 5.0 5.3

Ascending Cholangitis Hyperkalemia Bradycardia 2/2 above Lactic Acidosis Transaminitis

Scenario 2 On arrival at the OSH GCS 1-1-2 B/P 60/40, 124, 36, 38 90% Arrived on Bi-PAP by EMS Has received 500 cc fluid and is receiving another bolus now Has had episodes of VT—1 bolus of Amio

Mg 2.3 AST 344 Phos 4.0 ALT 126 Lipase 500 CPK 2700 9.0 153 124 110 18.2 88 28 6.8 7 2.7 35 Neutrophils 75 % Monos 6% Bands 22% Eosonophils 5% Lymphs 18% Basophils 3% Mg 2.3 AST 344 Phos 4.0 ALT 126 Lipase 500 CPK 2700 Ca++ 7.8 Alk Phos 100 Lactate 5.5 T Bili 1.3 Troponin 0.46 D Bili 0.3

Polydrug ingestion AKI 2/2 Rhabdomyolysis RLL infiltrate 2/2 Aspiration Acute Respiratory Failure Diffuse Cerebral Edema Lactic Acidosis

Scenario 3 48 year old female found down at home—Long standing hx of polysubstance abuse EMS found her altered, GCS 2-3-4, Euglycemic Brought to the ED, became increasingly confused—intubated for airway protection

Labs CBC BMP ABG Miscellaneous WBC 14.2 Na 125 pH 7.04 ALT 126 RBC 3.5 K 5.4 pCO2 48 AST 134 HGB 12.3 CL 88 pO2 86 Lactate 4.6 HCT 35.8 CO2 5 HCO3 11 Serum Osmolality 318 PLT 120 SCr 8.5 BE -12 Ca 7.2 BUN 64 SaO2 92% MG 2.3 Glucose 66 ETOH 1.2 mg/dl

Acute AMS AKI WGMA Toxic Alcohol Poisoning 2/2 Ethylene Glycol Ingestion