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Check out this ridiculous case today....
53 yo M w/ ESRD on HD, HTN, Asthma (intubated x3), comes into the ED last night at 2am in severe respiratory distress (he drove himeself in), c/o 1-2 hrs SOB, ran out of inhalers and didn't take his BP meds b/c he's getting dialysis in the morning at 5:30am. Vitals 36.5 260/155 146 48 82% RA. He was brought straight back and the charge nurse called me to the bedside. His lungs were silent, no wheezing, no crackles. No LE edema. Denies any other symptoms (no cp, no cough, no f/c).
I immediately start him on bipap and give a continuous neb w/ decadron and mag for asthma. I recycle the pressure twice and both repeats are >250/150 so I dump 3 SL nitros into his mouth and slap on 4 inches nitro paste now realizing it's probably more flash pulmonary edema from diastolic dysfxn. Within about 5 min his pressure drops to 180/120 and his WOB dramatically decreases. Within another 10 min his pressure drops 111/70 HR 120 and I rub off his nitro paste.... For the next hr and a half his pressure fluctuates between 120 and 170 systolic and I give him hydralazine 10mg IV twice to keep it under 160... I let him know that he's gonna get admitted, and he says "there's no damn way--I need to get to dialysis at 5:30". I tell him we can do it here, but he persists. His CXR showed mild edema but nothing impressive; however he had a BNP of 48,000! His CBC, BMP, CE were normal. It's now 4:00am and he is still insistant on wanting to make dialysis and he's got a RR 12 on Bipap, so I decided to wean him, since he's going to leave AMA no matter what. He's weaned off Bipap, to FM, to NC, to RA over the next 75 min, while I order down 10mg norvasc PO and 10mg hydralazine PO from pharmacy. At 5:10am his last set of vitals were 140/95 110 14 95% RA.... no wheezes/no crackles on exam, breathing comfortably. I discharged him at 5:15am so he could drive to dialysis!!!
This guy was 30 seconds away from an ETT 3 hrs ago.... Fastest, most dramatic turn around I've ever seen.
53 yo M w/ ESRD on HD, HTN, Asthma (intubated x3), comes into the ED last night at 2am in severe respiratory distress (he drove himeself in), c/o 1-2 hrs SOB, ran out of inhalers and didn't take his BP meds b/c he's getting dialysis in the morning at 5:30am. Vitals 36.5 260/155 146 48 82% RA. He was brought straight back and the charge nurse called me to the bedside. His lungs were silent, no wheezing, no crackles. No LE edema. Denies any other symptoms (no cp, no cough, no f/c).
I immediately start him on bipap and give a continuous neb w/ decadron and mag for asthma. I recycle the pressure twice and both repeats are >250/150 so I dump 3 SL nitros into his mouth and slap on 4 inches nitro paste now realizing it's probably more flash pulmonary edema from diastolic dysfxn. Within about 5 min his pressure drops to 180/120 and his WOB dramatically decreases. Within another 10 min his pressure drops 111/70 HR 120 and I rub off his nitro paste.... For the next hr and a half his pressure fluctuates between 120 and 170 systolic and I give him hydralazine 10mg IV twice to keep it under 160... I let him know that he's gonna get admitted, and he says "there's no damn way--I need to get to dialysis at 5:30". I tell him we can do it here, but he persists. His CXR showed mild edema but nothing impressive; however he had a BNP of 48,000! His CBC, BMP, CE were normal. It's now 4:00am and he is still insistant on wanting to make dialysis and he's got a RR 12 on Bipap, so I decided to wean him, since he's going to leave AMA no matter what. He's weaned off Bipap, to FM, to NC, to RA over the next 75 min, while I order down 10mg norvasc PO and 10mg hydralazine PO from pharmacy. At 5:10am his last set of vitals were 140/95 110 14 95% RA.... no wheezes/no crackles on exam, breathing comfortably. I discharged him at 5:15am so he could drive to dialysis!!!
This guy was 30 seconds away from an ETT 3 hrs ago.... Fastest, most dramatic turn around I've ever seen.
