Fun "intern/night float" case 2

[Crayola227]

---

Members don't see this ad.

================================================================================
Case 2

72-year-old man with no known pulmonary history admitted to the hospital with E. coli sepsis due to cholecystitis. He receives antibiotics, fluids, and narcotic analgesia. On hospital day 3, he gets out of bed to go to the bathroom and becomes “winded.” When you arrive to see him, he is sitting on the edge of the bed with his elbows on his knees, with a RR of 30 breaths/min. He states he cannot catch his breath. His pulse ox registers an SpO2 of 87%.

1. What is the differential diagnosis of this patient’s acute respiratory failure?

2. Detail your immediate and short-term management (i.e. orders including immediate interventions, treatments, and tests).
================================================================================
Case 1 (link)

ID: 72 yo w/ e.coli sepsis 2/2 cholecystitis
HD#3
S: now "winded", can't catch breath
O: Vitals: RR 30, SpO2 87%
I/O: ??
PE: Gen: tripoding
Meds: has had abx, IVF, narcs
Labs: ??
A/P:

I wanted to point out that the position is tripoding.
I like to write out how I would SOAP this, and cuz these prompts drive me nuts

Plus it's good to get reminded of the orignial case as we go along the thread.

 

[Crayola227]

This is meant to elicit more thinking, so feel free to respond whenever.


The vitals and your clinical exam/abbreviated history should guide your decision-making here. If the patient is "clinically euvolemic", why are you going down the path of getting fluid off of them?

Why morphine? I would not give this patient morphine. The only people in respiratory distress that I would give morphine to are comfort care patients with air hunger.

Goes back to what I previously said. If the patient's clinically euvolemic, it doesn't make sense to give diuretics. If the patient is genuinely in flash pulm edema, IV 40 of Lasix isn't that huge of a dose. Regardless of whether or not they're Lasix-naive, I'd give them 160 IV and deal with the kidneys later. Regardless, the most important thing you can do for this patient after giving Lasix is checking to make sure they're actually producing urine.

Sure, you can call an RRT. No one will ever fault you for calling for help too early. Apart from the tachypnea, what makes you worried this guy's going to decompensate in front of you? If you're going into IM, you'll frequently be called to bedside for dyspneic patients who are satting (briefly) in the mid-to-upper 80s. As you gain experience, you'll get a better sense of when to call for help early and when you know you have time to figure things out.

In this case, you have time to figure out what's going on. Unless they've been super tachypneic for a good bit of time (and I have clinical/ABG findings supporting that), I'm not worried about them tiring out right in front of me.

Regarding CPAP vs. BiPAP, which scenarios would you choose one over the other? I don't necessarily think BiPAP is a bad choice if you had to choose it here, but if someone was flashing on me, I'd generally use CPAP.

Additionally, what does PPV do RV preload and RV afterload? Does that change whether or not you'd place them on PPV if you're worried about RV dysfunction?

NTG is fair if you genuinely think someone's flashing on you (though I wouldn't start it as a drip when the SL gives a whopping 400 mcg dose right off the bat -- assuming they don't have critical AS or pulm HTN or RV dysfunction).

The problem here is that you're worried about this guy maybe having submassive vs. massive PE and RV dysfunction. What's your rationale for dropping the preload on a failing right heart?

Several questions here:

1. How does an EKG tell you someone's having a "hypertensive exacerbation"?

2. IV ACEi? Why'd you pick that one? There are far, far better go-to's for IV drips in the case of HTN emergency. I cannot imagine a single scenario where I'm choosing IV ACEi. Not only that, even if you really wanted to, good luck convincing the pharmacy to let you use that.

Depends where you're training.

All very excellent points.

 

[Crayola227]

1. Its a tricky situation but essentially you're giving fluid boluses while also titrating inotropes (dobutamine) and pressors (norepinephrine). Many people will also go ahead and insert an IABP or LVAD to improve cardiac output but there's never been any mortality benefit. The bottom line is that this patient needs the cath lab or lytics ASAP.

2. First try to sedate the patient with Ketamine. Oftentimes that will help patients who aren't tolerating BiPAP.

The fear on the floor of using ketamine is real. I don't know why, then again, never seen it used outside the ED.

Although I did have a patient on the floor who had HAs managed outpt with ketamine (which I didn't even know was a thing (neither did the attending))
and asked for it on the floor. Let's just say when I got paged for this, I deferred to the senior and attending. Their rxn? 😱

I've only seen ketamine used by medicine in the ICU for RSI. I don't know how you use it in patients you want to be somewhat with it, like BIPAP/CPAP, HA.

 

[lymphocyte]

.

 

[Doctor Bob]

Doctor Bob!! Yes! I really hope you pop your head in the other case discussions too!

I know not of these other case discussions of which you speak...

Two questions I'm unclear about:

1. Inferior STEMI, wet chest, goes hypotensive with clinical signs of hypoperfusion, and help is far away. Would you consider dobutamine? You can give it peripherally, but it's beta-1 so you might exacerbate ischemia. And this guy isn't winning with fluids either. Not sure what's in my bag of tricks here.

Well, it depends (you'll see a lot of my responses start with this...)
What do you mean by far away? If you've got dead myocardium from a blocked vessel and that dead (dying?) heart wall is causing a pump problem, there's not going to be a lot of benefit to making the rest of the heart squeeze harder. Sure, the kidneys and brain might be happier. If the hypotension is from a tight coronary and by increasing perfusion you can improve coronary perfusion, that's when the question of time to definitive intervention comes in. It's not something I'd consider for a long term; I might think about it for a short term. But generally when I have a pump problem I'm reaching for epi drips far more often than dobutamine. Pump failure from MI? I'm not too keen on either drug; I want to fix the underlying problem.

2. New onset A-fib with RVR and confusion fighting BiPAP. I think he needs synchronised cardioversion but RSI too? Not sure how to manage on the airway front (other than waiting for the airway team--and waiting might be the best answer if otherwise haemodynamically stable). Any thoughts would be appreciated.

#2 I'd call a code and prep for RSI + cardiovert, if we're assuming the AMS is cardiopulmonary etiology. If they're altered due to hypercarbia/hypoxia or not perfusing brain, theyre not "otherwise HD stable", theyre sick

Well we know they're unstable or you wouldn't be thinking about RSI and cardioversion. The question is are they stable enough to wait to get to the unit or do you need to do it right then and there?
If you're going to have to do it on the floor, I'm a fan of etomidate, tube, clear, zap. How you do it also depends on the skill of your airway operator. I've done thousands of airways so I will drop an ETT and inflate the balloon while the machine is charging (if they're really that unstable). Don't worry about any potential BP drop from the meds; once you fix the primary problem (the RVR) their pressure will improve. But just in case have the push-dose pressors ready. Don't have someone who is still getting comfortable with the ETT placement doing that part of the procedure.
Interestingly, it's not all than infrequent that the intubation procedure vagals the patient and they convert.
Also of interest, keep in mind that in a very unstable patient... you don't have to sedate them. They won't give you good evaluations afterwards ("that sombitch done kicked me in the chest!") but they'll be alive.

2. First try to sedate the patient with Ketamine. Oftentimes that will help patients who aren't tolerating BiPAP.

Not to say it can't be done, but just consider the catecholamine surge from the ketamine might make your RVR worse. In this clinical scenario it wouldn't be my first choice, but I wouldn't say it's contraindicated either...

The fear on the floor of using ketamine is real. I don't know why, then again, never seen it used outside the ED.

Not sure. I've seen the same fear when I show up at a near-code on the floor and ask for it. Love me some ketamine though...

 

[lymphocyte]

I know not of these other case discussions of which you speak... .

Case 1 (non-responsive s/p knee surgey): http://forums.studentdoctor.net/threads/situation-in-hospital-what-do-u-do.1216194/
Case 3 (hypertensive "urgency" and sepsis): http://forums.studentdoctor.net/threads/intern-nf-case-3.1217005/#post-18049290

Thank you so much for your thoughts!

 

[sozme]

Case 5

Put it up today.

 

[sozme]

So here is what I have... (critique any of it)

1. VTE/Pulmonary embolism, cardiogenic pulmonary edema, acute coronary syndrome, sepsis-related pulmonary vasodilation/shunting, peritonitis (decreased chest wall compliance/increased elastic work), pneumonia, pneumothorax, electrolyte disturbance.
2. Management:

• Start with 2-4 L/min LFNC or 4-8 L/min via Venturi mask (approx. 24-40% FiO2)
  • If no improvement from this…? Then….? BiPAP?
• Call for assistance/have other personnel call for assistance. Call for crash cart.
• Quick re-check of vital signs and physical exam, noting:
  • Signs of respiratory failure (tachypnea, tachycardia/bradycardia, use of accessory muscles, perioral cyanosis, acrocyanosis, altered mental status, hypertension, tremor, restlessness/agitation, papilledema, asterixis, conjunctival hyperemia, etc).
  • Wheezes, rhonchi, prolonged expiratory phase, diminished breath sounds (airway etiology).
  • Stridor (anaphylaxis, foreign body aspiration)
  • S3 gallop, bibasilar crackles, jugulovenous distention, bilateral 2-4+ pitting edema of distal LE (heart failure)
• Tests to order:
  • Critical care panel/ABG (immediately) and 1-2 hours following supplemental oxygen (or ~20 minutes post-intubation)
  • Secure 2 large-bore IV sites
  • BMP
  • Serum Magnesium
  • CBC with differential
  • Serum lactate (if not already part of critical care panel)
  • CK-MB
  • Troponin T
  • PT/INR
  • aPTT
  • 2-site blood cultures
  • Portable CXR
  • EKG
  • Duplex U/S of bilateral lower extremities
  • TTE
  • +/- bedside echo (if you have U/S at hand and are proficient enough at noting RV strain)
  • nT-BNP (even if this sub-massive or massive PE, this can be used as a surrogate for RV strain in the absence of quick echo)

Point is think about what you would do with the little info you have right there in the first 5-10 minutes at the bedside by yourself, and assuming you are the only physician available in the interim between now and when the senior resident or outside service resident/attending arrives.

Especially looking for comments on red colored text items.

Still looking for final feedback on this one. I actually forgot why CTa wasn't included in the immediate management? It's been a few months.