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Yep we usually give 100 mLs of bicarbonate which is equivalent to 200 mLs of 3% saline.
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Post a good case, dammit.
Started by RustedFox
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Yep we usually give 100 mLs of bicarbonate which is equivalent to 200 mLs of 3% saline.
It's either extremely underestimated or something else was going on. A 12 pack of diet coke isn't that absurd. There's people out there who drink several of the 2Ls of diet soda a day.
OMG. A friend of mine had a chole and was wearing a scopolamine patch afterwards. She texts me and says "I'm SOB and I have blurry vision, and one of my pupils is more dilated than the other." I was quite puzzled by this (and BTW I wasn't worried about the SOB either). Anyway. She went to the ER later that day and ER in combo with Ophtho diagnosed it as coming from the scopolamine patch. I'd never heard of that.
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Somehow using EMS when you are literally holding your guts in your hands does not seem like an abuse of that service.
hyponatremia causing seizures. Give benzos, then follow status meds pathway, protect airway early. Check lytes, reverse hyponatremia if that is the cause in conjunction with intensivist
You're right, reviewed the emcases article on this and looks like immediately reverse with 100mL 3%NS over 10 minutes repeated until correction of mental status or 5meQ increase in sodium. Crash cart bicarb also works here. Only at that point do you subsequently involve nephro/intensivist
This is fairly common. Patient touches the patch, then rubs their eye. I don't put scop patches on patients very often but I sometimes will on someone I'm admitting with severe nausea/vomiting/vertigo. I always warn them not touch the patch for precisely this reason.
now that is expensive, sounds like he should have driven to the tertiary center instead
I claim credit for the "Old German farmer sign."
If an old, German, farmer voluntarily comes to the ED, skip triage, skip fast-track, put him in a room and let me know as soon as I am out of a room.
If he asked his wife to drive him in, put him in one of the resuscitation bays and get me immediately.
If he called EMS, relax. He is dead. Call the coroner.
An heuristic clinical rule, and it doesn't have the "evidence based" seal of approval, but if anyone wants to do a retrospective study I guarantee it will be as good as most of the others floating around.
Perfect timing but just had probably one of the craziest cases of my career that I had to share.
As many people know I do a lot of international work and I'm currently in Africa helping with their COVID surge.
Long story short our ER is completely full right now with COVID patients and we have no beds available causing patients to have to sit outside the hospital in the parking lot hooked up to portable oxygen. Anyway I'm working yesterday afternoon and a car pulls up to the ambulance bay and the family runs inside screaming that their daughter is having a bad asthma attack and isn't breathing. Come outside to help and find her in the back seat of the car unresponsive and gasping for breath. Slap on a finger pulse ox which showed HR 160 and SpO2 40. Listen but can barely hear anything with absent breath sounds and no air movement. Pull her out of the car and into a wheelchair but there aren't any beds available plus the nurse is refusing to take her inside because of the COVID patients. Not trying to waste time arguing so basically said **** it lets do this right here in the ambulance bay. Told her to start two large bore IVs and hang a couple liters. Ran inside and grabbed a BVM and my airway bag. Came back and had a nurse bag her while I set up with a mac 3 bougie and 6-0 tube. Sat her upright with her head back and tubed her right there while in the wheelchair with no meds or suction. Told the nurses to give all the asthma meds but apparently we ran out last week and nothing was available including albuterol, solumedrol, magnesium, or theophylline. Didn't want to give up cause she's young and healthy otherwise so grabbed some push dose epinephrine and just started pushing 10 mcg every couple min. Gave a total of 5 doses and she began to slowly improve to the point that she developed significant audible wheezing in both lungs. After 30 min the wheezing started to decrease with good air movement and her vital signs improved to HR 120 and SpO2 100. After 60 min she started waking up opening her eyes on her own and then all of the sudden before we could give sedation she suddenly stood up and pulled out the tube. Convinced her to sit back down and put her on an NRB mask but she's speaking in full sentences and yelling at her family about why they brought her to the hospital. After 2 hrs she demands to leave and the family basically walks out before security arrives. Came back to work earlier this afternoon wondering if she went home and died last night when she walks in the front entrance asking if she can have a refill on her inhaler because she had difficulty breathing all night long and feels terrible.
As many people know I do a lot of international work and I'm currently in Africa helping with their COVID surge.
Long story short our ER is completely full right now with COVID patients and we have no beds available causing patients to have to sit outside the hospital in the parking lot hooked up to portable oxygen. Anyway I'm working yesterday afternoon and a car pulls up to the ambulance bay and the family runs inside screaming that their daughter is having a bad asthma attack and isn't breathing. Come outside to help and find her in the back seat of the car unresponsive and gasping for breath. Slap on a finger pulse ox which showed HR 160 and SpO2 40. Listen but can barely hear anything with absent breath sounds and no air movement. Pull her out of the car and into a wheelchair but there aren't any beds available plus the nurse is refusing to take her inside because of the COVID patients. Not trying to waste time arguing so basically said **** it lets do this right here in the ambulance bay. Told her to start two large bore IVs and hang a couple liters. Ran inside and grabbed a BVM and my airway bag. Came back and had a nurse bag her while I set up with a mac 3 bougie and 6-0 tube. Sat her upright with her head back and tubed her right there while in the wheelchair with no meds or suction. Told the nurses to give all the asthma meds but apparently we ran out last week and nothing was available including albuterol, solumedrol, magnesium, or theophylline. Didn't want to give up cause she's young and healthy otherwise so grabbed some push dose epinephrine and just started pushing 10 mcg every couple min. Gave a total of 5 doses and she began to slowly improve to the point that she developed significant audible wheezing in both lungs. After 30 min the wheezing started to decrease with good air movement and her vital signs improved to HR 120 and SpO2 100. After 60 min she started waking up opening her eyes on her own and then all of the sudden before we could give sedation she suddenly stood up and pulled out the tube. Convinced her to sit back down and put her on an NRB mask but she's speaking in full sentences and yelling at her family about why they brought her to the hospital. After 2 hrs she demands to leave and the family basically walks out before security arrives. Came back to work earlier this afternoon wondering if she went home and died last night when she walks in the front entrance asking if she can have a refill on her inhaler because she had difficulty breathing all night long and feels terrible.
Wow lol
Nice save.
She's gonna give you all 1's on your Press Ganey survey because you didn't offer her a turkey sammich.
I’m not sure Press Ganey is big in the African ER market.
Only if you're in IM/Peds.
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How low was the Hemaglobin.
I’d be really interested if this person was treated only with a dose of Venofer instead of a unit of lrRBC.
I’d be really interested if this person was treated only with a dose of Venofer instead of a unit of lrRBC.
Does anyone else give IV iron in the ED?
Never done that before.
I've done it for patients sent in for a transfusion for "critical anemia" who wind up having a Hb of 8.x or something and have a hx of iron deficiency anemia. This is almost entirely customer satisfaction driven though, as it allows me to explain why I'm still doing something even though they don't need the blood transfusion that they were told that they did.
Incidental non severe anemia gets no ED intervention and PCP followup.
Nice. Yeah, I've been doing it for several years, although I'm much more of a believer. I think it's good for patients, as so many either can't tolerate or are just nonaderent to PO iron. Personally I don't transfuse for Fe-deficiency until the Hgb gets below 5.5 or something in healthy people absent high-grade symptoms.
all the time!
I do it regularly for stable IDA when the Hg is > 6. What's the point of giving blood? They need iron. iron sucrose 200 mg IV x1 in place of giving pRBC.
Got a patient im trying to get ecmo for who is 20 and drowned. But get this……
Our F’ing helipad has too slippery of paint that was applied to it and is **** down…..
Our F’ing helipad has too slippery of paint that was applied to it and is **** down…..
Wouldn’t it be near drowning at this point?!? I keed I keed. Sorry about your patient. Just horrible ARDS or something?
Ya, was doing well when I left this morning, now on 3 pressors, proned, sating 92 on 100fio2 and peep 16. Not good not good.
It's also way more bioavailable / efficacious than PO iron, so with a few doses you can replete much more of the total body deficit than starting someone on oral iron which as mentioned many people stop taking. Way faster than giving a unit of blood, too.
22 yo F w/ a hx of anemia and pseudoseizures presents for hematemesis. Pt states she has been having off and on hematemesis for 4-5 months. She is in the waiting room because we have no beds. I get a report from nursing staff that patient had a hematemesis episode in the bathroom and passed out, now looks pale, and has blood surrounding her mouth, with a piece of blood clot hanging on her lips. I walk in to the restroom to see a morbidly obese woman lying on the bathroom floor who is awake, with blood smeared around her mouth. She denies any hx of ulcers, liver disease, alcohol abuse, and NSAID use.
They place her into one of our triage rooms to start lab work on her. VS are all perfect. I get called in again to see her because she is having a seizure. I walk in to find the patient flailing her arms and legs around.
"Ma'am, this is really important, I need to know what medications work for your seizures, because giving the wrong meds can kill you!"
"Ativan"
"Sorry, I don't think that is an appropriate medication, but I'll see what you've received in the past."
"I'm going to have another seizure if I don't get ativan, doctor."
"I'm sorry ma'am, but that is a risk we are going to have to take."
......
5 minutes later: "Doctor, she's seizing again."
"Okay, let her tire herself out."
......
We get labs on her with everything coming back normal. Before I can go talk to her to let her know she will be going home, the nurse calls me into the bathroom again.
"Doctor, she threw up blood again and passed out on the floor." She is lying on the floor feigning loss of consciousness with another blood clot attached to her lips. No blood in the toilet. No blood around toilet. No blood in her teeth or in her throat. The only other place blood is present is on her fingernails.
"Did anyone actually witness her throw up blood?"
"Well, no."
"Ma'am, please open your eyes so we can talk and I can figure out what's going on."
*She opens her eyes*
"Are you currently on your menstrual period?"
"Yes."
"Ma'am, please stop smearing period blood on your face to fake throwing up blood."
This is where she starts yelling that she is going to call her lawyer and she is going to get her fiance to come get me for thinking she would fake throwing up blood. I then feign that there is a test I can perform to definitively tell whether that blood around her mouth is definitively coming from her stomach. At this point, she starts faking a seizure again. I then tell the nurse loud enough for the patient to hear, "I don't have time for this sh**. Call security to escort her off of hospital property." The patient then begins to yell at me again.
They place her into one of our triage rooms to start lab work on her. VS are all perfect. I get called in again to see her because she is having a seizure. I walk in to find the patient flailing her arms and legs around.
"Ma'am, this is really important, I need to know what medications work for your seizures, because giving the wrong meds can kill you!"
"Ativan"
"Sorry, I don't think that is an appropriate medication, but I'll see what you've received in the past."
"I'm going to have another seizure if I don't get ativan, doctor."
"I'm sorry ma'am, but that is a risk we are going to have to take."
......
5 minutes later: "Doctor, she's seizing again."
"Okay, let her tire herself out."
......
We get labs on her with everything coming back normal. Before I can go talk to her to let her know she will be going home, the nurse calls me into the bathroom again.
"Doctor, she threw up blood again and passed out on the floor." She is lying on the floor feigning loss of consciousness with another blood clot attached to her lips. No blood in the toilet. No blood around toilet. No blood in her teeth or in her throat. The only other place blood is present is on her fingernails.
"Did anyone actually witness her throw up blood?"
"Well, no."
"Ma'am, please open your eyes so we can talk and I can figure out what's going on."
*She opens her eyes*
"Are you currently on your menstrual period?"
"Yes."
"Ma'am, please stop smearing period blood on your face to fake throwing up blood."
This is where she starts yelling that she is going to call her lawyer and she is going to get her fiance to come get me for thinking she would fake throwing up blood. I then feign that there is a test I can perform to definitively tell whether that blood around her mouth is definitively coming from her stomach. At this point, she starts faking a seizure again. I then tell the nurse loud enough for the patient to hear, "I don't have time for this sh**. Call security to escort her off of hospital property." The patient then begins to yell at me again.
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The patient actually returned the next day doing the same, but was caught by a nurse placing menstrual blood in her mouth and was immediately escorted out again.
Dear god! What was the test to distinguish where the blood is coming from? An NG tube?
The supposed test was a lie. If she called my bluff, I was just going to grab some pH paper and claim the lack of acidity proved this blood was definitively not from her stomach.
This is disgusting in multiple ways
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- and the number one cause of burnout is...
Menstrual cycles?
on very rare occurrences we do as a way to prevent admission or follow up with a infusion clinic -usually at the direction of their heme/onc MD - the behind the scenes money game is not my world, but if (a big if) it doesn't mess things up to tie up a bed to it, it can save a trip back to the hospital, or an uncessary admission.
My contribution -
I get a call from a cards NP in the middle of the night about how to treat a patient who high K. Basically pt had high K in the ED, and was SOB, was treated with the usual cocktail, and admitted to cards. K dropped, now it is back high again (~6.5 or something like that). I pull up the chart just to make sure not hemolyzed, etc. I notice the WBC is like 50k+ and ask what is going on with that, do they have some sort of leukemia or lymphoma? (baseline WNL)
NP - "Not that I know of?"
Me - have you considered some sort of tumor lysis syndrome? (I know spontaneously TLS isn't very common). Basically I told her she really needs to draw labs (uric acid) and consult someone who can give better insight and can management this as it is more than just simple hyperkalemia. She doesn't want to - she just wants to give some SPS and call it good until morning. The best part is we have these vocera speaker phones so everybody around can hear both sides to the conversation (PS I hate those things). One of the ED doc's I am sitting next to hears this as I get pushback from the NP.
Finally here says "give me the phone" and basically tells her these are the types of pt's that can go downhill quick and could code and needs to be taken to the unit and evaluated for emergent dialysis. She reluctantly agrees.
Moral of the story - pt ends up having a K >7 despite treatment, uric acid elevated, diagnosed with TLS and pt ends up getting emergent dialysis.
I get a call from a cards NP in the middle of the night about how to treat a patient who high K. Basically pt had high K in the ED, and was SOB, was treated with the usual cocktail, and admitted to cards. K dropped, now it is back high again (~6.5 or something like that). I pull up the chart just to make sure not hemolyzed, etc. I notice the WBC is like 50k+ and ask what is going on with that, do they have some sort of leukemia or lymphoma? (baseline WNL)
NP - "Not that I know of?"
Me - have you considered some sort of tumor lysis syndrome? (I know spontaneously TLS isn't very common). Basically I told her she really needs to draw labs (uric acid) and consult someone who can give better insight and can management this as it is more than just simple hyperkalemia. She doesn't want to - she just wants to give some SPS and call it good until morning. The best part is we have these vocera speaker phones so everybody around can hear both sides to the conversation (PS I hate those things). One of the ED doc's I am sitting next to hears this as I get pushback from the NP.
Finally here says "give me the phone" and basically tells her these are the types of pt's that can go downhill quick and could code and needs to be taken to the unit and evaluated for emergent dialysis. She reluctantly agrees.
Moral of the story - pt ends up having a K >7 despite treatment, uric acid elevated, diagnosed with TLS and pt ends up getting emergent dialysis.
She probably doesn’t even know what TLS is
She probably thought it was a hip-hip group from the 90s.
I barely know what TLS is, so a Cards NP most definitely has never heard of TLS......
That's an error I've gotten from SDN in the past -"error completing TLS handshake", or some sort. I'm confident that something from networking and something from heme/onc HAS to be the same thing!
I knew she probably didn’t. I am not a onc person by any means. But I know you need someone who knows what they are doing to treat it. Crazy thing is that they didn’t have diagnosed cancer (yet).
Unngh. WBC of whatever it was (it was sky-high, not going back to the last page to look), and Jenny McJennyson doesn't know enough to recognize what it might be.
Yep.
Heart of a nurse, brain of a... tree stump.
I'm not gonna lie--if I had a pt w/ hyperkalemia w/ a super high wbc my first thought would be spurious hyperK rather than TLS...
I could write posts all day about this new Jenny mcjennyson we have working nights. The question I get that are so outside my realm. I think she is deathly afraid to call her attending
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Would The white cell lysis show up on the labs? I honestly don’t know. That is why I recommended a uric acid level and calling someone who knows more than me. I admit I may have just been lucky.
Ps. They did have peaked t waves on their ekg. I did leave that info out. Only slightly relevant. 🙂
Anyone noticing a huge uptick in substance abuse? 75+% of icu patients this week have all had histories of either etoh or drug abuse. Seems to always be meth and heroin here.
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In the or I have noticed a lot more people in alcohol withdrawal or came in with abscesses while doing meth or heroin.
I just admitted a TLS the other day. h/o CLL, WBC 420, Uric Acid about 18, and LDH be like 1200. K+ initially 8.1, but something about the clotting in the tube...my Oncologist recommended I rerun it on plasma only and they redrew and it was 3.9. Anyway good case. Renal function was OK and we didn't end up giving rasbinuicurisenasebease. I only know about that from residency, apparently it's a $10K drug and I probably will never order it unless my Oncologist asks me to.
rasbinuicurisenasebease.
Dude, you made that up.
Admit it.
It's a perfect parody name for these weird-ass biologic drugs.
Dude, you made that up.
Admit it.
It's a perfect parody name for these weird-ass biologic drugs.
Lol, not sure if you’re joking or not, but he’s referring to rasburicase which is one of those classic learn for the boards and forget medication because you will probably never use it in reality.
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