Remember when we used to share "good cases!" on here? Well, here's one.

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RustedFox

RustedFox

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Title says it all.
Attendings; let the students/terns have first crack at questions/details/advancing the case.
Snarky-ass comments welcome.

57 year old female arrives via EMS after an episode of syncope, witnessed by husband. She has failed to return to any meaningful degree of consciousness; but had pulses on EMS arrival. EMS placed an i-Gel airway (yeah; don't get me started) and establishes IV access. She is transferred from EMS stretcher to resus bay bed.

Initial vitals are unremarkable.

HR = 92 and regular, no ectopy. BP = 119/78. RR = 14 (estimated, but spontaneous). Afebrile.

I'm deliberately stopping here for now.


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Glucose? Narcan?

I don't have an issue with EMS putting in a king tube or an i-gel for that matter. Would rather they bring the patient to the ED quicker, then waste more time screwing with airway issues in a sub optimal environment.
 
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Psst. What did I say about attendings letting the students and terns have first crack?

Glucose was normal as per EMS.
They gave her 2mg Narcan with no effect.
 
RustedFox said:
Title says it all.
Attendings; let the students/terns have first crack at questions/details/advancing the case.
Snarky-ass comments welcome.

57 year old female arrives via EMS after an episode of syncope, witnessed by husband. She has failed to return to any meaningful degree of consciousness; but had pulses on EMS arrival. EMS placed an i-Gel airway (yeah; don't get me started) and establishes IV access. She is transferred from EMS stretcher to resus bay bed.

Initial vitals are unremarkable.

HR = 92 and regular, no ectopy. BP = 119/78. RR = 14 (estimated, but spontaneous). Afebrile.

I'm deliberately stopping here for now.
Click to expand...
Emotionally triggered by a micro-aggression?
 
rcordova said:
Gcs? Anything on exam?
Click to expand...

Okay, let's play!

GENERAL: 57 year old white female, not named Karen, who appears slightly older than stated age; but curiously lacks the disgusting redundant adiposity of the age group. She actually has a decent body habitus, but is wearing an adult diaper. She has shat all over herself during transport, making you happy that you're wearing a facemask.

HEENT: NC/AT. i-GEL still in place, causing as much unnecessary tissue edema as possible because using an LMA isn't "in the EMS protocol".

CHEST: Normal without deformity/trauma. Has the boobs of a 25 year old female, which are far too big for her frame. Augmentation scars are visible while standing at the foot of the bed.

ABDOMEN: Soft. Nontender/nondistended. Why a 57 year old female is wearing a belly-chain adorned with a wooden flower charm, you may never know.

EXTREMITIES: Multiple tattoos of varying ages are present; but seem to adhere to a hippie/granola-muncher theme. Lots of "harmony with nature" imagery is present, including the phrase "love your mother" above a poorly-drawn globe, and the phrase "the left and right wings are part of the same bird". You manage to keep your judgments to yourself.

TOES: Ten toes are present, 7 of which are adorned with toe-rings. A snake. A turquoise tortoise. That stick-figure guy blowing on a flute that we all hate. You get the idea.

NEURO: No meaningful movements of the extremities, even to painful stimuli. No babinski reflex to evaluate. Pupils are PERRL, and the vestibulo-ocular reflex remains intact.


Anything else you want to know?
Next steps?
 
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RustedFox said:
Okay, let's play!

GENERAL: 57 year old white female, not named Karen, who appears slightly older than stated age; but curiously lacks the disgusting redundant adiposity of the age group. She actually has a decent body habitus, but is wearing an adult diaper. She has shat all over herself during transport, making you happy that you're wearing a facemask.

HEENT: NC/AT. i-GEL still in place, causing as much unnecessary tissue edema as possible because using an LMA isn't "in the EMS protocol".

CHEST: Normal without deformity/trauma. Has the boobs of a 25 year old female, which are far too big for her frame. Augmentation scars are visible while standing at the foot of the bed.

ABDOMEN: Soft. Nontender/nondistended. Why a 57 year old female is wearing a belly-chain adorned with a wooden flower charm, you may never know.

EXTREMITIES: Multiple tattoos of varying ages are present; but seem to adhere to a hippie/granola-muncher theme. Lots of "harmony with nature" imagery is present, including the phrase "love your mother" above a poorly-drawn globe, and the phrase "the left and right wings are part of the same bird". You manage to keep your judgments to yourself.

TOES: Ten toes are present, 7 of which are adorned with toe-rings. A snake. A turquoise tortoise. That stick-figure guy blowing on a flute that we all hate. You get the idea.

NEURO: No meaningful movements of the extremities, even to painful stimuli. No babinski reflex to evaluate. Pupils are PERRL, and the vestibulo-ocular reflex remains intact.


Anything else you want to know?
Next steps?
Click to expand...

EKG, labs, spin her head for a bleed and find a competent adult who can give you a decent hx (cardiac hx, neuro hx/why does she wear pampers? etc...) quick RUSH exam while we're in the bay to look for obvious causes (tamponade, PTX, free fluid in pelvis, etc)
 
Botulism from adventures in self-canning. Diaper is for the relentless GI side effects.
Have the anti toxin flown up from Atlanta.



I'm usually pretty good at being able to keep my wet blankety-ness to myself, but I gotta say...
The cheap jokes about her appearance and lifestyle would not play well if the public were reading them. It's one thing to make fun of hippie grandmas - it's another thing to make fun of intubated hippie grandmas in the most vulnerable moments of their lives. I'm sure her husband was terrified. Even with these details being embellished for effect and likely not reflecting an actual patient, just consider how a layperson would read this and what they'd think of the doctor writing it.
 
surely said:
Botulism from adventures in self-canning. Diaper is for the relentless GI side effects.
Have the anti toxin flown up from Atlanta.



I'm usually pretty good at being able to keep my wet blankety-ness to myself, but I gotta say...
The cheap jokes about her appearance and lifestyle would not play well if the public were reading them. It's one thing to make fun of hippie grandmas - it's another thing to make fun of intubated hippie grandmas in the most vulnerable moments of their lives. I'm sure her husband was terrified. Even with these details being embellished for effect and likely not reflecting an actual patient, just consider how a layperson would read this and what they'd think of the doctor writing it.
Click to expand...

Boo.

I couldn't make up the "left/right wing" thing. That was for real. So was the number of toe rings.

Husband is now here, having driven the John Deere all the way to the ER after stopping off at the discount cigarette outlet. He offers more history: "She dun fell over in front of me. She says salt is bad for you. She doesn't take no medicines."

He is categorically not terrified, which is also telling.
 
God it’s so obvious.
She had a LEFT otitis media.
I would give her amoxicillin, let her self d/c the airway device when she is ready, and d/c.

just don’t look at the back of her head where you might find bits of fractured skull.
 
RustedFox said:
Husband is now here, having driven the John Deere all the way to the ER after stopping off at the discount cigarette outlet. He offers more history: "She dun fell over in front of me. She says salt is bad for you. She doesn't take no medicines."
Click to expand...

All he needs is a Tudor's Biscuit World supertanker of Dr. Pepper and I'd think this is one of my patients here in WV

Detailed as I can get neuro exam
Swap the I-gel for ETT before going to CT. CT head/neck. +/- CTA's
EKG
CBC
CMP with Mag and Phos
T4/TSH
Serum and urine drug screens
Urinalysis +/- urine lytes
Talk to family and get a good HPI

Admit to ICU
 
The question for the students and ‘terns is “what’s going to kill this young lady in the next 30 minutes”, and make sure it doesn’t happen.

It’s pretty straight-forward, bread and butter EM. And if your answers contain the following letters: MRI, ECHO, TSH, FREET4, NEUROLOGY CONSULT, or TATTOO DESCRIPTION then please go to a different field.

RF, why are you doing a vestibulo-ocular reflex on a pt with an alanto-occipital dislocation?
 
thegenius said:
The question for the students and ‘terns is “what’s going to kill this young lady in the next 30 minutes”, and make sure it doesn’t happen.

It’s pretty straight-forward, bread and butter EM. And if your answers contain the following letters: MRI, ECHO, TSH, FREET4, NEUROLOGY CONSULT, or TATTOO DESCRIPTION then please go to a different field.

RF, why are you doing a vestibulo-ocular reflex on a pt with an alanto-occipital dislocation?
Click to expand...

Screw off, I want a tattoo description now. Arguably more than a physical exam.
 
thegenius said:
The question for the students and ‘terns is “what’s going to kill this young lady in the next 30 minutes”, and make sure it doesn’t happen.

It’s pretty straight-forward, bread and butter EM. And if your answers contain the following letters: MRI, ECHO, TSH, FREET4, NEUROLOGY CONSULT, or TATTOO DESCRIPTION then please go to a different field.

RF, why are you doing a vestibulo-ocular reflex on a pt with an alanto-occipital dislocation?
Click to expand...

Because I can; and because c-collars are bogus.
 
TimesNewRoman said:
Or he did something to cause it.
Click to expand...
I'm pretty sure I had a patient once where the family held the synthroid until the patient went into a myxedema coma and died. Only put it all together in my head sometime later.
 
Would definitely ask the husband if this has happened before given his weird reaction.

Glucose, vbg, ekg, Ett, continuous monitoring with tele pulse ox and including etco2 if you got it, 2 lines or io

2 of Narcan is kind of a sissy dose for some of the fentanyl cut stuff we have up here, might repeat that if I’m sure I can manage the airway if she doesn’t wake up cus it was polysubstance. I usually don’t bother if they’re already tubed, it’s just punitive at that point.

Has she done this before
Did she take anything that might have caused this
Why the f*ck is she wearing depends when she looks like a normal person
No fever, no other preceding symptoms?
No one else sick?
Any shaking after the fall?
Was this a fall onto a couch or was this a tumblr backwards down the stairs for seventeen flights after syncope?
Did she see a chiropractor, faith healer or other assassin?
No chest pain, sob, leg swelling etc before

Exam looking for trauma, toxidrome, source of infection or other obvious process, track marks, check eyes to ensure not gaze preference or seizure, check feet for Babinski like you did

Labs including cbc, tsh (I don’t care but might help someone else), cmp, trop, bnp, scan everything esp cta head/neck. Would also do a decent pulse exam and consider cta chest or ctpa, though with those vitals/exam getting below head and neck with ct might be waste of time. if I’m doing that much might as well get belly. Not who I’m saving healthcare resources on.

Abx, admit icu if nothing clear At that point. Would check her eyes a couple times to make sure I didn’t miss a subtle epileptic event.
 
thegenius said:
The question for the students and ‘terns is “what’s going to kill this young lady in the next 30 minutes”, and make sure it doesn’t happen.

It’s pretty straight-forward, bread and butter EM. And if your answers contain the following letters: MRI, ECHO, TSH, FREET4, NEUROLOGY CONSULT, or TATTOO DESCRIPTION then please go to a different field.

RF, why are you doing a vestibulo-ocular reflex on a pt with an alanto-occipital dislocation?
Click to expand...

I don’t really disagree but what harm does the tsh do for you? It adds some small cost I guess but it takes about as long as a CBC to come back and has a fractional chance of helping you. Admittedly really unlikely, especially with those vitals and that exam, but honestly I don’t see the harm.

Echo (unless POc which I might do as part of my exam) neuro consult mri etc are ridiculous but I wouldn’t care if a med student said it. Just correct em
 
dadaddadaBATMAN said:
I don’t really disagree but what harm does the tsh do for you? It adds some small cost I guess but it takes about as long as a CBC to come back and has a fractional chance of helping you. Admittedly really unlikely, especially with those vitals and that exam, but honestly I don’t see the harm.

Echo (unless POc which I might do as part of my exam) neuro consult mri etc are ridiculous but I wouldn’t care if a med student said it. Just correct em
Click to expand...

I would not make emergency management decisions pending the result of a TSH. Most places it doesn't even come back quickly. Takes a day.

It's fine to send that off for the inpatient team, and in fact I would send off several other labs too that come back later.

But this patient is critically ill and you don't order MRI's and TSH's trying to find a diagnosis in the ED. You do a good history, physical exam, pattern recognition, and come up with a list of the top killers (and especially those you can fix) that she could have and address them immediately. What's potentially interesting about this case is she has normalish vital signs yet is markedly obtunded.
 
I’m surprised to see so many people ask for bedside US. It seems unlikely that you would find something in a patient with stable VS.
 
URINALYSIS:

Ur Color Amber
Ur Clarity Cloudy
Ur Spec Grav 1.017
Ur pH 5.0
Ur Leuk Est Small
Ur Nitrite Negative
Ur Protein 100 mg/dL
UR Glucose Negative mg/dL
Ur Ketones Negative mg/dL
Ur Urobilinogen Negative mg/dL
Ur Bili Negative mg/dL
Ur Blood Large
Ur WBC 28 /HPF HI
Ur RBC 3 /HPF
Ur Bacteria Rare
Ur Squam Epithelial 1 /HPF
Ur Renal Epi 2 /HPF HI
Ur WBC Clumps Many /HPF
Ur Mucous Rare /LPF
Ur Bud Yeast Rare /HPF
Estimated Creatinine Clearance 16.51 mL/min


ABG:


pH Arterial 7.37
Art pCO2 37.3 mmHg
Art pO2 462 mmHg HI
Art HCO3 21.6 mmol/L LOW
Art tHB 9.5 gm/dL LOW
FiO2% 100.0 NA
Pt Temp 37.0 NA
Allen's Test Positive
Site R Radial
PEEP 5 NA
Tidal Volume 0.450 NA
Notified To Dr Black
Art ABE -3.6 mmol/L LOW
Art sO2 100.0 %
O2Hb 99.0 %
O2 Delivery Ventilator
Mode #1 CMV
Rate 20 NA

CBC:

WBC 11.02 x10e3/mcL HI
RBC 4.17 x10e6/mcL LOW
Hgb 11.1 gm/dL LOW
Hct 34.2 % LOW
MCV 82.0 Femtoliters
MCH 26.6 pg
MCHC 32.5 gm/dL
RDW-CV 14.0 %
Plt 753.0 x10e3/mcL HI
MPV 10.6 Femtoliters
NRBC % 0.2 /100 WBC HI
NRBC # 0.02 x10e3/mcL HI


CMP/TOX:


Glucose Level 114 mg/dL HI
Sodium 120 mmol/L LOW
Potassium 1.7 mmol/L CRIT
Chloride 77 mmol/L LOW
CO2 23 mmol/L
Anion Gap 20 mmol/L NA
BUN 89 mg/dL HI
Creatinine 3.56 mg/dL HI
BUN/Creat Ratio 25 NA
Calcium 6.7 mg/dL CRIT
Albumin. Level 1.8 gm/dL LOW
TP 5.8 gm/dL LOW
A/G Ratio 0 NA
T Bili 0.6 mg/dL
Alk Phos 154 units/L HI
AST 263 units/L HI
ALT 100 units/L HI
eGFR Non-African American 13 mL/min/1.73m2 NA
eGFR African American 16 mL/min/1.73m2 NA
eGFR Pediatric Not Reported
Ethanol <3 mg/dL
Troponin I 0.244 ng/mL CRIT
Acetaminophen Lvl <2.0 mcg/mL LOW
Salicylate <1.7 mg/dL LOW


EKG:

76 BPM. NSR with PVC every third beat. Nonspecific ST/T wave changes. No acute ischemic changes.
 
Last edited:
Would definitely ask the husband if this has happened before given his weird reaction.

He's not much for information. He's out for his third cigarette. You found him, and here's what he has to say:

Has she done this before

"No."

Did she take anything that might have caused this

"Hell, I don't know; she don't take nothin' that's not all-natural."

Why the f*ck is she wearing depends when she looks like a normal person

"She says she pees her pants a little if she laughs too hard."

No fever, no other preceding symptoms?
No one else sick?
Any shaking after the fall?

"No."

Was this a fall onto a couch or was this a tumble backwards down the stairs for seventeen flights after syncope?

"She done fell as soon as she done stood up offa the couch."

Did she see a chiropractor, faith healer or other assassin?

"She don't take nothin' that's not all-natural. She don't eat nothin' that ain't been like, blessed by the goddess of the earth an'that. So she's real healthy."
 
RustedFox said:
Would definitely ask the husband if this has happened before given his weird reaction.

He's not much for information. He's out for his third cigarette. You found him, and here's what he has to say:

Has she done this before

"No."

Did she take anything that might have caused this

"Hell, I don't know; she don't take nothin' that's not all-natural."

Why the f*ck is she wearing depends when she looks like a normal person

"She says she pees her pants a little if she laughs too hard."

No fever, no other preceding symptoms?
No one else sick?
Any shaking after the fall?

"No."

Was this a fall onto a couch or was this a tumble backwards down the stairs for seventeen flights after syncope?

"She done fell as soon as she done stood up offa the couch."

Did she see a chiropractor, faith healer or other assassin?

"She don't take nothin' that's not all-natural. She don't eat nothin' that ain't been like, blessed by the goddess of the earth an'that. So she's real healthy."
Click to expand...

Does she consider ethylene glycol to be a natural substance? But honestly, florid renal failure, work on those electrolytes enough to prevent a code, ct non con head and c spine looking for significant bleed or sequelae of fall, admit. The belly and chest seem like a waste to me, but I wouldn’t care if someone wanted them or someone ordered them. Toss an hd line in if you’re the one who does those where you work.

As far as the u/s question, I consider it to be part of an exam in a person like this. Unlikely to change much, wouldn’t spend twenty minutes doing it but taking a quick look doesn’t hurt anything. The CT’s fall in the same boat to me except head and c spine. if you can get more info without wasting time before admit or transfer great.

I guess maybe I’ve worked at weird places, I’ve been at 7-8 different hospitals and tsh always comes back in an hour or so. Also don’t really care about tsh though, so would skip if send out.
 
TimesNewRoman said:
I’m surprised to see so many people ask for bedside US. It seems unlikely that you would find something in a patient with stable VS.
Click to expand...
Probably not, but it takes 2 minutes and takes alot of things off the differential for syncope
 
RustedFox said:
Would definitely ask the husband if this has happened before given his weird reaction.

He's not much for information. He's out for his third cigarette. You found him, and here's what he has to say:

Has she done this before

"No."

Did she take anything that might have caused this

"Hell, I don't know; she don't take nothin' that's not all-natural."

Why the f*ck is she wearing depends when she looks like a normal person

"She says she pees her pants a little if she laughs too hard."

No fever, no other preceding symptoms?
No one else sick?
Any shaking after the fall?

"No."

Was this a fall onto a couch or was this a tumble backwards down the stairs for seventeen flights after syncope?

"She done fell as soon as she done stood up offa the couch."

Did she see a chiropractor, faith healer or other assassin?

"She don't take nothin' that's not all-natural. She don't eat nothin' that ain't been like, blessed by the goddess of the earth an'that. So she's real healthy."
Click to expand...

Does any of her all natural diet include mushrooms that she picked herself?
 
BoardingDoc said:
Does any of her all natural diet include mushrooms that she picked herself?
Click to expand...

No idea.
The message here to the students/terns is that you need to GIT GUD at working with no data, and with people who are actively ignorant of even basic life skills.

1 or 2 posters mentioned this, and now I have the time to get to it:

I called "STROKE ALERT" shortly after arrival and immediately CT/CTA'ed her head/neck. Brainstem strokes present like this. Neuro and rads were in agreement that CT/CTA were both normal/negative, and neuro recommends tPA.
 
What’s wrong with I-gel? I-gel = similar performance to LMA, but easier to place (data>weird strong opinions)
 
RustedFox said:
I have never seen an i-Gel that has not mangled an airway.
I have never seen an LMA mangle an airway.
Click to expand...
Lol anecdote. We exclusively use I-gel’s, Both EMS and in the department. No mangled airways. Your experience here is strange and not factual (for myself and the hundreds of folks who have trained recently at my program). Now sure, Kings and combitubes have a bit higher risk. But an I-gel?! It’s soft for gods sake. Ya know, like gel.
 
WildcatS11 said:
Lol anecdote. We exclusively use I-gel’s, Both EMS and in the department. No mangled airways. Your experience here is strange and not factual (for myself and the hundreds of folks who have trained recently at my program). Now sure, Kings and combitubes have a bit higher risk. But an I-gel?! It’s soft for gods sake. Ya know, like gel.
Click to expand...
And I totally get that I countered your anecdotal experience with mine. Oops.
 
WildcatS11 said:
Lol anecdote. We exclusively use I-gel’s, Both EMS and in the department. No mangled airways. Your experience here is strange and not factual (for myself and the hundreds of folks who have trained recently at my program). Now sure, Kings and combitubes have a bit higher risk. But an I-gel?! It’s soft for gods sake. Ya know, like gel.
Click to expand...

I think the fact that my average i-Gel'ed patient is a tiny, frail, brittle senior probably has something to do with it.

God, I hate Florida sometimes. A lot of times.
 
RustedFox said:
No idea.
The message here to the students/terns is that you need to GIT GUD at working with no data, and with people who are actively ignorant of even basic life skills.

1 or 2 posters mentioned this, and now I have the time to get to it:

I called "STROKE ALERT" shortly after arrival and immediately CT/CTA'ed her head/neck. Brainstem strokes present like this. Neuro and rads were in agreement that CT/CTA were both normal/negative, and neuro recommends tPA.
Click to expand...

Before or after electrolytes came back?
RustedFox said:
No idea.
The message here to the students/terns is that you need to GIT GUD at working with no data, and with people who are actively ignorant of even basic life skills.

1 or 2 posters mentioned this, and now I have the time to get to it:

I called "STROKE ALERT" shortly after arrival and immediately CT/CTA'ed her head/neck. Brainstem strokes present like this. Neuro and rads were in agreement that CT/CTA were both normal/negative, and neuro recommends tPA.
Click to expand...

While I doubt it harmed anything I don’t know that I would congratulate myself for giving this patient tpa. It isn’t fixing her severe hyponatremia and electrolyte disarray, and while basilar stroke is a possible dx it’s also pretty rare and if it’s not present on the cta I wouldn’t pursue it further.

How did she do?
 
Before or after electrolytes came back?

Long before.

While I doubt it harmed anything I don’t know that I would congratulate myself for giving this patient tpa. It isn’t fixing her severe hyponatremia and electrolyte disarray, and while basilar stroke is a possible dx it’s also pretty rare and if it’s not present on the cta I wouldn’t pursue it further.

How did she do?

tPA given at the STRONG recommendation of neurology. She did fine. I felt the same way you do.
 
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