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PA-S Case Study


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OK, I wanted to run another case through for the future PA's to get their brains thinking like future EM PA's.  Walk us through the initial steps of the assessment and stabilization, then onto differential diagnosis and management.  This is a patient I took care of recently.

 

You are working a shift in the critical care pod of the ED, when EMS rolls in with a new patient.  Chief complaint is listed as "alcohol intoxication".  They give a report of a 49yo female with no PMH who was found confused at work.  The patient was speaking nonsensically at first, and is now non-verbal.  They report that she has a history of coming to work occasionally with some evidence of recent drinking.

 

What are your first priorities? 

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Ok, getting outta my comfort zone now talking about tests to order, so I apologize if I use the wrong names.

CT scan of her brain.  Basic labs, ABG, I'd also like to know ammonia levels.  How is her abd, any grimace with palpation?  Skin signs? Temp?

Is she protecting her airway at this point (swallowing secretions)?

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Ok, getting outta my comfort zone now talking about tests to order, so I apologize if I use the wrong names.

CT scan of her brain.  Basic labs, ABG, I'd also like to know ammonia levels.  How is her abd, any grimace with palpation?  Skin signs? Temp?

Is she protecting her airway at this point (swallowing secretions)?

Getting outta your comfort zone is a good thing :)

CT scan ordered, but they have a trauma on the table.  Full panel of labs is sent, along with i-stat chemistry panel/lactic acid/VBG.  Abdominal exam shows no tenderness, soft abdomen.  No obvious skin lesions; skin is pink, non-diaphoretic.  Temp is 98.6F.

She is presently maintaining her own airway.

 

Would also want to know electrolytes and BAC levels. Any abnormal DTRs?

 

You attempt a breathalyzer level both orally and nasally, both read .000.  Didn't specifically look at DTR's.

 

Intubate her!  Then continue primary head to toe.  I will assume it is otherwise normal?

 

Basic labs then send her for a non-contrast head CT.

 

She is maintaining her airway at the moment, so you start preparing the patient and your equipment for intubation but don't necessarily need to do a crash airway this minute.

Are there any specific parts of the physical exam that you'd want to know about?  Some findings are more valuable than others in an AMS patient.

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Shot in the dark here, but would a wood's lamp be helpful if you were to say to examine the patient's urine from the Foley? Thinking ethylene glycol ingestion. Nonetheless, agree with previous posts I would be mindful of the patient's ability to maintain her airway with a GCS that low and would be looking at pupil size.

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They eyes are the doorway to the brain.  Pupils?  Fundoscopic: Papilledema/ hemorrhage?

 

I would also give her some narcan if the medics haven't.

 

Personally, I still think she has an acute ET tube deficiency....but I understand your reasoning. 

 

 

Pupils were equal and constricted, about 1-2mm bilaterally.

 

No narcan given by EMS, so we gave .4mg with no response.

 

A big part of me wanted to just drop the tube immediately, but with a high suspicion for a significant neurologic event our attending wanted to preserve the neurologic exam for potential consultants.  Given the fact that the patient had an intact respiratory drive, we felt OK deferring it until we secured a rapid CT scan (20 feet down the hall, and I brought my airway equipment to CT with the patient).

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Shot in the dark here, but would a wood's lamp be helpful if you were to say to examine the patient's urine from the Foley? Thinking ethylene glycol ingestion. Nonetheless, agree with previous posts I would be mindful of the patient's ability to maintain her airway with a GCS that low and would be looking at pupil size.

 

Tox is definitely in the differential, and we sent an alcohol panel.  Remember that the Woods lamp urine technique has very limited reliability, so it's probably not the first thing to look at in a relatively new patient.

 

http://www.ncbi.nlm.nih.gov/pubmed/16182989

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Tox is definitely in the differential, and we sent an alcohol panel.  Remember that the Woods lamp urine technique has very limited reliability, so it's probably not the first thing to look at in a relatively new patient.

 

http://www.ncbi.nlm.nih.gov/pubmed/16182989

Was unaware of that, thanks for the info! Pretty far out of my comfort zone in looking at the CT scan, but I'm excited to learn. If I had to guess I would say intraventricular hemorrhage. Put pt on ICP monitor, and start mannitol?

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I am not sure if this is relevant, but are there any infections? (Remember I am a wanna be PA-S). p12016.gif

Always good to look for, but no signs of infection

 

OY VEY!

My thoughts exactly (although I'm sure my actual words where much more NSFW...)

 

Was unaware of that, thanks for the info! Pretty far out of my comfort zone in looking at the CT scan, but I'm excited to learn. If I had to guess I would say intraventricular hemorrhage. Put pt on ICP monitor, and start mannitol?

 

Head bleed is correct; thalamic hemorrhage with 3-4mm of midline shift.  We shot a quick CTA brain while still on the table, with neurology and neurosurgery notified before she was back on the stretcher.  Neurology was able to do a quick exam at bedside before I intubated her, and there were already signs of deterioration (loss of corneal reflex, ? posturing).

 

So you've now got a patient who is comatose with a large intraventricular bleed.  The airway is secured; what are your next steps to manage this patient?  The repeat vital signs post-intubation are:

 

HR-72, SBP- 190/98, SpO2- 100%

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So you've now got a patient who is comatose with a large intraventricular bleed.  The airway is secured; what are your next steps to manage this patient?  The repeat vital signs post-intubation are:

 

HR-72, SBP- 190/98, SpO2- 100%

 

 

I'm concerned about the increasing blood pressure, would you give mannitol or lopressor?

If you have capnography available,  titrate the respiratory rate to co2 of 35-40

Does neurosurgery determine it's operable?  

 

Monitor to ensure she stays sedated and no seizure activity

 

Which drugs did you use for the RSI?

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