Interesting case for students

[medic25]

Not trying to derail the thread, but what were the results of the trial, in terms of patient outcomes? Do you have a sepsis protocol? Was it just used to rule in suspected sepsis, or were there broader indications? My EMS system was supposedly creating a trial of the same device, but it got scrapped with an explanation that the meters were no longer available.

It was more of a proof of use/feasibility study; no look at outcomes. IIRC, they matched up well with our lab lactates until you got really high (like 12+); at that point, you don't really care as much about the number.

[GetMeOuttaThisMess]

Quick throw in, why did OP only give a 500ml fluid bolus at the time that he did?

[fakingpatience]

The head CT was to r/o cva or bleed. Chest due to the diminished LS. Abd because I thought that was were the infection was originating.

 

We carried lactate monitors at my last EMS job. Nice to have, just to confirm sepsis but you got false positives (especially on seizure patients), and the hospitals never believed our numbers anyway. Didn't change the care for the pts

[PYRITE]

Quick throw in, why did OP only give a 500ml fluid bolus at the time that he did?

Pt. was not hypotensive, also test results not in yet so cardiac function unknown at the time?

[GetMeOuttaThisMess]

^^^, correct in that CV function and renal function remains unknown pending lab review, thus since CV disease is part of your immediate differential a large fluid bolus could throw the individual into congestive failure/pulm. edema.

[winterallsummer]

Had a patient last night that was a great learning case.  Any PA students want to play?

 

78 yo nursing home patient presents to VERY rural ED (4.5 hour drive from level 1 center) with decreased LOC throughout the day.  Nursing staff reports he has been up going to the bathroom several times during the day, but they eventually found him slumped over on the toilet.  Pt has significant left side weakness X 10 years apparently due to MS, however wife (who brings him coffee and donuts every morning) states he is typically ambulatory and communicative. 

 

He is somnolent, however wakens briefly to verbal for a few seconds before dozing off again.  Initial vitals are 135/65, P133, R36, SpO2 94% on 4L, T 101.3.  Lung sounds slightly diminished left side, abdomen soft and nontender.  Large b/l inguinal hernias, but not ttp. 

 

What is your top 3 dx?  What bad things must you rule out in the ED (if you want to work ED, you cannot miss one of these).

 

What labs/imaging do you order?

 

What initial treatment??

 

Here is my take after going through the OP's posts and weening out unnecessary information.

 

A 78 y/o SNF pt presents with c/o of urinary frequency and found down slumped over a toilet.  His baseline is ambulatory and AOx3.  He is obtunded with stable BP - if his med list truly includes no HTNs, this is stable for him as it is wnl - tachycardic, slightly desatting on 4L (which may be baseline for him) and febrile.  He has a focal abnormality in the left lung with a non-impressive abdominal exam, and two large inguinal hernias (no mention if they are reducible or not - assuming they are not, they are probably not related to this case), and no clear signs of bleeding.

 

Immediately a ddx includes sepsis - likely from PNA or a UTI -CVA, MI, hypoglycemia, or some complication of MS (which is last on the ddx).  Because little is known about his case and a proper hx cannot be collected, CVA must be r/o with a non-contrast CT, MI r/o with an EKG and troponins, hypoglycemia with an accucheck, A UA and CXR also would be ordered to address UTI and PNA, respectively.  Additionally, two blood cultures should be sent at this time due to concern for sepsis.  MS is also addressed to an extent with the CT, and also a CMP, CBC w/ diff and LA should be ordered.  

 

Some providers would order a chest/abd/pelvic CT at this time and some would not.  A CTA to r/o PE, mesenteric ischemia is not unreasonable and would depend on if he remained stable or not.

 

After these initial tests are ordered, assuming he remains stable, fluids W/O, vanc/zosyn for presumed sepsis should be started, and a more thorough PE conducted.

 

Ddx:  You forgot cardiac (although you ordered EKG).  And don't forget cardiac can be pipes (MI), electrical (arrhythmias), or structural (CHF/pericardial effusion).

 

Labs:  You ordered EKG which will help r/o STEMI and look for arrhythmia's, but what about troponin?  You ordered blood sugar, but do you want to know about his electrolytes??

 

Why would you order the chest, abd and pelvis CT at this time?  What is your indication?  What are you looking for??   Sometimes we do shotgun tests in the ED because we have a sick person and have no idea what is wrong, or because we're busy and don't have time to adequately narrow down our ddx with a proper exam yet, but generally you want to have a significant pretest probability before you order a test, otherwise you will increase your false positive rate. 

 

Pupils were sluggish but reactive, no skin signs.  Just an obtunded old guy.

 

 

Surprisingly few meds.  Think it was only apap and a multivitamin.  Confirmed this three times cause I didn't believe it.

 

History fairly unremarkable.  Put in skilled nursing 10 years ago after a flare of MS left him with a weakened left side.  NO oxygen at home.

 

Correct, neurontin increase wouldn't explain fever and tachycardia.

 

Speaking of fever and tachycardia (and tachypnea)....what definition does that buy us?

 

Okay, here's what I was thinking at the time.

 

Old guy, nursing home, chronic left sided weakness, altered, febrile, tachy, tachypnic, requires 4L to maintain 94%, diminished left side breath sounds....I'm thinking sepsis from pneumonia. 

 

I ordered CBC, CMP (because we always do that in the ED, I had no indication of liver dz), EKG, troponins, CXR, and urine.  I tried to order lactic acid, but it is a send out.  ABG wouldn't be a bad idea, but I'm pretty sure it would tell me he was hypoxic and acidotic...I already knew that. 

 

Ordered a 500CC bolus of NS.

 

First things back were the CXR, CBC and EKG.  CXR showed a patchy infiltrate in RML, otherwise normal.  CBC showed white count of almost 27K with 44% bands.  EKG showed a RBBB, left bifasicular block, with no sign of S1Q3T3.

 

Do you have a diagnosis?  If so, what's your treatment??

 

 

 

The CXR finding confirms PNA which likely lead to sepsis.  This, however, does not mean he also had a CVA, MI, etc etc.  Stress on the body may have lead to one of these complications.  Although he is relatively stable, at this time the CXR should be back and can be read for other life threatening events that may be concerning based on certain findings, such as air space or widened mediastinum.  

 

A high white count with a left shift confirms sepsis.  Anaerobic converage could be added, depending on the provider.  PE has not been ruled out as the most common sign of PE on EKG is tachycardia and S1Q3T3 is both non specific and non sensitive.  A block and RBBB are likely not involved pending r/o of MI per troponins.  At this time abx are continued, maitenence fluids are started after his bolus, and a few other labs such as pBNP and coags are added on.

 

Allright, kinda what I was thinking too.  Figured we had a little aspirational pneumonia going on.  As I was waiting for the CMP and trop to come back we hung levaquin I was writing admission orders for pneumonia.

 

Then the CMP came back.  ALT 350, AST 250, Alk Phos 200.  Otherwise normal.  Trop negative. 

 

Now what are you thinking??

 

Aspiration PNA is a valid concern regarding his CXR findings and an elderly pt with MS.  Adding levaquin is reasonable although vanc/zosyn would cover much concern here.  At this time it is more than appropriate to begin his admission as this will certainly require more than two overnight stays.

 

The CMP returns with signs of inter-hepatic dysfunction and elevated AP.  With this in mind, one notes that he meets a classic pentad for ascending cholangitis.  A slew of other, less emergent dx also exist.  Abx may be adjusted now to add anaerobic coverage and a stat RUQ U/S is ordered.  While waiting for the orders you return to do a better abdominal exam.  You also check for any scleric jaundice that may show the alk phos has been elevated for some time due to some pancreatic, hepatic or biliary cancer.  Trop (-) is reassuring but serial trops are still required because even if his heart is fine for now, an NSTEMI may develop due to all the stress on his body.  

 

CA will certainly be worked up.  If the RUQ U/S is not helpful, a CT at this time can be ordered, as it surely will be oredred during his admission anyways and may help you address something immediate that you missed on exam.  

 

 

Alk phos in old guy almost always = CA.

 

So with his LFTs and alk phos, and hx of constipation, I'm thinking he's got pneumonia and a CA in Hus belly.

 

CT reversed that for me. Choledocolithiasis with dilatation + mesenteric lymphadenopathy. And the infiltrate looked more like a mass on CT.

 

So, what does he have? What is ER tx and next step??

 

You likely discovered jaundice on closer re-examination and note that Reynad's pentad is confirmed along with a scan showing the same.  The infiltrate may or may not be a mass.  If it is, it may be a primary or secondary malignant one.  Or it may be an infiltrate from PNA that just appears to be a mass.  Abx are left and this will be sorted out later.  Surely much of this will be worked out during his admission.

[Boatswain2PA]

Here is my take after going through the OP's posts and weening out unnecessary information.

 

A 78 y/o SNF pt presents with c/o of urinary frequency and found down slumped over a toilet.  His baseline is ambulatory and AOx3.  He is obtunded with stable BP - if his med list truly includes no HTNs, this is stable for him as it is wnl - tachycardic, slightly desatting on 4L (which may be baseline for him) and febrile.  He has a focal abnormality in the left lung with a non-impressive abdominal exam, and two large inguinal hernias (no mention if they are reducible or not - assuming they are not, they are probably not related to this case), and no clear signs of bleeding.

 

Immediately a ddx includes sepsis - likely from PNA or a UTI -CVA, MI, hypoglycemia, or some complication of MS (which is last on the ddx).  Because little is known about his case and a proper hx cannot be collected, CVA must be r/o with a non-contrast CT, MI r/o with an EKG and troponins, hypoglycemia with an accucheck, A UA and CXR also would be ordered to address UTI and PNA, respectively.  Additionally, two blood cultures should be sent at this time due to concern for sepsis.  MS is also addressed to an extent with the CT, and also a CMP, CBC w/ diff and LA should be ordered.  

 

Some providers would order a chest/abd/pelvic CT at this time and some would not.  A CTA to r/o PE, mesenteric ischemia is not unreasonable and would depend on if he remained stable or not.

 

After these initial tests are ordered, assuming he remains stable, fluids W/O, vanc/zosyn for presumed sepsis should be started, and a more thorough PE conducted.

 

 

The CXR finding confirms PNA which likely lead to sepsis.  This, however, does not mean he also had a CVA, MI, etc etc.  Stress on the body may have lead to one of these complications.  Although he is relatively stable, at this time the CXR should be back and can be read for other life threatening events that may be concerning based on certain findings, such as air space or widened mediastinum.  

 

A high white count with a left shift confirms sepsis.  Anaerobic converage could be added, depending on the provider.  PE has not been ruled out as the most common sign of PE on EKG is tachycardia and S1Q3T3 is both non specific and non sensitive.  A block and RBBB are likely not involved pending r/o of MI per troponins.  At this time abx are continued, maitenence fluids are started after his bolus, and a few other labs such as pBNP and coags are added on.

 

 

Aspiration PNA is a valid concern regarding his CXR findings and an elderly pt with MS.  Adding levaquin is reasonable although vanc/zosyn would cover much concern here.  At this time it is more than appropriate to begin his admission as this will certainly require more than two overnight stays.

 

The CMP returns with signs of inter-hepatic dysfunction and elevated AP.  With this in mind, one notes that he meets a classic pentad for ascending cholangitis.  A slew of other, less emergent dx also exist.  Abx may be adjusted now to add anaerobic coverage and a stat RUQ U/S is ordered.  While waiting for the orders you return to do a better abdominal exam.  You also check for any scleric jaundice that may show the alk phos has been elevated for some time due to some pancreatic, hepatic or biliary cancer.  Trop (-) is reassuring but serial trops are still required because even if his heart is fine for now, an NSTEMI may develop due to all the stress on his body.  

 

CA will certainly be worked up.  If the RUQ U/S is not helpful, a CT at this time can be ordered, as it surely will be oredred during his admission anyways and may help you address something immediate that you missed on exam.  

 

 

 

You likely discovered jaundice on closer re-examination and note that Reynad's pentad is confirmed along with a scan showing the same.  The infiltrate may or may not be a mass.  If it is, it may be a primary or secondary malignant one.  Or it may be an infiltrate from PNA that just appears to be a mass.  Abx are left and this will be sorted out later.  Surely much of this will be worked out during his admission.

Bravo, very thorough.

 

A few thoughts from the field:

 

1.  While yes, you could justify a head CT for every geriatric with new altered LOC, you will find a very low yield with this unless you find a focal neurological deficit on exam.  He had none other than excessive sleepiness.  Furthermore, CT won't help you with MS exacerbations.

 

2. Same with CT of chest, abd, pelvis.  While yes, you could justify these, it's a huge expense that is very low yield unless you have some indications of what you're looking for.  I did the abd CT due to his history of constipation, liver enzymes, and Alk Phos. 

 

3. Yes, went back for "better re-examination" of belly, with even deeper palpation of RUQ....no pain response AT ALL.  And no visible jaundice noticeable.

 

4. Sono would indeed be better, however was not available.  (Pretty sad that rural America can have 24/7 CT, but no u/s).