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44 minutes ago, EMEDPA said:

We have just the opposite problem. They cath everyone. The first cardiologist I called about this was wondering why I called because they felt it was an "obvious inferior stemi in evolution", while myself and the ED attending thought great story, worrisome, but not slam dunk EKG. At least they didn't want to give her TPA before we shipped her. I felt that might have been over the top given no pain and nl trop #1 and no change in ecg at 30 min post #1. yes, she got heparin and plavix. I was on board for that. 

Slam dunk huh? Makes me feel better about my reading skills. Don't suppose there was a prior ECG in the system anywhere?

Did you check a myoglobin? 😆

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It will be fascinating, while tragic, some day to know exactly why the diverse outcomes of this strange disease. It is beyond comorbidities, while they contribute.

What we are seeing is this: Asymptomatic screen + from large workplace screenings. sent home to quarantine one week later looks like death warmed over and crashing. generally arrives by priv

Many the time I've seen the fellows throw dopamine onto a non-hypotensive patient with rates that they "just aren't comfortable with" with a resultant BP in the 180s+. Dobutamine is a fantastic +

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21 minutes ago, MediMike said:

Slam dunk huh? Makes me feel better about my reading skills. Don't suppose there was a prior ECG in the system anywhere?

Did you check a myoglobin? 😆

no prior ekg available.

have not checked a ckmb or myoglobin in years. 

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16 hours ago, EMEDPA said:

above pix from my phone. can't add text for some reason. known covid +. walked in with sao2 40% on RA. 78% on NRB. failed bipap. intubated, central line, transfer. 

I've had the same issue. 

Walked in at 40% huh? I've had a couple folks who are just hanging out in the 80s and I just let them hang. The "happy hypoxic" phenotype is a lot more rare than was initially billed but it's pretty neat to see it in action.

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I've seen lots, usually in the 55+ population, that are speaking easily when lying in the bed at sats in the 80's but plummet even when transferring to a bedside commode.  The progression I'm seeing is:

  • 1st ED visit: some COVID s/s but not hypoxic, d/c home
  • 2nd ED visit: usually 2-5 days after 1st.  Now dyspneic on exertion, hypoxic but easily corrected with 2-4 lpm NC.  Med-surg admision, dexamethason, remdesivir.
  • 2-4 days later on the floor: after progressing through NC, high-flow NC, mask, and self-proning gets BiPap'd & transferred.
  • LONG stay at receiving hospital, often weeks  If intubated, long ICU stays.
  • If survive, d/c to some sort of ECF for long, slow rehab.

These folks are around my age, not necessarily with massive comorbidities.  Very scary.

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21 hours ago, ohiovolffemtp said:

I've seen lots, usually in the 55+ population, that are speaking easily when lying in the bed at sats in the 80's but plummet even when transferring to a bedside commode.  The progression I'm seeing is:

  • 1st ED visit: some COVID s/s but not hypoxic, d/c home
  • 2nd ED visit: usually 2-5 days after 1st.  Now dyspneic on exertion, hypoxic but easily corrected with 2-4 lpm NC.  Med-surg admision, dexamethason, remdesivir.
  • 2-4 days later on the floor: after progressing through NC, high-flow NC, mask, and self-proning gets BiPap'd & transferred.
  • LONG stay at receiving hospital, often weeks  If intubated, long ICU stays.
  • If survive, d/c to some sort of ECF for long, slow rehab.

These folks are around my age, not necessarily with massive comorbidities.  Very scary.

What we are seeing is this:

Asymptomatic screen + from large workplace screenings. sent home to quarantine

one week later looks like death warmed over and crashing. generally arrives by private vehicle with sao2 < 75%

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14 hours ago, jmj11 said:

It will be fascinating, while tragic, some day to know exactly why the diverse outcomes of this strange disease. It is beyond comorbidities, while they contribute.

I sure wish there was better data currently available on this.  I've seen some of the models, but my "risk stratification" is pretty much the same as seeing how the patient is doing over time.

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Patellar tendon rupture with comminuted avulsion fx of tibial tuberosity where the tendon tore off.

Transferred to regional pediatric hospital after review with peds ortho for repair. The concern is that ongoing bleeding in the joint may result in compartment syndrome. This pt had no evidence of that.  This was a high school basketball player who landed wrong after a dunk. 

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3 hours ago, TheFatMan said:

Any more history?

fussy with diarrhea. Holding abd. afebrile with stable VS and unimpressive exam and nl labs.

CT abd/pelvis actually was read as normal. So, that plain film fooled me, my attending, and a radiologist. 

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1 hour ago, EMEDPA said:

fussy with diarrhea. Holding abd. afebrile with stable VS and unimpressive exam and nl labs.

CT abd/pelvis actually was read as normal. So, that plain film fooled me, my attending, and a radiologist. 

Funny, I saw that and immediately thought the same.  Wonder if that section of bowel just lined up perfectly behind the diaphragm and is giving the appearance of free air?

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18 hours ago, EMEDPA said:

fussy with diarrhea. Holding abd. afebrile with stable VS and unimpressive exam and nl labs.

CT abd/pelvis actually was read as normal. So, that plain film fooled me, my attending, and a radiologist. 

Wow! That is interesting. Great case, thanks for sharing!

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