Kwame E Posted January 19, 2016 Share Posted January 19, 2016 This would probably be targeted towards those who work in the ER, but I'd like feedback from everyone who's willing. I'm asking because I'm pre-PA and would like to know how you guys who are PAs would approach this scenario. Basically, I'd like to know the thought process involved. In the ED, an 84 year old man comes in via EMS. He has fallen at this residence where he lives alone. He's conscious, but disoriented and it's not clear if he's aware of what all is going on. He says that he hasn't eaten in 2 weeks because he ran out of food. He's very pale and sweaty. His blood pressure is low, and when he stands it drops to a dangerous level. As a clinician, what would you do first? What's your thought process? Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted January 19, 2016 Moderator Share Posted January 19, 2016 he certainly is getting a big workup. sepsis vs trauma vs recent stroke vs ACS, all of the above +/- rhabdo, etc. he needs a line (or 2) , a foley, and resuscitation. standard labs to work up all of the above and a head CT. if there is any suspicion for sepsis he needs significant fluid resuscitation and early abx. If on meds with measurable levels he needs all those checked. is he dig toxic, etc. Did he take too much or too little of any rx med.? He needs all potential sources for infection quickly evaluated if you suspect sepsis, certainly guided by the exam. portable cxr, cath ua, blood cultures, etc does he have an exam c/w significant fx or dislocation? you can lose a lot of blood into a pelvic or femur fx. does he need to be transfused if anemic? see here: http://emcrit.org/misc/lls-score/ do a little research into the aeioutips method for evaluating aloc. start here: http://www.emergencymedicalparamedic.com/aeiou-tips/ and here: http://acronyms.thefreedictionary.com/AEIOUTIPS everyone has their own version of this and includes different things, but it is a good place to start in the eval. Link to comment Share on other sites More sharing options...
bike mike Posted January 19, 2016 Share Posted January 19, 2016 Septic vs cardiogenic shock work up. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted January 19, 2016 Moderator Share Posted January 19, 2016 VS trauma, right. the c/c was "fall at residence". probably several issues here regardless.... Link to comment Share on other sites More sharing options...
KMD16 Posted January 19, 2016 Share Posted January 19, 2016 Agreed w/ E & bike Mike. Link to comment Share on other sites More sharing options...
bike mike Posted January 19, 2016 Share Posted January 19, 2016 VS trauma, right. the c/c was "fall at residence". probably several issues here regardless.... true....need to work up for possible injuries that may have occurred 2/2 fall that was likely 2/2 sepsis vs cardiogenic shock. 84 yr old......I smell a hip fracture. Link to comment Share on other sites More sharing options...
TWR Posted January 19, 2016 Share Posted January 19, 2016 FIRST THING?? Hydrate! then all the above Link to comment Share on other sites More sharing options...
Moderator True Anomaly Posted January 19, 2016 Moderator Share Posted January 19, 2016 Without doing an exam, hard to add to anything that E has suggested. The real question is what caused him to be found on the ground, and THEN what sort of pathology has resulted because of it Link to comment Share on other sites More sharing options...
Simplify Posted January 19, 2016 Share Posted January 19, 2016 This would probably be targeted towards those who work in the ER, but I'd like feedback from everyone who's willing. I'm asking because I'm pre-PA and would like to know how you guys who are PAs would approach this scenario. Basically, I'd like to know the thought process involved. In the ED, an 84 year old man comes in via EMS. He has fallen at this residence where he lives alone. He's conscious, but disoriented and it's not clear if he's aware of what all is going on. He says that he hasn't eaten in 2 weeks because he ran out of food. He's very pale and sweaty. His blood pressure is low, and when he stands it drops to a dangerous level. As a clinician, what would you do first? What's your thought process? There are "think first" and there are "do first" patients. This is patient falls into the later. While we are getting him on the monitor we are also getting IV's x 2, rainbow of labs including CBC, CMP, CK, troponin, lactate, cultures (followed by broad spectrum abx if i get even a whiff of a septic picture), ECG, portable CXR and maybe pelvis depending on how he looks and concern for trauma. He is hypoglycemic until proven otherwise but that is quickly sorted out with a finger stick. Then he is getting fluids, lots of fluids until I can get to the EMR and find out if he is a CHF or renal patient (in which case he gets a touch less fluid). The only other things that I would do here that the others haven't mentioned is POC cardiac ultrasound to evaluate gross cardiac contractility and to look for wall motion abnormalities. Link to comment Share on other sites More sharing options...
sdpa Posted January 28, 2016 Share Posted January 28, 2016 To piggy back off the above ultrasound suggestion the new hip way of determining low volume- POC Ultrasound the IVF. Not sure that's the 1st thing I would do but it would be up there. http://emcrit.org/podcasts/ivc-ultrasound-for-fluid-tolerance-in-spontaneously-breathing-patients/ Link to comment Share on other sites More sharing options...
CAAdmission Posted January 29, 2016 Share Posted January 29, 2016 The place I work the triage nurse would have put this guy in fast track. Link to comment Share on other sites More sharing options...
GreatChecko Posted January 29, 2016 Share Posted January 29, 2016 The place I work the triage nurse would have put this guy in fast track. "Pt states tripped and fell - NAD, walking without assistance, asking for sandwich" Link to comment Share on other sites More sharing options...
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