Case For Students

[MediMike]

We haven't done this for...a long time.  I'll provide a brief patient scenario (very brief to begin with) and you will tell me what you want.  If you want a history, ask the questions, if you want labs/imaging/procedures I'll get you the info.  Experienced people give the students a chance but of course feel free to jump in with advice for them.

You're sitting behind the nurses station in the ED on your very first rotation, you are at a small critical access hospital in a rural area.  You have 5 beds, 2 are currently occupied by a belly pain and a febrile kiddo.  There is a small "ICU" with the ability to manage CPAP/BiPAP but no long term mechanical ventilation, you have a CT scanner but no MRI, full lab capabilities.

A nurse comes up to your preceptor who is deep into a crossword puzzle (it's Monday so he knows he can probably do it without cheating), she murmurs something to him about a patient in triage and he waves at you to go out and see them.  The nurse sighs a little bit and leads you to the small room up front.

You walk in and see a female, approximately 75 years old tripoding in the exam chair.  You hear audible wheezing, observe accessory muscle use and she looks distracted.  SpO2 monitor is reading 78%.

Okay go.  Throw out some differential diagnoses and what history/exam/labs etc you want to confirm those.  Feel free to just throw out a few things so that you don't crush it for anyone else who is trying to play.

[ohiovolffemtp]

OK, if it's Monday, probably no crossword puzzle.  Mondays are traditionally the busiest days in the ED, followed by Sunday & Tuesday.  

Other than that, great start.  One hint: think about this case in terms of:

• What thing(s) might be causing this, i.e. your differential
• What work-up to do
• MOST IMPORTANT: what interventions do you want to start right away while you're doing 1 & 2

[TheFatMan]

1 hour ago, MediMike said:

We haven't done this for...a long time.  I'll provide a brief patient scenario (very brief to begin with) and you will tell me what you want.  If you want a history, ask the questions, if you want labs/imaging/procedures I'll get you the info.  Experienced people give the students a chance but of course feel free to jump in with advice for them.

You're sitting behind the nurses station in the ED on your very first rotation, you are at a small critical access hospital in a rural area.  You have 5 beds, 2 are currently occupied by a belly pain and a febrile kiddo.  There is a small "ICU" with the ability to manage CPAP/BiPAP but no long term mechanical ventilation, you have a CT scanner but no MRI, full lab capabilities.

A nurse comes up to your preceptor who is deep into a crossword puzzle (it's Monday so he knows he can probably do it without cheating), she murmurs something to him about a patient in triage and he waves at you to go out and see them.  The nurse sighs a little bit and leads you to the small room up front.

You walk in and see a female, approximately 75 years old tripoding in the exam chair.  You hear audible wheezing, observe accessory muscle use and she looks distracted.  SpO2 monitor is reading 78%.

Okay go.  Throw out some differential diagnoses and what history/exam/labs etc you want to confirm those.  Feel free to just throw out a few things so that you don't crush it for anyone else who is trying to play.

Thanks Mike.

Bring into a room and get help. IV access, O2 (although possible she is a CO2 retainer, so be careful with this), monitor. Full set of vitals. Is anyone with her to help with history?

To start: Onset? Chest pain? Febrile? Recent travel? COVID vaccination status/exposures. Whatever medical history is available (COPD/DVT/PE/Cancer/immunocompromise/CAD/CHF)

Will wait on other history/physical/workup for someone else to chime in.

[MediMike]

16 hours ago, TheFatMan said:

Thanks Mike.

Bring into a room and get help. IV access, O2 (although possible she is a CO2 retainer, so be careful with this), monitor. Full set of vitals. Is anyone with her to help with history?

To start: Onset? Chest pain? Febrile? Recent travel? COVID vaccination status/exposures. Whatever medical history is available (COPD/DVT/PE/Cancer/immunocompromise/CAD/CHF)

Will wait on other history/physical/workup for someone else to chime in.

Great! You exhibit your stellar IV skills gained over a 2 hour single day experience in tech skills class by slamming an 18g into the L AC. 

The RN places her on an NRB @15lpm with sats increasing to 88% and she looks more comfortable.

BP 210/124

HR 116

RR 24

BGL 202

Temp 37.8

Onset: "A while ago"

ROS 

+CP, +Vaccinated status, - travel

PMHx

She nods her head when you say COPD, CHF, CAD and cancer

-------------

Alright what's next? Good thinking on the COPD and hyperoxia thing, in the moment though don't worry about it. Fix the hypoxemia and then titrate the O2 down, patient isn't going to go out on you like a light.

XC: Why do COPDers get hypercapnic with hyperoxia?

[Apollo1]

6 hours ago, MediMike said:

XC: Why do COPDers get hypercapnic with hyperoxia?

IIRC, related to decreased respiratory drive. These pts like to live in the high 80s-low 90s, and with increased FIO2 the brainstem doesn't keep their RR up like when they're on RA. Decreased respiratory rate leads to retained CO2.

[TheFatMan]

Okay so broad differential at this point: AMI, PE, dissection, tamponade, COPD/CHF exacerbation, pneumonia possibly due to COVID, lung cancer, pneumothorax.

What's on the monitor? I don't think it would hurt to have a crash cart nearby.

Order a 12-lead, chest x-ray, CBC, CMP, trop, coags, lactate, ABG.

While waiting for those do an exam, heart, lungs, abd, look for JVD, LE edema or signs of DVT, mental status.

I have a feeling looking in her chart might be more helpful than asking more about history - so after exam I'd do a chart dissection. Could also ask about asthma, trauma, history of clots, smoker status (and other risk factors). 

[MediMike]

On 8/31/2021 at 4:45 PM, Apollo1 said:

IIRC, related to decreased respiratory drive. These pts like to live in the high 80s-low 90s, and with increased FIO2 the brainstem doesn't keep their RR up like when they're on RA. Decreased respiratory rate leads to retained CO2.

Great reply! Classic training was the idea that they run off of a hypoxic drive rather than one based on chemoreceptor sensing of CO2 like the rest of us, so if you "fix" their hypoxia you knock out their respiratory drive. 

Current thinking has to evolved to consider more:

Shunting/Dead-Space: In your classic hypoxic response you get vasoconstriction of the pulmonary vasculature, this helps shunt blood away from poorly oxygenated regions of the lung and towards units better suited for exchange.  With an increase in oxygenation in COPDers you  don't really have all that many units that are better suited, so you flood areas with few functioning lung units resulting in worse gas exchange than before. 

There are a couple of cool articles I can pull if anyone is interested that shows a linear relationship between hyperoxia and hypercapnea on serial ABGs.

[MediMike]

16 hours ago, TheFatMan said:

Okay so broad differential at this point: AMI, PE, dissection, tamponade, COPD/CHF exacerbation, pneumonia possibly due to COVID, lung cancer, pneumothorax.

What's on the monitor? I don't think it would hurt to have a crash cart nearby.

Order a 12-lead, chest x-ray, CBC, CMP, trop, coags, lactate, ABG.

While waiting for those do an exam, heart, lungs, abd, look for JVD, LE edema or signs of DVT, mental status.

I have a feeling looking in her chart might be more helpful than asking more about history - so after exam I'd do a chart dissection. Could also ask about asthma, trauma, history of clots, smoker status (and other risk factors). 

Great DDx list!

Monitor: Sinus tach

12 Lead:

CXR

 

CBC

WBC 12.2

Hgb 10

HCT 32

MCV 101

----------------

CMP

Na 131

K 4.2

Cl 89

CO2 26

Glu 245

BUN 48

Cr 1.23

LFTs - WNL

------------------

Troponin - 0.06

PT/INR - WNL

Lactate - 2.4

ABG 7.48/30/58/Nobody should believe the bicarb on here/I'm not going to calculate the base deficit

----------------

Cardiac: S1/S2, -S3, +S4, +Holosystolic murmur heard best at 5th ICS MCL

Lungs: Diffuse crackles throughout, equal rise and fall, intercostal muscle usage noted

Abdomen: Soft, non-tender

JVD: To angle of the jaw

LE: No pitting edema noted, negative Homans (worthless), no palpable cords/redness

Mental status: Improving, A/Ox3

Addt'l PMHx - No asthma, truama, clots, 45pck/yr

--------------------

She's new to your system and you don't have CareEverywhere

Any other lab you could think of to throw in upfront to help narrow your differential?

[TheFatMan]

Of course she is new to the system 

Off the top of my head though, I forgot to add a covid test and blood cultures.

Other than that, I'll wait and see if anyone else wants to chime in.

[MediMike]

5 hours ago, TheFatMan said:

Of course she is new to the system 

Off the top of my head though, I forgot to add a covid test and blood cultures.

Other than that, I'll wait and see if anyone else wants to chime in.

Respiratory patients keep BNP and the dreaded Dimer in your thoughts.

You can't PERC this lady out, what do you think her risk of PE is with her hx and presentation?

What will a BNP tell you?

Yeah COVID is neg. I'm sick of it so don't expect to see it in a scenario

[Sacarroll10]

10 hours ago, MediMike said:

Respiratory patients keep BNP and the dreaded Dimer in your thoughts.

You can't PERC this lady out, what do you think her risk of PE is with her hx and presentation?

What will a BNP tell you?

Yeah COVID is neg. I'm sick of it so don't expect to see it in a scenario

Hx of cancer (hyper coagulable state) + dyspnea + sinus tachy --> I have some concern for a PE. Definitely want a D-dimer. Can we get some clarification from the pt on the dyspnea for "a while" (days, months, years?) and is it worse today than normally? 

Elevated BNP will show stretching in the ventricles. I am worried about an acute CHF exacerbation. Does the pt know if she has had that murmur or if that is a new finding (crossing fingers here that she actual knows lol)? CXR looks like bilateral pulmonary edema. How does my preceptor feel about a point-of-care echo?

[MediMike]

2 hours ago, Sacarroll10 said:

Hx of cancer (hyper coagulable state) + dyspnea + sinus tachy --> I have some concern for a PE. Definitely want a D-dimer. Can we get some clarification from the pt on the dyspnea for "a while" (days, months, years?) and is it worse today than normally? 

Elevated BNP will show stretching in the ventricles. I am worried about an acute CHF exacerbation. Does the pt know if she has had that murmur or if that is a new finding (crossing fingers here that she actual knows lol)? CXR looks like bilateral pulmonary edema. How does my preceptor feel about a point-of-care echo?

Beautiful.  Great recognition of those PE risk factors.  There's also a stupid one hidden in one of the images I put up.  Has a sensitivity of ~Crap as it is only found in about 20% of patients with PE and has horrible specificity as well.  Just about everyone's favorite thing to pimp on though so take another look.

Sure! She's coming around a bit more and doing that kind of annoying "feisty old gal" thing were she says "Well it started before I got here" and "Wouldn't you like to know".  Happily the pained look on your face gets her to report the onset to be about 3 hours ago and was getting worse.  Denies dyspnea at baseline.

She is quite proud of the fact that she has a murmur, she'll be danged if she can tell you which valve it is though.  Anyone want to venture a guess?

I think your CXR interpretation skills are pretty on point. Your preceptor waves in the general direction of the ancient SonoSite with about 2 crystals remaining.  Your thoracic U/S shows B lines all through bilateral lung fields, no signs of an effusion.  Grossly normal RV/LV function, LVEF visualizes to >65%, no pericardial effusion, IVC 2.4cm with a decrease on ~50% on sniff test.

[Sacarroll10]

S1Q3T3 on ECG? Plus acute dyspnea, might as well CT PE protocol now.

B lines present, so she has HFpEF. I had to look up the sniff test, looks like she is probably euvolemic? 

Does she have mitral regurgitation? 

[LT_Oneal_PAC]

Trying to stay silent. It’s @MediMike’s show and he’s doing a great job.

I see many concerned about a PE. If present, does it require emergent (aka in the next few hours) treatment? Why or why not? All the info needed to answer this question has been presented.
 

back to @ohiovolffemtp’s point about immediate interventions, do we have enough information to act now to provide some treatment?

remember treatment and continued eval can occur concurrently in the ED, except in the case where a treatment may cause harm in a suspected ddx you haven’t ruled out.

have we really completed the history? There is some more information we could get that could be helpful (maybe not since she seems ornery and not in the system)

there are 2-3 emergent ddx I have not seen mentioned, one I believe particularly important in this case, most of them the same ED treatment.

please tell me to shut up mike if I’m getting them off base. Still a few things it could be.

[rev ronin]

Here's another thought: How long is it going to take to get a D-dimer run?  What is the sensitivity of d-dimer in ruling out DVT/PE? How available is ultrasound?  What is its sensitivity in ruling out PE? Understand that trained point of care ultrasound has a wonderful potential to answer this question realistically in very short order. I would encourage those who might be seeing UC or ED patients to strongly consider getting themselves a probe and appropriate training.

https://www.sciencedirect.com/science/article/pii/S2211816013001646

[LT_Oneal_PAC]

23 minutes ago, rev ronin said:

Here's another thought: How long is it going to take to get a D-dimer run?  What is the sensitivity of d-dimer in ruling out DVT/PE? How available is ultrasound?  What is its sensitivity in ruling out PE? Understand that trained point of care ultrasound has a wonderful potential to answer this question realistically in very short order. I would encourage those who might be seeing UC or ED patients to strongly consider getting themselves a probe and appropriate training.

https://www.sciencedirect.com/science/article/pii/S2211816013001646

I think a better question is the sensitivity of US to detect submassive and massive PE, i.e. one possibly requiring true emergent treatment with thrombolysis ?

to further illustrate your excellent point, what is the sensitivity of CXR vs US for pulmonary edema and how long does a CXR take versus POCUS

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6484641/

[MediMike]

17 hours ago, Sacarroll10 said:

S1Q3T3 on ECG? Plus acute dyspnea, might as well CT PE protocol now.

B lines present, so she has HFpEF. I had to look up the sniff test, looks like she is probably euvolemic? 

Does she have mitral regurgitation? 

Good thoughts when you are looking at each individual test in isolation! One of the hardest parts of medicine is taking allllll these data points and figuring out the likelihood of a certain dz process over another.  You will definitely meet some folks who will just shotgun every lab/imaging modality possible, and depending on how sick the patient is that's oftentimes the only approach you can take, A) Buys you time to wrack your brain and B) Sometimes more than one thing is going on

Alright, back to the case:

B-Lines on thoracic U/S can indicate edema, nice work.  So you've got a little old lady with a CXR consistent with pulmonary edema, U/S findings consistent with pulmonary edema, and a murmur that you've correctly identified as MR.

1) Do you still want to have this lady (who is still working hard to breathe and requiring hi flow oxygen) lay flat for a CT scan?

2) Is there anything besides the S1Q3T3 and hx of CA that makes you think this lady has a PE that is causing her immediate issues?

I try to develop a mental model of several differentials, what labs/imaging/diagnostics/exams I can perform to rule those differentials in/out.

So let's revisit:

Older lady working hard to breathe. 

SpO2 88% on 15lpm NRB. 

Speaking 3-4 word sentences. 

Elevated neck veins. 

Loud murmur.

Significant HTN.

What are your working differentials and how do you start helping this lady who is probably going to start crashing soon if you don't do something?

[MediMike]

@LT_Oneal_PAC and @rev ronin I totally agree POCUS is a fantastic tool in the right hands.  But throw a probe at someone who doesn't have the opportunity to scan many folks and all you get is a really slippery patient.  (Or a really clean one when I can't find any ultrasound gel and it's all about that hand sani)

@LT_Oneal_PAC I was wondering how long you EM folks were gonna hang by the sidelines while the ICU guy dicked around with an ED scenario. Jump on in and help guide/teach my man.  I am almost 100% positive you are able to generate a much broader list of differentials than I would any day! (that gif about killed me btw)

Edited September 4, 2021 by MediMike

[MediMike]

24 minutes ago, LT_Oneal_PAC said:

I think a better question is the sensitivity of US to detect submassive and massive PE, i.e. one possibly requiring true emergent treatment with thrombolysis ?

to further illustrate your excellent point, what is the sensitivity of CXR vs US for pulmonary edema and how long does a CXR take versus POCUS

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6484641/

Do you have any idea what they used as a "positive" CXR finding in those studies? I'm honestly a little too lazy to read through all 6 in the MA.  Wonder if they had to ONLY have pulmonary edema or if they allowed "increased interstitial markings" etc.  Was also interesting that the majority of them used a PA modality rather than AP if I read through correctly.  (Okay, maybe I scanned/glanced)

[LT_Oneal_PAC]

6 hours ago, MediMike said:

Do you have any idea what they used as a "positive" CXR finding in those studies? I'm honestly a little too lazy to read through all 6 in the MA.  Wonder if they had to ONLY have pulmonary edema or if they allowed "increased interstitial markings" etc.  Was also interesting that the majority of them used a PA modality rather than AP if I read through correctly.  (Okay, maybe I scanned/glanced)

I’m not entirely sure. It was a meta analysis, so it could be different for the individual studies. But it’s at least as accurate, and I don’t have to wait for the tech to show up. Plus I can check like 7 more things by the time the portable arrives.
 

you’re right in that people need the skills before they start doing it. That’s why I really try to encourage it because many are so intimidated. A crash course and a doing a few hundred while also getting a second image test to confirm can get one pretty decent. 

[ohiovolffemtp]

Mike - you're doing a great job of teaching the analytical diagnostic process.  There is a key difference in how emergency medicine thinks that I don't think has come through yet: is there stabilization/resuscitation needed while we're working up the patient.  Based on what I'm interpreting from the scenario, the answer is YES!!!

This patient appears to have LLS - Looks Like S@#$.  She's tachypneic, tachycardic, hypoxic - with insufficient improvement after high flow O2.  She's wheezing (or could it be rales?).  She was tripoding.  She's had lots of birthdays.  So, she's in respiratory distress, impending respiratory failure, and old enough to have minimal reserves.  You know all this the minute you walk in the room with the patient.  Then. add in vitals and some of the physical exam findings.  The stat CXR is very helpful but isn't necessary to start the stabilization.

So: consider that ventilation has 3 components:

• air movement
• gas exchange
• circulation

Rhetorical question: which portions of this need support in this patient?  So, what interventions will help with these problems?  Supplemental O2 isn't enough.  Once those interventions are in place, all of the other diagnostic workup can continue.  There are some excellent ideas that have already been put forward.  

Get this patient stable (or at least closer to it), then you all can U/S, CT, wait for lab results, etc with less worry that you'll be coding and tubing this patient.

Let's let the students chime in and after awhile I'll make suggestions on the flow of the visit.

[TheFatMan]

Sorry playing a little catch-up here. Didn't read everyone's comments, sorry!

Real quick, I think I asked about chest pain but not sure if that was answered.  Also want to ask if it looks like she is perfusing clinically - does she have warm or cold extremities? Could we get a pro-calcitonin? 

In terms of other factors that make you think of PE in this case, I'd say she has signs of right heart strain. 

Would not get a d-dimer. She's already moderately high risk, so if we are thinking PE she would go to the scanner. Problem is (in addition to her being unstable and the problem of lying flat), her BUN is elevated (creatinine is okay though). Someone help me out here, does she get contrast or would you do a VQ? No signs of DVT so not sure if duplex would help here.

Others on DDx (apologies if some of these have been mentioned)

- acute/chronic mitral regurgitation (possibly secondary to rheumatic fever, endocarditis, ischemia, cardiomyopathy, trauma, [or PE?]). This explains the murmur and the pulmonary edema/CHF sx.

- Sepsis...she has a lactate and a temp. qSOFA is 1 or 2 depending on if you think she is altered.

- ARDS, I think pretty likely, meets Berlin criteria from what I can tell, just not sure what the exact cause is at this point. This could also be due to a pancreatitis, can we get a lipase?

- She has an AKI as well.

As for treatment. Right now we need to decrease her afterload. Would use nitroprusside or nitroglycerin. Slowly reduce MAP by 25% in 1st hour. Furosemide for acute pulmonary edema. Hypoxia has improved but has work of breathing? Consider early intubation here possibly with proning. Don't want to delay treatment if she has a big PE, so anticoagulate with LMWH after making sure it isn't contraindicated, VTE prophylaxis is also indicated for ARDS so I think its a good idea. 

Probably also a foley to 1) check for urinary cause (UA + culture) and 2) monitor diuresis.

 

EDIT: Doesn't look like we can actually intubate. Start Bi-PAP and get on the phone because she'll likely need to go somewhere else.

Edited September 9, 2021 by TheFatMan

[ohiovolffemtp]

14 hours ago, TheFatMan said:

As for treatment. Right now we need to decrease her afterload. Would use nitroprusside or nitroglycerin. Slowly reduce MAP by 25% in 1st hour. Furosemide for acute pulmonary edema. Hypoxia has improved but has work of breathing? Consider early intubation here possibly with proning. Don't want to delay treatment if she has a big PE, so anticoagulate with LMWH after making sure it isn't contraindicated, VTE prophylaxis is also indicated for ARDS so I think its a good idea. 

Probably also a foley to 1) check for urinary cause (UA + culture) and 2) monitor diuresis.

 

EDIT: Doesn't look like we can actually intubate. Start Bi-PAP and get on the phone because she'll likely need to go somewhere else.

THIS!!!  The key point in EM is to start stabilization of the patient with the limited information you can get quickly while you're gathering information for yourself and downstream providers to move towards a more definitive diagnosis and treatment.

This patient is having significantly increased work of breathing.  Whether she has some sort of restriction of air movement or impairment of gas exchange, e.g. fluid filled alveoli - or more likely both, she needs pressure support.  This will both keep the small airways open and push the fluid in her alveoli back into the tissue.  She needs STAT BiPAP to (hopefully) avoid intubation.  Nitrites are a good choice.  You can give her a SL nitro while you're putting her on BiPAP, then go with IV or nitro paste if you're having trouble getting IV access.

Try to avoid tubing the patient if you can, she could be very hard to tube and very hard to wean.  Don't send her out of the dept until her breathing is stable.  You can get a portable chest in the dept.  Ask the rad tech what their limits on GFR for use of contrast before you do the CTA chest.

In terms of flow:

• Back to room, with provider following patient in to room
• Vitals, eyeball patient, lung sounds, touch legs
• O2, call for BiPAP STAT, nitro
• BiPap - should be on patient ASAP, ideally within 5 min (I'm spoiled, small ED, can make things happen fast)
• Then EKG, IV, labs, STAT bedside CXR.  Hopefully the portable has a screen so you can view the image at bedside.
• Someone stays at bedside until pt's breathing stabilizes.

Other thoughts:

• Foley may not be necessary.  Some institutions policies limit their use.  You can get a good sample for a UA without it and close enough info on UOP from bedside commode.
• Pro-calcitonin: won't help you any, can be helpful for the inpatient folks.  But, can you even do it in-house or is it a send-out (think 2 days later)?
• D-dimer: can be one of the slower labs to result.  You can make a clinical decision on need for CTA without it.

[LT_Oneal_PAC]

@TheFatMan Great job! You're thinking and I love it!

 

@ohiovolffemtp I love the SL NTG while throwing on the bipap. I've even used this almost diagnostically sometimes it's so quick and easy. Totally agree on the pro-cal. Helps the inpatient people to use antibiotics, but we don't have the luxury of time in the ED. If we think they are septic, they get those abx NOW. Love your flow as well, though of course, I'm a big US person  I would be throwing the probe on nearly as my first thing to narrow my ddx in about 30 seconds. Depending on the time of day, it could take my rad tech up to 20 minutes to ARRIVE in the department. I've had this argument with admin before. If the clinician has to be immediately available, then all the people I need to perform my job need to be immediately available, but many of them are call from home including rads, RT, and lab. We did just get a new portable XR with viewer and I'M LOVING IT SO MUCH.

 

 

Great thinking on the nitrates and bipap. She needs these things ASAP.

We still seem to be hinging on PE, and I'm not saying that's wrong. While she is at risk, if you develop a PE, where is the obstruction? Where does it cause fluid to back into? Does it lead to pulmonary edema? what is making you believe there is heart strain from a PE? How does heart strain manifest in imaging and lab work? What part of the heart is strained? If you believe she is having heart strain, do you want to thrombolyse her with tPa? What are some indications to give thrombolytics?

Anticoagulation prevents the propagation of clot, but this is not emergent life saving treatment. It does need to be done soon, but it's not what is going to fix this patient. It's closer to one of the last steps I do. 

I do not see where she has a temp unless I missed something. I saw 37.8C which is <38C (100.4F). A sepsis work up would not be out of the question in the early undifferentiated patient. 

This is definitely subject to the clinician at hand, and I practice the way I was taught in residency. The newer lower osmolar contrast agents are not thought (by EM anyways, rads loves dogma) to really cause contrast induced nephropathy. I never withhold contrast when I think someone has a PE (depending on if stable), dissection, or other ddx that requires me to know NOW. I just get it done and I will hydrate them afterwards. Even if I do cause a hit to the kidney's, dialysis is a lot easier than ECMO if I wait too long, in my opinion. 

I do believe duplex is helpful when considering PE. 70-75% of all PE's originate from DVT of the lower extremities. If you do a quick 3 point DVT US (which has been shown to be non-inferior to radiology interpreted duplex), then you can lower your concern for PE. If you are doing the CTA regardless, it's not that helpful unless there are actual signs of DVT. 

Nitrites can be lethal in PE. The sicker ones even needs some pressors. That doesn't mean slam them with fluids either, as that can worsen their right heart strain. They are a delicate balance act. Referring back, where is the clot? How does heart strain manifest and affect the pump? If you do think someone is having a massive/submassive PE, you can throw 5mg NTG into a nebulizer and you have a poor man's (or poor rural hospital's) nitric oxide to dilate the pulmonary vasculature with systemic dilation.

Intubation in PE can also be very detrimental. You want to avoid this at all costs if you can. Sometimes it has to be done, but the cardiac effects of sedating someone and stopping ventilations even briefly can be catastrophic. 

Acute on chronic mitral regurgitation is a excellent Ddx. Why is it all of the sudden worse? Look back at the vitals. What emergent diagnosis causes sudden fluid in the lung? It can also cause acute kidney injury, acute heart failure, confusion, seizures, end organ damage.

After some answers, I'll tell you what I would have done with this patient. Also hope to hear from @MediMike

[MediMike]

15 hours ago, TheFatMan said:

Sorry playing a little catch-up here. Didn't read everyone's comments, sorry!

Real quick, I think I asked about chest pain but not sure if that was answered.  Also want to ask if it looks like she is perfusing clinically - does she have warm or cold extremities? Could we get a pro-calcitonin? 

In terms of other factors that make you think of PE in this case, I'd say she has signs of right heart strain. 

Would not get a d-dimer. She's already moderately high risk, so if we are thinking PE she would go to the scanner. Problem is (in addition to her being unstable and the problem of lying flat), her BUN is elevated (creatinine is okay though). Someone help me out here, does she get contrast or would you do a VQ? No signs of DVT so not sure if duplex would help here.

Others on DDx (apologies if some of these have been mentioned)

- acute/chronic mitral regurgitation (possibly secondary to rheumatic fever, endocarditis, ischemia, cardiomyopathy, trauma, [or PE?]). This explains the murmur and the pulmonary edema/CHF sx.

- Sepsis...she has a lactate and a temp. qSOFA is 1 or 2 depending on if you think she is altered.

- ARDS, I think pretty likely, meets Berlin criteria from what I can tell, just not sure what the exact cause is at this point. This could also be due to a pancreatitis, can we get a lipase?

- She has an AKI as well.

As for treatment. Right now we need to decrease her afterload. Would use nitroprusside or nitroglycerin. Slowly reduce MAP by 25% in 1st hour. Furosemide for acute pulmonary edema. Hypoxia has improved but has work of breathing? Consider early intubation here possibly with proning. Don't want to delay treatment if she has a big PE, so anticoagulate with LMWH after making sure it isn't contraindicated, VTE prophylaxis is also indicated for ARDS so I think its a good idea. 

Probably also a foley to 1) check for urinary cause (UA + culture) and 2) monitor diuresis.

 

EDIT: Doesn't look like we can actually intubate. Start Bi-PAP and get on the phone because she'll likely need to go somewhere else.

Nice. Thank you for initiating treatment

Couple items:

Do you need to scan this patient? What makes you think she has a PE? Is her CXR compatible with it? Hemodynamics? Echo?

A V/Q scan in a patient with any kind of other lung pathology (edema, consolidation, atelectasis, infiltrate) will be useless as you will inherently have a mismatch in ventilation. Great thought though! I remember them being pushed hard in PA school, outside of the classroom they are only ever used in stable patients in my experience, workups for PH etc.

ARDS criteria can't be met if you believe this has a cardiogenic component to it. We don't do DVT prophylaxis BECAUSE of ARDS, we just do it on everybody that comes in the hospital who is immobile.

Treatment;

Absolutely fantastic. This lady appears to have flash pulmonary edema, possibly due to worsening mitral regurgitation. Afterload reduction is key, and in this setting I'd take her down until the dyspnea resolves. You also want to reduce her preload, and positive pressure ventilation does both of those. She would definitely benefit from CPAP! The PEEP generated will reduce preload, redistribute water, and increase functional residual capacity, "popping open" those soggy alveoli. BiPAP is an option too, can help reduce the work of breathing.

If you need to intubate you can definitely intubate. Someone can bag the patient if need be.

What do you do if she starts fighting the mask and refusing to wear it?