Approach to the found down patient Dr. Alasdair Nazerali-Maitland Internal Medicine (Queens) Critical Care Medicine Fellow (U of C) CHES Clinical Education Fellow (UBC) July 10th 2015 PollEv.com/alasdairnaze107
Outline Systemic Illness Shock Toxidromes Neurological Injury Delirium Approach Cases Helpful tips
things to not miss Glucose Expose patient Medication errors (oxygen is a drug!) Allergic / anaphylactoid reactions Acute neurologic Timing - decontamination can save lives Track marks
Systemic Illness Decompensated liver failure - Ammonia? Hypo/hypernatremia Hyper/hypoglycemia Hypercarbia Hypoxemia Hypercalcemia Hyper/hypothyroidism Severe alkalosis / severe acidosis
SHock Covered in core lecture with Adam Peets/ Eric Sy Collection of symptoms/signs to aid in diagnosis. You will need help early!
Phenylephrine Distributive shock unresponsive to IV fluid What is it? How do you mix it? 100mcg/ml - try 2-3mls at a time
Toxidromes 1 Fentanyl on the rise 25% of drug-related deaths in BC in 2014
Toxidromes 2 MATCH THE ANTIDOTE! Naloxone Atropine Supportive Benzodiazepine Flumazenil
SS vs NMS SS - clinical and must have taken offending drug *CTU drugs NMS - elevated CK, leucocytosis, elevated ALP/transaminases MH - clinical diagnosis - usually intraoperative
Double gaps / toxic ETohs
Neurological injury Ischemia Hemorrhage Seizures - post-ictal or non-convulsive status Psychiatric - catatonic schizophrenia CNS infection - meningoencephalitis Movement disorders - PD
Everyone’s fav - neuroanatomy
Key factors Airway protection - GCS<8, potential for deterioration especially if imaging needed Trajectory —> over last few hours more obtunded? If suspicion of raised ICP - very sensitive to oxygen/co2 levels - think about bagging/hyperventilating Effective 2 minute assessment key - see the patient before the chart
Delirium Hypoactive Covered in another session - Mark Fok Identification is key Missed meds (Thyroid, PD) Be aware of this in your ICU transfers!
Approach Monitor/Help/Code Status/Start CPR? A - Airway open, protection, smell of breath B - Resp status/ respiratory effort / apply additional oxygen / O2 sat/ RR C - feel peripheries / look for mottling / heart sounds / new murmur? / JVP D - Disability - calculate best GCS, look for asymmetry, pupils E - Exposure - legs, back, abdomen, temperature, facial droop, gaze preference, moving 4 limbs Ix/Rx - Naloxone , 1 amp D50, Labwork, ECG, ABG
Antidotes Oxygen - in Emergency settings - 100% non-rebreather appropriate initially Naloxone - vials are 0.4mg - trial of between 0.1 to 0.4. Whatever dose used to reverse should be given hourly in an infusion Glucose —> Dextrose - no harm and huge potential benefit Flumazenil - benzodiazepine antagonist - can induce seizures* Thiamine - with glucose if suspicion of alcoholic encephalopathy
AEIOU-TIPS A - Alcohol E - Epilepsy / Encephalopathy / Electrolytes I - Insulin O - Opiates / Oxygen U - Uremia T - Trauma / Temperature I - Infections P - Poisons or Psychogenic S - Shock / Stroke / SOLs / SAH
Case 1 55 year old with history of previous alcohol related injuries - MSK ++ and withdrawal seizures. Soft admit with pneumonia, put on alcohol withdrawal protocol with CIWA scale. Scores of 30+ each of past 4 hours. Has been given 10mg Haldol PRN over that timeframe but still very agitated, sweaty and hypertensive.
How would you treat this A) Suck it up buttercup B) Diazepam 10-15mg po/iv q6h prn C) Lorazepam 1-2mg po/iv q1h prn D) Diazepam 10-15mg po/iv q6h regular and Lorazepam 1- 2mg sl/iv q1h PRN for CIWA>20
Reassessment After your benzodiazepines and haldol kick in - four hours later the patient has a GCS of 8. The CCOT has arrived and they are recommending a trial of Narcan/Flumazenil. They aren’t allowed to give it as nurses but are hoping that you as the R1 can do it. What would you like to do? A) Give it IV - they are the outreach team B) Offer it to the medical student to do as they haven’t given an IV push before C) Insist that it takes place in a monitored setting like the ICU and give it there D) Insist that the patient be moved to a monitored setting and give neither of the medications.
Case 2 72 year old admitted with a COPD exacerbation and sats of 83% on room air. Admission ABG is 7.28/60/50/36/83% Lactate of 1.2. One of the earnest student nurses applies 10 L of oxygen via facemask to the patient and their sats immediately jump up to 100% An hour later the patient has a GCS of 9, has myoclonus- like jerks, ABG is repeated and it is 7.11/100/90/36/95%. How did this happen?
A) The patient needs some nebs, he’ll be fine after Combivent B) Sounds like an acute PE - he should go for a CTPE and get UFH C) Too much oxygen - turn it down and arrange for BIPAP D) Too much oxygen - he’s too drowsy for BIPAP and needs intubation
Haldane effect http://www.ccforum.com/content/pdf/cc11475.pdf Small effect of increased circulating oxygen leading to hypoventilation Larger effect from pre-existing hypoxic pulmonary vasoconstriction -> increased alveolar deadspace ventilation Oxygen induces rightward shift of CO2 dissoc curve -> increase CO2 and for those who cannot hyperventilate —> hypercarbia
Case 3 Fireworks finale and you are the resident on St. Paul’s. One of your patients has a pass for the evening and returns to the ward (7th floor) and the nurses call you that he’s suddenly really drowsy. He was fine 2 minutes ago, took a swig from his water bottle. You arrive at the bedside and the patient isn’t responding. He has an obvious pulse with a HR of 55 and his BP is 100/60. He has no gag, his resp rate is 4 and was 8 three minutes ago. It is busy in the ED and the senior resident has 4 consults to distribute and he wants to know whats going on…
What do you want to do? A) Order some screening labs/ECG/CXR, try an antidote cocktail of Dextrose/Oxygen/Thiamine B) Reassess the patient in an hour - he’s tired C) Call CCOT - he is not protecting his airway and needs more monitoring +/- intubation D) Try out what is in his water bottle - its definitely too strong for him
GHB Gamma - hydroxybutyric acid Prior agitation followed by abrupt coma is usually clinical picture Airway/breathing/ ICU support Usually respond very quickly and when stimulated —> abrupt reversal of coma No role for decontamination Flumazenil and naloxone not clinically effective
Case 4 The emergency department at SPH is slammed. You have 15 consults pending, your senior has called in the staff to help with a few patients and she has asked you to see a drowsy patient in majors. The patient is groaning, opens his eyes to painful stimuli and fully localizes to pain with all 4 limbs. He cannot follow commands even with asking him nicely.
What is the patient’s gcs? C) 9 D) 1 A) 8 B) 6
Case 4 cotd The lab work comes up for the patient and his Na is 103. As you are going through the chart, the emergency nurse runs over to you and says that the patient is seizing now. You… A) Get some intubation equipment - this is your time to shine B) Give 100cc of 3% saline IV push C) Give 5mg rectal diazepam stat D) Place an NG and give 1000mg of Keppra
Case 5 You’ve been asked to see a patient with recently diagnosed breast cancer. She is awaiting a full workup at the BCCA but has been referred to your rapid access GIM clinic with headache and feeling unwell. She is reporting central vision loss. Her clinic blood pressure is 210/130 and she can barely walk into the clinic room and is barely able to talk to you without long pauses Her HR is 52. Screening hematology/biochemical bloodwork is normal.
Ix
WHat do you do? A) Call CCOT - 10mg IV Dexamethasone stat, send to Emerg for IV bp control - with Nitroprusside B) Call CCOT - 10mg IV Dexamethasone stat, send to Emerg for IV bp control - with Labetalol C) Discharge her to the care of her family doctor - that BP is putting her at risk for a stroke D) Tylenol, Ibuprofen and bedrest - Ta Da
Helpful Tips Good residents can come up with a management plan and put it into play Great residents can see where the patient is heading in 1, 2,12,24,48 hours Use the resources of your hospital/setting - getting CCOT involved early if needed, subspecialty services, your senior resident/staff (they’d much rather know and want to help…) Get the nurse to start a second IV, call for labs early, ask the RT to take a blood gas
Crisis Resource Management Stabilize the patient rapidly Strategic, prioritized approach Do not be afraid to hand over to someone with more experience http://lifeinthefastlane.com/ccc/crisis-resource-management-crm/
Questions? anmccm@gmail.com Please contact me!
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