Posted: 3/2/2016 10:50:01 PM EDT
[Last Edit: AGW][Edited]
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Here's an interesting case for you all to digest. The patient's history was central to his treatment and disposition but was difficult to obtain (mom wasn't forthcoming with details for some reason). Digest and enjoy. I'm interested to see what some of you would do for this patient before reading the spoilers. 18YO African American male with a history of T4 paraplegia (I'm unsure of mechanism, but chronic). Per family, he's been "sick" for a couple of days. He had a decub on his sacrum debrided a few weeks ago, now it kinda smells and he feels dizzy, so they decided to come in. HR 139 BP 74/28 RR 24 O2 56% N: Arousable but minimally interactive CV: No murmur, no edema P: Tachypneic with increased work of breathing, MSK: Cacechtic 2/2 paraplegia, severe clubbing of his fingernails The feeling around the room was that this pt was septic and needed to be intubated and bundled immediately. But Mom was super chill, very unconcerned about his hypoxemia... Stand by for more details.... can't get spoiler tags to work |
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Does the pt have an elevated temp?
And yes, what are his labs? Lactate level, WBC count… etc Clubbing… Is the SaO2 a reliable reading? Is the pulseOx tracking? What do his lungs sound like? Do we need an ABG? I enjoy a mystery 
oh yeah… a 12 lead too! |
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Originally Posted By Metallitera:
I want more Hx. Use of ETOH, cigs, recreational drugs? Allergies? Meds? Other medical Hx? What about labs? CBC, ABG? Sepsis jumps out to me too, but ned to know more. Clubbing fingers is odd. Clubbing is a clinical sign of prolonged respiratory disease. |
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Originally Posted By GypsyDoc: Clubbing is a clinical sign of prolonged respiratory disease. Originally Posted By GypsyDoc: Originally Posted By Metallitera: I want more Hx. Use of ETOH, cigs, recreational drugs? Allergies? Meds? Other medical Hx? What about labs? CBC, ABG? Sepsis jumps out to me too, but ned to know more. Clubbing fingers is odd. Clubbing is a clinical sign of prolonged respiratory disease. Ding ding ding... we're on to something now. Labs had been sent but not resulted at this point (this is a 5 second glimpse at the pt). Except maybe a blood gas which will show a compensated respiratory acidosis. But is he acidemic because he's making lactate or because of some underlying pathology.... either way his SOFA score was 87 (which indexes to an APACHE score of 8,000). Lungs are clear but dim, stable PO2 waveform, sinus tach without cor pulmonale, but some weird axes. In noticing this 18 year old's severely clubbed fingers, you turn to mom and push for more history and get..... pulmonary atresia. Your next move (besides turfing  )?To bolus or not to bolus... |
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Originally Posted By GypsyDoc:
Clubbing is a clinical sign of prolonged respiratory disease. Originally Posted By GypsyDoc:
Originally Posted By Metallitera:
I want more Hx. Use of ETOH, cigs, recreational drugs? Allergies? Meds? Other medical Hx? What about labs? CBC, ABG? Sepsis jumps out to me too, but ned to know more. Clubbing fingers is odd. Clubbing is a clinical sign of prolonged respiratory disease. Yes, but I meant odd in this case. usually seen in those a lot older than 18yrs lol |
-ReD
Firefighter/Paramedic
Firefighter/Paramedic
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Any history of surgical repair, maybe with a technique that admixes venous and arterial blood? Dig more into hx and see if he had Tetralogy of Fallot.
If so, Dispo: Call up a children's hospital and have them start dropping quarters in the ECMO machine? 
Not sure I'd jump right to an aggressive fluid bolus if he's having possible RV failure. That could wind up quickly on the road to milrinone and pressor support. Maybe a short-acting vasoconstrictor (i.e. phenylephrine) could be enlightening. It could tighten up arterial tone, slow heart rate, and also preferentially move more blood to the pulmonary system if he has a right to left shunt. At T4 para level, he could also have autonomic dysreflexia superimposed on suspected sepsis and cardiopulmonary abnormalities. You said no murmur, but that doesn't rule out possible septic pulmonary embolism. He's got a source of infection, immobility, and abnormal pulmonary vasculature. Just spitballing here, as there could be a lot going on, and I'd want to lay eyes on the kid. If he's not protecting his airway or is fatiguing from work of breathing, then think about airway control. Move the clothes from his neck to see if he has a trach stoma. Posted Via AR15.Com Mobile |
Like fine herbs, dreams only develop their full fragrance when crushed and ground into a fine powder.
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-LowBeta
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Originally Posted By Azygos: Any history of surgical repair, maybe with a technique that admixes venous and arterial blood? Dig more into hx and see if he had Tetralogy of Fallot.  Our boy has a BT shunt and had a Glenn procedure. He's also got a therapeutic ASD and patent ductus (but no murmur somehow). So everything is wired into the pulmonary artery. Want to start an IJ on this kid (aka a swan)? All of this makes him preload dependent, btw, or atleast the Glenn procedure. No trach stoma but that sternotomy/pericardial window sure makes sense His baseline sats are 60-80%, per mom. A wiff of O2 gets him there. |
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Originally Posted By AGW:
Our boy has a BT shunt and had a Glenn procedure. He's also got a therapeutic ASD and patent ductus (but no murmur somehow). So everything is wired into the pulmonary artery. Want to start an IJ on this kid (aka a swan)? All of this makes him preload dependent, btw, or atleast the Glenn procedure. No trach stoma but that sternotomy/pericardial window sure makes sense
His baseline sats are 60-80%, per mom. A wiff of O2 gets him there. Originally Posted By AGW:
Originally Posted By Azygos:
Any history of surgical repair, maybe with a technique that admixes venous and arterial blood? Dig more into hx and see if he had Tetralogy of Fallot.
Our boy has a BT shunt and had a Glenn procedure. He's also got a therapeutic ASD and patent ductus (but no murmur somehow). So everything is wired into the pulmonary artery. Want to start an IJ on this kid (aka a swan)? All of this makes him preload dependent, btw, or atleast the Glenn procedure. No trach stoma but that sternotomy/pericardial window sure makes sense
His baseline sats are 60-80%, per mom. A wiff of O2 gets him there. Cyanotic heart defects have way too many eponyms for me to remember without consulting a reference. My reasoning behind the short duration phenylephrine was to emulate the "sqaut" that some kids learn to do with their tet spells. It briefly increases the SVR and reverses some of the right to left shunt.
I'm not doing the central line. You do the central line. "Asps. Very dangerous. You go first."
Posted Via AR15.Com Mobile |
Like fine herbs, dreams only develop their full fragrance when crushed and ground into a fine powder.
-LowBeta
-LowBeta
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So, a BT shunt is an anastomosis of the innominate artery and the pulmonary artery, and a Glenn anastomoses the R SVC with the pulmonary artery as well. On top of that, he has a retained atrial-septal defect and patent ductus arteriosus, so it's as if this guy has only half a heart the way he shunts/DO2. His preload dependent state made him a good candidate for fluids because it increased preload, and therefore increased perfusion to his lungs, improving both his pressure and his sats. Abx, labs galore, PICU problem after that. Thanks for playing! Excellent MDM. ETA: An alpha-agonist will work in a paraplegic? Because of the level of the SCI (T4, i.e. he still has sympathetic tone... HR of 139 so duh) or because it's not a direct sympathomimetic? |
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Originally Posted By AGW:
So, a BT shunt is an anastomosis of the innominate artery and the pulmonary artery, and a Glenn anastomoses the R SVC with the pulmonary artery as well. On top of that, he has a retained atrial-septal defect and patent ductus arteriosus, so it's as if this guy has only half a heart the way he shunts/DO2. His preload dependent state made him a good candidate for fluids because it increased preload, and therefore increased perfusion to his lungs, improving both his pressure and his sats. Abx, labs galore, PICU problem after that. Thanks for playing! Excellent MDM. ETA: An alpha-agonist will work in a paraplegic? Because of the level of the SCI (T4, i.e. he still has sympathetic tone... HR of 139 so duh) or because it's not a direct sympathomimetic? Direct agonists like phenylephrine, norepi, etc. don't rely on intact spinal cord innervation. A spinal anesthetic gives a partial sympathectomy, and that's one of the ways of counteracting it. Conversely, indirect agonists like do require some portion of innervation. Ephedrine still can work to some extent with BP in the absence of spinal function, but still requires endogenous catecholamines to be present at the postsynaptic receptors. In this case, the heart rate was already high. The tachycardia from ephedrine, norepi, or dopamine could potentially be counterproductive. Now, if you had told me that the guy had a heart transplant too, we'd be talking about the denervation and unresponsiveness to vagal maneuvers/atropine/glycopyrrolate. In his case, a T4 injury may be high enough to impair his cardiac accelerator nerves. He could still get a heart rate increase, albeit more gradually, from circulating catecholamines. |
Like fine herbs, dreams only develop their full fragrance when crushed and ground into a fine powder.
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