The Case of the Sinister Syncope

[Arcan57]

73 yo male presents with a chief complaint of passing out when he tries to sit up. He arrives by ambulance and has several family members in room that had followed the ambulance to the ED.


And go...

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[beakerdan]

Alright, I'll play.

ABC's please

Assuming there's nothing there, can I have:
H&P, vitals, medication list, PMH

Working differential:
Medication side effect (alpha/beta blockers)
Cardiac
Anemia/hypovolemia
Vasovagal (?)
Probably some zebras I'm forgetting about...

 

[bad virus]

73 yo male presents with a chief complaint of passing out when he tries to sit up. He arrives by ambulance and has several family members in room that had followed the ambulance to the ED.


And go...

replying from iPhone just to say, YAAAAYYYY, I love these. The Foxes legacy lives on . . .

 

[RustedFox]

Ha HA ! Hey, I didn't forget about these; I've been looking for "good" cases every day when I go to work, but recently its just been "I'm old and don't feel right, or I've fallen."

EKG FTW.

 

[RustedFox]

(and because I watched "The Hunger Games" last night)...


.... and may the odds be ever in your favor.

 

[Arcan57]

Alright, I'll play.

ABC's please

Assuming there's nothing there, can I have:
H&P, vitals, medication list, PMH

Working differential:
Medication side effect (alpha/beta blockers)
Cardiac
Anemia/hypovolemia
Vasovagal (?)
Probably some zebras I'm forgetting about...

Pt is able to speak and is tachycardic. Pt and family speaks Spanish-only, as I'm walking into the room the paramedic pulls me aside and says "Doc it's the weirdest thing. Everytime we tried to raise the head of the stretcher up he'd pass out."

Initials vitals:
64/35 130 20 100% (on EMS's 4L) 98.9

Family that speaks the most English says: "He just had a robotic prostatectomy yesterday at another hospital and he has been passing out today everytime he tries to get up"

What specifically do you want to know on the physical exam?

Rusted - EKG looks ugly. Sinus tach in the 120s but has ST-elevation in III and AVR with ST-depression in the lateral leads.

 

[alreadylernd]

With those vitals, get an ultrasound on his belly to look at the aorta (AAA) and for any free fluid (thinking recent instrumentation and possible solid organ injury leading to internal bleeding badness).

Pt is able to speak and is tachycardic. Pt and family speaks Spanish-only, as I'm walking into the room the paramedic pulls me aside and says "Doc it's the weirdest thing. Everytime we tried to raise the head of the stretcher up he'd pass out."

Initials vitals:
64/35 130 20 100% (on EMS's 4L) 98.9

Family that speaks the most English says: "He just had a robotic prostatectomy yesterday at another hospital and he has been passing out today everytime he tries to get up"

What specifically do you want to know on the physical exam?

Rusted - EKG looks ugly. Sinus tach in the 120s but has ST-elevation in III and AVR with ST-depression in the lateral leads.

 

[Arcan57]

With those vitals, get an ultrasound on his belly to look at the aorta (AAA) and for any free fluid (thinking recent instrumentation and possible solid organ injury leading to internal bleeding badness).

I didn't see a dilated aorta and he didn't have fluid in Morrison's pouch.

 

[beakerdan]

With those vitals, I agree with alreadylernd that we want to look for free fluid in the abdomen with the US.
I'd also like to start fluids to try to bring the pressure up.

Physical exam:
General - distress? pale?
Cardiac - matches the sinus tach we see on EKG? Pulses in extremities (especially legs)?
Abdomen - soft / tender? pulsatile midline mass?
Skin - color in the arms and legs?


Thoughts now:
1. Abdominal organ injury due to instrumentation
2. AAA
3. Atypical MI (a funky pattern, but that looks like what might be reciprocal changes in lateral leads)
4. (my zebra) Sympathetic damage during prostatectomy leading to dilation in the legs

 

[Tiger26]

bedside echo--effusion?

 

[WilcoWorld]

Does he have a history of pacemaker? I've heard of pacemaker wire problems presenting this way. Damage to a VP shunt is also to be considered, but it would seem odd for this to be so precipitous.

In any case, my initial orders:
CBC, chem + magnesium, troponin, type & screen, ECG, CXR and bedside FAST. I'm also doing a rectal exam, starting an NS bolus and looking closely at his med list for causes of syncope.

 

[bad virus]

bedside echo--effusion?

on that note, I want to start some fluids, but can you tell us if there are any right sided heart signs like pedal edema, JVP, etc . . .

After that, I'm gonna start w/ some crystalloids and then move on to pressors. This guys not really stable w/ all that Hypotension, tachychardia and confusion . . . sounds like some hypoperfusion already.

 

[loveoforganic2]

Meds? Particularly, did they just start him on an alpha blocker?

 

[Rendar5]

99% of post-op complications are infection (unlikely w/ an afebrile pt), bleeding (urologic procedure = retroperitoneal, you've already ruled out the less likely peritoneal bleed with FAST, which was also what i'd do first), and damage to surrounding structures (parasympathetics could have been hit, though you'd think this would be picked up in the PACU). Only other post-op complication that's in unrelated structures is a PE. So my differential is
1. retroperitoneal bleed
2. retroperitoneal bleed
3. retroperitoneal bleed
4. PE
5. Post-surgical zebra such as massive hematuria, aortoenteric fistula, parasympathectomy, etc.
6. Completely unrelated issue such as tamponade, sepsis, medication, etc.

The crappy thing is this patient is too unstable for CT, which is the only realistic way to identify #'s 1,2, and 3 on the differential. So while stabilizing the patient, we may as well start looking at 4, 5, and 6 on the differential.

So while a call's put out to his urologist (he'll know if there were procedural complications), the rest of my history is to get someone collecting a med list and to establish his PMH. My physical exam is really to check for lung sounds (gotta r/o a process leading to heart failure before giving IVF and blood products), JVD (the same), legs (for DVT), and rectal (for GI Bleed). The u/s you already did and you may as well take it to the IVC to see if it's engorged or collapsing and the heart for effusion and RV collapse or RV dilation. And a foley is definitely in order for a hematuria zebra.

Labs are pretty much what everyone else said.only thing I'd add to Wilco's list would be coag's and u/a. But I've got a feeling that we're only going to arrive at the final diagnosis with a CT, an angiography, or an operation.

 

[glorfindel]

Quick neuro exam -- gross deficits?
Echo -- looking for rv mobility, left atrial thrombus/embolus, effusions

 

[Xerxes1729]

You can get a gas embolism from laparoscopic (or robotic) surgery, but I think those usually occur intraoperatively, and I can't think of any particular reason one would present this late.

 

[Arcan57]

Lots of good ideas on this. I really like Rendar's breakdown of their thought process. So more info

Physical exam
PERRL, 3mm
oral pharynx clear
+JVD (big enough I put a 14g EJ in on first try)
Lungs CTA B
tachy no m/g/r nl PMI equal pulses in all 4 distal ext.
abd s/nt/mildly distended
no flank ecchymosis, no CVA ttp
A&Ox3, moves all 4 ext with nl strength

We have no POC testing, so a rainbow of tubes was sent off. BP is now 85/60. Pt denies chest pain or shortness of breath.
The rest of the bedside sonographic exam showed no IVC change with respiration and a + McConnell's sign on the cardiac exam.

What next?

 

[goodoldalky]

heparin and then I'd call the cath lab for embolectomy rather than lytics

 

[Tiger26]

heparin and then i'd call the cath lab for embolectomy rather than lytics

+1

 

[glorfindel]

A painless, non-dyspneic, big PE? Good case!

My thought process is similar to Rendar's but a lot less organized. I'm still also suspicious of some goombah in the heart. Still need stat formal echo if available.

Strong work on the EJ.

I think with this exam that a retroperitoneal bleed is much less likely; the exam doesn't suggest aortic bleeding. It's now almost all pointing to embolism/thrombus, so....

Heparinize the guy now? Good for PE, thrombus, and MI. Bad for hemorrhagic shock which I don't think this guy has. He's getting better in the ED, with treatment, not worse. I would feel much more comfortable w/heparin after a scan, but they don't pay me to be comfortable. This is the big fork in the road.

I say heparinize the guy.

His pressure is better with fluids. Continue fluids. Gather more past med hx/old records. (WW asked about pacer, etc). Did we get the med list beakerdan wanted? Why hasn't that urologist called back? Is he sleeping? Why didn't I learn more Spanish in college?

Advanced airway equipment to the bedside, of course.

Got to make some calls now for a co-coffin-carrier in case the guy dies on me. I'd call the hospitalist now for presumed massive pe to get him/her thinking along with me as I await the labs and the all-important portable CXR. We ordered that, didn't we?

Run off to Room #7 to discharge the URI/common cold pt so my LOS times look good.

Good case. How many hours until the end of my shift?

 

[Arcan57]

A painless, non-dyspneic, big PE? Good case!

My thought process is similar to Rendar's but a lot less organized. I'm still also suspicious of some goombah in the heart. Still need stat formal echo if available.

Strong work on the EJ.

I think with this exam that a retroperitoneal bleed is much less likely; the exam doesn't suggest aortic bleeding. It's now almost all pointing to embolism/thrombus, so....

Heparinize the guy now? Good for PE, thrombus, and MI. Bad for hemorrhagic shock which I don't think this guy has. He's getting better in the ED, with treatment, not worse. I would feel much more comfortable w/heparin after a scan, but they don't pay me to be comfortable. This is the big fork in the road.

I say heparinize the guy.

His pressure is better with fluids. Continue fluids. Gather more past med hx/old records. (WW asked about pacer, etc). Did we get the med list beakerdan wanted? Why hasn't that urologist called back? Is he sleeping? Why didn't I learn more Spanish in college?

Advanced airway equipment to the bedside, of course.

Got to make some calls now for a co-coffin-carrier in case the guy dies on me. I'd call the hospitalist now for presumed massive pe to get him/her thinking along with me as I await the labs and the all-important portable CXR. We ordered that, didn't we?

Run off to Room #7 to discharge the URI/common cold pt so my LOS times look good.

Good case. How many hours until the end of my shift?

ASA given immediately, heparin started after the U/S showed lg RV. PMHx is hypertension, prostate CA, CAD. No allergies.

The urologist was from a hospital 25 minutes away and didn't seem relevant to the problem at hand. I decided to do the CTPE without waiting for labs because of the hemodynamic instability with RV dilatation (despite the BP going up into the 80's he's still tachy in the 120s). CT shows bilateral PEs (but not saddle). We don't have the ability to catheter/IA thrombectomy and I'm arranging transport to our tertiary care center because he's POD#1 and looks like he may need that clot removed due to how sick he is.

Pt's pressure starts dropping immediately after getting back from CT scan (I went with him to CT) despite aggressive fluids so I place an U/S IJ for pressors. I'm pulling out the wire when the patient loses their pulse.

What now?

 

[goodoldalky]

Since that is the position you're in, I'd systemically lyse him. Some would argue with the hypotension, as soon as your echo is done the patient needs embolectomy or if you don't have that capability, lytics. He had the prostatectomy but that's irrelevant. This is a lethal PE without immediate lytics. During your ACLS bedside U/S would be useful just to make sure you didn't cause a tamponade while inserting the line but barring that he's coding from the PE.

 

[45408]

Don't mind me, just perusing the case discussion. Had to Google McConnell's sign...

Family that speaks the most English says: "He just had a robotic prostatectomy yesterday at another hospital and he has been passing out today everytime he tries to get up"

And did they just walk out of the hospital and into your ER? Why oh why would they not go back to where they just had an operation?

99% of post-op complications are infection (unlikely w/ an afebrile pt), bleeding (urologic procedure = retroperitoneal, you've already ruled out the less likely peritoneal bleed with FAST, which was also what i'd do first), and damage to surrounding structures (parasympathetics could have been hit, though you'd think this would be picked up in the PACU). Only other post-op complication that's in unrelated structures is a PE. So my differential is
1. retroperitoneal bleed
2. retroperitoneal bleed
3. retroperitoneal bleed
4. PE
5. Post-surgical zebra such as massive hematuria, aortoenteric fistula, parasympathectomy, etc.
6. Completely unrelated issue such as tamponade, sepsis, medication, etc.

An infection would be very, very unlikely on post-op day 1.

And a foley is definitely in order for a hematuria zebra.

He probably still has a Foley anyway - I would be surprised if they pulled it so soon. It would not be a zebra the day after his bladder neck was transected, and it also seems like a bad idea without having the urologist at least say "Sure, go ahead and put one in."

I think with this exam that a retroperitoneal bleed is much less likely; the exam doesn't suggest aortic bleeding. It's now almost all pointing to embolism/thrombus, so....

Heparinize the guy now? Good for PE, thrombus, and MI. Bad for hemorrhagic shock which I don't think this guy has. He's getting better in the ED, with treatment, not worse. I would feel much more comfortable w/heparin after a scan, but they don't pay me to be comfortable. This is the big fork in the road.

I've never seen any physical exam findings in any of the large retroperitoneal bleeds I've seen, especially when you know that it had to have happened in the last 36 hours.

 

[Arcan57]

Don't mind me, just perusing the case discussion. Had to Google McConnell's sign...


And did they just walk out of the hospital and into your ER? Why oh why would they not go back to where they just had an operation?

His surgery was done at a hospital about 25 minutes away from us and none of the local ambulances will transport more than 10 minutes away.

 

[Rendar5]

An infection would be very, very unlikely on post-op day 1.

He probably still has a Foley anyway - I would be surprised if they pulled it so soon. It would not be a zebra the day after his bladder neck was transected, and it also seems like a bad idea without having the urologist at least say "Sure, go ahead and put one in."

I agreed that infection was unlikely which is why I didn't put it on my differential. Though the classic deep-space surgical infection would be unlikely so early, I've seen sepsis with bacteremia from urologic procedures the next day, and then it's pretty obvious and dramatic (rigors, high fevers, etc.). Something about the prostate that lends itself to significant bacteremic seedings at times.

I agree that a transected urethra wouldn't be a zebra, but hematuria leading to hemorrhagic shock would be pretty rare in my mind. You've got a good point about deferring foley to urologic discussion, which I hadn't considered.

 

[akomark]

A lot of y'all are just putting way too much stock in your bedside echo. Sure this guy is post-op and with legitimate risk for VTE, and he also has physical exam findings to support a diagnosis of right heart failure/cor pulmonale...but just b/c someone (in general) has RV enlargement/hypokinesis on a bedside echo does not mean they have a PE. I can rip off 5 other diagnoses that could cause the exact same findings on an echo, none of which would be treated with anticoagulation/fibrinolytics. I swear the next time someone tells me "I saw an enlarged RV, the pt must have a PE" I am going to scream...that's presuming they are even able to identify the RV from the LV.

And back to this particular pt...he speaks spanish, if he had any intrinsic lung disease (PHTN, COPD, RA, Scleroderma, Sarcoidosis) that could lead to the echo findings how likely are you to know this? This is a great case by the way, and by no means am I trying to take anything away from it, I just want folks to pump the breaks a little bit when trying to effectively incorporate bedside echo into their practice.

Please return to your regularly scheduled programming...

 

[dchristismi]

I'd like epi for $100, Alex.
Time for chest compressions, and what rhythm are we in?

And I'm toying with 100 of TPA as well, being a code situation... But I'm not completely sold that it's the PEs. If you'd seen a big honking saddle, I'd be sold, but I'm not completely on board yet.
How far down did your CT cut? Get a look at that retroperitoneum?

 

[glorfindel]

I'd like epi for $100, Alex.
Time for chest compressions, and what rhythm are we in?

And I'm toying with 100 of TPA as well, being a code situation... But I'm not completely sold that it's the PEs. If you'd seen a big honking saddle, I'd be sold, but I'm not completely on board yet.
How far down did your CT cut? Get a look at that retroperitoneum?

Case keeps getting better. Agree with above. US for ptx and tamponade.

While the CT results are pending, we have a guy dying in front of us from an uncertain cause. Decision-making under uncertainty. Love it.

I'm not 100% sold on the PEs as the cause of the code either, but for me the fact that we found bilateral PEs means I order the lytics stat. Thrombus is still #1 on my differential.

How odd would it be that in a guy dying of a retroperitoneal bleed, we'd find RV hypokinesis (pending the formal echo, agree w/akomark but we've got to act on what we have), jvd, bilateral PEs on CT?

It's odd, but possible. Especially in a guy with no cp or dyspnea, POD#1 from urologic procedure, and no saddle embolus. Which is why retroperitoneal bleed is #2 on differential. Good case.

 

[ORL10]

Whose cath lab is taking unstable patients without a definitive diagnosis of PE to cath? I mean at ABEM general maybe, but where I work my bedside US with a dilated RV with hypokinesis isn't selling cardiologist to take them to cath.

The only people I have had success with this is interventional radiology. They usually will take the patient to IR to complete an angiorgram where they can make a diagnosis and treat with catheter-directed thrombolysis.

Also, heparin is for the next "big one" and although SOME retrospective data suggests that empiric heparin administration may save some lives (klines paper "Estimating the pretest probability threshold to justify empiric administration of heparin prior to pulmonary vascular imaging for pulmonary embolism") suggests the margins are QUITE small. I'd be weary of giving a drug that has the potential to definitively kill someone with marginal benefits. Scan his legs with vascular probe and see if he has a big DVT.


The other questions I have is you say bilateral PE which is vague. Are these bilateral PE's in the main pulmonary arteries, or do we have scattered sub segmental PE's as a few plts stuck together by some fibrin probably didn't cause the guy to arrest. It's also a little weird he would have a PE on POD 1, although not impossible.

If this is definitely a PE, (BIG PE on CT with RV strain as seen on your repeat echo) then I would push tPA 50 mg through your IJ.

If you don't think PE is your number 1,2, and 3 diagnosis figure out what made him crash. I guess he could pass out when he sits up because he is reducing his venous return which is compromised by a PE, and some intra-abdominal insufflation during the robotic prostatectomy, these people intra-operatively can be very sensitive to positional changes and cardiac output can change dramatically. T-burg and give some fluids, (assuming this was his position while doing the IJ and then you quickly sat him up after placing the catheter?) Interesting...

 

[Rendar5]

I'd caution calling it a 100% lethal PE and jumping on the lytics until we know for sure that we didn't pop a lung or cause a vfib by irritating an already irritable mycoardium (Right Ventricular MI hasn't been ruled out yet) with the guidewire. so while yes start CPR, at least hold the lytics in your hand and listen to the lungs and glance up at the monitor. And then at least try a round of CPR before giving lytics. If you get too cowboyish with the 100mg tPA or whatever you want to use, you're just gonna kill the guy when he does have a massive retroperitoneal bleed and massive hemothorax and you sheepishly realized all you needed was electricity or finger poked into the pleural space. Not saying not to use it at all. Just hold off for a minute or two and think if there's anything else to do since this guy does have pretty strong contraindications to lysis.

 

[beakerdan]

Arcan, while we were waiting for the CT results, did we get the med list from the patient/family/EMR?

 

[Arcan57]

I'd caution calling it a 100% lethal PE and jumping on the lytics until we know for sure that we didn't pop a lung or cause a vfib by irritating an already irritable mycoardium (Right Ventricular MI hasn't been ruled out yet) with the guidewire. so while yes start CPR, at least hold the lytics in your hand and listen to the lungs and glance up at the monitor. And then at least try a round of CPR before giving lytics. If you get too cowboyish with the 100mg tPA or whatever you want to use, you're just gonna kill the guy when he does have a massive retroperitoneal bleed and massive hemothorax and you sheepishly realized all you needed was electricity or finger poked into the pleural space. Not saying not to use it at all. Just hold off for a minute or two and think if there's anything else to do since this guy does have pretty strong contraindications to lysis.

Just so everyone knows, Rendar is not a plant.

There are some bits of information that I didn't go into detail on that people want to know in order to make their decisions. Some of these data points I didn't include because I didn't want premature diagnostic fixation, some because I didn't have the information available yet, and some because I never got the info. In no particular order:

ORL10: Pt was in T-berg when he became unresponsive and lost his pulse. It was an U/S guided IJ into a honking R IJ so I felt pretty good about not having dropped the lung. I'm pretty shallow about how far I put in the wire (we have the kits where you thread the wire through the syringe and needle) and I didn't see any ectopy monitor during the procedure. I never actually got to sew in the line, but that's more of an aside than a plot point.

dchristismi: he's in PEA, he got epi and chest compressions which he liked. At this point radiologist calls me back and tells me he sees B PEs (noted on my look through the lungs) but nothing else acute (I scanned through to pelvis with run-off from the PE protocol). And after 2 rounds of epi and ~5 min of CPR he gets ROSC.

Continuing the case:

I intubated him without event. Now I'm open to discussing that he should have been tubed prior but he was oxygenating well and I thought having a very clear look into his mental status was worth the metabolic demand from his work of breathing. He was complaining of some abdominal pain on arrival and continued to complain of it until he coded so until CT took retroperitoneal hemorrhage off the table. All of this contributed to the diagnostic uncertainty and being able to communicate with him helped somewhat.

So I was ready to push lytics if they had been available during the code, but now he's got ROSC and while he doesn't have a current bleed his risk for intra-abdominal hemorrhage is huge. So he's gone done once, popped back up relatively quickly and is looking stable-ish. He's on heparin already, and his pressure is in the mid 90's on a levophed gtt. Still waiting for the OSH transfer center to answer the damn phone. I relook at the CT on our PACS and while the emboli themselves aren't huge, most of his lung is black on CT (I can't identify any subsegmental and maybe one segmental branch that are opacified).

Still waiting for the tPA to come from pharmacy (which I had ordered after the 1st round of epi hadn't worked) when he codes again. Epi, CPRx6 minutes, and up'ing his levophed result in ROSC again. Vascular surgeon from OSH calls back, accepts the patient to transfer by air, and asks whether you're going to give IV t-PA.

???

 

[pinipig523]

A lot of y'all are just putting way too much stock in your bedside echo. Sure this guy is post-op and with legitimate risk for VTE, and he also has physical exam findings to support a diagnosis of right heart failure/cor pulmonale...but just b/c someone (in general) has RV enlargement/hypokinesis on a bedside echo does not mean they have a PE. I can rip off 5 other diagnoses that could cause the exact same findings on an echo, none of which would be treated with anticoagulation/fibrinolytics. I swear the next time someone tells me "I saw an enlarged RV, the pt must have a PE" I am going to scream...that's presuming they are even able to identify the RV from the LV.

And back to this particular pt...he speaks spanish, if he had any intrinsic lung disease (PHTN, COPD, RA, Scleroderma, Sarcoidosis) that could lead to the echo findings how likely are you to know this? This is a great case by the way, and by no means am I trying to take anything away from it, I just want folks to pump the breaks a little bit when trying to effectively incorporate bedside echo into their practice.

Please return to your regularly scheduled programming...

In the setting of a crashing patient and if your pretest for a massive PE is high given the right clinical conditions, there is nothing else other than a massive PE or massive MI that would cause RV dilatation and right heart strain.

And by RV dilatation - I mean McConnel's sign of RV apical hyperkinesis in the setting of akinesis of the RV free wall.

But I understand that you have to take it into clinical context.

 

[UnderwaterDoc]

This is also what we are taught. With no PMHx suggesting pulmonary hypertension or chronic lung badness, I would trust my bedside echo every day. Besides, none of the chronic conditions are gonna cause sudden onset hypotension, tachycardia, and syncope.

 

[EM2BE]

Vitals after 2nd ROSC? (rpt ABCs before moving on)

What did the post-intubation CXR look like? Still could get PTX or right mainstem as complications of PPV and placing the tube.

Is the line placement correct (seen on post-intubation CXR)? Did it get secured after the first code?

As far as the EKG findings - repeat EKG? Trop back yet? Other labs back yet?

I think an Epi drip may help to a point, but would have to make sure HR stays controlled.

Where were the PEs? Did the radiologist say this in the conversation with you?

How do the lungs look on CT? Any evidence of lung issues (effusion, infarction) or heart issues (pericardial effusion)?

Did the vasc surgeon push for tPA? Were they indifferent? I think if there is no other cause pointing to hypotension other than the PEs it should be given when available, knowing it will not work immediately. How about heparin as well as tPA if really thinking it's the cause? Get on the phone with pharmacy and tell them you really need it and can someone come get it now? (I know this works at one location I'm at for certain drips...I call saying I need it ASAP and they will mix it while someone goes to pick it up. Another location it's a fat chance of getting anything faster.)

Another thought I had only because no list of meds mentioned was a trial of glucagon to see if it's a BB/CCB issue causing problems. Not likely with tachycardia though. I wouldn't jump to this before having more proof of BB or CCB, but would definitely reconsider if the pt becomes bradycardic. Could be a new medication for accidental OD or purposeful OD.

We can often get our secretaries to get med lists from pharmacies for us as well. This is something that could be getting worked on while concentrating on patient duties. However, many pharmacies in town aren't open 24/7, so at night, this is harder to accomplish.

Curious, what time of day is this? Not that it changes management, but at many places, it changes staffing available and transfer abilities as well (nights are sometimes harder when the tertiary center only has one doc on at night but 10 during the day...if they are in a procedure, they may ask you to keep the pt until a certain time so they have someone managing the pt while they are busy; also bed-finding abilities tend to differ day vs night since it's likely no one is being discharged in the middle of the night).

How far out is transport?

 

[Arcan57]

So to wrap up:
After the second code, there wasn't much illusion that he was going to become stable without intervention. He received 75mg IV tPA and had improvement in his hemodynamics. The patient had some spontaneous movement (biting on tube, semipurposeful arm movements) and given the extremely high risk of bleeding coupled with a suspected short time of cerebral ischemia I elected not to cool the patient. Pt flew to the OSH where I get a call from the vascular surgeon saying that the patient had been weaned off pressors and they were going to watch the patient instead of going immediately to angio. Pt was transferred neuro intact to the floor 5 days later. On POD#11 urology is consulted for hematuria, their note makes no mention of the tPA but attributes the bleeding to the heparin gtt. The foley is flushed to clear without difficulty. In their note they recommend stopping anticoagulation...

 

[45408]

On POD#11 urology is consulted for hematuria, their note makes no mention of the tPA but attributes the bleeding to the heparin gtt. The foley is flushed to clear without difficulty. In their note they recommend stopping anticoagulation...

lol, sounds about right. So no other abnormality was found except the PE? Any guesses as to what caused the immediate syncope with postural changes?

 

[turkeyjerky]

lol, sounds about right. So no other abnormality was found except the PE? Any guesses as to what caused the immediate syncope with postural changes?

uhh...the PE?

 

[45408]

uhh...the PE?

wasn't a caged ball valve to his brain...why would it be so positional and so rapid?

 

[Rendar5]

wasn't a caged ball valve to his brain...why would it be so positional and so rapid?

because PE causes hypotension.

 

[glorfindel]

Good case!

Strong work!

 

[Ibuprofen]

This was awesome... it's not fair all of the toys the ER docs get to use unlike us EMS providers...whatever fits in the ambulance.

Why did you guys not suspect sepsis at first? I caught the AAA like you guys did. That's what I thought of first before any lab results came in. Could a septic infection implode that fast from his robotic colon whatever?

 

[migm]

I think sepsis should be on the differential, but further down in the setting of recent instrumentation. Plus it's unlikely for a surgical site to be infected so quickly as someone mentioned (typically >5 days) so it'd have to be unrelated (which is still possible)