emDOCs Podcast – Episode 85: Tricky Cases Part 1

Case 1:

• 42-year-old male, GCS 3, HR 190, BP is 90/48 mm Hg, T 105F. Found in garage, hot, question of illicit drug use. 
• IV fluids started, concern for SVT. Cardioverted, followed by sinus tachycardia, remains GCS 3.
• Intubated with etomidate and rocuronium, propofol started for sedation. Broad-spectrum antibiotics administered.
• Temp 106F on repeat evaluation. Cooling blanket placed, but temperature increases to 107F.
• Immersion cooling completed with ice between body bags. Temperature starts to decrease. Removed from cooling at 102 and admitted to ICU.
• Must consider differential in complex cases.

Learning points:

• Consider differential – sepsis, thyroid storm, thalamic stroke, exertional and classic heat stroke, serotonin syndrome, neuroleptic malignant syndrome, sympathomimetic toxicity, and anticholinergics.
• Complete primary and secondary survey.
• Start cooling as quickly as you can, and stop at 102.
• Resuscitate and administer antibiotics.

Reference:

• EM@3AM – Heat Stroke

Case 2:

• 40-year-0ld female feels unwell but no other specific complaints. ROS unremarkable. On exam, she was febrile, tachycardic, hypotensive and tachypneic, but her oropharynx was unremarkable, lungs were clear, abdomen was soft, no meningismus/nuchal rigidity, no rash, no vaginal discharge.
• Labs demonstrate critical illness. Leukocytosis in the 20sK with 10% bandemia, acute renal failure with electrolyte derangements, elevated LFTs, lactate 8. Clear CXR and normal UA.
• IV fluids administrated, IV vancomycin and piperacillin-tazobactam. Continues to decompensated, so vasopressors started.
• Differential Diagnosis for patient: Infectious endocarditis, CNS infection or abscess, necrotizing soft tissue infection, toxic shock, obstructive pyelonephritis, toxic ingestion, TTP, anaphylaxis with primarily hemodynamic effects, thromembolic phenomenon.
• Shock types: distributive, cardiogenic, obstructive, metabolic, hypovolemic, adrenal.
• Considerations when patients continue to decompensate despite resuscitation and vasopressors: acidosis, endocrine issues like adrenal insufficiency or hypothyroidism, hypocalcemia, anaphylaxis, hemorrhage, multiple causes of shock, ingestion.
• Approach: Focused history and examination, think through differential, consider US (RUSH, etc.).
• Central line placed to continue vasopressors. CT shows occlusive right ureteral stone, pyelonephritis. Arterial line started. Patient intubated, IR performs percutaneous nephrostomy.

Stay tuned for Part 2!