Clinical Vignette thread

He's speaking half words. You can hear him wheezing and cracking from end of bed. Trachea central.

Chest has widespread expiratory wheeze.

Oxygen on, cannulas in. 250mLs goes in, no change.

Bloods sent. Results to follow shortly.

GCS 15, BM is 7.8

Nothing on exposure.

ECG is sinus tachy.
CXR: Left mid and lower zone consolidation.

(On the 4L he was on with paramedics)
pH: 7.27
pCO2: 7.4
pO2: 8.2
Bicarb: 38
Lactate: 2.6

Following on from the previous management:

0. Sit patient upright if possible.
1. Nebuliser - salbutamol and atrovent all in one driven by oxygen.
2. If no recent hospital admissions or known resistance pattern, and no known penicillin allergy, IV cephuroxime 1.5g STAT
3. 250ml bolus is pathetic unless there's evident decompensated CCF or known severe LVF in PMH or GP record. Get a litre running in and re-assess after the first 500ml is pushed in with a pressure infuser.
4. 200mg Hydrocortisone IV STAT
5. Re-assess within 10mins of all of above; if pt deteriorates or ABP not responding then call for ITU support immediately.

Reply 201

Etomidate

15

Original post by Friar Chris

Following on from the previous management:

0. Sit patient upright if possible.
1. Nebuliser - salbutamol and atrovent all in one driven by oxygen.
2. If no recent hospital admissions or known resistance pattern, and no known penicillin allergy, IV cephuroxime 1.5g STAT
3. 250ml bolus is pathetic unless there's evident decompensated CCF or known severe LVF in PMH or GP record. Get a litre running in and re-assess after the first 500ml is pushed in with a pressure infuser.
4. 200mg Hydrocortisone IV STAT
5. Re-assess within 10mins of all of above; if pt deteriorates or ABP not responding then call for ITU support immediately.

So you've got a neb running, IV abx as per local policy, a decent fluid bolus going in and some steroids.

10 minutes later, he's much the same. Obs haven't particularly changed: systolic about 80, HR 150. About 500mLs fluid has gone in so far. You call ITU and they ask you if he is appropriate for ITU admission and what it is you're wanting them to do for the patient?

In the mean time they suggest back to back nebs and repeat the gas after 8 to 10 doses.

What is this guy's main problem(s)?

Bloods are back:
Raised WCC, CRP. Has a moderate AKI with normal electrolytes.

(edited 7 years ago)

Reply 202

Kaylain

6

Original post by Etomidate

So you've got a neb running, IV abx as per local policy, a decent fluid bolus going in and some steroids.

10 minutes later, he's much the same. Obs haven't particularly changed: systolic about 80, HR 150. About 500mLs fluid has gone in so far. You call ITU and they ask you if he is appropriate for ITU admission and what it is you're wanting them to do for the patient?

In the mean time they suggest back to back nebs and repeat the gas after 8 to 10 doses.

What is this guy's main problem(s)?

Bloods are back:
Raised WCC, CRP. Has a moderate AKI with normal electrolytes.

Spoiler

Reply 203

Friar Chris

19

Original post by Etomidate

So you've got a neb running, IV abx as per local policy, a decent fluid bolus going in and some steroids.

10 minutes later, he's much the same. Obs haven't particularly changed: systolic about 80, HR 150. About 500mLs fluid has gone in so far. You call ITU and they ask you if he is appropriate for ITU admission and what it is you're wanting them to do for the patient?

In the mean time they suggest back to back nebs and repeat the gas after 8 to 10 doses.

What is this guy's main problem(s)?

Bloods are back:
Raised WCC, CRP. Has a moderate AKI with normal electrolytes.

Was rather assuming he'd have had multiple nebs and a good whack of fluid before calling ITU but I suppose I did walk in halfway through here.

Identified problems:

1. Shock likely combination of distributive and hypovolaemic, likely secondary to:
2. Severe septicaemia currently likely due to severe CAP
3. Acute airway obstruction given widespread nature likely secondary to exacerbation of primary pulmonary disease but consider also anaphylaxis. Either way causing:
4. Type II Respiratory failure with retention of CO2 causing a respiratory acidosis with evident metabolic compensation here, suggesting that he retains chronically to some degree and/or that he has had a gradually worsening acute disease process over previous hours or days before this point
5. Likely also nearing exhaustion and total respiratory compromise due to 3. and 4.

Differential diagnoses:

1. Severe CAP with exacerbation of COPD.
2. Pulmonary embolism with necrosing infection of infarcted parenchyma
3. CXR misinterpretation with ARDS due to other primary inflammatory cause
4. Malignancy with surrounding infection (+/- no. 2 with this)
5. Anaphylaxis, doesn't match original vignette though consider delayed onset.
6. Undetected trauma with intrathoracic (or elsewhere, though noted nil on exposure) haemorrhage misinterpreted on CXR
7. CCF and unusually severe and atypically presenting cardiac asthma
8. Upper airway obstruction though we have clarified regarding stridor and auscultation and this appears unlikely.

Management plan:

0. Regular reassessment of all obs and fluid status and repeat ABG after high-flow oxygen and nebulisers especially.

1. Assuming the pt has now had much more voluminous fluid resuscitation and numerous repeated nebulisers by the time I had called ITU... Subtly suggest the ICU reg stops being a primadonna and request assessment for possible inotropic support, and preparation in case intubation and ventilation is required in what is a haemodynamically unstable man with severe sepsis and nearing fatal airway obstruction from the description given.

2. 2g/8mmol of MgSO₄to be started now over 20min. In reality probably ask someone to keep some doxapram handy, in a vignette being the reg or consultant might be more bold about using if pt becomes CO₂ narcosed.

3. If amenable and improved sufficiently would consider BIPAP given the TIIRF but currently with the degree of obstruction described the pressures required would make it uncomfortable, ineffectual and higher risk.

4. Bedside ultrasound wouldn't be unreasonable to check for any missed bleeding and have a glance at the heart.

5. I can't comment on his oxygen as we don't have up-to-date SaO2 or ABG on the latest post. If he's saturating reasonably you could consider very carefully titrating oxygen down and running nebs with air given the hypercapnia but narcosis doesn't appear to be the current problem from most recent description.

Original post by Kaylain

Spoiler

Lactate is already given and is always on ABGs, 2.6. High but not on unholy levels.

I suppose in my mind I assume the nurses or ANPs have already started the fluid monitoring and cultures but fair point. Try to think beyond just 'sepsis 6' though; guidelines buy the patient time to get proper assessment but as it's a vignette you get to pretend to be the SpR and actually work it out - just doing sepsis 6 is a fruitless exercise as it's written on a sheet! :yes:

Anyone who needs to be on inotropic support should really at least be on HDU if not ITU. Each unit will faff around with its own criteria but at the end of the day someone who is bordering on respiratory and/or circulatory failure and for full escalation will meet those criteria unless it is immediately reversible and reversed.

Correct, moderate AKI wouldn't generally mean you need to urgently dialyse someone; generally you don't unless they were in gross renal failure. Unless grossly uraemic and overloaded, then fluids and supportive therapy to re-perfuse the kidney need to be done first and ongoing assessment of recovery or decline of kidney function performed. If the patient was in gross renal failure you might haemofilter or even dialyse them initially, or if they continued to deteriorate on ITU.

Good thought about culturing sputum but good luck getting guy who can barely breathe to cough up a sample. He'll be treated with broad-spectrums until stable anyway and for the acute septicaemia the blood cultures will be more important.

(edited 7 years ago)

Reply 204

nexttime

22

Original post by Kaylain

Start sepsis 6, ideally would have obtained blood culture before the antibiotics, culture the sputum as well.

:thumbsup:

In our AMU so many supposedly sick septic patients would arrive without blood cultures. Shouldn't delay antibiotics of course but definitely ensure its done ASAP, ideally with the cannula.

Does the ABG come with a lactate? If not probably should have done that with the initial bloods

It does. In fact, a blood gas is realistically the only way to get a lactate. Lactate degrades quickly (in the order of 5 minutes) so to get a formal lab measurement you generally have to find some ice water and a container, and transport it to the lab in that immediately (i.e. likely yourself). I find that generally the best thing to do if a consultant asks for a formal lab lactate is to stare at them darkly until they agree that actually that's a silly idea.

Your 'initial bloods' should pretty much always include a VBG though - gives you rapid ideas of Hb, electrolytes, and will tell you pH and lactate. So hopefully you'd have a lactate already.

(edited 7 years ago)

Reply 205

Etomidate

15

Some good points so far.

So after nearly 2 litres of fluids and a load of nebs, he seems a little brighter. He's starting to speak in 2-3 words now.

A repeat ABG is done after 2 litres:

pH: 7.11
pCO2: 6.9
pO2: 9.4
Bicarb: 36
Lactate: 3.4

So as identified, the main issues here are severe pneumonia and what's starting to look like septic shock. The ABG shows underlying chronic respiratory disease but a superimposed metabolic acidosis secondary to the sepsis.

A catheter is placed so that urine output can be measured hourly.

Ionotropes seem like a reasonable suggestion now, particularly if his hypotension persists. Fortunately after 2L it's now hovering around 110 systolic. His tachycardia persists at 140 likely a consequence of the salbutamol as well as the hypovolaemia.

RE: dialysis - this is a decent thought, especially with the results of the second gas. This would be not so much for the AKI but for the acidosis. As it's trending dangerously downwards, he's at risk of arresting if this doesn't start to turn around with fluid resuscitation.

RE: Mg in COPD - the evidence shows that it increases PEF, but no difference in symptoms, admission, mortality, hospital stay etc. It's good in young patients with asthma, but not much else particularly.

So this guy (a true case), having had resolution of his hypotension, went to the respiratory ward. He didn't require NIV but started to get a little overloaded, so fluid IVI was slowed. His urine output slowly picked up and his AKI and acidosis subsequently resolved. His BP trended upwards, heart rate trended downwards. He continued to be quite chesty for a while but improved enough to go home.

(edited 7 years ago)

Reply 206

Friar Chris

19

Original post by Etomidate

RE: Mg in COPD - the evidence shows that it increases PEF, but no difference in symptoms, admission, mortality, hospital stay etc. It's good in young patients with asthma, but not much else particularly.

I do recall, but it falls in my mind into that grey zone of 'nothing ventured nothing gained' when someone with COPD is that unwell and more definitive management is awaited, especially before I consider getting out or asking my boss to consider respiratory stimulants or urgent ventilation.

Also I'm one of those fetishists who just loves magnesium :sogood:

Good case

Reply 207

Friar Chris

19

Here's an anecdotal vignette.

Difficulty: MBChB 5/FY1 (I'm guesstimating :ahee:

it's probably easier)
Setting: General Practice, Suburban, moderately affluent area

A 25 year old white gentleman presents with a six-day history: he initially had three days of worsening URTI-like symptoms with a blocked nose, cough and headaches and thought little of it. Unfortunately, for the last three he has felt much more unwell with mild fevers, during which he feels cold but describes no rigors, and has slowly developed a cough that gets worse each day, and for the last 24 hours has started to bring up thick sputum and his upper chest is hurting as well as his throat when he coughs. He helpfully shows you a captured sample; it is a purulent, opaque dull green. He has also noticed his headache has been getting worse and is somewhat concerned as he has found himself mildly breathless when eating and walking around.

He has no PMH except epilepsy as a child - he is on no medications and has not had a seizure since he was 17 years old. He works in a hospital A&E department and has not travelled abroad in the last year.

Reply 208

Brachioradialis

18

Original post by Friar Chris

Here's an anecdotal vignette.

Difficulty: MBChB 5/FY1 (I'm guesstimating :ahee:

it's probably easier)
Setting: General Practice, Suburban, moderately affluent area

A 25 year old white gentleman presents with a six-day history: he initially had three days of worsening URTI-like symptoms with a blocked nose, cough and headaches and thought little of it. Unfortunately, for the last three he has felt much more unwell with mild fevers, during which he feels cold but describes no rigors, and has slowly developed a cough that gets worse each day, and for the last 24 hours has started to bring up thick sputum and his upper chest is hurting as well as his throat when he coughs. He helpfully shows you a captured sample; it is a purulent, opaque dull green. He has also noticed his headache has been getting worse and is somewhat concerned as he has found himself mildly breathless when eating and walking around.

He has no PMH except epilepsy as a child - he is on no medications and has not had a seizure since he was 17 years old. He works in a hospital A&E department and has not travelled abroad in the last year.

Hx
1. SOCRATES for the headache and chest pain. Same if positive Hx for facial pain (sinuses) or ear pain?
2. Has he noticed any blood at all in the sputum?
3. On any medications? Any allergies?
4. Has he been around anyone with similar symptoms over the past couple of weeks (e.g. in hospital at work?)
5. Smoking history
6. ICE -- you never know...

Ex
1. Obs (pulse, BP, temperature, RR)
2. General appearance and exam -- does he look well? Lymphadenopathy over cervical chains, jaw or pre/post-auricular?
3. What can I see at the back of the throat and in the ears?
4. Anything from inspection/palpation/percussion of the chest on front or back?
5. On auscultation: any wheeze, crackles or other findings over the apices or upper/middle/lower lobes?

(edited 6 years ago)

Reply 209

Ghotay

13

Original post by Friar Chris

Here's an anecdotal vignette.

Difficulty: MBChB 5/FY1 (I'm guesstimating :ahee:

it's probably easier)
Setting: General Practice, Suburban, moderately affluent area

A 25 year old white gentleman presents with a six-day history: he initially had three days of worsening URTI-like symptoms with a blocked nose, cough and headaches and thought little of it. Unfortunately, for the last three he has felt much more unwell with mild fevers, during which he feels cold but describes no rigors, and has slowly developed a cough that gets worse each day, and for the last 24 hours has started to bring up thick sputum and his upper chest is hurting as well as his throat when he coughs. He helpfully shows you a captured sample; it is a purulent, opaque dull green. He has also noticed his headache has been getting worse and is somewhat concerned as he has found himself mildly breathless when eating and walking around.

He has no PMH except epilepsy as a child - he is on no medications and has not had a seizure since he was 17 years old. He works in a hospital A&E department and has not travelled abroad in the last year.

I'm in GP? Obs + resp exam. Send sputum. A week of amox + safetynet to return if worsening/not improving

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Reply 210

Friar Chris

19

Original post by Brachioradialis

Hx
1. SOCRATES for the headache and chest pain. Same if positive Hx for facial pain (sinuses) or ear pain?
2. Has he noticed any blood at all in the sputum?
3. On any medications? Any allergies?
4. Has he been around anyone with similar symptoms over the past couple of weeks (e.g. in hospital at work?)
5. Smoking history
6. ICE -- you never know...

1.

It's a global headache, no particular predilection for any given time of day, usually lasts 10-90 mins, moderately severe but relieved well by paracetamol and ibuprofen, and with no particular exacerbating factors.

2.

No

3.

NKDA. As stated, no regular medications. Has taken paracetamol and ibuprofen for symptom relief at the licensed doses.

4.

He sees up to a dozen people a day with coughs and chest infections alone. He can't recall any recent contact with patients with TB but otherwise can't remember the specifics given how many he's seen in the last two weeks. He has a BCG scar on his left upper arm.

5.

Never smoked.

6.

He laughs heartily and asks you to carry on.

Original post by Brachioradialis

Ex
1. Obs (pulse, BP, temperature, RR)
2. General appearance and exam -- does he look well? Lymphadenopathy over cervical chains, jaw or pre/post-auricular?
3. What can I see at the back of the throat and in the ears?
4. Anything from inspection/palpation/percussion of the chest on front or back?
5. On auscultation: any wheeze, crackles or other findings over the apices or upper/middle/lower lobes?

1.

HR 122bpm regular, ABP 120/76, RR 22rpm, SaO2 99%, Temperature 38°c.

2.

Looks rather under the weather but not acutely compromised. Warm peripheries and a strong radial pulse despite the noted tachycardia. pCRT 2s, cCRT 1s. There is a single tender left submandibular lymph node but this feels to be in isolation. It is mobile, firm not hard, and not of very concerning size.

3.

Bilateral otoscopy reveals no abnormalities. The pharynx is, perhaps, mildly erythematous but with no oedema nor exudate. Dental hygiene is good.

4.

The gross anatomy of the thorax is normal. Percussion is resonant and equal to each hemithorax. There are no evident rashes, wounds or bruises and the thorax is non-tender. The patient is a little uncertain why you are pressing so thoroughly around his chest in the absence of any chest pain in the history but thinks you're a nice doctor so lets you anyway :wink: