Transcript a 82 y old man

Case presentation
Samane Nabi
Emergency medicine resident
93.5.14
A 82 y old man with
The chief complaint of
WEAKNESS
coming to ED
(HAZRAT_E_RASUL
HOSPITAL)
At
22:45 Pm
92.12.22
CC: Weakness
PI:
a 82 y old man was referred to ED With the chief
complaint of generalized weakness which had been
started 5 days before the entrance to ED.
He complaint from intermittent burning retro sternal
chest pain and epigastric pain that was radiated to
the back with no relation to feeding It was
accompanying with nausea, vomiting and cold
sweating. content of vomiting was the eaten food and
without blood and bile.
He had no dyspnea. He had normal defication.no Melena.
He had no fever.
Patients with these symptom, was hospitalized for 2 days in
another hospital before entrance to ED that due to the
general deterioration, left center.
PMH:
IHD +
CCU addmition +
HTN+
DMDyspepsia or epigastric
discomfort +
DH & HH:
Patient had not history of drug
using.
Alcohol –
Smoking –
Opium –
P/E:
VS:
PR: 97
BP: 100/60
RR:17
T: 35 Axillary
O₂ sat: 90%
BS: 250
Patient was conscious, ill and pail and he
had cold sweating.
No JVD.
Lung: normal
Heart: s1 and s2 were detected with no
pathologic sounds or murmur
Abdomen: Guarding- , Distention-, Mild
Epigastric Tenderness+
Extremities: Extremity pulses were
symmetrically full.
What's your differential diagnosis?
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Differential diagnosis
1.
2.
3.
4.
5.
6.
7.
Acute coronary syndrome
Aortic dissection
Acute pancreatitis
Peptic ulcer perforation
Bowel perforation
GIB
Electrolyte disorder
ECG:
Patients with clinical suspicion of
acute coronary syndrome, was
treated.
com + pom
Plavix
ASA
Enoxaparin
Iv nitro
Captopril
Metoral
O2 with mask
Serial ECG
Internist consultation
laboratory data:
WBC: 13400
Neut: 90%
HB: 16.2
HCT: 44
PLT: 262000
VBG:
PH: 7.43
HCO3: 19.5
PCO2: 30.1
BE: -10
After 1 hour, the patient's clinical condition
worsened.
he opened the eyes with voice
his blood pressure was non measurable.
Only carotid pulse was palpable.
The patient was
transferred to the
resuscitation
room
Central vein line was inserted
CVP:2
Foley catheter was inserted
Urine out put: 0
RUSH EXAM:
IVC WAS Collapsed
No hypokinesia in heart, no tamponed no
plural effusion
In inter loop and Morison patch there was
non homogenous fluid
In patient with septic shock
Vancomycin and meropenem was
administered.
After received of 2 liters normal
slain CVP was 6 and urine out put
was 200 cc
BP: 100/60
PR: 90
Surgery consultation was done.
CXR was taken.
Bs: 119
Na: 138
K: 3.5
BUN: 63
Cr: 3.5
CTNT : Negative
PT: 14
PTT: 35
INR: 1
Surgery consultation:
Spiral CT scan of abdomen & pelvic
with IV and oral contrast
Patient in 7 am transferred to operation
room with Peritonitis diagnosis due to
hallo viscus perforation
Operation report:
D1 perforation with Purulent discharge
Distal gastrectomy with wound closing
and gasterogegenostomy
After this surgery he transferred
to SICU and because of
anastomose leak and bowel
evisceration Twice again
operated.
Patient any time win and after 30
days hospitalization and five
times CPR expired.
shock
in ED, shock is rarely listed as a primary
diagnosis.
Arterial hypotension, defined as a systolic blood
pressure (BP) below 100 mm Hg, is measured at
least one time in 19% of ED patients; however,
diagnosed traumatic, cardiogenic, or septic shock
is less common, constituting about 1 to 3% of all
ED visits.
Patients in the ED are in shock with no obvious
cause.
Rapid recognition of shock requires immediate
history and physical examination
In general, patients with shock are ill, asthenic, pale,
often sweating, and usually tachypneic or grunting,
and often have a weak and rapid pulse.
HR can be normal or low in shock.
BP initially can be normal because of adrenergic
reflexes.
a single systolic BP less than 100 mm Hg in the ED is
associated with a threefold increase in in-hospital
mortality and a tenfold increase in sudden death.
Shock can be strongly supported by the presence of
a worsening base deficit or lactic acidosis.
The HR/systolic BP ratio may provide a better
marker of shock than either measurement
alone, a normal ratio is less than 0.8.
Urine output provides an excellent indicator
of organ perfusion.
normal out put: >1.0 mL/ kg/hr , reduced: 0.51.0 mL/kg/hr, severely reduced: <0.5 mL/
kg/hr
A lactate concentration greater than 4.0 mM
or a base deficit more negative than −4
mEq/L predicts the presence of circulatory
insufficiency.
Empirical Criteria for Diagnosis of
Circulatory Shock
MANAGEMENT:
• Monitoring Perfusion Status
all patients with shock, HR, BP, and oxyhemoglobin saturation are
continuously monitored
• Quantitative Resuscitation
pulmonary artery catheter
Lactate clearance
Mixed venous oxygen saturation (SvO2)
• Ventilation
Rapid sequence intubation is the preferred method of airway
control in most patients with refractory shock.
• Volume Replacement
The goal in volume replacement is slightly elevated left ventricular
end-diastolic volume, which is a difficult measurement to make in
the ED. The CVP is most often used to estimate right ventricular
filling pressure and is used in some quantitative resuscitation.
Definitions and Criteria for Septic, Hemorrhagic,
and Cardiogenic Shock
Septic shock:
Treatment begins by establishing adequate ventilation
to correct hypoxia and acidosis and to reduce systemic
oxygen consumption and left ventricular work. This often
requires endotracheal intubation and sedation for
mechanical ventilation.
Etomidate !!!!
The second goal is to achieve adequate ventricular
filling. Initial volume replacement should include rapid
infusion of 20 to 25 mL of crystalloid per kilogram. If hypo
perfusion is persistent, 5- to 10-mL/kg boluses of a natural
colloid (such as albumin) should be considered. Blood
should be transfused in the ED to restore hematocrit to
30%.
The third directive is to eradicate the infection with
antimicrobial therapy and, where necessary, surgical
drainage.
Septic shock refractory to volume restoration (urine
output or BP remains low, lactate increases) requires
vasopressor support. norepinephrine (0.5-30
μg/min)
The use of corticosteroids in the treatment of
sepsis and septic shock has been investigated with
mixed results. Most current guidelines recommend that
low-dose hydrocortisone be administered only to
patients receiving chronic steroid
replacement and in patients with refractory
shock despite adequate fluid and
vasopressor support