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Clinical Case 103: Midnight MacGyver Medicine

This is an exercise in medical minimalism.  I am going to throw you a case and a set of resources – you need to say how you would manage it.  I am going to release my strategy in a few days.  So here we go – here is the case…

Firstly, a little bit of background you get from the old file:

Monica is a 49 yo woman who has had a long history of renal trouble.

She was diagnosed with type 2 DM at age 21, with early nephropathy.

By age 40 she was on CAPD, and by 43 was dependent on haemodialysis.

She got lucky and was the recipient of a cadaveric transplant at age 45…..  but, that kidney isn’t doing so well. She has had multiple episodes of threatened rejection and ongoing renal impairment.

In the last year her new kidney started to pack it in and she has had yet another AV fistula formed… in anticipation of ongoing HD.

So here we are – most recently her creatinine was 500, with normal K+ and bicarb of 18.  She has advanced renal osteodystrophy, hypertension, anaemia [on darbopoeitin],  also has chronic asthma / COPD.  Oh, and her BMI is 40, with really tough IV access due to previous fistulae surgery…  good luck.

On the bright side – she has no documented ischemic / valvular heart disease.

Meds: prednisolone 5 mg, ramipril 10 mg, amlodipine 5 mg,  tacrolimus 1 mg, salmeterol inhaler, CaCO3, cinacalcet 30mg and aspirin 150 mg.

It is 5 minutes to midnight on your night shift at “Janus General” hospital in a remote location.  You are on your own.

Here is the scenario:

The Ambos roll in the door with Monica on the stretcher – she is looking pretty crook.  She called ‘000’  as she was getting increasingly ‘short-winded’ and her puffers were not helping.

The ambulance crew have her on 8 L/min via a nebuliser mask with salbutamol nebs over the last 20 minutes.

Obs are:  Resp rate 36/min, pulse 110/min, SpO2 = 94%, BP is 180/110, she is afebrile and coughing with green sputum.  She is alert and oriented.  Her new fistula is buzzing nicely

A quick auscultation of her chest reveals diffuse, bilateral, coarse crackles.  A few scattered wheezes but reasonable air entry.  She is working pretty hard – tripoding.

In between gasps she indicates some (R) sided chest pain  – it appears to be pleuritic.

Her legs are both really oedematous – with pitting oedema up to her kneess… maybe a little more on the right.

The monitor shows sinus tachycardia and an ECG the same  – with maybe some slight depression of the ST segments laterally.

The differential diagnosis is looking pretty broad at the moment!  Take a moment to contemplate the possibilities….

Here is what you have:

  • A well stocked, small, rural ED
  • Oxylog ventilator – capable of NIV
  • a POC blood gas analyser (basic biochem and gas panel + lactate)
  • a bedside ultrasound machine [ of course ;-)  ]
  • two really great nurses
  • a telephone to phone a friend / specialist  – but none will be able to attend.

Here is what you do not have:

  • Any formal radiology
  • Any laboratory tests other than the POC machine
  • Any immediate, physical backup
  • Any way of transferring Monica anywhere in the next 12 hours. [ though the sun will rise in 6- usually makes things seem better!]

So – here is the challenge:

  1. Get IV access somehow!
  2. Initiate empirical therapy – what would you use up front
  3. make some sort of diagnosis (es)
  4. Make a plan for the next 12 hours (the lab and Xray department will be available then…)

Welcome to Broome.    Go!

Casey

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Comments

  1. I would start with lung/cardiac/DVT US.

    Assess for fluid overload with diffuse B lines,if localized/consolidation and less B lines in other fields, consider infection/aspiration given green sputum.

    Immunocompromised, so need to consider weird and wonderful bugs in addition to usual CAP/HAP.

    Cardiac Us to r/o uremic pericarditis/effusion, and if skilled to do so, RV failure in context of possible PE or obvious wall motion abnormality.

    DVT compression us of both legs.

    IV access possibilities are the non-fistula side, or subclavian line. I’d stay away from IJ because they may need it for tunneled vasc cath later. The other option is to do an axillary vein catheter, no risk of PTX.

    I think some CPAP/BIPAP might help if it’s not pneumonia or pericardial effusion. Start off with an ABG on 100% FiO2 and reassess after 30mins on NIPPV to assess for improvement or deterioration.

    • Nice, very nice Dr Zhou. I like the way you think!
      Any other potential downside to the CPAP / BiPAP in this pt? What if she has popped a lung already? IS there any downside to NIV if the diagnosis turns out to be pneumonia?
      Casey

  2. I am country nurse-Poss-bronchitis-peumonia-PE-CHF-DVT-Never with hold O2, mini-neb, CXR, maybe lasix, ECHO- anticaogulant, culture everything, Iv abt-Zpac is great antinflammatory, Monitor BS and all labs and reeval.

    • Yep -- it is a very broad differential diagnosis list.
      Sorry no CXR or labs available… such is life in the bush.
      Will further nebs of B2A be a problem if she is in APO ?
      C

  3. Jimmy D says:

    Ok, she needs an immediate dose of IM hydrocortisone 100 mg, and likely some subcut. epinephrine, 300 mcg. I realize you are worried about acute myocardial ischemia with your comment on the ST segments—take the most life threatening problems first, and eliminate them step by step.

    Portable chest X ray and a blood gas--then make some more decisions. IV access to be determined. Does look like heart failure superimposed on something else. Don’t intervene with BiPAP until you resolve the acute bronchospasm--it may not help, and the patient will not agree (and will not cooperate). Antibiotics can be given IM as well (speaking as someone who received a gram of Ceftriaxone IM after a needle stick exposure in the mid 90’s).

  4. Great case. I agree with everything Taylor has started with. No radiology needed for most of this. Ultrasound will get you pericardial effusion, pulmonary edema and PTX. The DVT study gets you to PE most of the time.

    I don’t have a problem with non-invasive regardless and we should be able to rule out PTX pretty quickly (might actually be able to rule it out before NIV set up).

    For access, I’d start with an IO, either humeral (contralateral to the fistula) or proximal tibia. Especially if you’re on your own since this goes in in 5 seconds. Once resuscitated, I can do a central line, nice, clean and slow.

    I’d cover with broad spectrum antibiotics and I’d consider double pseudomonas coverage. I’d be almost as liberal with heparin (unfractionated or low molecular weight) because even if there isn’t a PE, you’ll likely need DVT/PE prophylaxis. I probably wouldn’t use lytics even if I saw a PE without some back up (i.e. NSGY) or a plan with a receiving hospital.

  5. Ron Cassano says:

    First of all that certainly is not Broome!
    Broome has a skilled 2nd on call with airway experience , BiPap, XR and path on call 24 hrs!!
    So either you want the scenario , truly remote, with NO on call, NO bedside US, NO radiology or lab…..or you want it in Broome (complete with HDU)!!!

    So, where I’m working in SW Qld, really remote, only dr.,as above: I would
    1/ I would get IV access somehow, resorting to ext jug (which will be raised) or femoral if necessary.
    2/ continue O2 and do a VBG, Hb, WCC, Tni all POCS, and start empiric treatment, as follows
    Based on possible diagnoses
    A/ CCF, likely from overload, but possibly from an event ie MI, PE, infection
    B/ asthma, or acute on COPD
    C/ resp infection or other sepsis
    Or all 3!
    Treat w IV GTN, titrated to BP, v high dose frusemide, likely 250mg, repeated twice as needed, iV ceftriaxone 1G, iv heparin stat and infusion, dose dependant on renal team advice. Iv hydrocortisone 200mg.
    Then review some results and progress and discuss with the evac team and receiving hospital ; if CO2 retaining or SOB/RR not improving consider Cpap NIV until stable or better CO2; if Tni v high (and much higher than her normal mod high level Tni) consider add in oral Clopidogrel; if wheezy give Neb Salbutamol/Atrovent as needed.
    Obviously needs urgent t/fer as likely will need urg haemodyalisis ; if improves wait for evac; if not needs intubation prior to evac. If becomes febrile or v high( or v low) WCC consider 2nd line AB, 1 dose of Vanc and/or Gent may be appropriate, after renal transplant team advice.
    Obviously would have collected basic bloods including blood and sputum cultures for the evac team
    In Broome would have used US for Iv access, possibly check lungs and heart with it too, call 2nd on call and XR in for sure !!
    Cheers

    Ron

    • Thanks Ron
      As always -- cases take place in a small hospital near Broome -- Janus General (St Elsewhere’s)
      It is a GedankenExperiment -- a thought exercise in how to do this when you have limited resources.

      Troponin is -- as you say, pretty useless in this context -- maybe if you had a doubling it would be helpful? Expert opinion required on that…
      Agree -- multiple pathologies is probably the most likely scenario with 1 leading to 2 and exacerbating 3…. tricky. Not a linear process at all!
      C

  6. M. Watford says:

    If she can talk Id ask a bit more on urine output over the past few days or weeks and any changes, or last dialysis session. While the DDx list is large and given whole scenario this sounds like a volume overload case with possible pneumonia.
    For access options id exhaust the following options before access the fistula: 1. the neck (EJ) using standard PIV catheter Largest bore I could fit. 2. IO access (tibial), 3. Use US to see if there is anything deeper in the arm provided I had catheters of adequate length. 4. The fistula.
    Labs: ABG with lytes, chem panel, cardiac enzymes, thoracic US.
    Meds: Lasix 80mg IV, captopril, mag sulfate 1gm, solumedrol 125mg, ceftriaxone 1gm and other broad spectrum coverage. transdermal nitropatch to the chest and go from there..(20mg hydralazine… nitro drip… goal to open up vasculature and get fluid outta the lungs)
    Interventions: Foley catheter, CPAP with PRN Albuterol/ipratropium nebs, continuous monitoring SP02, 4 lead ECG, BP q10m.

    Gal is gonna need hemodialysis which is the only reason I would only access that fistula as a last resort (haven’t seen too many unsuccessful IO’s so probably wouldn’t access it).

    Next 12hrs (lab and rad): CBC, CMP, BNP, D-Dimer, chest film, US of BLE,
    TSH, hemodialysis if available.
    Probably more but as a new ED NURSE this is my best go.

  7. I actually think this lady is not too dire at this point. In my neck of the woods she is
    a fairly typical 4am patient. Aggressive immediate treatment for ccf + infection +/- copd with and endpoint of getting her somehwere that can dialyse her would be my initial game plan. Broad differentials but up top would be fluid overload & chest infection with contributing COPD. Cardiac ischaemia less so with ECG not really diagnostic. VTE, pericardial effusion down the track given hypertension.

    Access would be OK with US available -- as others have said I/O, ext jug, deep upper arm vein with US, quick & dirty fem CVC that I could change to an IJ clean & slow if she settles ; sub clavian last resort as a new pneumo could be a disaster -- pefer R over L as has R pleuritic pain already (?already has ptx)

    Bang on some hi flow oxygen, cardiac monitor & run off a graph. One nurse sets up NIV, the other gives sub lingual / patch gtn while I get access & do eFAST. Get some ‘roids and broad-spectrum antis in. Small fluid bolus to support intravascular volume, art line because I can and she’ll need frequent ABG’s probably. Slide in a catheter and then a central line to put the icing on the retriever’s cake. On the phone to nearest hospital that can dialyse her.

    More formally:
    A- seems OK for the moment
    B- I’d start CPAP from the get go based on WOB ; I’d be confident to exclude pneumothorax with ultrasound ; if I saw one I’d got for the chest tube & leave NIV in situ until her WOB settled ; salbutamol & atrovent nebs or MDI with cpap continuing
    C -- GTN sub ling & patches until I got access, then infusion looking for an SBP around 150; exclude pericardial effusion with ultrasound, stress-dose steroids
    D -- alert currently
    E -- I’d not be super excited by the unequal oedema initially; DVT/PE is a little way down my list based on sats, BP
    F -- lasix, big dose -- say 80 + 80 + 20 based on response to other therapies ; probably a small bolus 250mls to prop up intravasc volume
    G -- belly sounds OK ; fast may help
    I -- ECG is non-diagnostic, I’d treat for pneumonia without a cxr and worry about that in the morning, US will help with pneumothorax, significant pericardial effusion, large PE

    Next 12h:
    ABG result will be very useful. Her K+ may be up requiring frequent rounds of calcium/insulin/dextrose until dialysis ; if she pees then ongoing lasix maybe infusion ; I’d continue NIV unless she completely settles ; more ‘roids, antis, bronchodilators, judicious iv fluids , magnesium up my sleeve if very wheezy/ hypercarbic ; would be unsurprised if she ends up intubated or on norad + adrenaline ; lysis if develops STE or marked hypoxia/hypotension with RV strain or eventual clear cxr ; might consider blood if really anaemic (Hb <70) and ECG changes persist or not improving -- but would need to be given slowly and would be very hesitant if anuric and dialysis many hours away

    Can't think of anything else! My big concerns would be eventual cardiogenic shock, recalcitrant hyperkalaemia or development of overwhelming sepsis in a lady with a shit heart and shit kidneys in the middle of nowhere…

  8. 3 top differential diagnosis :
    Pneumonia /Sepsis
    Fluid overload
    PE

    Approach :
    Resus:
    Airway and breathing -- oxygen and Bipap to help with breathing -- ( considering intubation at the back of the mind. Also clinically rule out immediate emergency like pneumothorax. maintain 02 >92%
    Circulation -- use ultrasound to cannulate.if fail than to do IO insertion.Do istat electrolyte to rule out electrolyte imbalance.VBG or ABG and lactate level

    Specific management :
    Sepsis -- immediate broad spectrum IV ab
    Fluid overload -- GTN and observe the response /intermittant dose of IV Frusemide can be given
    PE -- renal dose of clexane /Bedside ultrasoumd to look at RV size and also Pericardial effusion and global contractility of the heart
    Pain -- titrated dose of morphine or fentanyl for pain

    Monitor and see the response to treatment. Keep looking for things that can be corrected and get ready to transfer this patient first thing in the mane.

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