You are called to the ward by a nurse because a patient is hypotensive. The patient is a 76 year old man admitted 3 days ago by your colleague because of pneumonia. He has a history of dementia and type 2 diabetes. The pneumonia was a clear-cut infiltrate on chest x-ray, and he has been treated with azithromycin and ceftriaxone.
The nurse says that when she gave the ceftriaxone dose (his 3rd), the patient was doing well. 20 minutes later she returned to check on the IV, and found that the patient had facial, lip and hand swelling, tachycardia (120/min), tachypnea (26/min) and a BP of 80/40.
What is your approach?
The Learning Issues:
1. How to react to unstable vital signs being given over the phone?
2. How to do a rapid initial assessment?
3. How to do a rapid secondary assessment?
4. When and how to react before you have full information in this situation?
5. What additional information do you need?
6. What is the emergency response to suspected anaphylaxis?
7. What precautions need to be taken for airway management?
8. What subsequent actions should be taken after emergency management?
Resources:
A very good full text reference from the CMAJ can be found here.
Please comment on this case!
Here are the points that were raised in the rounds today...
ReplyDelete1. It is difficult to describe what you would do in an "action-oriented" scenario like this one. In real life, you would be doing multiple assessments and interventions simultaneously or in close parallel. There is an "art" to depicting this verbally when you are being evaluated.
2. One of the commonest early errors made in management (which may lead to increased mortality) is not giving the epinephrine early enough. It should be given as soon as the possibility of an anaphylactic reaction is deemed reasonably high.
3. In emergency situations, it may be dangerous to get into complicated (or even simple) calculations. Some of us don't have math skills that hold up under stress! Memorize doses of emergency drugs like epi in simple terms that everyone can identify quickly, eg. 1/3 of an amp, 1/2 an amp, etc.
4. Airway management may be complicated by the fact that many devices can increase airway edema by simple trauma and further local activation of mast cell degranulation. It may be unwise to manipulate the airway early - think about drugs (epi) first.
5. Remember that these patients have "warm shock" but intact sympathetic drive, hence tachycardia is common, and may be a subtle early sign of impending cardiovascular collapse.
6. Benadryl and steroids are part of the "late" management strategy since they don't work immediately, and are NOT replacements for epi.
Please post other comments!