“ER Patients” From the 2001 Physiology Class

Case # 1

(from "The Longer You Stay”)
by Kara Telesmanick

Scenario:

Scene I:
Paul, a 27-year old artist, is brought in unconscious. His blood pressure is 108/76 and pulse is 110. His pulse ox is 98 and he is not responding to narcan. His brother tells doctors that Paul had been complaining of chest pain all day and that Paul thought it was due to a meatball sandwich he had eaten. Paul has also been sleep deprived lately. Paul's brother says there is no history of early heart disease in the family, but his grandmother did have diabetes. A chem panel, CBC, 12 lead, and a portable chest are ordered. Paul's ECG shows drastic St elevations, which indicate a major MI. The doctor suspects the possible trigger of MI to be cocaine, which causes vasoconstriction. He orders a tox screen and also wants to give 40 of tenecteplase, a thrombolytic drug.

Scene II:
Paul is receiving nitro at 10 mikes and an order is given to titrate to a systolic of 100. The chief resident enters the room and is told that Paul has had no recent surgery, has no bleeding disorders, and that his X-rays are clean. They decide to go ahead and administer tenecteplase. Soon after administering the drug, the tox screen comes back and it is negative for cocaine and amphetamines. No lipid panel was ordered. Paul then goes into V tach. He has no pulse and so they
start compressions. The doctor makes the remark that it is "too early for reperfusion arrhythmia." They push and amp of epi and prepare to intubate him. They also use a defibrillator to shock his heart at 200 and 300. He is still in V fib. They give him 100 lidocaine and again charge the defibrillator to 360.

Scene III:
Paul is given 4 units of FFP. He has a weak pulse with compressions. His chest tube output is 4 liters. One of the doctors insists they open his chest, but he is told that the proximal lesion can not be cross clamped. They stop compressions.

Diagnosis:

  • Stimulant induced Myocardial Infarction (MI)- Stimulant to drugs (i.e. cocaine) can cause vasoconstrition, which in turn can lead to MI (irreversible damage to cardiac muscle).
  • Marfan Syndrome - Inherited disease which affects connective tissues in the body. It results in many skeletal deformities (long arms and legs, long thin fingers, abnormal spine curvature,
    pectus excavatum (caved-in chest), loose joints, etc.) as well as problems with the heart and blood vessels (cardiovascular system). Wall of aorta is prone to stretching and over time becomes increasingly weak. This can result
    in aneurysm and possible rupture.
  • Aortic Dissection - Weakened portion of the thoracic aorta begins to tear along the longitudinal axis of the vessel. Symptoms usually include severe chest pain.

Symptoms:

  • Chest pain
  • Fatigue

Signs:

  • ST elevation - Displacement of ST segment of ECG upward or downward can indicate myocardial injury or inadequate blood flow. (Normally in ST segment, ventricular cells are in the plateau phase.)
  • Ventricular tachycardia (V tach)
  • Ventricular fibrillation (V fib)

Tests:

  • CBC - Complete blood count; determines the number of RBC's and WBC's and platelets in a sample of blood.
  • Chem Panel - Gives overview of blood chemistry that can reveal problems in specific cells and tissues. Checks key minerals, enzymes, sugars, and proteins. Also measures metabolites.
  • 12 lead ECG
  • Portable Chest X-ray
  • Pulse Oximetry (pulse ox) - Measures oxygen in the blood. Expressed as the ratio of oxygenated hemoglobin to total hemoglobin.
  • Toxicology screen - Checks blood and/or urine for toxic substances and drugs. Can determine the type and amount of substance injected, ingested, or inhaled.
  • Lipid Panel - Screens lipid level in blood: cholesterol, triglycerides, and HDL


Drugs Administered:

  • Narcan - Narcotic antagonist. Used to reverse effects of narcotic overdose and in cases of coma with unknown cause.
  • Nitroglycerine (Nitro) - Vasodilator, relaxes smooth muscle
  • Reopro - An anti-platelet antibody. When used in addition to coronary stents, it reduces the risk of heart attack by 53%.
  • Tenecteplase - Thrombolytic drug used to break up blood clots and thus treat acute myocardial infarction. It can be administered in a single dose over a time period of 5 seconds
  • Lidocaine - Antidysrhythmic drug. Given in cases of ventricular ectody, V. Tachycardia, and V. fibrillation.
  • Epinephrine (epi) - Causes vasoconstriction thus increasing heart rate and blood pressure, used to treat cardiac arrest.
  • Cryoprecipitase (Cryo) - Precipitate formed when plasma is frozen and then thawed, particularly rich in fibronectin and clotting factor VIII.


Treatment:

  • Stent - Tube made of metal or plastic inserted into a blood vessel to keep the lumen open.
  • Endotracheal Intubation
  • Defibrillation
  • O - negative blood
  • Fresh Frozen Plasma (FFP) - Plasma containing clotting factors and platelets.
  • Thoracotomy - Incision made to open the chest cavity.
  • Chest Tube
  • Central line - Intravenous line inserted through the chest and threaded into a large vein near the heart. Has multiple ports that can be used to draw blood, give fluids, and monitor
    central venous pressure.


Other:

  • Reperfusion arrhythmia - Arrhythmia induced by restoration of blood flow to the heart (?)
  • Exsanguinate - Literally means to remove circulating blood, to make bloodless.



Case # 2
(from “A Simple Twist of Faith”)
by Terry Panetta

Scenario:

 

The patient studied was Abby, and she was brought in after being punched in the face by her next door neighbor. He entered her apartment, by way of forced entry, and proceeded to hit her in the face. The blow to the face came with such force that she was knocked to the floor. The police came to her apartment and brought her to the hospital. There she was treated, by the doctors, for the injuries that she had received to her face. During the examination it was noticed that she had a bruise on her thigh, and it was suggested that she may have been raped. When this was discovered, a rape kit was requested and through examination the test came back negative. Abby had suffered a fractured nose and severe bruising to the face and thigh.

Test Performed:

  • Rape Kit: Used to determine it a victim was raped or not. They check for any trauma that the vaginal canal may have suffered. They also check for abrasions
    and to see if any semen is present.
  • Head and Facial CT: A cat scan was requested to see if there was any trauma to the brain, and to check if there were any broken bones in the face.
  • CBC: Complete Blood Count, this test counts the number of red blood cells, white blood cells, the total amount of hemoglobin, the fraction
    of blood composed of these cells, and the size of the red blood cells.
  • Dip a Urine: Tests for blood in the urine.

Drugs:

  • Tylenol was given to try and bring the swelling in the face down and to relieve any pain the victim was feeling.
  • Morphine was suggested for pain relieve.
  • Vicaden was also another suggested pain reliever.

 

Diagnosis:

 

The rape test came back negative. The head and facial CT also came back negative. The victim suffered from a fractured nose and severe contusions to the face and thigh area.

Case # 3
(from “Damage is Done”)
by Noreen Kordziel

Scenario:

 

A 35 year old male was rushed from his house on an ambulance. His name was Mr. Brower and he had opened a package that had come in the mail that was full of explosives. Mr. Brower suffered face, neck and chest injuries. He had an unknown LOC, his GCS was 14, and he was hypertensive because his pulse was 130/80. The doctors try to figure out if everything is working correctly. The nurse checked his blood pressure and it was 140/80. Dr. Weaver asked Mr. Brower if he could see out of his one eye because it looked like he had a lobe rupture by having him follow the light with his eye. Dr. Greene checked his heart with his stethoscope and heard increased blood sound on the left side. Betadine administered for Mr. Brower's burn wounds to fight infections. A chest tube was put in to drain fluid from the pleural space surrounding the heart. The pleurae was being tested when Mr. Brower's eyes closed, his pressure dropped. His systolic pressure was 70, which is the maximum arterial pressure of the left ventricle. A second chest tube was put in and a vacotomy tray was ordered. An
ultrasound was used to see where the fluid was located. It was found that the AC was 12 at 100%, the tidal volume was 500 and there was fluid in the Morrison pouch and the left pericardium. The Morrison pouch is in the abdomen surrounding the liver and kidneys where the pericardium surrounds the heart. Atropine was administered to increase the heart rate. Mr. Brower's heart stopped pumping and he went into cardiac arrest, which is known as asystole. He also did not have any pulse. Mr. Brower went into v-fib, which is ventricular fibrillation; this is where the heart is not able to pump blood to the arteries. Dr. Greene used the paddles to correct this condition by electrical defibrilliation at 200 and then again at 300. This process stimulates depolarization throughout the heart. This did not work so Mr. Brower's chest was opened up. The injuries caused his heart to stop beating. The doctors continued to try and shock Mr. Brower's heart for 30 minutes but were unsuccessful in returning the heartbeat. Mr. Brower went into Whitness arrest were there is a 10% chance of survival. Mrs. Brower told the doctors that they could stop because Mr. Brower was gone. The package that was sent was sent to Mrs. Brower, she is a doctor of research that was working on creating stem cells using DNA (cloning). She had failed to tell her husband about the threats that she had received and the package was meant for her not her husband or her daughter.

Treatments:

  • (2) Chest Tube - plastic tubes used for drainage of air or fluid from the pleural space (surrounding the heart and lung)
  • Electrical Defibrillation (paddles) - Electrical current used to stimulate the heart into normal rhythm.

Tests:

  • Pleura - Tells you if there is fluid in the pleural cavity that surrounds the heart and lungs.
  • Ultrasound - high frequency sound waves that are transmitted through the abdomen to rule out any internal bleeding especially around the heart.
  • EKG - Records the electrical activities of the heart.

Symptoms:

  • Hypertension - The blood pressure is above the normal range (140/80)
  • Asystole - Cardiac arrest, no heart beat. In this case they opened the heart to shock him.


Medication Administered

  • Betadine - A drug that is a germicide or disinfectant that would guard against infection of the opened burn wounds on Mr. Brower's blody.
  • Atropine - A drug used to stop muscular spasms, it effects the vagus nerve and increases the heart rate.


Case # 4
(from “Four Corners”)
by Jenna Gustafson

Scenario:

 

A 20 year old girl named Alice appears on a "Jerry Springer like" talk show with her mother. On the show, Alice's mother reveals to her that her boyfriend is also her half brother (they share the same father). Alice is shocked by this disturbing news and a brawl breaks out. Alice is beaten with a foldingchair and her wrist is broken. At the end of the show and violent activities, several patients are admitted to the ER. Alice is brought in and is diagnosed with a facial fracture, abdominal pain, and a broken wrist as a result of the talk show brawl. Dr. Benton conducts an ultrasound to rule out internal bleeding and although no internal bleeding is present, it is shown that she is approximately 10 weeks pregnant. Alice, who had a feeling that she may be pregnant, is terrified by this news...that she is pregnant with her brother's baby, and become both disgusted and embarrassed. Alice is left crying in her examination room while Dr. Benton orders psys consult. The consult and other treatment arrive too late. Alice throws herself out of the 4th floor window. The emergency department staff rush to her rescue and she is in critical condition. She is rushed into the trauma room and attempts are made to save her life. Two chest tubes are thrust down her throat with the hope of draining excess fluid from the pleural space. Large doses of blood are administered in order to replace blood lost after her fall. In their last attempts to save her life, epinephrine, isoprel and atropine are pumper into Alice's system. The EKG shows she's asystole and Alice inevitably dies.

Treatments:

  • Psys Consult: awaiting for a psychologist to perform a psychological evaluation of the patient.
  • Chest Tubes: plastic tubes used for drainage of air or fluid from the pleural space (surrounding the heart and lungs).
  • 8 Units of Packed Cells: 8 units of red blood cells collected from on individual that are packed into a small volume for transfusion into a patient.
  • Pericardiocentesis: tapping a passage into the pericardium with a hollow instrument to remove fluid.
  • Two Units of O negative: Two pints of O negative blood (the universal donor)

Tests:

  • Ultrasound: high frequency sound waves that are transmitted through the abdomen to rule out any abdominal bleeding.
  • CT (CAT) Scan: Computerized Axial Tomography, noninvasive method for diagnosing disorders in the body using a computerized combination of multiple
    tomograms to form and image.
  • EKG: Electrocardiogram; the graphic record of the electrical activity that reaches the surface of the body as a result of cardiac depolarization and repolarization.
  • X - Rays: Photographs using electromagnetic radiation for diagnosis and treatment of bone fractures and such.
  • Pupil Dilation: Using natural response to light of the eye, this indicates whether or not there is brain injury.

Symptoms:

  • Tamponade: Reduced venous return to the heart due to compression of major veins by increased volume of fluid in the pericardium.
  • Asystole: Cardiac standstill or arrest, absence of a heartbeat.
  • Tension Pneumo: Short for tension pneumothorax; air present outside the lung and trapped inside th thorax resulting in increased pressure within the chest
    cavity and restriction of lung expansion and function.
  • Pulse OX 74: a procedure using a pulse oximeter to estimate the amount of oxygen in the blood right through the skin. The normal level is about 95% (out of 100)
  • Blood in Pericardium: Blood found in the membrane sac that encloses the heart.

Medications Administered:

  • Epinephrine: Referred to as "Epi," a sympathetic drug that mimics the actions of the adreneric nerves, regulation blood pressure and opening airways.
  • Atropine: Ach blocking agent; counteracts effects of vagus nerve causing the heart reate to be increased.
  • Isoprel: A bronchodilator often for asthma patients. Can cause change in moods.

 

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