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Heavy Lies the Helmet

This episode features three challenging cases encountered in the emergency department. The scenarios include a 65-year-old male with abdominal pain and respiratory distress, a patient with altered mental status and substance abuse history, and a female with acute kidney injury and toxic alcohol poisoning. Explore the diagnostic and management approaches to these complex presentations.

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Heavy Lies the Helmet

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  1. Heavy Lies the Helmet Episode #30 Case Studies

  2. Scenario 1 • 65-year-old male who presented to the emergency department today at the outside hospital complaining of some diffuse abdominal pain, General malaise, nausea and vomiting and subjective fever. • He has a history of coronary artery disease, type II diabetes and moderate COPD. The patient is a one pack per day smoker and reports some alcohol use.

  3. He was hypotensive on his presentation in the ED and has received 1 L of NS in the ED. • The chest x-ray shows bilateral consolidation in the bases unclear for infiltrate vs atelectasis, (clinical correlation recommended). CT imaging has been deferred secondary to the serum creatinine. EKG LBBB—Ventricular rate 48

  4. Vital Signs: HR: 48 BP: 70/30 RR:26 T: 101.6 SpO2: 95% • General malaise. Skin: Cool, pale • Lungs: Scattered wheezes bilaterally, Diminished airflow in the bases and scattered petechia on the anterior chest • ABD: Diffusely tender, firm and distended there is some mild guarding in the upper right quadrant. It is difficult to appreciate bowel sounds, no Cullens sign, no Grey turners sign

  5. 9.0 35 126 116 55 21.2 88 28 10 3.3 7.1 Neutrophils 88 % Monos 8% Bands 35% Eosonophils 3% Lymphs 18% Basophils 2% 26 75 Mg 2.3 AST 1122 Amylase 140 Phos 4.0 ALT 1804 Lipase 500 Ca++ 7.8 AlkPhos 580 Lactate 7.4 T Bili 6.2 Troponin 0.33 D Bili 5.0 5.3

  6. Ascending Cholangitis • Hyperkalemia • Bradycardia 2/2 above • Lactic Acidosis • Transaminitis

  7. Scenario 2 On arrival at the OSH GCS 1-1-2 B/P 60/40, 124, 36, 38 90% Arrived on Bi-PAP by EMS Has received 500 cc fluid and is receiving another bolus now Has had episodes of VT—1 bolus of Amio

  8. 9.0 18.2 153 124 110 28 88 35 7 2.7 6.8 Neutrophils 75 % Monos 6% Bands 22% Eosonophils 5% Lymphs 18% Basophils 3% Mg 2.3 AST 344 Phos 4.0 ALT 126 Lipase 500 CPK 2700 Ca++ 7.8 AlkPhos 100 Lactate 5.5 T Bili 1.3 Troponin 0.46 D Bili 0.3

  9. Polydrug ingestion • AKI 2/2 Rhabdomyolysis • RLL infiltrate 2/2 Aspiration • Acute Respiratory Failure • Diffuse Cerebral Edema • Lactic Acidosis

  10. Scenario 3 • 48 year old female found down at home—Long standing hx of polysubstance abuse • EMS found her altered, GCS 2-3-4, Euglycemic • Brought to the ED, became increasingly confused—intubated for airway protection

  11. Labs

  12. Acute AMS • AKI • WGMA • Toxic Alcohol Poisoning 2/2 Ethylene Glycol Ingestion

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