How To Treat An Unplanned Pregnancy

Transcription

1 Eleventh Annual Emergency Medicine Reality ED Expert Panel Michigan College of Emergency Physicians 40 th Annual Emergency Medicine Assembly Grand Hotel, Mackinac Island Tuesday, July 30, 2013 Distinguished Panelists: John Hoyle, Jr., MD, FACEP Helen DeVos Children s Hospital/Spectrum Health, Grand Rapids Brent Felton, DO, FACEP McLaren Greater Lansing Hospital, Lansing Christopher Rancont, DO, MS, EMT-P Alpena Regional Medical Center, Alpena Kelly Sawyer, MD, MS William Beaumont Hospital, Royal Oak Moderator: James C. Mitchiner, MD, MPH, FACEP St. Joseph Mercy Hospital, Ann Arbor 1

2 Objectives: the distinguished panel will discuss the management of actual Michigan cases that cover some of the interesting clinical aspects of contemporary emergency medicine. At the conclusion of this session, the audience will have a better understanding of how the experts would manage these challenging patients. Audience participation is anticipated and highly encouraged! Case Selection is generally based on meeting one or more of these criteria: Interesting and/or challenging Occurred in Michigan Unusual presentation of a common emergency Typical presentation of a rare emergency Administrative challenges you re likely to encounter Controversies in pre-hospital care An occasional zebra NOTE: these cases are provided for educational discussion and physician peer review only, and confidentiality is protected under applicable Michigan laws. Reproduction and further discussion outside of this venue is prohibited. 2

3 Case 1: An Unusual Cause of Fever 5 year-old male with 3-day illness marked by fever (105.1 max), sore throat, vomiting, anorexia. He was seen in his PCP s office 2 days earlier and noted to have cervical adenopathy. He was started on Augmentin and given an influenza vaccine. On the day of his ED visit, he was seen again in the PCP s office for continued fever, more swollen glands, sleeping most of the day, and decreased urinary output. His WBC was 10,700. ROS: no rash, cough or diarrhea. PMH: unremarkable. Immunizations UTD. No medications or allergies. SH: lives with parents Vital Signs: BP 89/50, P 128, R 58, T F, O 2 sat 96% (RA), weight 19.7 kg Exam: No acute distress. Tired and moderately ill-appearing. Head normocephalic. Neck supple, nontender, no meningismus. Eyes: bilateral conjunctival injection, without icterus. ENT: TM s clear. Dry lips, slightly cracked (lip corners spared), tacky mucous membranes, strawberry tongue, mild posterior pharyngeal erythema. CV: no murmurs or gallop. Normal perfusion, no edema. Resp: lungs clear to auscultation, no wheezes, rales or retractions, no grunting or nasal flaring. Abdomen: diffuse tenderness; no localized guarding or rebound. Bowel sounds normal. No organomegaly. Skin: warm, dry, pink, no rash. Neurologic: normal ROM of extremities, no focal deficit Labs: WBC 8,900 (6.0 neut, 0.9 lymph, 0.9 mono, 0.3 eos, 0 baso), Hb 11.7, Hct 35.5, Plt 345K, Na 133, K 5.2, Cl 98, HCO 3 21, Glu 115, BUN 12, Creat 0.56, Ca 8.6, Alk Phos 437, ALT/SGPT 160, AST/SGOT 79, Bilirubin 5.8 (direct 3.3), protein 6.8, albumin 3.0, ESR 21, CRP 15.8, Mono screen negative ED Course: child was given Tylenol and hydrated with IV fluids, and treatment initiated for suspected. 1. What is your differential diagnosis? 2. What disease/syndrome did he have? 3. What is the treatment? 3

4 Case 2: It s All in the Head 37 year-old female G1P1Ab0, 4 days postpartum after C-Section with hysterectomy (for postpartum hemorrhage), presents to ED with lightheadedness, nausea, vomiting, for 2 days, associated with decreased oral intake and general malaise. Denies headache, fever, chills, vertigo, chest pain, SOB, syncope, abdominal or back pain, or diarrhea. ROS: bilateral lower extremity edema with feet discomfort. No urinary symptoms. PMH: Recent C-section delivery complicated by obstetrical hemorrhage requiring supracervical hysterectomy and blood transfusion (8 units PRBCs, 5 units FFP, 5 units platelets); uterine adenomyosis, Hepatitis B carrier. Medications: none Allergies: none SH: denies alcohol and tobacco. Vital Signs: BP 119/81, P 75, R 18, T 98.4 F, O 2 sat 100% (RA) Exam: No acute distress. Alert, appears tired. Head normocephalic. Neck supple, nontender. Eyes: PERRL, EOMs intact. ENT: no pharyngeal erythema or exudate. CV: regular rate and rhythm, no murmur, normal peripheral perfusion. Resp: lungs clear to auscultation, no wheezes. Abdomen: postoperative scars without dehiscence, drainage or infection; no localized guarding or rebound; normal bowel sounds. Extremities: bilateral lower extremity edema. Neurologic: alert, oriented, no focal neurologic deficit. Skin: warm, pink, moist. Labs: WBC 6,900, Hb 10.1, Hct 29.0, Platelets 176,000, Na 109, K 3.7, Cl 82, HCO 3 20, Glu 90, BUN 6, Creat 0.39, Ca 7.1. ED Course: patient admitted to ICU for treatment of hyponatremia. Additional lab tests were ordered. 1. What is your differential diagnosis? 2. How would you treat her hyponatremia? 3. What is the risk of over-correction of low sodium levels? 4. What additional lab tests were ordered? 4

5 Case 3: A Pediatric Blue Bloater 9 week-old male brought to ED by parents with complaint of looking pale, acting fussy and having loose mucousy stools for the past 2 days. Baby is 2 weeks s/p laparotomy with segmental colon and small bowel resection with ileocolic anastomosis for perforated intussusception. Tolerating oral intake well (Isomil). No history of fever, respiratory distress, cough, wheezing, vomiting or rash. ROS: no cough, fever, or decreased urination. PMH: Born by NSVD at full term. No known allergies or immunizations. PSH: as above. Circumcision. SH: lives with parents Vital Signs: BP 120/66, P 175, R 32, T 97.6 rectal, O 2 sat 74% (RA), weight 4.35 kg Exam: Well-nourished, irritable but consolable, cries on exam, cyanotic. Head normocephalic with flat anterior fontanelle. Eyes: PERRL, normal conjunctivae. ENT: moist mucous membranes and normal oropharynx. Neck supple, normal ROM. CV: tachycardic, no murmur, palpable pulses. Resp: no respiratory distress; lungs clear to auscultation, no wheezes, rales or retractions, no grunting or nasal flaring. Abdomen: surgical scars clean and dry, mild distension, increased bowel sounds; no tenderness, guarding or rebound. Skin: pale, warm, dry, no rash; normal turgor. Musculoskeletal: normal ROM of extremities. Neurologic: alert, normal muscle tone, normal suck. ABG s: ph 7.43, pco , po2 66.1, Hb 7.2 Labs: WBC 30,000 (65% polys, 21.5% lymphs. 2.5% eos, 11% mono), Hb 8.2, Hct 23.5, Plt 571K, Na 139, K 5.2, Cl 111, HCO 3 16, Glu 74, BUN 4, Creat 0.29, Ca 9.0, LFTs normal except for albumin 2.6; urinalysis normal Imaging: CXR and abdominal series unremarkable. ED Course: IV access unsuccessful; baby had IO access established in left tibia, and was given IV saline at 20 ml/kg and PRBCs at 10 ml/kg. Cyanosis treated with high flow oxygen by face mask, with pulse ox increasing to 83-85%. A diagnostic test was done. 1. What is your differential diagnosis? 2. What condition did the baby have? 3. What is the treatment? 5

6 Case 4: An Unusual Cause of Small Bowel Obstruction 62 year-old female presents to ED complaining of progressive diffuse abdominal pain for 1 week, with nausea, vomiting, and unable to tolerate oral fluids. She also complains of constipation; claims no BM or passage of flatus for the past week. Denies fever, chills, rectal bleeding, trauma, back pain. ROS: unremarkable. PMH: CAD, COPD, multiple myeloma s/p remote stem cell transplant, gallstones PSH: Negative SH: non-smoker Vital Signs: BP 138/88, P 110, R 18, T 98.7, O 2 sat 95% (RA) Exam: alert, no acute distress. Head normocephalic. Eyes: PERRL, normal conjunctivae. ENT: moist mucous membranes and normal oropharynx. Neck supple, nontender. CV: regular rate and rhythm, no murmur, normal peripheral perfusion. Resp: no respiratory distress; lungs clear to auscultation, breath sounds equal. Abdomen: soft, diffuse tenderness, non-distended, normal bowel sounds, no guarding or rebound. Rectal: heme negative stool. Skin: warm, dry, no rash. Musculoskeletal: normal ROM and strength; no tenderness. Neurologic: alert and oriented, no focal neurologic deficit. Labs: WBC 10,100, Hb 19.7, Hct 57.5, Plt 257K, Na 141, K 3.5, Cl 92, HCO 3 27, Glu 144, BUN 46, Creat 2.68, Alk Phos 317, ALT/SGPT 116, AST/SGOT 38, Total Bili 1.1, lipase 101, amylase 127, urinalysis normal Abdominal Series: nonspecific air/fluid levels without bowel dilation. ED Course: Patient given IV fluids, analgesic and antiemetic IV. Patient had persistent nausea and vomiting in ED and was unable to tolerate po fluids. An NG tube was placed (gastric fluid; no blood). A diagnostic test was done. 1. What is your differential diagnosis? 2. What diagnostic test did the patient have? 6

7 Case 5: A Suicidal Patient who Refuses Transfer 18 year-old female with no significant past medical or psychiatric history, brought to ED by a friend, complaining of depression and suicidal ideation for 3 months. According to the friend, she cries all the time and had considered overdosing on melatonin last night. The friend felt she was unsafe at home. She has no physical complaints. ROS: negative PMH: unremarkable Medications: denied Allergies: denied. SH: single; denies alcohol or tobacco abuse Vital Signs: BP 128/96, P 125, R 18, T 97.6, O 2 sat 99% (RA) Exam: alert, no acute distress. Head normocephalic. Eyes: PERRL, normal conjunctivae. ENT: moist mucous membranes, no pharyngeal erythema or exudate. Neck supple, nontender. CV: regular rate and rhythm, no murmur, normal peripheral perfusion. Resp: no respiratory distress; lungs clear to auscultation, breath sounds equal. Abdomen: soft, nontender, non-distended, normal bowel sounds. Musculoskeletal: normal ROM and strength; no tenderness. Neurologic: alert and oriented, no focal neurologic deficit. Psych: flat affect, cooperative. Skin: warm, dry. Labs: WBC 8100, Hb 12.8, Hct 37.9, Plt 249K, Na 137, K 3.9, Cl 106, HCO 3 26, Glu 102, BUN 3, Creat 0.42, Ca 9.4, LFTs normal, EtOH 0, urinalysis normal, Urine Drug Screen negative ED Course: Repeat pulse 68/min. The emergency physician cleared the patient medically and signed a clinical certificate for involuntary psychiatric hospitalization. Because the patient lived in Wayne County, and the Wayne County Probate Court did not recognize the jurisdiction of the probate court in the county where the hospital was located, the hospital asked the emergency physician to transfer the patient involuntarily to a Wayne County psychiatric facility. The patient (with her mother s support) refused the transfer. 1. Does this patient have the right to refuse transfer to another facility? 2. If the hospital has capacity and capability of treating the patient and the patient is transferred against her wishes, is this a potential EMTALA violation? 3. What would you do? 7

8 Case 6: An Unexpected Twist of Events 33 year-old male with history of alcohol abuse (2 fifths of rum daily) transferred to the ED from the local alcohol rehabilitation center for alcohol withdrawal. His last drink was approximately 8 hours earlier, and he complained of tremors, auditory hallucinations, palpitations, nausea and nonbloody vomiting. He denied chest pain, dyspnea, fever, chills, abdominal pain, diarrhea, suicidal ideation, LOC, recent falls or other trauma. He has a past history of delirium tremens and seizures after attempts to quit drinking. He was given a single oral dose of carbamazepine 1 hour prior to ED arrival. ROS: unremarkable. PMH: hypertension, cirrhosis, hepatitis C, DTs, seizures SH: drinks alcohol daily, smokes cigarettes occasionally Medications: none. Allergies: none known. Vital Signs: BP 188/107, P 124, R 18, T 99, O 2 sat 98% (RA) Exam: alert, in severe distress, anxious. Head normocephalic, atraumatic. Eyes: PERRL, normal conjunctivae. ENT: moist mucous membranes, normal oropharynx. Neck supple, nontender. CV: tachycardic, no murmur, normal peripheral perfusion. Resp: lungs clear, non-labored respirations, breath sounds equal. Abdomen: soft, nontender, non-distended, normal bowel sounds. Musculoskeletal: normal ROM and strength, no tenderness. Neurologic: alert, oriented x3, normal motor, normal sensory, normal speech, no focal neurologic deficit, hand tremors noted. Labs: WBC 7300, Hb 11.8, Hct 34.1, Plt 153K, Na 137, K 3.6, Cl 97, HCO 3 25, Glu 109, BUN 6, Creat 0.60, Ca 9.4, AlkPhos 106, ALT/SGPT 70, AST/SGOT 218, Protein 7.2, albumin 4.0, Bilirubin 0.8, EtOH 183, UDS (11 hrs after admission to hospital) positive for barbiturates and benzodiazepines ED Course: patient given IV fluids ( banana bag ) and lorazepam 2 mg IV for initial Clinical Institute Withdrawal Assessment (CIWA) score of 34. Repeat CIWA score 2.5 hours later was 12; given additional lorazepam 2 mg. Hospital course: patient admitted to MICU. Fourteen hours after admission, patient was found unresponsive with a cardiac rhythm shown on next page. 1. What is the specific arrhythmia that caused him to become unresponsive? 2. What caused it? 3. How would you treat it? 4. Could it have been prevented? 8

9 Case 6 Rhythm Strips 9

10 Case 7: Altered Mental Status + Fever 21 year-old male prisoner transferred to ED for evaluation of confusion and fever. He had been incarcerated for 9 days, and was being treated for abnormal behavior (no further details) and agitation with haloperidol. On the morning of admission he was reportedly found down in his cell. He was brought in by prison guards who were unable to provide additional information. ROS: unremarkable. PMH: Fabry s Disease (X-linked lysosomal storage disease due to alpha-galactosidase deficiency; manifestations include cardiomyopathy and renal failure) PSH: unknown Medications: haloperidol IM SH: history of alcohol and drug abuse Vital Signs: BP 170/65, P 109, R 34, T (by Foley catheter), O 2 sat 97% (RA) Exam: alert, moderate distress. Head normocephalic, atraumatic. Eyes: PERRL, normal ROM ENT: dry mucous membranes, no pharyngeal edema. Neck supple, nontender. CV: tachycardic, regular rate, no murmur, normal peripheral perfusion. Resp: lungs clear to auscultation, no wheezes. Abdomen: soft, nontender, non-distended, normal bowel sounds, no guarding or rebound. Skin: warm, pink, moist. Musculoskeletal: extremities with intermittent rigidity and myoclonus. Neurologic: awake, non-verbal, does not follow commands, no obvious focal motor deficit. Labs: WBC 11,600, Hb 14.3, Hct 40.5, Plt 317K, Na 144, K 4.5, Cl 107, HCO 3 19, Glu 103, BUN 27, Creat 1.37, Ca 9.8, Mg 2.9, lactate 7.6, LFTs normal, myoglobin 425, troponin 0.04 Chest X-ray: negative Head CT: no hemorrhage, midline shift, or mass effect LP: clear, colorless CSF (Tube 1: 350 RBC, 2 WBC; Tube 4: 0 RBC); normal protein & glucose ED Course: Patient given IV fluids, IV diphenhydramine 50 mg, Ativan 2 mg with gradual improvement in his agitation and vital signs. He was admitted to MICU. 1. What is the Differential Diagnosis? 2. What other lab(s) would you order? 3. What other medication would you consider in treating him? 10

11 Case 8: Chest Pain with an Oriental Twist 84 year-old female with history of lung cancer complained of chest pain while undergoing outpatient chemotherapy. She was also found to have anemia (hemoglobin = 8.4) and transferred to the ED. Her chest pain was described as pressure and was intermittent for the past 3 days, located on the left side, and non-radiating. She denied dizziness, shortness of breath, nausea, vomiting. No associated neck, back or arm pain. No other complaints. At triage, she had an abnormal EKG (attached). ROS: no fever, chills, weight loss, vision changes, cough, SOB, N/V/D, abdominal pain, urinary symptoms, dizziness, sensory changes or motor deficits. PMH: hypertension, dyslipidemia, hypothyroidism, non-small cell lung cancer, TIA, COPD PSH: thyroidectomy, cataract surgery Meds: aspirin, Coreg, Pepcid, Synthroid, lisinopril, Zocor FH: unknown types of cancers in her brothers SH: denies current alcohol or tobacco use; widowed and currently lives with her daughter Vital Signs: BP 96/49, P 79, R 17, T 36.5 C, O 2 sat 100% on O 2 Exam: NAD, alert, oriented x3. HEENT: PERRL, EOMI, conjunctivae normal. Neck: no JVD. Cardiac: regular rhythm, S1& S2 normal, no murmurs/rubs/gallops. Lung: CTA bilaterally, no wheezes. Abdomen: soft, nontender, nondistended. Extremities: trace edema bilaterally, FROM x 4. Neuro: non-focal exam. Skin: warm, dry, not diaphoretic. EKG: see attached Labs: WBC 13,200, Hb 10.5, Hct 33.1, Plt 352K, Na 133, K 4.8, Cl 101, HCO 3 24, Glu 135, BUN 10, creat 0.77, CK 54, troponin 0.86, BNP 338 A bedside test was done in the ED, and a consultant was called. 5. What is your initial treatment? 6. What bedside test was done? 7. Which consultant was called, and what did he/she recommend? 11

12 Case 8 12