chbare Posted May 25, 2011 Author Share Posted May 25, 2011 Before we do all our lab, X-ray and fancy stuff ourselves (I'm surprised what you really have in your ambulances, whow...): what is the complete diagnosis of the ER docs? Simply "altered mental status" is not their whole finding, I hope... Unless I have a complete misunderstanding of the ER setting at this site. Please correct me then. The patient has been diagnosed with DKA and altered mental status. Upon examination, you find that his GCS is about 13 as stated earlier. Specifically, he is lethargic, but the primary concern appears to be his airway and breathing. He is breathing about 44 times a minute and appears to be struggling. His respirations are very shallow and you note accessory mucsle usage. The nurse reports that the patient has been developing progressive dynspea since the patient presented about an hour ago. The family also reports that the patient had become "more and more tired of breathing" in the hours prior to ER admission. Take care, chbare. Link to comment Share on other sites More sharing options...
Just Plain Ruff Posted May 25, 2011 Share Posted May 25, 2011 The patient has been diagnosed with DKA and altered mental status. Upon examination, you find that his GCS is about 13 as stated earlier. Specifically, he is lethargic, but the primary concern appears to be his airway and breathing. He is breathing about 44 times a minute and appears to be struggling. His respirations are very shallow and you note accessory mucsle usage. The nurse reports that the patient has been developing progressive dynspea since the patient presented about an hour ago. The family also reports that the patient had become "more and more tired of breathing" in the hours prior to ER admission. Take care, chbare. ok what were the results of the CBC and other lab tests? What is his breathing pattern now? Rapid or slow, deep or shallow? I'm going to work on getting his blood sugar down but not till I see what the lab results are. Have the results been reviewed? I would start with 10 units of regular insulin IV. That's of course what my physician ordered for the guy who had the blood sugar of 800+ I'm thinking that there are zebras in this thread though. But I'm still thinking horses. Link to comment Share on other sites More sharing options...
ERDoc Posted May 25, 2011 Share Posted May 25, 2011 Can we get a CBC, CMP, ABG, lactate? Repeat lung exam and cxr. Any more history? Can you describe this flu-like illness? Any travel, sick contacts? Are immunizations up to date? Has there been any problems with the insulin pump? Any chest pains? Repeat EKG? Let's get ready to intubate. Link to comment Share on other sites More sharing options...
Just Plain Ruff Posted May 25, 2011 Share Posted May 25, 2011 Can we get a CBC, CMP, ABG, lactate? Repeat lung exam and cxr. Any more history? Can you describe this flu-like illness? Any travel, sick contacts? Are immunizations up to date? Has there been any problems with the insulin pump? Any chest pains? Repeat EKG? Let's get ready to intubate. My next step is to intubate also. This guy is certainly not going to get any better, hence the requirement for transport. But having him intubated prior to transport is a good idea. Link to comment Share on other sites More sharing options...
chbare Posted May 25, 2011 Author Share Posted May 25, 2011 Can we get a CBC, CMP, ABG, lactate? Repeat lung exam and cxr. Any more history? Can you describe this flu-like illness? Any travel, sick contacts? Are immunizations up to date? Has there been any problems with the insulin pump? Any chest pains? Repeat EKG? Let's get ready to intubate. My next step is to intubate also. This guy is certainly not going to get any better, hence the requirement for transport. But having him intubated prior to transport is a good idea. You can assume "typical" DKA labs. Because the patient is not ventilation effectively, there is no respiratory compensation when looking at the ABG. You guys intubate the patient with a 7.5 ETT and note placement at about 22 cm. Saturations remain above 90%, no cyanosis is noted, no haemodynamic changes are noted, and you have a plateau shaped waveform on the capnograph. Unfortunately, you note unequal chest rise and fall. The right side of the chest rises first followed by the left side of the chest when performing manual ventilation. Take care, chbare. Link to comment Share on other sites More sharing options...
Just Plain Ruff Posted May 25, 2011 Share Posted May 25, 2011 You can assume "typical" DKA labs. Because the patient is not ventilation effectively, there is no respiratory compensation when looking at the ABG. You guys intubate the patient with a 7.5 ETT and note placement at about 22 cm. Saturations remain above 90%, no cyanosis is noted, no haemodynamic changes are noted, and you have a plateau shaped waveform on the capnograph. Unfortunately, you note unequal chest rise and fall. The right side of the chest rises first followed by the left side of the chest when performing manual ventilation. Take care, chbare. Allrighty then so what could cause this to occur? His chest x-ray was ok? Did he have a CT of the chest? We are at least ventillating him well aside from the chest rise and fall. Did he have any history of trauma? So what things could cause paradoxical or irregular chest rise and fall. Was this chest rise and fall problem noted prior to intubation? One thing I did notice in researching paradoxical chest wall movement was that one cause could be a issue with the nerve that controls the diaphragm. Could we have caused this issue by intubating this guy? Or could the medications given to paralyze/sedate him cause it? The one thing that I can think of that could cause the damage to the nerve could be due to Cervical spondylosis. Did when we intubated the patient cause the Cervical Spondylosis to damage the nerve to the diaphragm? How old was this guy again? Link to comment Share on other sites More sharing options...
ERDoc Posted May 25, 2011 Share Posted May 25, 2011 (edited) Could we have caused this issue by intubating this guy? Or could the medications given to paralyze/sedate him cause it? The one thing that I can think of that could cause the damage to the nerve could be due to Cervical spondylosis. Did when we intubated the patient cause the Cervical Spondylosis to damage the nerve to the diaphragm? Don't forget, when we RSI'd this guy we made the nerves pretty much irrelevant. If he is paralyzed and still having the abnormal chest movement you need to think about something structural in the chest. I'm gonna go with Ruff and say we need a chest CT. With the prodromal fly-like symptoms, has this guy developed an abscess that is compressing the left bronchus? I'd expect to see something on cxr but I guess it would be possible to be hiding in the heart shadow. The CT would also tell us if there was something structural going on with the heart such as a pericardial effusion (again related to the prodromal syndrome), but again I'd expect to see something on cxr. Edited May 25, 2011 by ERDoc Link to comment Share on other sites More sharing options...
chbare Posted May 26, 2011 Author Share Posted May 26, 2011 (edited) Pre-intubation film: Post-Intubation Film: CT scanner is currently down. You withdraw the tube slightly with no change in the asymmetrical movement. Saturations are 100%, ABG now shows a partially compensated metabolic acidosis, lung sounds are clear. What do you all think? Take care, chbare. Edited May 26, 2011 by chbare Link to comment Share on other sites More sharing options...
chbare Posted May 26, 2011 Author Share Posted May 26, 2011 Analysing this scenario with labs will not help. I tried to give you a picture of a DKA patient who has been huffing away to the point of exhaustion. This was why I had an uncompensated metabolic acidosis and shallow respirations. Basically, I had to give you a patient that required intubation. Focus on upper thoracic anatomy for hints. This is a scenario that I modified from a case study encountered in a fluid dynamics course. It's a zebra for sure, but an interesting one. Take care, chbare. Analysing this scenario with labs will not help. I tried to give you a picture of a DKA patient who has been huffing away to the point of exhaustion. This was why I had an uncompensated metabolic acidosis and shallow respirations. Basically, I had to give you a patient that required intubation. Focus on upper thoracic anatomy for hints. This is a scenario that I modified from a case study encountered in a fluid dynamics course. It's a zebra for sure, but an interesting one. Take care, chbare. Link to comment Share on other sites More sharing options...
DwayneEMTP Posted May 26, 2011 Share Posted May 26, 2011 Hmmmm.... It initially sounded like a R sided intubation, but the tube was retracted without relief. It does sound as if the R lobes are filling and then spilling over into the the L perhaps. Other than tumors, as mentioned by the Doc, I can't imagine what is doing that. Unfortunately the xrays are wasted on me. I'm also haunted by the name of the thread and am confident that it is directing us towards an answer..I'm just not sure what the hell that answer would be! Excellent scenario...Thanks for taking the time to do it! Dwayne Link to comment Share on other sites More sharing options...
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