Case discussion Stephen Lo

Case 1  21 year old female presents to the ED with abdominal pain. You attend as part of the medical emergency team at resus, as she was noted to have SBP of 70 despite fluid resuscitation in the ambulance. How would you manage this patient?

Initial resuscitation  ABC  Airway: drowsy, GCS 13, M6, but maintaining airway  Breathing: Sats 98% on 6 L/min Hudson, RR 40/min  Circulation: BP 70/50, HR 145/min, Cool peripheries

Initial resus  IV access  IV fluid  Erect CXR  Blood gas  Bloods

Blood sugar  BSL 1.5 mmol/L  What is your differential diagnosis?

Low BSL  Na 121  K 6.8  Cl 96  HCO3 11  Urea 16.3  Creatinine 146  Lactate 4.8

Hypoglycaemia differential diagnosis  Drug overdose  Addisonian crisis/pituitary failure  Liver failure  Insulinoma  Sepsis  How would you manage her?

Adrenal insufficiency  Investigations:  Initial:  Random cortisol, ACTH, aldosterone, renin, other pituitary hormones  Specific management:  Dexamethasone 4mg iv or Hydrocortisone 100mg iv  Subsequently hydrocortisone, 50mg q8h  Treat underlying cause:  Sepsis, hypovolaemia  General therapy  Follow up studies:  Further imaging

BSL  46mmol/L  Diagnosis and management?

ABG  pH 7.01  HCO2 2.5mmol/L  Na 137 mmol/L  Cl 113  K 4.6  BE  Lactate 4.2

Management  How would you manage this patient  Fluid therapy and electrolyte therapy  Insulin therapy

Key issues  Pseudohyponatraemia and cerebral oedema  Calculating corrected Na  Avoid excessive correction of fluid therapy  Gentle insulin infusion 0.1U/kg/hr  Monitor BSL and Na corrected  Potassium depletion  Continue iv insulin until resolution of DKA  Starting IV glucose once BSL<15mmol/L  Wait until normalization of anion gap  The patient can eat  Look for underlying cause

Case 2  You are referred a 76 year old female who has hyponatraemia with Na of 109 by the medical team. She presented with Na of days ago and has been given 0.9% Normal Saline infusion at 80ml/hr. She has a background of HTN and mild COPD. How would you assess this patient?

Management  What is your differential diagnosis

Differential diagnosis  Dehydration  SIADH  Diuretic therapy  Endocrine: hypothyroidism, addisonian  Heart failure  Renal failure  Liver failure  Hypovolaemia  Primary polydipsia  Pseudohyponatraemia  Elevations of lipids and proteins  Hyperglycaemia

Investigations  Serum osmo and Na  Urinary osm and Na  Consider other imaging looking underlying cause

Sodium correction  If symptomatic, may need rapid correction with 100ml 3% or 20ml 4M  Calculation of Na deficit  =TBW x (target Na – plasma Na)  Correct at no faster than 0.5mmol/L/hr  Up to 120, then would fluid restrict

Osmotic demyelination syndrome/central pontine myelinolysis  Due to overly rapid correction of Na  Occurs 2-6 days after correction  Sx  Dysarthria  Dysphagia  Paraparesis  Quadriparesis  Behavioraldisturbances  Lethargy  Confusion  Coma

Relowering of Na  Some people advocate relowering based on animal studies  Use D5W and DDAVP

Case 3  42 year old female who presented with fevers and general unwellness. She is referred to the ICU for sepsis and fast Af, rate of 162/min. Her BP is 140/80 and temp is 38.9C.

Differential diagnosis  What is you differential?  Infectious  Non infectious  Immunological  Bleeds, clots  Drug induced, NMS, Serotoninergic syndrome, MH  Endocrine  Malignancy

Investigations  CRP, PCT  FBC  ANCA, ANA  TSH, T3, T4  Cultures  U+Es  CXR

Results  TSH <0.02 ( )  T4 36 (12-22)  T ( )

Management  Beta blockers  Steroids, hydrocortisone 100mg iv q8h  Carbimazole, up to 60mg divided daily dose  Consider:  Iodine  Cholestyramine