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
126
116 55
21.2 35 88 28
7.1 10
3.3
Neutrophils % Monos %
Bands % Eosonophils 3%
Lymphs % Basophils % 26 75
Mg AST Amylase 140
Phos ALT Lipase
Ca Alk Phos 580
Lactate T Bili 6.2
Troponin 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. Mg 2.3 AST 344 Phos 4.0 ALT 126 Lipase 500 CPK 2700
9.0
153
124
110
18.2 88 28
6.8 7
2.7 35
Neutrophils % Monos %
Bands % Eosonophils 5%
Lymphs % Basophils %
Mg AST Phos ALT Lipase CPK 2700
Ca Alk Phos 100
Lactate T Bili 1.3
Troponin 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 CBC BMP ABG Miscellaneous WBC 14.2 Na 125 pH 7.04 ALT 126 RBC 3.5K
pCO
AST 134
HGB 12.3
CL 88 pO
Lactate 4.6
HCT 35.8
CO2 5
HCO3 11
Serum Osmolality 318
PLT 120
SCr 8.5 BE
Ca 7.2
BUN 64
SaO %
MG 2.3
Glucose 66
ETOH 1.2 mg/dl

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