#SimBlog: I'm fine Doc, honestly!
"86-year-old woman who was last seen by family 2 days ago is brought into the ED."
She has no package of care. Found by daughter on the living room floor. Usually fully independent. Was unable to get up from the floor unassisted but does not complain of pain or injuries.
Observations
A – Patent
B – RR 18, Sats 99% air, No respiratory distress
C – HR 110, BP 98/65, Heart sounds normal
D – GCS 14, PEARL size 3, BM 5.2
E – No injuries, Catheter in situ
Clinical Findings
No injuries to find
Mild hypertension
NKDA
Why We Simulated?
This simulation was designed to highlight one of the many problems created if you have been lying on the floor for a long time. The patient has presented with a non-injury fall, with a long lie on the floor for up to two days.
Her observations are mildly deranged with a slight tachycardia and mild hypotension. Isn’t this just a simple bit of dehydration??
The bloods are done and the VBG (venous blood gas) shows a potassium of 7.8 with a lactate of 3.0.
Her ECG is shown below, showing some of the tell signs of Hyperkalaemia...
Tall "tented" T waves
Flattened P waves
Broad QRS complex
Once the bloods return it is apparent that this patient not only has hyperkalaemia, but has an acute kidney injury with/caused by rhabdomyolysis.
Further Reading:
Learning Outcomes
You must always check the electrolytes in patients who have been lead on the floor for some time.
Remember to carefully review the results of tests given to you i.e. ECGs, VBGs, ABGs and imaging. If you are being bombarded by lots of requests, it is ok to say can you comeback to me when I’ve finished doing this task.
It is important to get senior help ASAP, these patients are at high risk of arresting.
Positive Feedback
- Good teamwork
- Good communication with the patient and clear instructions
- Considered rhabdomyolysis early
