#MiniTeach: I Was Fit As A Horse Until 3 Weeks Ago!
"A 61-year-old male self presents to ED after developing difficulty with his breathing."
His family have noticed that his eyes have become yellow and this morning he is finding it difficult to breathe. He has nausea but no vomiting. He’s been seen by his GP who referred him to the chest pain clinic, but no cardiac cause for his pain was found. Yesterday he went to the UCC and was started on antibiotics for a UTI. He has no past medical history, doesn’t drink, smoke or take other medications.
In Assessment bay, his observations are: Pulse 85/min, RR 40/min, SpO2 97% (on room air), BP 88/57, Temp 34.5°C, GCS 15/15
1. As the Assessment Bay nurse: What concerns you in his Early Warning Score?
He is scoring 3 for his respiratory rate as this is above 30 breaths per minute and 2 for his blood pressure as his systolic is between 80-89mm Hg. This makes his total score 5. He is also hypothermic, which is concerning.
2. Do you think the patient needs Resus? The Resus co-ordinator says a bay will be ready in 5-10 minutes. What steps would you take while waiting for the bay?
If the patient can’t be seen immediately in Resus, you should ask the assessment bay senior doctor to get involved (the estimated time for a resus bay being ready may differ from the reality). Try and site an intravenous cannula, take bloods and start fluid resuscitation. Assess his pain score and get appropriate analgesia prescribed.
If the patient had presented acutely with upper abdominal pain, it would be worth getting an ECG as sometimes acute coronary syndrome can present with this type of pain. This patient has had the pain for three weeks however and has already been seen in the chest pain clinic, so in this case it is more important to get intravenous access and start fluids than perform an ECG, which can wait until he is in resus. Always try and tailor what investigations you do in assessment bay towards the patient in front of you.
Resus is busy and the Registrar assigns the Resus SHO to start seeing the patient. The patient has a soft abdomen with tenderness in the RUQ and epigastrium. He is clinically jaundiced. The chest is clear.
3. As the SHO, what bloods would you consider keeping differentials in mind?
We have a patient who is unwell, jaundiced and has abdominal pain. Differentials would include hepatitis (infective, drug induced – ask about Paracetamol overdose, medications and double check alcohol intake, auto-immune), pancreatitis, biliary sepsis, liver abscess, malignancy.
Initial bloods should include: FBC, U+E, LFT, Coagulation, Bone, LDH, Blood cultures, Venous blood gas, G+S.
4. The assessment bay team were unable to get a cannula in. After two attempts, you haven’t succeeded. What should you do now?
It looks as though this patient has really difficult IV access. Generally speaking, IV access is like a game of tennis – you get two serves and then you have to forfeit. Ask someone with more experience to help with cannulation (this may be the resus nurse, but make sure you let the registrar know that you’re struggling as you may need their skills).
Ultrasound can be useful in helping to find a peripheral vein or the external jugular vein can be cannulated by placing the patient in a head down position. If these fail the options are to proceed to central line access (always with ultrasound guidance – with great care as the patient is likely to have coagulopathy).
5. As the Registrar in Resus, you are busy dealing with another very sick patient. Your SHO is struggling and asks for help. The patient has been in resus for 20 minutes. How would you proceed?
This is quite a common scenario and one of the reasons why it is so important for the lead doctor and nurse in resus to maintain situational awareness. You don’t want to delay the patient’s care but aren’t in a position to respond yourself – resus is full!
Call for the doctor in charge and be clear about what you need: a senior doctor to help cannulate and assess the patient that the SHO is struggling with – you may be able to re-deploy the SHO to another task. (The Nurse In Charge of Resus may be able to make this call for you).
In the meantime, ask the SHO to do a femoral stab to do the bloods to organise a Chest X-ray.
Eventually, a venous blood gas is obtained. It shows: pH 85/min, pO2 40/min, pO3 97% (on room air), HCO3 88/57, Base Deficit 34.5, K 8.3, Na 124, Lactate (out of range), Urea 15.7, BM 6.2
6. What do you think of the blood gas?
Severe metabolic acidosis with lactate out of range.
Severe hyperkalaemia probably due to acute kidney injury.
7. What are your management priorities?
Asses and treat the hyperkalaemia – get an ECG, start treatment according to the department’s hyperkalaemia guidelines (see attached). Make sure that the patient is on a cardiac monitor.
Aggressive fluid resuscitation – this means being actively involved in delivering 20 – 30mls/kg fluid in the first instance. Writing up a bag of fluids and walking away is not ok – make sure your access is working (2 cannulas if possible), use pressure bags, make sure that fluids aren’t stopped to give drugs. Catheterise (hourly bag) and monitor fluid balance.
Give antibiotics (ensure they cover biliary sepsis).
Check and correct any coagulation abnormalities.
Review Chest X-ray – ensure there’s no sign of perforation, pneumonia or raised hemi-diaphragm.
You may want to perform a bedside ultrasound to look for evidence of free fluid (? Ascites).
Chase lab bloods.
Involve ITU early as the patient may need organ support.
The bloods come back showing an obstructive picture. You discuss the case with the surgical registrar on call, who is scrubbed in theatre with his consultant. He thinks that there’s probably ‘something medical going on’, but advises you to get a CT scan in the meantime. After resuscitation, the patient is stable for scan.
8. What do the images above show?
This might sound like a familiar scenario. The surgical advice may be to get a scan, but the radiologist isn't keen to do the scan as the patient has acute kidney injury and he thinks the surgeons need to see the patient.
Patient safety comes first – ensure that the hyperkalaemia has been successfully treated and that the patient has been resuscitated as much as possible. Use this time to establish: how long is the surgical registrar going to be? Get an ITU review. Make sure that the doctor in charge is aware of the situation so that things can be escalated if necessary. Have a frank discussion with radiology regarding the best imaging modality – would an ultrasound be more useful and appropriate? This could potentially be done in Resus.
In this instance, a CT abdomen was performed and this shows widespread metastatic masses in the liver from a cancer of the head of the pancreas. There is also splenic hypoperfusion and ischaemia secondary to encasement of the splenic artery by the pancreatic mass.
Key Learning Points:
Tachypnoea with normal saturations can be due to respiratory compensation for a severe metabolic acidosis.
Pancreatic cancer commonly presents late
Aggressive fluid resuscitation means just that – you have to be involved with the process.
Consider getting ITU involved early if patients are showing signs of multi-organ dysfunction (sometimes the patient will be more appropriate for palliative care, but this may not be apparent to start with).
Try and maintain situational awareness and don’t be afraid of asking for help.