“ER Patients” From the 2002 Physiology Class

Case # 1

(from "Lockdown")
by Cara Marchese, Nicole Anderson
 
Scenario:

 

Two children came in with an unidentified rash. After waiting for forty-five minutes, a doctor came to look at the rash. Upon viewing, the children were
immediately brought to a private room in the hospital. They were thought to have smallpox, an airborne infectious disease not seen in the U.S. since 1949. When interviewed, it was found not only that the same two children had been treated in the ER a week prior for what was diagnosed as the flu, but also that the children had returned from a trip to Africa two weeks prior. In the E.R. the five year old female child died. Adam is her ten year old brother who appeared to be less critical than his younger sister. While he was in the room his condition became steadily worse until his pulse rate dropped so low he was on the verge of death. This was a result of lack of oxygen due to the lesions inside his lungs, so a tracheostomy had to be performed.

Symptoms:

  • week old fever
  • 3 day old rash
  • firm, deep-seated pustules
  • centrifical distribution sparing the body
  • enlarged thyroid isthmus
  • upper airway covered in lesions


Diagnostic Tests:

  • Punch Biopsy: A biopsy performed using a punch, an instrument for cutting and
    removing a disk of tissue. For example, a punch biopsy of the skin may be
    done to make the diagnosis of a malignancy.
  • Electron Microscopy: microscopy in which an electron beam replaces light to form
    the image. EM has its pluses (greater magnification and resolution than
    optical microscopes) and minuses (you are not really "seeing" objects, but
    rather you are looking at their electron densities, and meaningless
    artifacts may abound). Nonetheless, EM has extended the range of the microscope.


Treatment:

  • Etomidates: Imidazole derivative anesthetic and hypnotic with little effect on blood gases, ventilation,
    or the cardiovascular system. It has been proposed as an induction anesthetic
  • Formal Tracheostomy: The surgical creation of an artificial airway in the trachea (windpipe) on the anterior surface of the neck.
  • Manual oxygen mask squeezed every 3 sec.
  • Heliox: Switch tank Helium-oxygen mixtures ('heliox') have a lower gas density than air or air
    mixed with supplemental oxygen.
  • Multifocal P.V.C.s: Abbreviation for premature ventricular contraction. PVCs are contractions of the
    lower chambers of the heart, the ventricles, which occur earlier than usual, because of abnormal
    electrical activity of the ventricles. The premature contraction is followed by a pause, as the heart
    electrical system "resets" itself and the contraction following the pause is usually more
    forceful than normal. These more forceful contractions are frequently perceived as palpitations.
  • CPR: Also called cardiopulmonary resuscitation, involves applying external chest compression
    to make the heart pump and breathing for the victim by mouth-to-mouth ventilation.


Case #2
(from “Dead Again”)
by Tricia George and April C. Martel
 
Scenario:

A young woman by the name of Alma is rushed to the emergency room with a gun shot wound to the left side of her neck. The doctors tried hard to determine whether the gun shot wound would affect the other parts of her body, mainly because the bullet was close to her spinal chord. She was then stabilized and sent to the operating room where the bullet would be removed.

Symptoms:

  • Bruising to the spina l chord
  • Patient has trouble feeling her legs
  • Entry would to the left mid Sternocliedomatstoid with a large hematoma
    Sternocliedomastoid- one of two muscles arising from the sternum and inner part of the clavicle
    Hematoma- a swelling or mass of blood (usually clotted) confided to an organ, tissue, or space and caused by a break in a blood vessel.
  • Blood behind the left ear
  • Morrison's is dry-
  • Peridolic gutter looks good Peridolic gutter- tissue around the intestinal diverticulum
    (A small sac-like structure that sometimes forms in the walls of the intestines)
  • Patient is pregnant

Treatment:

  • Blood pressure was taken
  • Pulse was taken
  • An lateral x-ray of the neck was taken
  • Nasal cannula (5 Liters) - Tubing that allows oxygen to pass through the nasal cavity. (cannula = tubing)
  • IV Bolus- a one time of dose of fluids through an IV using a fast drip
  • 30 mgs per kilo of Methylprednisoalone was given through an IV Methylprednisoalone- is a corticosteroid that is indicated for severe
    inflammation or immunosuppressant
  • Ultrasound- a medical procedure that uses sound waves to see inside the body; health care professionals can use ultrasounds
    to study the heart, to help check the health of an unborn baby and it can help diagnose medical conditions such as cancer,
    gallbladder disease, blood clots and eye disorders. It is a simple procedure which is very effective and it used in
    place other more expensive examination methods or surgeries.
  • The blood bank supplies blood in case there is a large loss of blood
  • The patient is then sent off to; the operating room where the bullet will be removed from the patient's neck.

 

Case # 3
(from “Chaos Theory”)
by Adrienne Metz and Sarah Brown
 
Scenario:

 

While getting patients ready to load into a medical helicopter Dr. Romano dropped his clipboard. As he stood up from picking up the clipboard, his arm was amputated by the tail blades of the helicopter at the distal end of his humerus. He lost half of his blood volume and went into shock.

Symptoms:

  • Vomiting
  • Shocky –Circulating disturbance produced by severe injury or illness and due in large part to reduction in blood volume;
    features include a fall in blood pressure, rapid pulse, pallor, restlessness,
    thirst and cold clammy skin
  • Cold
  • 20cm lac (lacuna) over 5th rib – any minute cavity, as in the substance of bone
  • Bradying (Bradycardia) –Slow rate of heart contraction, resulting in a slow pulse rate
  • No pulse
  • Amputated distal humerus –Arm was cut off by a clean cut at the far end of the humerus, the upper bone in the arm, just above the elbow
  • Ice –used to preserve the severed arm
  • Dropped crit (hematocrit) to 18 –the proportion by volume of red blood cells in the blood; part of the complete blood count (CBC)
  • Hemorrhagic shock –shock produced by the escape of blood from a vessel
  • Perfusion –blood flow thru the organs and tissues
  • Epi pressure –pressure of the epicardium, which is the inner lining of the serous pericardium lining directly on the heart, the outer most layer of the heart
  • Post-op erythema –reddening of the skin

Treatment:

  • Vascular clamps –used to clamp off blood vessels
  • BP cuff –measures blood pressure, which is the pressure exerted by blood on blood vessel walls
  • Kelly’s and needle driver –clamping instruments which they used in place of vascular clamps to clamp off the blood vessels
  • IV (intravenous) line –a line put within the vein; allows the administration of fluids and drugs into the vein
  • 1mg. epi and IV push –epinephrine, hormone that can be prepared synthetically and is used in circulatory collapse, administered in dilute
    solution (1 to 100,000) by slow intravenous (IV) infusion
  • Blood transfusion –intravenous replacement of lost or destroyed blood by compatible citrated human blood
  • Retracting of the deltoid –Use of a surgical instrument for holding apart the edges of a wound to reveal underlying structures; in this case
    they retracted the deltoid, which is a triangular muscle in the upper arm
  • Atropine –A drug given before anesthetic to decrease secretion in bronchial and salivary systems and to prevent cardiac depression
  • Intubate –insertion of a tube into a hollow organ; tracheal intubation maintains an airway and permits suction of the respiratory tract
  • Antibiotics –antibacterial substances derived from fungi and bacteria; used to fight infection
  • Orthopedic surgeon –branch of surgery dealing with all conditions affecting locomotor systems
  • Trauma surgeon –branch of surgery dealing with bodily injury
  • FFP (Fresh frozen plasma) –used to restore protein clotting factors
  • Paralyze –induce complete or incomplete loss of nerve function to a part of the body
  • Dextran –blood plasma substitute obtained by the action of a specific bacterium on sugar solutions; used as a 6% or 10% solution in hemorrhaging, shock, etc.
  • Narcotics –Describes a drug which produces abnormally deep sleep

Case # 4
(from “Dead Again”)
by Sara St-Laurent, Kristin Walton, and Diana Page

Scenario:

 

Middle-aged male brought in after a pedestrian walkway collapsed on him. Only a secretary accompanied him.

Symptoms:

  • Complains of possible broken ribs
  • Difficulty breathing, due to collapsed lung
  • Facial lacerations
  • Denied LOC. (Level of consciousness)
  • Decreased ability to speak
  • Pulmonary contusions (bruising to the lungs)
  • Tachy (cardiac) 120 (fast heart rate)
  • Blood pressure falling, Systolic 70
  • Widened mediastinmun (mediastinmun I the area where the heart is, when it is widened it indicates presence of blood)
  • Labile hypo tension (possible instantaneous decrease in blood pressure)
  • Sats 88. Oxygen saturation was 88, normal is 93.

Treatment:

  • Thoracacostomy tray. (Tray of instruments used to open the chest. Can be used to access heart and massage after heart failure.)
  • Angio cath. (Tube used to extract fluid from a cavity of the body)
  • Rapid Infuser. Pressurized bag put over blood bags to get fluid into the body quickly.
  • 500 cc's (of fluid) at chest tube.
  • Aortagram. The injection of dye into the circulatory system, used with MRI to create observable images of tears in the heart.
  • T.E.E. Trans-ephological echo. Another means of looking at how the heart functions and damage done to the heart.
  • Sub Clavins. Major vein in upper chest area. Above collarbone, used for quick intake of fluid. Used in conjunction with the rapid infuser.
  • Spleenic fracture- fracture of spleen which is a sensitive organ.
  • Flail chest. An unstable chest wall resulting from fractures of sternum or ribs.

Case # 5
(from “Dead Again”)
by Lilia Gershgorin and Molly Troup
 
Scenario:

 

A forty-two year-old man named Mr. Royston comes into the ER with his two young sons Derek and Pete. He had playing basketball and began to get pains in his chest. He waited an hour to go to the ER. Three doctors worked on him.

Symptoms:

  • Very severe chest pain, on a scale of 1-10, a pain of "40"(described by patient)
  • Feeling of "elephant on chest"- a symptom often described by patients before having a heart attack
  • Fatigued
  • Diaphoretic-perspiring
  • Blocked heart vessel- causing the pain on chest, lack of blood going to heart
  • No pulse
  • Acute Inferior MI- Acute Myocardial Infarction: Heart Attack
  • V-fib: a ventricular fibrillation- bizarre rapid irregular ineffective rhythem with electrical wave forms varying in size and shape
  • V-tach: regular or slightly irregular rhythm, heart rate over 200

Treatment:

  • Tombstones in two, three, and "F"- Non medical way of describing the line tracings on an EKG
  • Spray under tongue
  • Aspirin, gave him 80
  • Push 5 of metoprolol: Meoprolol is used in the treatment of hypertension, to relieve angina and in IHD patients to help prevent
    recurrent Myocardial Infarction, to correct cardiac arrhythmias, in hyperthyroidism. It has a membrane stabilizing effect in large doses.
    It causes decreased automaticity, conduction velocity and increases the refractory period to nerve impulses in nerve conduction. As a result, they decrease
    the heart's need for blood and oxygen by reducing its workload. They also help to maintain the cardiac rhythm.
  • Started compressions:
  • Opened an intubation tray: something that contains equipment that opened airways to allow you to breath: a tube is inserted orally
    or nasally into trachea, which can be attached to a ventilator to assist in breathing
  • Titrate morphine
  • Heparin- anticoagulant, used to decrease the clotting ability of the blood and help prevent harmful clots from forming in the blood vessels
  • Nitro drips- drugs administered by IV infusion
  • Catheterization: also known as an angiogram: a tube is inserted through an artery, x-ray pictures are taken of the heart.
    This test is used to evaluate the patients cardiac condition
  • Lidocaine: belongs to the family of anesthetics, antiarrhythmic drug commonly used to restore a regular heartbeat in patients with arrhythmia.
    This effect is produced both by delaying abnormal nerve pulses to the heart and reducing irritability of the heart tissue. This effect is produced both
    by delaying abnormal nerve pulses to the heart and reducing irritability of the heart tissue.
  • Procainamide: Used to correct irregular heartbeats to a regular rhythm and to slow an over-active heart
  • Thrombplytic therapy: a treatment for acute MI,
  • Tenecteplase: A medicine used to prevent heart attack damage by helping the body's own system to dissolve the clot in the heart

After Note:

 

After all of these treatments, Mr. Roysten was pronounced dead. However, after the other doctors left, Dr. Pratt decided to resurrect him because he was in
V-Tach and he said that he could shock him to bring him back. He does so and gets a BP of 90 palp. The patient has a beating pulse, but no consciousness.
He will have lack of basic brain function indefinitely, so his wife decides to pull him off life support machines.

Case # 6
(from “One Can Only Hope”)
by Dallas Dunn and Carolyn Wills
 
Scenario

A twenty-six year old female collapses in a crosswalk. She tells the doctors that she suffers from alpha-1 antitrypsin deficiency. She has been previously
treated with Prolastin, which she had to discontinue because of an allergic reaction. She has also previously undergone a lung-volume reduction surgery and a liver transplant. Her lungs are rapidly failing and her only option is a complete heart-lung transplant, so she decides she wants to sign a DNR.

Symptoms

  • collapsed lung
  • no breath sounds
  • ABG: arterial blood gas; method provides a blood specimen for direct measurement of partial pressures of carbon dioxide and oxygen, hydrogen ion
    activity, total hemoglobin, oxyhemoglobin saturation, and the dyshemoglobins carboxyhemoglobin and methemoglobin
  • tachy 120: refers to tachycardia, which is increased heart rate
  • pulseox: measures oxygen saturation in the bloodstream as well as the pulse
  • GCS: Glascow coma scale, a scored scale used to quantify level of consciousness after brain injury. 13 is a good score, 15 is the best possible score.
  • panacinar emphysema: affects all air spaces distal to the terminal bronchioles; i.e. respiratory bronchioles and alveolar ducts and spaces; lower lobes
    are most affected, especially lung bases althoughthe entire lung may be abnormal; lungs are characteristically very large, overlapping the heart, and fail to
    collapse on opening of the pleura
  • bilateral pneumos: pneumonia in both lungs
  • alpha-1 antitrypsin deficiency: also called A1AD; a genetic disease caused by a protein deficiency that leads to early onset of advanced
    emphysema in young adults; white blood cells release an enzyme called neutrophil elastase that can damage the lungs. In normal lungs, alpha-1 antitrypsin
    protects the lungs from the harmful effects of neutrophil elastase. When the lungs do not have enough alpha-1 antitrypsin, neutrophil is free to destroy lung tissue.
    As a result, the lungs lose some of their ability to expand and contract, and this leads to emphysema and breathing difficulty.
  • anaphylactic shock: shock due to an allergic reaction characterized especially by respiratory symptoms, fainting, itching, urticaria, swelling
    of the throat or other mucous membranes, and a sudden decline in blood pressure
  • cirrhosis: scar tissue replaces normal tissue and blocks blood flow within the liver

Treatments

  • intubate: to insert a tube into a body cavity or hollow organ, as in the trachea or stomach; intubation via the trachea is used when patients cannot get enough oxygen
  • pressure mask: an alternative to intubation; it uses oxygen under high pressure to force air into the patient's lungs;
    works the same way as a ventilator but without the use of the intubation tube
  • ventilator: machine which increases surrounding atmospheric pressure to force air into the lungs, facilitate chest expansion, and
    allow for the inward flow of oxygen through the intubation tube in the patient's trachea
  • antirejection meds: approximately 60-70% of liver transplant patients experience a rejection episode; antirejection medications such as Neoral, Prograf,
    and Imuran reduce the risk of rejection but may also make the body more susceptible to infection
  • Prolastin: a drug derived from human blood plasma; it is administered intravenously and is currently the only available product for chronic
    replacement of alpha-1 antitrypsin; its purpose is to prevent the continued lung destruction caused by neutrophil elastase; an allergic
    reaction to Prolastin can cause the patient to go into anaphylactic shock
  • lung volume reduction: a surgery once considered a treatment option for alpha-1 antitrypsin deficiency; it is not often feasible because of the
    diffuse mechanism of injury of the disease
  • liver transplant: because the protein alpha-1 antitrypsin is formed by the liver, the deficiency disease can often be cured with a liver transplant;
    however, the damage the disease causes in the lungs will not be corrected by the liver transplant
  • heart/lung transplant: only performed when the patient suffers from severe pulmonary hypertension, which is a large increase of blood pressure in
    the vessels in the lungs which limits blood flow and delivery of oxygen to the rest of the body
  • DNR: do not resuscitate; the patient can sign this release form if he or she does not wish to be kept alive by intubation, defibrillation, or other invasive or painful treatments.

 

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