Can't breathe or pee

[DartmouthDave]

Hello,

You are dispatched to a rurual home 30km from town for SOB.

Upon arrival you find a 55 year-old frail looking female in obvious distress. She is hunched forward, tachypenic, and using assessory muscles. Her colour is pale. She is very anxious.

She is surrounded by a large and loving family that is on the verge of panic. Her husband states that he wanted to call an ambulance yesterday but his wife wouldn't let him. He says that she has cancer (lymphomas)and that she has been getting cytotoxic therapy and has been going down hill over the past three days. She has not voided for the past 24 hours.

On exam;

GCS 15

BP 190/110

HR 120 irregular/bounding

Temp 39

Generalized pitting edema. Lungs have course crackles in all lobes. Elevated JVD. A PICC line is note in her right arm. An old surgical scar is noted in her lumbar region (Laminectomy).

Her past medical history is obtained from the husband. Her history includes lower back pain and a Laminectomy 5 years ago. Lymphomas with some renal issues. The husband can not remember more about her renal issues.

Her current midications are Colace BID, Hydromorphone 2mg PRN, Allopurinol 400mp BID, Ativan 1mg SL PRN, Venalfaxine 150mg OD and Immovaine 15mg QHS.

What would you do and why?

Cheers....

[rock_shoes]

Hello,

You are dispatched to a rurual home 30km from town for SOB.

Upon arrival you find a 55 year-old frail looking female in obvious distress. She is hunched forward, tachypenic, and using assessory muscles. Her colour is pale. She is very anxious.

She is surrounded by a large and loving family that is on the verge of panic. Her husband states that he wanted to call an ambulance yesterday but his wife wouldn't let him. He says that she has cancer (lymphomas)and that she has been getting cytotoxic therapy and has been going down hill over the past three days. She has not voided for the past 24 hours.

On exam;

GCS 15

BP 190/110

HR 120 irregular/bounding

Temp 39

Generalized pitting edema. Lungs have course crackles in all lobes. Elevated JVD. A PICC line is note in her right arm. An old surgical scar is noted in her lumbar region (Laminectomy).

Her past medical history is obtained from the husband. Her history includes lower back pain and a Laminectomy 5 years ago. Lymphomas with some renal issues. The husband can not remember more about her renal issues.

Her current midications are Colace BID, Hydromorphone 2mg PRN, Allopurinol 400mp BID, Ativan 1mg SL PRN, Venalfaxine 150mg OD and Immovaine 15mg QHS.

What would you do and why?

Cheers....

For starters let’s get this lady some O2. The SPO2 monitor probably isn't going to be overly helpful given the patient's lymphoma (type?stage?) and cytotoxic therapy. 12-lead? BGL? At first glance I'm thinking renal failure that has progressed to the point the patient is displaying s/s of CHF. Renal failure and the patient’s already immune compromised state could also mean the patient has an opportunistic infection explaining the elevated temp. Over the short term BiPap or CPap if available would probably be helpful. IV access if the PICC is not the type you can access (no fluids just yet), position of comfort, Lasix (wondering if a loop diuretic is best practice given the suspected renal failure), Nitro if not contraindicated.

How long has this patient been taking the Allopurinol? I'm curious as renal failure is specifically listed as a potential side effect and the patient has a history of unspecified renal issues.

In hospital tests I would be interested in:

Kidney Function Panel (If the receiving facility uses such a thing)

CBC(RBC, Hematocrit,ect.)

Metabolic Panel (Uric acid, Albumin, BUN, Electrolytes, Bilirubin, Creatinin ect.)

ABG

Trops

This is where my thought process is right now as a PCP. These next couple of years in school and more experience might yield an altogether different answer.

Edited March 18, 2010 by rock_shoes

[mfprincess]

Hello,

You are dispatched to a rurual home 30km from town for SOB.

Upon arrival you find a 55 year-old frail looking female in obvious distress. She is hunched forward, tachypenic, and using assessory muscles. Her colour is pale. She is very anxious.

She is surrounded by a large and loving family that is on the verge of panic. Her husband states that he wanted to call an ambulance yesterday but his wife wouldn't let him. He says that she has cancer (lymphomas)and that she has been getting cytotoxic therapy and has been going down hill over the past three days. She has not voided for the past 24 hours.

On exam;

GCS 15

BP 190/110

HR 120 irregular/bounding

Temp 39

Generalized pitting edema. Lungs have course crackles in all lobes. Elevated JVD. A PICC line is note in her right arm. An old surgical scar is noted in her lumbar region (Laminectomy).

Her past medical history is obtained from the husband. Her history includes lower back pain and a Laminectomy 5 years ago. Lymphomas with some renal issues. The husband can not remember more about her renal issues.

Her current midications are Colace BID, Hydromorphone 2mg PRN, Allopurinol 400mp BID, Ativan 1mg SL PRN, Venalfaxine 150mg OD and Immovaine 15mg QHS.

What would you do and why?

Cheers....

The patient appears to be in flash pulmonary edema (CHF). CPAP is definately indicated, nitro paste, lasix which may not be usefull since the patient is most likely also in renal failure. It will be very difficult to manage this patient in the field so rapid transport to a facility that can handle her multiple medical issues is indicated.

Edited March 18, 2010 by mfprincess

[DartmouthDave]

Hello,

Here is some more:

Airway/Breathing:

The patient is dose not want intubation at all. I forgot to add the SPO2. The monitor shows 82% on room air. So, CPAP or BI-PAP is a solid option.

Circulation:

As noted above. Gross edema. An IV looks impossible. So, the PICC would seem to be the only option here.

The EKG shows Sinus Tachycardia with peaked T waves. Also, there is a fair degree of irritability as evident by numerous multifocal PVC's (one every 2-3 seconds or so).

Additional History & Assessment Information:

A BGL is done. He blood sugar is 12.5

The husband say the cancer is 'bad' (terminal) and the chemo was done to 'Give her more time.' She is a DNR (No CPR or Shock) but wants active treatment including ICU admission.

Her renal function was fine. She was voiding fine until recently. The Allopurinol was started a few months ago to manage a complication of her cytotoxic therapy. She has been compliant with taking her medications.

She hasn't been eating well at all. She has been losing weight. Sometimes, she takes a multivitamin. It was suggested by a Dietitian. But, she dose not take it often because it upsets her stomach.

Treatments Considered:

NTG? Dose? IV? SL?

Lasix? Dose?

CPAP/BI-PAP Settings?

Any considerations for the EKG? Causes? Treatment?

Ventolin?

Ativan?

So, why may be the cause of the renal issues?

Use the PICC?

I hope this helps. Some brain gym. I based this case on an interesting patient that came through the ICU quite a few months back.

Off for yet an other night shift. =(

Cheers

[HellsBells]

NTG? Dose? IV? SL?- I'd start with SL @ 0.4mg

Lasix? Dose?- meh, don't know if id use lasix- the dose would be 1mg/kg (or 20-40mg). The concerns I'd have would be the renal shutdown, but it seems acute, so it may be benefical

The EKG findings point to Hyperkalemia, so Tx should include

- calcium chloride- 8-16mg/kg

- Sodium Bicarb- 1mEq/kg

- ventolin neb- 5-20mg

- insulin/glucose- 10U/25g- over 10-15 min

So, why may be the cause of the renal issues? I think that the renal failure is caused by the cytotoxic therapy the pt is undergoing, but not sure of the specific patho behind it.

Use the PICC?

if IV access was a problem, I guess I wouldn't have much choice, although I'm not sure if it would be a good idea to put the bicarb down the same line as the other drugs, does anybody have an opinion on that?

[DartmouthDave]

NTG? Dose? IV? SL?- I'd start with SL @ 0.4mg

Lasix? Dose?- meh, don't know if id use lasix- the dose would be 1mg/kg (or 20-40mg). The concerns I'd have would be the renal shutdown, but it seems acute, so it may be benefical

The EKG findings point to Hyperkalemia, so Tx should include

- calcium chloride- 8-16mg/kg

- Sodium Bicarb- 1mEq/kg

- ventolin neb- 5-20mg

- insulin/glucose- 10U/25g- over 10-15 min

So, why may be the cause of the renal issues? I think that the renal failure is caused by the cytotoxic therapy the pt is undergoing, but not sure of the specific patho behind it.

Use the PICC?

if IV access was a problem, I guess I wouldn't have much choice, although I'm not sure if it would be a good idea to put the bicarb down the same line as the other drugs, does anybody have an opinion on that?

Hello,

The PICC is a triple lumen line so lots of room.

The general consensus is:

- Start Bi-Pap

- Go for the PICC

- Give NTG .4mg SL

- CalCl, NaHCO3, Insul, D50W, Ventolin for the peaked 't' waves

- Consider Lasix IV

Response to treatment:

Once the Bi-Pap mask is applied the patient settles some. Her SpO2 creeps up to 86% and her rate is in the 30's

NTG drops the BP some (BP 170/80).

The T-waves are coming down slowly. She is still quite tachy with numerous multifocal PVC's. With what appears to be occasional runs of polymorphic VT (6-8 complexes). During these runs her LOC decreases.

The patient is quite anxious as well. Her husband wants to give her an Ativan. He finds it makes her breathing better. From time to time she try to pull the mask off.

Pardon any typos....trying to knock this post off while at work. Here is a hint as to the patho of the renal failure. Think about the lysis of tumors from the chemo. =)

Cheers....

[rock_shoes]

Airway/Breathing:

The patient is dose not want intubation at all. I forgot to add the SPO2. The monitor shows 82% on room air. So, CPAP or BI-PAP is a solid option.

At my current license level the best option available to me would be assisted vents adding PEEP using a BVM.

Just for fun I’m going to pretend I have any typical EMS resource I want on this one including a CCT endorsed ACP license (might as well kill pretend patients while learning instead of real ones right). Since BiPAP isn’t in the standard PCP SOP I’m going by reference numbers only. Let’s start with an IPAP at 10 mmH2O and an EPAP at 5 mmH2O. Vent or Squint this would be a great spot to chime in.

Circulation:

As noted above. Gross edema. An IV looks impossible. So, the PICC would seem to be the only option here.

Given the circumstances as a PCP I would be SOL so far as gaining circulatory access other than the PICC line (peripheral IV access only).

I’m starting to query Endocarditis as a possibility. If that is the case the patient’s PICC line is a potential culprit. That makes me a little leery with regards to using it. Your first post indicated JVD so worst case scenario an external jugular should be an option. I’m thinking an EJ is probably better than an IO. Anyone with more experience here is welcome to chime in. Would it be advisable to use a potentially infected PICC line anyways in this case? I’m thinking not but I could certainly be wrong.

I’m also giving consideration to Myocarditis and Pericarditis. You didn’t mention the patient having chest pain pleuritic or otherwise so Pericarditis is a little lower on the list.

The EKG shows Sinus Tachycardia with peaked T waves. Also, there is a fair degree of irritability as evident by numerous multifocal PVC's (one every 2-3 seconds or so).

So we should also be considering hyperkalemia. This patient’s heart is seriously stressed. JVD and pitting oedema indicating RVF, course crackles throughout the lung fields indicative of LVF. Gentle gentle with this one I think.

Additional History & Assessment Information:

A BGL is done. He blood sugar is 12.5

Her renal function was fine. She was voiding fine until recently. The Allopurinol was started a few months ago to manage a complication of her cytotoxic therapy. She has been compliant with taking her medications.

Hyperuricemia is a potential complication of cytotoxic therapy thus the Allopurinol correct?

She hasn't been eating well at all. She has been losing weight. Sometimes, she takes a multivitamin. It was suggested by a Dietitian. But, she dose not take it often because it upsets her stomach.

Is there any way of finding out what’s in this multi-vitamin? I usually like to take a patient’s prescriptions and vitamins etc. with me.

Treatments Considered:

NTG? Dose? IV? SL?

Let’s go with 0.8 mg SL for the first one.

Lasix? Dose?

40 mg IV (I’m still skeptical about using Lasix with suspected renal failure). Not too worried about causing hypokalemia given the patient’s ECG findings.

Ventolin?

No. Considering the patient’s precarious cardiac status I’m extremely hesitant to consider using Ventolin initially. I’ve never seen Ventolin cause an excessive adrenergic response but this patients tolerance to any additional cardiac stress would be extremely low.

Ativan?

Probably not a bad idea. 1mg Ativan SL could help her to calm herself which would only serve to help improve her condition. Other treatments listed for the Hyperkalemia when I looked them up included CaCl, Sodium Bicarbonate, Glucose/Insulin, Ventolin. I think the Sodium Bicarbonate would be worth consideration in particular partially due to the suspected potential for hyperuricemia.

So, why may be the cause of the renal issues?

Hyperuricemia? Infection related to one of the carditis’ (Endo, Myo, Peri)? Renal injury subsequent to her cytotoxic treatments? When was her last treatment btw?

Use the PICC?

I’m suspecting the PICC is a potential culprit so no.

I hope this helps. Some brain gym. I based this case on an interesting patient that came through the ICU quite a few months back.

Off for yet an other night shift. =(

Cheers

This is quite an interesting case Dave. I’m running through it as a learning exercise since most of the considerations/treatment modalities are beyond my current license level. Maybe I’m way off base. Either way I’m learning something about multiple conditions through the process.

Regards,

Ed

Edit: You posted your last one while I was hammering this one out so sorry for any repeats.

[ccmedoc]

With the JVD, why is IV access not possible. E.J. is a viable option. Unless you have experience with PICC lines, I would suggest you stay away from this option.

EJ is not a last option, it is a very good primary option for IV access..

Edited March 19, 2010 by ccmedoc

[chbare]

Want to consider tumor lysis syndrome.

Take care,

chbare.

[DartmouthDave]

With the JVD, why is IV access not possible. E.J. is a viable option. Unless you have experience with PICC lines, I would suggest you stay away from this option.

EJ is not a last option, it is a very good primary option for IV access..

Hello,

I think a PICC is a safe option here. Sure, an EJ would work. But, why risk it if you have a perfectly function PICC line? As for Perm-Caths and Quinton more cation would be required and an EJ would be a better go. IMHO.

Cheers