CASE ABG
CASE ABG
A 77 yo man presents to your ED feeling generally unwell for several days.
He has a pulse rate of 36/minute and a BP of 150/80.
ABG and some biochem is performed.
Questions:
1. Describe these results.
2. What other investigations will you do ?
3. How will you manage this man ?
ABG
FiO2 0.3
pH 7.19
pCO2 30
pO2 119
HCO3 14
Base excess -15
SpO2 97%
Na 132
K 6.9
Cl 98
Creatinine 1050
Urea 49.4
Glucose 6.1
Lactate 3.5
Digoxin 5.9
Answers
1. Describe these results.
Acid Base Status
• there is a moderate metabolic acidaemia (HCO3 14, Base excess -15)
• respiratory compensation is appropriate (Winter's formula)
• Anion gap is elevated - 20 if you don't include K ; 27 if you do
• Delta ratio (increase in anion gap / change in bicarb) = 0.8 - a borderline number
Electrolytes
• Na - mildly low, no need to correct for glucose
• K - hyperkalaemia - given pH, this is both overall K excess as well as extracellular shift (correcting to pH 7.4 would be expect to drop K to 5.9)
• Urea + Creat : impressively elevated, suggestive of severe ARF (or ARF on CRF). High urea ratio makes you consider prerenal cause, but urea : creat not that high. Other considerations such as post renal (especially in an old man), or intrinsic renal pathology remain on the table.
Oxygenation
• Using alveolar air euqation, A-a gradient is 57 - ie elevated.
• Concerning for shunt - new or preexisitng respiratory pathology.
Others
• Digoxin level = 5.9
- this is a very high level and indicative of digoxin toxicity - a life threatening diagnosis
- given the stem, it is likely this is chronic toxicity, precipitated by renal failure rather than an acute overdose
What other investigations will you do ?
• ECG - looking for AV block (note bradycardia), pseudonormalised slow AF (almost pathognomonic of digoxin toxicity) or other abnormalities of conduction & automaticity
• Ca / Mg / PO4
• Bladder scan / ED POCUS - post renal ARF needing IDC
• Medication review - precipitants of ARF
• Septic screen- as driver for ARF
• Volume assessment - likely to be dry
How will you manage this man ?
• This man has acute renal failure with a raised anion gap metabolic acidosis and chronic digoxin toxicity - he is critically unwell an needs to be managed in resus or time critical in a monitored bed.
• Good IV access
• IV fluid to rehydrate - this may well also drop the K
• Digoxin immune Fab - 2 vials in 100mls NSaline over 30 minutes
May need more - review after this and see - can work out amount needed based on dig level and weight - but I would suggest getting it started and then breaking out the calculator !
• Insulin + Dextrose for hyperkalaemia - avoid Calcium in dig toxicity (some debate around this)
• IDC
• Will need dialysis - refer ICCU (vascath, RRT and close watching)
CASE - The swollen toddler...
A 3 yo boy is brought to ED by his concerned parents who have noticed he has put on weight and appears to be puffy. As a routine, one of the nursing staff obtains a urine which they notice to be quite frothy.
What clinical syndrome does this young boy have ?
Why is the urine frothy and what do you expect the disptick to show ?
What are the causes of this presentation and what are its complications ?
How are you going to manage this young boy ?
[pic][pic]
Answer
1. This young boy has Nephrotic syndrome.
Nephrotic syndrome is a manifestation of glomerular disease (a constellation of signs and symptoms) rather than a specific diagnosis. It is characterised by :
- proteinuria > 40mg/m2/hour (3.5g / day in adults) or morning urine prot:creat ratio >200mg/mmol (3-4+ on dipstick)
- hypoalbuminaemia ( ................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related searches
- strategic management case study pdf
- 1 page business case template
- simple business case template
- business case one page template
- business case examples
- florida board certification case manager
- certified case manager certification florida
- case management certification in florida
- case management software nonprofit
- case quoting another case blue book
- upper case and lower case abc s printables
- pacer case locator case search