Case Presentation #1: Pole runs out in front of car.

[Robert F]

You are on the ball, AmadaWIRN. You caught the "internal bleeding", etc.

Once you start talking to the patient and begin your thorough assessment, your patient tells you that there is pain whenever you palpate the Left Upper Quadrant.

Hmm, that hematocrit is low; but the RBC's havent taken a hit? Could there be an organ in the Left Upper Quadrant that has something to do with RBC's?

I'll give you a hint, if your right shoulder has radiating pain, you usually think Gallbladder, if your left shoulder has radiating pain, you usually look for?

A green EMS provider could have assumed the pain the patient reported to them that radiated to the shoulders was from Angina/MI. Hmm..

[AmandaWIRN]

lacerated spleen!

Wow, this chick's not having a good day, MI, MVC, tib/fib fx, and now a lacerated spleen.....


As an aside, when reading my previous response, I noticed that my wonderful typing skills had me ordering a CT of her "elvis." Perhaps that would show that her insides are "all shook up..." hehe

[Robert F]

That's right. The lateral force exerted by the car as it hit was enough to rupture that spleen, keeping the Red Cell count elevated(however old they may be) while the patient was having an internal bleed, all the while EMS was suspecting cardiac issues and worrying more about the tib fib they didnt do a proper assessment, or at least report what they found.


Sorry about that, I didnt catch the CT part. Yes, you would've caught the spleen had I been on the ball. lol.

The meds the patient was on masked alot of the symptoms. The rapid response to the scene, did not give the CK-MB enough time to elevate, and the pain of the Tib fx, masked the pain the patient had from the ruptured spleen.

Could there be some reason for ST Elevation, LBBB or Early Repolarization?

Summary
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The reason I put this particular case study together was to prove several points.

1. As WinterinED, pointed out, this is a zebra. Meaning, when you hear hoof beats you usually think horsey, not zebra; However, sometimes it is important to consider all factors.

Many Emergency Providers when they are new to the job see a car wreck and never think to ask if there was something medical going on with the patient.

2. Alot of new providers do not take into account the effects that a patients medications & conditions can play on their Lab results and overall presentation, as referenced by AmandaWIRN with regard to the Lasix & Metoprolol; maintaining the chemistries and the heart rate.

Key Points:

Always do a thorough assessment on every patient taking into account even the most minute of pertinent medical details. Usually with a patient who is on lasix, I would automatically check K+ levels. Perhaps, just perhaps the cardiac event was brought about by a higher than normal K+ level, and the lasix; being a potassium wasting diuretic brought it down temporarily.

What effect can a high K+ have on an EKG?
ST-Segment Elevation Resulting From Hyperkalemia -- Sims and Sperling 111 (19): e295 -- Circulation

It is so great to see that people here are on the ball. You guys nailed this one.

Case Study #2 will be posted in a week.

[WinterInED]

OK, but tell me what is DCAP-BTLS...I have been out of trauma nursing for too long. (A VA ER nurse) Really need the update training and am excited to be taking a ER Nursing class here in Phoenix at a local community college!!

[AmandaWIRN]

DCAP-BTLS = Deformities, Contustions, Abrasions,Penetrations, Burns, Tenderness, Lacerations, Swelling

Kind of like the secondary survey.

[Ricu]

Always late to the party...

RNMedic, I've been meaning to thank you for putting this together. What a great idea. Although I was too late for the discussion part, I got a lot out of reading the dialogue. You guys are sharp. Hopefully I'll be able to participate in the next one.

R

[Robert F]

Don't worry RICU. Case Study #2 is currently under development and will be posted toward the end of this week. Also, if you would like to help me write some future case studies that would be great. I am trying to write case presentations for all fields of nursing rather than just Critical Care or Trauma.

You are welcome for the case studies section.

[Ricu]

Originally Posted by RNmedicTN

Don't worry RICU. Case Study #2 is currently under development and will be posted toward the end of this week. Also, if you would like to help me write some future case studies that would be great. I am trying to write case presentations for all fields of nursing rather than just Critical Care or Trauma.

You are welcome for the case studies section.

Hey Robert,

I look foreward to the upcoming case. Thanks too, for the offer to contribute. I'll keep my eyes open for interesting cases.

R

[Robert F]

They don't necessarily have to be real life cases. For instance, I made up case study #1 to prove a point. I found some images on the net supporting the kinematics of the event, and an EKG showing the finding I was looking to represent, and made my vitals/lab tests match the findings.