# what the heck happened to my pt. today?



## 04_edge (Mar 8, 2011)

Hx  47 yo Asian male.  NMPHx, no meds, allergies ect. Basically a healthy male that has not been out of the country for 6-7 years.  

3-4 months prior pt spiked a high fever~40C, it only lasted for a day and went away(unknown if pt had any other S/S during this time)

Pt comes into ER today, ambulatory with GCSx15 C/O fever x1 day, again ~40C.  2-3 hours later pt was intubated, 6 hours after admitance to the ER pt coded for the first time.

We ended up working the Pt for over 2 hours.  Everytime we got a pulse back he was very tachy, the first time it was in the 180's, and everytime after it was in the 140's(which im sure was because of all the sympathomimetics dumped into him)  Basically everytime he came back, he would be ok for ~5-10 minutes and his H.R. would slow down, eventually into PEA in the 110-130's.

Pt ended up with 7 or 8 liters of NS, 4U of blood and 2-4 of plasma.  Zero urine output in this time.  During the middle of the code, Levophed, Dopamine, Vasopressin, and EPI were all running on a drip at the same time, on top of the 1mg EPI being pushed every 3-4 minutes.  Pt also got lots of bicarb during this time.

In the last 30-45 minutes the pt began having DIC(i guess thats how its used in a sentence) and eventually lost 1-2 liters of blood through the ETT.

The docs thought it may have been a bowel obstruction, although the pt was incontinent.  Chest x-ray showed a "haziness" that led them to believe he possibly had a staph infection in his lungs.

Any other ideas?  I find it hard to believe that a pt became septic and died within one day from a bowel obstruction, even if it was perforated, i dont see it happening that fast.  Not to mention there was no melena or hematochezia.

P.S.  sorry if this was scattered out, i was just trying to cover all my bases.


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## usafmedic45 (Mar 8, 2011)

Ask the doc to follow up with the medical examiner and tell him you are interested in learning from the case.  Most docs are eager to teach younger providers if you are truly interested and wanting to learn.  That'll give you the best and most definite answer to this.  Without an autopsy, you're simply going to get half-assed guesses on here.  Rely on the hard facts.


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## MrBrown (Mar 8, 2011)

Brown would be interested in learning about what this was too


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## 04_edge (Mar 8, 2011)

I am definitely trying to find out what happened with this guy. Not only because im curious, but because i got this guys blood all over my boots/pants and am wondering if there is anything i should be worried about. This was my last hospital rotation though, so im not sure how succesful i will be.


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## usafmedic45 (Mar 9, 2011)

> Not only because im curious, but because i got this guys blood all over my boots/pants and am wondering if there is anything i should be worried about



Unless it came into contact with broken skin or with mucous membrane, you should be OK.  However, I would definitely ask your medical director.


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## medicstudent101 (Mar 9, 2011)

This is a very interesting case. I too doubt this was a bowel obstruction even with a massive perf. I myself am towards the end of my rotations and gearing up for the national registry. Good luck to ya!!


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## M3dicDO (Mar 9, 2011)

usafmedic45 said:


> Without an autopsy, you're simply going to get half-assed guesses on here.  Rely on the hard facts.



He's right. You mentioned many things in your case that are not unique to any form of infectious disease. The fact that the pt. went into respiratory arrest prior to cardiopulmonary compromise is very suspicious because you didn't mention any shortness of breath (SOB). Community acquired pneumonias are nasty, but they usually present to the ED with SOB in addition to fever of a few days. You didn't mention presence of any nuchal rigidity either, but then again meninigitis cannot be ruled out 100% simply on the basis of negative physical findings, especially on a super sick patient like this one. Do you remember seeing any rashes?



04_edge said:


> Chest x-ray showed a "haziness" that led them to believe he possibly had a staph infection in his lungs.



You mentioned staph infection in the lungs, which is also a possibility. Your case sounds like bacteremia leading to septic shock. The source could have been anywhere in the body. The fact that the physician saw "haziness" in the CXR could be because either either hospital acquired MRSA or as a result of DIC. Again, the fact that your patient did not present with SOB would indicate that the "haziness" is not the likely source of his symptoms.



04_edge said:


> The docs thought it may have been a bowel obstruction, although the pt was incontinent.
> 
> Any other ideas?  I find it hard to believe that a pt became septic and died within one day from a bowel obstruction, even if it was perforated, i dont see it happening that fast.  Not to mention there was no melena or hematochezia.




I doubt bowel obstruction is a cause, because the abdominal xrays and CT-scans would have picked it up. Also, the patient didn't present with abdominal complaints. It's not very likely that the pt. would deteriorate so rapidly due to a bowel obstruction within a few hours of presenting to the ED.

There is too big of a list of differentials for your case. If you can post some lab values (comprehensive) and radiology reports, we can work on narrowing down the possible causes for the pt.'s symptoms. The best way to find the cause of his condition would be through an autopsy report. Pathologists do an amazing job of finding causes of death. Please keep us updated on if you find out what happened to him!


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## firetender (Mar 10, 2011)

*Let's try THIS!*



04_edge said:


> Hx  47 yo Asian male.  NMPHx, no meds, allergies ect. Basically a healthy male .
> 
> (3-4 months prior pt spiked a high fever~40C, it only lasted for a day)
> 
> ...



I do not get that the Docs, at any time, had a clue as to what they were treating. 

This is clearly treating one (unlisted) symptom at a time which led into a juggling act.

It got so grossly out of proportion that it would be most impossible to distinguish what of any of the drugs administered or disease processes evident actually took the guy down.

At a certain point, he definitely got overloaded, but by what, who can tell?


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## EMTinNEPA (Mar 10, 2011)

Sepsis sucks.  It sounds like this patient went into cardiac arrest secondary to septic shock.  Was the patient tachypneic and tachycardic prior to arresting?

EDIT: when you find out the specific cause of death, please let us know.  This sounds like an interesting case.


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## Cindy (May 8, 2011)

*Ards*

My 62 y/o aunt was presented to ER for SOB, nausea and vomitting.  She has a hx of hypothyroidism and DM without complications and has never been hospitalized before.  She is not overweight.  She was admitted to ICU at midnight and by noon the next day, she had to be intubated and was hypotensive 70/40.  Sats were 70-80 on 100% O2.  She was started on levophed drip and vasopressin.  By 1800 she was in renal failure and fingers and toes became ishemic.  Chest x-ray showed bilateral infiltrates and blood cultures were positive.  It turns out she has ARDS (Acute Respiratory Distress Syndrome) where the alveoli fills with fluid and inflammatory cells that don't permit the exchange of O2 and CO2.  She also has DIC (Disseminated Intravascular Coagulopathy), Hemolytic-Uremic Syndrome and septic shock.  All of these illnesses alone have a high mortatlity rate and combined, her prognosis is very poor.  It sounds like your patient may have had ARDS as well and mortality is very high with ARDS.


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## usafmedic45 (May 13, 2011)

That's all fine and well, but ARDS doesn't generally just happen.  I think he was wondering more what triggered the case rather than what was the final shove into the grave.


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## mycrofft (May 13, 2011)

*Why treating for hypovolemia?*

I missed the data for why they jumped into the IV fluids, and blood, and vasopressors. BP? BP versus pulse? Was he third-spacing fluids on presentation? Pulse ox (did I say that?)? Any other labs like PTT, CBC with diff and RDW? Exactly what did the pt cite as the reason he came in this time, and was he coughing, or incontinent before he hopefully lost consciousness?

After a certain point in treatment with multiple meds, you start getting in your own way, having to account for one med's effects and side effects before you add another, sometimes accepting a bad interaction because there is a chance it may help an increasingly out of control situation...which makes things that much harder to control overall. If he was cultural as well as ethnically asian, there is a chance he had some herbals or imported OTC's on board not helping the picture either.

Big picture, this sort of reminds me of internal (not nasal or oral) staph exotoxic intoxication. Doesn't fit everything. My half-arsed guesses include a staph abscess up under the diaphragm that finally opened (hard to see on xray). Tox screen, after all thse drugs...? Good luck ever seeing any of that, though.

If he had diarreah, consider late _C. difficile_ maybe? Again, half my arse is missing here.

PS: watery incontinent BM is one possible sign of bowel obstruction.
PPS: remember that "Pt's lie"; not always intentionally, but we all are bad historians when we are the subjects.


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