Interesting EKG

[Christopher]

Alright, hold the phone... This seems like a case of ignorance, if you want my opinion.

Please tell me that you weren't thinking AMI because aVR and aVL were showing some elevation. I just had a similar ECG presented to me where a medic was concerned that their "STEMI" patient wasn't sent to the cath lab despite elevation in aVR and aVL. The confusion lay in the fact that they thought aVR and aVL were "continuous leads", whereafter I had to explain to them that, despite the leads being displayed next to each other they were not, in fact, contiguous leads, and that there was little correlation between the two.

I had to have a whole sit-down teaching session where I explained the schematic...

I Lateral aVR V1 Septal V4 Anterior
II Inferior aVL Lateral V2 Septal V5 Lateral
III Inferior aVF Inferior V3 Anterior V6 Lateral

Although the leads appear next to each other, they do not necessarily look at the same parts of the heart.

Don't forget that aVL and V2 are contiguous.

Don't forget that I and aVL are rarely elevated together in a high lateral.

aVR and aVL and -aVF are contiguous leads.

 

[Psych]

Since when is aztreonam available PO? Unless she had an IV at the SNF. I rarely see it used to begin with. Levequin is an appropriate treatment for a UTI. The risk of seizures is minimal and really only a major concern in patients with preexisting seizure histories. Levaquin can result in supratheraputic INR when used in patient's on coumadin but is usually not an issue in the relatively short time they are on an antibiotic regime.

I have rarely, if ever, seen a case of sepsis with any sort of complication treated with oral medications at a SNF, most of the time it is going to be going through a PICC line. Levoquin is an issue in patients with extensive cardiac history who are at risk for complications d/t urosepsis, you can find multiple instances of the paperwork on this. The risk of seizures is not minimal in a patient who is already exhibiting AMS.

Where do you see clear mutliorgan dysfunction? I see AMS. I wouldn't consider hyperglycemia. Is increased metabolic demand and ischemia an organ dysfunction? That is pushing it. Depending on white count, which I assume is elevated, she barley meets SIRS criteria. She is non-tachy, non-hypoxic, and not hypotensive. I do not think she was in deteriorating septic shock. Will it end up there? Most likely. But I have seen numerous patients with significant AMS from infections without sepsis and shock.

I didn't consider hyperglycemia either. Are increased metabolic demand and ischemia organ dysfunction? No. Are they both indicative of that happening? Yes. She is breathing at 20 a minute, her BP is crashing, she has a Hx of "encephalopathy" with a rapid degeneration of mental status, she is developing an arrythmia. She's developing multiple organ dysfunction, I am certain of that. We KNOW she has urosepsis, because that's what the diagnosis was. So it's not like she's developing AMS from "infection" and not sepsis, as you say. These things are easily tied together by an explanation, why do you need to find a way that they are not?

 

[Psych]

Where do you see clear mutliorgan dysfunction? I see AMS. I wouldn't consider hyperglycemia. Is increased metabolic demand and ischemia an organ dysfunction? That is pushing it. Depending on white count, which I assume is elevated, she barley meets SIRS criteria. She is non-tachy, non-hypoxic, and not hypotensive. I do not think she was in deteriorating septic shock. Will it end up there? Most likely. But I have seen numerous patients with significant AMS from infections without sepsis and shock.

On second thought, I should have said deteriorating into septic shock and that multiple organ dysfunction was probably imminent without some sort of rapid treatment different from however they were treating it at the SNF. Sorry sometimes when you're fresh off a complicated patient that crashes every similar case starts to look identical and I think that's what happened here.