Understanding Adrenal Emergencies and Management in the ED

Show Notes

Shownotes

Asha SE, Miers JW. A systematic review and meta-analysis of D-dimer as a rule-out test for suspected acute aortic dissection. Ann Emerg Med 2015. PMID: 25805111

Dierks DB et al. Clinical policy: critical issues in the evaluation and management of adult patients with suspected acute nontraumatic thoracic aortic dissection. Ann Emerg Med 2015; 65: 32-42. PMID: 25529153

Acid-Base Cases

 

Quick questions & answers:

1. For acute respiratory acidosis or alkalosis, how much does the pH change for every 10mm change of PCO2?
2. What is the Winter’s formula?
3. For stable chronic respiratory acidosis, for every 10 mm increase in PCO2, how much should the pH decrease by?

For each of the following cases, please analyze the acid-base status (i.e. anion gap metabolic acidosis, respiratory alkalosis, non-AG metabolic acidosis with respiratory acidosis, etc…) for further discussion in the workshop.

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1) A 25 year old woman is found at home c/o thirst, shortness of breath, and spasms of her arms and legs.

Vital signs: BP 90/50 mmHg; pulse 155/min; RR 32/min; afebrile; RA O2 sat 98%.

137     84   18   274    Calcium 9.6

2.4     29   1.2

VBG:   7.66   / 25.5   / 29.1

• What is the acid base abnormality?
• What abnormality is responsible for her neuromuscular symptoms?
• What other electrolyte abnormalities would you expect?
• How should she be treated?

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2) A 21 yo female presented to ED after reportedly ingesting an entire bottle of pills (drug and formulation unknown) and now complaints oftinnitus, nausea, and vomiting.

Exam: A, O x3, Pupils – dilated, reactive, Neuro – no hyperreflexia, rigidity or clonus

Lungs – + tachypnea, CV – tachycardia, no murmurs, skin nl

VS:   BP 92/67, HR 100/min, RR 18/min, T 98.6, RA O2 sat 99%

135   104     12   145

3.8       11     0.9                  Ca 7.8

ABG:   7.47 /   14   /109   /10

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3) A 56 yo female with a past medical history of heroin use (on methadone maintenance therapy) and chronic ETOH use presents with chest pain, shortness of breath, body aches, as well as nausea, vomiting and diarrhea.

VS:  BP 164/84, HR 112/min, RR 22/min, T 98, RA O2 sat 98%

MS – awake, alert and oriented x2, CV – tachycardic, RR no m, abd nl, skin nl

136   98   7   277

3.4   19   0.9

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4) 53 y/o M referred to the ED for severely elevated BP of 235/135. He c/o 1 week of polydipsia, polyuria, fatigue, and some dyspnea on exertion.

No known PMH but has no doctor evaluation for many years.

VS: BP 191/94, HR 88/min, RR 18/min, T 97.4

143       89       23       253

2.3       45         1.0

ABG: 7.56   / 53.6   /   65.4     lactate 3.2

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5) A 62 y/o M with h/o stage IIIa rectal ca s/p diverting ileostomy 5 months ago & currently on chemotherapy presented with 3 days of repeated vomiting, watery diarrhea, and generalized weakness.

VS: BP 80/47, HR 100/min, RR 26/min, T 95^o, RA O2 sat 96%

PE: thin M, tired appearing

121     86   166     164

4.4       8     13.6

VBG:   7.04 / 31   / 28.6   bicarb 7.9                   WBC 7.5 / 14/41.8   / 180K

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6) 66 y/o M presented to the ED because of alcohol withdrawal.

VS: BP 144/98, HR 130/min, RR 22/min, T 98.3, RA O2 sat 97%

141   102   8     85                                      ABG on O2     7.45   /   24    / 136

4.3     13     0.7

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7) A 32 y/o F with hx of DM x 20 yrs on canagliflozin presented to the ED c/o polyuria x 2 days, epigastric pain, and not feeling well.

VS: BP 139/77, HR 112/min, RR 32/min, T 98.5, RA O2 sat 99%

135   104   17   191

3.4       3     0.4                                 7.06 / 11   /   125

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8) A 55 y/o M with history of asthma but non-compliant with all medications and follow up presented to the ED with asthma exacerbation over the past few days. He appears to be SOB, able to speak to you & complete his sentences. + mild accessory muscle usage, mild wheezing

VS:   BP 150/90,   P = 115/min, R = 30/min, T = 98 , RA O2 sat 87%

ABG:     7.22   / 85   /   55

143     102   25   99

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3.8     36   1.3

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9) A 70 y/o M with h/o COPD presented with 2 days of vomiting and weakness.

VS:   BP 150/ 85, HR   100/min,   RR 18/min , T 99,   RA O2 sat 90%

136   85     28     65                               7.19 / 60   /   55     bicarb 25

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4.1       25    1.4                                          AST/ALT     150 / 100     Alb 2.5

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10) A 37 y/o M presents to the ED in a coma.

VS:   BP 110/80, HR 125/min, RR 30/min, T 97, O2 sat 99% on RA

142        |   104   |   15   |   89                           7.05       /   15     /   115     bicarb 5

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3.9        |     5     |   1.9