Something doesn’t add up… March 26, 2012

Posted by Andy Jagoda, MD in: Cardiovascular, Neurologic, Trauma , 31 comments

A 29-year-old woman is brought in by EMS after a motor vehicle accident in which she was an unrestrained driver. She was found by the medics lying across the steering wheel with a large gash on her forehead. At the scene, she was awake, but disoriented, and there was a strong odor of alcohol on her breath. Her ED assessment revealed a small right-sided subdural hematoma and a zygoma fracture. Her serum ETOH level was 260 dL/mL, and she was placed under observation status on the trauma service. Six hours later, she becomes agitated and then rapidly develops left-sided weakness and neglect. Your first thought is that she must have had a seizure and is left with a Todd paralysis . . . but it doesn’t quite add up, and you wonder what else might have happened.

Is there anything you should be doing?

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“A case of Rhabdomyolysis…” Case Conclusion March 6, 2012

Posted by Andy Jagoda, MD in: Uncategorized , add a comment

The Conclusion Is…

The patient had clearly developed pneumonia, which was unsuccessfully treated from the previous hospitalization, and now presented with severe sepsis. You treated her with broad-spectrum antibiotics, taking into account her risk for gram-negative bacteria, and started crystalloid infusion to support her hemodynamically. You found that the she had developed rhabdomyolysis from sepsis and had already developed acute renal failure, with a BUN:Cr ratio concerning for myoglobinuria-induced renal failure. You checked the urine pH, which was 4.6, and switched her normal saline to 0.45% saline with 2 ampules sodium bicarbonate per liter to alkalinize the urine to a pH > 6.5. You continued early goal-directed therapy, performed endotracheal intubation to decrease her work of breathing, and consulted your intensive care unit for admission.

Congratulations to  Dr. Hugo, Dr. Anda, Dr. Achacoso, Dr. Cohen, and Dr. Peschanski— this week’s winners of Emergency Medicine Practice’sRhabdomyolysis: Advances In Diagnosis And Treatment!” For an evidence-based review of the etiology, differential diagnosis, and diagnostic studies for Rhabdomyolysis, read this issue.

A case of Rhabdomyolysis… March 1, 2012

Posted by Andy Jagoda, MD in: Musculoskeletal Emergencies, Renal and Genitourinary Emergencies, Trauma , 11 comments

A nurse informs you of a new patient who “just doesn’t look well.” You assess the patient, a 69-year-old woman who is coughing up green sputum, saturating 89% on room air, and is febrile, tachypneic, and tachycardic with a blood pressure of 86/40 mm Hg. The patient’s daughter informs you that her mother was just released from the hospital 6 days earlier after being treated for pneumonia. You suspect septic shock and instruct the nurse to place a nonrebreather mask on the patient. You administer broad-spectrum antibiotics, draw cultures and labs (including a venous lactate and a cardiac panel), and initiate a 30-cc/kg crystalloid infusion. The blood pressure normalizes, so you breathe a sigh of relief, but soon after, the lactate returns elevated at 8 mmol/L, which confirms your suspicion for severe sepsis. The nurse places a Foley catheter and reports that there is scant and “dark” urine in the bag. The WBC count returns at 18.4, and her BUN and Cr are 32 and 5.5, respectively. You note that the BUN:Cr ratio is odd, considering her previously normal renal function; you expected an increased ratio due to prerenal azotemia from severe sepsis. You then notice that the CK level is 67,000 U/L with normal MB fraction. To confirm your hunch, you check the UA, which returns positive for “blood” but does not show any red blood cells in the sediment.

This case reminds you that rhabdomyolysis has many causes, but the treatment in all cases is based on an aggressive hydration strategy. You recall that sodium bicarbonate infusion may be indicated and wonder: when, and how should it be initiated? You also wonder, “Is there anything else I can do for this patient that would mitigate against complications from renal failure?”

What’s Your Next Step?

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