sweet & sour…

The case.

A 7 year old boy presents to your ED with a 3-4 day history of fevers, nausea and vomiting. There is some associated non-specific abdominal pain. He has a history of Type 1 Diabetes Mellitus. His blood glucose at triage is reading ‘HI’ and his finger-prick ketones are 6.4 mmol/L. He is therefore taken through to your resus bay, where you achieve IV access and get the following set of results…

BloodGas

EUCs

How do you approach this child ?
What are your principles of management ??
Would your approach be different if he was 37 years old ??? Continue reading

an obscure acidosis…

The Case.

64 year old male attends your ED with a complaint for 3 months of progressive weakness, however over the past 7 days he has had multiples falls secondary to his ‘legs just completely giving way’.  You note on the hospital records that he has a history of alcoholism (150-250 grams per day). After a long & drawn out discussion (think, blood from a stone) in an attempt to elaborate his history, you gain the knowledge that …

  1. he has had some chronic worsening, low back pain
  2. he has not eaten a proper meal for over a week (and no alcohol in that time either)
  3. he has lost a ‘decent amount of weight’, but cannot objectify it any further.

He has no known past medical history & takes no regular medications.

He looks crook. Pale, diaphoretic and clammy. Tachycardic (@120/min) and hypertensive (165/110 mmHg). He is afebrile however. No murmurs, chest clear. Tender hepatomegaly. No midline back pain. Normal power, sensation and reflexes to both legs (with good peripheral pulses).

Here is his venous blood gas and accompanying chemistry….

VBG01

What are your thoughts ?
Differential diagnoses ??
What are you going to do next ???

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iatrogenic acceleration…

The Case.

A 46 year old restrained passenger in a high-speed MVA rolls into the resus bay. She is intubated & sedated [easily ventilated & oxygenated, no evidence of chest trauma], persistently tachycardic @ 160/min with a systolic BP of 90mmHg & has a very postive FAST exam….

She spends less than 15 minutes in your ED (extra IV access, blood transfusion continued, limbs splinted) before heading for a trauma laparotomy. She has a liver laceration (repaired) and capsular haematoma, complete bladder rupture (repaired) and splenic haematoma (managed conservatively). Post-op she goes via radiology for a ‘pan-scan’….

Her post-operative ICU stay is a rocky one, marked by ongoing transfusion, coagulopathy and persistent tachycardia (still around 160 beats per minute). Some 6 hours later with her haemoglobin & INR stable, she remained tachycardic at 150-60 (still sinus) & has developed a temperature of 38.6*C.

What are your thoughts ??

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