Case-based-Learning

While bringing in toys from outside, an eight-year-old male was bitten by a juvenile Western Rattlesnake. He noticed immediate pain in his right third digit. EMS was activated and transported the patient 45 minutes to our facility in 45 minutes. EMS noted normal vital signs and discoloration to the digit. They also noted redness to the arm which was attributed to the blood pressure cuff. The patient was immediately evaluated, and an envenomation was diagnosed. He was immediately given the four units of crotalid antivenom in the pharmacy. The areas of redness were noted to ascend to the right axilla. The outer limits were marked and timed. Labs to included CBC, CMP, PT/INR, and PTT were sent and normal. The patient’s arm was elevated with pillows. The transfer process was initiated; however, the regional quaternary children’s hospital did not have antivenom in its formulary. Thus, a smaller hospital with pediatric capabilities was chosen. Air transport was unavailable due to significant thunderstorms in the area, and ground transport was also delayed. In the interim, the patient’s arm pain worsened, as did the erythema of the arm. Two additional doses of antivenom were acquired from a neighboring hospital and transported to our facility by EMS. Approximately five hours after arrival, the patient was transported to the receiving facility with the aircrew providing patient care and infusing the additional two vials of antivenom. The patient was admitted to the ICU, received six additional vials of antivenom, and recovered well. He was discharged home four days later with instructions for daily wound care. Each year, approximately 8,000 people are bitten by snakes in the United States. The overwhelming majority of these are from the crotalid family, which includes rattlesnakes, cottonmouths, and other pit vipers. Crotalid venom degrades structural proteins (like collagen and fibrin), which compromises…

A 62-year-old male presenting to the emergency department with a 2-week history of progressive dyspnea and generalized weakness.  He had not noticed any palpitations, but cardiac monitoring showed atrial fibrillation with a ventricular rate of 170.  EKG did not show any signs of acute ischemia or infarction.  CT angio of the chest showed no PE but moderate bilateral pleural effusions, worse on the right, with mild pulmonary edema.  The patient had no previous history of CHF (EF unknown).  Patient’s heart rate was controlled with IV Cardizem.  BNP was 21,000 and troponin 3,600. The patient was suspected of having a tachycardia-induced cardiomyopathy.  The patient was transferred to VM for further evaluation. Echo showed moderate global LV hypokinesia with EF 38%.  There was an LV apical clot measuring 1.26 cm.  The patient was diuresed and rate was controlled with digoxin and metoprolol.  Heart cath showed no significant coronary artery disease.  He was placed on GDMT for HFrEF with the 4 pillars of HFrEF medications.  His history was not compatible with alcohol or methamphetamine induced cardiomyopathy, and viral cardiomyopathy also seemed unlikely.  It was felt that he most likely had tachycardia-induced cardiomyopathy.  He was anticoagulated on Eliquis and discharged on sacubitril/valsartan (entresto), metoprolol, spironolactone, empagliflozin (jardiance), lasix and digoxin.  Repeat echo 2 months later showed resolution of the global LV hypokinesis, and the EF returned to normal at 55-60%.  He remained in atrial fibrillation.  Six months after his initial presentation he underwent electrical cardioversion resulting in sinus rhythm but had recurrent atrial fibrillation.  He was started on amiodarone and there is a pending plan for ablation therapy. Tachyarrhythmia-induced cardiomyopathy is a relatively rare cause of dilated cardiomyopathy and can result from virtually all types of tachyarrhythmias, as well as from high PVC burden (higher risk if greater than 15% of total beats on…

UNUSUAL CASE OF CHEST PAIN The Patient Presentation: A 57-year-old male with a history of IV methamphetamine use, Hepatitis C, and hypertension presented to the ED because of a one-week history of tenderness and discomfort along the right anterior chest wall. It began with an audible pop and subsequent pain felt at the right sternoclavicular area. Symptoms were worsening in severity, acetaminophen or ibuprofen were not beneficial. The were no associated symptoms of shortness of breath, fevers, nausea or vomiting. He denied any history of injecting drugs into the area or trauma. Social history was notable for homelessness, medication noncompliance, marijuana use and prior 10-year history of IV substance abuse and denied recent drug or alcohol abuse. Upon presentation vital signs were notable for temperature of 97.2°F, blood pressure 128 / 76, heart rate 87 beats per minute, respiratory rate 16 breaths per minute and room air oxygen saturation of 98%. Physical exam was notable for tender raised right SCJ (sternoclavicular joint) without any fluctuance. Diagnostic Studies: Notable for a white blood cell count of 12,300 platelets 639,000 ESR of 120mm per hour (0 to 15 mm/hr) and C reactive protein of 34 milligrams per liter (8 to 10 mg/L). POC US Revealed a fluid collection and captured extension along the SCJ concerning for septic arthritis. CT imaging revealed an SCJ effusion bony erosions in the clavicle and adjacent sternal manubrium and associated extensive soft tissue inflammation concerning for septic arthritis and osteomyelitis. Orthopedic surgery was unable to aspirate the joint, interventional radiology successfully aspirated and biopsied the joint area. Treatment: In the emergency room the patient was begun on piperacillin tazobactam pending cultures result. Aspiration cultures after admission to the hospital were positive for gram positive cocci in chains and antibiotics were changed to ceftriaxone. The patient ultimately was…

A 74-year-old female presented to the ED with complaints of left-sided weakness for 24-36 hours. EMS reports they have been to the house three times in the past 2 days for lift assist. She denies any injury from falls, says they were all from trying to stand and sliding back down the couch. The patient says she had COVID several months ago and has had generalized weakness, brain fog, and malaise that have persisted. She complains of a right frontal headache. She was nauseous and vomited several times today. She denies numbness or tingling, no vision or speech changes. She developed a productive cough the day prior and had occasional wheezing. History- asthma, HTN, morbid obesity. Nonsmoker, non-drinker. Lives with daughter and SIL. Retired. Vitals BP 172/91, P 64, T 97.8, R 22, SpO2 96% on RA. Exam- Gen- no acute distress; HEENT- unremarkable; CV- regular with 3/6 systolic murmur; Pulm- clear bilat; Abd- soft, obese, ND/NT; Neuro- left facial droop, mild dysarthria. Weakness R leg > R arm and distal > proximal. Pronator drift on the right. Ataxia right arm and leg Labs- WBC 11.8, Alk phos 121. Lactic, TSH, trop, INR, COVID/flu, UA normal Rad- CTA head/neck- 5 cm rim enhancing lesion right frontal lobe with 1.9 cm left shift and subfalcine herniation concerning for malignancy, metastasis, or abscess On chart review, patient had been seen multiple times prior to arrival at our facility: She was seen at an ED in Spokane almost 2 months prior for facial pressure and ear pain, diagnosed with acute sinusitis and otitis media and treated with 7 days of Augmentin, ENT referral sent. She was seen at different outside hospital 5 days later with fatigue, persistent headache, and difficulty getting dressed. Afebrile, VSS, recommended complete abx, Flonase, saline rinses, Tylenol, get ENT…

Chief Complaint “Confusion and weakness” History of Present Illness A 72-year-old male with a history of diabetes and hypertension is brought in by EMS for altered mental status. Patient unable to give a history due to current mental status. Family reports 2 days of fever, decreased oral intake, and progressive confusion. Today he became difficult to arouse. Brief Physical Exam Initial Vitals Temp: 39.2°C, HR: 128 bpm, BP: 78/46 mmHg, RR: 26, SpO₂: 91% on room air General: Ill-appearing, obtunded HEENT: Dry mucous membranes Heart: Tachycardic, weak pulses, no murmurs, rubs or Gallops, Delayed capillary refill Lungs: coarse breath sounds, no wheezes, increased rate Skin: mottled, cool to touch, no rashes Brief ED Course / Medical Decision Making Patient identified as being in septic shock with acute organ dysfunction (altered mental status, hypotension). Immediate interventions: Rapid IV fluid resuscitation (30 mL/kg crystalloid) Broad-spectrum IV antibiotics within 1 hour Initiation of vasopressors (e.g., norepinephrine) for persistent hypotension Continuous cardiac and hemodynamic monitoring Frequent reassessments of perfusion and mental status Diagnostics: Blood cultures ×2 prior to antibiotics Lactate elevated at 5.2 mmol/L CBC: leukocytosis CMP: acute kidney injury Chest X-ray: right lower lobe pneumonia Why This Qualifies for Critical Care Time This patient meets criteria because: High probability of imminent life-threatening deterioration (shock, organ failure) Active physician management required to prevent death Multiple organ systems involved (cardiovascular, neurologic, renal) Time-intensive interventions and reassessments Example Critical Care Documentation Statement “The patient was critically ill with septic shock and acute organ dysfunction. I was immediately available and provided direct management including aggressive fluid resuscitation, initiation of vasopressors, interpretation of diagnostic studies, and continuous reassessment. The patient was at high risk for cardiovascular collapse and death. A total of 45 minutes of critical care time was provided, exclusive of separately billable procedures.” Critical care is the direct delivery of medical care by a physician or qualified healthcare professional to a critically ill or injured patient, involving high-complexity decision-making to treat or prevent life-threatening organ system failure. CMS…