While your friends at home are shivering in the Camden, NJ winter, you are on an elective retrieval medicine rotation in New South Wales, Australia. A 32 year old patient arrives in a rural emergency department obtunded. His friends state he was out hiking and may have used some cocaine as well. His initial vital signs are notable for hypotension and a core temperature of 41.5C (106.7F). There are no fans available for evaporative cooling and no gel adhesive body temperature controlling devices (such as those used following cadiac arrest). The patient requires intubation which is done uneventfully, the staff asks what tools you might use to rapidly reduce the body temperature.
Lars-Kristofer Peterson, MD
EMS brings in a 45 year old male with a PMHX of tobacco abuse who was rescued in a house fire. The report is that a cigarette dropped on the patient’s couch while he was sleeping and caused a smouldering fire. It resulted in a significant amount of smoke creation but very little fire damage in the house. The patient has no visible burns. On arrival, the patient’s pulse oximetry on room air is 84%. He is alert and oriented but notes a sense of persistent dyspnea. His workup is significant for a lactate of 2.2 but otherwise benign. Co-oximetry is normal without evidence of severe carbon monoxide poisoning. The patient does not display evidence of inhalational burns. The patient’s new hypoxia and dyspnea is worrisome so you planned admission to the hospital but wonder if you should give hydroxycobalamin empirically in case of occult cyanide toxicity.
As you scan the ED trackboard, you recognize the name of a 22 year old patient who you saw the week before after a house fire. At that time, the patient was treated for carbon monoxide (CO) poisoning and briefly admitted to the hospital. Today’s chief complaint is dyspnea and chest pain. You note that the patient is tachycardic, hypoxic, and complained of pleuritic chest pain at triage. You wonder if the prior exposure to carbon monoxide should raise your pre-test probability for certain diagnoses.
EMS brings in a 67 year old male in a PEA arrest. ROSC is obtained after twenty minutes of downtime. He was intubated by EMS during transport. A colleague talks to the family and she lets you know that he was complaining of shortness of breath and chest pain for an hour before he had a witnessed cardiac arrest and that his PMH includes HLD and HTN. The respiratory therapist is asking for the ventilator settings.
A patient has arrived with increased work of breathing, hypoxia, and altered mental status requiring intubation. After intubation, the patient stabilizes and their oxygenation improves. You know that both hypoxia and hyperoxia are bad for patients and that initial ED mechanical ventilation strategies are often continued after admission1. How can you titrate the patient’s fraction of inspired oxygen (FiO2) to keep them safe from both hypoxia and hyperoxia?
Case: A 34 year old female with no PMHX presents to the ED with unilateral right lower extremity swelling, dyspnea, and moderate pleuritic chest pain. Vitals: BP 130/65, HR 68, RR 20, SPO2 89% on room air, Temp 37.8. A CT finds evidence of PE bilaterally at the segmental level. BNP and troponin are both mildly elevated. Point of care cardiac ultrasound shows mild RV dilation. After interviewing the patient, you don’t identify any contraindications to anticoagulation. Pregnancy testing is negative. Her renal function is normal. You consider what is the preferred agent for anticoagulation in this patient.
Physiologic alarms in the ED frequently sound without any meaningful change in patient management. Understanding the effects of unnactionable alarms and their consequences is vital for the EM physician.
Patients presenting to the ED with critical illness may require transfer to a different hospital for a higher level of care or for services unavailable locally. Here are some considerations to be made when tansferring a critically ill patient.