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Acute Medicine Skills Part Two
- 1. Patient 2 Dr Clare Philliskirk ST5 Acute Internal Medicine
- 2. Carmel, 63 year old female Recent diagnosis of Stage 3c Endometrial Cancer Previously fit and well, was working as a carer until 1 month ago Phone call to her specialist nurse from her family ⢠General decline over the past few weeks - Decreased mobility, not got out of bed for 3 days - Confused and agitated - Not eating and drinking Advised to bring her into AMU for assessment
- 3. Medical Clerking History confirmed ⢠Decreased mobility ⢠Poor oral intake ⢠Confused PMH â hypertension DH - Amlodipine Examination ⢠Dehydrated ⢠Normal cardiovascular/resp/abdo examination ⢠No obvious focal neurology (difficult) Observations Temp 36.5 BP 145/80 HR 78 Sats 96% RA RR 18
- 4. Thoughts?
- 5. Blood results FBC HB 10.3 WCC 9.6 Neuts 6.7 Plts 168 INR 1.0 Biochemistry Ur 18.5 Cr214 Na 147 K 4.6 Ca 5.2 Alb 31 LFTs - Normal CRP16
- 6. Further Investigations - CXR
- 7. ECG
- 8. J waves in Hypercalaemia
- 10. Immediate Management Fluids Bisphosphonates Where? Cause for hypercalcaemia?
- 11. Progress Repeat bloods 48hrs later Ca 4.7 Na 151 K 4.2 Cr 250 Ur 19 Further treatment optionsâŚâŚ.
- 12. 48hrs after thatâŚ.. Bloods Ca 3.6 Ur 24 Cr318 K 5.4 Na 161 Clinically Remains confused, drowsy mostly but agitated at times Difficult maintaining IV access Minimal oral intake Urine output <10ml/hr
- 13. What should we do next? A. Continue aggressive treatment on the ward with fluids/NG feeding/further bisphosphonates B. Accept that she is deteriorating despite our best efforts and aim for best supportive care C. Refer to ITU D. Refer to renal for haemodialysis
- 14. What can Level 2 Care add? Access â fluids, blood sampling NG feeding + NG water Higher intensity nursing care Haemofiltration
- 15. Progress 5 day admission to Critical Care ⢠Central line and Arterial line ⢠NG feeding ⢠Reversal of AKI ⢠Confusion improved Transfer to Gynae ward ⢠On-going hypercalcaemia â denosumab being considered ⢠Having physio/rehab with aim for surgery
- 17. Patient 3 Dr Ashling Lillis ST7 Acute Internal Medicine
- 18. Patient 3 73 year old Previous Ischaemic Heart disease (Myocardial infarction 2004),Type 2 diabetes, hypertension and rheumatoid arthritis Worked in a shop and retired 12 years ago Ex-smoker Limited exercise tolerance due to pain in hip & knees prior to cancer diagnosis
- 19. Diagnosed with ovarian cancer 6 months ago. ⢠Stage 3 at diagnosis (abdomenal deposits, no distant metastases, BRCA negative) ⢠Treated with de-bulking surgery ⢠Slow Post Operative recovery ⢠Now on 3rd cycle of chemo (1x sepsis admission)
- 20. Presentation Breathless on exertion Worse at night when trying to sleep, some ankle swelling no fever, mild non-productive cough, no chest pain Much worse today so called her CNS and as breathless at rest said go to local ED Triage Obs- RR 24, Spo2 89% on air, BP 111/65, P92 (regular), GCS 15, CPR 2s, Temp 37.4
- 21. Stabilise and assess ED get the ball rolling ABC approach- sit up, high flow oxygen ECG- Sinus Rhythm, Left BBB (old) poor r wave progression, non specific changes Labs- mild acute kidney injury, high WCC, elevated LFTs, troponin and BNP requested but not yet available ABG
- 24. whatâs your diagnosis ⢠Pneumonia ⢠Heart Failure ⢠Progressive disease ⢠Myocardial infarction
- 25. Bedside ECHO
- 26. Initial Treatment of CCF High flow oxygen Immediate treatment- GTN (IV or sublingual) Furosemide 40-80mg IV Continuous Positive Airways Pressure (CPAP) Coronary care bed Assess for ischaemia, sepsis, progressive disease Continuous Positive Airways Pressure Coronary care bed Assess for ischaemia, sepsis, progressive disease Initial Treatment of Congestive Cardiac Failure (CCF)
- 28. The big questions What will we do if this doesnât work? What is the prognosis from her underlying disease? What does she know about her prognosis? What discussions have been had around escalation of care and end of life wishes? What are we going to say to her and her family?
- 29. Looking worse, feeling worseâŚ. Increasing oxygen requirement Acute kidney injury and acidosis Progressive hypotension Becoming confused ALT>400, Cool to touch Brain Naturetic Peptide (BNP) >1500, Troponin mildly elevated
- 30. What next? Possibilities include ⢠Intubation and ventilation & Renal Replacement therapy on ITU ⢠CVC and inotropes on HDU ⢠Increase CPAP and give more furosemide ⢠Best supportive care
- 31. Multi organ failure- an acute medic approach ⢠Patient, What do you know, what do you want? ⢠How many organs have failed? ⢠Can we reverse the underlying cause? ⢠Prognosis of multi organ failure? ⢠Prognosis of multi-organ failure in advanced cancer?
- 32. Consideration of critical care in cancer âI want you to do everything for her doctorâ ⢠Honest discussions are key ⢠Reversibility of issues are key ⢠Critical care âIs like running a marathon every dayâ ⢠Severe functional limitation at baseline is associated to mortality in ICU ⢠Treatment escalation planning (TEP) offers an opportunity to explore expectations about prognosis, outcomes, CPR and advance care planning
- 33. ICU and Cancer ⢠Adult oncology ICU patients who donât require ventilation have a ~25% in-hospital mortality, similar to that of non oncology ICU patients ⢠Multiple organ dysfunction syndrome has the worst prognosis, >60% when 2 or more organs fail and near 100% when 4 or more organs fail. ⢠Disease-related factors that are associated with worse prognosis in the critically-ill cancer patients: ⢠poor response to chemotherapy, ⢠cancer relapse or progressive disease ⢠progressive or recurrent disease,
- 34. Progress Discussion with critical care, oncology and family Further invasive treatment not likely to be successful Best supportive care in hospital, died with family present that night