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Case study

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Case study

  1. 1. Case study from ambulance placement
  2. 2. Dispatch info http://farm9.staticflickr.com/8038/7975785281_1833efde56_z.jpg A 20 year old female, febrile, abdominal pain, altered conscious state, Code1 single car
  3. 3. On arrival http://i.imgur.com/O1x1UtO.jpg Pt sitting in front of heater, shortness of breath, c/o feeling weak, been vomiting for 10/7, thirsty, polyuria, no appetite, took panadol 2/24 ago
  4. 4. On examination PSA • BP: 85/60 • HR: 110 • Skin: cool, pale, dry • Cons: alert GCS • E: 4 • V: 5 • M: 6 RSA • Appearance: anxious • Speech: full sentence • Auscultation: clear • RR: 28 • Rhythm: regular • Effort: labour • Pulse: as PSA • Skin: as PSA • Cons: as PAS Secondary •BSL: 21.9 •Temp: 34 History • PHx: abscess • Med: ICE user • Allergy: N/A
  5. 5. Key findings PSA • BP: 85/60 • HR: 110 • Skin: cool, pale, dry • Cons: alert GCS • E: 4 • V: 5 • M: 6 RSA • Appearance: anxious • Speech: full sentence • Auscultation: clear • RR: 28 • Rhythm: regular • Effort: labour • Pulse: as PSA • Skin: as PSA • Cons: as PAS Secondary •BSL: 21.9 •Temp: 34 History • PHx: abscess • Med: ICE user • Allergy: N/A
  6. 6. More findings at ED BSL 35 Ketone 6 Temp 33.8 http://resources2.news.com.au/images/2013/10/03/1226676/575398-frankston-hospital.gif
  7. 7. http://plpnetwork.com/wp-content/uploads/2012/05/bigstock-Critical-Thinking.jpg
  8. 8. Differential diagnosis (1) Local infection Systematic infection SIRS Sepsis? Sepsis Severe sepsis Criteria • Temp >38 or <36 • BP <90 • HR >90 • RR > 20 ? sepsis if any 2 of above detected Septic shock Organ failure Death McCance K, Huether S, Brashers V, Rote N. Pathophysiology: The biologic basis for disease in adult and children. 6 ed. Maryland Heights, Missouri: Mosby Elsevier; 2010. Small M. Recognising and managing severe sepsis in the pre-hospital environment. J Paramedic Prac. 2012;4(11):631-7.
  9. 9. Differential diagnosis (2) Mechanism: • Sympathomimetic effect • Enhance catecholamine release and inhibit uptake • CNS and peripheral stimulation CNS CVS Tachycardia, hypertension, dysrhythmia, ACS, APO, acute cardiomyopathy, haemoptysis PNS Mydriasis, sweating, tremor Psych Amphetamine? Hyperthermia, rigidity&myoclonic movement, seizure Euphoria, anxiety, agitation, paranoid, hallucination Medical Rhabdomyolysis, dehydration, renal failure, complications hyponatraemia, cerebral oedema, AAA, SAH/ICH Murray L, Daly F, Little M, Cadogan M. Toxicology Handbook. 2 ed. Chatswood, NSW: Elsevier Australia; 2011.
  10. 10. Differential diagnosis (3) Insulin deficiency BSL Lipolysis DKA? Ketone bodies pH Clinical features • Polyuria • Polydispia • Polyphagia • Weight loss • Fatigue • Kussmaul respiration • Fruity-smelling breath Metabolic acidosis Death McCance K, Huether S, Brashers V, Rote N. Pathophysiology: The biologic basis for disease in adult and children. 6 ed. Maryland Heights, Missouri: Mosby Elsevier; 2010.
  11. 11. Differential diagnosis (4) Key findings Sepsis BP 85/60 V HR 110 V Skin cool/pale/dry PSA V Appearance anxious RSA DKA V V V V V RR 28 V Effect labour V V V V BSL 21.9 Secondary Amphetamine V V Temp 34 V Weakness V V V
  12. 12. The winner is... DKA http://www.colourbox.com/preview/3655283-504549-sports-collection-1st-place-winner.jpg Although pt has no history of diabetes and amphetamine can cause additional effect on insulin control, the presenting problems and ED investigation both indicate that the pt is more likely to be the first episode of DKA caused by type 1 diabetes.
  13. 13. Discussion 1. Amphetamines produce sympathomimetic effect => inhibit insulin production => result may be similar to insulin deficiency => also influence diabetes pt to control BSL 2. Pt has no previous diagnosis of diabetes => may affected by amphetamine or 1st onset of diabetes 3. Pt’s vital signs mainly meet both features of sepsis and DKA 4. Five minutes to Frankston ED => Pt is sick but able to walk to ambulance => Need immediately treatment from paramedics with in 5/60? 5. ECG and SpO2 had better being checked next time
  14. 14. References 1.! Ambulance Victoria. Clinical Practice Guidelines for Ambulance and MICA Paramedics. Doncaster, Victoria: Ambulance Victoria; 2012. 2.! Gama MP, de Souza BV, Ossowski AC, Perraro RC. Diabetic ketoacidosis complicated by the use of ecstasy: a case report. Journal of medical case reports. 2010;4:240. 3.! Ng RSH, Darko DA, Hillson RM. Street drug use among young patients with Type 1 diabetes in the UK. Diabetic Medicine. 2004;21(3):295-6. 4.! McCance K, Huether S, Brashers V, Rote N. Pathophysiology: The biologic basis for disease in adult and children. 6 ed. Maryland Heights, Missouri: Mosby Elsevier; 2010. 5.! Murray L, Daly F, Little M, Cadogan M. Toxicology Handbook. 2 ed. Chatswood, NSW: Elsevier Australia; 2011.
  15. 15. QUESTION

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