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Case 24 yrs old lady
H/o found unresponsive 30 min before presentation
1 survey R2
1 survey R2
2 survey R1 2 survey R1 History R1
History R1
DD R3 DD R3 Invex R4Invex R4 RX R4RX R4
Dispostion
Dispostion
Primary survey A: patent B: RR:25 , Spo2: 95% in r.a, chest:clear C:PR:100, BP:150/90 D: GCS:10/15 E2M5V2, pupils 3 mm b/l
reactive , reflow:6 E: T:37
History H/o sob before she collapsed at home H/o vomiting and loose motion several times that
day , no blood or mucus No h/o fever, trauma Deny h/o drug ingestion No h/o travel or contact sick people H/o recurrent generalized twitching movement with
upprolling of eyes and frothing in last few days, did not seek any medical treatment for that
PMH Diagnosed to have high BP for last 3 weeks
and she is under investigation in LHC , referred to BPC physician to be started on medication
All lab investigation ,ECG , CXR was done at that time and was normal
She is checking her BP regularly at LHC and all her readings are high
Exam Head: no signs of trauma Neck: no neck stiffness Chest: clear CVS:s1,s2, no murmur p/a: obese , no tenderness CNS: no focal neurological deficit , GCS:
10/15 E2M5V2
Progress I was called to see one of my
patients( Treatment room ) as she is having severe abdominal pain
ECG, VBG,bloods Investigation is being done for our patient,
Resus bell rings I ran to the resus
My patient had tonic clonic convulsion Medical on call who was seeing other patient
order 5 mg diazepam IV Seizure was aborted
Primary Survey 2 A: she had lots of secretion with tongue obstruction
with snoring , suctioning done , OP applied with 100% oxygen
B: RR:35-40 , Spo2: 88% before the above and picked upto 97% , auscultation b/l course crep
C:PR:120, BP:160/100 D: GCS:9/15, pupils 4 mm b/l slugish reaction,
reflow:8.4 E: T:38
ECG
VBG PH: 7.01 , PCO2:16, PO2:55, HCO3:10 Na:140 , k:4 , cl:108
High AG metabolic acidosis with respiratory alkalosis
What u want to do next: CXR : showed b/l
consolidation
CT brain: NAD
Lab investigation CBC : Hb: 12.1, Plt: 71 , WBC: 16.4,
neutrophils: 15.1 UE1: Na: 140, K: hemolysed, CO: 10, Cl: 108
, urea: 5.7 , creat: 143 LFT: biliru: 31, AL: 102 , ALP: 58 , album:
30 Mg, bone: hemolysed
Lab investigation CK: hemolysed Lactate: > 11 mmol/l Uric acid: 511 Troponin: 0.122 Coag: Normal Acetaminophen : < 66 umol/l Salicylate : negative
Progress 21:45 We tried urinary cath to take urine for urine
dipstick and preg test ,but she strongly refused again and was kicking us
I brought the ultrasound machine and wanted to do scan to her abdomen but she started to kick again and was shouting and asked the nurses to hold her but could not scan here
Sedated with diazepam to do scan,
Scan finding
Progress 21:50 Anasthesia and ob/gy on call stat referral Mg sulphate 4 gm IV infusion over 20 min Hydralazine 5 mg iv bolus Labetolol 20 mg iv bolus Gyn started hydralazine infusion 2 mg/hr Mgso4 infusion at 1gm/hr
Admission progress Patient got intubated , admitted to ICU Termination of pregnancy was decided by gyn She was induced and passed the fetus by next
morning She remained in ICU for 2days , extubated next
day , and shifted to the ward Treated with IV antibiotics for aspiration
pneumonia for 7 days Discharged home in good condition with f/u
High risk emergency medicine
and
error reduction
How Emergency Clinicians Think
We practice within the disorder of a busy ED Potential for system errors
We clinicians must in addition deal with the potential for intrinsic errors
Sources of error
High levels of diagnostic uncertainty; "Decision density," or the volume of decisions that
are made in a given amount of time; A high amount of cognitive load needed to process
the large volume of data; Narrow time windows for patient assessment; Multiple care transitions for any given patient; A multitude of interruptions and distractions
throughout the thought process.
Physician Interruptions
■ Emergency physicians are interrupted 30.7 times in every 180-minute cycle (1)
■ They experience 20.7 “breaks in task” per cycle (1)■ EPs are interrupted 9.7 times per hour while office-based physicians
are interrupted 3.9 times per hour (2)■ Emergency clinicians spend two-thirds of their time managing
multiple patients (three or more) While office physicians spend less than one minute per hour managing multiple patients ( 2)
(1) Acad Emerg Med 2000;7(11):1239; (2) Ann Emerg Med 2001;38(2):146.
Multi-Tasking Makes You Stupid
Multi-Tasking Makes You Stupid A study at Carnegie Mellon University. Doing several things at once reduces the brainpower a person
can devote to each task… Researchers asked subjects to listen to sentences while
comparing two rotating objects Although these tasks use different parts of the brain, the
resources available for processing visual input dropped 29% While brain resources for listening dropped 53 % The results were worse when the two tasks used the same part
of the brain