case presentation

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