Case COnference - Dr. Kiefer

Intoxicated with Chest Pain

• Intoxicated patients are a HIGH RISK patient population.  Always talk to the patient and take them seriously.  These patients need to be gowned appropriately.

• EMS providers, nurses, and physicians frequently have significant emotional bias before ever interacting with these patients.  Understanding that bias exists, we must always be on guard for truly sick patients that have fallen through the normal triage system.  
  

• Ripping/tearing chest pain (OR ~11) or migrating chest pain (OR ~7.5) are highly concerning historical features for aortic dissection.

• Goals of initial medical management include first HR control for HR <60 BPM (i.e. esmolol, labetalol, etc) and then secondarily with BP control for SBP 100-120 mmHg (i.e. nitroprusside)
  

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Infected Kidney Stone

• Waiting for patients to urinate for a clean catch specimen is ONLY appropriate for stable patients where urine studies are NOT paramount to an evaluation.  Obtain cath urine specimens in ANY patient where a urinalysis is pivotal to patient care. 

• Patient sign outs are the MOST dangerous time for patient care.  If a clear diagnosis has not been made then inform the oncoming provider and seek help in difficult patients. Sometimes a fresh set of eyes is all that is needed.

• Interestingly, B-type natriuretic peptide (BNP) is frequently elevated in sepsis with proven distributive shock (as evidence by lactate >4, ScvO2 <70%) in patients with normal echocardiography.  Do not make a false assumption that elevated BNP = fluid overload, as this is NOT the case!  Patients with septic shock and an elevated BNP have a worse prognosis and severe intravascular volume depletion.