M&M - Dr. Kiefer

Missed Dialysis & Syncope

• K+ was 7.4
• Hyperkalemic EKG changes

       - Narrow based peaked T waves, bradycardia
       - PR prolongation, QRS widening - can be a full block
       - Sine wave

• New blocks in setting of bradycardia - be concerned for hyperK+ (most other blocks are acceleration dependent)

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RUQ Abdominal Pain

• RUQ wnl except some ascites & UPT positive 
• Initial Transvaginal US - no IUP; left adnexal mass with beta < 300
• Pt seen by OBGYN... decision to follow beta levels as outpatient.
• Beta quant levels noted to be decreasing, but found to have increasing adnexal mass.
• Worsening pain. Went to OR. Histology was consistent with ruptured ectopic pregnancy!

** important note - can have bradycardia with 40% of cases of hemoperitoneum**

**** Can have ectopic pregnancy with declining beta****

• In order to be able to manage a possible ectopic expectantly you need:  compliance, demonstrate some sort of resolution, no evidence of rupture. 

Missed Pubic Rami Fracture

• Elderly patient s/p mechanical fall with resultant proximal humerus fracture > missed pubic rami fracture.

    **** Make your patients walk when they leave the ED****
    **** Fully examine your patients and document well & make sure to reassess****