M&M - Dr. Zahn

Case 1 - 61 year old with Rapid Heart Rate

• When dealing with A-Fib with RVR, consider what is making the patient tachycardic, in addition to ensure you manage the arrhythmia.
• Communication is key. Talk to transferring physicians/facilities. Clarify any discrepancies.
  
• Acute limb ischemia is a time sensitive diagnosis. Order an arterial duplex and page Vascular.

Case 2 - 30 year old with abdominal and rectal pain

• Be leery of the diagnosis of constipation.  Be even more leery of multiple ED visits for the same complaint!
• Mesenteric Ischemia

1. Arterial - ~85%
2. Non-occlusive ~ 15%
   
3. Venous thrombosis - very rare

• Venous thrombus develops more insiduosly - should be higher on differential in those with vague abdominal pain complaints with pain out of proportion and a family/personal history of DVTs/hypercoagulable.

Case 3 - 63 year old with dyspnea and uri symptoms

• For patients that are being admitted who are staying in the ED for prolonged periods, ensure that they are being reassessed.
• It is also important that vital admission medications (ex, continued respiratory therapies) are ordered while in the ED.
• Notes must be completed on all admitted patients before leaving the hospital.
  

• ABG vs VBG
  

1. Venous blood gas is excellent for pH in most situations (excluding profound shock).
   
2. Utilization of pCO2 is cautioned except for screening for hypercarbia and trending the level.
   
3. Still need to obtain ABG for exact pCO2 level.
   
4. Encourage ABG in mixed acid base disorders and when performing acid base calculations that will change management.