This case is inspired by listening to the RAGE podcast #2 – if you haven’t already listened, do so ASAP (download from iTunes) or click here.
RAGE = Resuscitationists Awesome Guide to Everything and is a nice 60 min or so podcast full of clinical pearls. Rural doctors may be wondering what relevance this has for them? Experienced rural docs know that ‘critical illness does not respect geography’ and it pays to be aware of useful tips and pearls.
So here’s today’s case, one which I’m also working though with the PRCC students attached to Kangaroo Island in 2014 in sim and theory. Then listen to RAGE podcast #2
THE SCENARIO
The setting, as always, is a small rural ED in Australia. Transfer times are 60 mins by rotary wing, 2 hours by fixed wing (airstrip is remote from clinic and requires ambulance transfer by volunteer crews).
Facilities include small resus bay with point-of-care INR, proBNP and Chem 4/Chem 8 iStat, CXR (but you have to take the radiograph yourself), and the usual resus drugs, 2 lead ECG, telemetry, adrenaline as sole inotrope etc. There’s an old Oxylog 2000 plus transport ventilator. There is also an old SonoSite Titan ultrasound unit with linear and curvilinear transducers. Nearest CT scanner is 300 km away.
THE PATIENT
A 54 yo obese patient presents complaining of acute shortness of breath, approx 2 hours duration. She complains of pain on inspiration and feels unwell. She denies prodromal symptoms such as fever, chills, sputum. She is a smoker, on HRT and tells you that she flew in from London 5 days ago.
Q1 : What are possible causes of her acute dyspnoea? What key features on history and examination will help you decide?
Q2 : What are appropriate & available tests that may guide your management?
Q3 : Her ECG is as below. What does it show and what are your options?
Q4 : 30 mins later her SBP drops to 88/50 and remains so despite 2 x 250ml fluid load. HR 123 a/fib. Spo2 94% 15l via NRB. Apyrexic.
Results (iStat) show : Hb 145, pO2 63 mmHg, pCO2 33 mmHg, Aa gradient 24 mmHg, lactate 2.9, glu 6.2
What next?
Sadly the retrieval service are tied up with other urgent tasks in the State. They reckon they can get a physician-paramedic crew to you in 90 minutes via fixed wing at the earliest. Meanwhile she remains hypoxic, hypotensive and tachycardic. She looks grey and unwell and about to die…
Would you consider thrombolysis?
If so, what criteria or other tests would guide you?
Over to you…
PLEASE COMMENT BELOW
Rural Doctors Net 
Thrombolytics would NOT be my first step.
1. O2 100% by mask plus 7L by NC
2. establish 1-2 large bore IVs if possible quickly; if not, IO. start first liter NS or RL
3. Focused PE: Lung sounds? (wheezes, difference between sides?) JVD? Heart sounds (muffled?) Belly (tender?) Legs (oedema? symmetric?)
4. U/S – FAST (blood in belly?) Cardiac (blood in pericardidal sack? R heart collapse?) Lung (sliding lung seen?)
What I do next depends on what I find on PE and US
…of course O2, IV access.
No consolidation, wheeze, HS dual, pCXR normal. Nil oedema, Belly soft nontender.
ABG – as shown.
eFAST – no PTX/consolidation/no fluid in belly/around heart ie: eFAST neg – except, maybe RV dilatation on ECHO
You’re thinking PE…
Then she drops her bundle – worsening haemodynamic instability. Gonna be a while before can get her to tertiary centre..
Thrombolyse? Or die?
1) #1 is PE, after that ihd and mi? And chf. Infection less likely with sudden onset, ? Pericarditis??
Pin down the hx. How sudden was the onset. Cough ? Haemoptysis. Leg swelling? Orthopnoea etc. past hx of all of the above? Previous PE . So far looks and quacks like a PE .
2) tests . Uss legs for DVT, moderate level of confidence doing this. CXR if I think it’s doable. Uss over chest wall to exclude pneumothorax. / check for cardiac tamponade while there. Her neck veins are probably too well hidden to see.
3)ECG af and ? S1q3t3? Suggestive of PE but not diagnostic
4) I would have a big medico legal worry with thrombolysis, but if she is getting worse would be on the phone to our retrieval center to spread the blame :). DVT on uss, and a good hx like this may convince me, would use the standard thrombolysis exclusion criteria from mi rx. While I’m waiting , I’d be throwing some clexane into the mix if I’m happy we don’t have a bleed as a cause.
Having said all this, I’m one of the few lucky rural docs with a ct 15 meters from Ed, and a high speed link to upload for rapid reporting 24 hours a day, so if I was at home would be ct and treat from there.
Nicely reasoned Hamish…
Yeah, the issue here is whether to lyse the PE clot or not…in absence of CTPA but in face of a patient going down gurgler
Tough call.
You lucky bugger – rural AND a CT. Is Cooma that far from Canberra? Oh yeah…ski fields!