You’re in the ED when an ESI 2 rolls up – an ill-appearing 75 year-old man who was brought in by EMS for nausea and vomiting x 3 days. The patient’s heart rate is 108, blood pressure is 136/82, and he is breathing 20 per minute. The triage nurse brings the patient to the critical care area where they are busy dealing with 3 gunshot wounds, 2 stabbings, and a room full of police officers. The resident quickly evaluates the patient and notices the patient looks dehydrated. They start a peripheral line, send some labs, and hang a liter of fluid. The patient is eventually sent to you in the main ED.
You go see the patient and here is what you discover:
75 year-old man with HTN, DM type II, dyslipidemia presents with 3 days of nausea and vomiting that began after he ran out of his insulin. He called his PMD who sent his prescriptions via E-prescribe but wasn’t able to pick them up because he couldn’t get out of bed. He has had no fevers, chills, URI symptoms, rashes or skin changes. His chest is burning but he attributes that to vomiting. He’s been taking Maalox® at home to make himself feel better. He has had no recent travel or sick contacts.
PSH: Hernia repair at age 4
Medications: Insulin detemir 30U qHS, sitagliptin 50 BID, metformin 1000 BID, amlodipine 10mg qD, atorvastatin 80 qD, lisinopril 40mg qD
Allergies: Penicillin – rash
Social: No drugs, alcohol or tobacco. Lives with son who has been on vacation the last 2 weeks.
VS: HR 110, RR: 20, BP: 148/100
GEN: Thin male
HEENT: Normal sclera and conjunctiva. PERRL, EOMI; dry mucous membranes; no lymphadenopathy
PULM: CTA BL
CV: Tachycardia, 2/6 systolic murmur
Abd: +BS, soft, minimal epigastric tenderness, non-distended, no rebound or guarding.
Ext: No cyanosis, clubbing, or edema.
The liter of normal saline is finishing when the lab results come back:
Venous Shock: pH 7.274, PaCO2 44.2, Pa02 42.5, Na 130, Cl 80, HCO3 18 BE -5.8, Lactate 3.3
CBC: WBC 12; Hb 15; Platelets 350
Chem: Na 119 K 3.8 Cl 80 HCO3 18; BUN 38 creatinine 1.5 Glucose 230 GFR 48
Serum ketone: negative
EKG: Sinus tachycardia, no ST-T abnormality
CXR: No consolidation
You give the patient additional IV fluids and admit to medicine for “dehydration”, but the patient still looks terrible.
- What is your differential?
- How do you use the ABG to put the story together?
- Is the lactate of 3.3 very concerning? What about in the setting of a base excess of -5.8? Why or why not?