85-YO male in ED

good article on medical response to Boston Marathon bombing


Drs. Voyles, Busby, Spaulding

85-YO male in ED

Diagnosis of COPD should be supported by objective data (e.g., PFT)


unable to assess CVP by JVD in obese patients


Cold upper and lower extremities; slight mottling of lower extremities = vasoconstriction

2/6 early SEM at the base only - could be due to turbulence from tachycardia, anemia, sclerotic valve leaflets

gallop uncertain - hard to tell at high heart rates S3 and S4 may blend with shortened diastolic period.  also hard to hear due to low pitch.  S4 occurs with atrial kick and LV hypertrophy from chronic HTN

Shallow respirations and decreased breath sounds in both bases; coarse rhonchi in all lung fields; scattered expiratory wheezes; no rales  -  rhonci = gunk in airways; shallow sounds = low volume breaths;  expiratory wheezing could be airway sounds or "cardiac asthma" where edema in lymphatics constricts airways = wheezing.  no rales or crackles could be due to shallow breaths and no opening of collapsed airways.  may become audible if pt. sits up and takes a big breath.

not making urine - maybe he voided in ambulance or is not making urine.  BPH may contribute.  ??? not making urine vs. not voiding.  hypotension responsible?
Place Foley catheter  and maybe bedside bladder scan.

Echocardiograms hard to obtain with morbidly obese pts.  transesophageal echo is a way around this.

don't give nl saline and furosemide at the same time.  need more data; e.g., blood pressure (via arterial line with pressure transducer in obese pts. since cuffs aren't accurate)  saline may increase 
BP BUT worsen pulmonary edema. 

Flank pain presenting complaint -  don't drift far from this; e.g., AAA
no abdominal tenderness since abdominal pain is peritoneal and AA is in peritoneal space.
CT scan problematic with high Cr.  Do it anyway if suspicion is AAA.

PE vs. AAA   -  in one case heparinize  not in AAA (would kill him)

Calcification occurs with smoking, obesity, and HTN


PE does not present with back and flank discomfort but AAA that ruptures does.
Tests for AAA

1. KUB xray
2. aortagram
3. CT scan - 

AAA can create ATN if renal arteries are involved.  

Huge surgical risks with this pt.  (not a candidate for a haircut)

option = endovascular repair  

pt. died on operating table with refractory shock.