6 January 2020 - Haem/Onc — StV ED Teaching

Khalid presented a great pick up on a patient with a snake bite envenomation who had been in the WR and then fast track for many hours until medical review. Several key learning point include:

Consider snake-bite in any patient with a “ ? bite” and systemic symptoms
Always call the poison information line in confirmed cases of snake-bite
Learn the snake bite management pathway relevant to your location

ECG of the Week

A 64 year old female presents to your tertiary centre with chest pain, now 2/10 severity. Below is her ECG after GTN and morphine were given.

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The ECG shows inferolateral T wave inversion and Q waves (not quite pathological as they are not deep enough). There is a biphasic T wave pattern in V3-V4. There is a first degree HB. There is also mild ST elevation in V3-V5.

The ECG is somewhat concerning for Wellen’s syndrome but doesn’t quite meet the criteria. Review Wellen’s here

This ECG does not (yet) meet criteria for urgent reperfusion therapy but is very concerning for ischaemia and close monitoring and repeat ECGs are required.

Image of the Week

A 63 year old lady presents with lethargy. Her oxygen saturations on room air are 75%.
An axial slice of her CT chest is shown below.

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This is a single axial slice of a contrast enhanced CT chest.

There is consolidation of the left lower lobe. It is a good example of hepatisation of the lung with a clear view of one of the bronchioles.

There is also a moderately sized right sided pleural effusion.

No surprise she was hypoxic!

Blood Gas of the Week

A 100 yo patient present feeling “unwell”

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Albumin = 28

This blood gas is typical of an elderly patient who has stopped drinking.

There is a moderate acidosis with only a small decrease in base excess so there must be a respiratory acidosis.

Fencl-Stewart Interpretation

164 + 5.5 - 116 = 54. Therefore there is a moderate hypocloraemic metabolic alkalosis contributing +12 to the base excess
Albumin effect = Mild hypoalbuminaemic metabolic alkalosis with base excess effect of +3.5
Lactate effect = -3
Sum effect = -12, The actual base excess is - 2.5 so there is an unexplained metabolic acidosis contributing -10 to the base excess. This is likely to be starvation ketosis. Other differentials that are unlikely in this patient would be euglycaemic DKA from a gliptin or alcoholic ketosis.

Other key features on this blood gas include severe hypernatraemia, mild hyperkalaemia, and a high haemoglobin likely secondary to haemoconcentration.

This patient has a high risk of death and palliative care should probably be considered in this case.