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MAJOR / LONG CASE - EMERGENCY MEDICINE

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CASE DETAILS

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TRIAGE ASSESSMENT

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PRESENTING COMPLAINTS

1. Reduced responsiveness / altered sensorium since 07:00 AM (2 hours PTA)
2. History of fall - 1 day prior
3. Inability to bear weight on left lower limb since fall
4. Left hip/groin pain
5. Multiple episodes of vomiting - 4-5 episodes since yesterday
6. Burning micturition / foul-smelling urine - 3 days
7. Reduced urine output (oliguria) since previous day
8. High-grade fever with chills and rigors - since 2 days
9. Generalized weakness and lethargy - 3 days

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HISTORY OF PRESENTING ILLNESS

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PAST MEDICAL HISTORY (PMH)

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FAMILY HISTORY

• Father - died of cardiac disease
• No family history of renal disease or malignancy

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SOCIAL HISTORY

• Widowed, lives with son
• Non-smoker, non-alcoholic
• Dependent for ADLs partially (uses a walking aid)
• Low-salt, diabetic diet prescribed; poorly compliant

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PRIMARY SURVEY (ABCDE)

A - Airway

• Partially compromised - gurgling secretions audible, patient unable to protect airway independently (GCS < 8 effective)
• Jaw tone reduced, tongue position borderline
• Action: Suction performed, jaw thrust applied, oropharyngeal airway (Guedel) inserted; intubation standby kept ready
• C-spine precaution maintained in context of fall

B - Breathing

• RR: 28/min (tachypnoeic)
• SpO2: 98% on 8L O2 via non-rebreather mask
• Chest: Air entry bilateral, equal; no crepts, no wheeze - CLEAR
• Work of breathing: increased (accessory muscle use)
• Interpretation: Tachypnoea likely metabolic (Kussmaul breathing component in setting of high RBS and possible DKA/HHS overlap), and partially sepsis-driven

C - Circulation

• HR: 80/min, regular, low volume pulse
• BP: 80/52 mmHg (hypotensive - SEPTIC SHOCK)
• CRT: > 3 seconds (peripherally shut down)
• Temperature: 38.9°C (febrile)
• Skin: Cold peripheries, mottling noted over lower extremities
• Action: Two large-bore IV cannulas (16G bilateral antecubital) inserted; IV fluid bolus initiated; bloods drawn

D - Disability (Neurological)

• GCS: E4V1M5 = 10/15 (Confused, eyes open spontaneously, localises to pain)
• RBS: > 600 mg/dL (critical hyperglycaemia)
• Pupils: 3 mm bilaterally, sluggish reaction to light
• Interpretation: Altered sensorium - multifactorial: septic encephalopathy + hyponatremia + severe hyperglycaemia (HHS component) + poor cerebral perfusion from shock

E - Exposure

• Left hip/groin: Swelling, external rotation, shortening, bruising of left lower limb
• Painful passive movement of left hip
• No open wound, no obvious long bone deformity elsewhere
• Sacral/heel skin: Stage I pressure injury noted
• Abdomen: Soft, suprapubic tenderness present
• Foley catheter inserted - urine: dark amber, foul-smelling; measured output: < 15 mL/hour (oliguria)

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RESUSCITATION INITIATED (Concurrent with Primary Survey)

• O2 via NRM 8L
• IV access x2 (16G bilateral)
• IV NS 500 mL rapid bolus (to be reassessed)
• IV fluid: Ringer's Lactate 30 mL/kg started (Surviving Sepsis Bundle)
• Cardiac monitor + SpO2 continuous
• Foley catheter inserted, hourly urine output measurement
• Bedside ECG done (rule out cardiac arrhythmia/peaked T-waves)
• RBS: > 600 mg/dL confirmed on glucometer

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SECONDARY SURVEY

SAMPLE History (from Son / Attender)

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SYSTEMIC EXAMINATION

General

• Elderly obese female, drowsy but arousable to painful stimuli
• Icteric tinge: absent
• Pallor: present (+)
• Cyanosis: absent
• Clubbing: absent
• Lymphadenopathy: absent
• Oedema: bilateral ankle pitting oedema (+)

Vital Signs (post initial resuscitation - 30 min)

CNS

• GCS 10/15; oriented to eye opening, does not speak, localises pain
• Pupils: 3 mm, sluggish bilateral
• No focal neurological deficits detectable at this level of consciousness
• No neck stiffness, no Kernig's sign (assessed carefully)
• No clonus, plantars - mute bilaterally

Cardiovascular

• S1 S2 heard, no murmurs
• JVP: Not elevated
• Peripheral pulses: feeble bilaterally

Respiratory

• Bilateral air entry, chest clear
• Trachea central

Abdomen

• Soft, mild suprapubic and right iliac fossa tenderness
• No guarding, no rigidity
• Liver and spleen: not palpable
• Bowel sounds: present, sluggish

Genitourinary

• Suprapubic tenderness on palpation
• Foley catheter in situ: urine - dark amber, turbid, offensive odour, < 15 mL/hr

Musculoskeletal (Left Lower Limb)

• Left leg: shortened by ~2 cm
• Left hip: externally rotated
• Swelling and bruising over left greater trochanteric region
• Tenderness on palpation over left hip
• Passive range of motion: severely restricted and painful
• Neurovascular status: dorsalis pedis palpable bilaterally, sensation grossly intact
• No skin breach

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INVESTIGATIONS ADVISED & RESULTS

Bedside/Point-of-Care

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Laboratory Investigations

Complete Blood Count (CBC)

Renal Function Tests (RFT)

Liver Function Tests (LFT)

Blood Glucose & Related

Arterial Blood Gas (ABG) - on 8L O2

Coagulation Profile (DIC screen)

Sepsis Markers

Urine Analysis & Culture

Cardiac Biomarkers

Thyroid Function

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Imaging

X-Ray Left Hip (AP and Lateral)

• Findings: Fracture line through left intertrochanteric region of femur
• Varus deformity noted
• Fracture appears comminuted (4-part, AO type 31-A2.3)
• Greater and lesser trochanter involvement
• No dislocation

Chest X-Ray (AP, portable)

• Cardiomegaly (CTR ~0.55)
• No consolidation, no pleural effusion
• No pneumonia at this time
• Mild cephalisation of pulmonary veins

CT Head (Non-Contrast)

• No intracranial bleed
• No focal infarct
• No mass lesion or midline shift
• Mild generalised cerebral atrophy (age-related)
• Small vessel ischaemic changes periventricular

USG Abdomen & Pelvis

• Kidneys: B/L mildly enlarged (R: 12.4 cm, L: 12.1 cm) with loss of CMD and Grade 1 hydronephrosis bilaterally
• Bladder: Prior to catheterisation - distended (retained urine suggestive of neurogenic/obstructive component)
• Liver: Mild hepatomegaly with increased echogenicity (fatty liver)
• No cholelithiasis, no appendicitis
• No free fluid

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DIFFERENTIAL DIAGNOSES

Primary Diagnosis (Working)

1. Urosepsis with Septic Shock (qSOFA 3/3, PCT 28.4, pyuria, febrile, hypotension)
2. Septic Encephalopathy (altered sensorium in context of sepsis, no structural cause on CT)
3. Hyponatraemia (Na 122 mEq/L - symptomatic, dilutional + SIADH in setting of infection)
4. Acute Kidney Injury - Stage 3 (Cr 4.2, oliguria - prerenal + intrinsic, sepsis-induced)
5. Left Intertrochanteric Femur Fracture (fall 1 day back, X-ray confirmed)

Secondary / Contributory

1. Hyperosmolar Hyperglycaemic State (HHS) (Glucose 628, Osmolality 352, trace ketones)
2. Early DIC (thrombocytopenia, elevated D-dimer, deranged coagulation)
3. Metabolic Acidosis (mixed: high-AG + non-AG; lactate 4.8)

Differentials to Exclude

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ED MANAGEMENT

Resuscitation Bundle (Surviving Sepsis Campaign - Hour-1 Bundle)

• Measure Serum Lactate (Result: 4.8 mmol/L)
• Blood cultures x2 sets drawn (before antibiotics)
• Urine culture sent
• Broad-spectrum antibiotics started
• IV fluid 30 mL/kg crystalloid (Ringer's Lactate - preferred over NS to avoid hyperchloraemic acidosis)
• Vasopressor started (for persistent hypotension after fluid)

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Specific Treatment Orders

1. Airway & Breathing

• O2 via NRM at 8L/min, titrate to SpO2 > 95%
• Oropharyngeal airway in situ
• Anaesthesia team alerted - intubation standby
• If GCS drops < 8 or airway compromised further - RSI and intubation

2. Septic Shock / Urosepsis

• IV Piperacillin-Tazobactam 4.5g IV Q6H (first dose stat - broad-spectrum, covers urinary Gram-negatives including Pseudomonas)
• Alternate: IV Meropenem 1g Q8H if local ESBL prevalence high or prior resistant organisms
• IV Metronidazole 500 mg Q8H if anaerobic coverage needed
• Blood cultures x2 sets (peripheral + catheter), urine C&S - PRIOR to antibiotics ✓
• PCT and CRP - baseline ✓

3. Fluid Resuscitation & Vasopressors

• IV Ringer's Lactate 30 mL/kg (= ~1800 mL for ~60 kg patient) over 3 hours - bolus complete
• Reassess with bedside echocardiography / IVC collapsibility post-bolus
• If BP still < 65 mmHg MAP post-fluid:
  • Start IV Norepinephrine 0.1-0.3 mcg/kg/min via central line (target MAP ≥ 65 mmHg)
  • Avoid dopamine (increased arrhythmia risk in elderly)

4. Hyponatraemia Management

• Cause: Euvolemic/hypovolemic in context of infection (SIADH component + vomiting + fluid loss)
• Na = 122 mEq/L - symptomatic hyponatraemia (altered sensorium)
• Treatment: Restrict free water intake; IV NS (0.9%) as maintenance fluid
• Target sodium correction: No more than 8-10 mEq/L per 24 hours (to prevent osmotic demyelination syndrome / central pontine myelinolysis)
• If seizures develop: 3% hypertonic saline 100 mL IV over 10 min (max 3 doses) - raise Na by 2-3 mEq/L acutely
• Recheck serum Na every 4-6 hours
• Monitor urine sodium and osmolality

5. Hyperglycaemia / HHS Management

• Insulin therapy: IV Insulin infusion - start at 0.05-0.1 U/kg/hr (hold if K+ < 3.5)
• K+ currently 5.6 - monitor closely; start insulin only with K monitoring
• Target: Glucose reduction of 50-75 mg/dL/hr (not > 75 mg/dL/hr - hypoglycaemia risk)
• IV Fluids: RL / 0.45% NS at 250-500 mL/hr (correct osmolality gradually)
• Hold Metformin (contraindicated in AKI and iodinated contrast potential)
• Hourly RBS monitoring

6. AKI Management

• IV fluids to restore renal perfusion (as above - cautious in oliguria)
• Strict hourly urine output monitoring (target > 0.5 mL/kg/hr)
• Avoid nephrotoxic drugs (NSAIDs, aminoglycosides, contrast, Metformin - all HELD)
• Renal team consultation
• If K+ continues to rise (> 6.0 mEq/L) or acidosis worsens or urine output < 200 mL/12 hrs:
  • IV Calcium Gluconate 10 mL 10% IV (cardiac protection)
  • IV Insulin + Dextrose, Sodium Bicarbonate
  • Nephrology consult for emergent haemodialysis/CRRT

7. Left Intertrochanteric Femur Fracture

• Immobilise limb in neutral position - pillow between legs, no external rotation
• IV Paracetamol 1g IV Q8H for analgesia (avoid NSAIDs in AKI)
• IV Morphine 2 mg slow IV bolus (titrated) for breakthrough pain - monitor GCS
• Orthopaedic surgery consultation for definitive management (PFNA/DHS - to be planned after medical stabilisation)
• X-Ray left hip AP and lateral - done
• Hold any surgical intervention until patient is medically optimised (sepsis controlled, electrolytes corrected, renal function improving)
• DVT prophylaxis: Hold LMWH currently (thrombocytopenia 98K, deranged coagulation, AKI) - plan sequential compression devices, re-evaluate anticoagulation in 48-72 hrs
• Bone density workup post-stabilisation

8. Septic Encephalopathy

• No specific pharmacotherapy - treat the underlying cause (sepsis control, fluid, antibiotics)
• Correct metabolic derangements: electrolytes, glucose, acidosis
• Avoid benzodiazepines and sedatives unless seizures develop
• Continuous neurological monitoring - reassess GCS hourly
• If no improvement in GCS with sepsis control and metabolic correction - consider LP to rule out meningitis, repeat CT head

9. Additional / Supportive

• IV Pantoprazole 40 mg OD - stress ulcer prophylaxis (ICU admission, mechanical ventilation risk, coagulopathy)
• Thiamine 100 mg IV - empirical (altered sensorium, possible nutritional deficiency in elderly)
• Pressure injury care - foam dressing sacrum/heels; pressure-relief mattress
• NPO/NG tube placement for medications if GCS does not improve
• Blood transfusion if Hb drops below 7 g/dL (currently 9.8 - monitor)
• Sepsis-related adrenal insufficiency: IV Hydrocortisone 200 mg/day (50 mg Q6H) if vasopressors > 0.25 mcg/kg/min norepinephrine required

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MONITORING PLAN

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DISPOSITION

• Septic shock (MAP < 65 mmHg, vasopressor dependent)
• Altered sensorium / septic encephalopathy with high aspiration risk
• Stage 3 AKI with oliguria and electrolyte disturbances
• Symptomatic severe hyponatraemia
• HHS with glucose > 600 and osmolality > 350
• Left IT fracture requiring orthopaedic planning
• Multiple organ dysfunction - requires multi-team management

1. Urology/Nephrology - Urosepsis, AKI management, hydronephrosis
2. Orthopaedic Surgery - Left intertrochanteric femur fracture
3. Endocrinology / Internal Medicine - DM management, HHS, hyponatraemia
4. Neurology - Septic encephalopathy; LP decision
5. ICU team - Critical care management

• High-risk patient - elderly, multiple co-morbidities, multi-organ dysfunction (SOFA ≥ 11)
• Informed consent obtained from next of kin (son)
• Goals of care discussion initiated

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SUMMARY DIAGNOSIS LIST

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