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Fluids and Electrolytes

Staying BalancedStaying Balanced

Spring 2008Spring 2008

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Water – H2O

• ““Universal solvent”Universal solvent”–60% of body’s weight60% of body’s weight

–Cells “haf to have it.” Cells “haf to have it.” »––Arnold SchwarzeneggerArnold Schwarzenegger

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How much is that?

• 154# person x .60 (60%) =154# person x .60 (60%) =– 92#92#– Water is approx 8# per gallonWater is approx 8# per gallon– 11 ½ gallons water11 ½ gallons water– (Obese people/ less)(Obese people/ less)– (Thin people/ more)(Thin people/ more)– InfantsInfants– EldersElders

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Basic Cellular Review

• The fundamental unitThe fundamental unit

• Requires:Requires:– Cell membraneCell membrane

– EnzymesEnzymes

– Internal membranesInternal membranes

– Genetic materialGenetic material

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Basic tissue types

• EpithelialEpithelial

• ConnectiveConnective

• MuscleMuscle

• NervousNervous

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The cellular environment

• All metabolic reactions occurAll metabolic reactions occur

• The precise regulation of volume The precise regulation of volume and composition of body fluid is and composition of body fluid is essential to health.essential to health.

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Body fluid compartments

• Intracellular Fluid - ICFIntracellular Fluid - ICF

• Extracellular Fluid – ECFExtracellular Fluid – ECF–Intravascular Fluid- Plasma Intravascular Fluid- Plasma

–Interstitial FluidInterstitial Fluid

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Intracellular - ICF

• Fluid in all body cellsFluid in all body cells

• 75% of the water (60%)75% of the water (60%)

–31.50 L (70 kg adult)31.50 L (70 kg adult)

• 40% of total body weight40% of total body weight

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Extracellular - ECF

• 20% of water (60%)20% of water (60%)–10.50 L (70 kg adult))10.50 L (70 kg adult))

• Includes intravascular Includes intravascular and interstitial and interstitial compartmentscompartments

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ECF

• Intravascular Intravascular –4% of (60%)4% of (60%)

»7.5 L7.5 L

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ECF

• Interstitial Interstitial –16% of (60%)16% of (60%)

»17.5 L17.5 L

• Fluid between cells and outside Fluid between cells and outside the vascular bedthe vascular bed–Connective tissue, cartilage, Connective tissue, cartilage,

bone, CSF, intraocular fluid bone, CSF, intraocular fluid

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Hydration

• Water - Water - Universal Universal solventsolvent

•Intake & Intake & Output Output (I&O)(I&O)

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Hydration

• HomeostasisHomeostasis–The body’s need for balanceThe body’s need for balance

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Aging and distribution of fluids

• Newborns – TBW ~ 80%Newborns – TBW ~ 80%• Children – TBW ~ 60-65%Children – TBW ~ 60-65%• Elders – TBW < ~ 60%Elders – TBW < ~ 60%

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Intake vs Output

• Food - 1200 mlFood - 1200 ml• Drink - 1000 mlDrink - 1000 ml• Metabolic Metabolic

sources - 300 sources - 300 mlml

= 2500 ml= 2500 ml

• Lungs - 400 mlLungs - 400 ml• Kidneys - 1500 mlKidneys - 1500 ml• Skin - 400 mlSkin - 400 ml• Intestine (Feces) - Intestine (Feces) -

200 ml200 ml

= 2,500 ml= 2,500 ml

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Hydration

• Osmoreceptors - anterior Osmoreceptors - anterior hypothalamushypothalamus

• Baroreceptors - carotid sinus, aortic Baroreceptors - carotid sinus, aortic arch, kidneysarch, kidneys– High and low blood pressureHigh and low blood pressure

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Hydration

• Anti-diuretic hormone (ADH)Anti-diuretic hormone (ADH)– If tide goes outIf tide goes out– Pituitary Gland ExcretesPituitary Gland Excretes

– Tide comes in!!!Tide comes in!!!» Re-absorb from kidneysRe-absorb from kidneys» Decrease urineDecrease urine

– Thirst also regulatesThirst also regulates

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Dehydration

• Abnormal decrease in TBWAbnormal decrease in TBW

– Thus the weigh-in at firesThus the weigh-in at fires

• Rarely involves only water lossRarely involves only water loss

• Electrolyte lossElectrolyte loss

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Dehydration causes

• Signs and symptoms?Signs and symptoms?

• Treatment?Treatment?

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Causes of dehydration

• GI lossesGI losses– N/V/DN/V/D

• Insensible lossesInsensible losses– Normal losses + with feverNormal losses + with fever

– HyperventilationHyperventilation

– High Environmental TempsHigh Environmental Temps

• Increased sweatingIncreased sweating

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Causes of dehydration

• Internal lossesInternal losses–““Third”spacingThird”spacing

»PeritonitisPeritonitis

»PancreatitisPancreatitis

»MalnourishedMalnourished• No protein to retain waterNo protein to retain water

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Causes of Dehydration

• Plasma lossesPlasma losses–BurnsBurns

–Surgical DrainsSurgical Drains

–Open woundsOpen wounds

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Signs and symptoms

• Signs of shockSigns of shock–Skin changes (turgor)Skin changes (turgor)–Orthostatic hypotensionOrthostatic hypotension–ThirstThirst–Increased pulse rateIncreased pulse rate–Furrowed tongueFurrowed tongue

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S/S, cont.

– Decreased BPDecreased BP

– Dry mucosaDry mucosa

– Infants: Anterior fontanelle sunkenInfants: Anterior fontanelle sunken

»Dry diapersDry diapers

»Absent tearsAbsent tears

»Cap refill > 2 secondsCap refill > 2 seconds

»Dry mucosaDry mucosa

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Treatment

• ABCsABCs• OO22

• FluidsFluids–Flavor?Flavor?

• Consider PASGConsider PASG• ECGECG

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Overhydration – “No thanks I’m full.”

• EdemaEdema–Peripheral vs. central Peripheral vs. central (more (more

later…)later…)

• Aggressive treatment if Aggressive treatment if Pulmonary EdemaPulmonary Edema

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Overhydration

• ABCsABCs

• OO22

• Consider ETTConsider ETT

• Meds: Meds: – NTG.NTG.

– LasixLasix

– M.S.M.S.

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Fluid & Electrolyte Disturbances

• Medical causesMedical causes–DiabetesDiabetes

–Heat Heat EmergenciesEmergencies

–Blood LossBlood Loss

• Traumatic causesTraumatic causes–Blood lossBlood loss

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Electrolytes

• In HIn H22O dissociate into ionsO dissociate into ions

• Cations = positiveCations = positive

• Anions = negative Anions = negative

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Principle CationsSodium-Potassium Pump

• Sodium (NaSodium (Na++))– Prevalent in Prevalent in ECFECF

»““Water follows Water follows it”it”

– Nerve impulsesNerve impulses– Hyper/Hyper/– HyponatremiaHyponatremia

• Potassium Potassium (K(K++))– Prevalent in Prevalent in

ICFICF– Nerve impulsesNerve impulses– Hypo/Hypo/– HyperkalemiaHyperkalemia

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Other Cations

• Calcium (CaCalcium (Ca++++))– Prevalent in Prevalent in ICFICF

– Muscle contractionMuscle contraction

– Nerve impulseNerve impulse

– Hypo/hypercalcemiaHypo/hypercalcemia

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Other Cations

• Magnesium (MgMagnesium (Mg++++))– Present inPresent in ICF ICF

• Necessary for many processesNecessary for many processes• Found in some:Found in some:

– AntacidsAntacids– LaxativesLaxatives

• Most associated with phosphateMost associated with phosphate– Renal FunctionsRenal Functions

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Principal Anions

• Chloride (ClChloride (Cl--))– Present in Present in ECFECF

– Balances cationsBalances cations

– Fluid balanceFluid balance

– Renal functionRenal function

– Usually found hanging around sodiumUsually found hanging around sodium

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Principal Anions

• Bicarbonate (HCOBicarbonate (HCO33--))

– Found in Found in ECFECF

• The BufferThe Buffer• Neutralizes Acidic (HNeutralizes Acidic (H++))

• Tx for acidosisTx for acidosis

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Anions

• Phosphate (HPOPhosphate (HPO44----))

– Found in Found in ICF - bufferICF - buffer

• Energy storesEnergy stores

• MgMg++++ in renal function in renal function

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• Electrolytes - mEq/LElectrolytes - mEq/L

• Non-Electrolytes - Non-Electrolytes -

–GlucoseGlucose

–UreaUrea

–ProteinsProteins

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How does it get there?

• OsmosisOsmosis

• DiffusionDiffusion

• Active TransportActive Transport

• Facilitated DiffusionFacilitated Diffusion

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• IsotonicIsotonic

• HypertonicHypertonic

• HypotonicHypotonic

• Osomotic gradientOsomotic gradient - difference in - difference in

concentrationconcentration

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Osmosis

• Movement of Movement of water water (solvent)(solvent)– Semi-Semi-

permeable permeable membranemembrane

• Towards Towards higherhigher solutesolute concentrationconcentration

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Diffusion

• Movement of Movement of solutessolutes–Across membrane Across membrane

•Towards Towards lesser lesser solutesolute concentrationconcentration

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Active transport

• Movement of solutesMovement of solutes–Across membraneAcross membrane

• Against osmotic gradientAgainst osmotic gradient–Requires energy (ATP)Requires energy (ATP)

• Sodium-potassium pumpSodium-potassium pump

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Active transport

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Facilitated diffusion

• Helper proteinsHelper proteins–InsulinInsulin

• Open gateOpen gate

• GlucoseGlucose

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Facilitated diffusion

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Osmotic Pressure

• Governs movement of water and Governs movement of water and solutes across cell membranesolutes across cell membrane

• Pressure exerted by concentration of Pressure exerted by concentration of solutessolutes

• Pulls from other side of membranePulls from other side of membrane

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Lysis Crenation

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Blood Plasma

• Colloid osmotic pressureColloid osmotic pressure– PlasmaPlasma

• Hydrostatic pressureHydrostatic pressure– Blood pressureBlood pressure

»FiltrationFiltration

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Edema

• LocalizedLocalized– Site of injurySite of injury

– Organ systems - brain, lungs, heart, Organ systems - brain, lungs, heart, abdomenabdomen

• GeneralizedGeneralized– Dependent edemaDependent edema

»Pitting edemaPitting edema

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RELATIVE HYDRATION

•Body water in interstitial Body water in interstitial spaces not available for spaces not available for metabolismmetabolism

•Relative dehydrationRelative dehydration

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Edema

• Decrease in production of plasma Decrease in production of plasma

proteinsproteins

– Liver disorderLiver disorder

– BurnsBurns

– Open woundsOpen wounds

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More about Edema

• Increase in hydrostatic pressureIncrease in hydrostatic pressure– Venous obstructionVenous obstruction

– Salt and water retentionSalt and water retention

– ThrombophlebitisThrombophlebitis

– Liver obstructionLiver obstruction

– Tight clothingTight clothing

– Prolonged standingProlonged standing

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And more about edema

• Increased capillary permeability - Increased capillary permeability - plasma proteins escapeplasma proteins escape– Inflammation and immune responseInflammation and immune response

– Allergic reactionsAllergic reactions

– Burns Burns

– TraumaTrauma

– CancerCancer

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And still more edema

• Lymphatic channel obstructionLymphatic channel obstruction

– InfectionInfection

– SurgerySurgery

54Blood transfusions

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Blood Components

• PlasmaPlasma

• Formed ElementsFormed Elements–Leukocytes (WBCs)Leukocytes (WBCs)

–Erythrocytes (RBCs) >99%Erythrocytes (RBCs) >99%

–ThrombocytesThrombocytes

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Plasma

• Mostly Water (92%)Mostly Water (92%)

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Leukocytes– Monocytes (Big Monocytes (Big

eaters, chronic)eaters, chronic)– Neutrophils Neutrophils

(bacteria)(bacteria)– Basophils Basophils

(inflamation)(inflamation)– Eosinophils Eosinophils

(allergies, parasites)(allergies, parasites)– Lymphocytes Lymphocytes

(intracellular)(intracellular)

• Indicate Combat Indicate Combat ReadinessReadiness

•State of the union

State of the union

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Erythrocytes & Hemoglobin

• Transports oxygenTransports oxygen

• 40-45% Hematocrit40-45% Hematocrit

– After specimen is After specimen is

spunspun

• Hemoglobin -Hemoglobin -– Iron-based compound; Iron-based compound;

binds with oxygenbinds with oxygen

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Thrombocytes

•Major role in Major role in blood clottingblood clotting

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Viscosity of blood

•Determined by ratio of Determined by ratio of plasma to formed elementsplasma to formed elements

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Blood types

• AntigensAntigens–Blood type proteinsBlood type proteins

• AntibodiesAntibodies–Resistance (in serum)Resistance (in serum)

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ABO system

• AA–A AntigenA Antigen

–B AntibodyB Antibody

• BB–B AntigenB Antigen

–A AntibodyA Antibody

• ABAB– A & B AntigenA & B Antigen– No AntibodiesNo Antibodies– ““Universal Universal

Recipient”Recipient”

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•OO–No AntigensNo Antigens–A & B Antibodies A & B Antibodies (serum)(serum)

–““Universal Donor”Universal Donor”

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RH factor

• Measured in + or –Measured in + or –• + = Anti-Rh antibodies present+ = Anti-Rh antibodies present

– - = Ok.- = Ok.

• - = No Anti-Rh antibodies pres.- = No Anti-Rh antibodies pres.– - = Ok- = Ok– + = Sensitization+ = Sensitization– ++ = Severe reaction / death++ = Severe reaction / death

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Blood products

Blood type Volume infused Time

Packed Cells:

Preferred method

250-350 ml 2 – 3 hours

Whole blood: 550 ml 2 – 3 hours

Leukopoor RBCs:

Prevents febrile non-hemolytic reactions

250 – 500 ml 2 – 3 hours

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Blood products, cont.

Blood type Volume infused Time

Irradiated RBCs

Used in immunodeficient clients

250 – 350 ml 2 – 3 hours

Fresh frozen plasma:

Has most coagulation factors

Used in DIC, liver disease

200 – 250 ml 1 hour

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Blood Transfusion

• Physician’s orderPhysician’s order• Check type and cross-match; verify with Check type and cross-match; verify with

partnerpartner• Check blood bag for bubbles, cloudiness, Check blood bag for bubbles, cloudiness,

dark color, sedimentdark color, sediment• Check patients vital signsCheck patients vital signs

– TemperatureTemperature– BPBP– PulsePulse– RespirationsRespirations

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• Rotate blood bag gentlyRotate blood bag gently• Pull back tabs on blood unit bag, Pull back tabs on blood unit bag,

expose port.expose port.• Spike blood bag port carefully and hang Spike blood bag port carefully and hang

unit. (Be sure clamp is closed).unit. (Be sure clamp is closed).• Open clamp and fill drip chamber. Make Open clamp and fill drip chamber. Make

sure filter is submerged in blood.sure filter is submerged in blood.• Open clamp on tubing, carefully run Open clamp on tubing, carefully run

blood through tubing, and place needle blood through tubing, and place needle on end of tubing.on end of tubing.

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• Check primary IV solution – Never use Check primary IV solution – Never use dextrose solutions!dextrose solutions!

• Attach blood tubing into IV port and tape Attach blood tubing into IV port and tape into place.into place.

• Shut off primary IV and begin Shut off primary IV and begin transfusion.transfusion.

• Administer blood slowly for first 15 Administer blood slowly for first 15 minutes, ~ 20 gtts/min.minutes, ~ 20 gtts/min.– ALLOWS TIME TO OBSERVE FOR ALLOWS TIME TO OBSERVE FOR

ADVERSE REACTIONADVERSE REACTION

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• When blood bag is empty, clamp off When blood bag is empty, clamp off tubing to bag, open clamp to normal tubing to bag, open clamp to normal saline bag, and flush line.saline bag, and flush line.

• Close all clamps and remove blood Close all clamps and remove blood tubing from injection port.tubing from injection port.

• Monitor patient for s/s of transfusion Monitor patient for s/s of transfusion reaction.reaction.

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Transfusion ReactionUsually occurs in first 15 minutes

• S/SSudden increase in temperature (may be 105o)

Hypotension

Dry, flushed skin

Abdominal pain

Headache

Lumbar pain

Sudden chill

Urticaria

Respiratory wheezing, laryngeal edema

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• Stop transfusion immediatelyStop transfusion immediately• Change tubingChange tubing• Observe for shockObserve for shock• Monitor vitals every 15 minutes until Monitor vitals every 15 minutes until

stablestable• Keep blood tubing and bag for ED staff.Keep blood tubing and bag for ED staff.• Control hyperthermiaControl hyperthermia• Consider antihistamine if allergic Consider antihistamine if allergic

reactionreaction

Treatment

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First Patient

• A 40 y/o male driver involved in a head-on A 40 y/o male driver involved in a head-on collision at ~ 40 mph. Pt is seat belted collision at ~ 40 mph. Pt is seat belted with a lap belt only. Pt is CAO PPTE on with a lap belt only. Pt is CAO PPTE on arrival, c/o acute abd. Pain and SOB. arrival, c/o acute abd. Pain and SOB. – P rapid, threadyP rapid, thready

– BP – unable to auscultateBP – unable to auscultate

– RR rapidRR rapid

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• DDX?DDX?

• Why?Why?

• TX?TX?

• Why? Why?

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Second Pt

• This patient is 82 y/o, and calls This patient is 82 y/o, and calls you at 0030, c/o feeling ill.you at 0030, c/o feeling ill.

• Pt is CAO PPTE, but slow to Pt is CAO PPTE, but slow to respondrespond– B/P 120/76B/P 120/76– P 94, irreg.P 94, irreg.– RR 24RR 24– Skin cool, dry, pale Skin cool, dry, pale – Mucous membranes dry with Mucous membranes dry with

furrowed tongue and sunken eyesfurrowed tongue and sunken eyes

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• DDX?DDX?

• Why?Why?

• Tx?Tx?

• Why?Why?

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Third Patient

• You are called to a 60 year old You are called to a 60 year old male c/o SOB, chest pain. His sx male c/o SOB, chest pain. His sx started ~ 2 hrs ago while painting started ~ 2 hrs ago while painting the garage. He says the chest pain the garage. He says the chest pain went away almost immediately, but went away almost immediately, but he’s increasingly short of breath.he’s increasingly short of breath.

• PMH: Pulmonary edema, Angina, PMH: Pulmonary edema, Angina, HTN, recent URIHTN, recent URI

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• Pt is CAO PPTE, anxious, in tripod Pt is CAO PPTE, anxious, in tripod position. position. – BBS decreased with coarse crackles in the BBS decreased with coarse crackles in the

basesbases– BP 130/60BP 130/60– HR 126, sl irreg.HR 126, sl irreg.– RR 36, shallowRR 36, shallow– Skin pale, cool, dry with poor turger, dry Skin pale, cool, dry with poor turger, dry

mucous membranes, furrowed tonguemucous membranes, furrowed tongue

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• DDX?DDX?

• Why?Why?

• Tx?Tx?

• Why?Why?

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