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  #1  
Old 04-30-2013
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EKG ST Elevation and T Wave Inversion!

a 30 year old male on road traffic accident now presents to the ER with the SOB. He is evaluated by the paramedics they only do pain management and forgot to push iv fluid. In the ER HE IS PLACED on mechanical ventilation. YOU noticed his FeNa to be less than 1% and BUN/CR>20/1. ON EKG he has ST segment elevation with T wave inversion. the most likely cause is:
a) pre existing pulmonary embolus
b) massive blood loss
c) rhabdomyolysis
d) increased cardiac output
e) decreased venous return
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  #2  
Old 04-30-2013
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" C " ... Rhabdomyolysis ?
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Old 04-30-2013
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E , decreased venous return .
its because of the positive intrathoracic pressure of the pt due to intubation that hinders in the venous return to heart-> reduced cardiac output->reduced renal blood flow->pre renal azotemia
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Old 04-30-2013
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yes, prerenal azotemia...and E) decreased venous return sounds perfect

but why not B) massive blood loss ??

thanks
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Old 04-30-2013
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B) blood loss
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Old 04-30-2013
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B) Massive blood loss

Because the heart isn't getting enough oxygen since the RBCs are too little..
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Old 04-30-2013
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Correct Answer e

Quote:
Originally Posted by rupesh View Post
a 30 year old male on road traffic accident now presents to the ER with the SOB. He is evaluated by the paramedics they only do pain management and forgot to push iv fluid. In the ER HE IS PLACED on mechanical ventilation. YOU noticed his FeNa to be less than 1% and BUN/CR>20/1. ON EKG he has ST segment elevation with T wave inversion. the most likely cause is:
a) pre existing pulmonary embolus
b) massive blood loss
c) rhabdomyolysis
d) increased cardiac output
e) decreased venous return
ok guys here the paramedic have to push the iv fluids first but they did not..next the attending physician just do mechanical ventillation without pushing ivf that causes the rise in intrathoracic pressure which results in decreased venous return ro the heart resulting in myocardial ischaemia and pre renal arf.
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  #8  
Old 05-02-2013
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Exactly Rupesh!
Mechanical ventilation esp. in a patient
with blood loss increases intrathoracic
pressure and reduces venous return thus
decreases the stroke volume and CO
and the Mean arterial pressure and this
kidney perfusion. Both decreased
kidney perfusion and baroreceptor activation
resulting in sympathetic activation (along
with anxiety due to pain) produce
all the sympathetic manifestations
that put strain on a heart that is underperfused +
activate the RAAS and
cause fractional sodium in urine to decrease
and BUN to be higher than urea (because
ADH causes urea to enter into the interstitum
along with free water which eventually
go back to the blood) causing
>BUN/Cr which is typical of prerenal failure.
This reduced mean arterial pressure
also reduces coronary perfusion and can
induce an MI in a patient who's BP is already low and tachycardic
resulting in reduced diastolic time and thus reduced
coronary filling time. All these factors produce an MI.
Moral of the story is to always give
IV fluids before doing PPV on a hypovolemic
patient.

Last edited by add1; 05-02-2013 at 05:14 AM.
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