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Hypotension & Retention

UnFiNiShEd CaSe CoMe BaCk LaTeR

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History of Present Illness:

A 62-year-old female on Coumadin for a-fib presents to the ED for near syncope and urinary retention.  She had a cardiac cath 2 days prior.  She hasn’t been able to pee more than drops since last night and feels like she has to.    She denies  or other complaints

Vital Signs & Physical Exam:

Vital signs are normal except for  BP of 77/49.  Physical exam is notable for suprpubic swelling and tenderness.  It is otherwise normal with no visible hematomas.

Initial Differential Diagnosis: Urosepsis

Initial Diagnostic Testing:

  • Foley: minimal urine
  • Labs: none ordered
  • Imaging: see bedside US below

QUESTIONS:

  1. What does the case image show?  
  2. What should you do next?  
  3. Want a 1-minute consult/tutorial on this case? 
  4. Want to know what happened with this patient?

SCROLL DOWN FOR ANSWERS & 1-MINUTE CONSULT

 

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ANSWERS:

  1. What does the case image show?  The image shows the longitudinal view of a pelvic hematoma.  At the top of the screen is the rectus abdominus and just behind that the less echoic hematoma and behind that more hyperechoic structures.
  2. What should you do next?  Type and cross, get an INR (it was 3.8). Reverse the coumadin.  Get a CT (images below show multiple hematomas and no distended bladder.  The small white circle is the Foley.  The other white areas are active bleeding).  Consult cardiology, general surgery and IR.
  3. Want a 1-minute consult/tutorial on this case?  See yellow area from sample page below.
  4. Want to know what happened with this patient?  See case conclusion below tutorial page.

pelvic bleed CT

Foley1-Minute EM Consult on the topic for this case from the Emergency Medicine 1-minute Consult Pocketbook

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CASE CONCLUSION: Hb dropped from 12 to 8.  Patient went to IR for embolization

CASE LESSONS:

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