Introduction
Linda Jantz, age 38 years female, with Type 1 Diabetes Mellitus (T1DM) was admitted for emergency care with injuries following a horse-riding accident. A potential underlying issue that needs to be attended to immediately is her clinical presentation. This assessment will assess Linda’s medical history and comorbidities in terms of how it might affect her recovery, further needed assessments to be done, the physiological basis of her symptoms and an appropriate course of action including possible escalation of care.
Impact of Medical History and Medications
Given the physiological stress of her injuries, Linda’s T1DM may cause hyperglycemia or hypoglycemia to occur, and requires careful blood glucose monitoring. Her smoking history accelerates risks of delayed wound healing, and respiratory complications (Alrouji et al., 2018). In addition, Topiramate, one of her migraine medications, can cause metabolic acidosis that may complicate her metabolic stability in the setting of trauma (Dalkilic, 2021). Her medications need to be reviewed given all of her injuries and hemodynamic instability, and with Topiramate withheld if metabolic acidosis is suspected.
Further Assessments and Mean Arterial Pressure Calculation
Possible hypovolemia or hemorrhagic shock is evidenced by declining blood pressure and increasing heart rate. A more complete assessment should involve serial blood pressure measurement, capillary refill time, monitoring for urine output, and a complete blood count for anemia. Calculation of her Mean Arterial Pressure (MAP) is essential:
MAP = [(2 x Diastolic) + Systolic] / 3
= [(2 x 46) + 88] / 3
= (92 + 88) / 3 = 60 mmHg
A MAP of 60 mmHg is concerning, as it is at the lower limit of adequate organ perfusion (Leibner et al., 2020). This suggests Linda is at risk of circulatory shock and requires urgent fluid resuscitation.
Physiological Basis and Patient Problem Identification
Given Linda’s symptoms which include tachycardia, hypotension, pallor, diaphoresis, and unsteadiness, she is likely to be losing or depleting blood or volume. An internal injury, like a hemothorax or splenic injury, might have occurred, which had resulted in hemorrhagic shock, owing to the fractured ribs. Signs of her difficulty in breathing and pain upon inspiration suggest pulmonary contusion or compromised ventilation (Lescroart et al., 2023). Immediate intervention of potential hypovolemia and respiratory compromise is required for the primary patient problem.
Response to the Situation
Management should include fluid resuscitation with isotonic crystalloids to restore blood circulating volume and prevent further deterioration in hemodynamics. The CT scan needs to be completed urgently given the concern for internal bleeding. Surgical intervention may be required if hemothorax or intra-abdominal bleeding is confirmed. To reduce respiratory suppression, oxygen therapy should be provided to maximize tissue oxygenation and pain management should be carefully controlled (Wyatt et al., 2020).
Actions While Awaiting Assistance
A Medical Emergency Team (MET) call should be made if Linda’s condition worsens. While awaiting response she should remain supine to maintain perfusion and IV fluids continued. Vital sign monitoring must be frequent, including reassessment of MAP and oxygen saturation (Groeneveld, 2008). Urgent blood samples for hemoglobin and coagulation studies are indicated and will help guide further intervention. Additionally, it is important to maintain communication with Linda and provide reassurance to reduce anxiety and prevent sympathetic overstimulation.
Conclusion
Lindas case points out the need for identifying early signs of shock and internal bleeding after trauma. Appropriate prompt and systematic approach can be given to her given her medical history, comorbidities and clinical presentation to optimize outcomes including fluid resuscitation, pain management, imaging, potential escalation of care.
References
Alrouji, M., Manouchehrinia, A., Gran, B., & Constantinescu, C. S. (2018). Effects of cigarette smoke on immunity, neuroinflammation and multiple sclerosis. Journal of Neuroimmunology, 329, 24–34. https://doi.org/10.1016/j.jneuroim.2018.10.004
Dalkilic, E. B. (2021). Effects of antiepileptic drugs on hormones. Neuroscience Letters, 754, 135800. https://doi.org/10.1016/j.neulet.2021.135800
Groeneveld, A. (2008). Hypovolemic shock. In Critical Care Medicine (pp. 485–520). https://doi.org/10.1016/b978-032304841-5.50029-7
Leibner, E., Andreae, M., Galvagno, S. M., & Scalea, T. (2020). Damage control resuscitation. Clinical and Experimental Emergency Medicine, 7(1), 5–13. https://doi.org/10.15441/ceem.19.089
Lescroart, M., Pequignot, B., Janah, D., & Levy, B. (2023). The medical treatment of cardiogenic shock. Journal of Intensive Medicine, 3(2), 114–123. https://doi.org/10.1016/j.jointm.2022.12.001
Wyatt, J. P., Taylor, R. G., De Wit, K., Hotton, E. J., & Hotton, E. (2020). Oxford Handbook of Emergency Medicine.
