Volume 83, Issue 10 (January 2025)
Tehran Univ Med J. 2025, 83(10): 748-751 |
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Abedzeydi H, Khavanin A. A complex multiorgan failure in a 63-year-old male with uncontrolled diabetes, sepsis, and acute coronary syndrome: challenges in emergency management: a case report. Tehran Univ Med J. 2025; 83 (10) :748-751
URL: http://tumj.tums.ac.ir/article-1-13887-en.html
URL: http://tumj.tums.ac.ir/article-1-13887-en.html
1- Department of Emergency Medicine, School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.
2- Department of Emergency Medicine, School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.| Clinical Research Development Unit, Imam Khomeini Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran. ,khavanin-a@ajums.ac.ir
2- Department of Emergency Medicine, School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.| Clinical Research Development Unit, Imam Khomeini Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran. ,
Abstract: (22 Views)
Background: Emergency department (ED) crowding is a systemic failure associated with increased mortality, medical errors, and staff burnout. The simultaneous management of multiorgan failure (MOF) requiring cardiac, renal, and respiratory support in such a resource-limited setting poses extreme clinical challenges. This case report describes the successful management of a patient with MOF in an overcrowded ED with no available ICU bed and limited vascular access.
Case Report: A 63-year-old man with uncontrolled diabetes, heart failure, and chronic kidney disease presented to the ED with decreased consciousness (GCS 9). Initial findings revealed severe hyperglycemia (blood glucose 561 mg/dL), respiratory distress with oxygen saturation of 62% on room air, and electrocardiographic evidence of ST-elevation myocardial infarction (STEMI). Arterial blood gas analysis showed severe metabolic acidosis (pH 7.12). Major challenges included: (1) the need for immediate intubation and mechanical ventilation with no available ICU bed for the next six hours; (2) severe metabolic derangements requiring emergency dialysis; (3) difficult vascular access due to previous hospitalizations; and (4) extreme ED crowding with a patient-to-physician ratio exceeding standard limits. Despite these limitations, the emergency team performed rapid-sequence intubation, inserted a high-risk subclavian central venous catheter under ultrasound guidance, initiated emergency hemodialysis, and coordinated with cardiology for anti-ischemic management. The patient survived the acute phase and received basic emergency care quickly and accurately without further complications.
Conclusion: This report provides three key takeaways for clinicians working in resource-limited, overcrowded EDs. First, successful management of MOF is possible even without immediate ICU access when dynamic prioritization and alternative low-cost interventions are implemented. Second, the main rate-limiting factor in such settings is not lack of individual clinical knowledge but systemic failure to adapt ideal care standards to real-world capacity a mechanism shifting "medical error" from the individual to the system level. Third, to our knowledge, this is the first comprehensive case report from Iran simultaneously analyzing MOF, systematic ED crowding, and hardware limitations (ICU bed shortage and vascular access difficulty). Clinically, this report offers a practical framework for emergency physicians to initiate life-saving interventions in overcrowded conditions, potentially reducing preventable deaths in similar low-resource settings.
Case Report: A 63-year-old man with uncontrolled diabetes, heart failure, and chronic kidney disease presented to the ED with decreased consciousness (GCS 9). Initial findings revealed severe hyperglycemia (blood glucose 561 mg/dL), respiratory distress with oxygen saturation of 62% on room air, and electrocardiographic evidence of ST-elevation myocardial infarction (STEMI). Arterial blood gas analysis showed severe metabolic acidosis (pH 7.12). Major challenges included: (1) the need for immediate intubation and mechanical ventilation with no available ICU bed for the next six hours; (2) severe metabolic derangements requiring emergency dialysis; (3) difficult vascular access due to previous hospitalizations; and (4) extreme ED crowding with a patient-to-physician ratio exceeding standard limits. Despite these limitations, the emergency team performed rapid-sequence intubation, inserted a high-risk subclavian central venous catheter under ultrasound guidance, initiated emergency hemodialysis, and coordinated with cardiology for anti-ischemic management. The patient survived the acute phase and received basic emergency care quickly and accurately without further complications.
Conclusion: This report provides three key takeaways for clinicians working in resource-limited, overcrowded EDs. First, successful management of MOF is possible even without immediate ICU access when dynamic prioritization and alternative low-cost interventions are implemented. Second, the main rate-limiting factor in such settings is not lack of individual clinical knowledge but systemic failure to adapt ideal care standards to real-world capacity a mechanism shifting "medical error" from the individual to the system level. Third, to our knowledge, this is the first comprehensive case report from Iran simultaneously analyzing MOF, systematic ED crowding, and hardware limitations (ICU bed shortage and vascular access difficulty). Clinically, this report offers a practical framework for emergency physicians to initiate life-saving interventions in overcrowded conditions, potentially reducing preventable deaths in similar low-resource settings.
Type of Study: Case Report |
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