Case Files: CPC Edition

A 51-year-old man walks into the ED after a week of vomiting blood, and by the time he arrives, his haemoglobin is 5.8 g/dL. Hosts Dr. Daniel Olinga and Dr. Emmanuel David sit down with Emergency Medicine physician Dr. Emuron to unpack a real case of upper gastrointestinal bleeding (UGIB), tracing the patient's journey from pre-hospital care through resuscitation, diagnosis, and disposition.

Key Discussion Points:

• Pre-hospital priorities for a suspected UGIB patient: IV access, careful fluid resuscitation, positioning, and a tight ISBAR handover
• Reading the primary and secondary survey — why "compensating" is not the same as "stable," and what clues like spider naevi, pitting oedema, and melaena reveal
• Building the differential: peptic ulcer disease, oesophageal/gastric varices, erosive gastritis, Mallory-Weiss tear, Dieulafoy lesion, and bleeding gastric carcinoma
• Blood vs. fluids — why crystalloid-heavy resuscitation can backfire, and the case for a restrictive transfusion strategy (Hb target 7–8 g/dL)
• The TXA debate — what the HALT-IT trial (12,000+ patients) actually showed about tranexamic acid in UGIB, and why it's not recommended here
• Airway management thresholds — when to intubate a GI bleed patient, including the pre-endoscopy scenario
• Solving the hyperbilirubinaemia puzzle — haemolysis vs. hepatocellular stress vs. gut-derived haem load
• Why pre-transfusion Hepatitis B testing matters even when the blood bank screens donor units
• Hospital course: endoscopy, H. pylori testing, PPI therapy, NSAID cessation, and screening for undiagnosed chronic liver disease

Takeaways:

1. Compensated ≠ stable — monitor relentlessly, because deterioration can be sudden
2. Resuscitate with blood, not fluid — target Hb 7–8 g/dL
3. TXA has no proven benefit in UGIB and raises VTE risk — skip it
4. Intubate based on genuine airway risk: falling GCS, active haematemesis, or pre-scope in a vomiting patient
5. Always ask about NSAID use by name — it can change both the diagnosis and the discharge plan Listen to learn. Share to save lives. Mastering Emergency Care

Disclaimer: For Educational Purposes only, refer to guidelines for definitive management

Show Notes & Resources:

· Watch the Full Case Video: https://youtu.be/qZZ86tknD8k?si=Pczbbe-vqvcti80V

Description:

Experts: Dr. Bernard Mwesigye & Dr. Umarashid Guloba

In this episode

A young type 1 diabetic patient arrives with: Restlessness, agitation, confusion (GCS 9/15)·

Vital signs: HR 146, RR 30, SpO₂ 89%, BP 186/89·

Key finding: Vitiligo patches on skin — signaling autoimmune disease (type 1 diabetes)·

History: Several days of vomiting/diarrhoea → couldn't keep food or insulin down

· Labs: Glucose 19 mmol/L, HbA1c 14%, ketonuria 3+· Diagnosis: DKA precipitated by gastroenteritis.

KEY DISCUSSION POINTS

1. Diagnosis & Differentials

· DKA confirmed (hyperglycaemia + ketones + acidosis)

· HHS ruled out (significant ketones present)

· Hypertension = symptom of metabolic crisis, not primary problem

· Sepsis considered — gastroenteritis = trigger; antibiotics started

2. The "Golden Rule" of DKA Management

NEVER give insulin if potassium < 3.5 mmol/L

· Insulin drives potassium into cells → can cause fatal arrhythmias

· Sequence: Check K⁺ → Replace if low → THEN start insulin

3. Four Treatment Pillars

Fluids 5–6L deficit; switch to dextrose when glucose < 14

Glucose Insulin 0.1 U/kg loading + infusion; reduce gradually

Electrolytes Potassium first; monitor every 2–4 hours

Acidosis Insulin stops ketones; bicarbonate almost never

4. Critical Pitfalls to Avoid

· Giving insulin before checking potassium

· Dropping glucose too fast → cerebral oedema

· Not treating the underlying trigger (infection)

· Stopping monitoring too early — patients can deteriorate rapidly

5. Euglycaemic DKA (Emerging Danger)

· Seen with SGLT-2 inhibitors (empagliflozin, etc.)

· Glucose may be normal despite full DKA

· Always check ketones in sick patients on these drugs

6. Uganda Context

· Insulin access, cost, and cold chain are major challenges

· Diagnosis possible with minimal resources: glucometer + urine dipstick + clinical exam

· Family education on warning signs and adherence is essential to prevent recurrence

Five Takeaways

1. Examine the whole patient — vitiligo signaled autoimmune type 1 diabetes

2. Four goals: Fluids → Glucose → Potassium → Acidosis

3. Potassium rule: Replace if < 3.5 BEFORE insulin

4. Find and treat the trigger — infections are the commonest cause5. Educate family — prevents the next admission

Listen to learn. Share to save lives. Mastering Emergency Care

Disclaimer: For Educational Purposes only, refer to guidelines for definitive management

Show Notes & Resources:

· Watch the Full Case Video: https://youtu.be/qZZ86tknD8k?si=Pczbbe-vqvcti80V

Description:

In this episode, an 11-year-old boy arrives unconscious, seizing, with a temperature of 40°C and tea-coloured urine. He was treated for malaria for four days. Now his kidneys are failing, his pressure is dropping, and the clock is running out.

In this real-life case review, Dr. Ann Kaguna Imelda (who managed the case) and Dr. Kenneth Bagonza (EM expert) walk through every critical decision—what worked, what didn’t, and why the child was unfortunate in the end.

special credit: Dr Daniel Oriba Longoya

Key points of discussion:

· The red flag triad

· Primary survey findings: threatened airway, shock, GCS 6

· Why dextrose has no role in septic shock resuscitation

· CSF Gram-positive diplococci = pneumococcal meningitis – treat immediately

· Managing hyperkalemia + AKI in a crashing child

· The 1-hour sepsis bundle (2026 guidelines)

· qSOFA at the bedside: RR ≥22, altered mental state, SBP ≤100 – no equipment needed

· Why “malaria not improving in 48 hours” demands a rethink

· Final reflection: system failures, early recognition, and what we owe the next child

Listen to learn. Share to save lives. Mastering Emergency Care

Disclaimer: For Educational Purposes only, refer to guidelines for definitive management

Show Notes & Resources:

· Watch the Full Case Video: https://youtu.be/qZZ86tknD8k?si=Pczbbe-vqvcti80V

· Rosen’s Emergency Medicine

· Tintinalli’s Emergency Medicine

· SSC 2026

Description:

In this episode, an 11-year-old boy arrives unconscious, seizing, with a temperature of 40°C and tea-coloured urine. He was treated for malaria for four days. Now his kidneys are failing, his pressure is dropping, and the clock is running out.

In this real-life case review, Dr. Ann Kaguna Imelda (who managed the case) and Dr. Kenneth Bagonza (EM expert) walk through every critical decision—what worked, what didn’t, and why the child was unfortunate in the end.

special credit: Dr Daniel Oriba Longoya

Key points of discussion:

· The red flag triad

· Primary survey findings: threatened airway, shock, GCS 6

· Why dextrose has no role in septic shock resuscitation

· CSF Gram-positive diplococci = pneumococcal meningitis – treat immediately

· Managing hyperkalemia + AKI in a crashing child

· The 1-hour sepsis bundle (2026 guidelines)

· qSOFA at the bedside: RR ≥22, altered mental state, SBP ≤100 – no equipment needed

· Why “malaria not improving in 48 hours” demands a rethink

· Final reflection: system failures, early recognition, and what we owe the next child

Listen to learn. Share to save lives. Mastering Emergency Care

Disclaimer: For Educational Purposes only, refer to guidelines for definitive management

Show Notes & Resources:

· Watch the Full Case Video: https://youtu.be/qZZ86tknD8k?si=Pczbbe-vqvcti80V

· Rosen’s Emergency Medicine

· Tintinalli’s Emergency Medicine

· SSC 2026

In this episode, we walk through a high-stakes emergency: a 53-year-old woman with known hypertension who collapses at home, seizes, and arrives at the ED with a GCS of 8 and a blood pressure of 209/120 mmHg.

Join your hosts Dr Daniel Olinga and Dr Emmanuel David Okumu, along with special guests Dr. Brian Twinemastiko and Dr. Ruzige Bashir

Rashid, as we explore the critical, real-world decisions made when the textbook meets

reality.

We Discuss

· How to build and narrow a differential for altered mental status

· Why dropping BP too fast can cause a stroke

· The pathophysiology of PRES (Posterior Reversible Encephalopathy Syndrome)

· Practical management in a resource-limited setting like Uganda

· Key pitfalls: oral antihypertensives, missed pulmonary edema, and nutrition neglect

Tune in to learn how to manage Altered Mental Status secondary to Hypertensive Encephalopathy a pragmatic approach.

Disclaimer: For Educational Purposes only, refer to guidelines for definitive management

Show Notes & Resources:

· Watch the Full Case Video: https://youtu.be/qZZ86tknD8k?si=Pczbbe-vqvcti80V

· Rosen’s Emergency Medicine

· Tintinalli’s Emergency Medicine

· BMJ 2024: Evaluation and Management of Hypertensive Emergency

· PubMed: 40818477, 10972386

· NEJM: 1990;323(17):1178–1184

In this episode, we tackle this exact nightmare scenario, breaking down a recent CPC case of

a polytrauma patient who develops ARDS. Join your hosts Dr Daniel Olinga and Dr

Emmanuel David Okumu, along with special guests Dr. Ambrose Okello and Dr. Umar

Rashid, as we explore the critical, real-world decisions made when the textbook meets

reality.

We discuss:

1. The Case: A rapid recap of the 48-year-old male patient, day 5 post-RTA with rib, femur, and mandible fractures, and his sudden respiratory decompensation.
2. Defining ARDS Without Resources: Why the classic Berlin Definition fails us and how the Kigali Modification (using SpO2/FiO2 ratios and POCUS) allows for a clinical diagnosis of ARDS without a ventilator or ABG.
3. The Management Dilemma
4. Global vs. Local Reality
5. Ventilation: Low Tidal Volume ventilation in the West vs. Awake Proning on High Flow Nasal Cannula (HFNC) in Uganda.
6. Monitoring: Daily CT scans vs. Lung POCUS to instantly differentiate edema from pneumothorax.
7. The Silent Killers: Why DVT prophylaxis is critical, why Tramadol isn't enough for pain, and the often-overlooked reality of nutrition—how a mandible fracture can lead to death from hypoglycemia if an NG tube isn't placed and the family isn't educated on liquid feeds.

Tune in to learn how to treat ARDS with what you have: Oxygen, positioning, ultrasound,

and a pragmatic approach.

Disclaimer: For Educational Purposes only, refer to guidelines for definitive management

Show Notes & Resources:

· Watch the Full Case Video: https://youtu.be/qZZ86tknD8k?si=Pczbbe-vqvcti80V

· The Kigali Modification: Riviello et al. (2016) - Diagnosing ARDS without ABGs or

Ventilators.

· ARISE-AFRICA Protocol: Recent trials on CPAP/HFNC in African settings.