Sick Patient

[chbare]

Good afternoon. EMS brought a 23 year old patient to the er. Patient was found on the floor unresponsive by family. History of hyperthyroidism, PSVT, and depression. Initial assessment findings; very lethargic opens eyes and answers simple yes no commands with verbal command, pupils 5 and very sluggish, slight movement of all ext with command, pale diaphoretic skin and allot of salivation and lacrimation noted, patient was initially able to manage their own airway, P-70 and reg, B/P-80/50, RR-12-14 lungs clear upper bilat and diminished lower bilat, belly soft non tender, no indications of trauma noted, o2 Sat: 99% on NRB, Temp 95 F, ECG sinus rhythm with a 1 st degree AV block. I continued the oxygen and put the bed in a head down feet up position and started two IV's NS wide open. The ER doc came in the room and agreed to a 2000ml fluid bolus. In addition, I put a bair hugger blanket around the pt. Labs were drawn and and a 12 lead was obtained. The family stated the patient quit taking beta blockers and thyroid meds a while ago but did not know anything else, specific meds were unavailable, Pt denied taking any substances. A foley was inserted and ongoing assessments continued. The B/P did not improve with two liters of fluid and the pt remained pale, lethargic, and diaphoretic. A neosynephrine gtt was ordered, I mixed it and started at 40 micrograms/min and started a 3rd IV just in case. The pressure stabilized at around 100-110 systolic. Then X-ray entered the room and I helped him get the machine in position for a portable, suddenly the patient started throwing up. I rolled the patient on their side and started to suction, the patient continued to throw up and sats dropped to 89-90%. I continued to suction and call for help. The doctor decided to intubate and RSI meds were given. The patient was intubated with a 7.5 ETT and placement was verified. An NG was also placed. A chest X ray was performed and the patient was put on the vent (TV 750 PEEP 5 R 14 FIO2 100). An initial ABG showed PH 7.44 O2 144 CO2 18 Bicarb 22) the vent settings were changed (TV 700 PEEP 5 R 14 FIO2 80) Labs started rolling in UDS neg, H & H 6&18, K+ 2.1, WBC 18, ETOH 230, chest xray-good tube placement, infiltrates everywhere (not the acute aspiration looking stuff-it looks like the patient has been sick for a while), and a huge heart. The house supervisor started making calls for a transfer while I pushed meds and hung drips. We did a K run, 2 units of blood, and rocephin, I gave vec and fentanyl for sedation/paralysis. The flight team arrived and we package the patient for transport. The funny thing is the Et Co2 was about 17-19 and this was confirmed with ABGs. Did we blow it all off or poor cardiac out put? I just wanted to get your input on the case. This was a sick patient with allot of problems.

Take care,

chbare.

[Jeep_911]

I can relate to a part of that call but halfway down thru your description of what happend you lost me. I dont have enough background to understand half of what you have.... ... very interesting tho

[AZCEP]

The initial ABG is a bit odd. Mild alkalosis with respiratory compensation, and a RR of 12-14?

Did the family say anything about an anti-depressant?

I'd agree with punting. A vent rate of 14 should not have altered the ABG all that much.

[ERDoc]

That first ABG may be from hyperventilating while intubating. Or could it be from something more sinister???

[chbare]

ERDoc, I agree, the first ABG I wrote off as blowing off CO2. It is just strange that the C02 never really normalized or moved in that direction. Even the flight team was confused. The patients pressures remained in the 110 systolic range, but could that have been the neosynephrine drip hiding really poor cardiac output?

AZCEP, I really do not know about antidepressant use. We knew the patient was on a beta blocker and antithyroid meds, and apparently quit taking meds per family. The whole drooling and lacrimation thing makes me question some kind of cholinergic toxidrome.

Jeep_911, dont worry, I do not quite understand what was going on with this patient.

Thank you for the replies.

Take care,

chbare.

[ERDoc]

OK, so let's take that first ABG and assume that it is not from hyperventilation. It means that we are looking at a chronic, compensated respiratory alkalosis. What sort of things can cause this? Well, chronic anemia (he's got it), hyperthyroid (he's got it, could be thyrotoxicosis), interstitial lung disease (sounds like he might have it), hepatic failure (sounds like a possibility), sepsis (he's got a white count). A resp alkalosis is usually a sign of something ominous going on, be very careful, the only thing more scary is metabolic alkalosis. I would like to see some more of his labs. chbare, I know it doesn't give you the answer, but I hope it helps.

[chbare]

ERDoc, thank you, I greatly appreciate your input. I agree that there was very ominous pathophysiology occurring. The liver enzymes and alk phos were a little elevated, the BUN and Creat were normal, and the TSH was very elevated. Cardiac enzymes were negative. The rest of the patients electrolytes were normal. The APAP & ASA levels were not elevated. The patient had about 4 liters of total fluid in and about 2 liters of total fluid out while in the er.

Take care,

chbare.