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MICU-ER Joint Conference

MICU-ER Joint Conference. Dr. Rachmale, Dr. Prasankumar 12/3/08. Case Presentation. 46 y/o F brought by EMS for tachypnea, confusion

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MICU-ER Joint Conference

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  1. MICU-ER Joint Conference Dr. Rachmale, Dr. Prasankumar 12/3/08

  2. Case Presentation • 46 y/o F brought by EMS for tachypnea, confusion • Friends state pt. not answering calls for past 3 days, her son did not go to school for 2 days so school official went to her house and found pt. somnolent and altered, so EMS called • Per EMS pt. was “feeling unwell” with flu-like symptoms for one week, reportedly seen at walk-in clinic and given Tylenol Cold which was found at bedside in addition to empty Ambien bottle • Also reportedly had fall during week, L periorbital contusion, unknown if (+) LOC • Pt. unable to provide any additional history

  3. Case Presentation (cont.) • Initial vitals: Pulse 85, BP 106/74, RR 18, O2 sat on RA 68% Temp 99.0 F FS 134 • PE: Lethargic, cyanotic No external sign trauma Diffuse rales in all lung fields PE otherwise unremarkable • Computer records show one prior visit one year ago for alcohol withdrawal seizure, discharged from ER with Librium Rx only. No other known medical problems

  4. ED Course • Intubated without complication, O2 saturation improved to 88% on 100%O2 • Initial ABG: 7.19 | 48 | 60 | 17.8 | 84.6% • CBC: WBC 4.9 (87% Neutrophils with many Bands), Hgb/Hct 13 / 37.5, Plt 261 • BMP: Na 131, K 3.4, Cl 93, CO2 19, BUN 50 / Cr 2.0 (baseline 19/0.7), Glucose 91, Anion Gap 19 • CK 797, trop. (-) • AST 135 ALT 37 • Coags WNL • APAP 7.1, ASA (-), Utox (-), EtOH <5

  5. ED Course (Cont.) • Repeat vitals: T 97.1 F, P 118, BP 96/69, O2 92% while ventilated on 100% O2 • Treated for sepsis likely due to bilateral pneumonia with EGDT, MICU team notified • Zosyn, Cipro given • Subclavian central line placed • Lactate 5.5, SvO2 77 • Ammonia 75, Lactulose given • Repeat WBC 1.7 • Brain CT ordered but not done in ER due to unstable status

  6. Differential Diagnosis • ARDS- PaO2/FiO2= 68, acute onset, bilateral infiltrates, no evidence CHF • Bilateral community-acquired pneumonia • Septic shock • Severe pulmonary trauma • Head trauma causing aspiration of gastric contents • Overdose of Ambien or Tylenol Cold causing aspiration, or hypoventilation

  7. Differential Diagnosis (cont.) • No external sign pulmonary trauma or long bone fractures • Report of head trauma but normal external and neurological exam • Subsequent brain CT done 3 days after admission showed no acute event • Aspiration- Altered mental status, but no evidence vomiting at patient home or in ED, initially protecting airway

  8. Differential Diagnosis (cont.) • Most likely cause of ARDS is untreated community acquired pneumonia and resulting sepsis • H/o URI infection the prior week • WBC count low with left shift, hypotensive • Multi-system organ failure with acute renal failure, elevated LFTs, altered mental status • Initial blood culture showed gram positive cocci

  9. Differential Diagnosis (cont.) • Tylenol Cold- Acetaminophen 325 mg, Dextromethorphan 10 mg, Phenylephrine 5 mg, +/- Chlorpheniramine • APAP level 7 • Dextromethorphan is an opiate-like cough suppressant may cause respiratory depression • Chlorpheniramine H1 anti-histamine can cause sedation, anticholinergic symptoms • Ambien (Zolpidem)- Imidazopyridine class similar to Benzos as GABA agonist, similar overdose profile • Overdoses of heroin, methadone, barbituates, aspirin, TCAs reported to cause ARDS • No known other home meds • Utox negative

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