# 32yr Male, "snoring, can't wake him up"



## McGoo (Aug 8, 2011)

Got a call for assistance  from the police at a home address. They had attended a welfare call, as a man hadn't shown up for work, work called the house, his housemate found him asleep in his bed and couldn't wake him up. 

We arrive to find a nice house that is messy in a bachelor-pad kind of way, not dirty though, and nothing to suggest drugs or alcohol abuse. The housemate of the patient works away and doesn't know the patient that well, he only knows that he has a medical condition he takes mess for. 

We see the patient supine on his bed, snoring resps at an unremarkable rate, but snoring of the sort that suggests obstruction. The patient won't take an OPA, but accepts an NPA. GCS of 6 (e1, v1, m4), one pupil Reactive and the other fixed and dilated, pulse 65-ish and regular, BP 140/68, afebrile to touch, SpO2 90% on room air. 

We look at the meds and find corticosteroids, warfarin, and a proton pump inhibitor. Medical history is ?lupus. Patient is normally fit and well. 

Worked it out yet?


----------



## truetiger (Aug 8, 2011)

Head bleed.


----------



## McGoo (Aug 8, 2011)

truetiger said:


> Head bleed.



But why?


----------



## truetiger (Aug 8, 2011)

Could be a number of reasons...did you check out his melon?


----------



## tickle me doe face (Aug 8, 2011)

Well the meds the patient takes fit in line with lupus and would not be expected to cause any of these patients problems.

The patient's breathing rate is described as "unremarkable", has a fairly normal blood pressure, and pulse rate, none of which agrees with kushings triad, so a brain bleed doesn't seem to fit quite right to me.

The blown pupil is concerning to me, but it could be fixed and delighted for tons of reasons, including degradation of the nervous system because of his lupus. 

I don't see enough to go on here to make any determinative diagnosis, but I am still a student, so i may of missed something (hope not :wub:!)


----------



## McGoo (Aug 8, 2011)

truetiger said:


> Could be a number of reasons...did you check out his melon?



Sure did. I hung around emergency until I found out what was wrong with him, but I'll let the bystanders have some fun before I spill the beans.


----------



## truetiger (Aug 8, 2011)

I think you may of over looked one of the medications....


----------



## foxfire (Aug 8, 2011)

I would want to do the usual work up, all the while I am strongly thinking a head bleed.  Plumbing might have sprung a leak in his head with warfarin on board.
Signs of vomiting? Possible cause of obstruction sounds
Bg?
Any signs of injury? 
Roommate know how long the Guy been sleeping? 
Has he been acting strange or different prior to going to sleep?
Establish a IV,  monitor, have suction ready if needed,( every head bleed I have had puked the whole way to the ER. )
Are the resps adequate depth and rate ? If not I would want to bvm and consider intubation.
Oh and not dilly dally the transport.


----------



## tickle me doe face (Aug 8, 2011)

truetiger said:


> I think you may of over looked one of the medications....



The Warfarin?


----------



## truetiger (Aug 8, 2011)

If it were my call.....head bleed until proven other wise. Call helicopter. Iv's, D stick, intubate (rsi if need be.)


----------



## tickle me doe face (Aug 8, 2011)

truetiger said:


> If it were my call.....head bleed until proven other wise. Call helicopter. Iv's, D stick, intubate (rsi if need be.)



If he is not posturing, isn't their still "time"?


----------



## truetiger (Aug 8, 2011)

Yup, the warfarin.


----------



## truetiger (Aug 8, 2011)

Once he's posturing you have problems. Remember the snoring respirations? He cannot protect his own airway anymore. He's not going to get better on his own, only get worse.


----------



## McGoo (Aug 9, 2011)

We don't do RSI on the road, only the crit cRe flight medics do that on the chopper. We can intubate, but if he won't take an OPA then there is no chance of a tube.


----------



## bigbaldguy (Aug 9, 2011)

I vote bleed. Warfarin and lupus. Stroked out. Could also be something like hydrocephalus that also causes difficult arousal or even a head injury, maybe days old.


----------



## Sam Adams (Aug 9, 2011)

McGoo said:


> We see the patient supine on his bed, snoring resps at an unremarkable rate, but snoring of the sort that suggests obstruction. The patient won't take an OPA, but accepts an NPA. GCS of 6 (e1, v1, m4), one pupil Reactive and the other fixed and dilated, pulse 65-ish and regular, BP 140/68, afebrile to touch, SpO2 90% on room air.



I'm seeing a deaf 32 yom w/ sleep apnea/ a deviated septum and a glass eye


----------



## rmabrey (Aug 9, 2011)

Sam Adams said:


> I'm seeing a deaf 32 yom w/ sleep apnea/ a deviated septum and a glass eye



Head bleed seems obvious so im gonna go with this


----------



## dixie_flatline (Aug 9, 2011)

rmabrey said:


> Head bleed seems obvious so im gonna go with this



So what is causing the snoring resps?


----------



## Patrick Smith (Aug 9, 2011)

The suspense is killing me! lol :lol:


----------



## firetender (Aug 9, 2011)

tickle me doe face said:


> The blown pupil is concerning to me, but it could be fixed and delighted for tons of reasons...
> QUOTE]
> 
> Ah, the importance of one little word in shifting the meaning of one little sentence!


----------



## rmabrey (Aug 9, 2011)

dixie_flatline said:


> So what is causing the snoring resps?



in which case, the head bleed, or the BS version im playing along with?


----------



## Melclin (Aug 9, 2011)

One blown pupil, GCS 6 pt, on warfarin, obtunded airway. Cushings triad is a late sign. Maybe he's no there yet. Maybe drugs are complicating it. You'd want your head read if you didn't assume he'd blown a head gasket and go from there.

Why no BGL? 
Is this the only hx and physical info we're ganna get?

I figure this scenario is about misinterpretting some of these details like the old, his pupil wasn't blown it was from cataract surgery, oh his GCS wasn't actually 6, he was just deaf or whatever etc.


----------



## rmabrey (Aug 9, 2011)

Actually im going with drugs....I know it said nothing to suggest drugs or alcohol so thats why im picking it


----------



## truetiger (Aug 9, 2011)

Other than not saying anything about drugs....why are you picking that?


----------



## rmabrey (Aug 9, 2011)

truetiger said:


> Other than not saying anything about drugs....why are you picking that?



Although If it were my scene I would assume head bleed till proven otherwise, the vitals just dont scream bleed to me.

ETA: im sure im way off but its fun to play along and learn


----------



## truetiger (Aug 9, 2011)

Are you waiting for Cushing's Triad before you call it a bleed?


----------



## rmabrey (Aug 9, 2011)

truetiger said:


> Are you waiting for Cushing's Triad before you call it a bleed?



No it could certainly be very early stage, but this is a scenario, and I can have fun with it and say drugs on a whim and nobody dies because of it.


----------



## pedsmedic (Aug 9, 2011)

ohh ohh ohh, the warafin. these products prolong the PT primarily through the inhibition of the vitamin K coagulation factors. Commonly found in some rodenticides. (for killing little critters) they can present as asymptomatic but can develop bruising and the unequal pupils you saw. 

Did you intubate him, if so was there any swelling of the esophageal lining because it also commonly causes internal GI hemmorage, which is why the rats die. 

  Or I could be totally off the subject and he could of been a really heavy sleeper.


----------



## McGoo (Aug 9, 2011)

Well, looks like most of you picked it long before my partner did at the time. She was sure it was drugs or trauma related, I kept on suggesting a head bleed, aaaaaaaannnndddd.......I was right. That bit wasn't hard to work out really. The tricky bit for me was why the hell did a 32 year old guy who looked fit and well stroking out? The MRI showed multiple, small, chronic subdural haematomas, and one big mother that had occurred recently, big enough to cause midline shift. The patients lupus required him to be on the warfarin, and obviously his cerebral arteries weren't handling the pressure all that well. 

There was no blood gas because primarily we don't do them in the truck, and also I couldn't remember the results at the hospital. Sae to say he had metabolic acidosis. As I said before, we don't RSI so he got the NPA, lateral position, and a diesel bolus. 

Last I heard the neurosurgeon was trying to contact the family to try and get permission to let him die, because otherwise he would have to intervene for zero chance of positive outcome. Sad, but there you go.


----------



## hippocratical (Aug 9, 2011)

I was hoping for the deaf glass-eyed snorer option...


----------



## clibb (Aug 10, 2011)

McGoo said:


> Well, looks like most of you picked it long before my partner did at the time. She was sure it was drugs or trauma related, I kept on suggesting a head bleed, aaaaaaaannnndddd.......I was right. That bit wasn't hard to work out really. The tricky bit for me was why the hell did a 32 year old guy who looked fit and well stroking out? The MRI showed multiple, small, chronic subdural haematomas, and one big mother that had occurred recently, big enough to cause midline shift. The patients lupus required him to be on the warfarin, and obviously his cerebral arteries weren't handling the pressure all that well.
> 
> There was no blood gas because primarily we don't do them in the truck, and also I couldn't remember the results at the hospital. Sae to say he had metabolic acidosis. As I said before, we don't RSI so he got the NPA, lateral position, and a diesel bolus.
> 
> Last I heard the neurosurgeon was trying to contact the family to try and get permission to let him die, because otherwise he would have to intervene for zero chance of positive outcome. Sad, but there you go.




I've had patients as young as 15 stroking out.


----------



## Smash (Aug 10, 2011)

Sarcoidosis!


----------



## CAOX3 (Aug 11, 2011)

Snoring respirations is a general term, differentiating between stokes, kussmaul, and biots can also help, but with medications laying there for you the coumadin puts head bleed ay the top of my list.


----------



## McGoo (Aug 11, 2011)

clibb said:


> I've had patients as young as 15 stroking out.



Colleagues have treated patients as young as four stroking out, but it isn't the first thing that comes into my head when you have an altered conscious state in a healthy looking young adult.


----------



## STXmedic (Aug 11, 2011)

McGoo said:


> Colleagues have treated patients as young as four stroking out, but it isn't the first thing that comes into my head when you have an altered conscious state in a healthy looking young adult.



One of the special needs children/frequent flyers in our district is 4 or 5 and has had multiple strokes


----------



## truetiger (Aug 11, 2011)

Don't let the age talk you out of it. Most things will not present like the book says they should.


----------



## exodus (Aug 12, 2011)

clibb said:


> I've had patients as young as 15 stroking out.



We had a health 14yom Stroke out a few months back. Only health issue was that he was MILDLY obese... Less so than 90% of the children today -.-


----------

