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

McGoo

McGoo

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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?
 
Could be a number of reasons...did you check out his melon?
 
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:!)
 
truetiger said:
Could be a number of reasons...did you check out his melon?
Click to expand...

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.
 
I think you may of over looked one of the medications....
 
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.
 
If it were my call.....head bleed until proven other wise. Call helicopter. Iv's, D stick, intubate (rsi if need be.)
 
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.
 
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.
 
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.
 
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.
Click to expand...

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