Sick as ten men

[Melclin]

We were too close to the hospital to ever take these obs ourselves but I'll give you some of the hospital's, prior to RSI, to further the scenario.

If we assume no RSI,

- Pupils dilated again @8mm.
- BSL: "Lo" (unrecordably low)
- BP: 229/117
-I can't remember the exact HR, but it was SR (ie, not tachy/brady).

Anyone pick it now?
I'd like to think given this third round of info, I would have got it, but who knows.

 

[Handsome Rob]

I am really curious to hear the diagnosis if possible. Had a colleague suggest beta-blocker OD, but that does not match the HTN, then tried out CVA resulting from cocaine OD, which does not account for the airway comromise. Stumped on this one, besides a diagnosis of "really jacked up".

 

[firetender]

happy to oblige!

I want to see a video of the monkey doing math

http://www.youtube.com/watch?v=JMd3rU9FSc4

 

[usalsfyre]

Bacterial meningitis and resultant increased ICP, septicemia and aspiration are my guess.

 

[Handsome Rob]

SWAG here...

drug induced lupus erythematosus: may have acute onset, S/S include muscle rigidity, erratic HR, fluctuating BP, fever (hmm...), pericardial effusion, as well as joint stiffness. Dunno about the fever though, as this guy was hypothermic...

 

[Melclin]

Some good guesses, but we're thinking zebras a little too much. Head back to towards the horses.

Y'all have till the end of my night shift (and subsequent nap) to figure it out...the clock is ticking.

 

[usalsfyre]

Some good guesses, but we're thinking zebras a little too much. Head back to towards the horses.

Y'all have till the end of my night shift (and subsequent nap) to figure it out...the clock is ticking.

Opiate OD with aspiration? Seizure thrown in there somewhere to complicate things?

 

[Handsome Robb]

Opiate OD with aspiration? Seizure thrown in there somewhere to complicate things?

I was thinking something along these same lines, but I don't know if it can be that easy. Although he did say look for horses not zebras :huh:

The thing thats bugging me is the pupils not being pinpoint on reexamination and the patient being hypertensive and rising pretty quickly rather than hypotensive which I would expect to see. Did you give any naloxone? It's not 100% indicated but in this case I don't think it could hurt, especially with the paraphernalia present.

As for the seizure. Wouldn't a patient be more likely to present with hyperthermia due to the extreme muscle exertion rather than hypothermia. If he was unresponsive for a lengthy period of time before being discovered could account for this I guess?

What about possible CVA, along the lines of a hemorrhagic stroke? He sort of is displaying Cushing's triad on the initial exam being bradycardic and a trend in widening pulse pressure, no irregular respirations though, but you did say tidal volume was variably adequate so this could be interpreted as irregular...

I give up.

 

[mycrofft]

Pituitary extension of a brain tumor?

lumping the hypertension versus heartrate, the low temp and the low glucose...

And the most common cause of frothy blood tinged sputum in trysmus, after cheek gnawing, is attempts to mechanically open the airway.

 

[Melclin]

Although he did say look for horses not zebras :huh:

The thing thats bugging me is the pupils not being pinpoint on reexamination and the patient being hypertensive and rising pretty quickly rather than hypotensive which I would expect to see. Did you give any naloxone? It's not 100% indicated but in this case I don't think it could hurt, especially with the paraphernalia present.

I said more towards the horses. But I wouldn't call this a horse in and of itself.

I think you'll all kick yourself when you hear the answer.

Also, pupils may not be pinpoint in opiate OD if the brain has been hypoxic for long enough. Or so I hear anyway. We didn't give it naloxone. The ED did, the result of which I will post when I give the answer.

 

[Smash]

Fluctuating pupil size. Respiratory depression. Altered conscious state. Hypoxic. Hypoglycemic (did you do anything about that?)

I'll stand by my first assessment, but I suspect the culprit is GHB.

 

[Handsome Robb]

I wanna know the final dx on this patient! haha

 

[Melclin]

We pulled this bloke off his bed and into a corridor for space and safety.

Given that I was not attending this job, I jumped on airway and struggled away there for a while. I wouldn't be surprised if the bloody sputum was my fault. I twice tried to pass an NP without any success (gagging and there was some obstruction too. I noticed small amount of old caked blood around his nose, so I wonder if the NP didn't revive and older epistaxis. His resps were so laboured along with stridor and tracheal tugging I was considering FBAO for a little while, but I didn't wanna scope him with a gag reflex and I couldn't after the trismus set it.

In retrospect having had him gag on an OP was less than desirable given the possible ICP issues he was having. But I was told to do it by the attending paramedic and at the time saw no super strong reason to disagree. I also would have liked to have had a temperature earlier on.

Other than oxygen and blankets, this guy got 25 grams of dextrose, brought his blood sugar up to about 5 (90). First BSL in hospital was again unreadibly low. He got 50 grams of dextrose, brought his BSL to 9.7. No luck with any narcan. A short while later his BSL was unreadibly low again. Initially they thought was that the culprit was a seizure. Before the tube drugs went in, his BP was 227/125. He was intubated and loaded with phenytoin. The docs were confused by the sugars but everything made sense when the facility we came from rang to say they had found several boxes of empty insulin pens (presumably stolen from one of the other residents, because he wasn't diabetic and insulin wasn't on his meds list) hidden in a draw.

So, massive insulin overdose with associated neurological damage. The doc told me later although there might have been some other drugs in the mix, he believed the main culprit was the insulin, with the long period of profound hypoglycaemia causing neuro damage, then aspiration and hypoxia as his GCS dropped to cause further damage. ICU took him but the registrar said it would be much better if he dies as there was almost no chance of any other outcome other than being admitted to the veggie patch.

So. An interesting case and I wish I had the chance to attend it myself.

Thoughts?

 

[Handsome Robb]

Didn't see that coming. Makes sense though. Would the trismus come from a relative state of hypokalemia? Seeing as insulin drives not only glucose but potassium into the cells as well?

 

[mycrofft]

Hm. I thought about it but disregarded

Didn't think about aspect of the brain damage the hypoglycemia then attendant hypoxia (seizures, trysmus) woud have lain on. Must have included some longer acting stuff than Regular.

Thoughts about the "high BP versus low pulse rate and hypothermia" complex?

 

[GoDucks]

Fascinating! What a great call. I never would have thought of a massive insulin OD, but you're right... I'm completely kicking myself for that now. Thanks for the post, this one sparked some great discussions between some of my coworkers and I.

 

[MrBrown]

How interesting, better than sitting at the Branch watching telly eh?

 

[mycrofft]

The only massive insulin OD I saw was also full of methamphetamines

She was the color of the frame around this text only a little darker, rapidly gasping, and had her back arched. She apparently lived with a bunch of crank cooks, was pregnant, and tried to abort with insulin. They tried to "wake her up" with meth. She lasted three more days, then died; she had so many ABG's and her clotting apparently was so diminished that her arm compartmentalized and would have needed ampuation. Of course, the fetus was killed also.

 

[Melclin]

Didn't see that coming. Makes sense though. Would the trismus come from a relative state of hypokalemia? Seeing as insulin drives not only glucose but potassium into the cells as well?

Thoughts about the "high BP versus low pulse rate and hypothermia" complex?

Don't know. My current theory is that he was actually seizing on and off.

Hypothermia just from exposure perhaps. It was a reasonably cold night, he was only wearing a tshirt and pants. Nanna on the floor all night type stuff.

 

[zzyzx]

Crazy. That's one you'll never forget.