22 yo male, found down

[kemple]

Case I had last night. 

22 yo male comes in via EMS unresponsive found on the bathroom floor, known hx of drug abuse and BS reading is "High". No further information 

PE: HEENT: Vertical Nystagmus, pupils 5mm and fixed
      Resp: LS Clear, subq emphysema
      Card: Brady, N S1 and S2
      Abd: Slightly distended
      Skin: Cold
      Neuro: Unresponsive, gaze deviation to the right, vertical nystagmus, unintentional movement


VS: BP 60/28, HR 47, RR 14, SpO2 100%

[Bjs04f]

There is air everywhere. Terminal QRS slurring on EKG seen in early repol. Did this guy perf an esophagus? 

[kemple]

Unfortunately I didn't get full chest on that quick snapshot. According to radiology small basilar left ptx but with laying on left side for a day air tracked up to the right. Initially we thought it was the Bair Hugger. Core temp 83.4F

[pbruss]

tox is pretty much the only thing that gives you verticle nystagmus. woner if you had a ph from an ABG. if i rmember correctly, he has a zero percent chance of survival if its below 6.9

[Bjs04f]

we resuscitated a DKA at ph 6.6 at TTH this year, it was awesome

[kemple]

ABG 6.8/78/121 on 15lpm NRB, WBC: 37 Lipase 722, Glucose 1232, Anion Gap of 27, CR 3.37, K+ 4.7, Tox: THC only. BTW this case was one for the books, FANTASTIC learning and thought processes went into it. 

Basically this kid came in as described above. His pressure was so low we held off intubation while we resuscitated him to prevent lowering his bp any more. He was ice cold and we started warming him right away, which alone started to improve the HR and fix his osborn waves. His sugars were "high" and as you can see why. We bolused 2L on the rapid infuser and 2L on the Ranger fluid warmer. We knew he needed intubation but with a pressure of 60-70 and clenching/non purposeful movements we weren't able to give RSI just yet, also, for the moment he was maintaining his airway. CXR as shown after talking to radiology a basilar PTX was seen on the left, we assumed it's b/c he was found laying on that side that the air tracked up to the right. Decided to go ahead with the chest tube, hey they can only help increase his bp right?! Placed that, then his pressure was 70-80's so we intubated. Did fine with that. Started him on bicarb and K+ gtts, started insulin drip. Repeat CXR after ETT, Chest Tube, and OG Tube was called as free air under the diaphragm. The patient was sent to the SICU for resuscitation, CT on the way up. CT ended up showing small R apical PTX (got another chest tube upstairs), mediastinal air which is what was seen in the belly on CXR, 6.8cm intussucception without any perfs in the belly, and lots of subq air.

So basically to sum it up we had a 22 yo known drug user and diabetic found down with. 

Severe DKA
Severe Hypothermia
Vertical Nystagmus, no pupil reactivity
Pancreatitis
B/L PTX with free air
Intussuception
Acute Renal Failure
Acute Resp Failure

Was a fantastic case to think through and learn from.

Checked up on him last night, no purposeful movements but he's on Versed/Fentanyl right now so it would be a while for that Versed to wear off. He has stabilized with regards to pH, hypothermia (had him up to 90F in department), AG had closed, glucose under 200, still in renal failure. I'm worried he has some sort of metabolic or anoxic insult to his brain.

[Bjs04f]

i read "couldnt RSI" 2 times in this, which tells me we need to have a chat about push dose pressors. Theres no chance in hell a pt needing intubation doesnt get it due to pressure. Grab yourself 1mL of cardiac epi toss in 9mL NS and boom 1mL delivers roughly 10mcg epi enough to allow tubing.

[kemple]

Problem is we figured part of the problem his pressure was low peripherally was due to shunting. As he was stable respiratorily we decided to hold off on pressors until we did some fluid resuscitation first.

[pbruss]

use ketamine as induction agent in this situation. can transiently increase cardiac output. can also start drip for sedation instead of propofol, versed, ect.

[kemple]

Never remembered to post but this guy had full neurological in tact outcome and walked out of the hospital about 3 weeks later.