January 2021 Critical Care Case of the Month: A 35-Year-Old Man Found Down on the Street

John J. Lee, BS

Ling Yi Obrand, MD

Janet Campion, MD

University of Arizona School of Medicine

Tucson, AZ, USA

History of Present Illness

A 35-year-old African-American man with a history of alcohol abuse presented to Emergency Department after he was found down. He was seen by a passerby on the street who witnessed the patient fall with a possible convulsive event. He was brought in by ambulance and was unconscious and unresponsive.

PMH, SH, and FH

The patient had a history of prior ICU admission in Yuma with septic shock secondary to a dental procedure requiring a tracheostomy in 2018. He also had a history of alcohol intoxication requiring an ED visit about 10 years ago and history of sickle cell trait. Per chart review, the patient took no home medications. Further history was unable to be obtained due to the patient's condition.

Physical Examination

On arrival the patient had a core temperature of 41°C, systolic blood pressure in the 70s-80s, heart rate of 185, respiratory rate of 19, and an oxygen saturation of 99% on room air. Patient was not able to answer any questions.

On examination, the patient had a Glascow Coma Scale of 6 (no eye response, no verbal response, and normal flexion). Pupils were 4 mm bilaterally and reactive to light. The remainder of his HEENT was unremarkable with no meningismus reported. Pulmonary exam showed rapid, shallow breathing and coarse breath sounds with no crackles, wheezes, or rhonchi. Heart examination showed tachycardia with no murmurs or extra heart sounds. Abdomen was soft and nondistended. Skin was diaphoretic without cyanosis, clubbing, or edema.

Laboratory, Radiology and EKG

Initial laboratory testing was significant for a potassium level of 7.5 mmol/L, creatinine level of 1.96 mg/dL which was increased from baseline of 0.93 mg/dL, CK level of 2344 U/L, AST 93 U/L, ALT 62 U/L, and total bilirubin 2 mg/dL. Lactic acid was within normal limits. His EKG showed sinus tachycardia. His urinalysis was cloudy with protein and blood. His head CT was negative for any intracranial abnormalities or bleed.

Hospital Course

He was given 3 L of IV fluids, empiric vancomycin and piperacillin/tazobactam, and his hyperkalemia was managed with calcium gluconate, insulin and glucose. He was intubated for airway protection due to his shallow breathing and GCS of 6, started on pressor support, and was admitted to the ICU.

Based on the initial findings, what is the most likely cause of the patient’s presentation? (Click on the correct answer to be directed to the second of six pages)

1. Acute encephalitis
2. Delirium tremens
3. Heatstroke
4. Malignant hyperthermia
5. Septic shock

Cite as: Lee JJ, Obrand LY, Campion J. January 2021 Critical Care Case of the Month: A 35-Year-Old Man Found Down on the Street. Southwest J Pulm Crit Care. 2021;22:1-7. doi: https://doi.org/10.13175/swjpcc051-20 PDF 

July 2018 Critical Care Case of the Month

Stephanie Fountain, MD

Banner University Medical Center Phoenix

Phoenix, AZ USA 

History of Present Illness

A 45-year-old man was brought to the Emergency Room by his mother complaining of weakness, dizziness, and trouble swallowing. He was also incontinent of stool and looked “sunburned”.

Past Medical History

He has a past medical history of:

• Schizophrenia
• Depression
• Polysubstance abuse
• Crohn’s disease
• Type 2 diabetes
• Hyperlipidemia

Medications

• Prazosin
• Venlafaxine
• Risperidone
• Buspirone
• Oxcarbazepine
• Gabapentin
• Hydroxyzine
• Lithium
• KCL
• Metformin
• Atorvastatin
• Adalimumab
• Mesalamine
• Prednisone
• Ferrous sulfate

Physical Examination

• Vitals: 80 kg / 97.3 degrees / 101 bpm / 100% 28RR  / BP 111/72 
• The patient was toxic appearing and flushed.
• Oriented to self only, very lethargic
• Dry mucous membranes
• Lungs clear to auscultation and percussion
• Heart tachycardic but no murmurs
• Abdomen without organomegaly, masses or tenderness
• Extremities without edema

Which of the following should be done at this time? (Click on the correct answer to be directed to the second of six pages)

1. Electrolytes
2. Lumbar puncture
3. Urine drug screen
4. 1 and 3
5. All of the above

Cite as: Fountain S. July 2018 critical care case of the month. Southwest J Pulm Crit Care. 2018;17(1):7-14. doi: https://doi.org/10.13175/swjpcc085-18 PDF

May 2017 Critical Care Case of the Month

Sapna Bhatia, MD

David Ling, DO

Michel Boivin, MD

Division of Pulmonary, Critical Care and Sleep Medicine

University of New Mexico School of Medicine

Albuquerque, NM USA

History of Present Illness

A 54-year-old Hispanic male who was incarcerated 3 days prior to hospital admission was brought into the emergency room from prison for alcohol related withdrawal seizures.

Physical Examination

Upon arrival to the ER, the patient was noted to be hypoxic with copious thick secretions in his mouth. He was intubated for airway protection, started on propofol and fentanyl drips as well as intravenous thiamine and folic acid.

Radiography

A chest radiograph was performed (Figure 1).

Figure 1. Portable anterior-posterior (AP) radiograph of the chest.

Which of the following are true regarding management of this patient?

1. Phenytoin should be administered for prevention of seizures
2. Prophylactic antibiotics for aspiration pneumonia should be administered
3. Thiamine and folic acid should be administered
4. 1 and 3
5. All of the above

Cite as: Bhatia S, Ling D, Boivin M. May 2017 critical care case of the month. Southwest J Pulm Crit Care. 2017;14(5):192-8. doi: https://doi.org/10.13175/swjpcc051-17 PDF