October 2016 Critical Care Case of the Month

Stephanie Fountain, MD

Banner University Medical Center Phoenix

Phoenix, AZ USA

Critical Care Case of the Month CME Information

Members of the Arizona, New Mexico, Colorado and California Thoracic Societies and the Mayo Clinic are able to receive 0.25 AMA PRA Category 1 Credits™ for each case they complete. Completion of an evaluation form is required to receive credit and a link is provided on the last panel of the activity. 

0.25 AMA PRA Category 1 Credit(s)™

Estimated time to complete this activity: 0.25 hours 

Lead Author(s): Stephanie Fountain, MD.  All Faculty, CME Planning Committee Members, and the CME Office Reviewers have disclosed that they do not have any relevant financial relationships with commercial interests that would constitute a conflict of interest concerning this CME activity.

Learning Objectives:
As a result of this activity I will be better able to:

1. Correctly interpret and identify clinical practices supported by the highest quality available evidence.
2. Will be better able to establsh the optimal evaluation leading to a correct diagnosis for patients with pulmonary, critical care and sleep disorders.
3. Will improve the translation of the most current clinical information into the delivery of high quality care for patients.
4. Will integrate new treatment options in discussing available treatment alternatives for patients with pulmonary, critical care and sleep related disorders.

Learning Format: Case-based, interactive online course, including mandatory assessment questions (number of questions varies by case). Please also read the Technical Requirements.

CME Sponsor: University of Arizona College of Medicine

Current Approval Period: January 1, 2015-December 31, 2016

Financial Support Received: None

A 27-year-old Caucasian man with past medical history of opioid abuse (reportedly sober for 10 years on buprenorphine), post traumatic stress disorder, depression and anxiety presented to the emergency department complaining of dysarthria after taking diphenhydramine and meclizine in addition to his prescribed trazodone and buprenorphine to try to sleep. He was discharged to home after his symptoms appeared to improve with intravenous fluid.

He returned to the emergency department the following afternoon with worsening dysarthria, dysphagia, and subjective weakness. The patient was non toxic appearing, afebrile, vital signs were stable and his strength was reported as 5/5. Computed tomography  of his head did not show any evidence of acute intracranial abnormality. Given his ongoing complaints, he was admitted for observation to the general medicine wards.

That night a rapid response was initiated when the nurse found the patient to be unresponsive, but spontaneously breathing. The patient’s clinical status did not change with naloxone administration. An arterial blood gas obtained demonstrated a profound respiratory acidosis with a pH of 7.02 and a pCO2 of 92. He was emergently intubated. A chest x-ray was performed (Figure 1).

Figure 1. Panel A: admission portable chest x-ray. Panel B: chest -ray immediately after intubation. 

Which of the following are present on his chest X-ray? (Click on the correct answer to proceed to the second or four panels)

1. Left lung atelectasis
2. Left pleural effusion
3. Right mainstem intubation
4. 1 and 3
5. All of the above

Cite as: Fountain S. October 2016 critical care case of the month. Soutwest J Pulm Crit Care. 2016:13(4):159-64. doi: http://dx.doi.org/10.13175/swjpcc095-16 PDF

November 2014 Critical Care Case of the Month: I Be Gaining on My Addiction

Nathaniel R. Little, MD

Carolyn H. Welsh, MD

University of Colorado and the Eastern Colorado Veterans Affairs Medical Center

Department of Medicine

Division of Pulmonary Sciences and Critical Care Medicine

Denver, CO

History of Present Illness

A 33 year-old man came by ambulance to the Emergency Department for progressive altered mental status and bizarre behavior. Per history from his significant other, the patient had a long-standing history of heroin addiction and diazepam abuse. Despite multiple failed attempts at prior detoxification, he had recently resolved to “take matters into his own hands.”

The patient had informed his girlfriend that he quit heroin “cold turkey” 3 days prior to admission. On the first day after his last heroin use, he was communicative, energetic, and appeared normal. On the second day, he was increasingly introspective, somnolent, and mute. He spent the majority of the day in bed, and had tremors of all extremities. On the third day, he experienced increased arousal, with auditory and visual hallucinations. His speech was “very technical and scientific” with episodes of “waxing philosophic.” Given increasingly erratic behavior, worsening tremors, and inability to ambulate; emergency services were called for transport to the hospital.

Past Medical History, Social history and Family History:

The patient had a history of heroin and diazepam addiction, with failed attempts at cessation. He carried prior diagnoses of depression and anxiety, with a history of suicide attempts in his youth. He took no prescribed medications. He was employed as a software engineer. Aside from daily intravenous heroin use, he did not smoke nor drink alcohol. Family history was non-contributory.

Physical Examination:

On admission , he was hypothermic (35.8 C), hypotensive (BP = 81/48), and bradycardic (HR =41). Respiratory rate and oxygen saturations were normal. He was pale, diaphoretic, altered, and responsive only to internal stimuli. Additional findings included nystagmus, with oral exam showing dry mucus membranes. Per cardiovascular exam, he had profound bradycardia, with diminished radial and dorsalis pedis pulses. His extremities were cool to the touch. Pulmonary and abdominal exams were normal. On neurologic evaluation, the patient demonstrated a Glasgow Coma Score of 9, opened eyes only to command, demonstrated mumbled speech, and had tongue fasiculations. He was able to move all extremities, but with severe ataxia. Deep tendon reflexes were normal.

Laboratory Studies:

Complete Blood Count: White blood cell count (WBC) 9.0 x 1000 cells/µL, hemoglobin 14.5 g/dL, hematocrit 43.0, platelets 220,000 cells/µL

Chemistry: Sodium 150 meq/L, potassium 3.6 meq/L, chloride 113 meq/L, bicarbonate (CO2) 25 meq/L, blood urea nitrogen (BUN) 31 mg/dL, creatinine 1.14 mg/dL, glucose 114 mg/dL, magnesium 1.6 meq/L, phosphorus 4.1 mg/dL, creatinine kinase 33.

Toxicology Screen: Urine drug screen positive only for benzodiazepines, negative for opiates.

Urine: trace ketones, otherwise unremarkable.

Imaging:

Figure 1. Admission AP of chest.

The patient’s clinical presentation thus far is most consistent with what type of shock: (click on the correct answer to proceed to the next panel)

1. Cardiogenic
2. Distributive
3. Hypovolemic
4. Neurogenic
5. Obstructive
6. Both 1 and 3
7. All of the above

Reference as: Little NR, Welsh CH. November 2014 critical care case of the month: I be gaining on my addiction. Southwest J Pulm Crit Care. 2014:9(5):257-63. doi: http://dx.doi.org/10.13175/swjpcc146-14 PDF