Крутой кейс с наркодилером 👍
🚢 Called to the ship port for agitated passenger.
We found the patient agitated, confused, and diaphoretic 😵💫
📺 BP 210/135, HR 130, RR 20, satting 100% on our arrival. No trauma.
Ship doctor 👨⚕️ reported no medical history per patient, but we were unable to confirm due to confusion. He was seen 2 hours prior to our arrival on deck behaving normally at the bar.
👩⚕️ Triage Nurse: 25 y.o. male with acute agitation and hypertension on arrival. Direct to resuscitation bay.
🔍 Exams:
👁️ HEENT Exam: Assess pupils for signs of a toxidrome. Normocephalic, atraumatic, PERRL at 6mm, mucous membranes dry.
🧠 Neck Exam: Assess for meningismus from possible meningitis. Trachea midline, no tenderness, full range of motion.
♥️ Cardiovascular Exam: Assess for cardiac murmur or extra heart sounds (S3, S4) in the setting of acute hypertension. Tachycardic rate, regular rhythm, no murmurs.
🫁 Pulmonary Exam: Assess for rales concerning for focal pneumonia or acute pulmonary edema in this critically ill patient. Bilateral symmetric breath sounds, normal chest rise. Clear lung sounds, no retractions, wheezes, or rales.
🩺 Abdominal Exam: Assess for focal peritoneal signs and tenderness that might signify any intraabdominal process. Diffuse abdominal tenderness, hyperactive bowel sounds, no guarding.
🩹 Skin Exam: Look for a rash that might signify meningococcemia in this critically ill patient. Warm and dry, no rashes.
🧠 Neurological Exam: Look for any lateralizing weakness concerning for acute stroke in this hypertensive patient. Agitated, confused, face symmetric, normal strength, no nystagmus.
Recommended Actions:
🩺 ECG: Assess the rhythm in this tachycardic patient.
🩸 Fingerstick Blood Sugar: Check a fingerstick on any critically ill patient to ensure a diabetic emergency is not present.
🧪 Basic Chemistry (Chem 7): Assess for acute renal failure in hypertensive emergency.
🧫 Complete Blood Count (CBC): Assess for acute hematologic abnormalities in this critically ill patient.
🧬 Liver Function Tests (LFTs): Abnormal LFTs could point to a toxidrome or biliary infectious process.
🩻 Abdominal Imaging: XR - Abdomen (KUB), CT - Abdomen. Checking for signs of foreign body (drug) ingestion is essential in this critically ill patient.
🧠 CT - Head: Rule out intracranial pathology in this critically ill hypertensive patient.
🫁 XR - Chest: Check for focal lung findings in this critically ill patient.
🩸 Blood Type & Screen: Needed for potential OR preparation.
🧪 Lactate: Assess for compromised end-organ perfusion.
🧪 Lipase: Screen for acute pancreatitis.
💧 Urinalysis: Check for dehydration, infection, or hematuria.
🧪 Results:
HR: 97, BP: 137/88, RR: 22, T: 38°C, O2: 100%.
Urine tox screen: Cocaine – POS, Opioids – NEG, PCP – NEG, Amphetamine – NEG, Marijuana – NEG, Benzodiazepine – NEG, Barbiturate – NEG.
Salicylate: 0 mmol/L, Osmolality: 276 mmol/kg H2O, LDH: 100 U/L, EtOH: 3.9 mmol/L, CK: 31.33 μKat/L, Acetaminophen: 0 μmol/L, Troponin-T: 0.09 μg/L, Mg: 0.65 mmol/L, Bilirubin (direct): 5.14 μmol/L, Bilirubin (indirect): 6.87 μmol/L, AST: 0.07 μKat/L, ALT: 2 U/L, Alkaline Phosphatase: 42 U/L. PT: 12 sec, PTT: 32.5 sec, INR: 0.9. WBC: 14.9 x 10^9/L, HCT: 0.49, HGB: 160.2 g/L, PLT: 365 x 10^9/L, Ca: 2.46 mmol/L, Type: O+, Lactate: 7.2 mmol/L. Na: 143 mmol/L, K: 4.8 mmol/L, Cl: 105 mmol/L, HCO3: 16 mmol/L, BUN: 9.3 mmol/L, Creatinine: 150 μmol/L, Glucose: 4.3 mmol/L. ABG: pH 7.26, pCO2 37 mmHg, pO2 96 mmHg.
CT – Abdo: multiple circular shapes in rectum and lower sigmoid concerning for FB. Normal solid organs, no free air.
💉 Immediate Actions:
💧Insert IV: This patient needs intravenous therapy for his hypertensive emergency.
📈 Attach Monitor: This critically ill patient needs continuous monitoring for hypertensive emergency.
💊 Benzodiazepine Treatment: Performed Lorazepam bolus; Midazolam bolus also appropriate. Anxiolysis may help reduce sympathetic overdrive in this patient’s condition. Benzodiazepine treatment will also abort seizure activity if it occurs (it did occurred indeed).
