Ultrasound for Critical Care Physicians: Sometimes It’s Better to Be Lucky than Smart

Robert A. Raschke MD and Randy Weisman MD

Critical Care Medicine

HonorHealth Scottsdale Osborn Medical Center

Scottsdale, AZ USA

We recently responded to a code arrest alert in the rehabilitation ward of our hospital. The patient was a 47-year-old man who experienced nausea and diaphoresis during physical therapy. Shortly after the therapists helped him sit down in bed, he became unconsciousness and pulseless. The initial code rhythm was a narrow-complex pulseless electrical activity (PEA). He was intubated, received three rounds of epinephrine during approximately 10 minutes of ACLS/CPR before return of spontaneous circulation (ROSC), and was subsequently transferred to the ICU.

Shortly after arriving, a 12-lead EKG was performed (Figure 1), and PEA recurred.

Figure 1. EKG performed just prior to second cardiopulmonary arrest showing S1 Q3 T3 pattern (arrows).

Approximately ten-minutes into this second episode of ACLS, a cardiology consultant informed the code team of an S1,Q3,T3 pattern on the EKG. A point-of-care (POC) echocardiogram performed during rhythm checks was technically-limited, but showed a dilated hypokinetic right ventricle (see video 1).

Video 1. Echocardiogram performed during ACLS rhythm check: Four-chamber view is poor quality, but shows massive RV dilation and systolic dysfunction.

Approximately twenty-minutes into the arrest, 50mg tissue plasminogen activator (tPA) was administered, and return of spontaneous circulation (ROSC) achieved two minutes later. A tPA infusion was started. The patient’s chart was reviewed. He had received care in our ICU previously, but this wasn’t immediately recognized because he had subsequently changed his name of record to the pseudonym “John Doe” (not the real pseduonym), creating two separate and distinct EMR records for the single current hospital stay. Review of the first of these two records, identified by his legal name, revealed he had been admitted to our ICU one month previously for a 5.4 x 3.6 x 2.9 cm left basal ganglia hemorrhage. We stopped the tPA infusion.

On further review of his original EMR is was noted that two weeks after admission for intracranial hemorrhage, (and two weeks prior to cardiopulmonary arrest), he had experienced right leg swelling and an ultrasound demonstrated extensive DVT of the right superficial femoral, saphenous, popliteal and peroneal veins. An IVC filter had been due to anticoagulant contraindication. The patient’s subsequent rehabilitation had been progressing well over the subsequent two weeks and discharge was being discussed on the day cardiopulmonary arrest occurred.

On post-arrest neurological examination, the patient gave a left-sided, thumbs-up to verbal request. Ongoing hypotension was treated with a norepinephrine infusion and inhaled epoprostenol. An emergent head CT was performed and compared to a head CT from four weeks previously (Figure 2), showing normal evolution of the previous intracranial hemorrhage without any new bleeding. 

Figure 2. CT brain four weeks prior to (Panel A), and immediately after cardiopulmonary arrest and administration of tPA (Panel B), showing substantial resolution of the previous intracranial hemorrhage.

A therapeutic-dose heparin infusion was started. An official echo confirmed the findings of our POC echo performed during the code, with the additional finding of McConnell’s sign. McConnell’s sign is a distinct echocardiographic finding described in patients with acute pulmonary embolism with regional pattern of right ventricular dysfunction, with akinesia of the mid free wall but normal motion at the apex (1). A CT angiogram showed bilateral pulmonary emboli, and interventional radiology performed bilateral thrombectomies. Hypotension resolved immediately thereafter. The patient was transferred out of the ICU a few days later and resumed his rehabilitation.

A few points of interest:

• IVC filters do not absolutely prevent life-threatening pulmonary embolism (2,3).
• Sometimes, serendipity smiles, as when the cardiologist happened into the room during the code, and provided an essential bit of information.
• Emergent POC ultrasonography is an essential tool in the management of PEA arrest of uncertain etiology.
• Barriers to access of prior medical records can lead to poorly-informed decisions. But in this case, ignorance likely helped us make the right decision.
• Giving lytic therapy one month after an intracranial hemorrhage is not absolutely contra-indicated when in dire need.
• As the late great intensivist, Jay Blum MD used to say: “Sometimes it’s better to be lucky than smart.”

References

1. Ogbonnah U, Tawil I, Wray TC, Boivin M. Ultrasound for critical care physicians: Caught in the act. Southwest J Pulm Crit Care. 2018;17(1):36-8. [CrossRef]
2. Urban MK, Jules-Elysee K, MacKenzie CR. Pulmonary embolism after IVC filter. HSS J. 2008 Feb;4(1):74-5. [CrossRef] [PubMed]
3. PREPIC Study Group. Eight-year follow-up of patients with permanent vena cava filters in the prevention of pulmonary embolism: the PREPIC (Prevention du Risque d'Embolie Pulmonaire par Interruption Cave) randomized study. Circulation. 2005 Jul 19;112(3):416-22. doi: [CrossRef] [PubMed]

Cite as: Raschke RA, Weisman R. Ultrasound for Critical Care Physicians: Sometimes It’s Better to Be Lucky than Smart. Southwest J Pulm Crit Care. 2021;22(6):116-8. doi: https://doi.org/10.13175/swjpcc016-21 PDF 

High Volume Plasma Exchange in Acute Liver Failure: A Brief Review

Matthew D Rockstrom, MD¹

Jonathan D Rice, MD^1,2

Tomio Tran, MD³

Anna Neumeier, MD^1,4

¹Department of Medicine, University of Colorado School of Medicine, Aurora, CO USA

²Department of Medicine, Division of Gastroenterology and Hepatology, University of Colorado School of Medicine, Aurora, CO USA

³Department of Medicine, Division of Cardiology, University of Washington, Seattle, WA USA

⁴Department of Medicine, Division of Pulmonary Sciences and Critical Care, Denver Health and Hospital Authority, Denver, CO USA

Abstract

Acute liver failure (ALF) is characterized by acute liver injury, coagulopathy, and altered mental status. Acetaminophen overdose contributes to almost half the cases of ALF in the United States. In the era of liver transplantation, mortality associated with this condition has improved dramatically. However, many patients are not transplant candidates including many who present with overt suicide attempt from acetaminophen overdose. High volume plasma exchange (HVP) is a novel application of plasma exchange. Prior research has shown that HVP can correct the pathophysiologic derangements underlying ALF. A randomized control trial demonstrated improved transplant-free survival when HVP was added to standard medical therapy. In this case, we examine a patient who presented to the intensive care unit with ALF caused by intentional acetaminophen overdose. She was denied transplant due to overt suicide attempt, was treated with HVP, and made a rapid recovery, eventually discharged to inpatient psychiatry and then home.

Abbreviations: ALF: acute liver failure: CVVH: continuous veno-venous hemodialysis; DAMPs: damage associated molecular patterns; FFP: fresh frozen plasma; HVP: high volume plasma exchange; MODS: multisystem organ dysfunction; NAC: N-acetyl cysteine; NNT: Number needed to treat; SIRS: systemic inflammatory response syndrome; SMT: standard medical therapy; TNF-α: tumor necrosis factor alpha

Introduction

Acute liver failure (ALF) is a rare, life-threatening condition. Although survival has improved in the transplant era, mortality remains high without transplantation. Here we discuss a novel therapy for ALF patients which may provide improved transplant-free mortality.

Case Report

A 21-year-old woman arrived by ambulance, found to be obtunded and hypotensive in the field, with an empty bottle of acetaminophen and a suicide note. She had a history of depression, infrequent alcohol and marijuana use, and was otherwise healthy.

Upon presentation, she was afebrile (temperature 36.5°C), tachycardic (heart rate 155 beats-per-minute) and hypotensive requiring norepinephrine of 0.1 μg/kg/min to maintain mean arterial blood pressure above 65.  Due to grade IV encephalopathy, she was intubated.  Admission lab work is shown below (Table 1). Viral hepatitis and HIV serologies were negative and ultrasound demonstrated patent vasculature and normal liver parenchyma.

Table 1: Lab work on admission, hospital day 2, and following high-volume plasma exchange therapy.

BUN: blood urea nitrogen, AST: aspartate aminotransferase; ALT: alanine aminotransferase; INR: international normalized ratio; APAP: N-acetyl-para-aminophenol

N-acetyl cysteine (NAC) was administered and transplant evaluation was obtained. Despite meeting King’s College Criterion for transplantation, she was declined due to presentation for suicide attempt. She was managed supportively with vasopressors, continuous veno-venous hemodialysis (CVVH), and high-volume plasma exchange (HVP) at a rate of 8 liters of fresh frozen plasma (FFP) daily, receiving 24 liters total. After initiation of HVP, vasopressors were immediately weaned. The following day, her encephalopathy improved, and she followed simple commands. CVVH was discontinued on hospital day 4. She was extubated on hospital day 6 and was eventually discharged home.

Clinical Discussion

ALF is a life-threatening syndrome characterized by acute liver injury, encephalopathy, and coagulopathy. In the United States, the most common etiology is acetaminophen overdose, accounting for ~46% of cases (1). Standard medical therapy (SMT) is supportive, treating the underlying etiology and mitigating manifestations of multisystem organ dysfunction (MODS). The advent of transplantation dramatically improved the mortality associated with ALF but the benefit of transplant must be balanced with high-risk surgery, lifelong immunosuppression, and organ scarcity (2). Given these risks, patients undergo evaluation including psychologic evaluation which commonly excludes patients presenting with intentional acetaminophen overdose. Without transplantation, mortality for these patients remains high.

The pathophysiology of ALF is not entirely understood but is largely driven by hepatic necrosis leading to hepatic metabolic dysfunction and release of intracellular contents. Intracellular damage associated molecular pattern (DAMPs) and Kupffer cell activation trigger the release of pro-inflammatory cytokines like tumor necrosis factor alpha (TNF-α), which result in systemic inflammatory response syndrome (SIRS) and vasodilation (3,4). Subsequent hepatic metabolic dysfunction is manifested by hyperbilirubinemia, hyperammonemia, coagulopathy, and hypoglycemia.

High volume plasma exchange (HVP) has shown promise as a new modality of treatment for patients with ALF. A new implementation of plasma-exchange therapy, patient plasma is exchanged with donor FFP. In one prospective, randomized control trial by Larsen et al, 15% of ideal body weight of FFP was exchanged daily for three days in addition to SMT. HVP plus SMT improved survival to discharge when compared to SMT alone (58.7 % versus 47.8%, respectively; number needed to treat (NNT) 9.2) (5). HVP plus SMT has been shown to reverse clinical parameters associated with ALF including INR, bilirubin, vasopressor requirements, reliance on renal replacement, hepatic encephalopathy (5-7). HVP was also shown to significantly attenuate DAMPs, including IL-6 and TNF-α, indicating an ability to attenuate the biochemical nidus of MODS (6,7). A systematic review of HVP found evidence of mortality benefit in HVP for both ALF and acute on chronic liver failure, though Larsen et al remains the only randomized prospective trial. Subsequently, HVP has become a level I, grade 1 recommendation in European guidelines for ALF (6).

There are limitations associated with HVP including utilization of FFP, concerns for precipitation volume overload, and worsening cerebral edema. Additionally, there is no clear optimal regimen for dose and duration of HVP. In a recent randomized control trial by Maiwall et al, standard volume plasma exchange was shown to improve transplant free survival using only 1.5 to 2 times calculated patient plasma volume (4).

Conclusion

In this case, a 21-year-old patient presented with ALF following acetaminophen overdose. Despite qualifying for transplantation, she was denied due to presentation for suicide attempt. She was treated with standard medical therapy and HVP and had rapid improvement in hemodynamics and mentation. While it is impossible to quantify the degree to which HVP contributed to her recovery, her clinical improvement was dramatic despite presentation with severe disease. HVP has been shown to reverse the pathophysiologic hallmarks of ALF, improve transplant-free mortality, and is now a level I recommendation according to European guidelines. More trials are necessary to determine the optimal dose and duration of this life saving modality.

References

1. Lee WM. Etiologies of acute liver failure. Semin Liver Dis. 2008 May;28(2):142-52. [CrossRef] [PubMed]
2. Lee WM, Squires RH Jr, Nyberg SL, Doo E, Hoofnagle JH. Acute liver failure: Summary of a workshop. Hepatology. 2008 Apr;47(4):1401-15. [CrossRef] [PubMed]
3. Chung RT, Stravitz RT, Fontana RJ, Schiodt FV, Mehal WZ, Reddy KR, Lee WM. Pathogenesis of liver injury in acute liver failure. Gastroenterology. 2012 Sep;143(3):e1-e7. [CrossRef] [PubMed]
4. Maiwall R, Bajpai M, Singh A, Agarwal T, Kumar G, Bharadwaj A, Nautiyal N, Tevethia H, Jagdish RK, Vijayaraghavan R, Choudhury A, Mathur RP, Hidam A, Pati NT, Sharma MK, Kumar A, Sarin SK. Standard-Volume Plasma Exchange Improves Outcomes in Patients With Acute Liver Failure: A Randomized Controlled Trial. Clin Gastroenterol Hepatol. 2021 Jan 29:S1542-3565(21)00086-0. [CrossRef] [PubMed]
5. Larsen FS, Schmidt LE, Bernsmeier C, et al. High-volume plasma exchange in patients with acute liver failure: An open randomised controlled trial. J Hepatol. 2016 Jan;64(1):69-78. [CrossRef] [PubMed]
6. Tan EX, Wang MX, Pang J, Lee GH. Plasma exchange in patients with acute and acute-on-chronic liver failure: A systematic review. World J Gastroenterol. 2020 Jan 14;26(2):219-245. [CrossRef] [PubMed]
7. Larsen FS, Ejlersen E, Hansen BA, Mogensen T, Tygstrup N, Secher NH. Systemic vascular resistance during high-volume plasmapheresis in patients with fulminant hepatic failure: relationship with oxygen consumption. Eur J Gastroenterol Hepatol. 1995 Sep;7(9):887-92. [PubMed]

Cite as: Rockstrom MD, Rice JD, Tran T, Neumeier A. High Volume Plasma Exchange in Acute Liver Failure: A Brief Review. Southwest J Pulm Crit Care. 2021;22(5):102-5. doi: https://doi.org/10.13175/swjpcc009-21 PDF

April 2021 Critical Care Case of the Month: Abnormal Acid-Base Balance in a Post-Partum Woman

Mohammad Abdelaziz Mahmoud, MD, DO

Andrea N. Pruett, BS

Emanuel Medical Center

Turlock, CA 95382

History of Present Illness

A 29-year-old healthy woman, who is 8 weeks postpartum, presented to the emergency department with severe shortness of breath, fast shallow breathing, nausea, several episodes of nonbloody nonbilious emesis, abdominal pain and malaise for 1 week. The patient delivered a healthy boy at full-term by spontaneous vaginal delivery. Her pregnancy was uneventful. She denied smoking or use of alcohol.

Physical Exam

On presentation to the emergency department her blood pressure was found to be 121/71, temperature 36.8°C, pulse 110 beats per minute, respiratory rate 20 breaths per minute and SpO2 saturation of 99% while breathing ambient air. Physical exam was remarkable except for dry mucous membranes, sinus tachycardia, and tachypnea with mild epigastric tenderness with light palpation.

Which of the following should be done? (Click on the correct answer to be directed to the second of five pages)

1. Complete blood count (CBC)
2. Metabolic panel
3. Chest x-ray
4. Arterial blood gases (ABGs)
5. All of the above

Cite as: Mahmoud MA, Pruett AN. April 2021 Critical Care Case of the Month: Abnormal Acid-Base Balance in a Post-Partum Woman. Southwest J Pulm Crit Care. 2021;22(4):81-85. doi: https://doi.org/10.13175/swjpcc007-21 PDF.

First-Attempt Endotracheal Intubation Success Rate Using A Telescoping Steel Bougie

Evan D. Schmitz, MD

La Jolla, CA USA

Kevin Park, MD, MBA, FCCP 

MLK Community Medical Group

Compton, CA USA 

Abstract

Background

There has been a renewed interest in using the plastic intubation bougie to facilitate first-attempt endotracheal intubation success. The sterile single-use telescopic steel bougie (AIROD) was invented to overcome the limitations of the plastic bougie which is easily deformed during storage.  

Methods

This is a retrospective study involving critically ill patients who were intubated with the AIROD in the intensive care unit at a single institution. The purpose of this case series is to compare the success rate of the AIROD to the generally accepted success rate for the traditional plastic bougie of 96%.

Results

A total of 54 patients were enrolled at a single ICU over a 10 months period. All patients were critically ill with 76% having a difficult airway, Cormack-Lehane grade view 2 or greater in 60%, and ARDS secondary to COVID-19 in 54%. The primary outcome of first-attempt intubation success in critically ill patients intubated in the ICU with the AIROD was 97% with a 95% confidence interval of 0.89 to 0.99. The average time for intubation of all airway classifications was 15 seconds.

Conclusion

The AIROD first-attempt intubation success rate was found to be similar to the rate for the traditional plastic bougie.

Introduction

The BEAM (Bougie Use in Emergency Airway Management) trial, renewed interest in the use of a bougie rather than a stylet (1). In the BEAM trial, first-attempt endotracheal intubation success using a plastic bougie was compared to a stylet during laryngoscopy in an emergency department. First-attempt success was achieved in in 98% compared to 87% in all patients. In patients with at least one difficult airway characteristic, first-pass success using a plastic bougie was 96% compared to 82% using a stylet.

In 2019, the sterilized single-use telescopic steel bougie, AIROD (AIRODMedical; FL, USA), was introduced to the USA market (Figure 1).

Figure 1. A: AIROD closed. B: AIROD open. C: AIROD with an endotracheal tube loaded on the distal end.

The thin surgical steel construction of the AIROD allows it to bend slightly while maintaining its integrity to help manipulate oropharyngeal tissue without causing trauma. The AIROD can guide a 6.5 mm or larger endotracheal tube into the trachea. To do so, the AIROD is introduced into the oropharynx alongside a laryngoscope, either direct or video, and advanced just past the vocal cords. An endotracheal tube is then slid down over the AIROD and into the trachea securing the airway to allow for mechanical ventilation. The AIROD telescopes from one foot when closed to two feet when opened, offering many storage options.

Several publications have demonstrated that the AIROD is a safe and effective tool for endotracheal intubation (2-5). In this manuscript we extend those observations.

Methods

A retrospective analysis of all endotracheal intubations that were performed with the AIROD in the ICU at a single institution (Mercy One Hospital in Sioux City, IA) between October 18, 2020 and January 1, 2020 were included.

A successful first-attempt intubation was defined as the placement of an endotracheal tube into the trachea upon the initial insertion of the laryngoscope into the oropharynx. If the laryngoscope had to be removed and a second-attempt performed, it was considered a failure. Airways were graded using the Cormack-Lehane grade view (Appendix 1).

A difficult airway was defined as the presence of body fluids obscuring the laryngeal view, airway obstruction or edema, obesity, short neck, small mandible, large tongue, facial trauma, stiff neck or the need for cervical spine immobilization (2). Intubation time was defined as the time from insertion of the laryngoscope to placement of an endotracheal tube with its cuff inflated.

Results

Patient characteristics are shown in Table 1. 

Table 1. Characteristics and outcomes of the critically ill patients intubated with the AIROD in the ICU.

A total of 54 patients with an average age of 62 years were included in the study. All patients were in critical condition. The average patient was obese with a BMI of 31.2 kg/m2. A difficult airway was present in 76% of the patients and 54% of the patients had COVID-19 infection. In total, 63% of the patients were male and 37% were female. Using the Cormack-Lehane grade view: 20% had a grade 4 view, 10% had a grade 3 view, and 30% had a grade 2 view.

Intubation first-attempt success rate was 97%. Subgroup analysis of first-attempt intubation success using the AIROD to intubate in patients with a difficult airway was 96%.

The average intubation time in the patients that were timed was 15 seconds (33/54 patients were timed). Of the patients with a difficult airway, the average time to intubate was also 15 seconds.

A bronchoscopy performed on 17% of the patients just after intubation revealed no evidence of tracheobronchial trauma.

Discussion

The patients intubated with the AIROD in the ICU had a first-attempt success rate of 97%. The first-attempt success rate for endotracheal intubation of the critically ill has been reported at only 70% (6,7). This corresponds to an absolute risk reduction of 27% in failure to intubate patients during the first-attempt with the use of the AIROD during the intubation of patients in critical condition.

Even when compared to patients who were not critically ill and were intubated with a plastic bougie in the emergency department in the BEAM trial (1), the first-attempt success rate with the AIROD was 97% vs. 98. In those patients who were critically ill and also had a difficult airway, the first-attempt intubation success rate with the AIROD was at 97% vs. 96% in all patients (not just the critically ill) with a difficult airway.

In this study, the average time to intubation in all critically ill patients was 15 seconds using the AIROD. For those patients who were critically ill and had a difficult airway, the time to intubation was also 15 seconds. A previous publication on consecutive COVID-19 patients with ARDS intubated using the AIROD also had an intubation time of 15 seconds (2). In the BEAM trial, the median time to intubation using the plastic bougie in all types of patients intubated in the emergency department was 38 seconds (1). In all critically ill patients, the AIROD was 23 seconds faster. Intubation with the AIROD took 40% of the time in those patients who were critically ill, including those with a difficult airway, as opposed to the plastic bougie. The decrease in time securing the airway may have an impact on overall decompensation and possible outcomes of the disease process. Further studies between low intubation time and disease outcome remain an area to be studied in the future. The decrease in intubation time using the AIROD was not accompanied by adverse events such as cardiac arrest or tissue damage.

During multiple intubations, the AIROD was used to lift the epiglottis and move the oropharyngeal tissue that was obscuring the vocal cords out of the way, improving the view of the vocal cords and allowing for successful tracheal intubation. The AIROD was also able to move copious secretions blocking the view of the glottis in a few patients including those patients receiving chest compressions. Even during blind intubation, including one time when the light on the laryngoscope failed, the AIROD provided tactile sensation to the tracheal rings known as “tracheal clicks” that helped ensure correct tracheal placement of the endotracheal tube (2).

This study is limited by its small sample size and retrospective nature, and by that fact that not all intubations were timed because of the emergent nature of some of the intubations. The inventor of the AIROD did most of the intubations and others might not achieve equal results. A prospective trial on the timing of first-pass intubation success using the AIROD would be most useful to confirm the findings in this study.

In conclusion, the AIROD first-attempt intubation success rate was found to be similar to the rate for the traditional plastic bougie. Direct inspection of the oropharynx during intubation confirmed no significant trauma occurred during intubation.

Conflicts of Interest

Evan D. Schmitz, MD is the inventor of the AIROD and was the primary operator for most of the intubations mentioned in this study. No financial assistance was provided for this study. The AIROD instruments were donated to the hospital from AIRODMedical.com.

Acknowledgments

The author thanks H. Carole Schmitz, Carol Fountain and Abra Gibson for their editorial comments.

References

1. Driver BE, Prekker ME, Klein LR, Reardon RF, Miner JR, Fagerstrom ET, Cleghorn MR, McGill JW, Cole JB. Effect of Use of a Bougie vs Endotracheal Tube and Stylet on First-Attempt Intubation Success Among Patients With Difficult Airways Undergoing Emergency Intubation: A Randomized Clinical Trial. JAMA. 2018 Jun 5;319(21):2179-2189. [CrossRef] [PubMed]
2. Schmitz ED. Decreasing COVID-19 patient risk and improving operator safety with the AIROD during endotracheal intubation. J of Emergency Services. EMSAirway. 11/2020.
3. Schmitz ED. AIROD Case Series: A new bougie for endotracheal intubation. J Emerg Trauma Care. 2020;5(2):20. [CrossRef]
4. Schmitz ED. Single-use telescopic bougie: case series. Southwest J Pulm Crit Care. 2020;20(2):64-68. [CrossRef]
5. Schmitz ED, Park K. Emergency intubation of a critically ill patient with a difficult airway and avoidance of cricothyrotomy using the AIROD. J of Emergency Services. EMSAirway. 01/2021. [CrossRef]
6. Collins SR. Direct and indirect laryngoscopy: equipment and techniques. Respir Care. 2014 Jun;59(6):850-62; discussion 862-4. [CrossRef] [PubMed]
7. Higgs A, McGrath BA, Goddard C, Rangasami J, Suntharalingam G, Gale R, Cook TM; Difficult Airway Society; Intensive Care Society; Faculty of Intensive Care Medicine; Royal College of Anaesthetists. Guidelines for the management of tracheal intubation in critically ill adults. Br J Anaesth. 2018 Feb;120(2):323-352. [CrossRef] [PubMed]

Cite as: Schmitz ED, Park K. First-Attempt Endotracheal Intubation Success Rate Using A Telescoping Steel Bougie. Southwest J Pulm Crit Care. 2021;22(1):36-40. doi: https://doi.org/10.13175/swjpcc004-21 PDF

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