CCS Practice Case 2 Flashcards
Location: ER
Vital: BP 100/60, HR 50 and regular, RR 10, temp 37C (98.6F)
HPI: 28 y/o white F brought to ER in unconscious state. Family reports she is very healthy, has no medical problems, not on any medications, and did not find any empty bottles. Has no allergies. Doesn’t smoke or drink alcohol. Has a boyfriend. Has never been pregnant. Father is very healthy except borderline HTN. Mother has DM. No other history is available.
How do you approach this patient?
Emergent management - hemodynamically unstable, so A, B, C, D
Airway:
- Suction
- Pulse ox, stat and continuous
- O2
Breathing: ETT indicated in patients who cannot protect their airway or if O2 saturation does not improve with O2 nasal/face mask, or PaO2<55 or PCO2>50 on ABG
- ABG
Circulation:
- IV access
- Continuous cardiac monitor, continuous
- Place a Foley
- Obtain a finger glucose
Drugs:
- Give thiamine D50, naloxone, NS - all IV bolus 1x
Exam:
Respiratory (assess breathing pattern)
She is slightly awake with the above treatment
Physical exam?
General HEENT/Neck Heart/CVS Skin Chest/Lung Abdomen Extremities Neurological exam
Results of exam:
Pinpoint pupils, very drowsy - thoughts?
Bradycardia + hypotension + pinpoint pupils -> narcotic OD
Diagnostic investigations?
EKG 12 lead CBC w/diff BMP CXR, portable, PA LFTs UA UTox B-HcG serum BAL
Initial treatment?
NG tube, gastric lavage -> reveals pill fragments
Activated charcoal oral, one time
Naloxone IV, stat, continuous
Next step?
Move patient to ICU NPO Bed rest, complete Urine output BMP, next day
Once better?
D/C oxygen, NG tube, cardiac monitor, IV fluids, naloxone
Regular diet
Educate family and patient
Psychiatry consult, stat (reason: 28 y/o w/suicide attempt) Suicide precautions Suicide contract Patient counseling Reassurance No alcohol No smoking Safe sex No illegal drug use Regular exercise Seat belts
Start on antidepressant if needed
Final diagnosis?
Narcotic overdose
Orthostatic hypotension resulting from mild peripheral vasodilation is common. However, persistent or severe hypotension should raise the suspicion of ____.
Co-ingestants
In all patients with moderate-to-severe toxicity, what baseline labs should be obtained?
CBC w/diff BMP LFTs ABG CK
Why should an EKG be obtained on all patients with intentional overdose?
Possibility of cardiotoxic co-ingestants
Why should a CXR be obtained in suspected OD, especially in a patient w/an unprotected airway?
R/o pulmonary edema or aspiration
Who should get naloxone?
Patients with significant CNS and/or respiratory depression
Why is continuous IV infusion of naloxone dangerous in patients who are opioid dependent?
May precipitate withdrawal symptoms
