Pertinent History

This patient is a 27-year-old female who presents by medic to the emergency department after a syncopal episode in class. She went up to her professor and said she didn’t feel well, then collapsed. The medics found her unconscious and apneic at the scene and began bag valve mask ventilation. She arrived in the emergency department unconscious being bagged at a rate of 12 times per minute. Her heart rate initially was 40, and her blood pressure was 40 systolic. No further information was available at the time.

Pertinent Physical Exam

Vitals: BP 40/Palp, HR 40, RR 12 (per BVM), Temp 98.9 °F/37.2 °C

Pertinent Test Results

ED Management

She was immediately intubated using rapid sequence induction and taken for head CT with the first thought being that this could be an intracranial hemorrhage. Simultaneous to the CT scan, an IV was established with fluids wide open. The CT scan showed no evidence of intracranial hemorrhage. The patient’s blood pressure and pulse were unchanged. She received 4 sequential, 1 mg doses of atropine with no change in her heart rate. A norepinephrine drip was started and titrated rapidly with her blood pressure rising to 45 systolic at maximum norepinephrine dosing.

Laboratory work showed a pH of 6.92 with a pO₂ of 550 a pCO₂ of 35 and a bicarbonate of zero. Her lactate was 20. The patient was given 4 Amps of sodium bicarbonate, and her pH on subsequent blood gas was 7.0. She was given 2 additional doses of atropine with no response in her heart rate. An epinephrine drip was substituted for norepinephrine and titrated. Her blood pressure was now around 50 systolic.

A central line was attempted in the right internal jugular, and the resident reported that she thought the blood was arterial, though it was not pulsatile. She then moved to a femoral central line and had a similar report when attempting to place the line. While the needle was in place, a second needle was placed more laterally and blood was obtained, which was pulsatile. The arterial stick was converted to an arterial line, and the initial presumably venous stick was converted to a central line.

Update 1

A repeat blood gas showed a pH at 6.8. She was given 4 more amps of sodium bicarbonate. Additional laboratory testing was performed that included a carbon monoxide level, which was 3, and a repeat lactate, which was now 23. A lumbar puncture was performed showing 2 white cells per high-power field and 10 red cells. No organisms were seen on Gram stain. Her white count came back at 19,000 with a hemoglobin of 12. Broad-spectrum antibiotics were initiated, and toxicologic screening was performed. A FAST scan was performed showing no evidence of intraperitoneal blood. Her heart did not show pericardial effusion; however, contractility was poor. Despite max dosing of epinephrine, her heart rate remained in the mid-40s and her blood pressure did not exceed 50 systolic. She remained unconscious. She was admitted to the ICU with cardiovascular collapse of unknown etiology.

Update 2

Two of her friends arrived in the emergency department and stated that she had been sick for a couple of days prior to this event. She is a Pharmacy Doctorate (PharmD) student and, except for cold symptoms, was otherwise healthy as far as her friends knew. The patient was going to graduate in the next week. After the patient arrived in the ICU, the comprehensive toxicology screen resulted, showing no detected no illicit drugs or medications other than sertraline and diphenhydramine.

Pertinent History

This patient is a 37-year-old male who was brought to the emergency department by EMS after being rescued from a house fire. He had suffered significant smoke inhalation. EMS said the patient was unresponsive and CPR was initiated, followed by return of spontaneous circulation. Post arrest, he was reported to be hypotensive and bradycardic at the scene. He was intubated at the scene without complication. The fire was reported to have started in a bedroom where it is possible that a family member had been smoking in bed. There were 2 fatalities at the scene.

Pertinent Physical Exam

Vitals: BP 50/P HR 35 RR 14 per BVM Temp 97.2 degrees F.

Pertinent Test Results

Test	Result 0230	Result 0350	Units	Normal
WBC	12		K/uL	3.8–11.0 103/mm3
HgB	14.4		g/dL	(Male) 14–18 g/dL (Female) 11–16 g/dL
Platelets	187		K/uL	140–450 K/uL
Sodium	139		mEq/L	135–148 mEq/L
Potassium	3.9		mEq/L	3.5–5.5 mEq/L
Chloride	105		mEq/L	96–112 mEq/L
Bicarbonate	9		mEq/L	21–34 mEq/L
BUN	9		mg/dL	6–23 mg/dL
Creatinine	0.6		mg/dL	0.6–1.5 mg/dL
Glucose	190		mg/dL	65–99 mg/dL
Lactate	14		mmol/L	<2.0
pH	7.01	7.29	–	7.35–7.45
PaCO2	24	30	mmHg	35–45
PaO2	550	529	mmHg	Depends on FiO2
Carboxyhemoglobin	16		%	<5

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