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3/2005Hasharon Hospital/251 A Confused Patient with Bradycardia G. Y. Stein, Z. Fradin, Y. Korobko, Y. Ori, P. Singer, A. Zeidman Department of Internal.

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Presentation on theme: "3/2005Hasharon Hospital/251 A Confused Patient with Bradycardia G. Y. Stein, Z. Fradin, Y. Korobko, Y. Ori, P. Singer, A. Zeidman Department of Internal."— Presentation transcript:

1 3/2005Hasharon Hospital/251 A Confused Patient with Bradycardia G. Y. Stein, Z. Fradin, Y. Korobko, Y. Ori, P. Singer, A. Zeidman Department of Internal Medicine B Hasharon Hospital

2 3/2005Hasharon Hospital/252 Patient Presentation A 42 year old woman, D+2A 42 year old woman, D+2 Presented with confusion and bradycardia of 20 bpmPresented with confusion and bradycardia of 20 bpm Party 30 hours earlier, drank large quantities of alcohol, abdominal pain and vomitingParty 30 hours earlier, drank large quantities of alcohol, abdominal pain and vomiting Failed to wake up – boyfriend called paramedicsFailed to wake up – boyfriend called paramedics Boyfriend denies drugs or medications other than occasional NSAID’s and SSRI’sBoyfriend denies drugs or medications other than occasional NSAID’s and SSRI’s

3 3/2005Hasharon Hospital/253 Physical Does not look neglected, no needle pricks, no signs of traumaDoes not look neglected, no needle pricks, no signs of trauma Spontaneous slow deep breathingSpontaneous slow deep breathing Disorientation, partially responsiveDisorientation, partially responsive No feverNo fever Pulse 20, strong carotid, femoral and radial pulsePulse 20, strong carotid, femoral and radial pulse Pupils dilated, partially responsive to light, circular nystagmusPupils dilated, partially responsive to light, circular nystagmus

4 3/2005Hasharon Hospital/254 Monitor What now?

5 3/2005Hasharon Hospital/255 Evaluation Monitor: wide QRS, peaked T wavesMonitor: wide QRS, peaked T waves Glucose per stick: 40 mg/dlGlucose per stick: 40 mg/dl 2 IV lines and a urinary catheter are placed2 IV lines and a urinary catheter are placed Blood for chemistry, blood gasses and PTBlood for chemistry, blood gasses and PT Urine: 50cc clear and concentratedUrine: 50cc clear and concentrated Urine sent for urinalysis and toxic screenUrine sent for urinalysis and toxic screen Vaginal bleeding - mildVaginal bleeding - mild

6 3/2005Hasharon Hospital/256 Management I.V Glucose 50% 40cc pushI.V Glucose 50% 40cc push Inh. VentolinInh. Ventolin I.V Glucose 5% + 10 units of reg. InsulinI.V Glucose 5% + 10 units of reg. Insulin I.V Adrenalin*2 and Atropin*2 pushI.V Adrenalin*2 and Atropin*2 push I.V Bicarbonate 2 ampoules pushI.V Bicarbonate 2 ampoules push I.V Calcium-Gluconate 10cc pushI.V Calcium-Gluconate 10cc push Patient stabilizes at 140bpm, good BP, recurrent hypoglycemiaPatient stabilizes at 140bpm, good BP, recurrent hypoglycemia

7 3/2005Hasharon Hospital/257 Monitor Recordings a b c After 1mg Adrenalin After Ca, Glu, Insulin, HCO3 Adrenalin

8 3/2005Hasharon Hospital/258 Test Results (pre-treatment) pH 6.94, PCO 2 76.2, PO 2 76.8, BIC 10.6, BE -18.9pH 6.94, PCO 2 76.2, PO 2 76.8, BIC 10.6, BE -18.9 Na 138, K 9.35, Cl 98, Glu 17, Cr 4.06Na 138, K 9.35, Cl 98, Glu 17, Cr 4.06 Uric acid 18.2, Ca 6.1, Phosphorus 19.7Uric acid 18.2, Ca 6.1, Phosphorus 19.7 CPK 5489CPK 5489 GOT 9790, Alk Phos 120, LDH 59, Bil 0.7GOT 9790, Alk Phos 120, LDH 59, Bil 0.7 HGB 13.8, WBC 14.9, Neut% 80.2, Plt 209HGB 13.8, WBC 14.9, Neut% 80.2, Plt 209 INR 2.9, Fibrinogen 60INR 2.9, Fibrinogen 60

9 3/2005Hasharon Hospital/259 Management – cont. Intubation and mechanical ventilationIntubation and mechanical ventilation More Calcium and Na-Bicarbonate I.V pushMore Calcium and Na-Bicarbonate I.V push Nephrologist called in for emergency hemodialysisNephrologist called in for emergency hemodialysis Still not hemodynamically stableStill not hemodynamically stable Cardiac arrest – CPR, atropin + multiple noradrenalin pushCardiac arrest – CPR, atropin + multiple noradrenalin push Patient stabilizesPatient stabilizes

10 3/2005Hasharon Hospital/2510 Patient Lab After Stabilization pH 7.15, PCO 2 47.6, PO 2 248, HCO 2 14.8, BE -12.5pH 7.15, PCO 2 47.6, PO 2 248, HCO 2 14.8, BE -12.5 Na 135.9, K 7.12, Glu 305Na 135.9, K 7.12, Glu 305

11 3/2005Hasharon Hospital/2511 Management – cont. Double lumen femoral catheterDouble lumen femoral catheter Transfer to ICUTransfer to ICU Emergency hemodialysisEmergency hemodialysis Hemodynamically stableHemodynamically stable

12 3/2005Hasharon Hospital/2512 Short Summary – Multi Organ Failure Severe high-anion-gap metabolic acidosis and respiratory acidosisSevere high-anion-gap metabolic acidosis and respiratory acidosis ARF m/p d/t RhabdomyolysisARF m/p d/t Rhabdomyolysis Severe hyperkalemia and acidosis d/t ARFSevere hyperkalemia and acidosis d/t ARF Cardiac toxicity and asystole d/t hyperkalemiaCardiac toxicity and asystole d/t hyperkalemia Severe liver damage with disturbed coagulation factorsSevere liver damage with disturbed coagulation factors DICDIC Resistant hypoglycemiaResistant hypoglycemia

13 3/2005Hasharon Hospital/2513 Management – cont. Factor V: 4%Factor V: 4% I.V. N-Acetylcystein (Parvolex) is administeredI.V. N-Acetylcystein (Parvolex) is administered Urine toxic screen: evidence of opiates and phencyclidine (PCP)Urine toxic screen: evidence of opiates and phencyclidine (PCP) Blood levels of alcohol are undetectableBlood levels of alcohol are undetectable

14 3/2005Hasharon Hospital/2514 Aftermath Patient transferred to another hospitalPatient transferred to another hospital I.V. Pravolex, Rocephine, FluconazoleI.V. Pravolex, Rocephine, Fluconazole Noradrenaline and NaHCO 3 in increasing dosesNoradrenaline and NaHCO 3 in increasing doses HCV positiveHCV positive

15 3/2005Hasharon Hospital/2515 Aftermath cont. On waiting list for liver transplantationOn waiting list for liver transplantation Daily hemofiltration and treatment with MARS (Molecular Adsorbents Recirculation System)Daily hemofiltration and treatment with MARS (Molecular Adsorbents Recirculation System) A day later – compartment syndrome in left arm – fasciotomyA day later – compartment syndrome in left arm – fasciotomy Treatment with FFP and bloodTreatment with FFP and blood Brain CT excludes intracranial hemorrhageBrain CT excludes intracranial hemorrhage

16 3/2005Hasharon Hospital/2516 Aftermath cont. On the 3 rd day the patient dies of liver failureOn the 3 rd day the patient dies of liver failure Family refuses PMFamily refuses PM

17 3/2005Hasharon Hospital/2517 Phencyclidine (PCP – Angel Dust) General anesthetic in veterinary medicine similar to KetaminGeneral anesthetic in veterinary medicine similar to Ketamin Voluntarily withdrawn from market in 1978Voluntarily withdrawn from market in 1978 Not used in humans d/t potent psychomimetic propertiesNot used in humans d/t potent psychomimetic properties Not widely used d/t “bad trips”Not widely used d/t “bad trips” Sometimes mixed with marijuana or cocaineSometimes mixed with marijuana or cocaine

18 3/2005Hasharon Hospital/2518 PCP – Clinical Effects EyesEyes –Horizontal, vertical and rotatory nystagmus –Blank stare CardiovascularCardiovascular –Hypertension – up to hypertensive crisis NeurologicNeurologic –Paranoid behavior, combativeness, seizures –Respiratory depression with eyes wide open –Toxic encephalopathy 36.9%

19 3/2005Hasharon Hospital/2519 PCP – Clinical Effects cont. EndocrineEndocrine –Hypoglycemia 22% PsychiatricPsychiatric –Severe psychosis –Paranoid and self destructive behavior

20 3/2005Hasharon Hospital/2520 PCP – Rare Complications Rhabdomyolysis 2.2%Rhabdomyolysis 2.2% Acute renal failureAcute renal failure Aspiration pneumoniaAspiration pneumonia Pulmonary emboliPulmonary emboli Intracranial hemorrhageIntracranial hemorrhage DICDIC Liver necrosisLiver necrosis

21 3/2005Hasharon Hospital/2521 False positive urine screen test Ketamine useKetamine use Massive venlafaxine overdoseMassive venlafaxine overdose Dextromethorphan and diphenhydramineDextromethorphan and diphenhydramine

22 3/2005Hasharon Hospital/2522 PCP Morbidity & Mortality Data AAPCC 1995-2002 a b c

23 3/2005Hasharon Hospital/2523 In Israel No documented cases as of nowNo documented cases as of now Primarily mixed with over-diluted opioids or cannaboids for enhancementPrimarily mixed with over-diluted opioids or cannaboids for enhancement Sometimes in “private stashes”Sometimes in “private stashes”

24 3/2005Hasharon Hospital/2524 Conclusion Can the patient’s situation be explained by PCP intoxication?Can the patient’s situation be explained by PCP intoxication? YesYes Is this really what happened?Is this really what happened? We will never know…We will never know…

25 3/2005Hasharon Hospital/2525 Thank you


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