Case of the Week - 7/16/11

 Grampa's Really Sleepy...



   A 74 year old man with a history of moderate dementia who is routinely cared for by his daughter is brought by the granddaughter, who indicates that “Grandpa is too sleepy.”  She drove him to the Emergency Department initially against his wishes. He is now less responsive to her, and “feels cold.”

    The daughter is the usual full time caregiver, but the granddaughter was filling in so that she could go to a seminar.  Grandpa is somnolent and not a reliable historian. The granddaughter brought his medication list. The daughter is now on the way to the ED, having been called by granddaughter. 

    The nurse calls you to area one to assess the patient.  On entering to room you see an elderly somnolent man laying on the cart  in no distress.  As you walk toward the patient the nurse informs you of the vitals from triage:

Review of Systems:  unable to obtain due to dementia / altered mental status

PMH:

Alzheimer's Dementia

CKD - stage 3

HTN

PSH:

no prior surgeries

Allergies: NKDA

Medications:

Aricept 10mg daily

HCTZ 50mg daily

Diltiazem 240mg SR daily

Social History:

no etoh, tobacco

lives with daughter and granddaughter

Family History: noncontributory

Physical Exam:

T 35.9C       BP 90/50     HR 35     RR 24       SaO2 94%

General: elderly man laying on cart, no distress, sonorous respiration, arousable only to painful stimuli

Neuro: solmnolent, arousable to painful stimuli, localizes to pain

HEENT: OP patent, no cervical lad, PERLA, atraumatic

CV: bradycardia, reg rhythm, no murmurs noted

Pulm: clear to auscultation bilaterally, no w/r/r

Abd: soft, nt, nd, +bs, no rebound/guarding

Extrem: cool to touch, cap refill 2-3 seconds,  1+ symmetric bilateral LE edema

Skin: mottled, cool, no rashes noted

 

 

 

CT head - negative for acute changes

EKG - 

Final Diagnosis:  CALCIUM CHANNEL BLOCKER OVERDOSE
Manifestations:

• Hypotension
• Bradycardia
• Heart block
• CNS depression

Work-Up

• EKG essential to check for conduction blocks
• tox screen
• electrolytes (for acidosis) and glucose (for hyper/hypo-glycemia)

Key Management Principles:

• Primary survey (ABC's)
• IVF resuscitation - vasopressors if no response (I did not give you changes in vitals based on therapy in this case)
• Calcium (Ca chloride 3 times more calcium available than Ca-Gluconate but more irritating to peripheral veins)
• Glucagon
• Insulin-Glucose (believed to work via cAMP mechanism like glucagon - maintain euglycemia while on insulin drip)
• Consider co-ingestion (tox screen, consider dig level as Ca could be deleterious)
• Detoxification 
• charcoal
  
• whole bowel irrigation is particularly useful for sustained-release preparations 
• calcium channel blocker acts as smooth muscle relaxant adversely affecting bowel motility

• Remember you can always use poison control as a resource in these cases (800-222-1222) 

 Disposition: ----> MICU

Great Work!  As always, contact me with any questions...






Suggested reference for further reading:

1. http://emedicine.medscape.com/article/813485-overview
2. Hasin T, Leibowitz D, Antopolsky M, Chajek-Shaul T. The use of low-dose insulin in cardiogenic shock due to combined overdose of verapamil, enalapril and metoprolol. Cardiology. 2006;106(4):233-6.