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
- EKG essential to check for conduction blocks
- tox screen
- electrolytes (for acidosis) and glucose (for hyper/hypo-glycemia)
- 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:
Suggested reference for further reading:
- http://emedicine.medscape.com/article/813485-overview
- 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.
Initial priorities are the less than desirable vital signs. Pt is near hypothermic (<35 degrees C), hypotensive, and very bradycardic. Initially I really want that HR and BP up.
ReplyDeleteAdditionally, I would want an ABG due to 94% on room air an RR 24.
I would cover him with blankets and see if his temperature increases as well.
Patient almost meets SIRS criteria w/ T 35.9 (0.9 away), RR >20, so I would want a sepsis workup which would include a CBC, BMP, U/A, UCx, BCx to evaluate if patient is indeed septic, his altered mental status could be secondary to this. His MAP is 63 which is good for the time being.
Also I would want an EKG, sinus bradycardia can be seen in the normal senior citizen heart but with the solmnolence it is less likely. Could also be secondary to an MI.
Increased ICP is another cause of somnolence and bradycardia so I would want to know if the patient had any falls or if he was on coumadin or other blood thinners.
Which brings me to another priority, which is the medication list. I would want to know what the patient is taking because 1) to see if he was on any sort of blood thinner and 2)to see if patient could have overdosed on any of his medications either inadvertantly or in a suicide attempt. Some common meds like beta blockers, clonidine, methyldopa, etc could slog an elderly patient and make him really brady. Additionally, with a history of dementia he could be have OD'd on his antipsychotics if he was on any.
I would want to give the patient some atropine and some fluid to see if we could get the vitals into a better range, also to see if the mental status changes at all.
Another test I would want would be a fingerstick glucose to rule out hypoglycemia.
Differetntial Dx:
1) Med overdose
2) Sepsis
3) increased ICP 2/2 ICH
4) MI
5) Hypoglycemia
That all being said, I would really like some additional history, so I would call the daughter on her cell and find out his PMH etc....
-Michael Boffa, PGY-1
My first thought for this patient is sepsis, given the vital signs and fact that the patient has cold extremities. I would start sepsis protocol, with normal saline bolus, and if the BP response is not appropriate, the patient probably needs a central line and vasopressors. In addition to cultures, basic labs, and CXR, I would get a lactic acid. If initial CXR and UA are unrevealing for a source (an we haven't figured out another cause of the presentation), he should be started on empiric broad antibiotics.
ReplyDeleteHe probably should get some supplemental O2 for his low saturation. ABG could give us more information regarding whether is his acidotic and whether a respiratory acidosis and CO2 retention are contributing.
Another concern is the patients bradycardia. This alone could be causing the hypotension. An EKG should be checked. If it's sinus brady, atropine could help. It could be some kind of block and the pt may need to be paced. ACS could also cause this picture, so we should get cardiac enzymes.
For AMS, if no other cause is found, pt should get a plain brain CT, urine tox screen.
ddx:
- sepsis
- symptomatic bradycardia
- ACS
- medication overdose
- CVA
Katherine Finn pgy3
The first and foremost concerning fact is his temperature. Since sepsis can manifest as hypothermia, especially in the elderly, I would definitely have that in the front of my mind. Given his low blood pressure, I would be worried about inadequate perfusion and would push to have a central line placed, and bolus him. If his pressures still remained low, I would initiate therapy with vasopressors, while evaluating his bradycardia with atropine. I would also initiate oxygen therapy with a 100% non rebreather. I would get basic bloodwork, chemistry,Lactate, UA, CXR, EKG, Blood and urine Cultures . Since the patient was left in the care of his granddaughter, there is an increased chance for an unwitnessed fall. I would get a CT brain without contrast to evaluate for a bleed. His vitals are somewhat consistent with a Cushing’s reflex. Once I have these steps done, I would want to get a more detailed history of physical before I proceeded any further.
ReplyDeleteDifferential Diagnosis
1. Sepsis
2. Medication error
3. Intracranial bleed 2/2 Fall
4. ACS
5. CVA
Sandeep Pillarisetty - PGY1
The first thing to note is the patient’s vitals. Two large bore peripheral IVs. Start him on warmed maintenance crystalloid solution and vasopressors if needed Also, I’d like to warm him with blankets and warmed humidified O2.
ReplyDeleteHe is bradycardic along with hypotensive so I’d like to do a cardiac work up (EKG, troponin, CKMB, BNP) to determine cause such as MI, sinus brady, AV block. For his bradycardia, I’d give him atropine if it was due to sinus brady or pace him for AV block.
Infection is the most likely cause given his age so I’d like to do a sepsis work up with CBC, CXR, Blood Cx, UA, Urine Cx, Serum Lactate, CPK, CMP, ABG. Start him on O2 BNC, watch his O2 sats and prepare for possible intubation and ventilation.
I also would like to get a UDS to see if he has accidently or intentionally overdosed on any medications.
I’d also like to get an accu check to rule out DKA or hypoglycemia as a cause his condition and give glucose if necessary.
Additionally, I’d want a CT head without contrast to see if he has increased ICP from a bleed.
Most importantly, I’d want to review his medication list, obtain a full PMH, and do a physical exam.
D/D
Infection
Toxin ingestion/med OD
ACS
CVA/ICP
DKA/hypoglycemia
Hypothermia
Basing priorities on vital signs,
ReplyDeleteMy first priority would be the low HR in the setting of these other signs/symptoms. After getting EKG and sending troponin, I would look at the med list and see if he is beta blocked, and if so try reversing it with glucagon, if no response atropine depending on EKG results
In this setting it seems possible that his bradycardia is a possible cause of his low BP, however his low temp could also indicate an infectious cause. Either way I would want to start fluid boluses on him, and if non responsive to those and the beta block reversal/atropine above I would go to epi. Labs wise, I would get the normal infectious items, blood/urine, cultures, cbc c xray.
Next I would think about other etiologies likely in this setting, get a CMP to assess for metabolic causes of AMS, check his med list and talk to his grandaughter about what he has been taking (since he is not with his normal care provider his meds may be abnormal)
If he was non responsive to the initial interventions/workup, then I would start broad spectrum abx, and get a non con head ct. This seems like the kind of guy who already has oxygen on from nursing when you get in the room, but if he didn't have it I would start him on 02.
Differential
Since this all started with a change in caregiver, my number one is med related (overdose insulin, b blocker etc)
2)Bradycardia
3)ACS
4)Sepsis
Nick
Excellent work thus far! All great comments and appropriate steps of work-up... with sick appearing patients or those with unstable vitals you can always resort to the mantra: IV, O2, monitor, then your ABCDE's (or CABDE's as it is these days)..
ReplyDeleteBased on this info, it looks like ACS/MI, head trauma, hypoglycemia are all lower on the dx list, no white count and no gap make me think sepsis is a little less likely, leaving meds highest on my differential. The calcium channel blocker toxicity fits well with his presentation, bradycardia and low BP; maybe with the elevated glucose as well so I will go with that as my final dx.
ReplyDeleteFor management specific to this I would use IV calcium chloride infusion, 10 mg glucagon, and start dopamine and follow his HR and pressure from there. Also I can try activated charcol. If he improves via this management or not by dispo would be to the ICU or step down for monitoring.
Nick
This comment has been removed by the author.
ReplyDeleteI retain my previous differential.
ReplyDeleteDifferetntial Dx:
1) Med overdose
2) Sepsis
3) increased ICP 2/2 ICH
4) MI
5) Hypoglycemia
For the same reasons I ranked them as is before. Head CT makes ICH low, MI is low 2/2 the EKG, hypoglycemia is r/o due to blood sugar being elevated.
Sepsis is less likely due to the WBC and lack of left shift, however he does have an elevated blood glucose. He is just on the cusp of SIRS right now so I would want to keep a close eye on him.
My leading diagnosis is STILL medication (calcium channel blocker ) overdose. Diltiazem has the side effects of AV block, bradycardia, & hypotension. Calcium channel overdose usually presents with hypotension and bradycardia(specifically in diltiazem) So given his clinical picture an overdose of this is defintely possible.
Plan
1) Make sure pt has IV, ***Fluid blous is key***, cardiac monitor, continuous pulse ox, neuro checks, Oxygen,
2) Atropine (0.5 mg to 1mg every 3 minutes to max dose of 3mg)
3) I would get pacing pads placed on the patient
4) evaluate the EKG for signs of PR interval prolongation and any bradydysrhythmia
5) CXR
6) If atropine and repeat Fluids fail to increase BP and bradycardia does not resolve can try (a)IV calcium gluconate 10-20 ml q20 mins, (b) IV glucagon 5mg x 2 doses, (c) IV high-dose insulin and glucose, or (d) IV norepinephrine,
7) Additionally, activated charcoal can help remove the excess from the GI tract.
Dispo: TO ICU for close management, in case of CCB overdose patients often deteriorate rapidly and require intubation. Needs to be in ICU in case of vent requirement.
No increased white count and only mildly decreased bicarb lowers the possibility of sepsis.
ReplyDeleteElevated BSL rules out hypoglycemia
EKG and no bump in troponin rules out MI/ACS
CCB OD usually presents with bradycardia and hypotension so that would be first on my differential.
Plan:
Continue to treat the hypotension with fluid boluses. If it doesnt improve- try atropine and if no result then start norepinephrine drip since heart block due to CCB OD is usually resistant to Atropine
Place pt on cardiac monitor, continue to monitor pt's EKGs for PR prolongation, stabilize the patient's airway, continue O2
CXR to rule out pulmonary edema (given the patient's age)
Try IV calcium gluconate, IV insulin/glucose, or IV glucagon if Atropine/NE don't help the hypotension.
Dispo:
Admit pt to MICU for continuous monitoring and possible intubation/ventilator support.