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CASE STUDY 2

History

A 22-year-old man was brought to the emergency department after being found unconscious at a movie theater. In the field, the paramedics inserted an intravenous (IV) line, performed a rapid reagent glucose test that was recorded as 88 mg/dL, and administered oxygen via nasal cannula at 4 L/min when his room air pulse oximetry was determined to be 91%. The patient had no medical records at the receiving hospital, and no useful information was found among his belongings.

Physical Examination

On arrival at the ED, the patient was unconscious, with no response to physical stimuli. Vital signs were: blood pressure, 92/56 mm Hg; pulse, 52 beats/min; respiratory rate, 10 breaths/min; temperature, 97.4°F (36.3°C) {rectal}; and oxygen saturation, 98% on 4 L O2/min. A repeat rapid reagent glucose was unchanged. Examination was notable for 2- to 3-mm pupils that responded to light, normal oculocephalic testing, nearly flaccid muscle tone, and downgoing toes bilaterally. His head was without signs of trauma, and his neck was supple. Examination of the chest revealed scattered coarse breath sounds and a regular heart rhythm with normal heart sounds and no murmurs. The abdomen was soft, bowel sounds were present, and no abnormalities were noted on the skin or extremities. When oxygen was removed, his saturation fell to 92%, and a continuous end-tidal CO2 monitor measured 48 mm Hg.

Immediate Management

Given the patient’s hypoventilation and small pupils, graded doses of naloxone were given (0.04, 0.1, and 2 mg IV) without response (Antidotes in Depth: A4). On further examination, the patient’s gag reflex was absent, prompting endotracheal intubation, which was performed without medications, and the patient was attached to a mechanical ventilator. A postintubation arterial blood gas, a complete blood count, electrolytes, and ethanol and acetaminophen (APAP) concentrations were obtained. Electrocardiography (ECG) showed sinus bradycardia with normal axis and intervals, and normal ST segments and T-waves were observed. A total of 1 L of 0.9% sodium chloride was infused, and his blood pressure increased to 102/60 mm Hg, with no change in his pulse. A nasogastric tube was inserted through which 60 g of activated charcoal was instilled into the stomach.

What Is the Differential Diagnosis?

This patient was comatose, with remarkable vital signs (hypotension, bradycardia, and hypoventilation) and remarkable physical findings (miosis, coma, flaccid muscles). The differential diagnosis is extensive and includes many xenobiotics from diverse chemical classes. The most common causes are listed in Table CS2–1. In many cases, it is not necessary to establish the correct diagnosis but rather to exclude diagnoses that require specialized care or are amenable to specific interventions.

What Clinical and Laboratory Analyses Help Exclude Life-Threatening Causes of This Patient’s Presentation?

Either a rapid reagent glucose determination should be obtained or hypertonic dextrose should be administered in every comatose patient (Chaps. 3 and 4 and Antidotes in Depth: A1 and A8). A normal blood glucose concentration or failure to respond to an appropriate dose ...

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