MICU-ER Joint Conference
Dr. Rachmale, Dr. Prasankumar
12/3/08
Case Presentation
 46 y/o F brought by EMS for tachypnea, confusion
 Friends state pt. not answering calls for past 3
days, her son did not go to school for 2 days so
school official went to her house and found pt.
somnolent and altered, so EMS called
 Per EMS pt. was “feeling unwell” with flu-like
symptoms for one week, reportedly seen at walk-in
clinic and given Tylenol Cold which was found at
bedside in addition to empty Ambien bottle
 Also reportedly had fall during week, L periorbital
contusion, unknown if (+) LOC
 Pt. unable to provide any additional history
Case Presentation (cont.)
 Initial vitals: Pulse 85, BP 106/74, RR 18, O2
sat on RA 68%
Temp 99.0 F
FS 134
 PE: Lethargic, cyanotic
No external sign trauma
Diffuse rales in all lung fields
PE otherwise unremarkable
 Computer records show one prior visit one
year ago for alcohol withdrawal seizure,
discharged from ER with Librium Rx only. No
other known medical problems
ED Course
 Intubated without complication, O2 saturation
improved to 88% on 100%O2
 Initial ABG: 7.19 | 48 | 60 | 17.8 | 84.6%
 CBC: WBC 4.9 (87% Neutrophils with many
Bands), Hgb/Hct 13 / 37.5, Plt 261
 BMP: Na 131, K 3.4, Cl 93, CO2 19, BUN 50 / Cr
2.0 (baseline 19/0.7), Glucose 91, Anion Gap 19
 CK 797, trop. (-)
 AST 135 ALT 37
 Coags WNL
 APAP 7.1, ASA (-), Utox (-), EtOH <5
ED Course (Cont.)
 Repeat vitals: T 97.1 F, P 118, BP 96/69, O2 92%
while ventilated on 100% O2
 Treated for sepsis likely due to bilateral
pneumonia with EGDT, MICU team notified
 Zosyn, Cipro given
 Subclavian central line placed
 Lactate 5.5, SvO2 77
 Ammonia 75, Lactulose given
 Repeat WBC 1.7
 Brain CT ordered but not done in ER due to
unstable status
Differential Diagnosis
ARDS- PaO2/FiO2= 68, acute onset,
bilateral infiltrates, no evidence CHF
Bilateral community-acquired pneumonia
Septic shock
Severe pulmonary trauma
Head trauma causing aspiration of gastric
contents
Overdose of Ambien or Tylenol Cold causing
aspiration, or hypoventilation
Differential Diagnosis (cont.)
No external sign pulmonary trauma or long
bone fractures
Report of head trauma but normal external
and neurological exam
Subsequent brain CT done 3 days after
admission showed no acute event
Aspiration- Altered mental status, but no
evidence vomiting at patient home or in
ED, initially protecting airway
Differential Diagnosis (cont.)
Most likely cause of ARDS is untreated
community acquired pneumonia and
resulting sepsis
H/o URI infection the prior week
WBC count low with left shift, hypotensive
Multi-system organ failure with acute renal
failure, elevated LFTs, altered mental status
Initial blood culture showed gram positive
cocci
Differential Diagnosis (cont.)
 Tylenol Cold- Acetaminophen 325 mg, Dextromethorphan
10 mg, Phenylephrine 5 mg, +/- Chlorpheniramine
APAP level 7
Dextromethorphan is an opiate-like cough suppressant
may cause respiratory depression
Chlorpheniramine H1 anti-histamine can cause
sedation, anticholinergic symptoms
 Ambien (Zolpidem)- Imidazopyridine class similar to
Benzos as GABA agonist, similar overdose profile
 Overdoses of heroin, methadone, barbituates, aspirin,
TCAs reported to cause ARDS
No known other home meds
Utox negative