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Coma & Hard to Bag

UnFiNiShEd CaSe CoMe BaCk LaTeR

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History of Present Illness:

A man in his 20’s is brought to the ED for coma & hypoxia.  He was normal when he went to bed but in the morning his roommate found him snoring strangely and could not wake him.  He has no known past medical history and no known substance abuse history or recent major emotional or psychiatric issues.  He has not been ill recently and had no known COVID exposures.  Medics state that he is really hard to bag in that they have to squeeze the bag with more than the usual amount of force.

Physical Exam:

His vital signs are notable for a pulse in the 110’s and a pulse ox in the low 80’s  BP and temperature are normal.  LUngs have bilateral rales without wheeze.  There is no edema.  He is unresponsive to deep painful stimuli with a GCS of 3.  There are no unusual odors or track marks

Initial Differential Diagnosis: Brain bleed, overdose, aspiration, COVID-19

Relevant Test Results:

  • EKG: none
  • Remarkable Labs: Creatinine elevated at 2,  WBC is low at 2
  • Imaging: a CHEST x-ray is done

QUESTIONS:

  1. What does the case image show?  
  2. What should you do next?  
  3. Want a 1-minute consult/tutorial on this case? 
  4. Want to know what happened with this patient?

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ANSWERS:

  1. What does the case image show?  The image shows bilateral infiltrates with a normal cardiac silhouette concerning for ARDS.
  2. What should you do next?  Intubate, head CT.
  3. Want a 1-minute consult/tutorial on this case?  See yellow area from sample page below.
  4. Want to know what happened with this patient?  See case conclusion below tutorial page.

1-Minute EM Consult on the topic for this case from the Emergency Medicine 1-minute Consult Pocketbook

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CASE CONCLUSION: He was intubated but his pulse ox continued to drop despite 100% inspired oxygen, and 12 of PEEP.  Head CT was negative.  He was proned and admitted to the ICU but continued to decompensate so was placed on ECMO.  5 days later he was taken off ECMO then extubated and had a 100% neurologic recovery.  Testing was all negative and when he awoke he admitted to trying a new spiked vape the night before

CASE LESSONS:

  1. Always consider ECMO in a salvageable, relatively healthy patient with an otherwise potentially fatal disease involving the heart or lungs.
  2. Never assume coma is permanent when evaluating on day 1
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