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Lice & SOB

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History of Present Illness:

A 42-year-old male is brought by ambulance to the ED for feeling SOB and lice.  He is homeless and before the nurses take him to the shower to rinse off the thousands of lice on his body the only conversation you have with him is his request for ice water.   When he comes back from his shower the nurses tell you he became suddenly lethargic with labored breathing.

Vital Signs & Physical Exam:

Initially: Vital signs were initially all normal.  Physical exam is notable for lice all over the place.  Conversant requesting ice water to drink.

After showering: He became tachycardic and  tachypneic.  Physical exam is notable for lethargy, delirium, and dark skin with pale palms.  It was hypothesized that the activity of the vasodilation from hot water may have contributed to this change

30 minutes later: cardiac arrest.  Lab called for results.  The requested a redraw for “contaminants”

Initial Differential Diagnosis:

  • CHF
  • Pneumonia
  • DKA
  • Other cause of metabolic acidosis
  • Anemia
  • Syphilis, the great imitator

Initial Diagnostic Testing:

  • Labs: Hb: 1.9, plt: 500, WBC:8, MCV: normal at 85.  Chem 7: Bun/Cr: 58/3.6, Lactate: 8
  • Imaging: CXR clear
  • Guaiac: hemoccult negative

QUESTIONS:

  1. What do the labs suggest?
  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 do the labs suggest? Severe normocytic anemia, renal failure and severe acidosis
  2. What should you do next?  ACLS and O+ blood transfusion.  Intubation with vent settings matching his pre-intubation spontaneous respirations.
  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: The patient coded multiple times, but was eventually stabilized and went to the ICU, where he eventually had a complete recovery.  Additional labs showed the following: nucleated RBC: 14, polychromasia/anisocytosis/ovalocytes/burr cells: all 1+, Haptoglobin/bili/LDH: all normal.  Total iron = 15 (normal 65-175)

Note: Burr cells are usually due to uremia, liver disease or artifact.  The other cell types are all consistent with iron deficiency anemia.  Not sure why the MCV was normal.  Perhaps also folate or B12 deficiency.

CASE LESSONS:

  • When someone is dark complected, pallor may not be apparent, but you will see it if you look at their palms.
  • When you intubate a patient with severe metabolic acidosis or Kussmaul breathing, start with initial vent setting that are similar to patient’s spontaneous respiration.  This may be a rate of 40 or more
  • Lice & anemia: https://www.ncbi.nlm.nih.gov/pubmed/20656443
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