Coming in Low and Slow

This is our 2nd of 3 cases exploring the care of patients with altered mental status in the Emergency Department.  Similar to our "Out on a Limb" and "Sepsis Smackdown" case series, the case presented is followed by a series of questions, with a discussion in the comment section facilitated by the post authors.  In approximately 1 month, the authors of the post will conduct a combined simulation/small group session reinforcing the learning points from the posts during Grand Rounds.  Around this time, they will also curate the comments from the discussion and publish a post highlighting these learning points.  Looking forward to a great discussion!

You are working an overnight shift at a Level 3 Trauma Center Emergency Department in a community hospital with most subspecialties available by telephone when EMS calls the charge nurse to report they are inbound with a new patient. As they roll through the ambulance doors, you note that the patient “looks” to be acutely ill and is immediately rolled into your resuscitation bay…

The patient is a 68 y/o M with unknown past medical history who was found by EMS to be unconscious and minimally responsive at home on the floor of his bathroom. He lives alone and was found there by a neighbor who had not seen him in several days and was concerned about him. EMS does not have any history on this gentleman and they did not bring his medications with him. Chart review of your EMR shows he has only ever been to your hospital once, for ankle pain, two years ago and there is no documentation of his medications or medical history.

As the nurses are hooking him up to the monitors, you do a quick physical exam. The patient opens eyes to verbal stimuli, responds to questions with inappropriate phrases and localizes briskly to pain with his upper extremities. He has a small cephalohematoma with abrasion on his right occiput but no other signs of trauma. Heart tones are regular without murmur, lung sounds are clear and the abdomen is scaphoid but soft. Extremities are cool and his distal pulses are 1+.

At this point, you finally have a full set of vital signs:

T 96.5F,  P 48, BP 78/34, RR 20, SpO2 98% on 15L NRB

Please respond to a single question and note in the discussion section which question you are responding by beginning your post with Q1, Q2, etc.

Question 1

What is your differential diagnosis in this patient who presents with seemingly undifferentiated hypotension and bradycardia?

Question 2

You are unable to get any collateral information on this patient to aid in determining the cause of his presentation. What are your initial diagnostic and management priorities? How would you begin to determine what the underlying pathology is?

Question 3

The patient’s neighbor finally arrives and informs you that he is pretty confident that the patient “took something.” The neighbor indicates that the patient has a long psychiatric history and has had prior ingestions, though the neighbor doesn’t know what they were. Discuss what particular ingestions/toxidromes could explain the patient’s presentation. What would you look for on physical exam or diagnostic studies to confirm or refute a particular ingestion.

Question 4

Suppose your exhaustive shotgun workup does not reveal a cause of the patient’s presentation. Laboratory studies only reveal a diffuse mildly hypo-perfusive state with a mild prerenal AKI and slight lactic acidosis (lactate 2.9). Despite aggressive fluid resuscitation, the patient’s vital signs and physical exam remain essentially unchanged. How do you proceed with management in this patient? Does your approach change if there is no change in the patient’s vital signs after several hours of monitoring in the resuscitation bay?

Written by Woods Curry, MD

Posted by Jeffery Hill, MD MEd