A Confused Patient with Bradycardia

1
A Confused Patient with Bradycardia

• G. Y. Stein, Z. Fradin, Y. Korobko, Y. Ori, P.
  Singer , A. Zeidman
• Department of Internal Medicine B
• Hasharon Hospital

2
Patient Presentation

• A 42 year old woman, D2
• Presented with confusion and bradycardia of 20
  bpm
• Party 30 hours earlier, drank large quantities of
  alcohol, abdominal pain and vomiting
• Failed to wake up boyfriend called paramedics
• Boyfriend denies drugs or medications other than
  occasional NSAIDs and SSRIs

3
Physical

• Does not look neglected, no needle pricks, no
  signs of trauma
• Spontaneous slow deep breathing
• Disorientation, partially responsive
• No fever
• Pulse 20, strong carotid, femoral and radial
  pulse
• Pupils dilated, partially responsive to light,
  circular nystagmus

4
Monitor
What now?
5
Evaluation

• Monitor wide QRS, peaked T waves
• Glucose per stick 40 mg/dl
• 2 IV lines and a urinary catheter are placed
• Blood for chemistry, blood gasses and PT
• Urine 50cc clear and concentrated
• Urine sent for urinalysis and toxic screen
• Vaginal bleeding - mild

6
Management

• I.V Glucose 50 40cc push
• Inh. Ventolin
• I.V Glucose 5 10 units of reg. Insulin
• I.V Adrenalin2 and Atropin2 push
• I.V Bicarbonate 2 ampoules push
• I.V Calcium-Gluconate 10cc push
• Patient stabilizes at 140bpm, good BP, recurrent
  hypoglycemia

7
Monitor Recordings
After 1mg Adrenalin
After Ca, Glu, Insulin, HCO3 Adrenalin
8
Test Results (pre-treatment)

• pH 6.94, PCO2 76.2, PO2 76.8, BIC 10.6, BE -18.9
• Na 138, K 9.35, Cl 98, Glu 17, Cr 4.06
• Uric acid 18.2, Ca 6.1, Phosphorus 19.7
• CPK 5489
• GOT 9790, Alk Phos 120, LDH 59, Bil 0.7
• HGB 13.8, WBC 14.9, Neut 80.2, Plt 209
• INR 2.9, Fibrinogen 60

9
Management cont.

• Intubation and mechanical ventilation
• More Calcium and Na-Bicarbonate I.V push
• Nephrologist called in for emergency hemodialysis
• Still not hemodynamically stable
• Cardiac arrest CPR, atropin multiple
  noradrenalin push
• Patient stabilizes

10
Patient Lab After Stabilization

• pH 7.15, PCO2 47.6, PO2 248, HCO2 14.8, BE -12.5
• Na 135.9, K 7.12, Glu 305

11
Management cont.

• Double lumen femoral catheter
• Transfer to ICU
• Emergency hemodialysis
• Hemodynamically stable

12
Short Summary Multi Organ Failure

• Severe high-anion-gap metabolic acidosis and
  respiratory acidosis
• ARF m/p d/t Rhabdomyolysis
• Severe hyperkalemia and acidosis d/t ARF
• Cardiac toxicity and asystole d/t hyperkalemia
• Severe liver damage with disturbed coagulation
  factors
• DIC
• Resistant hypoglycemia

13
Management cont.

• Factor V 4
• I.V. N-Acetylcystein (Parvolex) is administered
• Urine toxic screen evidence of opiates and
  phencyclidine (PCP)
• Blood levels of alcohol are undetectable

14
Aftermath

• Patient transferred to another hospital
• I.V. Pravolex, Rocephine, Fluconazole
• Noradrenaline and NaHCO3 in increasing doses
• HCV positive

15
Aftermath cont.

• On waiting list for liver transplantation
• Daily hemofiltration and treatment with MARS
  (Molecular Adsorbents Recirculation System)
• A day later compartment syndrome in left arm
  fasciotomy
• Treatment with FFP and blood
• Brain CT excludes intracranial hemorrhage

16
Aftermath cont.

• On the 3rd day the patient dies of liver failure
• Family refuses PM

17
Phencyclidine (PCP Angel Dust)

• General anesthetic in veterinary medicine similar
  to Ketamin
• Voluntarily withdrawn from market in 1978
• Not used in humans d/t potent psychomimetic
  properties
• Not widely used d/t bad trips
• Sometimes mixed with marijuana or cocaine

18
PCP Clinical Effects

• Eyes
• Horizontal, vertical and rotatory nystagmus
• Blank stare
• Cardiovascular
• Hypertension up to hypertensive crisis
• Neurologic
• Paranoid behavior, combativeness, seizures
• Respiratory depression with eyes wide open
• Toxic encephalopathy 36.9

19
PCP Clinical Effects cont.

• Endocrine
• Hypoglycemia 22
• Psychiatric
• Severe psychosis
• Paranoid and self destructive behavior

20
PCP Rare Complications

• Rhabdomyolysis 2.2
• Acute renal failure
• Aspiration pneumonia
• Pulmonary emboli
• Intracranial hemorrhage
• DIC
• Liver necrosis

21
False positive urine screen test

• Ketamine use
• Massive venlafaxine overdose
• Dextromethorphan and diphenhydramine

22
PCP Morbidity Mortality Data AAPCC 1995-2002
a
b
c
23
In Israel

• No documented cases as of now
• Primarily mixed with over-diluted opioids or
  cannaboids for enhancement
• Sometimes in private stashes

24
Conclusion

• Can the patients situation be explained by PCP
  intoxication?
• Yes
• Is this really what happened?
• We will never know

25
Thank you