Unresponsive Diabetic

[triemal04]

I found this on another site and figured it was worth passing on. (if anyone else has seen it please keep your trap's shut! ) I don't have any extra info beyond what is here, sorry, but with what's here you should be able to come up with a decent diagnosis. And if nothing else it's a good learning point and great review for some. I'll post the outcome in a couple of days.

(if you post treatments, be specific; don't list just the procedure but what meds (if any) were used and the dosage you used. same goes for cause; the more details you can provide the better this'll be for everyone)

EMS crews were dispatched to the home of an 81-year-old male. His sister found him lying on a bed. When he didn't respond to her, 9-1-1 was contacted. He had complained to friends that he hadn't been feeling well for three to four days, and neighbors who had periodically checked on him thought he was sleeping for more than 24 hours.

Upon arrival, the crew noted the patient to be unconscious with snoring respirations. The past medical history included non-insulin dependant diabetes and hypertension. Medications included metformin and glipizide, as well as an unspecified beta blocker for hypertension. According to the sister and friends, the patient hadn't expressed any suicidal ideations and didn't possess a Do Not Resuscitate (DNR) order of any type.

Physical assessment of the man demonstrated obvious coma with persistent trismus (stiff jaw). Copious amounts of emesis were present in the mouth and on the face. The initial vital signs included a heart rate of 89 beats per minute, blood pressure 150/82 mmHg and respirations of 24 per minute. The cardiac monitor demonstrated a sinus rhythm at a rate consistent with the pulse. Room air oxygen saturation was 82%. No end-tidal carbon dioxide (ETCO2) value was obtained prior to intubation attempts. The Glasgow Coma Scale (GCS) was estimated to be 3. The remainder of the physical examination was reported to be unremarkable.

Oxygen at 15 liters via non-rebreather mask was placed with improvement in oxygen saturation to 92%. Blood sugar determination revealed a value of 20 milligrams per deciliter (mg/dL). After an IV line was successfully placed, the patient received 25 grams of dextrose. The follow-up blood sugar was 93 mg/dL. No improvement in mentation was noted.

Given the patient's continued coma and apparent inability to protect the airway, consideration was given to Rapid Sequence Intubation (RSI) by EMS personnel. The pre-intubation airway assessment suggested the possibility of a difficult airway. The patient was noted to be obese. The neck seemed short and there was limited mouth opening to work with. The crew discussed these factors and, after some debate, elected to proceed. No 12-lead ECG was obtained prior to beginning the RSI.

The estimated weight was 110 kg. The patient was given appropriate dosages of etomidate and succinylcholine. Adequate paralysis was achieved. One attempt to intubate was made but was unsuccessful. During this time the head was repositioned and a bougie was utilized, but neither helped.

The patient was ventilated with a bag-valve-mask (BVM) and was suctioned. It was decided to place a Combitube. But this device was not able to be inserted far enough into the mouth and was ultimately abandoned.

Vital signs at this point were documented to consist of a blood pressure of 190/112 mmHg, respirations 12 per minute assisted, and a pulse rate of 48 beats per minute. Sinus bradycardia was seen on the monitor. No pulse oximetry value was recorded at this time. An oral airway was inserted, and the patient was continued on the BVM.

The patient rapidly became more bradycardic and then developed asystole on the monitor. No pulses could be palpated.

CPR was initiated.

What do you think might be causes for the patient's coma?

How would you have treated this patient?

What do you think might have caused this patient to go into cardiac arrest?

[Just Plain Ruff]

so they RSI'd a guy without a backup airway device handy? hmmmmm OOPS

[akroeze]

They had a combitube as a backup airway device.

[vs-eh?]

Pupils?

Temp?

Lung sounds?

It could be a lot of things but I'll go with CVA +/- aspiration pneumonia.

The post laryngoscopy/intubation attempt vitals could be explained by iatrogenic complications. Further increasing ICP (again secondary to airway maneuvers) could have caused the progression to asystole.

[Just Plain Ruff]

oops I missed that

[Scaramedic]

A couple of things. When administering RSI our protocols require hypoxic (82%) and patients with a heart rate of less than 100 (89 bpm) patients be given .5mg Atropine. Also 1.0mg/kg of Lidocaine should be administered to lessen an increase in ICP.

Also if the pt is R/O increased ICP, Sux should be given in 2 parts, 10% wait a minute and give the other 90%. This is supposed to decrease fasciculations which can increase ICP.

My theory is increased ICP resulted in Cushing's Triad. Did you notice the HR drop from 89 to 48 and the BP went from 150/82 to 190/112? Patient was paralyzed so you wouldn't be able to see a change in the respiratory rate.

[triemal04]

Good so far. For those looking at this as a CVA, dose the initial assessment completely add up for that? Any oddball things that were found? What would cause them? If this is due to a CVA, what could have caused it? Ischemic? Hemorrhagic? Hell, could something other than a stroke cause this type of presentation?

And again, I have no further info than what has been posted so far (sorry). Other than the final diagnosis anyway.

[Scaramedic]

You mean the stiff jaw and excessive sleep? How long had it been since sis had seen him? How long had he been hypoglycemic? I know you don't know the answers, but he could be in renal failure. The renal failure could lead to Hyperkalemia which could cause the jaw stiffness since it really screws with muscles. But I still think the contributing factor was increased ICP secondary to a half assed attempt at intubation via RSI. The unresponsiveness could be secondary to hypoxia from the HK. But finally the increased ICP lead to a downward spiral that lead to arrest.

[sassy_emt]

what about the possibility of a sever diabetic coma??? remember the initial blood sugar level was 20......way too low. If this started out as a diabetic come wouldn't the heart have struggled to maintain an even blood flow to increase the body's own insulin out put??? If all the right factors are there could it not cause the heart to stutter and when the crew showed up ......the sugar that was re-introduced into the system then caused an overload thus the heart went into first bradycardic then asystole rhythm?????

How long had he been without his meds???? At least 24 hours correct???? I am a type two diabetic and I know that if I miss more than one of my doses I begin to feel a tightness in my chest and a noticeable change in my heart rate.......the other signs I have include extreme exhaustion........

just a thought but maybe because of his history of hypertension and then (for lack of a better set of words) the shock of having even that small amount of insulin introduced into his system that maybe what caused the CVA???

[akroeze]

Don't take this the wrong way, but in general one '?' will suffice