History of Present Illness
A 49-year-old male is brought by EMS as a medical code to resuscitation. He was apparently found by police lying in the street.
EMS reports an initial rapid glucose of 32 mg/dL, which improved to 56 mg/dL with 1 amp of D50 and to 79 mg/dL following a second amp of D50. EMS noted an empty medication bottle near the patient, and only the words “to treat hypertension” could be made out on the label. EMS believes that they recognize this patient and have transported him many times in the past with seizure disorder, noncompliant with meds. EMS did not witness any seizure activity during their assessment and transport.
Review of systems not able to be obtained at this time.
PMHx: Per EMS, seizure disorder and apparently hypertension.
Meds: The patient does not know their names.
ALLERGIES: NONE per patient.
SocHx: Denies illicit drug use, or alcohol use today.
Vital signs on arrival to resuscitation: BP 90s/60s, P 30s, Respiratory rate varies with alertness, but never over 16, T 34.0 rectally. Pulse oximetry unable to be obtained as the patient is very cold.
On arrival to resuscitation the patient appeared disheveled and was somnolent, fully immobilized, wearing multiple layers of clothing. He opened his eyes to verbal command, spontaneously moved all 4 extremities and had no obvious signs of trauma.
HEENT: There are no obvious lacerations, contusions or depressions palpated on his scalp. Pupils were 2 mm and minimally reactive. Mucous membranes were moist.
Neck: The C-collar was left in place due to the patient not being awake enough to ascertain spinal tenderness. The trachea is midline and there is no JVD.
Respiratory: There is a slight amount of wheezing in the left lung.
Cardiac: Heart sounds are distant.
Gastrointestinal: Abdomen is soft and scaphoid. There is no palpable tenderness or appreciable rebound tenderness. Pelvis is stable. Extremities: No abrasions, deformities, or edema. Peripheral pulses are not readily palpable, the extremities are cold to the touch.
Skin: Cool and dry to the touch without rashes or lesions.
Neurological: GCS is 13 (E3, V4, M6), motor 5+/5+ in all extremities.
Initially in resuscitation, he was placed on supplemental oxygen, a cardiac monitor showed a wide complex bradycardia with a rate in the 30s to 50s, two large bore IV’s were established. The patient was observed to have periods of apnea for which naloxone 2 mg. IV push was given, which had little clinical effect. His initial accucheck blood sugar was 171 mg/dL.
While the ER staff attempted to verify his identity to review CIS, a 12-lead EKG was obtained and is shown here.
A portable chest x-ray was also obtained and was interpreted as normal.
1. Based on this patient’s clinical presentation, which of the following would be the most likely medication/class of drug suspected as an overdose?
a. beta blocker
b. calcium channel blocker
2. While considering all clinical information in this case, which of the following clinical findings helps to identify the most likely overdosed medication?
a. core body temperature
b. electrocardiogram findings
c. mental status
d. peripheral pulses / capillary refill
e. serum glucose values
3. Once the patient is stabilized, what treatment should be initiated and was recommended by poison control?
a. activated charcoal
b. calcium infusion
c. continuous intravenous hydration
e. whole bowel irrigation
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