Download - Case presentation
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CASE PRESENTATION
AL YAQDHAN AL ATBI, MDEM RESIDENT
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Objectives• Approach
Secondary survey SAMPLE history Primary survey
Disposition Investigations Differential diagnosis
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30 year- old, un employed, healthy gentleman brought by his brother, found to have:
• Bleeding from the nose• Blisters on Right hand • After he wakes up from 14hrs continuous sleep.
Presenting complain
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Approach
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Primary surveyIn deep sleep, snoringAble to wake him upConscious and oriented
Airway: intactBreathing: normalCirculation: HR:71, BP:140/92Disability: CGS:14/15 , BS 6.3, pupil equal and reactive Exposure: blisters in right hand, bruises in the right side
of the body, no rash, no injection marks
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Primary surveyVitals:
• BS: 6.3, T: 37.3C, RR: 19, SPO2:99%ECG: SR, no arrhythmias, normal interval, no ischemic
changes
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History
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History
Bleeding from the noseBlisters on right hand After he wakes up from 14hrs continuous sleep on his
right sideNot sleeping well previous few days
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History
-Not known to have any allergy-Denied any medical illness and not taking any
medications - He was outdoor, returned home ,entered his room and
slept for 14hrs- Wakes up, fully conscious, but drowsy- No feverMORE??
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History No neurological symptomsNo seizure, slurred speech or motor weaknessNo bowel or urinary symptom
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Secondary survey
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Secondary surveyHead: no signs of trauma or external bleedChest: NCVS: NP/A: N
Right UL: • Swelling of the hand up to forearm with blisters, no tenderness, pulses
intact, normal power, tone and reflexes
Right LL (thigh):• swelling, tender hematoma (PROPER EXPOSURE)
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Differential diagnosis
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Differential diagnosis• Toxin / drugs
• Alcohol• Drugs intoxications
• Hypoxia• Cardiac• Respiratory
• Metabolic• Hyper/hypoglycemia• Electrolytes• Thiamine vit B12 deficiency
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Differential diagnosis• Systemic
• Renal, liver failure• Thyroid disorder
• Neurological• Head injury• Epilepsy (post ictal)• Stroke/ TIA• Cerebral mets
• Infection• Septicemia• Meningitis/ encephalitis• UTI• RTI
• Blisters:• Burn• Allergy• ?bite• Infection
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Investigations• VBG
• Urine dipstick - Urine Tox
• CBC - UE
• Myoglobin - CK
• CRP - Bone profile
• LFT - Coagulation
• Cultures
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VBG
VBG:
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Urine dipstick ++ bloodUrine : concentrated, red in color
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Investigations• CBC:
• Hb 15.2• WBC 13.0 ; ANC 10.3• Plt 292
• U&E:• Na 135; K 4.0; CO 25; • Ca 2.5; PO 4 1.6• Ur 4.5; Cr 71
• LFT : WNL
• CK: 7230
• Myoglobin: 940
• CRP : 116
• Coagulation: WNL
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Myoglobin Vs. CK
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Radiology
•CT head•Hand, forearm XR
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CT head: normal
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XR rt hand and forearm: no soft tissue air
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Summary 30 year- old, un employed, healthy gentleman brought
by his brother, found to have bleeding from the nose, blisters on rt hand, after he wakes up from 14hrs continuous sleep
Primary survey: NSecondary survey: blisters, bruises, hematoma (thigh)Wbc:13 ,neut:10.5 , CRP:116CK: 7230, MYOGLOBIN:940
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RhabdomyolysisRhabdomyolysis
• Ischemia:• prolonged immobilisation : Alcohol and drugs
• Drugs and toxins • hyperthermia toxidromes: sympathomimetics (e.g. cocaine, amphetamines), malignant
hyperthermia, serotonin syndrome, neuroleptic malignant syndrome, salicylism• Illicit Drugs: amphetamines, opiates, ecstasy, and LSD
• Trauma:• Snake bite, crush injury, burns, electrocution
• Excessive physical activity• prolonged seizures, prolonged exertion
• Infection
• Metabolic disorders:• thyroid storm, phaeochromocytoma, myxoedema, DKA, HHS
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Disposition
•Medical vs. surgical on call
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Surgery
• Blisters drained• Watery• Abx advised
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Medicine Admitted HydrationI/O chartRepeat CK, serum myoglobin, daily UE and bone
profileIV augmentinWatch for sign of compartment syndromePatient signed LAMA
Cultures: -ve after 5 days
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IS IT THE END?Drug abuser14 tabs of LSD, 40cc morphineUsing anticubital and inguinal vesselsLast time right thigh and right arm
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MANAGEMENT• Resuscitation: ABCD
• Specific therapies• IV fluid therapy
• Aiming for hypervolemia to haemodilute blood
• Forced alkaline diuresis (e.g. furosemide, mannitol)• increases tubular flow and increases pH to prevent precipitation of
myoglobin in tubules
• Urine alkalization?• No proven benefits
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What are the possible complications of Rhabdomyolysis?
•Early:• Compartment ayndrome• Electrolyte Disorders and
Acidosis: • High H+, K+, PO4-• low Ca+2 early then high
• Hypovolemia• Hepatic Dysfunction?
unknown
• LATE:• Myoglobin-Induced Acute
Kidney Injury• Disseminated Intravascular
Coagulation
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• Food and durgs that can cause Red urine? Positive depstick?• beets, blackberries, rhubarb, food coloring, fava beans, phenolphthalein,
rifampin, doxorubicin, deferoxamine, chloroquine, ibuprofen, and methyldopa
• Can we utilize CK or Myoglobin as prognostic tests for development of AKI?
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• What are the indication for emergent dialysis?• Severe Metabolic acidosis• Life-threatening hyperkalemia and other electrolyte disturbances despite
medical management, • Manifestations of uremia, • Anuria or oliguria despite aggressive volume expansion with
complications related to fluid overload
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HOME MESSAGES
Secondary survey SAMPLE history Primary survey
Disposition Investigations Differential diagnosis
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Thank you