Case presentation nabhan

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Case presentation nabhan

  1. 1. Nabhan Al Mandhari R2 ( OMSB)
  2. 2. <ul><li>Case Scenario </li></ul><ul><li>Differential Diagnosis </li></ul><ul><li>Management </li></ul><ul><li>Pitfalls </li></ul><ul><li>Topic Discussion </li></ul><ul><li>Take Home Message </li></ul>
  3. 3. <ul><li>40 Y Indian Male </li></ul><ul><li>Brought by the EMS team to the A/E on 24/01/2010 at around 1644 hrs with h/o abnormal behavior </li></ul><ul><li>Prisoner in a police station for 2 days; detained for physical assault case </li></ul>
  4. 4. <ul><li>Language Barrier </li></ul><ul><li>No friends, relatives of the pt were around </li></ul><ul><li>A Police man gave h/o ? Seizures </li></ul><ul><li>Other history obtained from the pt; unreliable </li></ul><ul><li>due to incomprehensive speech </li></ul><ul><li>No h/o fever </li></ul>
  5. 5. <ul><li>No h/o preceding URTI </li></ul><ul><li>? H/O Trauma </li></ul><ul><li>? H/O Alcohol or Drug abuse </li></ul><ul><li>H/O Psychiatric problem is unknown </li></ul><ul><li>Unknown Past Medical History </li></ul>
  6. 6. <ul><li>Airway ( Speaking, Patent) </li></ul><ul><li>Breathing ( spontaneous, RR 28/min, SPO2 100 % in room air) </li></ul><ul><li>Circulation ( BP 130/80 mmhg, PR 130/min, regular) </li></ul><ul><li>Dextrose ( reflow 7.2 mmol/l); mod. dehydrated </li></ul><ul><li>Temperature; 37 </li></ul><ul><li>Exposure </li></ul>
  7. 7. <ul><li>Not alcohol smelling </li></ul><ul><li>No drugs injection sites </li></ul><ul><li>Head and Neck; no signs of meningism </li></ul><ul><li>Pupils; B/L dilated, ? Regular, ? Size </li></ul><ul><li>Hands Tremor + </li></ul>
  8. 8. <ul><li>Face; lacerated wound over nose with SD </li></ul><ul><li>Chest; NAD </li></ul><ul><li>CVS; NAD </li></ul><ul><li>P/A; soft </li></ul>
  9. 9. <ul><li>Upper and Lower Limbs; NAD </li></ul><ul><li>CNS; no neurological deficit </li></ul>
  10. 10. <ul><li>Post Ictal Prolonged confusion/ Delirium </li></ul><ul><li>Alcohol Withdrawal Vs Delirium tremens </li></ul><ul><li>Neurological; encephalitis/ meningitis </li></ul><ul><li>Other Drug over dose or toxins </li></ul><ul><li>Psychiatric disorders </li></ul><ul><li>Metabolic Disorders </li></ul>
  11. 12. <ul><li>ABG </li></ul><ul><li>PH; 7.19 </li></ul><ul><li>HCO; 12 </li></ul><ul><li>CO2; 25 </li></ul><ul><li>ECG </li></ul><ul><li>- Sinus Tachycardia 140/min; Right. Axis deviation </li></ul><ul><li>- Prominent R wave in AVR lead; QT normal </li></ul>
  12. 13. <ul><li>FBC </li></ul><ul><li>Hb 12.7, WBC 9.7, Neut. 7.1 </li></ul><ul><li>Glucose = 9.0 mmol/l </li></ul><ul><li>Coagulation Profile; WNL </li></ul><ul><li>D Dimer; 1.2 (0.19-0.67) </li></ul><ul><li>Trop; 0.02 </li></ul><ul><li>Lactate ; 8.9 (0.5-2.2) </li></ul>
  13. 14. <ul><li>LFT </li></ul><ul><li>ALT; 51 , AST 60 , ALK P 38 </li></ul><ul><li>Bone </li></ul><ul><li>phosphate; 1.65 </li></ul><ul><li>UE </li></ul><ul><li>anion gap; 11 </li></ul><ul><li>Serum Osmolaility; 297 </li></ul>
  14. 15. <ul><li>Drugs Assays </li></ul><ul><li>TAD, salicylic acid, paracetamol; Negative </li></ul><ul><li>GGT ; 377 </li></ul><ul><li>TSH; 6.22 </li></ul><ul><li>Coagulation; Normal </li></ul>
  15. 16. <ul><li>Chest x-ray </li></ul><ul><li>Normal </li></ul><ul><li>CT brain </li></ul><ul><li>Normal </li></ul><ul><li>CT Neck, Face </li></ul><ul><li>fractured C6, fractured nasal bones </li></ul>
  16. 17. <ul><li>On arrival to the A/E; </li></ul><ul><li>- started on IVF </li></ul><ul><li>- I/V diazepam 5 mg stat given </li></ul><ul><li>- lacerated wound got sutured </li></ul><ul><li>Later ; pt got agitated and violent </li></ul><ul><li>Physical restraint applied </li></ul><ul><li>Another 5 mg I/V diazepam given; no response </li></ul>
  17. 18. <ul><li>Diazepam 5 mg more was given; no response </li></ul><ul><li>I/V lorazepam4 mg given, no response </li></ul><ul><li>I/V haloperidol total of 10 mg in divided doses given; no response </li></ul><ul><li>Decision of Intubation was made; transferred to do CTs </li></ul>
  18. 19. <ul><li>Medical On call was informed </li></ul><ul><li>The case was discussed with Neurology consultant who advised to start the pt on </li></ul><ul><li>empirical antibiotic Rx; ceftriaxone and aciclovir </li></ul><ul><li>The pt was admitted to ICU ; Midozlam infusion was continued </li></ul>
  19. 20. <ul><li>On the second day of admission, pt was extubated and moved out of the ICU </li></ul><ul><li>The patient was continued on the antibiotic course </li></ul><ul><li>On the fourth day of admission, pt improved and discharged </li></ul>
  20. 21. <ul><li>History </li></ul><ul><li>Examination </li></ul><ul><li>Investigations </li></ul><ul><li>Management </li></ul><ul><li>- Choice of Benzodiazepines vs Haloperidol </li></ul><ul><li>- Decision of intubation </li></ul>
  21. 22. <ul><li>Delirium Tremens </li></ul><ul><li>Delirium tremens is a severe form of alcohol withdrawal that involves sudden and severe mental or neurological changes. </li></ul>
  22. 23. <ul><li>Precipitating Factors </li></ul><ul><li>Delirium tremens can occur after a period of heavy alcohol drinking, especially when the person does not eat enough food. </li></ul><ul><li>It may also be triggered by head injury, infection, or illness in people with a history of heavy alcohol use. </li></ul><ul><li>It is most common in people who have a history of alcohol withdrawal . </li></ul>
  23. 24. <ul><li>It is especially common in those who drink the equivalent of 4 - 5 pints of wine or 7 - 8 pints of beer (or 1 pint of &quot;hard&quot; alcohol) every day for several months. </li></ul>
  24. 25. <ul><li>Symptoms most commonly occur within 72 hours after the last drink, occur up to 7 - 10 days . Rapid progression </li></ul><ul><li>Body tremor </li></ul><ul><li>Mental status changes </li></ul><ul><ul><li>Agitation, irritability </li></ul></ul><ul><ul><li>Confusion , disorientation, hallucinations </li></ul></ul><ul><ul><li>Decreased attention span </li></ul></ul><ul><ul><li>Decreased mental status </li></ul></ul><ul><ul><li>Delirium (severe, acute loss of mental functions) </li></ul></ul><ul><ul><li>Excitement </li></ul></ul>
  25. 26. <ul><li>Seizures </li></ul><ul><ul><li>Most common in first 24 - 48 hours after last drink </li></ul></ul><ul><ul><li>Most common in people with previous complications from alcohol withdrawal </li></ul></ul><ul><ul><li>Usually generalized tonic-clonic seizures </li></ul></ul><ul><li>Symptoms of alcohol withdrawal </li></ul>
  26. 27. <ul><li>Clinical Signs include : </li></ul><ul><li>Heavy sweating </li></ul><ul><li>Increased startle reflex </li></ul><ul><li>Irregular heartbeat </li></ul><ul><li>Problems with eye muscle movement </li></ul><ul><li>Rapid heart rate </li></ul><ul><li>Rapid muscle tremors </li></ul>
  27. 29. <ul><li>Delirium can be difficult to Diagnose </li></ul><ul><li>Always follow the updated algorithm for managing delirium; including the right </li></ul><ul><li>medications </li></ul><ul><li>Keep the mind open for all possible </li></ul><ul><li>differential diagnoses </li></ul>
  28. 30. <ul><li>THANK YOU </li></ul>

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