CASE PRESENTATION

AL YAQDHAN AL ATBI, MDEM RESIDENT

Objectives• Approach

Secondary survey SAMPLE history Primary survey

Disposition Investigations Differential diagnosis

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

Approach

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

Primary surveyVitals:

• BS: 6.3, T: 37.3C, RR: 19, SPO2:99%ECG: SR, no arrhythmias, normal interval, no ischemic

changes

History

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

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??

History No neurological symptomsNo seizure, slurred speech or motor weaknessNo bowel or urinary symptom

Secondary survey

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)

Differential diagnosis

Differential diagnosis• Toxin / drugs

• Alcohol• Drugs intoxications

• Hypoxia• Cardiac• Respiratory

• Metabolic• Hyper/hypoglycemia• Electrolytes• Thiamine vit B12 deficiency

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

Investigations• VBG

• Urine dipstick - Urine Tox

• CBC - UE

• Myoglobin - CK

• CRP - Bone profile

• LFT - Coagulation

• Cultures

VBG

VBG:

Urine dipstick ++ bloodUrine : concentrated, red in color

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

Myoglobin Vs. CK

Radiology

•CT head•Hand, forearm XR

CT head: normal

XR rt hand and forearm: no soft tissue air

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

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

Disposition

•Medical vs. surgical on call

Surgery

• Blisters drained• Watery• Abx advised

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

IS IT THE END?Drug abuser14 tabs of LSD, 40cc morphineUsing anticubital and inguinal vesselsLast time right thigh and right arm

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

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

• 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?

• 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

HOME MESSAGES

Secondary survey SAMPLE history Primary survey

Disposition Investigations Differential diagnosis

Thank you