Case presentation
- 2. Objectives • Approach Secondary surveySAMPLE historyPrimary survey DispositionInvestigationsDifferential diagnosis
- 3. 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
- 4. Approach
- 5. Primary survey In deep sleep, snoring Able to wake him up Conscious and oriented Airway: intact Breathing: normal Circulation: HR:71, BP:140/92 Disability: 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
- 6. Primary survey Vitals: • BS: 6.3, T: 37.3C, RR: 19, SPO2:99% ECG: SR, no arrhythmias, normal interval, no ischemic changes
- 7. History
- 8. History Bleeding from the nose Blisters on right hand After he wakes up from 14hrs continuous sleep on his right side Not sleeping well previous few days
- 9. 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 fever MORE??
- 10. History No neurological symptoms No seizure, slurred speech or motor weakness No bowel or urinary symptom
- 11. Secondary survey
- 12. Secondary survey Head: no signs of trauma or external bleed Chest: N CVS: N P/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)
- 15. Differential diagnosis • Toxin / drugs • Alcohol • Drugs intoxications • Hypoxia • Cardiac • Respiratory • Metabolic • Hyper/hypoglycemia • Electrolytes • Thiamine vit B12 deficiency
- 16. 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
- 17. Investigations • VBG • Urine dipstick - Urine Tox • CBC - UE • Myoglobin - CK • CRP - Bone profile • LFT - Coagulation • Cultures
- 18. VBG VBG:
- 19. Urine dipstick ++ blood Urine : concentrated, red in color
- 20. 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
- 21. Myoglobin Vs. CK
- 23. CT head: normal
- 24. XR rt hand and forearm: no soft tissue air
- 25. 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: N Secondary survey: blisters, bruises, hematoma (thigh) Wbc:13 ,neut:10.5 , CRP:116 CK: 7230, MYOGLOBIN:940
- 26. Rhabdomyolysis Rhabdomyolysis • 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
- 27. Disposition •Medical vs. surgical on call
- 28. Surgery • Blisters drained • Watery • Abx advised
- 29. Medicine Admitted Hydration I/O chart Repeat CK, serum myoglobin, daily UE and bone profile IV augmentin Watch for sign of compartment syndrome Patient signed LAMA Cultures: -ve after 5 days
- 30. IS IT THE END? Drug abuser 14 tabs of LSD, 40cc morphine Using anticubital and inguinal vessels Last time right thigh and right arm
- 31. 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
- 32. 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
- 33. • 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?
- 34. • 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
- 35. HOME MESSAGES Secondary surveySAMPLE historyPrimary survey DispositionInvestigationsDifferential diagnosis
- 36. Thank you
Editor's Notes
- #18: TSH
- #21: Which one is relaible test: Myoglobuline vs CK myoglobin has a serum half-life of only 1 to 3 hours and is completely absent after 24 hours. This short window makes serum myoglobin an unreliable diagnostic tes
- #33: Hyperkalemia (early) Hypocalcemia (secondary to increased phosphate) Myoglobin release leading to acute renal failure (late) DIC due to release of thromboplastins (rare) Shock, due to “third space” losses from extravasation of fluid from extensively damaged muscle (if severe)