slide1 l.
Skip this Video
Download Presentation

Loading in 2 Seconds...

play fullscreen
1 / 31

Case - PowerPoint PPT Presentation

  • Uploaded on

The Case of the Comatose Prisoner James Roberts, MD The Medical College of Pennsylvania/ Hahnemann University Drexel University School of Medicine Mercy Catholic Medical Center Philadelphia, Pennsylvania. Case.

I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
Download Presentation

PowerPoint Slideshow about 'Case' - dinos

Download Now An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.

- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript

The Case of the Comatose PrisonerJames Roberts, MDThe Medical College of Pennsylvania/ Hahnemann UniversityDrexel University School of MedicineMercy Catholic Medical CenterPhiladelphia, Pennsylvania


A 28 y/o suspected cocaine dealer was involved in a police chase that ended with the suspect’s car ramming a pole. The extrication took 30 minutes due to significant vehicle damage. The man was awake at the scene and was taken to a hospital for evaluation.


At the hospital he had a pulse of 110/min but otherwise normal vital signs and no complaints. Other than a facial abrasion and a small scalp hematoma, the physical examination was normal. In the ED he was agitated and urinated on the floor of the examining room (“I couldn’t hold it”).


No laboratory tests or X rays were performed. He was observed for 2 hours, “remained stable,” and was discharged into police custody at 9pm with a diagnosis of “minor soft tissue injuries.” At the jail he was placed in a cell with 3 other prisoners. At 8am he was unarousable and was returned to the hospital.

  • Upon arrival:
    • Temp: 97.4 R
    • BP: 124/60
    • Pulse: 78/min
    • Resp: 16/min
    • POx 99% on RA
  • Monitor: sinus rhythm
  • He was incontinent of urine
  • Differential diagnosis at this juncture?
differential diagnosis
Differential Diagnosis
  • Head trauma
  • CVA
  • Hypoglycemia/Hyperglycemia
  • Drug Overdose (body packer, additional ingestion in jail)
  • Post Ictal
  • Malingering
  • Wernicke’s encephalopathy
  • Sepsis, CNS infection, hepatic coma, hypernatremia
further history
Further History:
  • No old records available
  • No answer at home phone
  • Police clueless
  • Previous ED visit confirmed
  • Next step: further evaluation/treatment
further examination
Further Examination
  • Facial injury/scalp hematoma
  • No Battle’s sign/ no hemotympanum
  • Abdomen/chest/extremities demonstrated no abnormality
  • No other signs of trauma
  • No sign of IVDA
  • Body habitus of chronic cocaine use
  • What are the key components of the neurologic examination?
neurologic examination
Neurologic Examination
  • No response to deep pain/no posturing
  • Pupils: 2-3 mm and sluggish
  • Dysconjugate gaze present
  • No gag reflex
  • Flaccid extremities/no reflexes elicited
  • Negative Babinski sign, no clonus, no fasciculations
  • Outline the Basic Initial Treatment
initial basic treatment
Initial Basic Treatment
  • Safety net: IV, Oxygen, monitor, pulse ox, dynamap
  • Dextrostick: glucose 110
  • Foley catheter: clear urine
  • ABG: pH 7.43; PO2: 145 torr on 2 liters; PCO2 42 torr; HCO3: 23
  • Intubated for airway protection
  • Note: no response to above procedures, including intubation
  • What definitive tests are required at this juncture?
results of tests
Results of Tests:
  • Head CT scan: negative
  • CBC, Electrolytes, BUN/CR, PT/PTT : Normal Urine drug screen: (+) cocaine, (-) for barbs, benzo, opiates
  • Serum ethanol : 10 mg%
  • Lumbar puncture: normal opening pressure, neg chemistry/no cells
  • EKG: Normal
  • Liver function/ammonia: normal
  • What therapies are reasonable?
therapy probably warranted
Therapy: Probably Warranted
  • Small dose naloxone, charcoal, thiamine
  • Toxicology/poison center consultation
  • Neurology consultation
  • ICU admission
therapy probably not warranted
Therapy: Probably Not Warranted
  • Flumazenil
  • Gastric lavage/WBI
  • Antibiotics
  • MRI
hospital course
Hospital Course
  • Admitted to the ICU. Over the next 12-16 hours the patient slowly woke up, was extubated, and admitted to a 2-week crack cocaine binge, but denied other drugs. He related numerous such “crashes” when he ran out of money for cocaine.
  • DIAGNOSIS: The cocaine washout syndrome
pathophysiology of the cocaine washout syndrome
Pathophysiology of the Cocaine Washout Syndrome
  • Most likely a lack of CNSneurotransmitters
    • Norepinephrine
    • Serotonin
    • Dopamine
incidence clinical caveats
Incidence/Clinical Caveats
  • Incidence unknown, likely quite common
  • No data in the medical literature, but street knowledge
  • Occurs when drug use halted (medical illness, jail, insolvent)
  • Precipitated in ED with minimal benzodiazepine administration
  • Vital signs normal, usually not hypotensive, bradycardic
  • Signs of cocaine toxicity absent
  • Patients appear in a deep sleep state
  • Nonresponsiveness may be quite impressive
clinical approach
Clinical Approach
  • Diagnosis
    • Clinical diagnosis/rule out other conditions
    • No known value of catecholamine level
    • Urine positive for cocaine
    • May require extensive, expensive R/O workup
  • Treatment
    • Supportive only/protect airway and vital signs
    • Stimulants not warranted
  • Course
    • Patients wake up slowly over 12-24 hours