An enigma at the ER

Prabhakar Reddy*

Head of Emergency Medicine, Kauvery Electronic City, Bengaluru, India

Clinical Presentation

On a busy Monday morning at the ER, we received 30 years aged female, with a history of acute onset of breathing difficulty for a few hours, following which she became unresponsive in a few minutes. She was brought in a taxi.

The patient had severe chest discomfort, along with bilateral upper abdominal pain, since the previous afternoon.

The last meal was the previous night. No known medical allergies.

She had undergone a second LSCS 3 months earlier and delivered a healthy female child who was breastfeeding. The first child was a 4 years-aged male. In between the two deliveries she had two miscarriages.

No history is suggestive of Pregnancy Induced Hypertension (PIH) or any other pregnancy complicated illness, drug overdose, or consumption of toxic substances.

The family did not reveal any other medical history, nor did they have any medical records or treatment summary from the past.

LMP-Day 1. Urine Pregnancy Test (UPT) – Negative.

Clinical Findings

On arrival, the patient was gasping and cyanosed, SpO2: 26% on room air.

On examination:

HR: 26/m, RR >25, BP: 180/140, GCS: E3V1M1, Pupils-Bilaterally sluggish reacting @ 2 mm, GRBS: 208 mg/dl.

On palpation: no tracheal deviation, prominent use of accessory muscles, and increased work of breathing. Unable to do percussion as the patient had engorged breasts.

On auscultation: pronounced rhonchi in both lung fields.

Evolution

The patient was intubated due to respiratory distress and impending arrest, with 7 size ET tube fixed at 20 cm after 5-point auscultation.

Initial ventilator settings: Rate: 26, volume 400 ml, PEEP: 8, I/E ratio: 1:4, FiO2:100%.

Initial ABG – type II Respiratory Acidosis.

pH: 6.8, pCO₂: 125, pO₂: 51, Lac: 1.9.

ECG: Infero-lateral ST depression, ST elevation in aVR. (Fig. 1).

Fig. 1. ECG pre-ICD

Bedside echo screening – reduced EF @45%, anterior wall hypokinesia and lung sliding +

Bedside X-ray called for in transit.

At this point, the patient is intubated, with premedication propofol and rocuronium. Started with Inj. Atropine (HR: 20), fluid boluses, nebulisation, iv magnesium sulphate and steroids.

Post intubation: SpO₂: 86%, Bilateral rhonchi. HR: 21, BP: 50/90 mmhg.

Planned for CT: Brain and CXR.

The consultant Cardiologist gave loading doses of antiplatelets and took the patient for Coronary Angiography (CAG) which indicated normal coronaries. Post Angio, the patient becomes hypotensive in transit; started on noradrenaline

Post-procedure patient shifted to CT room; CT- brain – within normal limits.

CT- Chest – Bilateral tension pneumothorax, bilateral collapse consolidation of lower lobes, partially aerated upper lobes with segmental collapse- consolidation (Fig. 2)

Fig. 2. CT of day 1

Patient shifted back to ER, bilateral Intercostal Drainage (ICD) inserted; post- ICD insertion, bedside X-ray done to check position.

Post-ICD ECG- Normal (Fig. 3)

Fig. 3. ECG post ICD

Patient’s hemodynamics improved; shifted to MICU for further management.

Before shifting: Patient vitals: HR – 92, SpO₂ – 100% on ventilator, BP – 110/70 with 3 mL nor-adrenaline infusion (tapering down), GCS-E4 Vt M6.

ABG- pH-7.2 pCO₂ – 47.

Blood reports: Trop I – 680 ng/l, Nt pro bnp – 3404 pg/ml, D Dimer – 779.73 ng/ml, Hb – 11.2, TLC – 12,760, N – 59.5% L – 35.4%.

RFT-WNL, LFT-WNL

Further evolution

Day 1: of admission: patient continued to be on a ventilator, started on antibiotics and VTE prophylaxis along with anticoagulants

Day 2: of admission: patient extubated @ 6pm

Day 3: CT Chest- Bilateral posterior basal and suprasegmental consolidation, bilateral intercostal tubes in situ (Fig. 4)

Fig. 4. CT of day 3

Day 4: patient discharged home in stable condition with oral antibiotics.

Follow up

Post-extubation, when we had a chat with the patient, she gave a history of fever and cough three days prior to acute sickness, for which she consulted a local clinic. She improved after medications.

On the day of the presentation, she went to a nearby clinic with chest pain, where they have started her on? IV medication following which she became breathless and felt that she was about to die.

Conclusion

The patient had presumably lower respiratory symptoms, with wheeze; later developed gastritis or wheezing for which she was given? IV medication, following which she developed an allergic reaction or severe bronchospasm that led to type 2 Respiratory failure. She developed barotrauma-induced pneumothorax. Bilateral ICD inserted, started on antibiotics, improved clinically, and discharged home.

Dr. Prabhakar Reddy

Head of Emergency Medicine

An enigma at the ER