Morning Report

Jen Menon, PGY2 9/23/2013

Youre the intern coming on this morning and you get this patient signed out

HPI
CC: Syncope HPI: 16 year old previously healthy male presents to ED after 4-5 syncopal episodes at home. Patients mother states that he was on the phone with his girlfriend upstairs when she heard a thump. When she found him, he was on the ground, talking to his girlfriend, and had no recollection of the event. Mom left, he finished the conversation, then mom heard another thump and found him on the ground, laughing. Patient again had no recollection of the event. He then started walking down the stairs and mom notes that he looked unsteady. He again passed out and went limp. Mom noted pallor and sweating, and was deeply concerned, so called 911. Glucose was checked and was 58, so IV glucose was given. He was brought to PCMC. He has never had an episode like this before. He is admitted to the inpatient team.

More History
PMH: No major illnesses. Immunizations UTD. PSH: No surgeries Medications: None Allergies: NKDA Diet: Normal for age FHx: No history of childhood cardiac illness. No history of sudden death or SIDS in the family. Mom has hypertension. SHx: Lives in Utah with parents and 2 siblings. Has a girlfriend who he has been seeing for about 2 months. Denies sexual activity, tobacco use, alcohol use, and illicit drug use.

Review of Systems

Constitutional: Decreased appetite, diaphoresis. Denies fevers, fatigue, weight loss, chills, and weakness. HEENT: No changes in vision or hearing, no recent URI symptoms or sore throat. CARDIOVASCULAR: Denies exercise intolerance, orthopnea, and dyspnea on exertion. No chest pain, palpitations, or edema. RESPIRATORY: No shortness of breath, cough or sputum. GASTROINTESTINAL: No abdominal pain, nausea, vomiting or diarrhea. No hematochezia or melena. GENITOURINARY: Denies dysuria, increased urinary frequency. NEUROLOGICAL: Per mom, he was behaving funny and not quite acting himself. He was confused and laughing inappropriately at the situation. No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control. MUSCULOSKELETAL: No muscle, back, or joint pain. HEMATOLOGIC: Pallor following syncope. Otherwise, no anemia, bleeding or bruising. SKIN: No rash or itching.

Physical Exam
T 36.8. HR 94. RR 20. BP 120/54. SaO2 96% on Room Air. WEIGHT - 69.6 Kg, (72%ile) HEIGHT - 170 cm, (28%ile), BMI - 24.1

GENERAL: fit young man, quiet, laying down in bed HEAD: normocephalic, atraumatic. EYES: pupils equal, round, and reactive to light, extraocular movements intact, conjugate gaze, no conjunctival injection, sclera anicteric. NOSE: no discharge or obstruction. OROPHARYNX: moist mucus membranes, tonsils 2+ without exudate, no pharyngeal erythema or lesions. NECK: supple without lymphadenopathy or tenderness to palpation. CARDIOVASCULAR: normal rate, rhythm, and S1/S2 without murmur or gallop. Pulses appropriate. Capillary refill time 2 seconds. LUNGS: clear to auscultation bilaterally, good air flow, no retractions. ABDOMEN: soft, non-tender, non-distended with active bowel sounds and no masses or hepatosplenomegaly. EXTREMITIES: all extremities warm and well perfused. No cyanosis, clubbing, or edema. GENITOURINARY: not examined. NEUROLOGIC: awake and alert, flat affect, quiet, cranial nerves II-XII grossly intact, grossly normal strength and tone, patellar tendon reflexes normal. SKIN: no rashes, mottling, jaundice, or unusual birthmarks

Differential Diagnosis?
Differential for this 16 year old male with syncope, diaphoresis, and altered mental status?

Differential Diagnosis

Cardiovascular

Neurologic

Vasovagal Syncope Seizure (atonic seizure) Orthostatic Hypotension Complex migraine Long QT Syndrome Conversion disorder/ Hysteria Brugada Syndrome Pulmonology Catecholaminergic polymorp Hyperventilation hic ventricular tachycardia Toxicology SVT Barbituates/Alcohol WPW TCA Coronary artery anomalies Cocaine Hypertrophic Marijuana cardiomyopathy/Dilated Inhalants cardiomyopathy Opiates Aortic Stenosis Carbon Monoxide Bradycardia

Patients labs/work-up
Orthostatic vitals: became dizzy with standing EKG: NSR w/ non-specific T wave changes Serum and Urine tox negative BMP wnl

So now you meet the patient

You decide to get more history surrounding the incident What do you like to do for fun?

Play video games Actually, his parents just got him a car recently, but it doesnt run

So about the car

Hes been working on the car with his dad, and about an hour before the first episode, he had been in the garage with his dad testing the engine. The garage door was open though. But then dad left and shut the garage door. Patient stayed in the garage for another 15-20 minutes unattended with the engine running before coming in for dinner.

So you order this test

Carboxyhemoglobin:

8.2%!

Carbon Monoxide Poisoning: Epidemiology

Colorless, odorless, non-irritating gas created by incomplete burning of carbonaceous fossil fuels
Same density as air equal distribution in enclosed area

3rd leading cause of accidental poisoning in US

>2000 deaths annually 15,000 40,000 nonfatal cases annually

Common sources: Smoke inhalation Heating systems Poorly ventilated fuelburning devices Camping stoves Charcoal grills Fires Underground electrical fires (think aftermath of hurricane)

Carbon Monoxide Poisoning: Pathophysiology

Gas inhaled, then rapidly diffuses across pulmonary capillary bed to bind hemoglobin 240x higher affinity for hemoglobin than oxygen, changes hemoglobin shape
Impaired oxygen binding to Hb Decreased oxygen delivery to tissues

Left shifted oxyhemoglobin dissociation curve (Haldane effect)

Favors Hb holding onto O2

Carbon Monoxide Poisoning: Pathophysiology

Population and organ with high metabolic needs affected worse

Infants, elderly Brain, heart, lungs

Carbon Monoxide Poisoning: Common Presentations

Winter
More indoor exposures

Post-storms and power outages

Increased use of generators

Non-specific symptoms
Fatigue, dizziness, headache, nausea, irregular breathing, dyspnea on exertion, palpitations, irritability, confusion, irrational behavior, pallor, cyanosis Lethargy and syncope more common in children

Chronic headache
Low level chronic exposure

Flu-like illness
HA, myalgias NO FEVER Similar sxs in family members Recently deceased pet from unknown causes

Management
Carboxyhemoglobin level Treatment

Mild to Moderate
Severe

>10%
>40%; or coma, arrhythmia, sz regardless of level

100% normobaric O2
Hyperbaric oxygen therapy

Diagnose with carboxyhemoglobin level >10%

Co-oximetry also being used

Treat until carboxyhemoglobin < 5% Carboxyhemoglobin level does not correlate with clinical severity, outcome, or response to therapy
Used to confirm exposure

Carbon Monoxide Half-Life

Room Air: 4-5 hours 100% normobaric O2: 1 hr Hyperbaric O2 (2-3 atm): 30 minutes

Studies promising that hyperbaric oxygen therapy for severe poisoning may preserve neurologic

Education
Avoid repeat exposures Carbon monoxide alarms

Long Term Sequelae

Incidence varies 12% - 74% Most common: cognitive, personality changes, and parkinsonism Other long term sequelae:

Memory loss, confusion, ataxia, incontinence, emotional lability, hallucinations, personality changes, blindness

May develop at initial exposure and persist, or after asymptomatic period

Asymptomatic period ranges 3-21 days (or longer)

References

Kind, Terry. In Brief: Carbon Monoxide. Pediatrics in Review Vol. 26 No. 4 April 1, 2005. pp. 150 -151 John L. Green, Michael Shannon, Frederick H. Lovejoy, Jr and Catherine DeAngelis. Index of Suspicion. Pediatrics in Review 1992;13;295 Shannon: Haddad and Winchesters Clinical Management of Poisoning and Drug Overdoses, 4th ed.