CASE STUDY

Erynn Dunnigan, RTS

October 31st, 2023
 INTRODUCTION

A 43 y/o male was transferred to CHI with a Hx. of substance abuse (meth),
asthma, HTN, CHF, morbid obesity (BMI 40.67), and a minor brain aneurysm in
2016.
Principal Problem: Acute Severe Meth Intoxication
Presented in the evening with symptoms the past 3 weeks:
• progressive SOB
• abdominal swelling
• Pitting (3+ on assessment) leg edema
He is a full code, , friend listed as POA
Home meds: Lasix 40 mg, Lisinopril 10mg
 ASSESSMENT

• no fever, no active cough, and no reported changes in

sputum.
• Clear urine output
• Auscultation revealed bilateral wheeze in all fields.
• Sp 82% ETC 67mmHg
• HR 167 bpm
• RR 33
• B/P 172/97
• periodic apneas
------------------------------------------------------------------------
BiPAP was initiated and not tolerated. Vitals were B/P
168/92, HR 87, Temp 96.7F, RR 20, SpO2 100.
 DIAGNOSTICS

• BUN/creatinine 21/1.6
• BNP 378 • Head CT (-)

• Decreased Magnesium • EKG – prolonged QT interval

• Ammonia elevated at 84
• CXR
• WBC increase 11,000
• Lactate and troponin normal
• ABG
• pH 7.39
• PaCO2 60mmHg
 NEXT STEP

Transferred to ICU on vent: ETT 8.0 26@ teeth and place 4.5 cm above the carina
AC/VC
FiO2 60
Vt 500
RR 20
PEEP 10
Flow Sens 2 L/min
Peak Pset 60
Ve 10.4 L/min
Peak obs 30cmH2O
MEDICATIONS GIVEN
Cefepime 2mg IV Q8hr
Doxcycycline 100mg IV BID
Vancomycin 2000mg initial dose
Furosemide 40mg IV Q6hr
Lisinopril 20mg QD
Heparin 5,000 units SubQ Q8hr
Insulin lispro 2-14 units SubQ Q4
Ipratropium-albuterol 3ml Neb Q6h
MgS 4g IV once
Fentanyl 200mcg/hr IV infusion
Nitroglycerin given once and then d/c
Propofol 50 mcg/kg/min IV infusion
 DAY 2
• Concerns w/ severe agitation and
combativeness
• FiO2 and PEEP weaned
• Labs:
Creatinine down to 1.5
BNP decreased 227
WBC left shift up to 13k
Sputum culture
Echocardiogram: normal EF, mild
mitral regurgitation
Medications:
Added: Ampicillin sulbactam 3g IV Q6hr
Pantoprazole 40mg IV QD
Budesonide 0.5mg/3ml Neb BID
Norepinephrine 0.04mcg/kg/min
Changed: Furosemide decreased to 20mg IV Q6hr
D/C: Cefipime 2mg IV Q8hr
Doxcycycline 100mg IV BID
 DAY 3 (MORNING)

Morning: Pt. remained sedated throughout the day on vent with SpO2 94% on
PEEP 8, had some sedation related hypotension so placed on a low dose pressor –
did have about an hour in the afternoon where he dropped to SpO2 88% and
ETCO2 54mmHg.
CXR: mild congestion
Labs: normalized

Medications:
Added hypertonic saline
Added Midodrine for hypotension (vasopressor alpha 1 agonist)
 DAY 3 (EVENING)
• 2 nd cardiac arrest
• PEA
• Attempted weaning from
• Ventricular tachycardia, ventricular
vent fibrillation
• Agitation  Precedex • Cardioversion x2 w/ 300mg
amniodorone
given
• ROSC w/ ST elevation
• B/P 75/57 • *EKG*
• ABG revealed compensated respiratory
• Spontaneous bradycardic acidosis w/ a PaO2 74 mmHg
cardiac arrest
• ROSC 3 minutes 1
epi: 1 CPR • Pt stabilized on dopamine,
norepinephrine and heparin.
• *EKG * • Auscultation- bibasilar rales and
rhonchi
• Pitting edema (4+)
 Hemodynamically stable and weaned off
pressors

Neuro status unresponsive w/

decreased activity – on fentanyl drip

PEEP 14
DAY 4 & 5 FiO2 100%

*CXR*
 Severe agitation

LVEF 40-45%

Attempt to wean
DAY 6

Continued
leukocytosis
 Severe agitation

Failed SBT, however

extubated anyway
DAY 7
Vitals stable and
sedation decreased
 Labs resolved

35% NC
DAY 8

Continued agitation
 Moved to general floor on 28%
NC
DAY 9
 • Became hypertensive
• RR 40
• SpO2 mid 80s
• Increased agitation -> Precedex given, and
sedation increased
• Reintubated with 9.0 ETT- difficult intubation
• AC/VC, 500ml, RR 20, PEEP 8 cmH2O, FiO2
DAY 10 60% then to 35%
• Balloon Rupture
DAY 11

​ ABG • Increased secretions

pH 7.48 • CXR baseline normal

PaCO2 40 • Auscultation: bilateral rhonchi

HCO 30
• 2nd balloon rupture
PaO2
87
• 8.0 ETT
 • Intubated w/ severe agitation and pulling at

tube despite restraints

• Suctioned moderate thick secretions

DAY 12 – MY
ENCOUNTER
• Self-extubated

• Reintubated 8.0 ETT

 Difficult to keep sedated

Weaned
DAY 13 – MY
ENCOUNTER
Extubated
*CXR*
 Encephalopathic

Placed back on
Precedex
DAY 14

Added Trazadone
 Continued confusion

Added valium

More orientated to
DAY 15 – MY
ENCOUNTER place, not time

On RA
 FOLLOW UP

Pt. remains in ICU requiring 1:1

observation and is being treated for anoxic
brain injury and hypertension.
PHYSIOLOGICAL IMPACT OF METH
• Cardiac valvular dysfunction can be related to the
serotonergic effects of methamphetamine -
degenerative mitral regurgitation
• First line sedation is benzodiazepines
• Next line of defense- neuroleptics (Contraindicated for
this patient w/ long QT.
• Restraint- related cardiac arrest: physical restraints
can cause isometric muscle contractions that can lead
to lactic acidosis and sudden cardiac collapse.
 WHY THE PRECEDEX?
Precedex
(Dexmedetomidine) is an
alpha 2- adrenoreceptor
agonist.
Therefor, has sympatholytic
effects to lower B/P and HR
Opoid “sparing” effects
Methamphetamine is a
sympathomimetic amine.
Precedex can counter the
sympathetic effects of meth.
Does pose risk of bradycardia and
hypoxia, however, is one of the very
few strong alternatives to use as an
analgesic and sedative for patients
with methamphetamine and opioid
tolerance.
 REFERENCES
Boyer, E., & Hernon, C. (2023). Methamphetamine: Acute Intoxication . UpToDate.
https://www.uptodate.com/contents/methamphetamine-acute-intoxication

Columbia University Irving Medical Center. (2023, January 29). Heart valve disease linked to serotonin.
ScienceDaily. Retrieved October 30, 2023 from www.sciencedaily.com/releases/2023/01/230129193418.htm

London, M. (2023) Intraoperative use of vasoactive agents. UpToDate. https://search.yahoo.com/search?

fr=mcafee&type=E211US1250G0&p=up+to+dat+intraoperative+use+of+vasoactive+agents