67 years old man k/c/o HTN and DM , was brought by the family with h/o altered mental status. He have been recently discharged from hospital after ischemic stroke and was under traditional treatment at home for the last 3 days . Family deny h/o trauma , fever , or GI symptoms. No h/o taking extra medication as well.
Clinically :
The patient is drowsy , GCS: 12/15 , pupils : b/l normal size and reactive
Vitals: HR: 110 , bp: 150/70 , spo2: 95% in R.A , afebrile, blood sugar is 15 mmol/l
Rest of exam is unremarkable , apart from residual lt side weakness
ECG: sinus tachycardia , normal QRS and QT, no ischemic changes
CT brain was done and showed old infarction , no acute insult
ABG is below
Q1: What is your finding and what are the expected clinical manifestations?
Q2: How you will manage this patient?
Sleepy Man Cont’
Thanks to all of you for your comments
It is CO poisoning case
Correlation of COHb levels and clinical features
Although CO level is used to confirm the diagnosis but they are a poor indicator for outcome and are altered by any previous oxygen that has been applied or delayed presentation.
<10% = Background level in a smoker
10% = Usually asymptomatic, slight headache
20% = Dizziness, nausea, dyspnoea, headache
30% = Vertigo, ataxia, visual disturbance
40% = Confusion, coma, seizures, syncope
50% = Cardiovascular compromise, respiratory failure, seizures, death
Clinical Manifestations:
Delayed Effects:
The persistent or delayed effects of CO poisoning are varied and include dementia, amnestic syndromes, psychosis, parkinsonism, paralysis, chorea, cortical blindness, apraxia and agnosia, peripheral neuropathy, and incontinence.
In patients admitted to an intensive care unit (ICU) for severe CO poisoning and treated with 100% oxygen, 14% of survivors had permanent neurologic impairment.
Management :
The mainstay of treatment is initial attention to the airway. One hundred percent oxygen should be provided as soon as possible by either nonrebreather face mask or endotracheal tube. Although concerns have been raised regarding toxicity from excess oxygen, patients poisoned with CO can still have cellular hypoxia despite normal oxygen saturation
Continuous cardiac monitoring and intravenous (IV) access are necessary in any patient with systemic toxicity from CO poisoning. Hypotension should initially be treated with IV fluids, with the addition of inotropes for persistent myocardial depression. An evaluation for cardiac ischemia, including ECG and cardiac markers, is recommended in symptomatic patients at risk: prolonged exposure (>2 hours), altered mental status, or male gender.
CO is eliminated through the lungs. Half-life of CO at room air temperature is 3-4 hours. One hundred percent oxygen reduces the half-life to 30-90 minutes. Hyperbaric oxygen at 2.5 atm with 100% oxygen reduces it to 15-23 minutes.
References
1.Goldfrank’s Toxicologic Emergencies 11th edition
2. https://litfl.com/carbon-monoxide-inhalation/
A blessing Friday
thanks for sharing such a great case.
I agree with Abdulmajeed, by the way we call it (Kanan), where people using over wrapping and sometimes putting hot water on the blankets and some of them are firing a charcoal to add on the temperature of the ambient air specially in winter.
I would add heat exhaustion and dehydration to my DDx.
Very high carboxyhemoglobin (COHb) level of 34%, confirming carbon monoxide poisoning. At this level you expect a lot of manifestation, mainly CNS: AMS, syncope, stroke-like focal findings, seizures, & even coma. Type 2 MI can occur as well. A lactate of 2.6 & a pH of 7.33 assures me against possible concomitant cyanide toxicity. There is also hypokalemia of 2.8. Hyperglycemia of 15, unlikely to be clinically significant.
Put him on 15L via NRM. Arrange for hyperbaric therapy. Replace potassium with 40meq in 400ml NS infused over 4 hours.
The likely cause fort his is the traditional therapy used in stroke/palsy, which is called "kanz". They cover the patient with layers of blankets in a closed room, & sometimes they turn on warmers or set in-room fires to warm the room further. It is believed to help the patient recover from his/her stroke symptoms.