A Barely Responsive Woman Dropped at the ED With a Note

Gregory Taylor, DO; Eric McDowell, DO


November 05, 2020

Physical Examination and Workup

Upon physical examination, the patient's rectal temperature was 94.2°F (34.6°C), heart rate was 124 beats/min, blood pressure was 90/62 mm Hg, respiratory rate was 30 breaths/min, pulse oximetry was 92% on room air, and weight was 130 lb (59 kg). She appeared much older than the age on her identification; she was disheveled, with poor hygiene and a Glasgow Coma Scale score of 8.

The patient did not respond to reversal medications and was subsequently intubated. Examination of the nose and oropharynx revealed poor dental hygiene, with dried blood on her lips and nares bilaterally. The cardiovascular examination revealed tachycardia and a holosystolic murmur best heard at the left lower sternal border. Her lung examination revealed coarse breath sounds bilaterally. Examination of her skin revealed multiple track marks over her jugular veins (bilaterally), arms, legs, and nail beds, consistent with intravenous drug use. Skin mottling was noted on the upper and lower extremities bilaterally, and an irregular, erythematous, macular rash was noted on her palms. Stool was Hemoccult negative.

A sepsis code was activated; two peripheral intravenous (IV) lines were placed, fluid resuscitation was initiated (30 mL/kg), lab studies and blood cultures were obtained, and broad-spectrum antibiotics were started. An ECG revealed sinus tachycardia at 122 beats/min, but no other abnormalities. Portable chest radiography demonstrated diffuse nodular airspace opacities, which were concerning for multifocal pneumonia and acute respiratory distress syndrome (Figure 1).

Figure 1.

Complete blood cell count revealed leukopenia (3200 cells/µL), a hemoglobin level of 7.6 g/dL, hematocrit of 23%, mean corpuscular volume of 91 fL/red cell, and platelet count of 7 × 106 cells/mL (reference range, 150-400 × 106 cells/mL).

Additional studies revealed the following:

  • Serum sodium concentration: 117 mmol/L (reference range, 135-145 mmol/L)

  • Potassium level: 3.3 mmol/L (reference range, 3.5-5.2 mmol/L)

  • Blood urea nitrogen level: 51 mg/dL

  • Creatinine level: 1.60 mg/dL (baseline, 0.70 mg/dL)

  • Aspartate aminotransferase level: 283 U/L (reference range, 10-37 U/L)

  • Alanine aminotransferase level: 84 U/L (reference range, 8-37 U/L)

  • Lactic acid level: 3.6 mEq/L

  • Arterial pH: 7.40

  • CO2 level: 28 mEq/L

  • O2 level: 69%

  • Bicarbonate level: 17 mEq/L

  • PaO2/FiO2 ratio: 86

Hemolytic and coagulopathy workup was pursued, resulting in the following:

  • International normalized ratio: 2.2 (reference range, 0.9-1.1)

  • Partial thromboplastin time: 75 sec (reference range, 26-37 sec)

  • Fibrinogen level: 186 mg/dL (reference range, 200-450 mg/dL)

  • Lactate dehydrogenase: 367 IU/L (reference range, 100-238 IU/L)

  • D-dimer level: 357 µg/L (reference range, 0-316 µg/L)

  • Haptoglobin level: 222 mg/dL (reference range, 40-240 mg/dL; a previously charted haptoglobin level was 304 mg/dL)

A peripheral blood smear revealed many schistocytes. These findings were concerning for disseminated intravascular coagulation, probably secondary to sepsis. The patient's urine drug screen results were positive for cocaine, opiates, and marijuana. Her ethanol, salicylates, and acetaminophen test results were negative. All other laboratory values were within normal limits.

After completion of 30 mL/kg of fluid resuscitation, the patient remained hypotensive. A central line was placed, and she was started on norepinephrine.

CT of the chest without IV contrast revealed extensive multifocal bilateral airspace opacities with air bronchograms. See Figures 2-3 below.

Figure 2.

Figure 3.

Approximately 5 hours after admission, the patient went into cardiac arrest. Advanced cardiac life support protocol was followed, but resuscitative efforts failed. A time of death was later determined.


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