Dyspnea in a Man Who Was Stuck in a Bathroom for 24 Hours

Joshua J. Solano, MD

Disclosures

November 04, 2020

The patient's treatment must be tailored to the underlying cause of the dyspnea. For example, attempting to treat a tension pneumothorax with intubation would result in cardiac arrest. In this case, the treatment of acute pulmonary edema from congestive heart failure exacerbation required bilevel positive airway pressure (BiPAP) with supplemental oxygen, nitrates, and a diuretic. This patient had a complicating factor: rhabdomyolysis, as evidenced by his elevated CPK level, blood in the urine, and myalgia. The rhabdomyolysis probably results from his being on the floor for a prolonged period. In such patients, all compartments should be checked to make sure that the cause of the rhabdomyolysis is not a compartment syndrome.

In addition, this patient has sustained a traumatic head injury and is receiving anticoagulation therapy with warfarin. Thus, a non-contrast head CT scan is required to rule out intracranial bleeding owing to the patient's advanced age, head trauma, and long-term use of anticoagulants and antiplatelet agents. A non-contrast cervical spine CT scan was also performed because of the patient's age and head trauma.

Currently, no clinical decision rule can effectively rule out cervical fracture in older adults, even in the absence of pain and tenderness. The rest of the physical examination results are reassuring for a lack of other traumatic injuries, which are common in older patients after a ground-level fall.

After the workup, the patient was treated with intravenous (IV) nitroglycerin and BiPAP. His condition improved initially, and he was admitted to the intensive care unit. However, his hospital course was complicated by worsening renal failure and fluid overload. After a discussion of the goals of care, the patient was transferred to hospice care and died.

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