Long case: (10 minutes to study case then questions for 20 minutes)
Clinical FRCA Viva
A 24 year old male, who is a known drug addict, has recently been admitted to medical ward. He was found unconscious at home with a history of ?heroin overdose. His conscious level improved with 200 mcg naloxone and he became agitated, with a Glasgow Coma Scale of 14. He is complaining of being unable to feel his legs and of generalised weakness. His blood pressure is 80/40 mmHg and his peripheries are cool.
He has a past history of depression and alcohol abuse.
|Arterial blood gases post-naloxone on air:
|| 8.0 kPa|
|| 6.0 kPa|
|| 20 mmol/L|
|Urea and electrolytes
|| 131 mEq/L|
|| 7.8 mEq/L|
|| 13.0 mmol/L|
|| 331 umol/L|
|| 50,000 IU|
ECG Rate 50 bpm sinus (abnormal intermittent p waves) Broad QRS peaked T waves
CXR CVP line in situ. Bilateral diffuse shadowing. R middle lobe collapse. No pneumothorax.
- Summarise the case.
- What may have made him unconscious other than heroin?
- What other drugs may he have taken?
- How would you determine this?
- What does the ECG show?
- Why can't he feel his legs and why is he weak?
- What may the cause of his raised K+ and his renal impairment?
- What is rhabdomyolsis and how does it cause renal failure?
- Why may he have it?
- How would you resuscitate him?
- How would you treat the K+ acutely and subsequently?
- What is the difference between haemofiltration and dialysis?
- How do they work, and which one would you use in this case, given the choice, and why?