Healthcare Acquired Pneumonia Diagnosis

[prettyNURSEtoMD]

I am a nurse and I had a very interesting case yesterday. I get a call saying I'm getting an ambulance 3 mins out. 77 year old male GCS of 3. EMS reports that patient was last seen normal at 0830 cooking breakfast with his wife. Wife reports that he began complaining of SOB and "looked like he was going to pass out", so she helped him to the ground. She said that when they were on the ground he was no longer able to speak.

Patient rolls in unresponsive. Right pupil pinpoint, left pupil approx 3mm unreactive. Patient withdraws from pain, after an IV stick, but not a lot of other movement. BP 120s, HR low 60s, RR 14, 99 % on RA. temp 96.2 via foley.

We intubate, Etomindate and Succ. And the patient remains on no post sedation drugs for the duration of the ER stay.

Hx of HTN and CHF

CBC, CMP unremarkable. Trop neg. BNP 888. D-DIMER 2.56.

CT head and chest negative for infarcts, hemorrhage or PEs
Chest Xray shows RUL Pneumonia

Started on Vanc, Zosyn, and Cipro. Sent to ICU. When we get to the unit, he begins to move a little, but not enough to buck the vent, ICU docs put him on Fentanyl/Versed for sedation.

I just don't know if Pneumonia is the cause of this patient being unresponsive.

MRI next right?

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[WilcoWorld]

What was his downtime? If he had an arrhythmia causing him to faint, and spontaneously converted prior to EMS arrival, he might have had anoxic brain injury as the cause of unresponsiveness if he was in a non-perfusing rhythm for any longer than a brief period. With BP 120s, HR low 60s, RR 14, 99 % on RA. temp 96.2 I wouldn't settle on pneumonia as the cause of this presentation.

 

[Tiger26]

Could be stroke or arrhythmia-->aspiration based on the sudden nature of the presentation and lack of alternative etiologies

 

[WilcoWorld]

Could be stroke or arrhythmia-->aspiration based on the sudden nature of the presentation and lack of alternative etiologies

It could be a stroke with just the right/wrong territory, but it's pretty uncommon for something intracranial that causes unresponsiveness to have a negative head CT.

 

[Tiger26]

It could be a stroke with just the right/wrong territory, but it's pretty uncommon for something intracranial that causes unresponsiveness to have a negative head CT.

I've seen it a few times with basilar artery occlusions where the only sign is a hyperdense artery but no other abnormalities on CT, which is a finding that's easily missed

 

[prettyNURSEtoMD]

Last known normal at 0830. He got to us at 0930. So I would assume maybe 45 mins to an hour? I will have to follow up and see what else they've done up in ICU...

 

[WilcoWorld]

I've seen it a few times with basilar artery occlusions where the only sign is a hyperdense artery but no other abnormalities on CT, which is a finding that's easily missed

I don't disagree, I'm just saying that it's uncommon enough to make you look elsewhere for a cause.