Case Study #3


30ish male wheeled to room from triage. Slumped over in wheelchair. Able to move to stretcher with a lot of assistance from 2 staff members. Per parent, pt was "fine today". However, pt went to bathroom, came out, "was not himself, he was lethargic and keeps zoning out, so I brought him in".

Pt responds to touch but cannot or will not answer questions, skin flushed, warm and dry, hr 160, bp 90/50, rectal temp 102.6, rr 28, pulse ox 95. Hx is psych and etoh. Per parent, pt saw psychiatrist this afternoon and was recently released from rehab.

Nu? Whatcha gonna do? Whatcha thinking? Whatcha wanna know and what're your priorities?

Have at it.....


67 Posts

Specializes in Cardiac Step down/ LTC.

I am thinking he took something in the bathroom/overdose. Need to get current med list from parent, send parent back home if need be to check all med bottles and have them call with what they find. Get a time frame for when symptoms started.

First obtain IV access- get fluids going. 2 liter O2 (got VS already), Blood sugar, get EKG, draw labs/ tox screen, UA. I am a new nurse starting soon in a IMCU so at this point I'm not sure how to proceed as far as setting up for gastric lavage or charcoal. Let me know what I am missing. I love these case studies!

Specializes in Emergency. Has 21 years experience.

Good thinking. Parents have list of meds which include suboxone, antabuse & seroquel.

What are your nursing concerns?

While the fluid is a good idea, any of those other vitals signs warrant some attention

Specializes in NICU, ICU, PICU, Academia. Has 46 years experience.

Neuroleptic malignant syndrome!


844 Posts

I was thinking perhaps anticholinergic toxicity? Presents like the little diddy I remember hearing somewhere about "hot as something, dry as a desert, blind as a bat, red as a beet, crazy as a fox" (I don't remember all of the words to it!) Just because the parents list three meds doesn't mean patient didn't down a bottle of cough syrup or something in the bathroom.

Well if pt had been in rehab I would wonder if they were perhaps in a 12-step or similar program. It would provide pt support to see if their sponsor could come in, especially if this is a case of relapse of some sort. I would be wondering what is the pt's psych dx and what complications go in hand with that? Does pt experience any auditory or visual hallucinations, things of that nature, just as a heads-up. Does pt work? Or is he sitting at home fresh off of rehab with nothing to do?

I'll have to mull this over tomorrow :) Thanks for posting another case study!

Specializes in Emergency. Has 21 years experience.

And then the pt went for ct. No issues. We get back to room, hook everything back up. Hr 150's, bp 90s/50s, pulse ox 98% ra, rr 20, no neuro differences. 5 minutes later, sat 89%, starts having intermittent apneic episodes lasting approx 10-15 seconds.

Esme12, ASN, BSN, RN

4 Articles; 20,908 Posts

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma. Has 43 years experience.

Remember to always think...ABC's. What should be your first response to this new development?

sat 89%, starts having intermittent apneic episodes lasting approx 10-15 seconds.


67 Posts

Specializes in Cardiac Step down/ LTC.

With this new change I am thinking he is going into respiratory failure and needs intubation and put on a vent. Draw ABGs. Now for the tachycardia would he be given lopressor or clonidine to get it down and get his BP up... This is where I'm confused and did his EKG show anything?

Lev, MSN, RN, NP

8 Articles; 2,803 Posts

Specializes in Family Nurse Practitioner. Has 10 years experience.

What's the temp from?

Does he need some narcan?

Specializes in Pediatrics, Emergency, Trauma. Has 18 years experience.

Possible ETOH withdrawal?

Poly pharmacy issues?

O2 is a priority; anticipate possible seizure activity, so make sure rails are padded, etc.

Fluids-a banana bag (if applicable)-I'm suspect ETOH withdrawal, but I could be wrong...

Temperature management to prevent a spike in fever and further neuro issues.

I'm trying to think of the medication management for ETOH withdrawal and I'm getting a blank; the I saw other posters suggestions for clonidine to be anticipated if this is not an ETOH case, but I can't shake the feeling that this pt is going through ETOH withdrawal for some reason.

Hope I'm on the right track! :up:

Lev, MSN, RN, NP

8 Articles; 2,803 Posts

Specializes in Family Nurse Practitioner. Has 10 years experience.

The elevated temp and heart rate fit with etoh withdrawal, but not the hypotension...with leads me to think the elevated HR is from the hypotension, but maybe not... also his skin is dry...doesn't fit with etoh withdrawal, they sweat..but no two patients present exactly the same. What's his rhythm? Is he seizing? The apneic episodes may be from narc overdose or it could have been seizure activity.

This could be a etoh withdrawal exacerbated by narc overdose. Ativan + Narcan.