Case #92 "Passed Out in a Running
Car"
by Charlene Babcock Irvin, MD, FACEP
A 33 y/o male is brought in comatose. He
was found on a cool fall day passed out in a
running car, parked at a liquor store. The
store clerk called the police when several
customers noted there was a man possibly
sleeping in his car in the parking lot. One
customer tried to get him to open the door,
but he did not wake up.
Police arrived, called an ambulance, and
broke into the car. There were several pills
scattered all over the floor, different
colors and different shapes. No pill bottles
found. EMS attempted to intubate, but the
patient vomited, so they just bagged him and
brought him in.
No PMH, SH, ROS, Medication history is
available. He has not been to this hospital
before.
PE: WDWN male, being bagged by
EMS, comatose with vomit on his shirt, which
smells of alcohol.
VS: 138/80, HR=105, RR estimated at 8-10/min
(he is breathing spontaneously, but he is
being assisted with Bag Valve mask at a rate
of about 20), Sat 100% with BVM on 100%
oxygen.
HEENT: PERRL, mid position, mid size. Neck
supple. Head without signs of trauma.
Heart: Slightly Tachy, RR, no murmurs.
Lungs: Clear bilaterally.
Abd: Soft, non-tender. Unable to hear bowl
sounds.
Ext/Skin: Normal, no rashes, skin not
flushed, no diaphoresis. Pulses are present.
No stigmata of liver disease. No bruising or
signs of trauma.
Neuro: Patients eyes remain shut even to
pain, minimal moan to pain, and some minimal
movement to attempt withdraw are made to
pain in all 4 extremities. (GCS= 1 (eyes) +
2 (verbal) + 4 (motor) =7. Reflexes
symmetric.
Patient is hooked up to oxygen, monitor,
second IV is established, and blood is
drawn.
Narcan 0.4 mg did not change the patient
status.
Patient is intubated using rapid sequence
protocol.
CXR post intubation reveals adequate tube
placement, no infiltrate.
EKG: Sinus tachycardia, narrow complex.
Blood is sent for Lytes, BUN, Cr, Glu, CBC,
ETOH, Osmolality, Tylenol, ASA, and a urine
drug screen is sent. An ABG is sent, and so
is a Carbon Monoxide level.
An NG is inserted, placed to suction, and
after no more liquid is aspirated, 50 gm of
charcoal are instilled.
CT of the head is ordered.
Questions:
1. What information that is essential did I
not give you?
2. What is a quick way to estimate carbon
monoxide level using the blood gas and pulse
ox?
3. What is a quick way to be sure the
patient doesn’t have any toxic alcohol’s
ingested? Which alcohol in toxic amounts
does NOT cause an anion gap metabolic
acidosis?
Click here for answers and to respond
