A 66-year-old male who was a long standing inmate in a forensic psychiatric hospital presented to the Emergency Department with a complaint of abdominal distention. The patient denied any nausea or vomiting but reported a decreased appetite which he attributed to abdominal discomfort. His last bowel movement was five days ago. The patient also endorsed dysuria. A computerized tomography (CT) scan of the abdomen and pelvis was performed prior to ED arrival and the images were brought with patient.
The patient had a past medical history notable for paranoid schizophrenia, bipolar disorder, latent tuberculosis, and ascending aortic aneurysm. There was no known history of liver disease. The patient's medications included clozapine, fluphenazine, lithium, paroxetine, lorazepam, and haloperidol. He had no known drug allergies and had no recent medication changes. Complete review of systems was otherwise negative. The patient had no history of previous surgeries, did not smoke, drink, or consume illicit drugs, and had a noncontributory family history.
On initial presentation to the ED his vital signs were heart rate (HR), 104; blood pressure (BP), 147/101; respiratory rate (RR), 22; pulse oximetry, 93% on room air; and temperature, 36.4 degrees Celsius.
On examination of the patient, his oral mucosa was noticeably dry. His cardiac exam was unremarkable with normal S1 and S2, no murmurs, rubs, or gallops, and 2+ pulses in all four extremities and his lungs were clear to auscultation bilaterally. The patient's abdomen was firm and grossly distended and was noted to resemble a full-term pregnant patient. Dilated superficial veins were noted on the abdomen and palpation revealed mild, diffuse tenderness without rebound or guarding. The patient was awake, alert, and orientated to time, date, and environment.
Labwork was notable for sodium of 115 mmol/L and a serum osmolality of 251 mOsm/kg. The potassium level was 5.2 mmol/L, chloride 80 mmol/L, bicarbonate 21 mmol/L, creatinine 1.58 mg/dL, lactic acid 1.5 mmol/L, troponin T < 0.01 ng/mL, and lithium level 1.0 mmol/L. The patient was mildly anemic with a hemoglobin of 11.5 g/dL, while his remaining complete blood count (CBC) was unremarkable with a white blood cell (WBC) count of 9.44/L and platelets of 318/L. An electrocardiogram was obtained during the ED evaluation (Figure 1) which showed a sinus tachycardia of 105 beats per minute, QRS 98s, QTc 415 ms, and peaked T waves in the precordial leads.
Upon review of the CT, large dilated loops of colon were noted up to 12 cm (Figures 2 and 3).
During the ED course, the acute care surgical service was consulted for further management. A rectal exam was performed by the resident physician with a plan for disimpaction immediately following. The patient was positioned on his left side. Soft stool was found on rectal exam. During the rectal examination, the nurse in the room noted that the patient was apneic and a code was called. The patient was unresponsive for less than one minute prior to the nurse noticing his status change. The patient had no new complaints prior to his arrest.
Unfortunately, the patient was not on a cardiac monitor at this time. Upon immediately placing the patient on a monitor, a bradycardic rate was noted. Following a pulse check, the patient was then found to be in pulseless electrical activity. Cardiopulmonary resuscitation (CPR) was started and advanced cardiac life support (ACLS) protocol was followed including intubation. Initial bedside ultrasound showed no cardiac activity. Following multiple rounds of CPR and ACLS medications, return of spontaneous circulation (ROSC) was obtained. The patient then again went into PEA with a bradycardic rhythm but ROSC was again obtained and remained. A postarrest arterial blood gas was notable for pH 6.84, pCO2 100 mmHg, and pO2 94.5 mmHg. The patient was then admitted to Intensive Care Unit (ICU) on epinephrine, norepinephrine, and vasopressin infusions. At time of ICU admission the patient was in a normal sinus rhythm of 98. Eight days later the patient expired following confirmation of anoxic brain injury and a decision made to provide comfort care.