Page 27 - JSOM Spring 2018

Challenges of Transport and Resuscitation of a
Patient With Severe Acidosis and Hypothermia in Afghanistan

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Michael J. Brazeau, DO ; Caroline A. Bolduc, DO ;
Brian L. Delmonaco, MD *; Azfar S. Syed, DO, MBA 4
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ABSTRACT
We present the case of a patient with new-onset diabetes, severe shortness of breath. He denied fevers, cough, or hemoptysis.
acidosis, hypothermia, and shock who presented to a Role 1 On examination at the Role 1 facility, he was normother-
Battalion Aid Station (BAS) in Afghanistan. The case is unique mic (oral temperature, 36.1°C [97°F]), mildly hypertensive
because the patient made a rapid and full recovery without (145/90mmHg), and tachypneic (respiratory rate [RR], 30–
needing hemodialysis. We review the literature to explain how 35/min); his heart rate (HR) was tachycardic (130–140 bpm),
such a rapid recovery is possible and propose that hypother- his oxygen saturation (Sao ) level was 97%. He was well de-
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mia in the setting of his severe acidosis was protective. veloped and well nourished; alert and oriented to self, place,
date, and situation; and spoke in complete sentences while in
Keywords: new-onset diabetes; severe acidosis; hypother- mild respiratory distress. Rales were heard in the left posterior
mia; shock; hemodialysis thorax on auscultation. The patient was tachypneic without
accessory muscle use; heart rhythm was regular and rate was
tachycardic without abnormal heart sounds; skin was warm
and dry without rash; and the remainder of his examination
Introduction
was unremarkable.
We present the case of a patient with new-onset diabetes,
severe acidosis, hypothermia, and shock who presented to a Telemetry demonstrated sinus tachycardia. Point-of-care ma-
Role 1 BAS in Afghanistan. The case is unique in that, despite laria and HIV tests were negative. Urinalysis was positive for
arterial pH of 6.681 and base deficit of −30mEq, core temper- ketones and glucose. No glucometer or other studies were
ature of 31°C (88°F), and hypotension requiring vasopressors, available. Sepsis from pneumonia was suspected, given the pa-
the patient made a rapid and full recovery without needing tient met systemic inflammatory response syndrome criteria
hemodialysis. (HR, >90 bpm; RR, >20/min) and presented with primarily
pulmonary signs and symptoms (i.e., dyspnea and tachypnea).
We review the literature to explain how such a rapid recov- A 1L intravenous (IV) bolus of normal saline (NS) was given,
ery is possible and propose that hypothermia in the setting as well as 1g of ceftriaxone IV.
of his severe acidosis was protective. The challenges unique
to expeditionary and en route care of this critically ill patient The Role 1 facility requested urgent, nonsurgical medical
are presented, including a discussion of the environmental and evacuation (medevac) of the patient to a Role 3 facility. Await-
nonenvironmental causes of hypothermia, expeditionary re- ing medevac, the patient received 2L of NS. The casualty
warming techniques, and iatrogenic hypothermia-avoidance evacuation, or dustoff, crew arrived at approximately 21:30
techniques. The lessons learned from the recognition and man- local time, and the patient was prepared for transport in a
agement of ketoacidosis and hypothermia are reviewed. hypothermia prevention/management kit (HPMK) in stable
condition. The planned medevac route was expected to take
90 minutes to the Role 3 facility and included a tail-to-tail
Case Presentation
handoff at a Role 2 facility, where a forward surgical team
A 38-year-old civilian contractor from Uganda presented to (FST) was located.
the Role 1 BAS in a remote forward operating base in Afghani-
stan with a chief complaint of weakness and dizziness on 5 At the Role 2 facility, the dustoff crew was unable to proceed
February 2017. He was previously healthy, had no prior sur- with the tail-to-tail handoff because of operational security
geries, took no medications, and had no drug allergies. He did and returned to the Role 1 facility at 2330 local time. The
not smoke or drink alcohol; he worked as a security advisor. patient worsened over the next hours and received 750mg of
levofloxacin IV. Although he was normotensive with stable
On review of systems, the patient endorsed 2 weeks of poly- oxygen saturation, the patient had become obtunded, his gag
uria, polydipsia, decreased appetite, weight loss, fatigue, and reflex was absent, and his work of breathing had increased.
*Address correspondence to bldmoto@gmail.com
1 Capt Brazeau is a board-certified, active duty Air Force internist deployed to Bagram, Afghanistan, in 2016–2017. He is currently completing
his gastroenterology fellowship. Capt Bolduc is currently assigned to Joint Base San Antonio where she works as a hospitalist and outpatient
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clinician. Col Delmonaco remains on active duty in the US Air Force and is assistant professor of emergency medicine and pulmonary and critical
care medicine at University Medical Center, University of Nevada School of Medicine in Las Vegas. He is board certified in emergency medicine
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and critical care medicine. Capt Syed is currently practicing as an active duty flight surgeon for the US Army in Stuttgart, Germany.
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