Author: Susie Hewitt / Code: CAP18, CC1, CC14, CC2, CC5, CC6, HAP3, HAP5 / Published: 29/10/2014
This is the first in a series of Emergency Casebooks from the virtual hospital CFN General, with key learning points for staff working in an Emergency Department.
A 30 year-old male, called an ambulance because he had a sudden onset of blurred vision and vomiting. He then collapsed at the top of the stairs. He told the paramedic that he had been out drinking the night before and admitted to smoking cocaine.
His heart rate, respiratory rate, blood pressure, blood sugar and GCS were within normal limits. The crew documented that while walking to the ambulance, he appeared not to be paying attention and hit his head on a wall. There was no loss of consciousness; however he sustained a 1cm laceration to the forehead. He complained of abnormal vision.
The patient was seen in the Emergency Department (ED) by one of the CFN General doctors. They documented that he was normally fit and well and on no regular medications but was now complaining of feeling generally unwell, dizzy and nauseous. They documented that the patient had drunk three-quarters of a bottle of spirits and smoked 1.5 grams of cocaine the night before. In the morning he had felt very unwell. He described being shaky, dizzy and sick, and he was unable to eat and drink. He did not complain of the light hurting his eyes or of neck stiffness.
On examination he was described as nauseated. His airway was patent and examination of his chest and heart revealed no abnormality. Examination of his abdomen was normal. An ECG was performed which was described as showing normal sinus rhythm. A pain score was nil and a BM was 6.3. A small cut to the forehead was also documented. The clinical impression was of dehydration with the side effects of alcohol and drugs.
He was given intravenous anti-sickness medication, paracetamol, intravenous fluids with a plan for home later. A full blood count and initial profile were normal apart from a bilirubin of 26. He was reviewed with his family some time later and the conclusion was a likely hangover, with a plan to discharge home. He and his family were specifically advised about worrying symptoms such as photophobia, neck stiffness and confusion and asked to return in the event of any concern.
The patient returned to the ED the following day after attending his GP surgery. The GP letter stated that he had a left sided weakness, blurred vision, a right sided headache, slight dysarthria and that he was not intoxicated.
He was seen in the ED by another CFN General doctor who documented left sided limb weakness and ophthalmoplegia. An urgent CT of the head with contrast was obtained and this showed no evidence of intracranial haemorrhage. However a low attenuation lesion was noted in the cerebellum consistent with an infarct. He was referred to the medical team on duty directly to the stroke ward, where he was started on aspirin and dipyridamole that evening. He subsequently had an MR angiogram on which confirmed the right cerebellar infarct and a right vertebral artery dissection. Mr M made a good recovery with minimal residual symptoms.
• Avoid negative perceptions of patients who use alcohol and illegal drugs and ensure examination is thorough.
• The patient had a collapse, complained of blurred vision and was described as unsteady sustaining a head injury however a structured neurological history and examination were not documented.
• The symptoms were sudden in onset suggesting a discrete event.
• Safety net advice was clearly documented.
• There is a known association between cocaine use and vertebral artery dissection.
• The most common problems associated with the use of cocaine appear to be independent of route and dose and are cardiovascular in nature; they include myocardial infarction and ischaemia, cardiac arrhythmias, and hypertension. Seizures, cerebrovascular accidents, hepatotoxicity, rhabdomyolysis, pulmonary complications, and obstetrical complications have also been reported.
Breach of duty was admitted on the basis that a neurological examination was not documented when the patient first attended ED. On the issue of causation, it was argued there was only a 24 hour delay before treatment (according to protocols in place at the time) and this had not had any impact on the outcome. It was also pointed out that there was contributory negligence by the patient because of his illegal drug use.
The claim was withdrawn.