Chief complaints
A 40-year-old male patient was found fainted at the scene of the fire and had a cardiac arrest.
History of present illness
The patient was receive CPR and sent to the emergency department of the Strategic Support Force Specialized Medical Center by firefighters on June 27, 2021 .Rescue measures such as strengthening the heart, supplementing blood volume, and assisting ventilation under tracheal intubation. After 30 minutes, the patient's spontaneous circulation (ROSC) was restored. In order to confirm the diagnosis, related examinations such as arterial blood gas analysis, TCD, and CT examination of the chest and brain were performed. According to the examination results, he was diagnosed with severe carbon monoxide poisoning, cerebral edema, severe brain injury, and 10% superficial second-degree burn of the skin. After being given high concentration oxygen (60%) combined with Peep (6cmH20), brain dehydration and skin burns, he was transferred to the ICU for advanced life support.
When he arrived in the ward, Sedated to reduce irritation and started using external cooling mattresses and headgear for therapeutic hypothermia. To protect the burned airway, a tracheotomy was performed under local anesthesia. Within 8 hours after ROSC, she reached the target body temperature (35°C) and head temperature (33°C). Therapeutic hypothermia is maintained for 24 hours. Due to the discovery of gastrointestinal bleeding, an emergency gastroduodenoscopy was performed, and the results showed hemorrhagic gastritis. The bleeding stopped after treatment with local thrombin. After 19 hours of therapeutic hypothermia, the patient developed polyuria (urine volume per hour>1000mL), total urine volume was 6.5L (input volume 4.3L).
History of past illness
The patient had hypertension.
Personal and family history
The patient had no history of smoking and familial cancer, but the patient drank about 800ml of beer before the accident.
Physical examination
The patient was still in a coma. The pupil does not respond to light, and the corneal reflection is not elicited. Vital signs: blood pressure 148/81 mmHg, heart rate 97 beats/min, body temperature 36.0°C, mechanical ventilation intubation (A/C mode, frequency 20 beats/min, oxygen concentration 60%, Peep6cmH20), SpO297%.
Laboratory examinations
When he arrived in ICU. Preliminary laboratory results showed that hemoglobin was 20.6 g/dL, carboxyhemoglobin was 40%, pH 7.29, Pco251.2mmhg, Po285.7mmhg, sodium 141.4mM/L, potassium 3.4mM/L, chloride 110.7mM/L.After 19 hours of therapeutic hypothermia,blood sodium concentration was 155.0mM/L the next day, and it rose to 165.8mM/L within three days, See Figure 1 for details. Urine specific gravity continued to be less than 1.005.
Imaging examinations
Head CT disclosed ventricular contraction and parenchyma edema(Figure 2),signaling brain edema.
Final Diagnosis
Central diabetes insipidus secondary to therapeutic hypothermia after cardiopulmonary resuscitation with carbon monoxide poisoning.
Treatment
The diagnosis of central diabetes insipidus was diagnosed. The patient received pituitary 24U (8ml/h) treatment. In the following 3 days, urine volume gradually decreased, blood osmotic pressure, urine osmotic pressure, blood sodium concentration and carbon Oxyhemoglobin returned to normal.
Outcome And Follow-up
In the afternoon of the 4th day after ROSC, the patient developed weak spontaneous breathing and was transferred to a secondary hospital by his family to continue treatment.