case_images: PMC10506872_01
case_images: Wine-colored urine. Image shows typical finding in patients who receive hydroxocobalamin as treatment following a toxic exposure. Our patient received hydroxocobalamin following exposure to hydrogen sulfide gas poisoning.
case_images: CRICC2023-1132406.001.jpg
case_images: PMC10506872_01_CRICC2023-1132406.001.jpg
case_images: fig1
case_images: ACLS. At the outside hospital, he was decontaminated and treated with hydroxocobalamin, which resulted in bodily fluids turning a wine color (Figure 1).
case_images: Computed tomography (CT) of the head (CTH). CTH showing diffuse cerebral edema (a) and pseudo-subarachnoid hemorrhage pattern (b, c).
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case_images: PMC10506872_01_CRICC2023-1132406.002.jpg
case_images: fig2
case_images: Computed tomography (CT) of the head was obtained (Figure 2). The CT of the head showed diffuse cerebral edema and pseudo-subarachnoid hemorrhage pattern (Figures 2(a)-2(c)).
case_images: Electroencephalography (EEG): EEG shows electrocerebral inactivity with diffuse cardiogenic artifact. Bipolar montage, sensitivity 7 muv, LF 1.6 Hz, and HF 70 Hz.
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case_images: fig3
case_images: Electroencephalography (EEG) showed electrocerebral inactivity (<2 muv) with diffuse cardiogenic artifact (Figure 3).
case_images: Mechanical ventilator waveforms:(a) pressure support (PS) ventilation trial using 100% FiO2, positive end-expiratory pressure (PEEP) of 5 cmH2O, and pressure support above PEEP of 5 showing respiratory rate of 25 breaths/min and tidal volume of 152 mL; (b) changing ventilator to a continuous positive airway pressure (CPAP) trial of 100% FiO2, PEEP of 5 cmH2O, and pressure support above PEEP of 0 shows respiratory rate of 32 breaths/min and tidal volume of 51 mL. (a) and (b) were with a flow trigger setting at 4 liters per minute; (c) with changing the flow trigger to a pressure trigger (-2 cmH2O), the pressure and flow waveforms showed a cardiac oscillation pattern which was independent from the heart frequency or heart rate which was 96-102. The increase in peak pressure and flow volume seen at the end of the recording was during an expiratory hold maneuver.
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case_images: PMC10506872_01_CRICC2023-1132406.004.jpg
case_images: fig4
case_images: He was noted to have "spontaneous breathing" on the ventilator despite adjustments to the flow sensitivity (Figures 4(a) and 4(b)). Given the ongoing concern for the ventilator findings (Figures 4(a) and 4(b)), the ventilator was replaced with an alternate and ancillary testing was recommended. The alternate ventilator allowed for adjustment of the trigger settings from a flow trigger to a pressure trigger setting, enabling cardiac oscillations to be easily visualized on the ventilator (Figure 4(c)).
case_images: Transcranial Doppler (TCD): TCD showing typical systolic spikes in the middle cerebral artery (MCA) bilaterally and the "to-fro" pattern in the anterior cerebral artery (ACA) territory best seen on the right.
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case_images: PMC10506872_01_CRICC2023-1132406.005.jpg
case_images: fig5
case_images: Transcranial Doppler (TCD) was obtained and showed systolic spikes in the middle cerebral artery (MCA) bilaterally with the "to-fro" pattern in the anterior cerebral artery (ACA) territory best seen on the right (Figure 5).