(P42) Hey Doc, i’m Feeling Blue!

Chief Complaint : Skin paleness and cyanosis of lips and fingertips

History of Present Illness : Patient is a 23-year-old female with a past medical history of myotonic dystrophy, presenting to the ED for evaluation of lightheadedness and near syncope, now with pallor and cyanosis of the lips and fingertips. She her wisdom tooth extracted earlier that afternoon. She took a nap after the procedure, woke up 3 hours later with these symptoms. She is unaware of what medications were used during the procedure. She denies any fever, chills, shortness of breath, chest pain, abdominal pain, syncope, headache, and vomiting. She has no history of previous similar symptoms.

Pertinent Physical Exam: GENERALIZED APPEARANCE: Patient is awake, alert, oriented x3, in mild distress
VITAL SIGNS: BP – 147/89, P – 99bpm, R – 20brpm, SPO2 – 91% on 15L
SKIN: (-) Diaphoresis, (+) Central, peripheral cyanosis, skin pale, cool, clammy.
EYES: (-) conjunctival pallor, (-) scleral icterus
ENMT: Pharynx: (-) erythema; airway patent: (-) stridor: mucous membrane moist.
CHEST AND RESPIRATORY: (-) rales, (-) rhonchi, (-) wheezes; breath sounds equal bilaterally
HEART AND CARDIOVASCULAR: (-) irregularity; (-) murmur, (-) gallop
VASCULAR: (+) distal pulses, (+) symmetric
NEURO: Mental status as above. Cranial nerves intact. No focal deficit. Speech is clear and fluid.

Pertinent Laboratory Data: ABG: pH – 7.43, pCO2 – 36mmHg, pO2 – 249mmHg, HCO3 – 24mmol/L, Base Excess -0.1mmol/L, HGB 13.5g/dL, O2 Hb – 73.8%, CO Hb – 0.0%, MetHb – 23.6%

Case Discussion: The patient presented with concern about pallor and cyanosis of the lips, fingertips, and skin which started after she had her wisdom teeth removed. She denied any chest pain or SOB, though did report lightheadedness earlier., While her initial triage showed an oxygen saturation of 94%, on room air, and subsequent vital signs, showed she was hypoxic to 89% on RA, and continued to be hypoxic even with increasing oxygen therapy, to a maximum saturation of 91% on 15L of O2. On the lab draw, the patient’s blood was noted to be chocolate brown as well. Due to the patient’s history of a dental procedure earlier in the day, suspicion for methemoglobinemia was raised, as she likely received lidocaine during her procedure, however, the patient was unable to recall what medications were used during it, and the surgeon was unavailable for a consult. A methemoglobin level was drawn, and it was noted to be >20%. Due to the patient having symptomatic and profound methemoglobinemia, methylene blue treatment was started, and she was admitted to the ICU.

References and Acknowledgements (Optional): N/A