A man in his 40s with a history of hypertension and alcohol dependency presented to the ED with respiratory distress, confusion, and vomiting. Prior to arrival, the patient was reported to be intoxicated and vomiting, with concern for aspiration.
His initial BP was 140/90 mm Hg; heart rate, 155 beats/min; respiratory rate, 36 breaths/min; and temperature, 40°C. Oxygen saturation was 85% on a nonrebreather mask. The patient was somnolent, disoriented, and urgently intubated for airway protection and hypoxia. The ECG showed sinus tachycardia with a new incomplete right bundle branch block. Chest radiograph showed bilateral infiltrates with opacification of the right hemidiaphragm (Fig 1). WBC count was 4.5 × 103/μL. Alcohol level was 225 mg/dL, and creatinine level was 1.8 mg/dL.