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Details have been changed etc. etc.

35 year old male without prior medical history with acute onset confusion at place of business.  A/O to location and wife, EMS arrived for transport, en route to ED generalized tonic clonic seizure activity lasting approximately 3 minutes.  Self terminated.  On arrival in ED concerns for airway protection, intubated.

Vitals:

BP 60/40

HR 124 Sinus tach

Vent AC/VC 16/550/10

------------------

We can do the old ya'll ask for labs/imaging/history etc or I can just relay it. Lemme know!

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OK, I'll start - from the EM perspective:

  • Any signs of recent trauma, especially head trauma, though the vitals don't sound like a Cushing's triad?
    • CT & CTA head & neck results?
  • Hypoglycemia: though that would have been fixed pre-hospital or in the ED - finger stick?
  • Electrolyte abnormalities: 
    • CMP, Mg, ammonia levels?
  • Tox:
    • UDS & ethanol levels
  • Dehydration: though doubt that would have made it to the unit.
    • Urine specific gravity
  • Cardiac:
    • any ectopy, intervals out of wack, etc on EKG
       
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20 hours ago, charlottew said:

Any recent history of headache, dizziness, weakness, parasthesias? ask the wife

 

None, otherwise healthy guy.  She says he's trying to lose weight.

23 hours ago, ohiovolffemtp said:

OK, I'll start - from the EM perspective:

  • Any signs of recent trauma, especially head trauma, though the vitals don't sound like a Cushing's triad?
    • CT & CTA head & neck results?
  • Hypoglycemia: though that would have been fixed pre-hospital or in the ED - finger stick?
  • Electrolyte abnormalities: 
    • CMP, Mg, ammonia levels?
  • Tox:
    • UDS & ethanol levels
  • Dehydration: though doubt that would have made it to the unit.
    • Urine specific gravity
  • Cardiac:
    • any ectopy, intervals out of wack, etc on EKG
       

No trauma, significant amount of sunburn on upper torso although it's peeling

CT/CTA clean

Glucose 293

Na 147, K 4.3, Cl 103, CO2 8, BUN 12, Scr 1.44, Ca 9.3, Mg 3, NH3 750

UDS/Ethanol wnl

Urine SG 1.014 Urine Na <10

12 lead no ectopy/weirdness

I'll throw in the lactate >24 for free 🙂

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23 hours ago, ohiovolffemtp said:

OK, I'll start - from the EM perspective:

  • Any signs of recent trauma, especially head trauma, though the vitals don't sound like a Cushing's triad?
    • CT & CTA head & neck results?
  • Hypoglycemia: though that would have been fixed pre-hospital or in the ED - finger stick?
  • Electrolyte abnormalities: 
    • CMP, Mg, ammonia levels?
  • Tox:
    • UDS & ethanol levels
  • Dehydration: though doubt that would have made it to the unit.
    • Urine specific gravity
  • Cardiac:
    • any ectopy, intervals out of wack, etc on EKG
       

@MediMikeSame, add as part of my standard young AMS eval: salicylate, APAP level, TSH, ABG (central VBG if line placed),troponin, CRP, PT/PTT,  ocular US for papilledema, RUSH exam. Some of that I think is actually important, some of it I know when I transfer I’ll be asked.

 BP response to fluids? Pressors required? Pressors resistant?Repeat lactic? CBC? Temp? Ask wife any preceding symptoms at all? Increased thirst, changes in urination? Vision changes, poor coordination, joint pains, vomiting, rash, travel? What’s his place of business? Send him upstairs and let the nerds figure it out 😉 

after seeing your response: BHB serum ketones, A1c, FeNA. what is he doing to lose weight? What rx and OTC meds/supplements is he taking?

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So, ammonia very high - what were the LFT's as part of his CMP?  Creatinine a bit high  Yes to all of the questions the Lt is asking.

Also, what tx did EMS and the ED try, esp fluids, and how did the pt respond?

Among the active ingredients in aloe vera (for his sun burn) are salicylates - so definitely include salicylate level.  Was he using a lot of sunburn cream with aloe vera?

Was a LP done?  If so, opening pressure?  CSF fluid analysis? 

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17 hours ago, LT_Oneal_PAC said:

@MediMikeSame, add as part of my standard young AMS eval: salicylate, APAP level, TSH, ABG (central VBG if line placed),troponin, CRP, PT/PTT,  ocular US for papilledema, RUSH exam. Some of that I think is actually important, some of it I know when I transfer I’ll be asked.

 BP response to fluids? Pressors required? Pressors resistant?Repeat lactic? CBC? Temp? Ask wife any preceding symptoms at all? Increased thirst, changes in urination? Vision changes, poor coordination, joint pains, vomiting, rash, travel? What’s his place of business? Send him upstairs and let the nerds figure it out 😉 

after seeing your response: BHB serum ketones, A1c, FeNA. what is he doing to lose weight? What rx and OTC meds/supplements is he taking?

ASA/APAP - Neg

TSH - 2.9

ABG - <6.8/Won't Compute/220/Won't compute HCO3 or base deficit/99%

Trop - Neg

Coags - WNL

CRP - Not obtained

FeNA - 0.0%

AST/ALT - 71/65

Operates a demolition yard.

Ding ding dong for the meds hx...

Phentermine, herbal laxatives, Orlistat, HCG diet supplements, 3 separate overseas SSRIs and a "GoSlimTea" which instead of brewing he would fill capsules with and just eat.

Loaded him with Keppra, propofol and fentanyl. Other than requiring around 5 liters of resus and multiple pressors this guy came around just fine.  Ammonia was down to 150 by the follow up check a couple hours later just barely avoiding HD.  Was actually extubated later in the afternoon.  Between a ridiculously controlled calorie diet, multiple stimulants and laxatives the guy just sent himself into a metabolic mess.

The ammonia of 750 is the absolute highest I've ever seen, had the lab repeat it just to make sure.  Explains the SZ activity and encephalopathy!

I had no idea that there were formulations of aloe with salicylates in them! That's great information to have @ohiovolffemtp

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1 hour ago, ohiovolffemtp said:

Actually, some of the naturally occurring active ingredients in the aloe plant are salicylates.  Was zebra hunting and thought excessive topical sunburn creams might be contributing.

Did the ammonia come down on its own, or did you give lactulose?  I've begun to see some articles which say it doesn't do much other than cause diarrhea.

Ended up coming down on its own. Only thing I've seen re: lactulose was a comparison with polyethylene glycol in a 20 person study. Noninferior and less GI issues with PG.

Anecdotally it works to lower ammonia, improve encephalopathy..and cause massive diarrhea.

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