MediMike Posted August 12, 2021 Share Posted August 12, 2021 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! 1 Quote Link to comment Share on other sites More sharing options...
ohiovolffemtp Posted August 12, 2021 Share Posted August 12, 2021 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 1 Quote Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted August 12, 2021 Moderator Share Posted August 12, 2021 All of the above plus the noncontrast head CT images. Quote Link to comment Share on other sites More sharing options...
CAAdmission Posted August 12, 2021 Share Posted August 12, 2021 5 minutes ago, EMEDPA said: All of the above plus the noncontrast head CT images. 1 Quote Link to comment Share on other sites More sharing options...
charlottew Posted August 12, 2021 Share Posted August 12, 2021 Any recent history of headache, dizziness, weakness, parasthesias? ask the wife Quote Link to comment Share on other sites More sharing options...
MediMike Posted August 13, 2021 Author Share Posted August 13, 2021 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 Quote Link to comment Share on other sites More sharing options...
Moderator LT_Oneal_PAC Posted August 13, 2021 Moderator Share Posted August 13, 2021 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? 1 Quote Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted August 13, 2021 Share Posted August 13, 2021 (edited) And where might his place of business be? Sounds like me at Costco 10 years ago w/o the hypotension but a souvenir occiput head lac that the ding-dong PA insisted on putting simple interrupted sutures in as opposed to a running horizontal mattress. Edited August 13, 2021 by GetMeOuttaThisMess Quote Link to comment Share on other sites More sharing options...
ohiovolffemtp Posted August 14, 2021 Share Posted August 14, 2021 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? 1 Quote Link to comment Share on other sites More sharing options...
MediMike Posted August 14, 2021 Author Share Posted August 14, 2021 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 1 Quote Link to comment Share on other sites More sharing options...
ohiovolffemtp Posted August 14, 2021 Share Posted August 14, 2021 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. Quote Link to comment Share on other sites More sharing options...
MediMike Posted August 14, 2021 Author Share Posted August 14, 2021 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. 1 Quote Link to comment Share on other sites More sharing options...
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