A 44 year old man was found unconscious at home. He was brought in to the ED by ambulance. On arrival GCS =3 with fixed and dilated pupils. Temperature 25.9, hypotensive.Bloods show:
pH 6.9
pCO2 58 (35-45 mmHg)
HCO3 7 (22-26 mmol/l)
BE -24
Sodium 132 (137-145 mmol/l)
Potassium 7.2 (3.5-5 mmol/l)
Cl 95 (99-111 mmol/l)
Urea 10.6 (3-8 mmol/l)
Creatinine 267 (<130 umol/l)
CK 1835
Lactate 26 (<2 mmol/l)
Bilirubin 71 (<21 umol/l)
ALP 152 (35-110 U/L)
GGT 88 (<51 U/L)
ALT 8791 (<56 U/L)
- Describe the abnormalities
- Interpret your findings and give reasonable differential diagnosis
- What are your immediate life threats?
- How would you proceed?
Just a CC paramedic here looking to practice with labs, so go easy on me! Patient is in an anion gap mixed acidosis, hyperkalemic, hypothermic and showing multi organ dysfunction.
Given age, presentation and liver enzymes I am thinking OD. Maybe acetaminophen?
Immediate life threats are acidosis, hyperkalemia, hypothermia.
I would proceed with manual ventilation at RR of at least 30. Warm patient with warm saline, blankets and warmer if present. Treat the hyperK, CaCl, insulin, dextrose, bicarb, and ventolin. Assuming by this point our pH has come above 7.1 and his pressure is manageable. RSI and mechanical ventilation with the goal of maintaining a pH > 7.25 if possible. Call a Doc and see about acetylcystine?
That’s where I run out of options and take him somewhere for further management.
Good effort – don’t have a lot more to add. I’ll post the answer later, please have a look. A few other causes to consider