# A Nosey One



## MrBrown (Sep 7, 2010)

It's 1am on a freezing cold morning in the middle of winter.  A harsh blizzard is blowing and you're sent way out into the sticks past the old Peabody place, right at the abandoned general store where the ghost eats souls and down a winding goat track to a rambling old house.

Meanwhile, the helicopter Doctors and Paramedics are tucked up warm in thier bed and won't be avaliable tonight, aren't ya jealous? 

Upon locating you find a 15 year old female wrapped in a blanket on the couch.  She is sweating profusely and the blanket is soaked with sweat.  The patient does not acknowledge your presence and there is vomit all over the floor.

The parents relay that about two days previously she had been at school when somebody hit her in the nose with a baseball bat during gym class.  Since then she has complained of a headache on and off but has been acting normally and went to school yesterday.  Tonight she has vomited several times, said she feelt very nauseous and "spaced out" when sitting in the lounge trying to watch TV.  She felt better after having a nap and moved to the couch about an hour ago after waking when she began to vomit.

Initial obs at 1.30am
BP 75/30
RR 14
HR 140
BGL 10mmol (~180 mg/dl)
GCS 13/15
SPO2 98% RA
Temp 37 C (checked twice)
Pupils equal and reactive to light

Repeat obs
BP 112/70
RR 14
HR 160
GCS 7/15
SPO2 98% RA
Temp 37 C (checked twice)
Pupils equal and reactive to light

More obs
BP 160/120
RR 14
HR 180
GCS 13/15
SPO2 98% RA
Temp 37 C (checked twice)
Pupils sluggish and non-reactive

No obvious frank signs of a head injury (CSF leaking, battle/racoon signs, swelling)

What do we think is wrong?


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## KY_EMT (Sep 7, 2010)

Sounds like a closed head injury patient I once had...just throwing that out there.


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## MrBrown (Sep 7, 2010)

Nope it's not a head injury although that is what everbody seemed to think.


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## Veneficus (Sep 7, 2010)

meningitis or cancer?


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## Sassafras (Sep 7, 2010)

Perhaps a whiplash type spinal injury causing neurogenic shock?  With the erratic bp and tachycardia I'm wondering about some sort of shock.  Wait, is it neurogenic I'm looking for?  The one w/ the spinal injuries...yeah that's right.  Almost got confused with psychogenic.


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## abckidsmom (Sep 8, 2010)

Thyroid storm.


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## MrBrown (Sep 8, 2010)

Veneficus said:


> meningitis or cancer?



what makes you think that and would a wbc of 19 10/9 per litre high band and segmented neutrophils and high erythrocyte sedimentation rate help with a diagnosis at all


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## Cawolf86 (Sep 8, 2010)

MrBrown said:


> what makes you think that and would a wbc of 19 10/9 per litre high band and segmented neutrophils and high erythrocyte sedimentation rate help with a diagnosis at all



Injury to the face in that area does give me a high index of suspicion for an infection....but where does the increasing BP and lack of fever fit into that story....hmm.


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## KY_EMT (Sep 8, 2010)

Hmmmmmmmm....yeah, I automatically thought of head injury/concussion. This is very similar to how I presented after my ambulance wreck. Or so I've been told LOL I was pretty outta it, so I don't know for sure.


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## lightsandsirens5 (Sep 8, 2010)

Cawolf86 said:


> Injury to the face in that area does give me a high index of suspicion for an infection....but where does the increasing BP and lack of fever fit into that story....hmm.



Good point. And the increasing BP is driving me away from shock. Isn't it generally; HR-up, BP-down? Except here we have HR-up, BP-up. Unless she is compensating extremely well. 

And what's with the pupils becoming sluggish all of a sudden? What size are they?

What I can tell you is that going from 75/30 to 160/120 is not a good thing. If that trend continues, she is gonna stroke out.


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## abckidsmom (Sep 8, 2010)

lightsandsirens5 said:


> Good point. And the increasing BP is driving me away from shock. Isn't it generally; HR-up, BP-down? Except here we have HR-up, BP-up. Unless she is compensating extremely well.
> 
> And what's with the pupils becoming sluggish all of a sudden? What size are they?
> 
> What I can tell you is that going from 75/30 to 160/120 is not a good thing. If that trend continues, she is gonna stroke out.



I could blame that on agitation related to the mental status changes, though.

I'm hoping to hear that this is some kind of an endocrine crisis resulting from a smack to the parathyroid.  It would be fun to be on the right track...


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## EMTinNEPA (Sep 8, 2010)

I'm leaning towards an infection with that WBC count.  Also, the good doctor is not telling us the circumstances around those VS changes.  Is that following treatment?  Fluid replacement therapy or pressors?


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## Melclin (Sep 8, 2010)

GHB overdose is something to consider. Although it does seem kinda unlikely given the setting and the obvious suspicious head trauma a few days previous. I wouldn't put my money on it but its just a thought to throw in the mix given the labile GCS, haemodynamic instability and profuse sweating.


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## Sam Adams (Sep 8, 2010)

I've read the discussion thus far a couple times, and pre-eclampsia keeps crawling out of the muck and mire. 

Dr. Brown, LMP?


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## MrBrown (Sep 8, 2010)

Thats Brown MBChB, FANZCA, FJCICM to you 

No, its not a GHB OD or a head injury and the vital signs were recorded without significant intervention eg fluids or pressors.


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## Veneficus (Sep 8, 2010)

MrBrown said:


> what makes you think that



They are on the short list of things that cause night sweats. The girl is 15, and most Acute Lyphoblastic Luekemias (ALL) occur in children. Acute Myleogenous Leukemia has an age of onset at about 15. (AML)




MrBrown said:


> and would a wbc of 19 10/9 per litre high band and segmented neutrophils and high erythrocyte sedimentation rate help with a diagnosis at all



No, it just confounds it more.

Increased WBC can be almost any inflammatory disorder and non specific. However, hyper segmented neutrophils are found in megagloblastic anemias. 
(often from vit B deficency) There is not often neurological changes in folate deficency, which might point to a pregnancy or malabsorbtion type event. but then there would be leukopenia most likely.

Then you add in banded neutrophils which are not fully matured and it brings you to an event that gives way to a massive immune reaction.

RBC sedementation could be caused by everything from pregnancy, to immune reaction (which we know we have) to polycythemia. (another potential indicator of AML or pre AML disease)

But getting away from lab values again,

sepsis does not always present with fever. meningitis would be consistant with that. 

baseball bat to the face suggests some of the normal nasal or oral flora could be in a compartment it doesn't belong in, and a hematoma somewhere could really feed bacteria.

It is not the blood count I would be interested in, it would be the lumbar puncture. Particularly looking for bacteria or a decrease in glucose. a Urine HCG would also help a lot.

The more I think about the epidemiology, the more i like meningitis. (When hearing hoof beats think horses not zebras right?) 

Cranio-facial trauma
Increased WBC includeding banded neutrophils
Low or no fever
Mental status changes
Night sweats

Could still be pregnant, but the physical exam findings of such were not listed. Especially with a previous RH sensitivity.

Need some more specific info than a blood test that simply adds to the list.


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## Simusid (Sep 9, 2010)

Veneficus said:


> It is not the blood count I would be interested in, it would be the lumbar puncture. Particularly looking for bacteria or a decrease in glucose. a Urine HCG would also help a lot.



Could you expound on your "decrease in glucose" thoughts a bit?   I'm just a nitwit EMT-B.   How does a lumbar puncture lead to low glucose?


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## Sam Adams (Sep 9, 2010)

MrBrown said:


> Thats Brown MBChB, FANZCA, FJCICM to you



I think we had a failure to communicate.

When was her Last Menses?

*edit: assuming her family knows ...


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## MrBrown (Sep 9, 2010)

LMP was about a month ago and has been normal supposedly


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## Saytuck99 (Sep 9, 2010)

Not that I could treat anything beyond BLS protocols in this case...it sounds like it could be an unrelated heart issue, but the pupils are the windows to the brain...something that would effect both things? How about a spinal cord/brain stem injury..that would throw all systems out of whack..brain..heart...core temperature regulation...

Then again it could just be an infection...just my two pennies worth


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## Veneficus (Sep 9, 2010)

*no need to call yourself names to ask a question*



Simusid said:


> Could you expound on your "decrease in glucose" thoughts a bit?   I'm just a nitwit EMT-B.   How does a lumbar puncture lead to low glucose?



One of the most important, if not the most important aspect of menigitis is to distinguish bacterial/fungal which left untreated is often fatal; from Viral, when left untreated often is not.

You are basically looking at the findings of the CSF. 

In Bacterial fungal infection, in CSF (as opposed to blood) you expect to see:

a cell count of 1000-20,000/mm3 (white cells)
>90% neutrophils
a decreased level of CSF glucose (from bacterial metabolism) Normally it should be between 45-80 mg/dl <40 is often diagnostic.
an increase in CSF protein
Usally it is a Gram + bacteria and the culture is most often positive (greater than 65% of cases) 

Viral:
<1000 cells/mm3 (white cells)
neutrophils for ~48 hours switching to lymphocyte/monocytes (normal for viruses everywhere)
CSF glucose WNL unless mumps or herpes is also present.
negative gram stain (there is no bacterial cell wall to be stained)


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## CAOX3 (Sep 10, 2010)

Polar bear attack, you got them in New Zealand right?


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## Melclin (Sep 10, 2010)

CAOX3 said:


> Polar bear attack, you got them in New Zealand right?



Nah mate. Drop bears. Although ours are bigger.


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## CAOX3 (Sep 10, 2010)

Veneficus said:


> a decreased level of CSF glucose (from bacterial metabolism) Normally it should be between 45-80 mg/dl <40 is often diagnostic.



Just curious any idea how long after onset of symptoms will these findings be present?

And soon I will have my cisternal puncture certification, its a four hour add on class this Saturday.


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## Veneficus (Sep 10, 2010)

CAOX3 said:


> Just curious any idea how long after onset of symptoms will these findings be present?



The lab findings should be present before symptoms. The CSF is very difficult for bacteria to penetrate into (it is the last place they are found) in order to create symptoms the microbes wold already have to be outstripping the immune response.



CAOX3 said:


> And soon I will have my cisternal puncture certification, its a four hour add on class this Saturday.



Four hours!!! if you just take the skill part instead of all that physiology stuff that doesn't make a difference in the field you can get it in 1.


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## Cawolf86 (Sep 13, 2010)

If no more brain storming on the scenario occurs - is it possible to post the results?

Thanks.


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## MrBrown (Sep 13, 2010)

It was meningitis


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