# Burly Bruce and the altered conscious state



## Melclin (Aug 5, 2011)

0832 on a cool morning, you are called to a "Person acting strangely". The location hx has a number or previous calls for psychiatric pts.

You are met by a woman in her 60's who says you are here for her husband. He complained of a headache in the early hours of the morning and is now acting very strangely. 

You find a male in his mid 60's sitting upright on the couch, eyes closed, mumbling. 

He responds to voice, but is clearly altered conscious. 

61 YOM

*Hx*
Liver failure (ETOH addiction), Spontaneous subdural haematomas (four this year, small, self resovling). Type II diabetes.

Current presentation is consistent with, but worse than previous presentations of subdural haematoma. Nil hx of intubation. Wife denies hx of UTI, but does note that her husband was complaining of difficulty urinating the previous day. Pt is on a low salt diet. Pt has been poorly motivated and often tired in past months + hypersomnolence. No recent hx of being generally unwell/fevers/coughs/cold/flu like symptoms etc. 

*Meds *Norfloxacin (don't know what it was for), Glicazide, Amiloride, Frusemide, Lactulose.

NKA

*O/E*
BP: 160/sys (he doesn't like the BP cuff and keeps moving too much to auscultate). 
Pulse: 80, BSL: 8.1, SpO2: 98%, RR: 16.
Temp: You are unable to get a temp because he cannot be made to stay still. He doesn't feel hot. 
GCS: 13 (E3,V4,M6)
ECG: Sinus rhythm with artefact and a wandering baseline (due to movement).

Atraumatic. PEARL, ascites evident, chest is clear as best you can hear with the movement anyway. Complaining only of nausea. 

Upon suggestion that he should walk out to the ambulance he becomes aggressive, saying repeditively that he doesn't want to go and starts stomping arround the house. He now replies to any questioning or any stimulus at all by repeating that he doesn't want to go. Show him a picture of his daughter and ask who it is and he motions to hit you screaming that he doesn't want to go, eyes closed the whole time. You could say now that he is GCS 12 (E3V3M6). While he wouldn't obey commands he I felt that it was more a matter of not wanting to rather (he was after all walking around at this stage) and that GCS12 most adequately reflected his conscious state.

*How are you ganna manage this bloke and what do you think is wrong with him? *


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## mycrofft (Aug 5, 2011)

*I suppose he didn't cooperate with a pupil check and mouth check?*

A CNS bleed of some sort is of course suspect #1. One must entertain potential portal hypertension. UTI is another suspect, even if the "mom-o-meter" (hand to forehead) failed to detect heat.

Meds list is interesting, looks like two uncommunicative physicians are ordering, or the pt is continuing Rx that has been superceded by newer orders. A lot of potassium yin-yang going on (lactulose, two different diuretics), and the potential problems with Norfloxacin for this pt are multiple, including potentiation for a bleed, and for nephrotic falure. (Since Norflox is a "last ditch" antibiotic, it might be important to find out why he is on it).

This all can be superimposed upon independent behavioral/cognitive alterations due to alcohol abuse, the psych calls listed earlier (why no psych meds?).

Effects on field treatment: not many. Reassure, transport to hospital for labs and other diagnostics. Be ready for resistive pt. If transport is long distance, be ready for urgent loose stool if he took his lactulose. Bring his meds, if that is the issue, steps can be taken to kill the prescriptions and the stock at hand destroyed.


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## Sam Adams (Aug 5, 2011)

How's his ammonia levels?


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## Leafmealone (Aug 5, 2011)

Sam Adams said:


> How's his ammonia levels?



Good luck trying to get this info.


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## MrBrown (Aug 5, 2011)

See if we can get wife (or daughter) to calm him down and have a chat

He is clearly self aware and able to communicate consistently on the fact he does not want to go - so he is competent to decline our recommendatory

Does he have any history of mental illness or psychosis? Who is his GP? Perhaps getting the GP on the phone for a chat?


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## Melclin (Aug 5, 2011)

I should clarify. The psych history for the location is a history of dispatch coding to that address, not a record of actual conditions. So if a person rings up and says, "My friend is acting weird and they have diabetes", its likely to get coded as "Diabetic problems, Alert" and attached to that address. The fact that they end up having huffed a bunch of pain thinner is irrelevant to the location hx.



mycrofft said:


> transport to hospital for labs and other diagnostics. Be ready for resistive pt.



But how to do that? He's not budging. Any suggestion otherwise meets with some screaming and at least once he swung a punch.


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## mycrofft (Aug 6, 2011)

*OK,, await unconsciousness then transport.*

 Naw, follow Brown there.

Ammonia test: sniff breath. If he urinates, you ought to be able to get that funky odor too.


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## boingo (Aug 6, 2011)

A little Thiamine couldn't hurt...


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## usalsfyre (Aug 6, 2011)

Hepatic encephalopathy, head bleed, there's several different possibilities. 

A small (very small) dose of nasal midaz, then back off and wait for the effects to start with.


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## Smash (Aug 6, 2011)

Beriberi with Wernicke-Korsakoff (I like his stomping gait), brain bleed, hyponatremia, occult sepsis... Who the hell knows?!

I agree with usalsfyre for treatment.


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## Melclin (Aug 6, 2011)

Well chaps and chapettes, some good guesses and some nice stuff in their as well. Quick and dirty ammonia tests, stomping gaits & beriberi (I wouldn't be surprised if I saw that working in the area that I do at the moment). 

CT showed evidence of an old subdural but nothing new. Electrolytes were good. Sepsis screen was negative. *Hepatic encephalopathy was the culprit*. I followed up with his doc a few days later and apparently he is a bit of a frequent flyer with the GI guys. He was admitted under GI, they drove a few truck loads of lactulose into him and he was all better. 

I put subdural on the top of my list due to the hx and because that changed our management more than anything else (going to a hospital that has neuro surg). Hyponatraemia was my next guess (it was an identical presentation to some hyponatraemia related alter conscious states I've seen in the past). We had police come down, manhandle him into restraints and I gave him 12.5mg of prochloperazine in the hopes that if we sorted his nausea and headache he might be a bit less cranky and I was hoping it would also sedate him a little. It worked quite well, he was asleep when we arrived at hospital and didn't give us too much grief moving off stretcher. He did need to be sedated for CT though. I had a chat with a senior paramedic on the radio about some midaz but he didn't feel comfortable with it in the setting of a possible subdural. I think we're a little too cautious when it comes to midaz and head bleeds here. Its frustrating having to wrestle people only to see them affectively and safely midazed on arrival.

I would love to have given the IN midaz a shot. I wasn't comfortable with having a bloke who may have blown a head gasket being wrestled and then fighting the restraints. 

For future reference, what dosages would you be thinking about IN? I would suppose he was about 90kgs, liver disease. 1-2mg?


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## abckidsmom (Aug 6, 2011)

Melclin said:


> Well chaps and chapettes, some good guesses and some nice stuff in their as well. Quick and dirty ammonia tests, stomping gaits & beriberi (I wouldn't be surprised if I saw that working in the area that I do at the moment).
> 
> CT showed evidence of an old subdural but nothing new. Electrolytes were good. Sepsis screen was negative. *Hepatic encephalopathy was the culprit*. I followed up with his doc a few days later and apparently he is a bit of a frequent flyer with the GI guys. He was admitted under GI, they drove a few truck loads of lactulose into him and he was all better.
> 
> ...



Speaking as a nurse, I don't think you're giving enough respect to the truckloads of lactulose this guy encountered.  I have never wished for poop to go all the way to liquid like I have when giving serial lactulose enemas and boluses down the NG tube.  Oh, the joys of a 23french foley, rectally, when it saves your day.

FYI:  If you want to be a nurse, you don't want to work on the transplant service.  Not one little bit.


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## usalsfyre (Aug 6, 2011)

Hepatic encephalopathy due to the ammonia was kinda #1 on my list, probably just because we have several liver failure guys in my area.

0.5-1mg. Remember anything you give is going to have a profound effect and stick around a very long time. Whatever you do you don't want to knock him down so far he can't protect his own airway. Digging around with a laryngoscope on a patient who has liver hx is not my idea of a good time...


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## Melclin (Aug 6, 2011)

abckidsmom said:


> Speaking as a nurse, I don't think you're giving enough respect to the truckloads of lactulose this guy encountered.  I have never wished for poop to go all the way to liquid like I have when giving serial lactulose enemas and boluses down the NG tube.  Oh, the joys of a 23french foley, rectally, when it saves your day.
> 
> FYI:  If you want to be a nurse, you don't want to work on the transplant service.  Not one little bit.



HAHAHA yeah when I was doing some reading after this job, I noted that lactulose had "almost certain diarrhoea" listed as a side affect. 

There is no amount of money you could pay me to be a nurse.


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## Melclin (Aug 6, 2011)

usalsfyre said:


> Hepatic encephalopathy due to the ammonia was kinda #1 on my list, probably just because we have several liver failure guys in my area.
> 
> 0.5-1mg. Remember anything you give is going to have a profound effect and stick around a very long time. Whatever you do you don't want to knock him down so far he can't protect his own airway. Digging around with a laryngoscope on a patient who has liver hx is not my idea of a good time...



They gave him 1.5mg IV to go to CT and it was a bit too much. He was out for the count and the EM reg was getting a little antsy.


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## mycrofft (Aug 7, 2011)

*Well I wasn't too far off , pragmatically speaking.*

"Effects on field treatment: not many. Reassure, transport to hospital for labs and other diagnostics. Be ready for resistive pt. If transport is long distance, be ready for urgent loose stool if he took his lactulose. Bring his meds, if that is the issue, steps can be taken to kill the prescriptions and the stock at hand destroyed".


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