# Campus Conundrum



## MrBrown (Oct 13, 2010)

You are called to a local frat house for a seizing female about 20. Her frat sisters report she was feeling unwell with nausea /vomiting the last few days, uanble to pee and had been having cramps. Tonight she was partying when she began to complain of a rapidly worsening headache and started to seize shortly thereafter.

Patient is unconscious w GCS 4 (1/1/2) 
BP is 160/100
PR is 84 reguar
RR is 20 NL
SPO2 is 98% RA
BGL is 6 mmol or 108ml/dl
Temp is 37°C or 98°F
Normal 12 lead although there might be some T wave inversion
No track marks
Pupils dialated 
No rash or other signs of meningitis 

The local hospital is twenty minutes down the road. 

You are whatever level of provider you wish to be and those handy fellows Brown and Oz from helicopter are sitting on thier bum watching telly should you require them.


----------



## jjesusfreak01 (Oct 13, 2010)

I dunno, sepsis following UTI?


----------



## Lifeguards For Life (Oct 13, 2010)

high flow 02 right? 25lpm via NRB? and 6lpm through a nasal cannula under that just to be safe?


----------



## Emtpbill (Oct 13, 2010)

Abdomen soft? Any masses?


----------



## mikie (Oct 13, 2010)

medications? medical hx?


----------



## Sandog (Oct 13, 2010)

With a GCS of 4 and possible stroke symptoms, I would call for Mr. Brown and his jumpsuit


----------



## Handsome Robb (Oct 13, 2010)

What's the ETA of Mr. Brown if called on? Doesn't sound like an infection because of the lack of fever. How about pupils?


----------



## Sandog (Oct 13, 2010)

NVRob said:


> What's the ETA of Mr. Brown if called on? Doesn't sound like an infection because of the lack of fever. How about pupils?



Dilated, see OP. ^_^


----------



## lightsandsirens5 (Oct 13, 2010)

Hmmm.....brain tumor? I dunno. 

There are some s/s of stroke, I don't know. I'll prolly call out Brown and Oz anyhow. 

"Control, 803, ILS, clear and transporting one, requesting air intercept for transfer to Sacred Heart. Coordinates to follow shortly, contact is 582 on LERN, 803."


Hey Brown.......we need a picture of your bird sometime.


----------



## jrm818 (Oct 13, 2010)

Emtpbill said:


> Abdomen soft? Any masses?



Like a baby?  What's the pt. look like - tall/short, petite/obese, abdomen grossly distended, flat, etc?

If we're still on scene, can we get any more history out of the frat sisters? Hopefully she's not a very private person. Is the pt. regularly sexually active?  Any chance we know if shes been having periods lately?  Any vaginal bleeding, discharge, etc?

Any history of drug use - today or in the past?  Ditto also on prescription meds?  What sort of etoh intake today?

What did the seizure look like?  How long did it last?  How long did it take us to get there/how long has she been unconscious?

In the absence of any further history its going to be a bit tough to make any sort of definitive diagnosis. 

Stroke is a possibility I suppose, but in a 20 y/o its sort of low on my list.

For now I think supportive treatment is all that can be done.  Maintain airway, think about working on the BP, get a line and prepare to terminate any further seizures, think about intubation I suppose (assuming the pt. doesn't start coming around).

Working differential list:

eclampsia
drug intake with a red herring history
seizure disorder, again with a red herring history
renal derangement/shutdown leading to electrolyte issues
stroke, but the rest of the history doesn't really fit with that
brain tumor
something different

If she isn't pregnant I'm really grasping at straws without a better history


----------



## CAO (Oct 13, 2010)

I'm in the boat of trying to get a little more from her sisters.

Did she ever get checked out for her prior complaints?

Was somebody with her the whole time she was partying?  Any chance anybody slipped anything into her drink?

Any recent surgeries?


----------



## CAO (Oct 13, 2010)

Forgot to ask.

Is the posturing bilaterally equal?


----------



## MrBrown (Oct 13, 2010)

jjesusfreak01 said:


> I dunno, sepsis following UTI?



Nope



Lifeguards For Life said:


> high flow 02 right? 25lpm via NRB? and 6lpm through a nasal cannula under that just to be safe?



Sure, why not I mean we all know it makes a difference right?



Emtpbill said:


> Abdomen soft? Any masses?



Yes and no



mikie said:


> medications? medical hx?



No meds and nothing her frat sisters know



NVRob said:


> What's the ETA of Mr. Brown if called on? Doesn't sound like an infection because of the lack of fever. How about pupils?



HEMS are ten minutes away, of course being a wholesome Republican party approved all American college town ... the volunteer fire department to set up a landing zone are thirty minutes away.



jrm818 said:


> Like a baby?  What's the pt. look like - tall/short, petite/obese, abdomen grossly distended, flat, etc?



The patient is a well nourished, healthy looking 20yof about 140lbs and 5'5" tall 



jrm818 said:


> If we're still on scene, can we get any more history out of the frat sisters? Hopefully she's not a very private person. Is the pt. regularly sexually active?  Any chance we know if shes been having periods lately?  Any vaginal bleeding, discharge, etc?



Unknown but she said that she was having trouble peeing ie unable to produce urine



jrm818 said:


> Any history of drug use - today or in the past?  Ditto also on prescription meds?  What sort of etoh intake today?



Nothing that anybody will admit too apart from some standard drinks



jrm818 said:


> What did the seizure look like?  How long did it last?  How long did it take us to get there/how long has she been unconscious?



The seizures lasted a few minutes and were tonic/clonic style without a postictal phase



CAO said:


> Did she ever get checked out for her prior complaints?
> 
> Was somebody with her the whole time she was partying?  Any chance anybody slipped anything into her drink?
> 
> Is the posturing bilaterally equal?



She didn't get checked out (broke college student) and she was alone for a period but nobody knows who with.

Here is some bloodwork:

Serum osm 200
CSF is hyperosmolar
Urine NA is 40 
Urine osm is 250
FENa .14
UP Creat 150
Preg neg 
BAC 0
BGL 6


----------



## Melclin (Oct 13, 2010)

Hyponatraemia?

Bet she's been on the bickies and hasn't been eating properly. But of course, I'd have to refer to the good doctor.

EDIT: Just saw the last post. Now I'm confuseded. I wanna press her about the ectasy. But if she hasn't been weeing then I'm stumped.


----------



## Aidey (Oct 13, 2010)

What was her K+?


Acute renal failure. Hyponatremia can be present because of all the extra potassium.


----------



## jrm818 (Oct 14, 2010)

Darn, I was hoping she was one of those pregnant and didn't know it girls you see on TV....guess that's out the window....

That moves us down my list to a renal issue.  I agree with the hyponatremia guess, and will go ahead and throw out a vote for renal shutdown leading to osmotic dilution and enough electrolytic imbalance to cause the sz and current ALOC.  

The anuria suggests to me that there's something obstructive going on.  My other thought (aided by google) was that inappropriately high ADH secretion could at least greatly diminish urine output, but her urine is pretty dilute (only slightly more concentrated than her serum) so the low/nil urine output is probably due to lack of flow through the kidney.

It seems to me that obstructive renal shutdown would explain the cramping, serum hypo-osmolarity, and would indeed eventually cause hyponatremia, higher FENa (or so says google), and could account for the proteinurea, raised creatine, and even the hypertension (thank you renin).  

Beyond this I'm way out of my depth, I'm not sure I know how to sort through the possibilities obstruction-wise...but very interested to hear the next update.  Further testing is called for I suspect....


----------



## CAO (Oct 15, 2010)

At this point in my training, I want to point at the sodium too.

The BP's has me wondering, though.

Gah...there's so much more I need to learn.


----------



## MrBrown (Oct 15, 2010)

Brown will have to start posting harder scenarios ......


----------



## jrm818 (Oct 15, 2010)

Does that mean someone won the prize??

Was this a real case?  I'm interested to know what caused her problems in the first place, and what the outcome is.


----------



## lightsandsirens5 (Oct 15, 2010)

MrBrown said:


> Brown will have to start posting harder scenarios ......



You cannot say that and then not tell!

And if you do start posting harder ones, that means that every time we solve one, you must remove one letter from the back of your jumpsuit. Ie. Brown's jumpsuit says DOCTOR. Brown posts scenario. EMTLife community solves scenario. Brown must alter jumpsuit to now read: DOCTO. This will continue for Five more scenarios until brown has a blank jumpsuit and everyone thinks he is the garbage truck driver. :-D


----------



## CAO (Oct 15, 2010)

MrBrown said:


> Brown will have to start posting harder scenarios ......



Ooh!  Please do.  I get a lot reading through these and seeing everyone's thought processes.

Just to make sure I understand something, the elevated BP was from when her body recognized the lowered sodium and attempted to conserve whatever it could by slowing down and stopping its excretion, which would also result in excess fluid being retained, right?


----------



## jrm818 (Oct 18, 2010)

CAO said:


> Ooh!  Please do.  I get a lot reading through these and seeing everyone's thought processes.
> 
> Just to make sure I understand something, the elevated BP was from when her body recognized the lowered sodium and attempted to conserve whatever it could by slowing down and stopping its excretion, which would also result in excess fluid being retained, right?



Actually I'm not so sure about that explanation.  That would be the normal response to hyponatremia, but the urine of this patient was rather dilute (about as dilute as their body serum) which does not indicate the sort of conservation you suggest.  It was that reason that I suggested an obstructive cause to the low flow - I figured physiologically low urine output would produce very concentrated urine, so this must not be physiological, and obstruction was the other source of low flow that occured to me.  Renal artery issues were the other, but given the lack of pain and young-ness of this pt., that seemed unlikely to me.

I was going with a osmotic dilution source of hyponatremia - e.g. the pt. was retaining most of their body water which produced the extremely dilute serum as shown in the lab results.  Combined with some of Meclin's proposed improper diet this could produce pretty severe electrolytic derangement.

At least that was my guess, but I'm still worry that I'm a bit off on the explanation.

Paging doctor brown. The natives are getting restless for an answer...


----------



## MrBrown (Oct 18, 2010)

jrm818 said:


> Paging doctor brown. The natives are getting restless for an answer...



Oh damn it to the bowels of bloody hell .... fine

*Brown crawls out from under the wreckage of the road traffic accident and dusts off his jumpsuit.  Oz, be a dear, let me know when the suxamethonium has worn off then shove in an LMA I have to go answer my pager ....

It was hyponatremia and syndrome of inappropriate ADH retention causing cereberal edema and seizure.

Patient was taken with much of the fastness to hospital where the people in blue scrubs had a fossik around in her noggin.


----------



## lightsandsirens5 (Oct 19, 2010)

MrBrown said:


> Oh damn it to the bowels of bloody hell .... fine
> 
> *Brown crawls out from under the wreckage of the road traffic accident and dusts off his jumpsuit.  Oz, be a dear, let me know when the suxamethonium has worn off then shove in an LMA I have to go answer my pager ....
> 
> ...



But what was the causation? Or do we even know?


----------



## MrBrown (Oct 19, 2010)

Wouldnt suprise me if it was MDMA


----------



## jrm818 (Oct 21, 2010)

MrBrown said:


> Oh damn it to the bowels of bloody hell .... fine
> 
> It was hyponatremia and syndrome of inappropriate ADH retention causing cereberal edema and seizure.



Rats - I had convinced myself that her urine wasn't concentrated enough to be SIADH.  I was all happy with myself for coming up with the obstructive guess on my own and then finding out it was a real possibility thanks to google.  Guess not...

Any clue what they did treatment-wise for her?  Any thoughts on how the pre-hospital treatment could have changed?

Great scenario, thanks for posting it.  You can go back to whirly-bird now...


----------



## ke5kce (Oct 21, 2010)

If hospital is a twenty minute drive away, no I would not call on the helicopter. By the time the crew gets out to the bird and wound up, I could be trucking down the road. High flow O2 and diesel.


----------



## Aidey (Oct 21, 2010)

ke5kce said:


> If hospital is a twenty minute drive away, no I would not call on the helicopter. By the time the crew gets out to the bird and wound up, I could be trucking down the road. *High flow O2* and diesel.



Why? She is 98% on RA.


----------



## jrm818 (Oct 21, 2010)

Aidey said:


> Why? She is 98% on RA.



to get her to 99!

99>98



http://www.youtube.com/watch?v=UeOXsA8sp_E&feature=related


----------



## CAO (Oct 21, 2010)

I'd have her on 2 liters, but that's only because the hospital would complain if I didn't have her on anything when I dropped her off.

Oxygen _is_ a drug, and it has effects.  Had this argument in class tonight, and it lasted way too long.

What's that sound?  I think it's Brown slamming his head into his desk from half a world away since the topic is still going, haha.


----------



## juxtin1987 (Jan 11, 2011)

Haven't been on here in a while and realize this post is a bit old but i'm backlogging to make up for lost time.

Just wanted to say that i dont buy this scenario one bit. Frat girl, 20 means second year of college found at a party so lets assume regular alcohol intake which makes MDMA next to impossible.

Am I wrong?


----------



## Melclin (Jan 11, 2011)

juxtin1987 said:


> Am I wrong?



Absolutely.

Why would drinking stop a person from taking MDMA?


----------



## MrBrown (Jan 11, 2011)

juxtin1987 said:


> Just wanted to say that i dont buy this scenario one bit. Frat girl, 20 means second year of college found at a party so lets assume regular alcohol intake which makes MDMA next to impossible.
> 
> Am I wrong?



Yes, dont read into that 100 hour course you took too much there mate


----------



## juxtin1987 (Jan 12, 2011)

MrBrown said:


> Yes, dont read into that 100 hour course you took too much there mate



That was meant to be ironic. Hyponatremia from MDMA's alone is a fairly common cause of demise in a frat house setting and the alcohol intake would only exacerbate said chance of demise.

AND Don't knock my 100 hour course Mr. Brown, everyone started with good intentions and a 100 hour course.


----------



## Melclin (Jan 12, 2011)

juxtin1987 said:


> AND Don't knock my 100 hour course Mr. Brown, everyone started with good intentions and a 100 hour course.



No not everyone. 

You whats unfortunate about your 100 hour course? It produces a bunch of providers so remarkably stupid that others make the mistake of thinking that a self evidently absurd comment, made in jest, was actually intended to be serious. Stupider things have been said here that were entirely serious. Apologies for my lapse in sarcasm detection


----------



## juxtin1987 (Jan 12, 2011)

Melclin said:


> Stupider things have been said here that were entirely serious.



This scares me :unsure:


----------

