45 yom, unknown medical problem

[Aidey]

Why the abrasions?
Jaundice is caused by liver failure, not renal failure.
Renal failure usually causes the breath to smell like ammonia, not alcohol.

 

[EMT91]

Why the abrasions?
Jaundice is caused by liver failure, not renal failure.
Renal failure usually causes the breath to smell like ammonia, not alcohol.

NOTE: I am a basic, so forgive me if I am not the brightest lol
The abrasions I got from the easy to bruise idea, a stretch but yeah.

http://medical-dictionary.thefreedictionary.com/jaundice
that mentions Kidney failure as a possible cause

The breath...well I never knew what it made the breath smell like, all I knew is that in one case one of my instructors told our class, she smelt alcohol and ironically enough:
"So, they admitted him for medically supervised detox, kept him on some benzos, and the theory goes that he will live happily ever after, except for his poor shriveled up, ammonia-poisoned brain. "

 

[mycrofft]

Stray shots:

ALCOHOL ON BREATH: so many people with other aromatics including diabetic acetone (DKA) and petroleum distillates have been identified as "ETOH on breath" that law officers and forensic health providers cite "alcohol-like odor" or "scent reminiscent of alcohol". Be careful.

ETOH DETOX: having many years of interesting observation subjects (arrested while drinking, so we had a confirmed date and time of last drink, followed by Q 4 hr vitals and frequent count/other observation), I can make these generalizations:
1. If the liver is working and the pt has no other contributing conditions or toxins, clinical detox (elevated BP, elevated pulse, complaints of abdominal distress, feeling jittery, sleeplessness) progressing to physiologic detox (tremor including areas not likely to have pseudo tremors, diarrhea, nausea/vomiting) starts within 48 hrs.

2. If the liver is not working well (evidenced by labs), the benzos for detox don't take effect promptly and seem to build in the bloodstream. I've seen pt's crash apparently from Valium OD on Day 4 post ETOH and the best we could ever figure out was the valium we kept pushing was not being activated by the liver, nor was it being excreted.


Focal paresis postictal! I need to remember that. I'll still teach by basic First Aiders to continue with their FAST eval for stroke, though.

 

[EMT91]

Stray shots:

ALCOHOL ON BREATH: so many people with other aromatics including diabetic acetone (DKA) and petroleum distillates have been identified as "ETOH on breath" that law officers and forensic health providers cite "alcohol-like odor" or "scent reminiscent of alcohol". Be careful.

ETOH DETOX: having many years of interesting observation subjects (arrested while drinking, so we had a confirmed date and time of last drink, followed by Q 4 hr vitals and frequent count/other observation), I can make these generalizations:
1. If the liver is working and the pt has no other contributing conditions or toxins, clinical detox (elevated BP, elevated pulse, complaints of abdominal distress, feeling jittery, sleeplessness) progressing to physiologic detox (tremor including areas not likely to have pseudo tremors, diarrhea, nausea/vomiting) starts within 48 hrs.

2. If the liver is not working well (evidenced by labs), the benzos for detox don't take effect promptly and seem to build in the bloodstream. I've seen pt's crash apparently from Valium OD on Day 4 post ETOH and the best we could ever figure out was the valium we kept pushing was not being activated by the liver, nor was it being excreted.


Focal paresis postictal! I need to remember that. I'll still teach by basic First Aiders to continue with their FAST eval for stroke, though.

So, my Renal Failure Idea was not a bad idea, per se?

 

[Veneficus]

You're on the truck today with your BLS partner, and the BLS first responders look at you and say "what do you need?"

A CT scan.

depending on the results of that, a neurosurgeon or neurologist with some mannitol, steroids, and Tpa.

 

[Aidey]

NOTE: I am a basic, so forgive me if I am not the brightest lol
The abrasions I got from the easy to bruise idea, a stretch but yeah.

http://medical-dictionary.thefreedictionary.com/jaundice
that mentions Kidney failure as a possible cause

The breath...well I never knew what it made the breath smell like, all I knew is that in one case one of my instructors told our class, she smelt alcohol and ironically enough:
"So, they admitted him for medically supervised detox, kept him on some benzos, and the theory goes that he will live happily ever after, except for his poor shriveled up, ammonia-poisoned brain. "

Jaundice is caused by a build up of bilirubin in the blood stream. Bilirubin is a component of hemoglobin which is the part of the red blood cell that allows the cell to carry oxygen. Red blood cells have a life span of about 3-4 months and when they die the bilirubin in them is released, processed in the liver and excreted as a waste product. Bilirubin is the reason urine is yellow, feces are brown, and bruises turn yellow. Your body is constantly excreting bilirubin because red blood cells die all of the time.

There are several conditions that cause abnormal red blood cell breakdown and kidney damage. Those patients can develop jaundice along with kidney failure, due to the extra bilirubin being released from the red blood cells and building up. I'm pretty sure those conditions are what the link was talking about. Look up hemolytic uremic syndrome, and that should explain it pretty well. It also is possible to run into patients who have both renal and liver dysfunction because they are just all around unhealthy people.

Chronic kidney failure actually causes anemia. The kidneys produce erythropoietin, which is a hormone that tells the bone marrow to make more red blood cells. When the kidneys fail, they stop producing epo, and thus the patient becomes anemic. Less red blood cells means less hemaglobin which means less bilirubin. As far as I know, jaundice is not a normal side effect of non-hemolytic kidney failure.


The very short version is that when you see jaundice, think liver, not kidneys.

 

[EMT91]

Jaundice is caused by a build up of bilirubin in the blood stream. Bilirubin is a component of hemoglobin which is the part of the red blood cell that allows the cell to carry oxygen. Red blood cells have a life span of about 3-4 months and when they die the bilirubin in them is released, processed in the liver and excreted as a waste product. Bilirubin is the reason urine is yellow, feces are brown, and bruises turn yellow. Your body is constantly excreting bilirubin because red blood cells die all of the time.

There are several conditions that cause abnormal red blood cell breakdown and kidney damage. Those patients can develop jaundice along with kidney failure, due to the extra bilirubin being released from the red blood cells and building up. I'm pretty sure those conditions are what the link was talking about. Look up hemolytic uremic syndrome, and that should explain it pretty well. It also is possible to run into patients who have both renal and liver dysfunction because they are just all around unhealthy people.

Chronic kidney failure actually causes anemia. The kidneys produce erythropoietin, which is a hormone that tells the bone marrow to make more red blood cells. When the kidneys fail, they stop producing epo, and thus the patient becomes anemic. Less red blood cells means less hemaglobin which means less bilirubin. As far as I know, jaundice is not a normal side effect of non-hemolytic kidney failure.


The very short version is that when you see jaundice, think liver, not kidneys.

Normally, I do think liver. I do not know why, but something just told me Kidneys. My instructor told us When you hear hoofs, think horses not zebras. . But was my thought process way off or do you see where I was coming from?

 

[Aidey]

The horse in this case would be the liver, not the kidneys.

 

[EMT91]

The horse in this case would be the liver, not the kidneys.

I know. But was my thought process way off or do you see how I arrived at renal?

 

[DPM]

I know. But was my thought process way off or do you see how I arrived at renal?

Renal isn't a bad guess, and is partly correct. It's just that it is most likely Renal failure / disease secondary to Liver Failure (and probably renovascular hypertension / Renal Stenosis too).

 

[Aidey]

I know. But was my thought process way off or do you see how I arrived at renal?

I think the best way I can put it is that I don't understand how you arrived at renal without stopping at hepatic first.

Renal isn't a bad guess, and is partly correct. It's just that it is most likely Renal failure / disease secondary to Liver Failure (and probably renovascular hypertension / Renal Stenosis too).

How is renal partly correct?

 

[DPM]

I should re-phrase that. The PT undoubtedly will have Kidney problems if they have Liver failure and uncontrolled hypertension. Atherosclerosis that is severe enough to require x4 cardiac stents is easily enough to start blocking up the delicate renal vasculature.

It isn't a Kidney issue that is causing the majority of our PT's problems, I was just pointing out that his seizure and liver failure aren't the only problems we're seeing evidence of.

 

[Melclin]

I'm familiar with Todd's paralysis but it didn't occur to me either. I've only every heard of Todd's in relation to partial motor seizures, and then with the caveat that the longer it goes on for, the less likely it is to be Todd's doing.

I think it would have been irresponsible not to call this in as a stroke. Bleed was highest on my list and I think it should be high enough on most people's list to warrant a stroke alert.

I don't look at stroke alerts as being a diagnosis of stroke on my part, I look at them as the recognition of the fact that the patient needs an emergent CT scan and neuro attention.

 

[abckidsmom]

I'm familiar with Todd's paralysis but it didn't occur to me either. I've only every heard of Todd's in relation to partial motor seizures, and then with the caveat that the longer it goes on for, the less likely it is to be Todd's doing.

I think it would have been irresponsible not to call this in as a stroke. Bleed was highest on my list and I think it should be high enough on most people's list to warrant a stroke alert.

I don't look at stroke alerts as being a diagnosis of stroke on my part, I look at them as the recognition of the fact that the patient needs an emergent CT scan and neuro attention.

Looking at him retrospectively with the thought of that witnessed by a "healthcare provider" seizure, this whole story changes. I think this just shows how important the history is, and how obnoxious it is when you can't get the information you need out of the people on the scene.

It's great that they turned him on his side to keep his tongue from occluding his airway, but other than that, the first responders actually got in the way on this one. The patient's mom, at the hospital, said something like, "I thought it might have been a seizure, but that guy didn't know, so I wasn't sure."

Awesome.

 

[VFlutter]

Wouldnt you expect a seizing patient to have slightly elevated lactate levels? They have a lot of muscle activity during an apnic state which would result in anaerobic metabolism and an increase in lactate? Just my thinking

 

[Melclin]

Looking at him retrospectively with the thought of that witnessed by a "healthcare provider" seizure, this whole story changes. I think this just shows how important the history is, and how obnoxious it is when you can't get the information you need out of the people on the scene.

It's great that they turned him on his side to keep his tongue from occluding his airway, but other than that, the first responders actually got in the way on this one. The patient's mom, at the hospital, said something like, "I thought it might have been a seizure, but that guy didn't know, so I wasn't sure."

Awesome.

Yeah good information to have but if I had a pt acting strangely with unilateral neuro symptoms who then has a seizure, I'd be more worried about a bleed, not less.

I don't think that knowledge would have changed anything for me other than to increase my index of suspicion for a bleed, but perhaps I'm wrong. How would it have changed your management or you handover other than adding the info?

 

[EMT91]

I think the best way I can put it is that I don't understand how you arrived at renal without stopping at hepatic first.



How is renal partly correct?

You are right. I am not sure how I skipped that link. The other symptoms were there and being that my knowledge only so far lol.

 

[blindsideflank]

I still think itsa bleed... No, but I was convinced too, especially if this was a call and I wasn't aware of a "tricky" scenario.
Subdural is the thought that comes to mind, add the meds (plavix I think) etoh, vitals and findings.


So with a bp/map that high and a high heart rate is it suggestive of not elevated icp? Vs say a bradycardia

 

[DPM]

So with a bp/map that high and a high heart rate is it suggestive of not elevated icp? Vs say a bradycardia

Hypertension, bradycardia and irregular breathing / widening pulse pressure would have made me think increased ICP. All we had was hypertension, which was borderline hypotension after the 2nd set of vitals...

It's a great scenario though, and I didn't know about Todd's until now. Ironically, I thought seizure before we got into the S/S... then the numbers came along and started to confuse me!

 

[abckidsmom]

I still think itsa bleed... No, but I was convinced too, especially if this was a call and I wasn't aware of a "tricky" scenario.
Subdural is the thought that comes to mind, add the meds (plavix I think) etoh, vitals and findings.


So with a bp/map that high and a high heart rate is it suggestive of not elevated icp? Vs say a bradycardia

This was a real call. They are all potentially tricky scenarios.