Hyperglycemia, Seizure, and Full Arrest

lightsandsirens5

lightsandsirens5

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Thoughts?

16 YOF. Insulin dependent Diabetic. No other medical hx. Called out at around 0800 hours, because she is lethargic and her CBG is elevated.

She is found in living room chair, very lethargic, semi responsive to loud verbal. Initial vitals as follows: B/P: 150/100. PR: 100. RR: 26. SPO2: 99%. Skin: Warm, flushed, dry. Temp: 99.1. GCS: E-3, V-2, M-4. Total=9. CBG: Above 500. According to her personal monitor, she appears to have been at or above a CBG of 400 for the past 24 hours. Physical assessment is completely unremarkable. Family states she seemed normal going to bed last night at approx 2200. This morning, they managed to get her awake, and with helping her/dragging her, got her to the living room. 911 was called.

Loaded her on the cot, semi-fowlers, and into the truck. Obtained a line, NS run just above TKO. Sinus on the monitor and 12 lead clear. Pupils PEARL. Just immediately prior to transport, she began to seize. Very gradually. Just a general tremor at first, progressing over 1-2 minutes into a tonic-clonic seizure, pt incontinent and apneic as well, during seizure. Apneic period lasted, at the longest, 10-12 seconds. 3mg of Versed admin with marked effect. All Sz activity terminated, RR of 28-30 restored.

Going down the road now. Pt still postictal, so maybe 3 minutes later. Pt suffers sudden cardiac arrest, going from Sinus Tach to VF with no other changes. In VF for approx 6-10 seconds before progressing into asystole. Compressions initiated, and in less than 60 seconds, pt had ROSC. No ACLS medication administration. No Defib. Nothing but compressions. ETT placed, and pt administered 2 more mg of Versed. No further changes during care. Vitals initially following ROSC (within 2 minutes) were completely unchanged except for B/P increasing to 180/120.

We left the ER with the staff still going WTF is going on here?

The only thing I can find online that sounds even remotely similar is a case with a toddler who had the same general symptoms, but that took days to develop. And there was a 12 hour period between his seizure and his full arrest. He also was receiving insulin, whereas this pt was, obviously, not. Apparently his phosphate or phosphorous levels (Something like that) were extremely low in conjunction with this. I have not been able to retrieve labs on this girl.

Questions?

Any ideas?
 
I would put money on hyperkalemia (not taking insulin, potassium remaining outside of cells) leading to ventricular fibrillation and hyponatremia (from polydipsia and polyuria) leading to tonic-clonic seizures.
 
You said you took a 12 lead, where there any changes that would indicate hyper kalmia?
TCA overdose? You did say the family mentioned she seemed normal the night before, but any mention if she took any medications, including her prescribed Insulin?
 
I think Lightsandsirens would have mentioned if he saw wide complexes (z-folds or sine waves) or tall narrow t-waves if there were any, however, lack of wide complexes or tall narrow t-waves wouldn't rule out hyperkalemia either.
 
I keep thinking HHNC for some reason. I think that presents as hypokalemia in labs...
 
Is it possible to have that much potassium build up to put some on in a V-fib without showing any signs on the EKG? I'm simply asking in regards to education?
 
AEMTstudent said:
I keep thinking HHNC for some reason. I think that presents as hypokalemia in labs...
Click to expand...
Talking about non ketonic hyperosmolar hyperglycemia (HHNK)? Nah, I don't think it does present as hypokalemia. It's similar to diabetic ketoacidosis (DKA), but instead of little to no insulin that they have to rely on breaking down fat (creating ketones), they have just enough insulin to not rely on breaking down fat, but not enough to get rid of all the glucose. I would expect the potassium to be similar to DKA, but less severe. So either normal to elevated. Maybe after insulin treatment, they could be hypokalemic.

URI said:
Is it possible to have that much potassium build up to put some on in a V-fib without showing any signs on the EKG? I'm simply asking in regards to education?
Click to expand...
I think they don't have to be severely hyperkalemic to go into arrest. They could have very elevated potassium though without signs of it on EKGs. A lot of blogs and podcasts I was reading or listening to said that it's a myth to be able to even determine if they mildly, moderately, or severely hyperkalemic.

Going to discredit myself here. *points to training* Just an EMT. I have little experience with labs and paramedicine. Would be nice to hear from somebody with more formal training and experience.

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Sounds like DKA to me. HHNK typically takes much longer to develop and is associated with much higher blood glucose levels.
 
Yea, sounds like DKA which can develop quickly in a type 1 insulin dependent diabetic.

She probably seized and then arrested from severe electrolyte disturbances, like hyper OR hypokalemia and/or hypo/hypernatremia or severe metabolic acidosis.

They can present as hyper or hypokalemia on initial labs but usually these folks whole body potassium "stores" are low. So extracellularly may have elevated K that we measure but still overall low potassium.

You can look online but there's a pretty standard flow chart we go through when treating DKA as it's not rocket science, but you HAVE to stay on top of frequent labs and replacing electrolytes or you can get in trouble real quick. The initial potassium may well be high on initial labs but once you start giving insulin and fluids they can tank quickly and you usually need to start replacing even when they are in the normal range.

So really she needs very aggressive fluids, IV insulin, and electrolyte replacement if this is DKA

We also look for a reason someone went into DKA besides just simple noncompliance, and it's usually some sort of infection which needs to be ruled out.
 
I had something similar, but with a woman in her mid 40's.. She was altered her sugar was listed as HI (which is 600+ on our glucometers) She was non compliant and showing signs of like a Head bleed. we got her to go to the hospital, While we were wheeling her out of the house. her arm started looking like it was posturing, I said "dude is she posturing?" that fast she started seizing. afterwards she coded immidiate defib brought her right back.

She then returned to conscious, then was put down by the flight crew for transport.

Turned out she had pancreatitis, to go along with DKA, and electrolyte imbalances.
 
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So THAT'S why all my cardiac patients die!






sorry, typoed.:ph34r:
 
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