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Case #48 Medical Mystery?


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#21 Mike MacKinnon

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Posted 21 August 2009 - 02:32 AM

Do we have a PTH Level or CT images of spine/head/abdomen
Renal Panel
phos level
Toxicology Panel
Did child have seizures at time of symptoms


Those labs not done.

No Sz noted.
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Mike MacKinnon MSN CRNA
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#22 Mike MacKinnon

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Posted 21 August 2009 - 02:34 AM

Was the leg pain there before the hypoglycemia? Any other complaints such as constipation?



Not sure but think so. He was out playing all day.

No other complaints.

Are we sure there was no ingestion of non-prescription or vitamin supplements?



When are we ever? :P
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Mike MacKinnon MSN CRNA
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#23 Mike MacKinnon

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Posted 21 August 2009 - 02:35 AM

Any significant external abnomalities i.e.: exothalmus, swollen lymphnodes, abdomial distention or masses.
Also EKG abnormailities, if any?



Nope. :)
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Mike MacKinnon MSN CRNA
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#24 Mike MacKinnon

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Posted 21 August 2009 - 02:37 AM

Is the BP still low after correcting the FSBS, is it trending < or >?


Seems to be a little higher (up systolic 10 points) but not great.
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Mike MacKinnon MSN CRNA
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#25 Mike MacKinnon

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Posted 21 August 2009 - 02:39 AM

Ok

So while thinking over the plan

The pt seizes.

Ruh Roh.
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Mike MacKinnon MSN CRNA
WWW.NURSE-ANESTHESIA.ORG

"What gets us into trouble is not what we don't know
It's what we know for sure that just ain't so" - Mark Twain

#26 Flightgypsy

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Posted 21 August 2009 - 03:04 AM

Ok so I am going to go with the ABC's and treat the seizure with benzo's at this point. If we are unable to get control of the seizures and need to secure the airway with RSI then I will proceed to that.

I am going to make a wild guess and suggest D-HUS (Hemolytic Uremic Syndrome without the gastrointenstinal prodrome) with possibly as yet undiagnosed antiphospholipid syndrome causing the complications of DVT's in his legs.

For a treatment plan mostly it will involve treating his symptoms for the transport, giving fluids cautiously but not withholding them if they are needed and especially if he responds to small boluses for his BP, watch the EKG for signs of hyperkalemia, treating his glucose and of course maintaining a patent airway and stopping his seizures.

I would be very cautious with the fluids as I said and be prepared to treat hypertension if it develops.

Sounds like he needs hemodialysis to start with.

If we need to and the fluids are not helping I would start inotropes cautiously and titrate very carefully.

Looking forward to finding out what is going on and the outcome.
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#27 PhilMoney

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Posted 21 August 2009 - 03:05 AM

Ok, I wish I came up with this by myself, but I have to give credit to Tarascon CC pocket book and Google: Hypercalcemia is frequently the result of hyperparathyroidism. A primary hyperparathyroidism is MEN Syndrome (Multiple Endocrine Neoplasia), which has the following S/Sx: mild hypercalcemia, bone abnormalities (rare in children), hypoglycemia, headache, visual disturbances, ABD pain from peptic ulcers, diarrhea and venous thrombosis (perhaps the cause of our leg pain).

Treating MEN directly would not be possible for HEMS. Fluid boluses are a good idea (especially in this hypotensive patient).

Could be barking up the wrong tree. I'ld want a consult before I went too far with exotic treatments. So, far I agree with everyone else.


Mike Welcome Back from San Diego!

Sorry everyone for being short the other day....Saw that Mike posted a new case and had to get a reply in before heading out the door. Totally stumped so far....here is what I've been pondering.... :huh:

Well said Backcountry! Seems like a Ca of 15 is out of my "mild" range but it seems to fit in all the other ways.

Dopler to confirm DVT? Bilateral....really? If so, then the kid is really unlucky.

On the flight safety side...how about Ketamine? maybe increase BP, chill the kid out for a while during flight but keep the airway patent, increase sats with some mild bronchodilation? Just a thought.

I may be way off..... :blink:
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Matt P. B.S., A.S., CCEMT-P, FP-C

#28 PhilMoney

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Posted 21 August 2009 - 03:07 AM

Ok so I am going to go with the ABC's and treat the seizure with benzo's at this point. If we are unable to get control of the seizures and need to secure the airway with RSI then I will proceed to that.

I am going to make a wild guess and suggest D-HUS (Hemolytic Uremic Syndrome without the gastrointenstinal prodrome) with possibly as yet undiagnosed antiphospholipid syndrome causing the complications of DVT's in his legs.

For a treatment plan mostly it will involve treating his symptoms for the transport, giving fluids cautiously but not withholding them if they are needed and especially if he responds to small boluses for his BP, watch the EKG for signs of hyperkalemia, treating his glucose and of course maintaining a patent airway and stopping his seizures.

I would be very cautious with the fluids as I said and be prepared to treat hypertension if it develops.

Sounds like he needs hemodialysis to start with.

If we need to and the fluids are not helping I would start inotropes cautiously and titrate very carefully.

Looking forward to finding out what is going on and the outcome.



Benzos for sure.

Everything else is over my head... :blink: Hello Google!
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Matt P. B.S., A.S., CCEMT-P, FP-C

#29 JClayborne

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Posted 21 August 2009 - 06:32 AM

This patient is presenting a textbook case of addisonian crisis. We have penetrating pain in the legs and abdomen, dehydration, hypotension, hypoglycemia, confusion/altered mental status, lethargy, hypercalcemia, hyponatraemia, hyperkalemia, and now seizures.

Treatment:
Ativan 4mg IV for seizures. Glucose check to assure seizure activity isnít a result of recurrent hypoglycemia. Start aggressive fluid resuscitation. Monitor glucose levels and treat hypoglycemia if indicated (I might consider hanging some D10 depending on how his glucose levels were trending during transport). Quickly discuss the administration of IV hydrocortisone with the attending/accepting physician. As always, manage his ABCs by initiating RSI and/or vasopressors for persistent hypotension.

Nice to know:
Has he been vomiting or had diarrhea?

Is he fibril?

Confirming labs and I'm sure I could come up with 20 question to ask but it's time to get in gear.
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JClayborne, NREMT-P, FP-C

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#30 Flightgypsy

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Posted 21 August 2009 - 08:32 AM

I think I would definitely be consulting with a Dr (hopefully a specialist at the receiving facility) about giving steroids. My instinct is to give them as it could be lifesaving for someone in an Addisonian crisis and won't hurt in HUS but I would definitely consult with a Dr just in case there is a chance that it could make the pt worse depending on what his diagnosis ends up being. Giving steroids can also be a big mistake in some diseases. I would not be waiting around for labs either so some of our decisions may be rather in the dark and we will just have to make them based on the information we have.
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#31 viking563

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Posted 21 August 2009 - 02:22 PM

As far as the bigger picture goes Im am over my head. Id manage with 4mg of ativan, recheck Blood Sugar and treat that if necessary, if needed RSI to manage the airway if he cannot maintain himself, and as soon as the patient stops seizing, load and go and call our med control doctor for a consult. Whatever it is we can't treat it here for the most part.
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Matt, NREMT-P

#32 Mattw

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Posted 21 August 2009 - 05:01 PM

It is nice not to be the only one thinking that there is more going on here than can be treated on site. Benzo for the seizures, aggressive airway management, blood glucose and an accurate temperature. Doing all of this while getting moving sounds like the best idea for me. This kid need a lot more than I can do. As far as general management of his care... strong tail wind, high flow jet fuel and a call to med cmd to see if there is anything else we can do.
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#33 ST RN/PM

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Posted 21 August 2009 - 05:16 PM

FSBS=FBS=BGL
Fingerstick Blood Sugar=Fasting Blood Sugar=Blood GLucose Level
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#34 viking563

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Posted 21 August 2009 - 05:25 PM

FSBS=FBS=BGL
Fingerstick Blood Sugar=Fasting Blood Sugar=Blood GLucose Level

Thanks, thats a new abbrevation for me.
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Matt, NREMT-P

#35 medic4cqb

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Posted 21 August 2009 - 05:35 PM

A CMP was done.

K 5.7
Na 124 mEq/L
BUN 38 mg/dL
Cr 1.1 mg/dL

rest is normal.

Cortisol lvl and ACTH & phos were not done, would you like to wait 30 minutes for them?

He was in his parents home and his mom and dad were both with him.


I was thinking about the ETOH level, because you mentioned no phos level yet, which drew my attention. I was thinking that the kid drinks and so I did some research that drew me to hypophosphatemia, which can be caused by too regular consumption of alcohol. That was the only thing we hadn't thought of. Some of the other described symptoms were also covered with this diagnosis, but now I'm wondering if I was going down the right path? Alcohol does cause vasodilation and bleeding and some of the other described symptoms, but whith not much else as far as history (as usual with EMS) I'd just package him up, fluids, O2, monitor and transport, call the doc and let them figure it out... :blink:
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#36 Gila

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Posted 21 August 2009 - 07:13 PM

With the H&P along with labs, I am going with Addison's, more accurately at this point, Addison's crisis. Look at stress dosing with cortisone and possible volume expansion. Can we contact the receiving and stress our findings to the receiving doctor? Pediatric sub-specialty resources will be needed with this patient.
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Christopher Bare
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#37 Canis doo

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Posted 21 August 2009 - 11:07 PM

I think your right on Gila. I'm still wating on more information.

Still he is in the pits, and as before, his heart rate, bp and sugar are off.

It would be nice to have a U/A to help rule out associated on iatrogenic DI, SIADH. The rough estimate osmolality 250is NAx2.
However, you stated he was azotemia. and hemodynamically compromised but no real toxicity of calcium or potassium. Seizures my be ongoing hyponatremia or hypoglycemia. or Pituitary problem
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Jason Howard LP, FP-C
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#38 fire_911medic

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Posted 22 August 2009 - 01:45 AM

I'm gonna step out on a different limb here and see if I get run over, but let's see what happens.

You said mom and dad are on beta blockers - makes me wonder did the kid OD on beta blockers? Would explain out the secretion of insulin as well as the unrecognized hypoglycemia allowing him to play until his levels were dangerously low and not recognize it. Also propanolol OD could explain the lowered blood pressure as well as the seizures. Also, beta blockers contribute to renal failure = the lack of urine at this time. If it's moderate toxicity, we may still see the symptoms, but not have major issues with the heart rate or rhythm yet though it's something I defintely want to keep a close eye on. Support breathing at this point as needed, stop the seizures. Alright - time to let someone else play now.
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When once you have tasted flight, you will forever walk the earth with your eyes turned skyward, for there you have been, and there you will always want to be. ~~~Leonardo DaVinci

#39 fire_911medic

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Posted 22 August 2009 - 02:10 AM

Scrap thought - I'm too tired to think right now - I"ll come back to play later.
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When once you have tasted flight, you will forever walk the earth with your eyes turned skyward, for there you have been, and there you will always want to be. ~~~Leonardo DaVinci

#40 EDMEDIC

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Posted 22 August 2009 - 02:05 PM

Just some thoughts as I near the "in over my head" point. Hyponatremia combined /c hyperkalemia and hypercalcemia lead me toward adrenal insufficiency as the problem. That's not so say that anyone here who thinks differently is wrong. I can't wait to hear the ending of this case. my 2 cents, Thanx ALL, Brian
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Brian EMT-P/CC
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