Bongy's Quiz No.1-PreHospital Diagnosis

[Bongy]

Dear colleagues!
As my first contribution to this forum I would like to invite you all about discussion about Hospital diagnosis issues.
For the beginning I would like to let you to think a little.
Call was received at 14:30
"Female,13 y/o,vomiting,convulsion"
Dispatcher add also,that it was a lot of noise and hysteric screaming at the background of a calling person.
On arrival:
Girl,13 y/o(as appears at her ID),stupor,signs of vomiting around,hugged by her brother(26 y/o). Mother and brother both hysteric and normal anamnesis unavailable.
Denied usage of any drugs,usually healthy person(but as I said - no full cooperation)
Physical: BP 140/90,Pulse 60,Sat with O2 mask 100%,EKG-Short PR,no other findings,pupils respond,but VERY slow,verbal - low response to voice, from her - non connected words and expressions(declaring geometric rules).
At arrival to the hospital - Serum Na 113... !!!
What do you thing it is?
Hint: Something very important missing in anamnesis...(important findings marked)
I will give further information later
Good Luck!

 

[Bongy]

One more important thing!
As we succeed to understand,it WAS short convulsion event(few seconds),no history of any neurological disease

 

[Ridryder911]

It appears the child had seizure activity possibly related to hyponatremia (<135 -145 mmol/) with the history of N & V. I did read the core temp. Hyponatremia is often associated with febrile seizures even in juvenile age. The lower the serum sodium level, the higher the probability of a repeat convulsion. The hypertension (systolic) can also be related to dehydration. Although many may assume the later.

Since this is possibly related to dehydration, particular attention should be focused on BUN, Creatinine, anion gap, as well.

Replacement of fluids with potential potassium supplement maybe needed.

R/r 911

 

[Bongy]

As I may see,there is not much activity,so take another hint...
This girl has a prescribed drug that she had from a family doctor...
This is an adverse effect...
Comm'on.. It's not so complicated... You can meet it in a field...

 

[Bongy]

It appears the child had seizure activity possibly related to hyponatremia (<135 -145 mmol/) with the history of N & V. I did read the core temp. Hyponatremia is often associated with febrile seizures even in juvenile age. The lower the serum sodium level, the higher the probability of a repeat convulsion. The hypertension (systolic) can also be related to dehydration. Although many may assume the later.

Since this is possibly related to dehydration, particular attention should be focused on BUN, Creatinine, anion gap, as well.

Replacement of fluids with potential potassium supplement maybe needed.

R/r 911

Ok... Hyponatremia is obvious.. But be careful with DEhydration diagnosis!!
Pay attention to signs of encephalopaty....Core temp. normal...

 

[Ridryder911]

Do you mean encephalopathy? Which has multiple branch diagnosis such as Wernicke encephalopathy? I would never base such an initial diagnosis or promote such as from the hint of such from just hyponatremia and single seizure activity.

Of course one is going to do a more detailed neuro work up, and pay close attention to ataxic symptoms and if there is any bacteremia, which again is only after blood cultures and a lumbar spinal tap is performed. Initial treatment, however is going to be from the history and symptoms of dehydration and the associated hyponatremia. Once the symptoms does not resolve and one can determine from the anion gap and urine if they are truly dehydrated or not. A CT scan will need to be performed to rule out bleed and neoplasms.

Electroencephalogram will be scheduled later if needed. Routine EEG's are not performed here for a single case of seizure activity, unless the Primary Care Physician (PCP) requests one.

Later in the patients PCP, more battery of test may be made if encephalopathy is suspected, but not in the emergency setting.

R/r 911

 

[VentMedic]

Bongy, we are well out of the pre-hospital ride with the sodium value.

Rid's summation had led us further into the hospital arena which would be the logical place to diagnosis an adolescent presenting with those symptoms and no way to run a chem panel on scene.

You did not mention any medications initially and presented the pt as relatively healthy prior to this episode. In the prehospital, one can only go with the scene, how the pt presents, and what information is voluntarily offered. I will always stress, don't guess. It will pigeon-hole your judgement.

That being said, even at the adolescent age hyponatremic encephalopathy symptoms can present for a variety of causes. There are a few medications that come to mind including Ritalin.

I would treat the symptoms as they appear in the field and go with further testing in the hospital unless I find the medicine bottle or the family volunteers the info on my way to the ambulance with the pt ready to travel.

Interesting case though.

 

[Bongy]

Ok... Some think to think it over:
1.Pt is highly hypertensive for her age with relative bradicardia(for her age)
2.HYPOnatremiya can be developed on two mechanisms:
*Loss of Na
*WATER RETENTION!!! Low sodium level is one of diagnostic signs for HYPERvolemiya with high level of free water.

Now,what can be a reasons for water overload?
Rid... For sure volume replacement can not be a good idea...
P.S. encephalopathy doesn't have to chronic,it can be developed rapidly...

 

[andrey]

May i say it is poisoning, Do,not ask me why?

 

[Bongy]

May i say it is poisoning, Do,not ask me why?

It's not a poisoning... Drug dose was OK.. But this is extremly strong adverse effect...

 

[andrey]

Perhaps is it a tumor of hypofis,vasopresin,s part?

 

[lfsvr0114]

Water intoxication?

 

[Ridryder911]

Ritalin is commonly now abused by crushing and then injecting as an IV form.
Of course the side effects is hyponateremia, as well as somnolence, and in some extreme cases seizures. One has to be cautious of other related adverse interactions with seizure meds, HTN med.'s such as Atenolol and MOA inhibitors.

Usually, close monitoring and potential emergency dialysis if compounds are too high.

R/r 911

 

[Bongy]

Ok... Let's make some things clear...
It is so-called water intoxicaton,but with different mechanism.
As Andrey says,some drugs,like vasopressin or hypophysys neoplasm can cause this condition. In indocrinic ethiology,inapropriate ADH secretion can cause water retention,and as result BRAIN EDEMA! Pay attention for ether cranial and pereferal NS pathology. We have convulsion and slow pupils response - condition that markedly shows general brain malfunction,without so-called side symptoms(non equal pupils or hemiparesis.
Low sodium cause due to too high level of free water. In CT scan that performed in a hospital was no finding of neoplasms in hypophysys,so...
What drug can couse high level of ADH?

 

[andrey]

I think it is aspirin

 

[lfsvr0114]

Is it DDAVP (Desmopressin Acetate)? This drug is used for persons who wet the bed. It keeps them from producing much urine during the night so they won't wet the bed.

I had a pt taking this medication this week, but was having no ill effects from it.

 

[Bongy]

Congratulation,Cindy!
As I wrote before,drug is commonly used in this age due to night diuresis...
You right about desmopressin-it's much less potential drug than...Minirine...
Minirine is clear ADH,without arginine attachment,fact that make this drug much more potent.
Pt,that use this drug MUST be instructed to reduce water consumption,in order to avoid situations like discribed...
References(let's try to be academic)
RXlist
PubMed

Thanks for all...(I'm a little bit disappointed from your activity,colleagues)
Next quiz coming up... Stand By!