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Lions and Tigers and Bears

Dr. Loice Swisher’s daughter had five episodes of unexplained vomiting without a fever in just one month during 1999. Thinking through the files in her mind, she was unable to shake the memory of a young child with the same complaint 12 years before. The well-looking child had been bounced out of the ED four times with "viral syndrome" and "gastroenteritis." The diagnosis was a posterior fossa tumor.

“How did this happen?” she asked. The attending shrugged, offering up various possibilities. It was a difficult diagnosis because the symptoms at first are nonspecific. It is uncommon. The prior docs probably didn't get her up to walk or look in her eyes. They probably didn't think of it. He concluded, "To an ER doc, unexplained vomiting is a brain tumor until proven otherwise."

That single phrase altered the course of her life. A "reassurance MRI" showed a 5 cm brain cancer, a medulloblastoma. Her daughter navigated a course of radiation, chemotherapy, and multiple complications, and Dr. Swisher started an entirely new medical education in the art of diagnosis.

Amal Mattu, MD, reminds those of us in emergency medicine to be on the lookout for lions and tigers and bears, not horses and zebras, Dr. Swisher explained. As an emergency physician and mother, she knows the profound impact this approach has on a patient's life. Using real cases, this blog aims to expose the lions and tigers and bears out there ready to bite.

Saturday, July 2, 2016

Beware the (Previously) Seriously Agitated Patient

"What do you think about this VBG from last night?" I asked, thrusting a ribbon of paper at my colleague.

Initial VBG
pH      <6.80
pCO2    47 mm Hg
pO2        59 mm Hg
Na+       149 mmol/L
K+           4.2 mmol/L
Cl-          99 mmol/L
Ca++     1.27 mmol/L
Glu     211 mg/dL
Lac     >20.0 mmol/L

tHb    16.3 g/dL
sO2        69.2%

"Was he dead?" he queried.


"What was his anion gap?" came the next question.


"Ethylene glycol? Did you intubate him?" he asked.

That was a great guess, but it was actually PCP and cocaine. The patient, out of control, was TASERed a few times. By the time he got to the ED, though, he was unresponsive, breathing like a freight train, and sweating so much he soaked the sheets. I didn't want to intubate him because he was doing a much better job blowing off his hydrogen ions than I ever could.

I certainly didn't want to make that acidosis any worse. I was surprised his heart could keep beating in the environment he already had. I went with benzos, several liters of fluids, and followed the end-tidal CO2 (which was only 16 on arrival). The gap was down to 21 within 90 minutes with a much improved VBG.

VBG 90 Minutes Later
pH      7.22
pCO2    39 mm Hg
pO2        38 mm Hg
Na+       140 mmol/L
K+           5.3 mmol/L
Cl-          112 mmol/L
Ca++     0.95 mmol/L
Glu     94 mg/dL
Lac     8.2 mmol/L

tHb    13.4 g/dL
sO2        63.1%

These previously combative but now "not fighting" patients are the ones that make me worry that they are on the edge of the cliff, potentially crashing at any moment. Perhaps that is because this isn't the first (or second or third) patient I have seen with a pH less than 6.8 from a drug-induced agitated state. Maybe the quiet ones should cause even more angst.

My guy went to the CCU, and his normal CPK was above 10,000 within 12 hours. He did require sedation until the PCP and cocaine wore off. The young human body is remarkably resilient; he was back to his regular life just a few days later.

​Take-Home Point: Beware of the unresponsive, previously seriously agitated patient; he may be close to death.