Hot Seat #46: 15 yo F w/ combativeness and AMS
Posted on: October 28, 2014, by : Fareed Saleh MD
by Fareed Saleh, Children’s National
with Maybelle Kou, Inova Children’s Hospital
The Case
15 yo F p/w combativeness and altered mental status. Per mother, pt was playing field hockey outside on freshly mowed field for 3+ hours this AM. Given that it was a hot day she consumed copious amounts of water and Gatorade. She then became progressively altered and noted to be hot to touch. EMS arrived and patient was aggressively cooled with ice packs. Also, EMS noted that the pt was becoming progressively more combative and administered lorazepam (2 mg) while being transferred to the ED.
PMH: Per caregiver, no illnesses or medical conditions, NKDA, no herbals/supplements/vitamins or medications
ROS: deferred
PE: VS: BPs 130s/90s / HR 50s-90s / RR 12-20 / >95% on 100% NRB / T37.8C (axillary)
Gen: Pt responds to pain, markedly combative at times
HEENT: PERRL 5 mm to 3 mm b/l (brisk response)
CTAB
CVS stable with cap refill 2-3 seconds
Abd soft, nontender
Neuro: AVPU – Pt responds to pain / GCS: ranges from 11 to 14 (on arrival, GCS E4/V4/M4)
Skin: not warm to touch, no bruising or rashes noted
A medical alert is initiated on arrival with access obtained and labs sent. Initial work-up includes iSTAT, serum toxicology, CMP, CBC all of which are pending.
Questions for you:
Interim Update:
After your intervention the patient is much less combative but continues to be altered. The iSTAT comes back with the following results:
Na 126
K 3.3
Gluc 108
VBG pH 7.3 / PaCO2 37 / PaO2 62 / BE -2
Lactate 3.2
“Other” results from MORE than 3 yrs PEM = NS bolus, NS bolus and “rectal temp please post benzo.”
How would you approach this case? Please share your opinions by clicking on “What do you think?” below.
Okay I’ll jump in. This I think is a tricky one. (I did have to go back and do some readings)
Summary: health teenager, playing sports outside for hours on a hot day, now with altered mental status, hyponatremia, and metabolic acidosis. -> Sounds like hyponatremic dehydration: Most probably she drank much more water than gatorade, and not enough of either while sweating out all the salt. Treatment: NS boluses then NS at 1-1.5 MIVF with admission, neuro checks etc.
However, she also has some hypertension and bradycardia, with the AMS -so does she she have increased ICP? Most probably, from cerebral edema secondary to the acute hyponatremia.
Treatment: Hypertonic Saline,100ml x 1-2 With admission, PICU, close monitoring of neuro status for improvement and Na levels. Will rehydrate with NS.
Also, she was playing field hockey, if it’s anything as close to ice hockey, she needs a head CT to r/o a traumatic bleed!! or any way a head CT for AMS where cerebral edema can also be seen.
Finally, for the agitation,I would prefer to start with physical restraints because of the initial AMS, before sedating her, however realizing that since she is altered, she may not be able to realize what is going on and relax herself, therefore I would have a low threshold for Benzos.
I’m sure there is more on the differential but I’m going to stick to this for now.
I have a hard time believing the mild hyponatremic could cause the agitation. I think if there was a rapid shift from free water overload I guess this is possible, but this would be more reason for me not to use 3% and to correct sodium slowly.
So in the absence of ingestion or other reversible metabolic cause, I’d tube the kid and put her in a scanner. If she does have edema, her hypertension will only make things worse. So sedation to control CPP is important. And you gotta get the kid in a scanner to r/o blown AVM, etc. GCS is not a great gauge for anything outside of trauma. So if I can’t fix it and I don’t know why she’s so agitated, I protect the airway and get the scan and do the LP and control her CPP with pharmacological sedation etc. and slowly correct the sodium.
It really helps to get a FeNa when patients are hyponatremic to differentiate potential sources. So foley helps and is another reason to tube her. But have to think about siadh, salt wasting, and free water overload. Fluid mgmt is different for each of these but I avoud 3% unless patient blows a pupil or is actively seizing with hyponatremia or patient symptomatic with crazy low levels (<118 or so).
Hotseat Comments from Maybelle. Fareed! This was a fun case to think through.
Quick summary: Altered Mental status in an athlete playing on a freshly mowed lawn…acting funny, hot to touch at the scene, EMS initiates cooling and transport to the ED where she is still an altered athlete, not hyperpyrexic, with very weird lytes.
Initial management: ABCDEs, Hs and Ts. Thank goodness she is a big kid so vascular access is not going to stress me out while we work her up. I would put heat stroke high on the list since it was a hot day, She felt warm to touch at the scene and treated with ice packs (I would love to know if she has improved since getting to the ED). Bottom line: we should obtain a core temp and not rely purely on the axillary temp in this situation since she was pretreated. We should also perform a full exposure exam for drug paraphernalia. As far as other hyperthermic or hypermetabolic possibilities this doesn’t really fit criteria for MH or NMS, off the bat, though thyroid storm is a possibility. CT is unequivocally required to rule out cerebral injury, ICH, mass, edema, empyema or what have you. Since meningitis can also do strange things, and the lactate is…ehh… 3, a round of rocephin and steroids is also a thought. We should also get an EKG as well while we wait to get her to the scanner to see if there are any conduction disturbances warranting action.
Since the story still doesn’t quite make sense, Cathleen (Clancy) always says to think about tox. We have no idea whether anticholinergics have been ingested (hot as a hare, mad as a hatter), and the clinical picture here includes variable heart rate, hypertension. Not sure if the “freshly mowed field” was a clue, but pesticides with organophosphates would give the SLUDGE-ies, rather than the picture seen here. We also don’t know whether aspirin or liniments (oil of wintergreen? aspercreme) have been used, but we should check for ASA, APAP, pregnancy and drugs of abuse.
We should check with team mates that the Gatorade was not “doctored” with any of the highly caffeinated monstrous matadorish mixtures that she could have had too much of over a period of time (sorry, trying not to create free advertising but rhymes with FULL). They are quite diuretic, too. As for the hyponatremia: Rasha and Dave have already brought up salient points about rehydrating slowly but 3% saline is a great choice if she starts deteriorating or seizing. At least have it close by.
I would definitely NOT use haloperidol as a first line agent for treating her agitation, also worries me that medics are using Ketamine for agitation in the field these days: wouldn’t use that either. Benzos would be my preferred choice. RSI with Etomidate and Roc if needed.
Plan: If she is stable enough to get to the scanner without intubation, continue passive “cooling”, sedation with benzodiazepines.
Additional tests: Urinalysis, urine lytes, Osm, BMP, ASA, APAP, TSH, T4, and a didja tube.
Regardless of whether the scan normal: if she is remains altered she still needs the PICU for Q15 neuro checks and close CR monitoring.
And if this turns out to be porphyria, I will never be a hotseat attending again.