Ammonia levels

[medicgirl05]

I had a recent patient that we found unresponsive. He was found by bystanders at a highly populated area so it is unlikely that he was down long. Everything about the patient is unknown except that the guy who sat close by him earlier reports he complained of back pain. Initial pulse is 30'ish. Breathing shallow. During transport he went into asystole. CPR initiated for about a minute and during the first pulse check we had a pulse back. Patient became tachycardic at about 130 before settling back into the most beautiful NSR ever. Nothing on 12 lead. Blood sugar was perfect. Patient started coming around and was combative. When we got to the ER he started becoming alert.

Test results showed a high ammonia level. The nurse told me it was over 100. I have done some research on ammonia levels but nothing that really shows how this patient coded and came back with just compressions. Anybody have any ideas? Maybe it had nothing to do with ammonia levels? The day after the event I learned his admitting diagnosis was hepatic encephalopathy...

I think I presented the pertinent info on how he presented but if there is something else that is important I'm happy to fill in the blanks. I just was completely confused by the way the call went.

Thanks for your input!

[scubanurse]

I think the patient's coding could have more to do with the hepatic encephalopathy than with the ammonia levels being elevated. Elevated ammonia levels are common in hepatic encephalopathy, but not isolated to just that disease process. This puts the patient at a much higher risk of C/V collapse and I would be curious to see the results from an LFT. What did the ECG show before arrest? Was the breath really musty or sweet?

Patient could have arrested also r/t the encephalopathy and increased intracranial pressure.

I'm curious to see what the smart people think on this one though Interesting case!

[fab]

Have you considered MAS-syndrome, av block? The elevated ammonia levels may be misleading and could you clarify which unit you are using.

I think most causes of hyperammonemia apart from hepatic failure are quite rare and looking at that you'll also see many other metabolic (and electrolyte) disorders which may have lead or contributed to the asystolie. But (as you said) that seems unlikely since the patient would have stayed in cardiac arrest until that cause had been removed.

Was his heart rate still at 30 bpm before he coded? Did you do something about the low rate, how was the output? When did you get the 12-lead (before or after asystolie)?

[medicgirl05]

There was no AV-block. I don't know what MAS-syndrome is...12Ld was after the asystole.

Heart rate was 30 for maybe 4 minutes. I didn't give Atropine because I didn't have a line yet. I didn't get the line until the asystole was over.

I didn't smell the breath.

Thanks!

[Kaisu]

This is an interesting case. My patients with high ammonia levels have all been patients with chronic liver disease. This causes the high ammonia levels, which in turn cause central nervous system and cognitive problems. These patients are combative, often incoherent. The encephalopathy is usually caused by the high ammonia levels, but can be caused by hypoxia as welI.

It makes sense to me that the general derangement of electrolytes that are the result of liver failure/dysfunction could easily cause cardiac arrythmias as well. I don't know enough about hepatic encephalopathy to comment further. Like you, I am waiting for the smart people to chime in.

[Just Plain Ruff]

Like you, I am waiting for the smart people to chime in.

They are all on the East Coast with no power.

[ERDoc]

It's really hard to answer all of your questions without knowing this guys history (which I realize you are not privy to). All we can do at this point is guess. Hepatic encephalopathy is most commonly caused by liver cirrhosis, most commonly from drinking. Ammonia levels don't necessarily correlate with the degree of encephalopathy. I've seen people walking around with levels of 100+ and others who were obtunded with levels in the 70s.

[fab]

Morgagni-Adam-Stokes, sorry for that... Had the patient collapsed before, any relevant cardiac history?

[medicgirl05]

I knew nothing about the patient. He was from out of town so the receiving hospital had no info about him either.

[wlittle]

I might have missed this above, but where was he found? I'm curious because it sounds like lead poisoning caused by bad moonshine. Any indication of alcohol use where he was found?