Ammonia levels

[chbare]

I am not an expert on heavy metal toxicity; however, I am not sure that elevated ammonia levels often indicate lead toxicity. Neurological impairment and nephrotoxicity are more often associated with lead toxicity.

[medicgirl05]

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?

He was found at a place that doesn't allow alcohol and there was no evidence of recent alcohol consumption. However, I won't guarantee that he hadn't been drinking.

[mikeymedic1984]

He had been drinking, drinking for years, which lead to his liver disease. The high ammonia level usually results in altered LOC, but not arrest. The causes of arrest could be any of hundreds. The good news is that his heart/vessels were probably pretty clean due to alcohol abuse, so his heart responded quickly to treatment, versus a patient who has had years of heart disease that may not have responded (similar to a young patient who arrests due to asthma).

[chbare]

I am not following the alcohol abuse and healthy heart correlation?

[AnthonyM83]

I always wonder about those cardiac arrests with confirmed asystole that come back spontaneously without any interventions other than CPR. I imagine just like other dysrhythmias, asystole can be a transient one while there's hiccup in the system, then eventually self-corrects or compensates. Luckily this guy had someone doing compressions for him during that time....

On the same note, I wonder how many times an ALS crew arrived to cardiac arrest with EMTs doing CPR, then found a pulse upon reassessment, probably assuming that the EMTs had screwed up their pulse check...

[FireEMT2009]

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!

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!

Medicgirl,

looking at your original posting compared to your posting just now about your patient being extremely bradycardic, why did you not start TCP? What where the vitals prior to coding? Looking at a pulse of 30ish, that is showing poor cardiac output. Why not place them on the TCP while you were working on the line? In this patient, since they were unresponsive and critical, why did you not start an IO? Not trying to armchair quarterback here, just trying to follow your rationale and train of thought.

What were the patient's pupils? How was the patient's blood pressure and Respiration rate prior to coding? Because a mix of hypertension, irregular respirations, and bradycardia would show me an increased ICP. I have seen hepatic encephalopathy before, but not in this severe of a case.

[medicgirl05]

Pulse was in the 30's when we made contact. I made the desicion to move him to the truck which took maybe 2 minutes. At that time I instructed my partner to put the patient on the monitor. When I looed up from trying to oxygenate the patient, my partner had put him on the 4Ld rather than the paddles. During the time it took to put the pads on, the patient went into asystole. I didn't have an initial BP as there were more important matters to attend to. The reason no IO was started was that the patient had decent veins, it just takes a little time to hang a bag and start the line. Starting an IO would have taken either the same amount of time or more. Plus our protocols don't support starting an IO without exhausting all efforts at a IV, which we didn't do. My partner stuck the patient once or twice with no success but on my first attempt I got access with an 18 at the AC.

Patient didn't have increased ICP. I didn't diagnose the hepatic encephalopathy, the ER doctor did.