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Dental Pain

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No history of migraines. You obtain a rectal temp and it is 35.4. The pt has not been outside. Labs:

Na 131

K 2.4

Cl 114

CO2 20

BUN 17

Creat 0.64

Glucose 107

WBC 14.7

Hgb 17.3

Hct 48.7

Plt 286

CT of the head shows a left frontal subarachnoid bleed

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He needs surgical intervention I believe. Get him to the OR STAT!!!!!!!!!

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It was an interesting case. It would have been so easy to just say that it was his tooth and send him on his way. It was the temp that made me take a second look and start a work up. Always question abnormalities. In the end, the working diagnosis right now is that he smoked some marijuana that was unexpectedly laced with something, which caused a vasculitis which bled. Still no explanation for the sepsis/SIRS.

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I'm not great at reading labs, but his CO2 is 20, so his HCO3- is probably around 18 mM, right? So, is the metabolic acidosis here just lactic acidosis? Also, why the hypokalemia / hyponatermia? Is there some SIADH here too? On one hand, his crit's 48, but his calculated osmolarity looks to be around 275?

Just wondering. I'm trying to get better with this sort of thing since I got access to an iSTAT and started working in the ER a little on the side.

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I wouldn't put too much on the sodium, it is just under normal. Hard to say why he was hypokalemic. It was replaced and never an issue again. His lactic acid was elevated at 2.7 which is probably the cause of the acidosis.

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