Clinical Case 102: Found down, Fluid please

Ok a quick case from the Kimberley.  It has been a while since I have done a quiz – so here we go!!

This one is for the metabolic geeks out there.  Here is your chance to win the love and respect of your peers

Imagine you are in a remote health clinic. 2 hours from hospital.  A 40 yo man with a known history of:

  • type 2 diabetes,  on a combination of Metformin 2 g XR tabs, Gliclazide 60 mg MR
  • mild associated renal impairment (Cr stable ~ 110 a month ago), on Ramipril 5 mg for proteinuria / hypertension
  • An acquired brain injury – with infrequent seizures and some behavioural problems.  He was taken off phenytoin a year ago after being seizure free for > 12 months

.. is rushed to ED by the volunteer Ambos after a family member found him unconscious in the morning – he was last seen ~ 12 hours earlier.  No witnesses to the night’s events.

The family stated that he has been well enough, though he had been out for a few drinks earlier in the evening… i.e. he was pretty hammered when he fell into bed.

Nobody saw or heard any seizures and the family are well aware of his usual episodes.  He has no injuries, blood in the mouth or incontinence noted.

He has been taking all of his Meds – a well used blister pack is brought in showing he has likely taken his usual tablets.

The Ambos could not get an IV in – but they did check his BSL – it was 1.8 mmol/l [LOW].

His Obs – he is normotensive with a BP 145/90, P = 115, pale skin, his RR is fast at 22/min, not hypoxic.  He looks dry in the mouth.  No focal neurology, his pupils are small and equal.

An IV line is placed.  A VBG drawn (thats the only bloods you have access to out here… and he is given some IV sugar.

After a dose of 25 mlx of 50% dextrose his BSL comes up to 5.0 [90 in the USA].  He does rouse with this, though still looks quite groggy.

Just now the VBG result prints off the Gas analyser:

pH = 7.10

  • PO2 = 29 mmHg
  • pCO2 = 46 mmHg
  • BE = -13
  • Na = 145
  • K = 7.8
  • Cl = 121
  • gluc = 1.8
  • HCO3- = 13
  • lactate = 2.2

In the meantime the RAN has inserted an IDC – and it is draining the slowest trickle of dark urine with sediment… hmmm.

OK – I think that is enough of the boring details.  What I want from you is answers to these 3 questions – go on, get creative.

Q 1:  What is going on here – why is he so sleepy?

Q2: interpret the VBG for us

Q3:  What IV fluid are you going to give this man?  BE very specific about what and how much…

BONUS QUESTION – if his ECG shows no changes of hyperkalemia – how will you manage the K+ – remember you are a long way from help…



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