Question 24.2

The previous SAQ, Question 24.1, presents the first part of the history:

"A 27-year-old patient was found unresponsive with no signs of life. Two rounds of CPR were performed prior to ROSC. A laryngeal mask (LMA) was placed en route to hospital."

The ABG presented in that SAQ demonstrated a severe respiratory acidosis with a PaCO2 of 192, severe metabolic acidosis with a lactate of 18, renal failure, and profound hypoglycaemia.

The same patient has another cardiac arrest in the Emergency Department with 2 minutes CPR and adrenaline administered. The patient is now intubated, ventilated and arrives to ICU on an adrenaline infusion. Subsequent results are available.

Parameter	Patient Value	Adult Normal Range
Albumin	32 g/L*	35 – 50
Protein	50 g/L*	60 – 80
Total bilirubin	11 μmol/L	< 26
Alanine transferase	10200 U/L*	< 35
Aspartate transferase	9200 U/L*	< 35
Alkaline phosphatase	164 U/L*	30 – 110
γ-Glutamyl transferase	251 U/L*	< 40
Ammonia	555 μmol/L*	11 – 32

Parameter	Patient Value	Adult Normal Range
Prothrombin time	18.0 secs*	12.0 – 16.5
International Normalised Ratio	2.0*	0.9 – 1.3
Activated Partial Thromboplastin Time	66.2 secs*	27.0 – 38.5
Fibrinogen	1.6 g/L*	2.0 – 4.0

Parameter	Patient Value	Adult Normal Range
Haemoglobin	100 g/L*	120 – 160
White Cell Count	18.5 x 109/L*	4.0 – 11.0
Platelet count	36 x 109/L*	150 – 350

a) Explain the abnormalities and the likely causes. (25% marks)

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College answer

Not available.

Discussion

In detail, the abnormalities are:

Borderline low albumin (has not had time to fall yet, as it has a long half life)
Borderline low protein (possibly diluted by some resuscitation fluid)
Normal bilirubin (has not had time to rise yet)
Massively elevated LFTs, in a pattern that suggests hepatocellular toxicity (the ALP value is the highest)
Hyperammonaemia, most likely due to the acute liver failure
Coagulopathy which looks like DIC (with the low fibrinogen suggesting consumption)
Thrombocytopenia, which also suggests DIC
The WCC is elevated as a part of the generalised systemic inflammatory response which occurs with acute liver failure

References

Bernal, William, et al. "Acute liver failure." The Lancet 376.9736 (2010): 190-201.

Rolando, Nancy, et al. "The systemic inflammatory response syndrome in acute liver failure." Hepatology 32.4 (2000): 734-739.

Ellis, Antony, and Julia Wendon. "Circulatory, respiratory, cerebral, and renal derangements in acute liver failure: pathophysiology and management." Seminars in liver disease. Vol. 16. No. 4. 1996.

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