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.


Patient Value

Adult Normal Range


32 g/L*

35 – 50


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


555 μmol/L*

11 – 32


Patient Value

Adult Normal Range

Prothrombin time

18.0 secs*

12.0 – 16.5

International Normalised Ratio


0.9 – 1.3

Activated Partial Thromboplastin Time

66.2 secs*

27.0 – 38.5


1.6 g/L*

2.0 – 4.0


Patient Value

Adult Normal Range


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.


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


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.