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Case of the Month
January 2010
56 year old male, confusion
Dispatch
Your BLS engine company is dispatched to a 56 year old male acting confused.
While en route the dispatcher notifies you that the police were dispatched to a 9-1-1 hang up call. The police officer on scene is requesting EMS for a confused person
En route your crew discusses the following considerations:
- Reasons for altered level of consciousness
- Transport needs
- Scene safety
Scene Size-up
Your engine arrives at the address given and there is a police car out front. You see the door wide open with damage to the door jamb. As you approach the door you announce yourself and you hear “We’re in hear”, you also hear the chatter of a police radio. You enter the house, which is well kept, and see a police officer down the hall. As you approach her she introduces herself and states that when she arrived she could hear yelling inside the house. She kicked the door and found the patient sitting on the bed acting confused. She then states “You might want to pinch your nose, it stinks in here”. The police officer has already cleared the rest of the house.
Initial Assessment
As you approach the patient, you see that he appears to have dry skin and good color. His breathing appears normal. He does not look at you as you enter the room, but you are immediately struck by the smell of putrid flesh. Looking him over you do not see any obvious source for this odor. He has a strong, regular radial pulse at 100. You decide he is NOT SICK. You request a BLS transport unit from the dispatch center.
Initial Treatment
As you and one of your team members evaluate the patient, the third member of your crew looks around the house for any indicators of why the patient is acting strange. During your assessment you find the patient knows where he is and who he is, but he cannot answer the month or the year. Whenever you ask him a question he stares at you for a few seconds and then answers slowly. With many of your questions he becomes annoyed, but then settles down again. Soon you realize the putrid odor is coming out of his mouth. Looking inside you see that he has a molar that is shaded grey with a black and yellow area in the top of the crown, the gum line around it is extremely inflamed.
Vital Signs
- Respirations 18
- Pulse Radial @ 100, regular
- Mental status Confused and slow to respond
- Blood pressure 108/66
- Blood glucose 88
- Pulse oximetry 98% on room air
Further Evaluation and Treatment
Your third member returns stating he has found nothing of concern; some prescription medications that are half full and the counts are correct, no alcohol and no suspected recreational drugs found either. Initially your patient is resistant to being transported to the hospital; however you realize he cannot be left at home in this confused state. After some coaxing he voluntarily allows a BLS transport.
At the hospital the patient is evaluated for drug and alcohol use, blood sugar level, and a range of blood tests. Seeing the infected tooth the ED physician also requests a head CT. Blood tests come back positive for elevated white count and indicate a bacterial infection. The CT scan finds a golf ball size mass in the brain that varies in density. The physician believes the patient’s neurological symptoms are tied to the mass in his head and the infection from the tooth may have spread to the brain creating the mass. The ED physician begins treatment with an antibiotic and calls in a neurologist for consult.
Brain Abscess
Brain abscesses occur when an infection by bacteria or fungi takes place in part of the brain. This infection causes an immune system response that creates a collection of white blood cells, pus, infected cells, and live and dead bacteria which coalesce into a mass. Although this mass often becomes covered in a protective membrane, the size of the mass, and associated swelling, can cause neurological symptoms. This is not a common situation, however it can be fatal.
A brain abscess often occurs when an infection, bacterial or fungal, somewhere else in the body is carried to the brain through the blood stream. What seems to be an isolated ear, mouth or lung infection can transmit itself to the brain causing catastrophic consequences.
Brain abscesses are relatively rare; however certain underlying medical conditions can raise the risk. These risk factors include:
- History of a weakened immune system
- Cancer
- Medications that suppress the immune system
- Right to left heart shunts
Signs and symptoms of brain abscess mimic can those of low blood sugar or alcohol intoxication. Decreased level of consciousness, confusion, slow response, irritability, and coma (among others) may all be field presentations. Field diagnosis is not possible and treatment is supportive – ABC’s, oxygen, evaluation, and transport with additional treatments as needed.
In the hospital the patient will be treated with antibiotics and possibly antifungal medications depending on the findings of tests. In some cases surgical drainage is necessary. Other medications may also be utilized to decrease brain swelling.
http://www.nlm.nih.gov/medlineplus/ency/article/000783.htm
http://emedicine.medscape.com/article/781021-overview
http://en.wikipedia.org/wiki/Brain_abscess
http://www.merck.com/mmpe/sec16/ch217/ch217b.html
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