Brought in vomiting and drowsy, a 24-year-old: an emergency case to work up

Why vomiting and drowsiness in a young adult matters

A young adult found unwell and alone, now drowsy, may have taken or been exposed to something, or may have an illness of the brain or metabolism. Keep the airway safe, check the glucose, and examine for a pattern (pupils, sweating, secretions, heart rate, muscles), which often tells you more than the history can.

What to ask in the history

• When he was last seen well, and exactly how he was found
• What the brother saw nearby: containers, bottles, tablets, a smell
• Access to pesticides, medicines, alcohol or drugs at home or work
• Headache, fever, injury, a fit
• Diabetes, epilepsy, other illness
• Diarrhoea, passing urine, what the vomit looked like
• Mood, recent stress, any previous self-harm (asked gently, and again in private when he can talk)

Red flags

• Falling conscious level, or an airway he cannot protect
• Noisy breathing, a lot of secretions, low oxygen saturation
• A slow or very fast heart rate, low blood pressure
• Seizures
• Very small or very large pupils
• Muscle twitching or weakness
• Any sign that this was self-harm

What to examine

• Airway, breathing, circulation; suction and oxygen as needed
• Conscious level and glucose
• Pupils
• Sweating, saliva and secretions; chest for crackles and wheeze
• Pulse rate and rhythm, blood pressure, temperature
• Muscles: twitching, tone, power, reflexes
• Smell of the breath and clothes; injuries, needle marks; neck stiffness

First investigations

• Capillary glucose
• Blood gas, electrolytes, kidney and liver function
• ECG: rate, rhythm, QT interval
• Cholinesterase level where available
• Paracetamol and salicylate levels when any overdose is possible
• Alcohol level and toxicology screen as available
• CT head if there is an injury or no other cause is found; lumbar puncture if infection is suspected

Differential diagnosis of vomiting and drowsiness in a young adult

Grouped, not ranked. Which one fits this patient is for you to work out in the case.

Common mistakes

• If a chemical exposure is possible, not removing contaminated clothing and protecting the staff caring for him.
• Forgetting paracetamol levels: a mixed overdose can look well at first.
• Treating the poisoning and never asking about self-harm or arranging a mental health review once he is well.