CLINICAL QUIZ
“Smoking” guns: Questions
Tammi Cooks & T. Keefe Davis & June Hu &
Rachel Metheny & Michael Schwartz & Roy Gerona
Received: 8 September 2014 /Revised: 9 September 2014 /Accepted: 29 September 2014 /Published online: 21 October 2014
# IPNA 2014
Keywords Kidney injury . TASER . Conducted electrical
weapon . Electronic control device . Synthetic marijuana .
Oxycodone . Acetaminophen
A 17-year-old male presented to the hospital following a
TASER (TASER International, Inc., Scottsdale, AZ, USA)
encounter and arrest by law enforcement. The patient exhibited
agitation and aggressive behavior. He admitted to
smoking “synthetic marijuana” as well as taking two tablets
of combination oxycodone and acetaminophen (Percocet). He
complained of retrosternal and upper abdominal pain. He
recently acquired a new supply of “Brain Freeze” and smoked
it multiple times in the last couple of days including the day of
admission. On exam he was tachycardic (heart rate 120 beats
per minute) and hypertensive (151/73 mmHg). His abdomen
was soft. He had mild non-localizing tenderness. He had bilateral
costovertebral angle tenderness. Laboratory evaluation was
remarkable for a serum bicarbonate of 8 mmol/l with an anion
gap of 29; creatinine 1.7 mg/dl; potassium 3.3 mmol/l; an
elevated creatinine kinase (CK) of 2,723 U/l with
myoglobinemia 3974.5 ng/ml (Table 1). Urinalysis revealed a
Table 1 Laboratory studies from the blood during the hospitalization
Investigation Results Reference
range
Day 1 Day
2
Day
3
Day
4
Day
5
Day
6
Sodium (mEq/l) 138 138 140 143 143 142 141 135–145
Potassium (mEq/l) 3.8 3.8 3.2 3 4 4.7 4.4 3.3–4.9
Chloride (mEq/l) 101 110 106 101 106 108 111 100–114
Bicarbonate (mEq/l) 7.8 18 25 36 32 29 24 20–30
BUN (mg/dl) 14 18 20 24 28 26 19 9–18
Creatinine (mg/dl) 1.7 2 2.9 5 6.1 5.2 3.7 0.4–1.2
Calcium (mg/dl) 9.2 8.4 8.3 8.1 8.8 9.1 9.6 8.6–10.3
Phos (mg/dl) 7 7.4 6.5 5.6 4.5 4 3–6
Albumin (g/dl) 3.9 3.8 3.4 3.6 3.5 4.2 3.2–5
CK (U/l) 405 2723 5143 3776 <300
Uric acid (mg/dl) 17a
0.7 3–8
BUN blood urea nitrogen; Phos phosphorus; CK creatine kinase
a
Treated with rasburicase
The answers to these questions can be found at http://dx.doi.org/10.1007/
s00467-014-2983-4.
T. Cooks
Washington University School of Medicine, St. Louis, MO, USA
T. K. Davis (*)
Division of Nephrology, Department of Pediatrics, Washington
University School of Medicine, 660 S. Euclid Ave., Box 8116, St.
Louis, MO 63110, USA
e-mail: davis_tk@kids.wustl.edu
J. Hu
Department of Pediatrics, St. Louis Children’s Hospital, St. Louis,
MO, USA
R. Metheny
Division of Pediatric Psychiatry, Department of Neurology and
Psychiatry, Washington University School of Medicine, St. Louis,
MO, USA
M. Schwartz
Department of Emergency Medicine, Emory University School of
Medicine, Atlanta, GA, USA
R. Gerona
Department of Laboratory Medicine, University of California, San
Francisco, CA, USA
Pediatr Nephrol (2016) 31:61–62
DOI 10.1007/s00467-014-2978-1
specific gravity of 1.010; pH of 6.0; 2+ protein; 2+ glucose; and
3+ blood. Urine microscopy did not identify red blood
cells, casts, or crystals. A urine drug screen was positive
for delta-9 tetrahydrocannabinol (THC). Renal ultrasound
identified normal-sized kidneys, but increased cortical
echogenicity. Additional studies including EKG, chest
radiography, and chest/abdomen/pelvis computed tomography
(CT) scan were normal. During 6 days of hospitalization,
his blood pressures remained above the 95th
percentile for age and height. He continued to experience
significant nausea and emesis. Urine output remained
brisk (>1.5 l per day). Blood work was performed at least
daily (Table 1).
Acknowledgments No financial support was provided to any author
in relationship to this manuscript. We acknowledge Lauren
Yaeger, MA, MLIS for her help in preparing this manuscript.
No author declares a conflict of financial interest in relationship to this
manuscript.
Questions
1. What is the diagnosis?
2. What is the mechanism of acute kidney injury?
3. What laboratory study over the hospital course is not typically associated
with diagnosis?
4. Is the conducted electrical weapon encounter clinically relevant?
62 Pediatr Nephrol (2016) 31:61–62
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