Here's an interesting one...

[mark]

You are toned out to respond to a 78y/o M for a seizure. On arrival, you take BSI precautions, note that the BLS engine is on scene with 2 FFs and captain. WIfe meets you at the door, states that pt is diabetic has Hx of hypoglycemic seizures, she found him down in bathroom against toilet, and seizure was not witnessed. You enter the apartment building, and walk down a flight of stairs finding pt supine in bedroom (fire moved pt from bathroom). Pt is 6'3", 260lbs, responsive to deep painful stimuli, snoring resps at 12, NRB in place at 15LPM by fire, good radial pulse at 128. Begin!

[Eydawn]

Well, first of all I'd *really* like to know what his blood sugar is and all of the medications he's on. Including vitamins and herbal supplements. I'd also like to know what he ate last, and when... and if he's had any recent illness or medication changes. Any other medical problems- associated with the diabetes or not- like cardiac history, etc.? Type I or II diabetes? Insulin dependent?

Pupils? Basic 3 lead ECG? Blood pressure? Tolerate the OPA or no? Any signs of traumatic injury- bruising, bleeding, etc. especially in the head region? Since she didn't see the seizure (if that is what happened) and he was down against the toilet he might have whacked himself on the way down...

That'll do for starters.

Wendy

CO EMT-B

[mobey]

I would also like to know what his skin looks like.

I'll have fire spike a bag of NaCL while I assess.

Also did his wife talk to or see him prior to entering the biffy? If so was he acting normal?

How is he responding to painful stimuli? Groaning, talking, localizing pain?

[explenture]

Was he having a BM and vageled? I'd do a 12 lead, is his skin tenting?

[mark]

All right. Here we go from the top down:

AVPU- pt responsive to deep painful stimuli with groan and flexion, Eyes-1, Verbal- 2, Motor- 3.

A- snoring resps stop with 32 NPA, no foreign bodies.

B- resps 12 and regular, NRB at 15LPM in place.

C- skin pale, cool, diaphoretic, slightly cyanotic but improving with O2, no bleeding, good pulse at 128 bpm.

Vitals: BP- 108/62 HR- 128 bpm Resps- 12 non-labored O2 Sat- 93%

HEENT- No obvious signs of trauma, PERRL 4 to 3, no JVD/deviation.

Chest- chest wall intact, no obvious trauma, clear lungs bilat.

ABD- soft, nontender (as best you can tell anyway), pelvis stable.

Extremities- +pulse=x4, no response to verbal commands for motor/sensory, - Babinski.

Back/Spine- no obvious trauma/stepoffs noted.

Monitor- Sinus tach staying around 130, no ectopy or abberancy.

CBG- 205 mg/dl (Sorry. I know that's not what you wanted to here, but if it was, it wouldn't be worth the post.)

SAMPLE (according to wife)

S- pt hasn't been feeling funny, running a fever, or anything else out of the ordinary.

A- Sulfa drugs

M- Unknown. Wife states pt recently changed to a new diabetic drug, unknown which one. Fire Captain said he wrote down all meds, but gave us the list after we loaded the pt and it had only 1 med on it and was misspelled beyond recognition.

P- DM Type 2, hypoglycemia induced seizures, rest unknown (wife poor historian).

L- Pt ate breakfast this morning ~0900 (now 1130), normal sized meal. Took morning meds.

E- Wife states she was in kitchen, heard a bang, and went into bathroom finding husband on floor between toilet and wall, seizure was not witnessed, toilet base dislodged from normal position.

Fire spikes line for you, IV access obtained, another CBG taken from stick is 224 mg/dl.

[Just Plain Ruff]

Is he boarded and collared?

[Eydawn]

If the toilet base is dislodged and he's NOT in full spinal precautions he should be...

Any history of opiate use? Recent pain scrips? Any idea what his "normal" BGL is? It varies per person...

Wendy

CO EMT-B

[fireflymedic]

Okay, first things first, I would like this gentleman boarded and collared. While we are doing this I am going to ask the wife to bring me his meds so I can see them. Also, determine whether he is insulin dependent or not and if so what type and how much.

Next, what type of reaction am I seeing to painful stimuli? Is he opening his eyes, attempting to talk, just moaning, posturing, etc? Do I see any blood or obvious injuries? As this is an unwitnessed seizure - who is stating it is such? Are pupils dilated? Reactive? Signs of bladder/bowel incontinence? Is the guy improving with time typical of post ictal? Does he tolerate an airway adjunct? NPA or preferably OPA? Intact gag reflex indicating he can protect his own airway?

Okay, now let's get a glucose courtesy of a finger stick as most machines are set up to evaluate capillary not venous blood. What do I get? I want a line and if glucose less than 80, I'll give an amp of D 50. If glucose is high, I want fluids. What is his skin condition? Color, temp, turgor? Does he look like typical insulin shock? What is his normal glucose range and does he have reasonable control over his diabetes?

I'll leave him on the 15 NRB for now provided he can protect his own airway. If he can't, we'll escalate, but it sounds like he can hold his own for now. Oh BTW, all the above is being done enroute. I'm not gonna stay and play with this gentleman.

[mobey]

Any complaint of a sore neck recently?

What is his temp now??

I am thinking a possible meningitis. (OK call me on it, & let me know why I could have ruled it out)

Consider gown & mask

[mark]

Sorry. I forgot to mention in my last post that 1 FF was holding c-spine and a collar was put on. He also was incontinent of urine. Unfortunately, meds (recent scrips/changes and the like) are unavailable as we did not get them. The fire captain said he had a complete list for us (see above) and we didn't double check. No excuse, but unfortunately how it worked out. First CBG of 205 was obtained via finger-stick. With all of this and the above information, what is your treatment plan? I know there are always more questions to ask, but at this point in the scenario, you have all the info we had.