The seizing lady

[ERDoc]

She had the PPD as a part of a routine initial physical at the county clinic. The pt had a nl cxr so she was started on INH. EKG is pretty useless due to seizure activity (for those that decided to RSI, it shows sinus tach at a rate of 126). VS BP 167/100, but difficult to assess accuracy due to pt seizing, about 126/72 when paralysed. Tha family denies any recent illness or special pets/herbs/plants. So, let's assume that she has gotten 3 doses of your benzo with no improvement. You decide to RSI her and once your paralytic of choice is onboard, she no longer has seizure activity. Someone brought up a good point here; just because her body is no longer seizing, her brain still is. Obviously not something that can be done in the field, but she needs to be on an EEG monitor.

Rid, I will give you a progressive ambulance with a CT which is read by the onboard radiologist as normal. You also have such a long transport time that you perform an LP and get the results before arrival at the ER (sounds like my job may be obsolete) and it is normal. I would not recommend doing the LP without doing the CT first though (extra credit for anyone that can tell me why). Your onboard EEG shows diffuse seizure activity.

The husband is now grabbing at you, praising your ability to make his wife "stop shaking. But can you tell me why she is doing this?"

[chbare]

ERDoc, we need to do a CT to rule out intracranial pathology. (Bleeding, possibly a ruptured berry aneurysm with subarachnoid hemorrhage. Bad juju to LP if we have a bleed or increased ICP.) All we have done with paralytics is block the nervous systems ability to tell the muscles to contract and relax. The mechanism will depend on the paralytic. (depolarizing vs non depolarizing) For a long transport without other meds, (ie, diprovan) we will probably be using a non depolarizing blocker after the initial intubation to maintain paralysis if needed. I will be curious to see what the CT shows. Excellent call on the CT Ridryder 911, I did not initially consider a bleed, but now it makes sense after you mentioned getting at CT and with the HX. of sudden onset SZ, I should of considered this earlier.

Take care,

chbare.

[ffpm41]

For starters, place her in a lateral position and insert OPA to help maintain airway (NPA if the OPA won't work d/t the seizure). High concentration O2.

I agree with everything else you said except the statement above, I'm not putting anything in her mouth unless it's a tube after I RSI her.

After benzos didn't work I'd most likely RSI her (lido, Versed, Roc). I guess you can also try Mag if you really wanted and it's in your protocols.

[Ridryder 911]

Man, this is one getting deep.. Neuro is not here yet ?.. Since, she is sedated & on a vent., I would probably try to either load her up on cerebyx or maybe after consulting with the nuero team on suggestions, possible deep heavy sedation to see if any changes of EEG ?..

Although, it will be forever to run, start the usual lab's and maybe see if toxicology comes with something I am sure I am missing something that is obvious. It's the usual 2 a.m. like in real life.. too much coffee... Hopefully, we can see something altered in her labs, order the usual CBC, CMP, BLDCLTRS., U/A.. anything remarkable on physical examination, since we have knocked her down and altered our p.e., that has not been earlier recognized ?..

I would try to get a better hx. if possible from the spouse.. unusual food (cooked or uncooked), related illness in family or those that was on the trip ?....

R/r 911

[ffpm41]

Rid, Thanks for adding the hospital based side to management of this patient.

[AKmedik8or]

Your Kung Fu is very deep for my known pre-hospital medicine, If the issue at hand is looking at a pre-hospital LP before a CT I would suggest at holding the LP to not change the volume of CSF prior to radiology.

Are we looking at a R/o meningitis? encephalitis?

Also has there been considerations for immunizations or treatment for pertussis?

[ERDoc]

chbare, you are half right about the LP before CT. There is no problem in doing an LP on someone with a bleed. CTs sometimes miss the bleeds so we actually do an LP to make the dx. This issue, and it is a theoretical one, is that if you have an increased ICP you can cause herniation. This has never actually been shown in the real world, but would you want to be the test case? The CT in this case is negative.

Now that she is not shaking you can do a full physical exam. You find nothing including track marks. She is still afebrile and her vitals are stable. There was no recent travel or unusual foods. Rid, all of the labs you mentioned are negative, as is a beta.

The neuro team shows up and says, "You have the answer already. Look over what you have and you will see it. Call us if you need us."

[akroeze]

The neuro team shows up and says, "You have the answer already. Look over what you have and you will see it. Call us if you need us."

And when we don't figure it out, they are promptly slapped with a huge law suit.

[chbare]

Thanks for the clarification ERDOc. What about acute INH overdose? I know this can cause sudden onset seizures. Her CT is negative, labs are negative, (no elevated WBC or left shift or out of whack electrolytes) and she is not febrile. Everything points to acute INH OD. We can check the anion gap and see if it is elevated. I think we need to load her with cerebyx and get Pyridoxine on board. I think pyridoxine dosage is based on the approximate amount of isoniazide taken. What does every body else think?

Take care,

chbare.

[ERDoc]

Sorry I didn't conclude this case. chbare, you are very close. The seizures are from INH toxicity, not necessarily an OD. Can you tell me how the INH causes seizures?