"convulsions"

[OVeractiveBrain]

Another case study:

28 yo caucasian female coming from home. She has an extensive psychiatric history with a number of meds, many new, that I did not recognize. She recently had a surgery that implanted a "neurlogical pacemaker" (a device that, when active, will stimulate afferents from the carotid sinus via the vagus and glossopharyngeal nerves that is supposed to increase the relative amounts of dopamine, seratonin and norepinephrine released into the brain to treat psychiatric disorders), with a sizeable incision with stitching near the left carotid artery. She went to the store at 1300 and took longer than she usually does, according to her parents, who she lives with. People started calling her "retarded" and she was so upset she returned home. She presents now at 1800 with restlessness and the inability to stop moving. Her extremities seem out of her control, making purposeless rolling and weaving motions. Despite her best efforts, she is unable to control her extremities. Finger touch / nose touch is out, though she is able to make good strong hand grasps and stand with assistance. Her speech is slightly slurred. She cant really stand up on her own, but it not that unsteady gait with CVA, its more of that "im a psych and OOPS i fell down" but im not ruling out unsteady gait.

Family Hx: No cardiac, No pulmonary, No Ca, No CVA, NO IDDM, lots of psych (bipolar, shizo, depression)

Social Hx:She is clean from cocaine and heroin for three years, denies any drug use. Amongst other psych meds she takes Yaz(brith control) and smokes cigarettes. Denies drug use, denies possibility of pregnancy, parents confirm compliance with medications.

HEENT: Normal, no discharge, PEARL

Speech: Slurred

Mentation: GC:15, CAOx4

Motor: PMSx4, unstedy gait, good hand grasps and muscular tone, uncontrolled movements, though can apply force in certain directions, cannot stop movements

VS:

BP: 140/80

HR:112 sinus tach,

12-Lead: refused 12-lead (female, psych, im a guy, no shirt off, gave ER trouble too)

RR: 16, clear equal bilaterally

Skin: Warm Pink & Dry, mildly flushed in face (faired skin girl, probably gets flushed easily), afrebrile, cap refill great

Sp02: 98% RA, 100% 4LPM

bG: 97

Pain: None

General Appearence: well kept, frustrated at the inability to stop moving, though not agitated nor anxious

I checked for tract marks and searched her purse/coat while the family checked her drawers while the FD was extricating her with our stair chair. I didnt find anything, and she had this aura of pride when she said she was clean. She didnt even take anything from anyone that might have been laced with something. Given her psych and drug history I was unsure as to whether i could trust her, so i prodded a little more to no avail. (I dont want it to sound like that this was my main focus because it has gotten so much attention in the post, but it was one of my promininet differentials).

To be honest, I didnt know what was going on. The slurred speech and "unsteady gait" made me nervous. Though it was unsteady becasue she was restless. With the amount of medication she is on (including schizophrenia meds) and with the new neurological pacemaker (which i never heard of) I got to thinking it might be stroke. Recent surgery in or around the carotid artery + overweight + birth control + smoking = CVA. But it didnt present like a CVA. It was like a giant dystonic reaction involving her entire body. Some research on the intarweb revealed a possible diagnosis of Tardive Diskythesia, a desire to move extremities as a result of dopamine insufficiency (seen with reglan and schizo meds*ding ding*). I went down the route of stroke, providing routine ALS and a priority I transport (lights + sirens) to the nearest facility (family wanted to go to the specialists' hospital for the next morning).

I reflected after doing some research on dystonia and realized that benadryl was NO WHERE in my mindset when considering this patient. I mean, we give benadryl with reglan to reduce extrapyramidal reactions, but I just never thought that a) this is a dystonic reaction and i could give benadryl to make it stop. To be honest, i really assumed dystonic reactions were more focal (in the hands, conjucate gaze, lip smacking, cervical torticullis, eye blinking, individual muscle flexion without release, etc). This was just so general. Since I didnt know what it was and she had some risk factors for CVA, i went with CVA. But that just sounds like im filling out my treatment code box and not treating the patient. She wasnt in any distress so i wasnt terrifically worried, but we were as far out in town as you can get, so I wanted her to a physician fast. Ultimately, Im thinking psych meds + natural dopmaine insufficiency (thus the "pacemaker") --> augmented restless leg syndrome or some sort of dystonic reaction.

But im interested to hear what people might be thinking along this one. Really it was just so strange that I wanted to share it; no one i talked to about it really knew what it was nor what they would do. But if anyone has any thoughts, throw em out there.

All the interesting cases happen at the end of my day, so i never have a chance to follow up with the patients afterwards.

[VentMedic]

You do live up to your sign on name

[OVeractiveBrain]

Thanks, i take that as a compliment

[crazycanuck]

Just to follow-up on the info here about the "brain pacemaker". This device is called the VNS (Vagus Nerve Stimulator). It is not a new device, however it is just more recently becoming more widely implanted in the treatment of both epilepsy as well as refractory depression. I am not sure of the FDA status for the implantation in depression, I believe large scale trails are still underway. As for the indication of implantation in epilepsy, it is mainly implanted for partial seizure disorders that are refractory to multiple medications in both single drug intervention as well as combination drug therapy.

I would guess that this VNS was implanted in this patient not for epilepsy, as you did not mention that as a diagnosis, but for depression/neurological involvement. The actual mechanism of action of the VNS is not completely proven, as we know the vagus nerve has so much involvement and control over the body in general. The basic theory behind it, is that by using impulses to stimulate the vagus nerve, it can cause neuronal discharge and interrupt abberant cortical activity as well as affect the production and balance of excitatory neurotransmitters.

Just FYI, the VNS is usually compared to a pacemaker because the general idea is very much similar. The programming on these devices can be altered as far as voltage and timing (pulse width) of interventions. The device can be set to intervene at specified intervals, or in the case of seizure disorders can be activated by a remote magnet (that the patient or parent can carry) that will intervene to hopefully lessen a current or oncoming seizure. Also useful to know, as in a "runaway pacemaker or pacemaker-mediated tachycardia", any device like the VNS has potential for programming error or interference. The VNS can be inhibited by a magnet depending on the settings, usually the patient/paretn will know how. (can be set to activate by one pass over the device and inhibit by holding over device, then turned back on- totally depends on programmed settings)

Now- with regards to this patient-- has this patient had any dose changes recently? Missed a dose? Added a new med? Taken any OTCs she forgot to mention?

My initial thought on this is that this patient is certainly having an issue of polypharmacy. This is perhaps unavoidable, as she may clearly have a need for the plethora of psychiatric and other medications she is currently taking. This could also, as you know, be a result of discontinuity of care and multiple physician interventions with poor patient report of current meds and history.

The motor response does possibly sounds that it's a result of meds, but the index of suspicion you had to r/o anything else is of high quality patient care, rather than assuming "it's just the meds" and there is nothing more serious going on such as CVA, etc.

Take a look at this if you like on Neuroleptic Malignant Syndrome. Helpful info on meds and s/sx.

http://www.emedicine.com/EMERG/topic339.htm

Emergency Psychiatry: Extrapyramidal Side Effects in the Psychiatric Emergency Service

http://psychservices.psychiatryonline.org/...t/full/51/3/287

A Guide to the Extrapyramidal Side-Effects of Antipsychotic Drugs

http://bjp.rcpsych.org/cgi/content/full/176/5/502

Info on VNS:

http://www.vnstherapy.com/

Often times, patient on multiple meds are on a balance of meds to reduce the possibility of the extrapyramidal effects they can create. Very interesting case, thanks for sharing.

[WendyT]

"brain pacemaker:

Given all the info on this, I wonder if this would help people who have eating disorders, would it be a benefactor and help stimulate the brain to act thus stopping the thought am I fat/do I look fat syndrome?

Would it work wonders for me? :roll:

[scope2776]

I reflected after doing some research on dystonia and realized that benadryl was NO WHERE in my mindset when considering this patient. I mean, we give benadryl with reglan to reduce extrapyramidal reactions, but I just never thought that a) this is a dystonic reaction and i could give benadryl to make it stop. To be honest, i really assumed dystonic reactions were more focal (in the hands, conjucate gaze, lip smacking, cervical torticullis, eye blinking, individual muscle flexion without release, etc). This was just so general. Since I didnt know what it was and she had some risk factors for CVA, i went with CVA. But that just sounds like im filling out my treatment code box and not treating the patient. She wasnt in any distress so i wasnt terrifically worried, but we were as far out in town as you can get, so I wanted her to a physician fast. Ultimately, Im thinking psych meds + natural dopmaine insufficiency (thus the "pacemaker") --> augmented restless leg syndrome or some sort of dystonic reaction.

I would have to say, "great job." You took the information you had available and come to several different differentials, which you prioritized and treated. Excellent critical thinking. You treated for the most serious differential (stroke), no problem at all. I don't have a CAT scan in my ambulance yet... she prob just got a little extra attention and faster ride to the ER... no harm done, i'm sure next time you'll be thinking Benadryl right away.

I was thinking dystonic reaction right off the bat, with the repetitive movements and mainly CNS complaints; along with history. I had a patient with the "deep brain stimulus" electrodes back in EMT school, that's really the only way i can remember. They look just like bilateral pacemakers, or at least on the patient i had. Normally those units are used for advanced Parkinson's disease, which is a deficiency of among other things dopamine. We treat the symptoms with 50mg Diphenhydramine IV or IM. Usually this works great and reduces symptoms immediately.

Now what are some other medications patients might be on at home, and overdose on, or be on a dose outside the therapeutic range on, that will also produce a similar dystonic reaction???

[Just Plain Ruff]

My first thought was that her implant went haywire.

you said it yourself, you suspected increased dopamine response - well her implant was made to increase dopamine Maybe the device was doing more than it should be doing thus causing this type of issue.

did she run home, did she jar something loose like the electrodes that cause the stimulation.

Or is her body finally reacting to the increased levels of dopamine in a negative(majorly) way?

Great thinking on this call. I'd like to hear what exactly happened to her in the end.

[ERDoc]

Did her legs seem to be more affected than her arms? This sounds like serotonin syndrome to me. With all of the psych meds she was on, I'm sure there is something that is affecting serotonin levels. I once had a kid who OD'd on an SSRI and presented with what sounds like the same kind of symptoms. I called to tox people who work at the large teaching hospital and they said that he should go to the Peds ICU. I got a call later saying that he had the classic presentation of serotonin syndrome. The tox doc said that you couldn't ask for a more textbook presentation. Like I said, from what you are describing it sounds like serotonin syndrome to me. Have I mentioned the word serotonin enough? Serotonin.

[firespec35]

OK just a medic student here but if it is a "Vagus nerve stimulator" It leads me to think that it is more of a pharm issue for the simple fact of when you stimulate the vagus nerve it should drop your pulse and BP. She was at 140/80 and 112. Now I have no experience with the device but when you perform a vagal manuver isn't that the same as stimulating the vagus nerve?

[Spock]

This is certainly a good topic. I've given anesthesia for stimulator placement to treat Parkinson's. The cases were interesting but also difficult because you have to sedate the patient while the neurosurgeon drills a hole in the skull but then have them awake for lead placement and testing. Challenging to say the least.

I agree that the best prehospital treatment is transport quickly to the hospital that implanted the device unless that was to far away. Supportive care would seem the best option because you can't be sure if the issue is device failure/malfunction or a neuroreceptor issue. You just don't have enough information as a medic.

The drug abuse issue may be a red herring but I would not be fooled by a proud look of being clean. When I worked as an athletic trainer in the NFL we brought in a college player for an interview prior to possibly signing him as a free agent. He had a history of drug abuse and had actually served time in prison. Yeah, I told the coach he was crazy for considering him but we had a losing team the year before. Anyway, we asked the player for a urine sample for a drug test. He gave me the specimen cup and with a sincere look on his face said "This is some clean stuff." Ok, not the exact words but you get my drift. The lab called me the next day and the tech said he had never seen a higher level of cocaine in a sample and asked if the specimen came from an unconscious person. Needless to say we didn't sign him and I never let the coach forget it.

Live long and prosper.

Spock