# Asking with my hat in hand...



## vquintessence (Apr 13, 2009)

Had a call the other day and it has been driving me absolutely nuts because I can't find a definitive answer. Here's the rundown, and my question will be posed at the end.

Called private residence for "medical aid". U/A found 36 Y/O African male lethargic and supine in bed. Family states pt was last seen an hour ago AOx3 (baseline). PMHx of active sz disorder (compliant c Keppra) and "brain damage from suicide attempt years ago". Med list comprised of two HTN meds and Depakote.

Per obnoxious verbal stimuli pt attempted subjugate gaze. Airway patent, breathing NL bilat c good tidal volume, skin pink/warm/dry, -HEENT --- pupils PERRL bilat, further physical exam unremarkable EXCEPT fixed/rigid extremities (one arm is fully extended and completely frozen in place), pts facial tone is also extremely rigid/tensed.

130/90, ~72 HR reg/strong, 15 RR spO2 98% (no capno here), PE stated above. Upon moving him to truck, his extremities and facial tone remained fixed however he becomes barely responsive to a good trap squeeze. Gave him Ativan 4mg IVP, and shortly he begins to again attempt to subjugate gaze following verbal stimuli, however his extremities (including extended arm) & face remain fixed/toned.

Only further diagnostic info I was able to gather: NSR s aberrancy, BG ~80 mg/dL. Not quite helpful/pertinent. I was convinced that the pt was still experiencing a Tonic Seizure, called for further Ativan, denied (probably because I couldn't paint the picture clearly of what I believed to be going on). Get to ED, they immediately order further Ativan. Have to leave for another call; I'm pissed that I couldn't stay to get an answer to this question:

Was my working dx of tonic seizure unrealistic due to: 1) how it was presenting and 2) the duration and frequencies. (almost want to say he was status...)

From what I've been reading up on, tonic seizures typically have a extremely short duration, and typically occur during sleep. Also was looking into links between tonic seizures and "Lennox-Gastaut Syndrome" (never heard of prior), and he doesn't seem to fit the bill for presentation. Family insisted his mental impairment was from brain damage due to SI attempt in his teens.

Books have been delved into, google has been exhausted, and nobody on duty has seen anything like this. The answer undoubtably lies with family or the pt. Argh


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## Veneficus (Apr 14, 2009)

What did the family say he was normally like?

Sounds like a focal seizure to me.


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## vquintessence (Apr 14, 2009)

Family stated baseline of AOx3, able to ambulate s difficulty, no dysphasia or anything.  They said he was fully capable of taking care of himself and that the only assistance he gets is with med administration.


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## skivail (Apr 14, 2009)

Sounds like a seizure, but I cant decide between focal or tonic...


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## Ridryder911 (Apr 16, 2009)

There are over 1000 seizure disorders and even then not even touching those with previous brain injury history. It would be hard for a ER Doc to determine and would generally classify as "seizure disorder r/t s/p brain injury". Turf to neuro for deeper interpretation. 

R/r 911


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