# 39 y/o male seizing



## NYMedic828 (Jul 18, 2012)

So we respond to a call for a stat-ep seizure.

BLS and fire are onscene 8 minutes ahead of us.

We get there they have him on O2 and say he's been seizing x15 minutes. The room was too packed for me to get in there so I let my partner handle it with the BLs and I started paperwork.

So my partner tells me she he is still seizing she is going to give 10mg of versed IM. I say ok. She gives it as I finally get over there and honestly I don't feel he was having a seizure. The patient wasn't having convulsions he was more along the lines of AMS severely agitated. He was swinging his head a bit all over lightly flailing arms and obvious hyperventilation. The other thing that made me feel he wasn't seizing was his VERY minor responsiveness to voice and full response to pain.

Patients history is only a motorcycle accident 6 years ago in which is legs were completely reconstructed and he has renal problems since. His bladder only holds 2cc of urine, so he pees in urinals all day. (he doesn't want a more permanent solution for some reason)

Normally the patient has trouble ambulatory but otherwise his mental condition is normal.

He has had emergency dialysis four times. He isn't normally on dialysis though.

His meds are only dilaudid and bicarb tablets.

Initial vitals 

BP 240/110
HR 120
RR 30, deep kushmauls respirations.
3 lead, STach
BGL 195

The 10mg of versed doesn't touch em. We get an IV and med director approves 10mg of Valium. Mind you he withdraws heavily to the IV stick pain. Anyway, Valium doesn't touch him either.

The family claims the onset was relatively sudden, maybe an hour ago something seemed a bit abnormal.

Anyway, we get him to the ER, last I knew he was being intubated and sent for a CT scan.

So what would you guys presumptively diagnose here?

I was thinking along the lines of a bleed, but at the same time he has the blatant kushmauls respirations and a pretty tachy pulse maybe suggesting an acidodic condition?

I had a similar patient a couple months ago and the diagnosis ended up being acute renal failure. We originally ruled a bleed.


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## code3gyal (Jul 18, 2012)

im not a paramedic but could it be septic shock? thats what it seems like to me aside from the bp thats the first thing that came to my head wild guess


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## VFlutter (Jul 18, 2012)

NYMedic828 said:


> S\
> *He has had emergency dialysis four times. He isn't normally on dialysis though.*
> 
> I was thinking along the lines of a bleed, but at the same time he has the blatant kushmauls respirations and a pretty tachy pulse maybe suggesting an acidodic condition?
> ...



I would think metabolic acidosis or electrolyte imbalance secondary to acute renal failure. Happen to get a 12 lead? Would also throw UTI or nephritis into the differential based on his bladder issues. 

Random Patho quiz: anyone want to explain RAAS and what it has to do with the kidneys and hypertension??


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## NYMedic828 (Jul 18, 2012)

ChaseZ33 said:


> I would think metabolic acidosis or electrolyte imbalance secondary to acute renal failure. Happen to get a 12 lead? Would also throw UTI or nephritis into the differential based on his bladder issues.
> 
> Random Patho quiz: anyone want to explain RAAS and what it has to do with the kidneys and hypertension??



I was thinking along the lines of acidosis due to the severe kussmauls respirations and his history of renal failure. 

Unfortunately he was too agitated to get a 12. We could barely get a readable 3 lead.

10mg versed IM and 10mg Valium IV didn't phase him. Usually has most patients out cold drooling.


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## VFlutter (Jul 18, 2012)

NYMedic828 said:


> I was thinking along the lines of acidosis due to the severe kussmauls respirations and his history of renal failure.
> 
> Unfortunately he was too agitated to get a 12. We could barely get a readable 3 lead.
> 
> 10mg versed IM and 10mg Valium IV didn't phase him. Usually has most patients out cold drooling.



Did you happen to notice any peaked T-waves on the 3 lead? Hyperkalemia is on the top of my list.


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## DPM (Jul 18, 2012)

Seizure or not, I would have thought 10 each of Valium and Versed would have snowed this guy...

Kidney failure / disease is my guess. If the kidneys are inappropriately excreting Renin then that would explain the Hypertension. It would also cause Hydrogen Ion acidosis, Hypernatremia and a bunch of other hyper things too.


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## NYMedic828 (Jul 19, 2012)

ChaseZ33 said:


> Did you happen to notice any peaked T-waves on the 3 lead? Hyperkalemia is on the top of my list.



Na pretty regular.

Ya, pretty surprising. Most people are on the floor after that much.


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## VFlutter (Jul 19, 2012)

NYMedic828 said:


> Na pretty regular.
> 
> Ya, pretty surprising. Most people are on the floor after that much.



I had a patient who was a ETOH/drug abuser who was on a versed drip @ 18mg per hour along with some fentanyl @ 200 mikes and he would still wake up at times. We had to change his IV tubing and within ~ 45 seconds off the pump he was fighting the restraints and required a 20mg bolus.

Never know how people will respond to drugs. Maybe he took benzos on a regular basis for anxiety or something.


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## NYMedic828 (Jul 19, 2012)

ChaseZ33 said:


> I had a patient who was a ETOH/drug abuser who was on a versed drip @ 18mg per hour along with some fentanyl @ 200 mikes and he would still wake up at times. We had to change his IV tubing and within ~ 45 seconds off the pump he was fighting the restraints and required a 20mg bolus.
> 
> Never know how people will respond to drugs. Maybe he took benzos on a regular basis for anxiety or something.



Lol that would kill most mortal men.


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## mycrofft (Jul 19, 2012)

How was his liver? No liver=no benzo (needs to pas through liver to become active metabolite).
Could be something intracranial (besides chemical imbalance).


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## NYMedic828 (Jul 20, 2012)

As far as anyone knew, his liver was just fine.


He suffered a bad motorcycle crash a few years back in which his lower body took a severe toll.

His legs are basically all plates and pins. He had a hip operation a week ago. Over the past couple of years he started to have kidney issues. He essentially has no bladder, he can only hold 2cc of urine so essentially he has to urinate constantly. (he has no foley or surgical means of urinating)

So in the 30 minutes alone that we were with him, I imagine he had a decent fluid backup already. His urine in the ER when they did a foley was a strange deep orange color like someone severely dehydrated may have.

He also had no incontinence, and with his condition I would think a seizure would certainly have caused some leakage.

Lastly, he may have suffered a brain injury from the accident and he had 1 generalized seizure 4 years ago. This is what lead them to believe it was another seizure. They never diagnosed or prescribed anything for epilepsy.


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## VFlutter (Jul 20, 2012)

NYMedic828 said:


> As far as anyone knew, his liver was just fine.
> 
> 
> He suffered a bad motorcycle crash a few years back in which his lower body took a severe toll.
> ...



Random fact; Phenazopyridine (pyridim) is an OTC drug used to treat pain associated with UTIs, it turns your pee and other body fluids including tears a bright orange color. Freaks a lot of people out if they do not read the label.


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## mycrofft (Jul 20, 2012)

Deep orange urine color. Need a dipstick value here, and a micro sedimentation. If strongly positive for haemoglobin, it may have been myoglobin, indicating rapid tissue catabolism. If negative for that but high specific gravity, then dehydration or renal failure letting stuff through it shouldn't. Yes some meds will color urine too, especially pyridium. (Never head about it staining tears, but I spray painted a lab room once when a tube of urine blew out in the centrifuge before lids were mandatory on "spinners").h34r:


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## EMT91 (Jul 20, 2012)

ChaseZ33 said:


> I would think metabolic acidosis or electrolyte imbalance secondary to acute renal failure. Happen to get a 12 lead? Would also throw UTI or nephritis into the differential based on his bladder issues.
> 
> Random Patho quiz: anyone want to explain RAAS and what it has to do with the kidneys and hypertension??



I am gonna agree with you. Any swelling/edema? Bruising?


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## BayArea (Jul 23, 2012)

Sounds liking they are stroking out and showing signs of Cushing's Triad. What did the CT show?


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## VFlutter (Jul 23, 2012)

BayArea said:


> Sounds liking they are stroking out and showing signs of Cushing's Triad. What did the CT show?



Why makes you think stroke?

Hypertension is present but they are not bradycardic (however in the first stage of the cushings reflex they would still be tachycardic, but that this point i would expect them to be brady) Also he was tachypenic with kussumal respirations so i guess you could take that to mean "irregular respirations" however when i think of cushings it is more of cheyne-stokes or slower, deep, irregular breathing. Kussumals is usually very regular and fast.

It sounds more like his body is trying to compensate for acidosis. HTN could be explained by the renal issues and RAAS.


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## skivail (Jul 24, 2012)

I'm going to agree it's kidney related.  Could also explain the high BP.  Pulse and MAP seem to be too high for cushings.


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## Handsome Robb (Jul 25, 2012)

ChaseZ33 said:


> I would think metabolic acidosis or electrolyte imbalance secondary to acute renal failure. Happen to get a 12 lead? Would also throw UTI or nephritis into the differential based on his bladder issues.



I'm going to agree with Chase on this. I'd love to see his labs. I bet they were all sorts of buggered.


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## BayArea (Jul 25, 2012)

Someone with ARF is going to be hyperkalemic. Based on the information given, there is no indication of hyperkalemia. This person has had a previous brain injury. Based on the limited information, I would still say hemorrhagic stroke. Also may or may not be a seizure. Based on the limited info and not seeing for myself, sounds like ALOC. But, just because the Valium/Versed didn't work does not rule out it being a seizure.


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