# Got called for a seizure-but it wasn't.



## Hockey (Jun 28, 2012)

Ideas?  Input on whats going on in the strip? Unable to obtain 12 lead because...well.  Things started going downhill fast.








It was a warm dark morning, the birds were starting to chirp, and yours truly was trying to get a nap in since we've been running all night.  Bam.  Called for a seizure.  No notes on the call or anything.  

We arrive at a nice home, met at the front door by some kids who ask if their mom will be alright.  Sorry guys, I'm not even on your porch yet, so I don't know.

We find patient (49/F) laying in bed unresponsive.  Patient husband speaks little English so everything is through talking with the kids.

Patient has agonal snoring respirations, and you can hear that she aspirated some.

Only medication she is on is Abilify for depression.  Filled last week, and the bottle was full.  No history of suicide attempts and no reason to think she overdose.

No drug, or alcohol problems.  No medical history besides depression.  No allergies, no change in diet, or mood.  No reason to think of foul play.  Patient was feeling fine when she went to bed at her normal hour.  

Patient was making "funny noises" and couldn't wake her up family said.  No seizure

Initial SPO2 74% room air.

I immediately started attempting to bag her as my student grabbed a NPA out.  NPA goes in fine.  First bag post NPA deployment, she vomits pink frothy sputum all over the place.  I run and grab suction and start suctioning.  Its bloody.  Its pink.  Its a whole lotta everything as usual.  

She had the beginning of some decorticate going on but as soon as it would start, it'd stop.  Not really sure.

Decision was to move her to ambulance immediately and go.  

Got her in the ambulance and my partner dropped the OPA which she took fine but it got pushed out (not sure what was going on there) somehow.  Bagging her but she was fighting it.  Sats up to 85%

So here are her vitals that we got (in the house)

BP 150/90
HR 110 every now and then irregular
Lung sounds...well..you can guess.
3 lead (look up at the top).  
Unable to obtain 12 lead.
BGS: 155
Pupils 3 or 4 non reactive.  
Unresponsive to verbal, painful stimuli, OPA or NPA.  Gag reflex was present only slightly.

Unable to obtain IV access since we were tied up worrying about her airway.  We were 1 mile from the hospital.

They RSI'd her in the ER before we left.

They agree they don't think she overdosed.

*So I'd like to hear everyones input, especially about the 3 lead.*


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## Handsome Robb (Jun 28, 2012)

Sinus with PVCs and PACs?  I'm not sure on that one.

Almost sounds like a ruptured aneurysm. Complaint of any headaches recently? Doesn't explain the rhythm although the ectopy could be secondary to hypoxia...


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## Hockey (Jun 28, 2012)

NVRob said:


> Sinus with PVCs and PACs?  I'm not sure on that one.
> 
> Almost sounds like a ruptured aneurysm. Complaint of any headaches recently? Doesn't explain the rhythm although the ectopy could be secondary to hypoxia...



Nope no headaches.  Family states she been absolutely normal the last few days.


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## Handsome Robb (Jun 28, 2012)

Hockey said:


> Nope no headaches.  Family states she been absolutely normal the last few days.



Family hx of CVAs or aneurysms? Increased risk for CVAs is a side effect of Abilify but that's generally in older patients. 

Does she smoke? Oral Contraceptives? Any recent trauma? Right or leftward gaze?

Does she respond to pain at all? Localize or withdraw? I know you said she had intermittent decorticate posturing. 

I'm interested now haha


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## Hockey (Jun 28, 2012)

No family hx that could be obtained but they said everyone is healthy so.  No trauma no BC no other meds.  No gaze...when I opened her eyes she looked right then down then that was it. But no neuro behind it


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## Achilles (Jun 28, 2012)

So um where from Michigan are you?


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## Anjel (Jun 28, 2012)

Achilles said:


> So um where from Michigan are you?



The cool part. Duh.


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## Hockey (Jun 28, 2012)

Achilles said:


> So um where from Michigan are you?



Depends...where are you from?


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## MadMedic (Jun 28, 2012)

Did you only get one set of vitals?  
Was there any changes in the time you were with her?
What was her skin like?  
Did they do a 12 lead at the hospital? if so, did you see it?
Did you get a chance to count the pills to see if any were taken?

I'm assuming you are on an ambo and it was only you and your EMT?


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## mycrofft (Jun 29, 2012)

A seizure need not look like a typical grand mal, and a seizure is not necessarily seizure disorder. Intracranial insult can cause seizureform activity. Pupils were equal? 

We had another post a while back about bloody respiratory stuff without a known etiology after an airway was inserted. Did she truly vomit, or cough the frothy material up? What are the chances that she had some trauma with airway insertion and it tinged the froth?

Anyone have a good knowledge of what happens to cardiac rhythm when cerebral control is degraded or cut off?


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## Melclin (Jun 29, 2012)

*Do you actually have an answer for us?*

What was her temp?

In addition to what has already been said:

Could be pneumonia that went south pretty quickly. Seems unlikely.
Anterior MI with LVF. 
Prescription opiate OD. 

None of them seem that likely. I'd say its pretty difficult to say given the information provided.


As far as the ECG goes, I think I'd need to see a bit more of a rhythm strip that didn't have a lot of PVC on it. Pending a further look, and how it responds to ventilation, I'd say the PVS were 2ndry to the hypoxia. Correct the hypoxia and see how that goes. 

-Position ears to sternal notch with towels.
-Suction. 
-NPA, BVM (or closed circuit if you have it to monitor tidal volume, RR) with 100% O2.

-2x IV access largest bore reasonable. Two bags. 
-Given her age and a lack of obvious causes, I think a 12-lead would be reasonably important here. 

-Expose her completely, for 2ndry, and cover with blanket. 

Do as much of this as I could before we got to hospital. 

Do you have any answers for us? I'm pretty certain on the information provided, nobody will be able to give you a house moment. 



> What are the chances that she had some trauma with airway insertion and it tinged the froth?



Yep, I've been responsible for that once or twice :blush:


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## mycrofft (Jun 29, 2012)

If it's pneumonia, then it's MRSA pneumonia. And maybe immunocompromised.
Then, severe aspiration of stomach contents can cause bloody tinge to respiratory foam, especially if the pt had a severe coughing jag.


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## Medic23 (Jul 3, 2012)

Poss pulmonary hypertension. Seems only other cause would be heart failure and fluid back up or a active progressive annurysem. Lastly I would def consider a active mi as I've witnessed three sz like episodes rt while pts are having active mi s they go into a mild seizure like activity and moments later crash. I always write down a name and check next time at hospital on ones that im curious


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## NHemt1 (Jul 6, 2012)

That 3 lead is FUBR, at this point you just treat the pt although a 12 may of given you a better view. Sinus Arrest? Thats my random guess because P wave is there, normalish? ST segment there...Im actually looking at my cardiology book  right now, and I just cant get it.
-Ryan


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## arici (Jul 7, 2012)

This was the only EKG you got?


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## Craig Alan Evans (Jul 7, 2012)

From the information you give it sounds like a seizure or intracranial bleed. Unfortunately it sounds like the complications you had may have been caused by your treatment.  What were her respirations per minute? Did you try a NRB before you went to BVM? Going straight to bagging a patient like that most likely is only going to force air into the stomach and cause them to vomit.  NP and OP airways very commonly cause minor bleeding.  Your best bet would've been suction, NRB, and RSI.
No recent headaches means nothing. If She had a bad intracranial bleed the onset of a headache and the unconsciousness would've been nearly simultaneous.  The EKG is just sinus with PVCs, also inconclusive.  Sounds like you were on the right track with managing her airway, but I'm guessing you don't have RSI protocols. Looks like you did the best you could do with the tools you were given. Good call. Thanks for sharing.


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## VFlutter (Jul 7, 2012)

mycrofft said:


> Anyone have a good knowledge of what happens to cardiac rhythm when cerebral control is degraded or cut off?



I'm guessing the heart would pace at the rate of its highest functioning pacemaker which would most likely be somewhere in the atria at a rate of ~ 60. I would expect an increase in ectopy because of varying overdrive suppression instead of a single depolrization from the SA node. 

No cerebral control = no rate control. Which can be a big problem, No reflex tachycardia, the heart can not respond to changes in homeostasis.


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## Anjel (Jul 7, 2012)

Craig Alan Evans said:


> From the information you give it sounds like a seizure or intracranial bleed. Unfortunately it sounds like the complications you had may have been caused by your treatment.  What were her respirations per minute? Did you try a NRB before you went to BVM? Going straight to bagging a patient like that most likely is only going to force air into the stomach and cause them to vomit.  NP and OP airways very commonly cause minor bleeding.  Your best bet would've been suction, NRB, and RSI.
> No recent headaches means nothing. If She had a bad intracranial bleed the onset of a headache and the unconsciousness would've been nearly simultaneous.  The EKG is just sinus with PVCs, also inconclusive.  Sounds like you were on the right track with managing her airway, but I'm guessing you don't have RSI protocols. Looks like you did the best you could do with the tools you were given. Good call. Thanks for sharing.



Ya there is only like 3-4 places in MI that have RSI protocols. And none around here. 

And the places that do have it, the protocol states it is for trauma pts only.


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## NomadicMedic (Jul 7, 2012)

Anjel1030 said:


> Ya there is only like 3-4 places in MI that have RSI protocols. And none around here.
> 
> And the places that do have it, the protocol states it is for trauma pts only.



That's a shame. I find we (the system) RSI far more medical patients than trauma.


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## medicsb (Jul 8, 2012)

Massive MI leading to severe LV failure would be high up on my list, but the of possibilities is pretty big.  Just a suggestion, next time I'd skip the BGL and go right for the 12 lead.  If you're really pressed for time, you can run a 6 lead with LP 12.


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## DPM (Jul 8, 2012)

Sinus arrythmia with unifocal PVCs... probably due to hypoxia.

I'd say seizure and there's a zillion reasons why you could have one of them. It explains the initially low SpO2, the hypertension, ALOC and it can explain the pupils. The ectopy on the ECG could then be from hypoxia.

Not too sure about the vomiting / blood stuff. Trauma from the airway has already been said and I'd agree with that.

What makes you say it wasn't a seizure?


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## almostmedic (Jul 8, 2012)

DPM said:


> Sinus arrythmia with unifocal PVCs...



That's my guess for the strip you showed us. 

Hard to guess about the tinged vomit since I'm guessing you didn't have time to take a picture of it to show us here on this forum  haha. NPA or OPA seems very likely but who know she could have been eating strawberries before bed. 

Good call thanks for sharing!


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## DPM (Jul 9, 2012)

Just wanted to add something about the pink froth. Are you sure it was vomit? It doesn't take a lot of anything for it to go "all over the place"... It might sound silly, but did it smell like barf? And you say 'pink tinged', so was it clear with a pink tinge? Oral trauma from OPAs is pretty common, and it wont take a lot of blood / spit to make a mess like that.

Either way, with 20:20 hindsight we haven't been able to really nail this one down, but from where I'm sitting it looks like you did everything you could. You got a fairly decent grip on the ABCs and did your best with what sounds like a tricky airway. Even with the OPA getting spit out, you got the SpO2 up from a nasty 74% up to a much better 85% in pretty short order. As for not getting the IV, it doesn't sound like you really needed one. I think you made the call getting her to Hospital instead of d*cking around for an IV that you most likely wouldn't be using yourself.

Well done, and thanks for sharing. I love these.


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## med51fl (Jul 9, 2012)

I would say a brain bleed.  The AMS, posturing, and vomiting would suggest this.  The EKG is merely a result of the hypoxia.  I would agree that your load-n-go was the way to go.


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## DPM (Jul 9, 2012)

med51fl said:


> I would say a brain bleed.  The AMS, posturing, and vomiting would suggest this.  The EKG is merely a result of the hypoxia.  I would agree that your load-n-go was the way to go.



Do you see Cushing's triad? The pulse pressure isn't that wide and there's tachycardia, not bradycardia.


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## med51fl (Jul 9, 2012)

True that all three components of Cushing's Triad (irregular respirations, widening pulse pressure, and bradycardia) are not present.  The only part presented in this case is the irregular respirations.  The widening pulse pressure cannot be determined since there is only one blood pressure to go by.  The only thing I would caution is that the full-blown "classic Cushing's Triad" is often seen late in significant bleeds.  More often early on in brain bleeds you will see vomiting, irregular respirations coupled with altered mental status.  The posturing could be as a result of a bleed or just a side effect of the hypoxia.

With that being said, there are several other possible conditions that could manifest with the original presentation such as first time seizures, over dose, undiagnosed brain tumor, etc.

The end result was the airway was managed as best they could and rapid transport to definitive care was provided.  The reality is this is our primary function (correct / stabilize the life threatening and rapid transport to definitive care).


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## DPM (Jul 9, 2012)

med51fl said:


> True that all three components of Cushing's Triad (irregular respirations, widening pulse pressure, and bradycardia) are not present.  The only part presented in this case is the irregular respirations.  The widening pulse pressure cannot be determined since there is only one blood pressure to go by.  The only thing I would caution is that the full-blown "classic Cushing's Triad" is often seen late in significant bleeds.  More often early on in brain bleeds you will see vomiting, irregular respirations coupled with altered mental status.  The posturing could be as a result of a bleed or just a side effect of the hypoxia.
> 
> With that being said, there are several other possible conditions that could manifest with the original presentation such as first time seizures, over dose, undiagnosed brain tumor, etc.
> 
> *The end result was the airway was managed as best they could and rapid transport to definitive care was provided.  The reality is this is our primary function (correct / stabilize the life threatening and rapid transport to definitive care)*.



The bolded area is the most important (of course) and I have no arguments there. My thinking was that if there was a bleed on the brain, and it was significant enough to cause posturing, then the bradycardia would have already kicked in. Likewise, I didn't think cerebral hypertension / Increased ICP was transitory, so why would the posturing come and go? And was it actual posturing, or was it the PT starting to move about now that she's postictal...


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## Hockey (Aug 22, 2012)

*UPDATE*


She died the next day.


From what I was told due to strong religious beliefs, family refused to have a full autopsy.  So the only thing was done was the exam they do to rule out obvious homicide.

She ended up having some sort of bleed though and that is what seemed to cause it.


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