# Psych Presentation



## BlueJayMedic (Feb 28, 2015)

Call comes in CTAS3/Code2 for a syncopal episode not seizing, now alert. 0840hrs.

46 y/o female found supine at cottage covered in a towel. Pt states she was going back and forth between the hot tub and cold shower to boost her immune system when she felt weak suddenly and boyfriend lowered her to the floor where she laid unconscious for 2+ minutes. Pt is emotionally upset (more than to be expected), and appears to be anxious and has a Hx of the same. Pt released from local psych unit after an 8 day stay for manic depressive episodes. Pt states for last 4 days at hospital she had a headache which was not treated by staff. No cardiac or neuro history. Pt takes daily anti-depressant (can't remember name, not TCA) as only medication, no allergies, last meal was the previous night.

Initial vitals while supine:
A/O x 3, BP 160/90, HR 112 NSR, RR 18 R/F, SPO2 98% on RA, BGL 5.6mmol/L
12-lead non-diagnostic, sinus tach, unremarkable.

Patient adamantly refusing to go to hospital and being extremely dramatic throughout call. Family arrives and finally pt is talked into transport.  In a fit gets up and agrees to go to hospital with EMS (as my partner is preparing the sign off paperwork) and storms out of the house on her own accord. Pt lays semi-sitting on stretcher, vitals are unchanged.

We depart scene and get about 3 house lengths down the road when the pt becomes unresponsive.

Vitals: GCS-3, BP 130/70, HR 48, RR 8 Regular and clear with airway positioning, Patient accepts OPA, no gag reflex. SPO2 98% on RA
Monitor shows sinus brad, 12 lead confirms sinus brad, otherwise unremarkable.

OPA is inserted and ventilations assisted with BVM, priority upgraded, FD requested to meet up en route (volunteer agency).  FD arrives and is loaded into the back. 2 minutes later (12 minutes unresponsive at this point), Pt sits up on stretcher, pulls out the OPA with a large gag and starts swearing and yelling.  Pt is now GCS-15 alert to person, place and time and is slightly lethargic after a yelling spell however otherwise back to how she was prior to leaving scene.

Vitals: GCS-15, BP 150/80, HR 90 NSR, RR 16 R/F, SPO2 100% on non-rebreather, monitor and 12 lead show sinus rhythm.

This call was run with BLS medics to local facility, stroke centre 15+ minutes longer, psych 10+ minutes longer and large full service centre is 45+ longer transport time. 

Just wondering what the community here would have done from BLS/ALS stand point and what everyone thinks is going on.  This call made me change the way I look at psych calls as me and my partner were 100% OK with signing this lady off and driving away had the family not talked her into going.


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## Ewok Jerky (Mar 1, 2015)

Even psych patients get sick (as do addicts and drunks).

You can't fake an absent gag reflex.  Not enough Hx to make assumptions but she needs a good workup including imaging for brain tumor and endocrinology workup.  I don't think a head bleed would deteriorate so rapidly and then recover just as rapidly.  Could be a complex partial seizure too.  

Only med is a single psych med? Why was she "boosting her immune system"? 

Any physical exam findings? Recent weight loss?  Does she look toxic? What does her skin look like? Is it tan? Breath sounds?  

As for treatment, thats tough I would really like a physical exam.  I would be running 12 leads at every stoplight.  Definitely getting a line with fluids ready to hang.  She doesn't sound hypotensive but adrenal insufficiency (primary or secondary) is bouncing around in my head, if she is decompensating I think having a line at the ready is prudent.  Transport to stroke center (I don't think she is stroking out but she needs a CT).


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## BlueJayMedic (Mar 1, 2015)

Ewok Jerky said:


> Even psych patients get sick (as do addicts and drunks).
> 
> You can't fake an absent gag reflex.  Not enough Hx to make assumptions but she needs a good workup including imaging for brain tumor and endocrinology workup.  I don't think a head bleed would deteriorate so rapidly and then recover just as rapidly.  Could be a complex partial seizure too.
> 
> ...


She was boosting her immunity as per her normal "immunity boosting" routine. I think the only Rx was an antidepressant if I recall correctly.
I totally get psych patients get sick this was more of an eye opener to look passed the psych presentation for me for sure. Not toxic, skin was normal cap refill normal, Breath sounds totally clear. 
Adrenal insufficiency never crossed my mind, good call on that for sure.
I do have the final outcome proior to transport to tertiary facility, stay tuned I will post after a few more people weigh in unless no one wants to then I'll spill the beans in a bit.


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## zzyzx (Mar 1, 2015)

Wow, thats a weird one. I dont think youre going to find a good medical explanation for this.  Of course you would want to consider a bleed, but I doubt this. Someone with a bleed can go from fully unresponsive to fully alert (lucid interval), back to unresponsive. Also, GHB users can wake up suddenly from being fully unresponsive and without a gag. But this doesnt sound like any of that. 
Keep in mind that quite a few people dont have a gag reflex.


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## BlueJayMedic (Mar 1, 2015)

zzyzx said:


> Wow, thats a weird one. I dont think youre going to find a good medical explanation for this.  Of course you would want to consider a bleed, but I doubt this. Someone with a bleed can go from fully unresponsive to fully alert (lucid interval), back to unresponsive. Also, GHB users can wake up suddenly from being fully unresponsive and without a gag. But this doesnt sound like any of that.
> Keep in mind that quite a few people dont have a gag reflex.


I have seen patients with absent gag reflexes before.  This patient not only had an absent gag, her rate went brady from tachy and dropped both systolic and diastolic pressure. She also withstood numerous sternal rubs, trap pinches and the famous arm drop test because we could not believe that she had gone from fully alert and stable to totally unresponsive with no warning sign, vital change or complaints prior to this.


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## CALEMT (Mar 1, 2015)

BlueJayMedic said:


> I have seen patients with absent gag reflexes before.  This patient not only had an absent gag, her rate went brady from tachy and dropped both systolic and diastolic pressure. She also withstood numerous sternal rubs, trap pinches and the famous arm drop test because we could not believe that she had gone from fully alert and stable to totally unresponsive with no warning sign, vital change or complaints prior to this.



Drug use? Like zzyzx said GHB goes from alert to unresponsive back to alert, can't wait to hear the outcome.


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## Ewok Jerky (Mar 1, 2015)

Any recent steroid use? Hx of hypertension? Any Hx of cancer? Can she be pregnant? Some psych meds can lower the threshold for seizures. Intertesting case I would love to work this up. But for pre hospital I'm worried about her airway and watching her pressure.

So you the immune stimulation is just a normal routine?


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## BlueJayMedic (Mar 2, 2015)

No drug use, GHB isn't very popular around here and she did deny use, I did not end up hearing about a tox screen after the fact. I will say no because we were not aware of any, no obvious signs of drug use either. Pregnancy maybe, she denied it and stated her LNMP was 3 weeks prior. If there was any seizure activity present it would have been absent I guess, no signs of seizure.  I do believe at one point prior to her coming out of it she did have some jaw tetany. 

No Hx of hypertension, cardiac Hx in the family she states. She was a good historian but it was difficult to believe every word she was saying because of her overall behaviour prior to transport. We did end up with family on scene to confirm a lot of this.


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## Ewok Jerky (Mar 7, 2015)

BlueJayMedic said:


> I do have the final outcome proior to transport to tertiary facility, stay tuned I will post after a few more people weigh in unless no one wants to then I'll spill the beans in a bit.


...


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## BlueJayMedic (Mar 7, 2015)

Sorry; fell and broke my ankle the other day, haven't been on here much and no one else seems to want to take a stab at it haha.

She was an epidural bleed and was flown to a neuro centre not far away. When we delivered this perfectly healthy symptomless patient to the ED the doc stood and looked at us and circled his hear with his finger and said "coo-coo", pulled her from resus and put her in an obs bed.  Her CT came back to show the bleed and he freaked just in time for her to go unresponsive again at which point they ordered the heli-transfer. We were witnessing the lucid intervals and the PMHx of headaches while in the psych unit for 6 days that were ignored by staff there and either no treated, or treated with tylenol ended up being ignored. 

Interesting case to say the least. Changes my perspective and assessments thats for sure.


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## NomadicMedic (Mar 7, 2015)

Definitely interesting, a zebra in a herd of horses. Even if you had asked her if she'd had a history of a fall or any head trauma, I'm sure she would've denied it.  

Only way to find that is with the CT.


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