Altered female

[NomadicMedic]

Scenario: at 1830, you arrive at a dirty single wide trailer, crowded with people, redolent of cigarette smoke, to find a 34 yo skinny female lying in bed. Altered, confused with slurred speech and asymmetrical mouth. Slow, languid twisting motions of her arms and legs. History of multiple drug use. Uses OxyContin, no idea how many taken today and can't find the bottle. Woke up at 1000, had breakfast with Mom, took excedrin and pain meds,went back to bed. Reported to have stumbled against a door at approx 1500, some slight abrasions around her left eye. Facial bones intact, no crepitus or pain on palp. Last oral was lunch at 1230. Been in bed since. Pupils 2mm, reactive. CBG 141, BP 128/70, 70 and normal sinus, 12 lead unremarkable. Field lactate 3.1. Respirs 16 and unlabored. Can't follow commands for Cinci Stroke Scale. Go...

 

[mycrofft]

Mixed bag.

If hx is reliable, that glucose is suspiciously high for that long a period without food, but currently not an issue.
Injury around left eye always suggest trauma (punchee facing the right-handed puncher), and "hitting the door" is a common lame excuse.
Oxy bottle is gone and pt took Excedrine (which has ASA/aspirin) and "pain meds" (???)...when was last dose, is detox a concern?
If an intracranial bleed occurred Excedrine would not be the way to go; neither would any other "pain meds" containing NSAIDS.

Do we have a temp, or is skin dry and hot, wet and hot, or not hot.

The writhing limbs thing sounds familiar but I can't place it. Can we presume everything is bilateral?

 

[NomadicMedic]

Normal temp, pink warm and dry.
No idea as to how much, when or where the med bottles may be.
Most of the writhing is on the right side. Right leg up in the air, right arm twisting and flexed.

Mom states no assault took place. Everything was normal til she went in to checkbox her at 1820, noticed the slurred speech and called 911.

 

[NomadicMedic]

However, she does present with flexion of her left arm as I attempted to start an IV, which became dislodged as I was drawing blood.

 

[epipusher]

I may be thinking zebra's here, but possible TBI from hitting the door with her face or the possible assault, or whatever it is that caused the facial injury? Consider c-spine precautions?

 

[NomadicMedic]

FWIW, I did not C-spine this PT.

 

[Brandon O]

This might be a case where naloxone would be diagnostically useful.

 

[NomadicMedic]

I didn't administer Narcan either. She had no respiratory depression.

 

[Dwindlin]

Is she moving the limbs or not? Hard for me to tell from your posts.

 

[Brandon O]

I didn't administer Narcan either. She had no respiratory depression.

I only mean to help differentiate some of the general neurological signs.

As it is, I find TBI somewhat dubious, but spontaneous stroke is not impossible. However, I would lean towards drugs, likely polysubstance.

 

[NomadicMedic]

Yep. Moving all her limbs. And I actually did consider Narcan, but I was having a hell of time getting a line... And after the IV became dislodged, I realized that I was about 2 minutes from the ED and I figured I let them deal with it...

 

[boingo]

sounds a bit dystonic.

 

[Dwindlin]

sounds a bit dystonic.

That was my thought, which is why I asked for clarification if the limbs were moving. It is very difficult (and painful) to move a limb that is rigid due to dystonia.

 

[NomadicMedic]

I thought so too, but it wasn't a typical dystonic reaction...

What else can I tell you?

 

[Brandon O]

What are your options for transport destination?

 

[NomadicMedic]

Level III 20 minutes by ground... And if I wanted a helo, I guess I could get one and be at a Level I in under an hour.

 

[NomadicMedic]

I'll let you ask questions and stuff for a day or two, then I'll fill you in.

 

[Handsome Robb]

Hey I feel like I read this somewhere else

Seems neurological.

Any abnormal behavior prior to the event? Drugs/ETOH onboard today? Family Hx of CVA? Vitals all are WNL...doesn't seem like there is an increase in ICP from trauma or a hemorrhagic CVA but it's possible.

 

[Localmotion34]

I tend to overanalyze things here, and take a different approach than most to altered mental status but here goes:

Altered, confused with slurred speech and asymmetrical mouth
Can result from a 7th cranial nerve damage, OR upper motor neuron damage in the cortex associated with motor tone
10 and 12th cranial nerve damage possible as well

History of multiple drug use. Uses OxyContin, no idea how many taken today and can't find the bottle. Pupils 2mm, reactive
Generally a 3rd cranial nerve abnormality ruled out, and the fact pupils are not pinpoint lessens the certainty that opioids are the root cause

took excedrin and pain meds
Possibly a delirium super imposed on top of whatever else is going on, depending on whatever else she took with the Oxy, due to CYP450 drug metabolism and interactions. Oxy and Excedrin are both partially metabolized by CYP2D6

Slow, languid twisting motions of her arms and legs
Were the movements in any way purposeful? Were pain and deep tendon reflexes intact? She could be in transition to decorticate, and then decerebrate disinhibition.

What was her breathing like? Any signs of degeneration into Cheyne-Stokes respirations? Were Babinski sign present? Sign of Hoffman?

Reported to have stumbled against a door at approx 1500, some slight abrasions around her left eye. Facial bones intact, no crepitus or pain on palp
See Natasha Henstridge as a prime example of how a knock to the head in just the perfect way can kill someone, after the person is seemingly fine since the trauma.

So, you have a deficit at possibly the level of cranial nerve 7 (pons) and/or 10 and 12 (medulla), symmetrical extremity motor abnormality, possibly affecting both corticospinal and cortico-thalamic tracts.

All this would seem to point to an increase in intracranial pressure, which presses the brain downward on the midbrain, pons, and medulla. This downward pressure affects motor tone and movement bilaterally, and ultimately if untreated, can affect the respiratory centers (re Cheyne-Stokes) Just enough asymmetrical pressure on the side ipsilateral to the 7th cranial nerve deficit is enough for a lower facial palsy.

There are very, very few other things that can affect the motor system bilaterally, including CVA. You'd have to have a near complete blockage of the basilar or vertebral artery, or profuse bleeding into the pontine cisterns.

 

[NomadicMedic]

Very interesting assessment. I'm going to guess you're educated slightly above the level of Paramedic.