My Wednesday night..,

[VentMonkey]

Absence seizure?

Of the stat ep variety.

 

[NomadicMedic]

Maybe. Zero history.

Honestly, seizure was the last thing on my list.

 

[EpiEMS]

Maybe. Zero history.

Honestly, seizure was the last thing on my list.

Paradoxical withdrawal symptoms? Totally speculative, obviously.

 

[Kevinf]

She never displayed any seizure like activity. At all. None. And an hour long postictal period is outside of anything if ever seen before. The hospital I took her to has 24 hour neuro and is THE stroke center for the metro. That's where (I believed) she needed to be. Not a stop at the local band aid station.

I've seen exactly one patient of mine present similar to yours, and I recorded a nearly 50 minute postictal state for her. Naturally, she became fully conscious and combative just after we transferred her to the ED bed. However I had the benefit of getting a history of poorly controlled seizures secondary to a traumatic brain injury in advance.

 

[CWATT]

@DEmedic - what was your thought process behind that bolus? Did you suspect high-spacing because of the low diastolic number? Or was it b/c the First Responder reported a BP of 84/Palp (even though your initial vitals was 114/58)?

 

[Akulahawk]

Given the presentation, I would have opted for the tertiary care center 50 minutes away. Why? The local hospital may be able to do a CT scan but once the patient becomes "theirs" they then have EMTALA to deal with and have to arrange for an appropriate destination, transportation, and the like. Sometimes this can take significant amounts of time especially if you have to wait for labs or you don't have an in-house Radiologist available. It sounds like you deduced that the closest, most appropriate destination was the Neuro/Stroke center that's 50 minutes away and by doing so you probably prevented an hour or two delay in getting the patient where she likely would have ended up anyway.

Good call!

 

[StCEMT]

Too late for me to throw out a guess, but I would go to the further location for the reasons akulahawk listed.

 

[BobBarker]

Given the presentation, I would have opted for the tertiary care center 50 minutes away. Why? The local hospital may be able to do a CT scan but once the patient becomes "theirs" they then have EMTALA to deal with and have to arrange for an appropriate destination, transportation, and the like. Sometimes this can take significant amounts of time especially if you have to wait for labs or you don't have an in-house Radiologist available. It sounds like you deduced that the closest, most appropriate destination was the Neuro/Stroke center that's 50 minutes away and by doing so you probably prevented an hour or two delay in getting the patient where she likely would have ended up anyway.

Good call!

I absolutely understand your method for the tertiary center. However, given the diagnosis, I don't think she "would have ended up there anyways". If the Level III can CT there, if there is no signs of a bleed/stroke and she has a seizure, they treat and workup accordingly. Once she woke up/found out about the seizure and her CT came back negative, they probably just would have admitted her there.

 

[Akulahawk]

I absolutely understand your method for the tertiary center. However, given the diagnosis, I don't think she "would have ended up there anyways". If the Level III can CT there, if there is no signs of a bleed/stroke and she has a seizure, they treat and workup accordingly. Once she woke up/found out about the seizure and her CT came back negative, they probably just would have admitted her there.

Here's the rub: if her CT came back positive for a bleed... now you've committed the patient to at least a 1-2 hour DELAY in getting the patient to definitive care and if the sending facility has instituted therapies that aren't in your scope of practice, the delay could be even longer. I see this stuff happen all the time. I work in a critical access hospital.

 

[NomadicMedic]

@DEmedic - what was your thought process behind that bolus? Did you suspect high-spacing because of the low diastolic number? Or was it b/c the First Responder reported a BP of 84/Palp (even though your initial vitals was 114/58)?

I'm not quite following what you're asking and I'm not familiar with the term high spacing.

Are you asking why I gave the patient a fluid bolus?

 

[NomadicMedic]

I absolutely understand your method for the tertiary center. However, given the diagnosis, I don't think she "would have ended up there anyways". If the Level III can CT there, if there is no signs of a bleed/stroke and she has a seizure, they treat and workup accordingly. Once she woke up/found out about the seizure and her CT came back negative, they probably just would have admitted her there.

Nope. This patient would have been transferred to the Tertiary.

 

[Carlos Danger]

Given the presentation, I would have opted for the tertiary care center 50 minutes away. Why? The local hospital may be able to do a CT scan but once the patient becomes "theirs" they then have EMTALA to deal with and have to arrange for an appropriate destination, transportation, and the like. Sometimes this can take significant amounts of time especially if you have to wait for labs or you don't have an in-house Radiologist available. It sounds like you deduced that the closest, most appropriate destination was the Neuro/Stroke center that's 50 minutes away and by doing so you probably prevented an hour or two delay in getting the patient where she likely would have ended up anyway.

It shouldn't ever be like that for critical patients, and fortunately, many places it isn't. All it takes is a transfer agreement between the community hospital and tertiary one stating that the tertiary facility will automatically accept a patient once the time-critical diagnosis is made. It streamlines the logistics dramatically.

 

[Akulahawk]

It shouldn't ever be like that for critical patients, and fortunately, many places it isn't. All it takes is a transfer agreement between the community hospital and tertiary one stating that the tertiary facility will automatically accept a patient once the time-critical diagnosis is made. It streamlines the logistics dramatically.

You're right, it shouldn't be like this. Unfortunately sometimes even with a transfer agreement in place things don't go smoothly, such as those times when you're out of ground transport options because the EMS system won't allow you to use a 911 unit for these time-critical patients and when your IFT units are all unavailable... it's bad. Happens too often.

 

[CWATT]

Are you asking why I gave the patient a fluid bolus?

Yes.

 

[NomadicMedic]

Because she was hypotensive, had signs of poor perfusion and was altered.