Scenario: Unresponsive Female

[Ridryder911]

Good catch.. of course your partner's sphincter tone just went up 3 notches, thinking he might have induced this when he started to intubate. You set the defib on synch and watch the ..."blep"...shock!.. This is what you have on the monitor..

You reassess her and and no change in LOC , pulse is now about 54, blood pressure is 70/40. You notice each time you touch the patient increasing fasciculations and tremors occur..

You ask the husband how bad was the head ache? He described that she said it what was really bad, but did not appear any worse than usual..


?????
R/r 911

 

[Ridryder911]

P.S... Her skin is now appearing to be more flush like in appearance....

R/r 911

 

[Airwaygoddess]

Well I would like to take a stab at it, intracranial bleed or brain stem rupture.

 

[Guardian]

Some thoughts…the fact her pupils are equal, normal sized, and negative “dolls eyes” without signs of seizure makes me not want to go down the road of CVA, intracranial bleed, etc…but it’s possible, especially in weird cases like this. With her age, VT, and the fact she’s been lying in a bed the last few days because of migraine or sickness, I want to say PE but that doesn’t really account for ALOC in the beginning. I think dehydration was a good guess…I’m inclined to think it’s a problem with electrolyte imbalance. It’s possibly encephalitis or meningitis and it could definitely be an overdose of some sort, I just don’t know what…

 

[FF/EMT Sam]

My guesses are now dehydration, intracranial bleed, or accidental OD.

I showed this thread to a paramedic where I work. Her response: "This patient is just f'ed up!!"

 

[DT4EMS]

Let's start pacing her.

How is her skin temp? Is it elevated?

I wouldn't rule out something funky around the brainstem. The fasiculations and tremors could be coming from an internal temperature regulation problem as well.

Again, working on H's and T's............

Ooohhhh give me more!!

 

[Ridryder911]

First of all... All excellent posts and suggestions. This was an intentional hard case I had....

Since this location is on outskirts of town, you have a return trip to the hospital of 15 minutes .. dependent on time and traffic.

You quickly review the assessment and hx. again.. attempting to narrow this complex situation. You again quickly ask the husband how much vomiting, diarrhea.. etc. He informs you he didn't think that she had than many episodes, but she told him that her head was hurting her and she was going to take some more of her headache medicine. Being the astute Paramedic you are, reviewing the unusual fasciculations, cardiac ectopi, and sudden B/P you as well initially assume neuro or dehydration, but so severe? You ask how if she was on any other headache medication and he informs you that she was not, she used to be on Imitrex but was not on effective. So they placed her on this one which appeared to work "a bit better".

You look at the medicine and note that the headache medication is Doxepin ? Not being familiar with this you pull out your handy-dandy pocket field guide & look it up.

BINGO !... It now makes sense!.. Doxepin is a tetracycline antidepressant that is widely used for migraines.... tetracycline/anticholinergic poisoning!. ..Neuro irritability (fasciculations) initially salivation now dry.. slightly erythematous flushed skin, arrhythmia's tachy to wide complexes.. she apparently self medicated herself additionally and with the additional antihistamine from NyQuil and caffeine and dehydration she has made herself a life threatening cocktail. As well she is very petite and low body mass and excellant metabolism does aid in absorption of medication .

You immediately establish fluid resuscitation and initiate a Dopamine drip at 6-8 mcg/kg/min as well drop a large oral gastric tube with irrigation of saline. You note some small pill fragments on return ...

ECG remains as noted but you do see some attempts of conversion with occasional sinus beats. Her pressure with fluids and Dopamine has reached 82/58 and her respiratory rate has increased a little.

You arrive in the ED and the ER Doc agrees with your speculation. A serum level is drawn as well as tox screen and cardiac profile and the usual other routine lab's. The patient is placed on ventilator and radiography films are taken as well as an emergency brain to pelvic CT scan.

You had to respond to another call but able to return about 2 hrs later.

The patient is being packaged and prepared for transfer to ICU.

The Doc personally comes to talk to you and pats you on the back and congratulate you on a job well done!. Her lab's is a train wreck with BUN and anion gap horrible showing severe dehydration. As well, her tox level initially was high but not severely dangerous.. but as the physician describes along with the other factors potentiated the tetracycline. CT is negative as well as cardiac markers .. except her CPK probably due to your cardioversion.

She was placed in the unit for consideration for emergency dialysis but due to severe dehydration was postponed. She regained consciousness about 8 hours later and ventilator was discontinued the next morning. She was rehydrated and discharged three days later, of course a change in medication. ..lol

Lesson learned... when one hears hoofsteps..don't always assume it is horses.. it might be zebras!
Multiple indications for medications can be confusing, i.e. NTG for esophageal spasms, Haldol for headaches.. etc.. Not only can trauma/medical patients can have multiple problems, medical patients can as well. Sometimes it appears they attempt to "test" our capabilities all the time.

Again, good going guys! Great responses.. !

R/r 911

 

[DT4EMS]

Dang............

So not only did she have the medication problem but the electrolytes were out too.

I started going away from the dehydration because initially her skin turgor was good and mucosa wasn't that dry.

Another awesome post Rid!

 

[Airwaygoddess]

antidepression medication strikes again!:wacko:

 

[Guardian]

Another great post, thanks.

I'm going to go brush up on tetracycline/anticholinergic poisoning...lol.

Great point about medical pt's having multiple problems. I had a MI pt the other day who just happened to have a seizure while I was asking him about his CP...first seizure in 2 years...lol, maybe i just have that effect on people.

 

[Ridryder911]

There used to be a saying (don't know ow true or accurate) Called the 50% Rule. 50% of the Tetracycline O.D.'s are asymptomatic and out of those 50% are fatal.

I know this one of the few poisoning we do irrigation and NG tubes or "Code Blue/Big Bertha" tubes on. We irrigate with about a gallon and a half of saline, then place Actidose w/sorbitol be sure to have a bathroom facility nearby.

Let us put it this way, it cleans them out from one end to another.

R/r 911

 

[Guardian]

In this case, would you have considered giving NaHCO3 in the field or at all because of the dysrhythmia (VT)?

 

[macinfire]

Doxepin also a good antihistamine......may be used for hives, etc...low dose