jaksasquatch
Forum Crew Member
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Hey everybody,
Had an interesting case the other night that got me thinking.
85 y/o female at a SNF. Patient has a DNR and DNI. Nurse relayed that during med pass the patient was more altered than usual (too frantic to give an accurate/coherent description of normal mental status) and that she noticed she was trembling/shaking. She states she believes that she is seizing and that she has been doing so for 30 minutes. No Hx of seizures or diabetes with a BGL of 113 mg/dl. Vitals as follows:
Tachycardic at 130 bpm Sinus Tach with present and strong radial pulses
RR is regular in frequency with a rate of 30-36 and very deep
ETCO2 is 45 mmHg with a normal waveform
SpO2 is 96% on 2 lpm (patient's normal O2 due to respiratory failure)
BP 106/61 mmHg
GCS of 4 initially (patient mumbles to a sternum rub but no eye opening) with nurse noting eye opening to a sternum rub 5 min. prior to our arrival
Skin is hot to the touch
Rhonchi present on the left with clear breath sounds on the right
Nurse denies any recent symptoms including fever, any other infections/ulcers, and recent developments. She notes further Hx of HTN and CKD with no dialysis needed currently or in the past. She fails to be able to provide a medication list and at this point it was 5 am on a 36 hour shift and I was immensely frustrated.
On physical exam there are tremors in both the arms and legs. The patient seems to be pulling her arms to her but is not in the classic decorticate posturing as it isn't mimicked in the legs. It's almost as if the patient is shivering violently and at his point I began to suspect this was infectious and not in fact a seizure. I called a Sepsis alert and began transporting emergent with continued O2 and BLS airway management (NPA and suctioning through said NPA with a French catheter to manage secretions as I begin to hear gurgling respirations. A yankeur was not able to be used because as I began to open the patient's mouth she would clench her jaw. Gurgling stops after suctioning approx 20 ml's of frothy secretions and patient begins to spontaneously open her eyes through all of these tremors (eyelids still rhythmically moving as well as arms at this point). Access was difficult with an IO being necessary. This was accomplished in the proximal tibia and a fluid bolus was started. On arrival to the ER staff began to believe she was indeed seizing and administered 5 mg of Versed which slowed the tremors with complete resolution after 30 seconds. No more suctioning was performed by staff with a quick assessment by the ER physician and a shrug of the shoulders as to the cause of this. Patient's HR decreased from 130 to 120 and patient's breathing rate remained 30 times per minute with the same depth. Patient was placed on BiPap and left on Bipap and admitted for Sepsis with a lactate of 5.1 and a confirmed diagnosis of UTI as the cause later in the day.
So my management was performed with the understanding that this was Rigor's (intense shivering mimicking clonic activity). Versed can terminate shivering (used post anesthesia from what I understand) and this is what I believe happened. This was also evidenced by the patient opening her eyes spontaneously enroute with the tremors still occurring to the eyelids as well as the arms. Her eyes were also focused on me and were not your typical grand mal stare. Is it possible that this was seizure activity due to Sepsis induced brain function causing a seizure and that I missed this? Also have any of you run across such a presentation before?
Had an interesting case the other night that got me thinking.
85 y/o female at a SNF. Patient has a DNR and DNI. Nurse relayed that during med pass the patient was more altered than usual (too frantic to give an accurate/coherent description of normal mental status) and that she noticed she was trembling/shaking. She states she believes that she is seizing and that she has been doing so for 30 minutes. No Hx of seizures or diabetes with a BGL of 113 mg/dl. Vitals as follows:
Tachycardic at 130 bpm Sinus Tach with present and strong radial pulses
RR is regular in frequency with a rate of 30-36 and very deep
ETCO2 is 45 mmHg with a normal waveform
SpO2 is 96% on 2 lpm (patient's normal O2 due to respiratory failure)
BP 106/61 mmHg
GCS of 4 initially (patient mumbles to a sternum rub but no eye opening) with nurse noting eye opening to a sternum rub 5 min. prior to our arrival
Skin is hot to the touch
Rhonchi present on the left with clear breath sounds on the right
Nurse denies any recent symptoms including fever, any other infections/ulcers, and recent developments. She notes further Hx of HTN and CKD with no dialysis needed currently or in the past. She fails to be able to provide a medication list and at this point it was 5 am on a 36 hour shift and I was immensely frustrated.
On physical exam there are tremors in both the arms and legs. The patient seems to be pulling her arms to her but is not in the classic decorticate posturing as it isn't mimicked in the legs. It's almost as if the patient is shivering violently and at his point I began to suspect this was infectious and not in fact a seizure. I called a Sepsis alert and began transporting emergent with continued O2 and BLS airway management (NPA and suctioning through said NPA with a French catheter to manage secretions as I begin to hear gurgling respirations. A yankeur was not able to be used because as I began to open the patient's mouth she would clench her jaw. Gurgling stops after suctioning approx 20 ml's of frothy secretions and patient begins to spontaneously open her eyes through all of these tremors (eyelids still rhythmically moving as well as arms at this point). Access was difficult with an IO being necessary. This was accomplished in the proximal tibia and a fluid bolus was started. On arrival to the ER staff began to believe she was indeed seizing and administered 5 mg of Versed which slowed the tremors with complete resolution after 30 seconds. No more suctioning was performed by staff with a quick assessment by the ER physician and a shrug of the shoulders as to the cause of this. Patient's HR decreased from 130 to 120 and patient's breathing rate remained 30 times per minute with the same depth. Patient was placed on BiPap and left on Bipap and admitted for Sepsis with a lactate of 5.1 and a confirmed diagnosis of UTI as the cause later in the day.
So my management was performed with the understanding that this was Rigor's (intense shivering mimicking clonic activity). Versed can terminate shivering (used post anesthesia from what I understand) and this is what I believe happened. This was also evidenced by the patient opening her eyes spontaneously enroute with the tremors still occurring to the eyelids as well as the arms. Her eyes were also focused on me and were not your typical grand mal stare. Is it possible that this was seizure activity due to Sepsis induced brain function causing a seizure and that I missed this? Also have any of you run across such a presentation before?
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