Sepsis Induced Seizure or Rigors?

jaksasquatch

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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?
 

Summit

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Temp??

And yes, electrolyte, thermal, and metabolic derangement in sepsis can trigger seizure.

Encephelopathy can occur.

You also see sz in meningitis.
 

VentMonkey

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@jaksasquatch have I encountered someone similar? Absolutely. These patients are ironically excellent clinical cases for interns.

A DNR would inevitably throw them for a loop almost everytime. Assuming the DNR was along the lines of supportive care, then cooling measures, noninvasive airway management, position of comfort, a lock, and judicious benzo’s are about what I would do. If my index of suspicion was up for meningococcal bacteria then perhaps extra PPE.

Were you just inquiring about different diagnoses? If so, @Summit hit some primary’s. Also, did I miss a BGL in your OP?
 
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jaksasquatch

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@jaksasquatch have I encountered someone similar? Absolutely. These patients are ironically excellent clinical cases for interns.

A DNR would inevitably throw them for a loop almost everytime. Assuming the DNR was along the lines of supportive care, then cooling measures, noninvasive airway management, position of comfort, a lock, and judicious benzo’s are about what I would do. If my index of suspicion was up for meningococcal bacteria then perhaps extra PPE.

Were you just inquiring about different diagnoses? If so, @Summit hit some primary’s. Also, did I miss a BGL in your OP?


BGL was 113 mg/dL. Because respirations were still regular, there was still eye opening, and there was mumbling initially I suspected it was Rigors and not a grand mal seizure. Looking back at this call I was concerned that I had possibly missed a patient that was indeed seizing and provided substandard care. It's more of a reach out to the more experienced to continue improving and to get comments as to my thought process on the treatment. I agree though that if we assume this is a grand mal that neurological infections are the highest on our list
 

VentMonkey

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Ah, what about IN or IM benzo’s? It sounds like you second guessed your gut-instinct. I feverishly encouraged my interns not to do this, or at least not make it a habit.

However, like I would tell them, if you recognized it chances of you not learning from it are slim to none.
 
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NPO

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@Summit @Remi @VentMonkey

I could see myself having the same difficulty with treatment decision as the OP. I am glad he posted this. Seizures are admittedly something I have been trying to get more education on. "Normal" seizures don't bother me, but I need to learn more about the atypical ones like absent, focal, etc... I had a patient and was told she had 13 different seizure disorder, and based on the evidence I had in front of me at the time I believed it, which bother me how little I know about 12 of them.

ANYWAY....
My question, say you weren't convinced this was a seizure, or let's say it wasn't a seizure (in a different patient with similar tremors). Would you recommend or support a low dose benzo like Ativan or Versed to help stifle the tremors, if for nothing else but to ease the patient and assist in patient care?
 

VentMonkey

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ANYWAY....
My question, say you weren't convinced this was a seizure, or let's say it wasn't a seizure (in a different patient with similar tremors). Would you recommend or support a low dose benzo like Ativan or Versed to help stifle the tremors, if for nothing else but to ease the patient and assist in patient care?
In a patient like the OP’s, most certainly. They’re clearly overcompensating so to stifle the tremors sure, but more so gentle judicious aliquots of a benzo for its sedative properties.

Think medically-induced homeostasis similar to that seen in preventative sedation measures, and/ or paralytics in head injuries.

I’m willing to bet that their CMP is all sorts of haywire like @Summit mentioned, and being that they’re a DNR as it is (assuming “comfort measures” are in play), the least we can do is our due diligence here.

As far as a patient with every single seizure you can imagine, plus some that I’ve never heard of—it really depends on their presentation.

If they’re displaying no indications that they’re in need of immediate intervention it’s the standard “supportive care”, and a trip to the hospital that their neurologist/s frequent/s. Particularly the neurologist who was last to dx the patient with the latest seizure disorder.

Did, or do you remember the staff meeting where Dr. Ostrom went over absent and subtle seizures?

For me those are almost always in the eyes. In fact I have given my share of benzo’s liberally when, at the very least, I could not get their eyes to track and no other arousable response.

The last two or so years before I started doing CCT I had a handful of cardiac arrests brought upon by seizures, so what did I do? I went and looked up SUDEP. So, I understand where you’re coming from.

That’s my $0.02, I’ll let the murses chime in:D.
 

StCEMT

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I actually had something exactly like this a few months back. I too was on the fence about if it was a seizure due to how subtle it was. Don't remember the final diagnosis, but a seizure was confirmed when I went back.
 

NPO

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Did, or do you remember the staff meeting where Dr. Ostrom went over absent and subtle seizures?

For me those are almost always in the eyes. In fact I have given my share of benzo’s liberally when, at the very least, I could not get their eyes to track and no other arousable response.
I must've missed that one. The only one I recall is the airway review in service where Dr Ostrom talked about squirting some 1:10 epi into the throat of an airway burn to facilitate ETT (one of my favorite party trivia bits lol).

But, your example makes me think.. I did have a call in internship. A 6 year old having seizures that the FD thought were febrile. Given his age and large size for his age, I found that unlikely. He was just laying there but I looked in his eyes and saw what I later learned is epileptic nystagmus.
 

VentMonkey

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“lip-smacking” is also consider fairly common with pediatric seizures, and I know to you guys it may go without saying, but PLEASE don’t forget to poke bey-bez heel.
 
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RocketMedic

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To me, this is a patient who can be ventilated/accessed before we get schwifty with Versed. I'd honestly probably trend more towards valium or ativan here, at low doses, and with regard for pressure.

WRT shivering, one of the other uses for Versed back in the early days of "therapeutic hypothermia" was to terminate post-ROSC shivering to reduce cardiac workload.
 

Carlos Danger

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@Summit @Remi @VentMonkey
ANYWAY....
My question, say you weren't convinced this was a seizure, or let's say it wasn't a seizure (in a different patient with similar tremors). Would you recommend or support a low dose benzo like Ativan or Versed to help stifle the tremors, if for nothing else but to ease the patient and assist in patient care?

Well you do have to be careful with benzos in old, sick people. But yeah, anytime you need to slow down the CNS, benzos are the way to do it.

Seizures can be tricky. Maybe the best way to approach a scenario where you can’t be sure whether a seizure is happening or not is to just err on the side of a seizure. Versed is safe and forgiving (providing you use appropriate doses) and is my preference because of its slightly faster onset and significantly shorter duration than the others. Of course which one you use depends on your protocols.
 

E tank

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Well you do have to be careful with benzos in old, sick people. But yeah, anytime you need to slow down the CNS, benzos are the way to do it.

Seizures can be tricky. Maybe the best way to approach a scenario where you can’t be sure whether a seizure is happening or not is to just err on the side of a seizure. Versed is safe and forgiving (providing you use appropriate doses) and is my preference because of its slightly faster onset and significantly shorter duration than the others. Of course which one you use depends on your protocols.

Agree with the cautionary note here...the diff between a mg of Ativan and a mg of versed in the elderly is the difference between a bud light and a long island iced tea.
 

tklingbeil

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The only one I recall is the airway review in service where Dr Ostrom talked about squirting some 1:10 epi into the throat of an airway burn to facilitate ETT (one of my favorite party trivia bits lol).
Have any more information on this? Peaked my interest.
 

NPO

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Have any more information on this? Peaked my interest.
I'm sure an evidence is anecdotal at best.
I've hypothesize that nebulized epi or racemic epi could be helpful.

My protocols have it for stridor in pediatric respritory distress. It wouldn't be that far off a stretch lol
 

E tank

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I'm sure an evidence is anecdotal at best.
I've hypothesize that nebulized epi or racemic epi could be helpful.

My protocols have it for stridor in pediatric respritory distress. It wouldn't be that far off a stretch lol

A "squirt" of something and a nebulizer are not in the same galaxy. A dubious claim at best.
 

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