What is causing this seizure?

TheLocalMedic

TheLocalMedic

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Good one from this past month:

30's female found actively seizing in a really crappy "home" (read: tweaker pad) that has virtually no furniture in it. Patient's "husband" says that she has been seizing for "about an hour", seizures off and on and "not making sense" between seizures (read: postictal, duh!) This guy was so clueless that he had even written the alphabet down on a sheet of paper and was trying to have her point to letters to spell out what was wrong with her (like she was going to spell out S-E-I-Z-U-R-E ?)

So, whatever... guy apparently doesn't realize that multiple (5+) seizures isn't normal and doesn't call 911 until an hour after she starts going off... He states no history, no meds and no allergies.

2 mg versed later the seizure is done and we're hauling her out to the ambulance. And here's where it gets interesting...

HR 140-150, resp 40+ with loud phonation, temp of 103 F, blood glucose of 79, pupils extremely dilated and initial BP of roughly 130/60. I suction her out and remove a significant amount of clear sputum from the oropharynx. And then we transport.

She remains GCS 3, still tachy at 140+, tachypneic 40-60 with phonation and her BP starts crashing. 130/60 becomes 90/40 becomes 60/30 and then isn't able to get a good reading. I dump fluids, pop in a second line, pressurize both saline bags and still can't get a pressure (weak carotid but not much else).

We arrive at the ED and they jump on her, but due to the system being super busy I'm not able to hang out to find out what's wrong with her. My initial tentative diagnoses were either a meth OD (although the "husband" adamantly denied any drug use) or sepsis.

I found out what exactly was going on with her later, but I'm curious as to what your thoughts are as to what might have been going on with her.
 
I'm going to guess Meth OD as well due to extremely dilated pupils, tachypnea and hyperthermia. Maybe the BP was a sign of the overdose as well.

Just out of curiosity, was PD there?
 
Sepsis.
 
did you get a lactate on her? did you try any narcan?

my ddx would be, sepsis, narc use, and cva for a zebra




Edit: forgot to take d50 out of my procedure list and diabetic seizure out of ddx. They were originally in there because i didn't initially see the BGL
 
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My Ddx is sepsis, Drug OD, thyrotoxicosis, or TBI.
 
Sepsis that bad would probably not have an elevated temp I'm thinking. Sepsis also wouldn't decompensate that quickly.

How much fluid did you get into her? Was she on a monitor? Pulse rate? Distal pulses present?

Edit: I'm gonna throw possible withdrawal into it.
 
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I'm also curious why you're saying no to sepsis ... The drug user who's been "out of it and seizing", coupled with the elevated temp, tachycardia, elevated respiratory rate and low pressure SCREAMS sepsis to me. A lactate would nail it, but she'd be getting COPIOUS amounts of fluid and probably Dope.
 
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DEmedic said:
I'm also curious why you're saying no to sepsis ... The drug user who's been "out of it and seizing", coupled with the elevated temp, tachycardia, elevated respiratory rate and low pressure SCREAMS sepsis to me. A lactate would nail it, but she'd be getting COPIOUS amounts of fluid and probably Dope.
Click to expand...

This almost mirrors the scenario I posted, except without hypotension and without tachypnea and without GCS issues.
 
Ready for the big reveal?

She was very sick to begin with... But there were ultimately three things in play with this patient.

1. Although the husband didn't remember it in the moment, the patient had been complaining of abdominal pain for the past few days... but that evening she suddenly felt a whole lot better. RUPTURED APPENDIX. She was septic septic septic!

2. The couple both used meth. Probably a lot of meth. And that night, when her severe abdominal pain suddenly went away, they both got high as per their usual routine. Positive for meth, marijuana and alcohol on tox screen.

3. This patient seized for a long time, probably off and on for about an hour per the husband. Her last seizure, which was still ongoing when we arrived had been quite prolonged. Our response time was about 8 mins, and the husband later stated that she had be seizing continuously for about 5 mins before he called 911 and continued until the versed stopped her. Probably somewhere around 15-20 mins of seizure activity. This is probably responsible for the significant subarachnoid bleed that showed up on the CT.

Sepsis, meth use and subarachnoid bleed. Triple whammy.

Any thoughts on her ultimate outcome? I'll give you a hint: it wasn't good...
 
And in this particular instance a lactate is probably not going to be all that helpful. She just had a prolonged seizure.... her lactic aid is going to be high.
 
FLdoc2011 said:
I think it was more likely that the SAH caused the seizure.
Click to expand...

Perhaps if those were the only two issues, but the rampant sepsis tips the scale more in favor of the seizure having been the cause of the bleed than the other way around.

Unless, that is, she just coincidentally developed a spontaneous SAH at the same time her appendix let go. That would be truly unlucky.
 
TheLocalMedic said:
Unless, that is, she just coincidentally developed a spontaneous SAH at the same time her appendix let go. That would be truly unlucky.
Click to expand...

If she had DIC from the sepsis that combined with her meth use made her high risk for a bleed.
 
TheLocalMedic said:
Perhaps if those were the only two issues, but the rampant sepsis tips the scale more in favor of the seizure having been the cause of the bleed than the other way around.

Unless, that is, she just coincidentally developed a spontaneous SAH at the same time her appendix let go. That would be truly unlucky.
Click to expand...

That's certainly possible, but still more likely that she experienced a SAH causing the seizure. I'm sure the meth contributed to it. Who knows if she had an underlying and undiagnosed AVM or aneurysm.

I'm sure the sepsis didn't help. And DIC is a good thought here, especially with an intraabdominal source and likely gram negative sepsis. If possible it'd be interesting to know her initial blood work. That would quickly let us know if DIC was an issue or not.

From dealing with a good number septic patients and intracranial hemorrhage patients on a routine basis I just don't see someone seize causing a hemorrhage.....unless they had an underlying vascular issue that ruptured due to hypertensive episode.

Ultimately this lady made bad choices... Not getting checked out earlier, and THEN deciding to abuse meth.
 
Let us know about the abdominal pain before you reveal the diagnosis next time!

Please:ph34r:
 
eprex said:
Let us know about the abdominal pain before you reveal the diagnosis next time!

Please:ph34r:
Click to expand...

The husband didn't mention any abdominal pain, and when I asked whether the patient had been sick over the last few days he said that he didn't think so. He only recalled the abdominal complaint when later confronted by the doc at the hospital when they diagnosed the appendicitis.

That was part of the mystery!
 
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