Moderator EMEDPA Posted June 4, 2018 Moderator Share Posted June 4, 2018 Interesting case the other day: 70ish yr old lady brought in by ems after "first time sz" at nursing home(not witnessed by ems and no tongue bite or incontinence). found to have minimally elevated temp(99.5 ish) with borderline low bp for her(given hx of htn) around 110/60 with pulse 105. sao2 98%. no hx of recent head trauma or illness and no reliable witness to sz. has baseline dementia and no one can really say if she is back to baseline with her current state of confusion. clear lungs, supple neck, no rashes, benign abd. Pt has DNR. lactate 3.4, which would be expected in setting of sz, but vs off enough to warrant SIRS/sepsis protocol with fluids, abx , etc. pt chronically anemic 8/24 ish and there today. wbc not impressive, like 11. Head ct neg. cxr neg. cath ua neg. blood cultures sent. remains confused, but VS improve with hydration, I speak with family by phone and they tell me this is probably baseline. Given oral loading dose of dilantin with plans to continue daily until f/u with neuro for eeg. We prepare to transfer pt back to nursing home when she seizes...a real seizure with eye deviation, full body involvement, tongue bite, incontinence, etc. it takes 8 mg of ativan to break the seizure and I hang fosphenytoin 15 mg/kg then her bp and resp rate drop...pressures in the 80s(mind you, after 3 L of saline earlier), resp rate 6-8. pulse 120ish. ok, fluids again, o2 by mask, etc. I call family to update them. they are unaware of dnr, but I assure them it is valid and signed by the patient in the presence of witnesses and they agree to not contest the dnr. pressures come up, resp rate improves, we are able to d/c 02 and never have to use pressors. pt admitted with dx of new onset sz of uncertain etiology. So question for you all: what causes a 70 yr old without obvious signs of infection or structural brain abnormality to start seizing out of the blue. Hospitalist also stumped and said he will continue abx until blood cultures back and may do an LP if no improvement in a few hrs. if returns to baseline will obtain eeg and neuro eval. weird case all around. Link to comment Share on other sites More sharing options...
camoman1234 Posted June 5, 2018 Share Posted June 5, 2018 You say cath ua negative, did that include a UDS? Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted June 5, 2018 Author Moderator Share Posted June 5, 2018 56 minutes ago, camoman1234 said: You say cath ua negative, did that include a UDS? good question. it did not. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted June 5, 2018 Author Moderator Share Posted June 5, 2018 nothing to suggest TCAs, but a good thought nonetheless. Link to comment Share on other sites More sharing options...
Moderator LT_Oneal_PAC Posted June 5, 2018 Moderator Share Posted June 5, 2018 Maybe Old bleed not showing on noncon ct, tumor needing MRI to define, Na different from baseline but maybe in “normal range”, toxic ingestion, or meningitis. Lp probably a good idea and maybe MRI Head and MRA Head/Neck Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted June 5, 2018 Author Moderator Share Posted June 5, 2018 all good thoughts, but I don't think they will be that aggressive with a demented, elderly pt who is dnr/dni. will let you know what they did next time I am there. I am guessing LP then start oral anticonvulsants and d/c to nursing home assuming cultures neg. Link to comment Share on other sites More sharing options...
Guest ERCat Posted June 10, 2018 Share Posted June 10, 2018 The most glaring question for me here - how was the EKG? That’s the number one thing I would want in an old person with first time seizure. Does she have a history of heart problems - could this be a manifestation of a bad arrhythmia like v-tach? Lactic acid is often elevated after a tonic clonic seizure and in cases where it’s unclear if the patient really did have a seizure - an elevated LA is a good indication they did. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted June 10, 2018 Author Moderator Share Posted June 10, 2018 45 minutes ago, ERCat said: The most glaring question for me here - how was the EKG? That’s the number one thing I would want in an old person with first time seizure. Does she have a history of heart problems - could this be a manifestation of a bad arrhythmia like v-tach? Lactic acid is often elevated after a tonic clonic seizure and in cases where it’s unclear if the patient really did have a seizure - an elevated LA is a good indication they did. EKG was sinus tach, otherwise nl. a prolactin level drawn on arrival came back elevated (several days later) indicating a likely sz. Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted June 10, 2018 Share Posted June 10, 2018 Surprised that dementia itself and microvascular CVA weren't mentioned since either can be cause of new onset sz. in elderly patients. Link to comment Share on other sites More sharing options...
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