Guest guest Posted July 12, 2011 Report Share Posted July 12, 2011 Cat-scratch encephalopathy? Sent from my iPhone Pupils/PMS/Cranial Nerve Responses (those you can check anyway)? -Brad Sent from my iPhone > High-dose phenobarbital drip calms her seizures for the duration of the drip only, the node is visibly swollen. You don't see or feel any other swollen lymph nodes. No s/s of anemia. > > Alyssa Woods, NREMT-B > > > > >> Phenobarbitol drip? Look for s/s of anemia... How big is the node? Reasesses paying attention for nodules? >> >> Sent from my iPhone >> >> >> >> She did not ingest a plant. Benzo's and phenobarbital stop her seizures for 30 seconds - 1 minute, paralytics for a few minutes. >> >> Alyssa Woods, NREMT-B >> >> >> >> >> Find out what plant she possibly ingested. Begin your normal treatment for siezure until you know more. >> >> Henry >> Mystery Diagnosis >> >> You're called out to a 5 year old girl who was playing in the yard, when she suddenly had a seizure. When you arrive on scene her parents instantly calm down and tell you she has no history, no medications, and no known allergies. Your patient is having a grand mal seizure which has been going on for at least 5 minutes. >> >> What's your treatment and what's happening to her? >> >> Alyssa Woods, NREMT-B >> >> >> ---------------------------------------------------------- >> >> No virus found in this incoming message. >> Checked by AVG - www.avg.com >> Version: 8.5.449 / Virus Database: 271.1.1/3759 - Release Date: 07/11/11 18:35:00 >> >> ---------- >> >> No virus found in this outgoing message. >> Checked by AVG - www.avg.com >> Version: 8.5.449 / Virus Database: 271.1.1/3759 - Release Date: 07/11/11 18:35:00 >> >> Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 12, 2011 Report Share Posted July 12, 2011 No pets. No cat scratches. Pt is pristine except for one swollen lymph node and one minor abrasion on her chin. Alyssa Woods, NREMT-B Sent from the itty bitty keyboard on my iPhone > Cat-scratch encephalopathy? > > Sent from my iPhone > > > > Pupils/PMS/Cranial Nerve Responses (those you can check anyway)? > > -Brad > > Sent from my iPhone > > > > > High-dose phenobarbital drip calms her seizures for the duration of the drip only, the node is visibly swollen. You don't see or feel any other swollen lymph nodes. No s/s of anemia. > > > > Alyssa Woods, NREMT-B > > > > > > > > > >> Phenobarbitol drip? Look for s/s of anemia... How big is the node? Reasesses paying attention for nodules? > >> > >> Sent from my iPhone > >> > >> > >> > >> She did not ingest a plant. Benzo's and phenobarbital stop her seizures for 30 seconds - 1 minute, paralytics for a few minutes. > >> > >> Alyssa Woods, NREMT-B > >> > >> > >> > >> > >> Find out what plant she possibly ingested. Begin your normal treatment for siezure until you know more. > >> > >> Henry > >> Mystery Diagnosis > >> > >> You're called out to a 5 year old girl who was playing in the yard, when she suddenly had a seizure. When you arrive on scene her parents instantly calm down and tell you she has no history, no medications, and no known allergies. Your patient is having a grand mal seizure which has been going on for at least 5 minutes. > >> > >> What's your treatment and what's happening to her? > >> > >> Alyssa Woods, NREMT-B > >> > >> > >> ---------------------------------------------------------- > >> > >> No virus found in this incoming message. > >> Checked by AVG - www.avg.com > >> Version: 8.5.449 / Virus Database: 271.1.1/3759 - Release Date: 07/11/11 18:35:00 > >> > >> ---------- > >> > >> No virus found in this outgoing message. > >> Checked by AVG - www.avg.com > >> Version: 8.5.449 / Virus Database: 271.1.1/3759 - Release Date: 07/11/11 18:35:00 > >> > >> Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 12, 2011 Report Share Posted July 12, 2011 Ok fine, it’s a buboe!! She has the plague!!!!! RUN!!!!!!!! From: texasems-l [mailto:texasems-l ] On Behalf Of Alyssa Woods Sent: Tuesday, July 12, 2011 1:34 PM To: texasems-l Subject: Re: Mystery Diagnosis Pupils equal but very sluggish if responsive at all and dilated. Negative babinski; she's not alert enough to follow instructions, both before and after sedation/RSI. Alyssa Woods, NREMT-B Sent from the itty bitty keyboard on my iPhone On Jul 12, 2011, at 13:28, Brad Sattler bradsattler@... > wrote: > Pupils/PMS/Cranial Nerve Responses (those you can check anyway)? > > -Brad > > Sent from my iPhone > > On Jul 12, 2011, at 11:22 AM, Alyssa Woods amwoods8644@... > wrote: > > > High-dose phenobarbital drip calms her seizures for the duration of the drip only, the node is visibly swollen. You don't see or feel any other swollen lymph nodes. No s/s of anemia. > > > > Alyssa Woods, NREMT-B > > > > > > > > > >> Phenobarbitol drip? Look for s/s of anemia... How big is the node? Reasesses paying attention for nodules? > >> > >> Sent from my iPhone > >> > >> On Jul 12, 2011, at 1:13 PM, Alyssa Woods amwoods8644@... > wrote: > >> > >> She did not ingest a plant. Benzo's and phenobarbital stop her seizures for 30 seconds - 1 minute, paralytics for a few minutes. > >> > >> Alyssa Woods, NREMT-B > >> > >> > >> > >> > >> Find out what plant she possibly ingested. Begin your normal treatment for siezure until you know more. > >> > >> Henry > >> Mystery Diagnosis > >> > >> You're called out to a 5 year old girl who was playing in the yard, when she suddenly had a seizure. When you arrive on scene her parents instantly calm down and tell you she has no history, no medications, and no known allergies. Your patient is having a grand mal seizure which has been going on for at least 5 minutes. > >> > >> What's your treatment and what's happening to her? > >> > >> Alyssa Woods, NREMT-B > >> > >> > >> ---------------------------------------------------------- > >> > >> No virus found in this incoming message. > >> Checked by AVG - www.avg.com > >> Version: 8.5.449 / Virus Database: 271.1.1/3759 - Release Date: 07/11/11 18:35:00 > >> > >> ---------- > >> > >> No virus found in this outgoing message. > >> Checked by AVG - www.avg.com > >> Version: 8.5.449 / Virus Database: 271.1.1/3759 - Release Date: 07/11/11 18:35:00 > >> > >> Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 12, 2011 Report Share Posted July 12, 2011 Uremia? Gene Bates > No pets. No cat scratches. Pt is pristine except for one swollen lymph node and one minor abrasion on her chin. > > Alyssa Woods, NREMT-B > > > Sent from the itty bitty keyboard on my iPhone > > > > > Cat-scratch encephalopathy? > > > > Sent from my iPhone > > > > > > > > Pupils/PMS/Cranial Nerve Responses (those you can check anyway)? > > > > -Brad > > > > Sent from my iPhone > > > > > > > > > High-dose phenobarbital drip calms her seizures for the duration of the drip only, the node is visibly swollen. You don't see or feel any other swollen lymph nodes. No s/s of anemia. > > > > > > Alyssa Woods, NREMT-B > > > > > > > > > > > > > > >> Phenobarbitol drip? Look for s/s of anemia... How big is the node? Reasesses paying attention for nodules? > > >> > > >> Sent from my iPhone > > >> > > >> > > >> > > >> She did not ingest a plant. Benzo's and phenobarbital stop her seizures for 30 seconds - 1 minute, paralytics for a few minutes. > > >> > > >> Alyssa Woods, NREMT-B > > >> > > >> > > >> > > >> > > >> Find out what plant she possibly ingested. Begin your normal treatment for siezure until you know more. > > >> > > >> Henry > > >> Mystery Diagnosis > > >> > > >> You're called out to a 5 year old girl who was playing in the yard, when she suddenly had a seizure. When you arrive on scene her parents instantly calm down and tell you she has no history, no medications, and no known allergies. Your patient is having a grand mal seizure which has been going on for at least 5 minutes. > > >> > > >> What's your treatment and what's happening to her? > > >> > > >> Alyssa Woods, NREMT-B > > >> > > >> > > >> ---------------------------------------------------------- > > >> > > >> No virus found in this incoming message. > > >> Checked by AVG - www.avg.com > > >> Version: 8.5.449 / Virus Database: 271.1.1/3759 - Release Date: 07/11/11 18:35:00 > > >> > > >> ---------- > > >> > > >> No virus found in this outgoing message. > > >> Checked by AVG - www.avg.com > > >> Version: 8.5.449 / Virus Database: 271.1.1/3759 - Release Date: 07/11/11 18:35:00 > > >> > > >> Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 12, 2011 Report Share Posted July 12, 2011 Uremia? Gene Bates > No pets. No cat scratches. Pt is pristine except for one swollen lymph node and one minor abrasion on her chin. > > Alyssa Woods, NREMT-B > > > Sent from the itty bitty keyboard on my iPhone > > > > > Cat-scratch encephalopathy? > > > > Sent from my iPhone > > > > > > > > Pupils/PMS/Cranial Nerve Responses (those you can check anyway)? > > > > -Brad > > > > Sent from my iPhone > > > > > > > > > High-dose phenobarbital drip calms her seizures for the duration of the drip only, the node is visibly swollen. You don't see or feel any other swollen lymph nodes. No s/s of anemia. > > > > > > Alyssa Woods, NREMT-B > > > > > > > > > > > > > > >> Phenobarbitol drip? Look for s/s of anemia... How big is the node? Reasesses paying attention for nodules? > > >> > > >> Sent from my iPhone > > >> > > >> > > >> > > >> She did not ingest a plant. Benzo's and phenobarbital stop her seizures for 30 seconds - 1 minute, paralytics for a few minutes. > > >> > > >> Alyssa Woods, NREMT-B > > >> > > >> > > >> > > >> > > >> Find out what plant she possibly ingested. Begin your normal treatment for siezure until you know more. > > >> > > >> Henry > > >> Mystery Diagnosis > > >> > > >> You're called out to a 5 year old girl who was playing in the yard, when she suddenly had a seizure. When you arrive on scene her parents instantly calm down and tell you she has no history, no medications, and no known allergies. Your patient is having a grand mal seizure which has been going on for at least 5 minutes. > > >> > > >> What's your treatment and what's happening to her? > > >> > > >> Alyssa Woods, NREMT-B > > >> > > >> > > >> ---------------------------------------------------------- > > >> > > >> No virus found in this incoming message. > > >> Checked by AVG - www.avg.com > > >> Version: 8.5.449 / Virus Database: 271.1.1/3759 - Release Date: 07/11/11 18:35:00 > > >> > > >> ---------- > > >> > > >> No virus found in this outgoing message. > > >> Checked by AVG - www.avg.com > > >> Version: 8.5.449 / Virus Database: 271.1.1/3759 - Release Date: 07/11/11 18:35:00 > > >> > > >> Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 12, 2011 Report Share Posted July 12, 2011 Uremia? Gene Bates > No pets. No cat scratches. Pt is pristine except for one swollen lymph node and one minor abrasion on her chin. > > Alyssa Woods, NREMT-B > > > Sent from the itty bitty keyboard on my iPhone > > > > > Cat-scratch encephalopathy? > > > > Sent from my iPhone > > > > > > > > Pupils/PMS/Cranial Nerve Responses (those you can check anyway)? > > > > -Brad > > > > Sent from my iPhone > > > > > > > > > High-dose phenobarbital drip calms her seizures for the duration of the drip only, the node is visibly swollen. You don't see or feel any other swollen lymph nodes. No s/s of anemia. > > > > > > Alyssa Woods, NREMT-B > > > > > > > > > > > > > > >> Phenobarbitol drip? Look for s/s of anemia... How big is the node? Reasesses paying attention for nodules? > > >> > > >> Sent from my iPhone > > >> > > >> > > >> > > >> She did not ingest a plant. Benzo's and phenobarbital stop her seizures for 30 seconds - 1 minute, paralytics for a few minutes. > > >> > > >> Alyssa Woods, NREMT-B > > >> > > >> > > >> > > >> > > >> Find out what plant she possibly ingested. Begin your normal treatment for siezure until you know more. > > >> > > >> Henry > > >> Mystery Diagnosis > > >> > > >> You're called out to a 5 year old girl who was playing in the yard, when she suddenly had a seizure. When you arrive on scene her parents instantly calm down and tell you she has no history, no medications, and no known allergies. Your patient is having a grand mal seizure which has been going on for at least 5 minutes. > > >> > > >> What's your treatment and what's happening to her? > > >> > > >> Alyssa Woods, NREMT-B > > >> > > >> > > >> ---------------------------------------------------------- > > >> > > >> No virus found in this incoming message. > > >> Checked by AVG - www.avg.com > > >> Version: 8.5.449 / Virus Database: 271.1.1/3759 - Release Date: 07/11/11 18:35:00 > > >> > > >> ---------- > > >> > > >> No virus found in this outgoing message. > > >> Checked by AVG - www.avg.com > > >> Version: 8.5.449 / Virus Database: 271.1.1/3759 - Release Date: 07/11/11 18:35:00 > > >> > > >> Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 12, 2011 Report Share Posted July 12, 2011 Could be mets ca? Just a thought.. Excuse any errors. Sent from my iPhone > No pets. No cat scratches. Pt is pristine except for one swollen lymph node and one minor abrasion on her chin. > > Alyssa Woods, NREMT-B > > > Sent from the itty bitty keyboard on my iPhone > > > > > Cat-scratch encephalopathy? > > > > Sent from my iPhone > > > > > > > > Pupils/PMS/Cranial Nerve Responses (those you can check anyway)? > > > > -Brad > > > > Sent from my iPhone > > > > > > > > > High-dose phenobarbital drip calms her seizures for the duration of the drip only, the node is visibly swollen. You don't see or feel any other swollen lymph nodes. No s/s of anemia. > > > > > > Alyssa Woods, NREMT-B > > > > > > > > > > > > > > >> Phenobarbitol drip? Look for s/s of anemia... How big is the node? Reasesses paying attention for nodules? > > >> > > >> Sent from my iPhone > > >> > > >> > > >> > > >> She did not ingest a plant. Benzo's and phenobarbital stop her seizures for 30 seconds - 1 minute, paralytics for a few minutes. > > >> > > >> Alyssa Woods, NREMT-B > > >> > > >> > > >> > > >> > > >> Find out what plant she possibly ingested. Begin your normal treatment for siezure until you know more. > > >> > > >> Henry > > >> Mystery Diagnosis > > >> > > >> You're called out to a 5 year old girl who was playing in the yard, when she suddenly had a seizure. When you arrive on scene her parents instantly calm down and tell you she has no history, no medications, and no known allergies. Your patient is having a grand mal seizure which has been going on for at least 5 minutes. > > >> > > >> What's your treatment and what's happening to her? > > >> > > >> Alyssa Woods, NREMT-B > > >> > > >> > > >> ---------------------------------------------------------- > > >> > > >> No virus found in this incoming message. > > >> Checked by AVG - www.avg.com > > >> Version: 8.5.449 / Virus Database: 271.1.1/3759 - Release Date: 07/11/11 18:35:00 > > >> > > >> ---------- > > >> > > >> No virus found in this outgoing message. > > >> Checked by AVG - www.avg.com > > >> Version: 8.5.449 / Virus Database: 271.1.1/3759 - Release Date: 07/11/11 18:35:00 > > >> > > >> Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 12, 2011 Report Share Posted July 12, 2011 Could be mets ca? Just a thought.. Excuse any errors. Sent from my iPhone > No pets. No cat scratches. Pt is pristine except for one swollen lymph node and one minor abrasion on her chin. > > Alyssa Woods, NREMT-B > > > Sent from the itty bitty keyboard on my iPhone > > > > > Cat-scratch encephalopathy? > > > > Sent from my iPhone > > > > > > > > Pupils/PMS/Cranial Nerve Responses (those you can check anyway)? > > > > -Brad > > > > Sent from my iPhone > > > > > > > > > High-dose phenobarbital drip calms her seizures for the duration of the drip only, the node is visibly swollen. You don't see or feel any other swollen lymph nodes. No s/s of anemia. > > > > > > Alyssa Woods, NREMT-B > > > > > > > > > > > > > > >> Phenobarbitol drip? Look for s/s of anemia... How big is the node? Reasesses paying attention for nodules? > > >> > > >> Sent from my iPhone > > >> > > >> > > >> > > >> She did not ingest a plant. Benzo's and phenobarbital stop her seizures for 30 seconds - 1 minute, paralytics for a few minutes. > > >> > > >> Alyssa Woods, NREMT-B > > >> > > >> > > >> > > >> > > >> Find out what plant she possibly ingested. Begin your normal treatment for siezure until you know more. > > >> > > >> Henry > > >> Mystery Diagnosis > > >> > > >> You're called out to a 5 year old girl who was playing in the yard, when she suddenly had a seizure. When you arrive on scene her parents instantly calm down and tell you she has no history, no medications, and no known allergies. Your patient is having a grand mal seizure which has been going on for at least 5 minutes. > > >> > > >> What's your treatment and what's happening to her? > > >> > > >> Alyssa Woods, NREMT-B > > >> > > >> > > >> ---------------------------------------------------------- > > >> > > >> No virus found in this incoming message. > > >> Checked by AVG - www.avg.com > > >> Version: 8.5.449 / Virus Database: 271.1.1/3759 - Release Date: 07/11/11 18:35:00 > > >> > > >> ---------- > > >> > > >> No virus found in this outgoing message. > > >> Checked by AVG - www.avg.com > > >> Version: 8.5.449 / Virus Database: 271.1.1/3759 - Release Date: 07/11/11 18:35:00 > > >> > > >> Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 12, 2011 Report Share Posted July 12, 2011 Could be mets ca? Just a thought.. Excuse any errors. Sent from my iPhone > No pets. No cat scratches. Pt is pristine except for one swollen lymph node and one minor abrasion on her chin. > > Alyssa Woods, NREMT-B > > > Sent from the itty bitty keyboard on my iPhone > > > > > Cat-scratch encephalopathy? > > > > Sent from my iPhone > > > > > > > > Pupils/PMS/Cranial Nerve Responses (those you can check anyway)? > > > > -Brad > > > > Sent from my iPhone > > > > > > > > > High-dose phenobarbital drip calms her seizures for the duration of the drip only, the node is visibly swollen. You don't see or feel any other swollen lymph nodes. No s/s of anemia. > > > > > > Alyssa Woods, NREMT-B > > > > > > > > > > > > > > >> Phenobarbitol drip? Look for s/s of anemia... How big is the node? Reasesses paying attention for nodules? > > >> > > >> Sent from my iPhone > > >> > > >> > > >> > > >> She did not ingest a plant. Benzo's and phenobarbital stop her seizures for 30 seconds - 1 minute, paralytics for a few minutes. > > >> > > >> Alyssa Woods, NREMT-B > > >> > > >> > > >> > > >> > > >> Find out what plant she possibly ingested. Begin your normal treatment for siezure until you know more. > > >> > > >> Henry > > >> Mystery Diagnosis > > >> > > >> You're called out to a 5 year old girl who was playing in the yard, when she suddenly had a seizure. When you arrive on scene her parents instantly calm down and tell you she has no history, no medications, and no known allergies. Your patient is having a grand mal seizure which has been going on for at least 5 minutes. > > >> > > >> What's your treatment and what's happening to her? > > >> > > >> Alyssa Woods, NREMT-B > > >> > > >> > > >> ---------------------------------------------------------- > > >> > > >> No virus found in this incoming message. > > >> Checked by AVG - www.avg.com > > >> Version: 8.5.449 / Virus Database: 271.1.1/3759 - Release Date: 07/11/11 18:35:00 > > >> > > >> ---------- > > >> > > >> No virus found in this outgoing message. > > >> Checked by AVG - www.avg.com > > >> Version: 8.5.449 / Virus Database: 271.1.1/3759 - Release Date: 07/11/11 18:35:00 > > >> > > >> Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 12, 2011 Report Share Posted July 12, 2011 OK, let's see if I can sum up the current findings of the last 40 odd messages. My comments are in line at >: Chief Complaint: New Onset Seizure History of Present Illness: 5 yo WF previously in good health, noted to have major convulsions after playing outside on a hot afternoon. Onset is un certain as the parents were unpacking from the recent move. The convulsions continued for at least 5 minutes, and recurred after appropriate initial treatment. Past History: no medical or surgical history, no allergies, no medications. Social history is positive for a pregnant mother who is slightly overdue, Just moved into a new house with a koi pond, but no plants besides grass, and no known history of chemical usage in the hard or pond >Is there anything interesting in the Family History Review of Systems: The node noted on the physical exam has been present for a week, and child has an appointment with her (? new) pediatrician already scheduled. Physical exam is positive for VS: Hypothermic at 95 F Rectal, o2: 90% room air RR: 8, very shallow and erratic, no gag reflex HR: 158, sinus arrhythmia, strong pulse BP: 98/56 Mental status: she is not responsive enough to answer questions or follow commands. Reaction to pain before RSI is NOT noted. HEENT: small abrasion on the chin, pupils are equal but very sluggish. mucosa is NOT pale. Gag Reflex is absent >What would be the effective Glasgow Coma Score of this patient? Neck: no nodes or obvious nuchal rigidity Chest and Abdomen findings are NOT reported. Extremities: a solid unilateral R inguinal/thigh node is noted. It is NOT a buboe. Skin: aside from the abrasion, there are no rashes or bruising noted. No evidence of arachnid bites or stings are noted. Neurologic: Babinski's reflex is normal. Deep tendon Reflexes are NOT reported. Working evaluation: Obtunded patient with ongoing seizures and ventilatory compromise, significant hypothermia. Treatment: Open Airway, apply oxygen, establish IV Access. IV ativan is given, and the seizures stop for less than one minute before tremors which progress to grand mal activity start. Core Body temp does NOT respond to environmental temperature and aggressive warming >note: WHY are you hanging around to try to warm this patient? Repeat VS: o2: 96% on 15 LPM NRB RR: 6, very shallow and erratic, no gag reflex HR: 164, sinus arrhythmia, strong pulse BP: 94/52 >At this point, more aggressive ventilatory support should be started. Question for the group: a: name *at least* two reasons for the decrease in ventilatory effort? b: name *at least* two methods for supporting ventilation? Further Treatment: The patient is set up for RSI- the seizures stop for 'a few minutes' under the influence of the paralytics. Phenobarbital is loaded, but is no more effective than Benzos at terminating the seizures, as they reported restart shortly after the loading drip is complete. >note: this is VERY unusual for seizures. question for the group: What is the next step in the treatment of the seizures *besides* transport. Active methods to support ventilation is NOT specified. Transport issues: You have one ER without so much as a dedicated pediatrician which is about 5-10 min northwest, and one which is a dedicated children's hospital 30-40 minutes in the opposite direction. The two closest flight teams are out on other calls, and consequently their ETA is worse than yours. >incidentally, this is a case where the patient needs a good EM doc, NOT your run of the mill pediatrician! I agree, there is significant internal derangement of this patient. As Ms. Wood has already noted that the diagnosis was difficult even in the ED, I doubt anyone will guess correctly at this point. What is next? ck Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 12, 2011 Report Share Posted July 12, 2011 you've got a pretty sophisticated set up if you can confirm sodium levels in the field. Also, sodium disturbances are vanishingly rare in children who are otherwise healthy, on no medications, and who have free access to food and water. leading to two follow up questions: First, what two electrolytes MIGHT you be able to guess are out of whack in the field, and what findings would lead you to suspect those derangements? Second: what medication has hyponatremia as the most classic idiopathic side effect? ck In a message dated 07/12/11 20:21:51 Central Daylight Time, jeremydriver@... writes: Hyponutremia? Sent from my iPhone OK, let's see if I can sum up the current findings of the last 40 odd messages. My comments are in line at >: Chief Complaint: New Onset Seizure History of Present Illness: 5 yo WF previously in good health, noted to have major convulsions after playing outside on a hot afternoon. Onset is un certain as the parents were unpacking from the recent move. The convulsions continued for at least 5 minutes, and recurred after appropriate initial treatment. Past History: no medical or surgical history, no allergies, no medications. Social history is positive for a pregnant mother who is slightly overdue, Just moved into a new house with a koi pond, but no plants besides grass, and no known history of chemical usage in the hard or pond >Is there anything interesting in the Family History Review of Systems: The node noted on the physical exam has been present for a week, and child has an appointment with her (? new) pediatrician already scheduled. Physical exam is positive for VS: Hypothermic at 95 F Rectal, o2: 90% room air RR: 8, very shallow and erratic, no gag reflex HR: 158, sinus arrhythmia, strong pulse BP: 98/56 Mental status: she is not responsive enough to answer questions or follow commands. Reaction to pain before RSI is NOT noted. HEENT: small abrasion on the chin, pupils are equal but very sluggish. mucosa is NOT pale. Gag Reflex is absent >What would be the effective Glasgow Coma Score of this patient? Neck: no nodes or obvious nuchal rigidity Chest and Abdomen findings are NOT reported. Extremities: a solid unilateral R inguinal/thigh node is noted. It is NOT a buboe. Skin: aside from the abrasion, there are no rashes or bruising noted. No evidence of arachnid bites or stings are noted. Neurologic: Babinski's reflex is normal. Deep tendon Reflexes are NOT reported. Working evaluation: Obtunded patient with ongoing seizures and ventilatory compromise, significant hypothermia. Treatment: Open Airway, apply oxygen, establish IV Access. IV ativan is given, and the seizures stop for less than one minute before tremors which progress to grand mal activity start. Core Body temp does NOT respond to environmental temperature and aggressive warming >note: WHY are you hanging around to try to warm this patient? Repeat VS: o2: 96% on 15 LPM NRB RR: 6, very shallow and erratic, no gag reflex HR: 164, sinus arrhythmia, strong pulse BP: 94/52 >At this point, more aggressive ventilatory support should be started. Question for the group: a: name *at least* two reasons for the decrease in ventilatory effort? b: name *at least* two methods for supporting ventilation? Further Treatment: The patient is set up for RSI- the seizures stop for 'a few minutes' under the influence of the paralytics. Phenobarbital is loaded, but is no more effective than Benzos at terminating the seizures, as they reported restart shortly after the loading drip is complete. >note: this is VERY unusual for seizures. question for the group: What is the next step in the treatment of the seizures *besides* transport. Active methods to support ventilation is NOT specified. Transport issues: You have one ER without so much as a dedicated pediatrician which is about 5-10 min northwest, and one which is a dedicated children's hospital 30-40 minutes in the opposite direction. The two closest flight teams are out on other calls, and consequently their ETA is worse than yours. >incidentally, this is a case where the patient needs a good EM doc, NOT your run of the mill pediatrician! I agree, there is significant internal derangement of this patient. As Ms. Wood has already noted that the diagnosis was difficult even in the ED, I doubt anyone will guess correctly at this point. What is next? ck [Non-text portions of this message have been removed] [Non-text portions of this message have been removed] ------------------------------------ Yahoo! Groups Links Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 12, 2011 Report Share Posted July 12, 2011 for those interested, the answer to question 7 reads thus: Patients with hyponatremic seizures tend to have lower temperatures than patients with seizures due to other causes. One of the most common causes of hyponatremic seizures is excess intake of free water. This may be due to improper formula preparation. Farrar H et al. (Hyponatremia as the cause of seizures in infants: a retrospective analysis of incidence, severity, and clinical predictors. Ann Emerg Med, 1995, 26:42-48) found the following results: 47 patients less than 6 months of age were enrolled. Median seizure duration was longer ( 30 minutes versus 17 minutes, p=0.007) in patients with hyponatremia, with a greater incidence of status epilepticus ( 73% versus 36%, p=0.02) Emergency intubation was performed more often in hyponatremic patients than in normonatremic patients ( p=0.009). Median temperature was lower in hyponatremic infants (35.5 degrees Celsius versus 37.2 degrees Celsius, p=0.0001) Temperature less than 36.5 degrees C was the best predictor of hyponatremic seizures. note that while hyponatremia and hypothermia were linked, the patients were less than 6 months of age, and still being bottle fed. I will agree that in *infants,* hyponatremia and hypothermia are more likely, and that there is a *small* chance that a 5yo kid might have managed to suck down enough cold water from a garden hose to cause problems, but in an acute situation, the kid would have to drink several *gallons* over the space of an hour or so for this to happen. ck In a message dated 07/12/11 20:33:25 Central Daylight Time, jeremydriver@... writes: I found this artical while researching this: http://www.acep.org/content.aspx?id=31418 Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 12, 2011 Report Share Posted July 12, 2011 for those interested, the answer to question 7 reads thus: Patients with hyponatremic seizures tend to have lower temperatures than patients with seizures due to other causes. One of the most common causes of hyponatremic seizures is excess intake of free water. This may be due to improper formula preparation. Farrar H et al. (Hyponatremia as the cause of seizures in infants: a retrospective analysis of incidence, severity, and clinical predictors. Ann Emerg Med, 1995, 26:42-48) found the following results: 47 patients less than 6 months of age were enrolled. Median seizure duration was longer ( 30 minutes versus 17 minutes, p=0.007) in patients with hyponatremia, with a greater incidence of status epilepticus ( 73% versus 36%, p=0.02) Emergency intubation was performed more often in hyponatremic patients than in normonatremic patients ( p=0.009). Median temperature was lower in hyponatremic infants (35.5 degrees Celsius versus 37.2 degrees Celsius, p=0.0001) Temperature less than 36.5 degrees C was the best predictor of hyponatremic seizures. note that while hyponatremia and hypothermia were linked, the patients were less than 6 months of age, and still being bottle fed. I will agree that in *infants,* hyponatremia and hypothermia are more likely, and that there is a *small* chance that a 5yo kid might have managed to suck down enough cold water from a garden hose to cause problems, but in an acute situation, the kid would have to drink several *gallons* over the space of an hour or so for this to happen. ck In a message dated 07/12/11 20:33:25 Central Daylight Time, jeremydriver@... writes: I found this artical while researching this: http://www.acep.org/content.aspx?id=31418 Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 12, 2011 Report Share Posted July 12, 2011 No plague, no pool chemicals, no recent algae treatments. Alyssa Woods, NREMT-B Sent from the itty bitty keyboard on my iPhone > Ok fine, it’s a buboe!! She has the plague!!!!! RUN!!!!!!!! > > From: texasems-l [mailto:texasems-l ] On Behalf Of Alyssa Woods > Sent: Tuesday, July 12, 2011 1:34 PM > To: texasems-l > Subject: Re: Mystery Diagnosis > > Pupils equal but very sluggish if responsive at all and dilated. > > Negative babinski; she's not alert enough to follow instructions, both before and after sedation/RSI. > > Alyssa Woods, NREMT-B > > > Sent from the itty bitty keyboard on my iPhone > > On Jul 12, 2011, at 13:28, Brad Sattler bradsattler@... > wrote: > > > Pupils/PMS/Cranial Nerve Responses (those you can check anyway)? > > > > -Brad > > > > Sent from my iPhone > > > > On Jul 12, 2011, at 11:22 AM, Alyssa Woods amwoods8644@... > wrote: > > > > > High-dose phenobarbital drip calms her seizures for the duration of the drip only, the node is visibly swollen. You don't see or feel any other swollen lymph nodes. No s/s of anemia. > > > > > > Alyssa Woods, NREMT-B > > > > > > > > > > > > > > >> Phenobarbitol drip? Look for s/s of anemia... How big is the node? Reasesses paying attention for nodules? > > >> > > >> Sent from my iPhone > > >> > > >> On Jul 12, 2011, at 1:13 PM, Alyssa Woods amwoods8644@... > wrote: > > >> > > >> She did not ingest a plant. Benzo's and phenobarbital stop her seizures for 30 seconds - 1 minute, paralytics for a few minutes. > > >> > > >> Alyssa Woods, NREMT-B > > >> > > >> > > >> > > >> > > >> Find out what plant she possibly ingested. Begin your normal treatment for siezure until you know more. > > >> > > >> Henry > > >> Mystery Diagnosis > > >> > > >> You're called out to a 5 year old girl who was playing in the yard, when she suddenly had a seizure. When you arrive on scene her parents instantly calm down and tell you she has no history, no medications, and no known allergies. Your patient is having a grand mal seizure which has been going on for at least 5 minutes. > > >> > > >> What's your treatment and what's happening to her? > > >> > > >> Alyssa Woods, NREMT-B > > >> > > >> > > >> ---------------------------------------------------------- > > >> > > >> No virus found in this incoming message. > > >> Checked by AVG - www.avg.com > > >> Version: 8.5.449 / Virus Database: 271.1.1/3759 - Release Date: 07/11/11 18:35:00 > > >> > > >> ---------- > > >> > > >> No virus found in this outgoing message. > > >> Checked by AVG - www.avg.com > > >> Version: 8.5.449 / Virus Database: 271.1.1/3759 - Release Date: 07/11/11 18:35:00 > > >> > > >> Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 12, 2011 Report Share Posted July 12, 2011 No uremia. Alyssa Woods, NREMT-B Sent from the itty bitty keyboard on my iPhone > Uremia? > > Gene Bates > > > > > No pets. No cat scratches. Pt is pristine except for one swollen lymph node and one minor abrasion on her chin. > > > > Alyssa Woods, NREMT-B > > > > > > Sent from the itty bitty keyboard on my iPhone > > > > > > > > > Cat-scratch encephalopathy? > > > > > > Sent from my iPhone > > > > > > > > > > > > Pupils/PMS/Cranial Nerve Responses (those you can check anyway)? > > > > > > -Brad > > > > > > Sent from my iPhone > > > > > > > > > > > > > High-dose phenobarbital drip calms her seizures for the duration of the drip only, the node is visibly swollen. You don't see or feel any other swollen lymph nodes. No s/s of anemia. > > > > > > > > Alyssa Woods, NREMT-B > > > > > > > > > > > > > > > > > > > >> Phenobarbitol drip? Look for s/s of anemia... How big is the node? Reasesses paying attention for nodules? > > > >> > > > >> Sent from my iPhone > > > >> > > > >> On Jul 12, 2011, at 1:13 PM, Alyssa Woods amwoods8644@...> wrote: > > > >> > > > >> She did not ingest a plant. Benzo's and phenobarbital stop her seizures for 30 seconds - 1 minute, paralytics for a few minutes. > > > >> > > > >> Alyssa Woods, NREMT-B > > > >> > > > >> > > > >> > > > >> > > > >> Find out what plant she possibly ingested. Begin your normal treatment for siezure until you know more. > > > >> > > > >> Henry > > > >> Mystery Diagnosis > > > >> > > > >> You're called out to a 5 year old girl who was playing in the yard, when she suddenly had a seizure. When you arrive on scene her parents instantly calm down and tell you she has no history, no medications, and no known allergies. Your patient is having a grand mal seizure which has been going on for at least 5 minutes. > > > >> > > > >> What's your treatment and what's happening to her? > > > >> > > > >> Alyssa Woods, NREMT-B > > > >> > > > >> > > > >> ---------------------------------------------------------- > > > >> > > > >> No virus found in this incoming message. > > > >> Checked by AVG - www.avg.com > > > >> Version: 8.5.449 / Virus Database: 271.1.1/3759 - Release Date: 07/11/11 18:35:00 > > > >> > > > >> ---------- > > > >> > > > >> No virus found in this outgoing message. > > > >> Checked by AVG - www.avg.com > > > >> Version: 8.5.449 / Virus Database: 271.1.1/3759 - Release Date: 07/11/11 18:35:00 > > > >> > > > >> Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 12, 2011 Report Share Posted July 12, 2011 No uremia. Alyssa Woods, NREMT-B Sent from the itty bitty keyboard on my iPhone > Uremia? > > Gene Bates > > > > > No pets. No cat scratches. Pt is pristine except for one swollen lymph node and one minor abrasion on her chin. > > > > Alyssa Woods, NREMT-B > > > > > > Sent from the itty bitty keyboard on my iPhone > > > > > > > > > Cat-scratch encephalopathy? > > > > > > Sent from my iPhone > > > > > > > > > > > > Pupils/PMS/Cranial Nerve Responses (those you can check anyway)? > > > > > > -Brad > > > > > > Sent from my iPhone > > > > > > > > > > > > > High-dose phenobarbital drip calms her seizures for the duration of the drip only, the node is visibly swollen. You don't see or feel any other swollen lymph nodes. No s/s of anemia. > > > > > > > > Alyssa Woods, NREMT-B > > > > > > > > > > > > > > > > > > > >> Phenobarbitol drip? Look for s/s of anemia... How big is the node? Reasesses paying attention for nodules? > > > >> > > > >> Sent from my iPhone > > > >> > > > >> On Jul 12, 2011, at 1:13 PM, Alyssa Woods amwoods8644@...> wrote: > > > >> > > > >> She did not ingest a plant. Benzo's and phenobarbital stop her seizures for 30 seconds - 1 minute, paralytics for a few minutes. > > > >> > > > >> Alyssa Woods, NREMT-B > > > >> > > > >> > > > >> > > > >> > > > >> Find out what plant she possibly ingested. Begin your normal treatment for siezure until you know more. > > > >> > > > >> Henry > > > >> Mystery Diagnosis > > > >> > > > >> You're called out to a 5 year old girl who was playing in the yard, when she suddenly had a seizure. When you arrive on scene her parents instantly calm down and tell you she has no history, no medications, and no known allergies. Your patient is having a grand mal seizure which has been going on for at least 5 minutes. > > > >> > > > >> What's your treatment and what's happening to her? > > > >> > > > >> Alyssa Woods, NREMT-B > > > >> > > > >> > > > >> ---------------------------------------------------------- > > > >> > > > >> No virus found in this incoming message. > > > >> Checked by AVG - www.avg.com > > > >> Version: 8.5.449 / Virus Database: 271.1.1/3759 - Release Date: 07/11/11 18:35:00 > > > >> > > > >> ---------- > > > >> > > > >> No virus found in this outgoing message. > > > >> Checked by AVG - www.avg.com > > > >> Version: 8.5.449 / Virus Database: 271.1.1/3759 - Release Date: 07/11/11 18:35:00 > > > >> > > > >> Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 12, 2011 Report Share Posted July 12, 2011 No uremia. Alyssa Woods, NREMT-B Sent from the itty bitty keyboard on my iPhone > Uremia? > > Gene Bates > > > > > No pets. No cat scratches. Pt is pristine except for one swollen lymph node and one minor abrasion on her chin. > > > > Alyssa Woods, NREMT-B > > > > > > Sent from the itty bitty keyboard on my iPhone > > > > > > > > > Cat-scratch encephalopathy? > > > > > > Sent from my iPhone > > > > > > > > > > > > Pupils/PMS/Cranial Nerve Responses (those you can check anyway)? > > > > > > -Brad > > > > > > Sent from my iPhone > > > > > > > > > > > > > High-dose phenobarbital drip calms her seizures for the duration of the drip only, the node is visibly swollen. You don't see or feel any other swollen lymph nodes. No s/s of anemia. > > > > > > > > Alyssa Woods, NREMT-B > > > > > > > > > > > > > > > > > > > >> Phenobarbitol drip? Look for s/s of anemia... How big is the node? Reasesses paying attention for nodules? > > > >> > > > >> Sent from my iPhone > > > >> > > > >> On Jul 12, 2011, at 1:13 PM, Alyssa Woods amwoods8644@...> wrote: > > > >> > > > >> She did not ingest a plant. Benzo's and phenobarbital stop her seizures for 30 seconds - 1 minute, paralytics for a few minutes. > > > >> > > > >> Alyssa Woods, NREMT-B > > > >> > > > >> > > > >> > > > >> > > > >> Find out what plant she possibly ingested. Begin your normal treatment for siezure until you know more. > > > >> > > > >> Henry > > > >> Mystery Diagnosis > > > >> > > > >> You're called out to a 5 year old girl who was playing in the yard, when she suddenly had a seizure. When you arrive on scene her parents instantly calm down and tell you she has no history, no medications, and no known allergies. Your patient is having a grand mal seizure which has been going on for at least 5 minutes. > > > >> > > > >> What's your treatment and what's happening to her? > > > >> > > > >> Alyssa Woods, NREMT-B > > > >> > > > >> > > > >> ---------------------------------------------------------- > > > >> > > > >> No virus found in this incoming message. > > > >> Checked by AVG - www.avg.com > > > >> Version: 8.5.449 / Virus Database: 271.1.1/3759 - Release Date: 07/11/11 18:35:00 > > > >> > > > >> ---------- > > > >> > > > >> No virus found in this outgoing message. > > > >> Checked by AVG - www.avg.com > > > >> Version: 8.5.449 / Virus Database: 271.1.1/3759 - Release Date: 07/11/11 18:35:00 > > > >> > > > >> Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 12, 2011 Report Share Posted July 12, 2011 Ok, I think it's time for a hint. You're all looking at external problems. I'd say look more towards something internal. And what's with that temperature?! Alyssa Woods, NREMT-B > Ok fine, it’s a buboe!! She has the plague!!!!! RUN!!!!!!!! > > From: texasems-l [mailto:texasems-l ] On Behalf Of Alyssa Woods > Sent: Tuesday, July 12, 2011 1:34 PM > To: texasems-l > Subject: Re: Mystery Diagnosis > > Pupils equal but very sluggish if responsive at all and dilated. > > Negative babinski; she's not alert enough to follow instructions, both before and after sedation/RSI. > > Alyssa Woods, NREMT-B > > > Sent from the itty bitty keyboard on my iPhone > > On Jul 12, 2011, at 13:28, Brad Sattler bradsattler@... > wrote: > > > Pupils/PMS/Cranial Nerve Responses (those you can check anyway)? > > > > -Brad > > > > Sent from my iPhone > > > > On Jul 12, 2011, at 11:22 AM, Alyssa Woods amwoods8644@... > wrote: > > > > > High-dose phenobarbital drip calms her seizures for the duration of the drip only, the node is visibly swollen. You don't see or feel any other swollen lymph nodes. No s/s of anemia. > > > > > > Alyssa Woods, NREMT-B > > > > > > > > > > > > > > >> Phenobarbitol drip? Look for s/s of anemia... How big is the node? Reasesses paying attention for nodules? > > >> > > >> Sent from my iPhone > > >> > > >> On Jul 12, 2011, at 1:13 PM, Alyssa Woods amwoods8644@... > wrote: > > >> > > >> She did not ingest a plant. Benzo's and phenobarbital stop her seizures for 30 seconds - 1 minute, paralytics for a few minutes. > > >> > > >> Alyssa Woods, NREMT-B > > >> > > >> > > >> > > >> > > >> Find out what plant she possibly ingested. Begin your normal treatment for siezure until you know more. > > >> > > >> Henry > > >> Mystery Diagnosis > > >> > > >> You're called out to a 5 year old girl who was playing in the yard, when she suddenly had a seizure. When you arrive on scene her parents instantly calm down and tell you she has no history, no medications, and no known allergies. Your patient is having a grand mal seizure which has been going on for at least 5 minutes. > > >> > > >> What's your treatment and what's happening to her? > > >> > > >> Alyssa Woods, NREMT-B > > >> > > >> > > >> ---------------------------------------------------------- > > >> > > >> No virus found in this incoming message. > > >> Checked by AVG - www.avg.com > > >> Version: 8.5.449 / Virus Database: 271.1.1/3759 - Release Date: 07/11/11 18:35:00 > > >> > > >> ---------- > > >> > > >> No virus found in this outgoing message. > > >> Checked by AVG - www.avg.com > > >> Version: 8.5.449 / Virus Database: 271.1.1/3759 - Release Date: 07/11/11 18:35:00 > > >> > > >> Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 12, 2011 Report Share Posted July 12, 2011 Ok, I think it's time for a hint. You're all looking at external problems. I'd say look more towards something internal. And what's with that temperature?! Alyssa Woods, NREMT-B > Ok fine, it’s a buboe!! She has the plague!!!!! RUN!!!!!!!! > > From: texasems-l [mailto:texasems-l ] On Behalf Of Alyssa Woods > Sent: Tuesday, July 12, 2011 1:34 PM > To: texasems-l > Subject: Re: Mystery Diagnosis > > Pupils equal but very sluggish if responsive at all and dilated. > > Negative babinski; she's not alert enough to follow instructions, both before and after sedation/RSI. > > Alyssa Woods, NREMT-B > > > Sent from the itty bitty keyboard on my iPhone > > On Jul 12, 2011, at 13:28, Brad Sattler bradsattler@... > wrote: > > > Pupils/PMS/Cranial Nerve Responses (those you can check anyway)? > > > > -Brad > > > > Sent from my iPhone > > > > On Jul 12, 2011, at 11:22 AM, Alyssa Woods amwoods8644@... > wrote: > > > > > High-dose phenobarbital drip calms her seizures for the duration of the drip only, the node is visibly swollen. You don't see or feel any other swollen lymph nodes. No s/s of anemia. > > > > > > Alyssa Woods, NREMT-B > > > > > > > > > > > > > > >> Phenobarbitol drip? Look for s/s of anemia... How big is the node? Reasesses paying attention for nodules? > > >> > > >> Sent from my iPhone > > >> > > >> On Jul 12, 2011, at 1:13 PM, Alyssa Woods amwoods8644@... > wrote: > > >> > > >> She did not ingest a plant. Benzo's and phenobarbital stop her seizures for 30 seconds - 1 minute, paralytics for a few minutes. > > >> > > >> Alyssa Woods, NREMT-B > > >> > > >> > > >> > > >> > > >> Find out what plant she possibly ingested. Begin your normal treatment for siezure until you know more. > > >> > > >> Henry > > >> Mystery Diagnosis > > >> > > >> You're called out to a 5 year old girl who was playing in the yard, when she suddenly had a seizure. When you arrive on scene her parents instantly calm down and tell you she has no history, no medications, and no known allergies. Your patient is having a grand mal seizure which has been going on for at least 5 minutes. > > >> > > >> What's your treatment and what's happening to her? > > >> > > >> Alyssa Woods, NREMT-B > > >> > > >> > > >> ---------------------------------------------------------- > > >> > > >> No virus found in this incoming message. > > >> Checked by AVG - www.avg.com > > >> Version: 8.5.449 / Virus Database: 271.1.1/3759 - Release Date: 07/11/11 18:35:00 > > >> > > >> ---------- > > >> > > >> No virus found in this outgoing message. > > >> Checked by AVG - www.avg.com > > >> Version: 8.5.449 / Virus Database: 271.1.1/3759 - Release Date: 07/11/11 18:35:00 > > >> > > >> Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 12, 2011 Report Share Posted July 12, 2011 Ok, I think it's time for a hint. You're all looking at external problems. I'd say look more towards something internal. And what's with that temperature?! Alyssa Woods, NREMT-B > Ok fine, it’s a buboe!! She has the plague!!!!! RUN!!!!!!!! > > From: texasems-l [mailto:texasems-l ] On Behalf Of Alyssa Woods > Sent: Tuesday, July 12, 2011 1:34 PM > To: texasems-l > Subject: Re: Mystery Diagnosis > > Pupils equal but very sluggish if responsive at all and dilated. > > Negative babinski; she's not alert enough to follow instructions, both before and after sedation/RSI. > > Alyssa Woods, NREMT-B > > > Sent from the itty bitty keyboard on my iPhone > > On Jul 12, 2011, at 13:28, Brad Sattler bradsattler@... > wrote: > > > Pupils/PMS/Cranial Nerve Responses (those you can check anyway)? > > > > -Brad > > > > Sent from my iPhone > > > > On Jul 12, 2011, at 11:22 AM, Alyssa Woods amwoods8644@... > wrote: > > > > > High-dose phenobarbital drip calms her seizures for the duration of the drip only, the node is visibly swollen. You don't see or feel any other swollen lymph nodes. No s/s of anemia. > > > > > > Alyssa Woods, NREMT-B > > > > > > > > > > > > > > >> Phenobarbitol drip? Look for s/s of anemia... How big is the node? Reasesses paying attention for nodules? > > >> > > >> Sent from my iPhone > > >> > > >> On Jul 12, 2011, at 1:13 PM, Alyssa Woods amwoods8644@... > wrote: > > >> > > >> She did not ingest a plant. Benzo's and phenobarbital stop her seizures for 30 seconds - 1 minute, paralytics for a few minutes. > > >> > > >> Alyssa Woods, NREMT-B > > >> > > >> > > >> > > >> > > >> Find out what plant she possibly ingested. Begin your normal treatment for siezure until you know more. > > >> > > >> Henry > > >> Mystery Diagnosis > > >> > > >> You're called out to a 5 year old girl who was playing in the yard, when she suddenly had a seizure. When you arrive on scene her parents instantly calm down and tell you she has no history, no medications, and no known allergies. Your patient is having a grand mal seizure which has been going on for at least 5 minutes. > > >> > > >> What's your treatment and what's happening to her? > > >> > > >> Alyssa Woods, NREMT-B > > >> > > >> > > >> ---------------------------------------------------------- > > >> > > >> No virus found in this incoming message. > > >> Checked by AVG - www.avg.com > > >> Version: 8.5.449 / Virus Database: 271.1.1/3759 - Release Date: 07/11/11 18:35:00 > > >> > > >> ---------- > > >> > > >> No virus found in this outgoing message. > > >> Checked by AVG - www.avg.com > > >> Version: 8.5.449 / Virus Database: 271.1.1/3759 - Release Date: 07/11/11 18:35:00 > > >> > > >> Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 12, 2011 Report Share Posted July 12, 2011 Hyponutremia? Sent from my iPhone OK, let's see if I can sum up the current findings of the last 40 odd messages. My comments are in line at >: Chief Complaint: New Onset Seizure History of Present Illness: 5 yo WF previously in good health, noted to have major convulsions after playing outside on a hot afternoon. Onset is un certain as the parents were unpacking from the recent move. The convulsions continued for at least 5 minutes, and recurred after appropriate initial treatment. Past History: no medical or surgical history, no allergies, no medications. Social history is positive for a pregnant mother who is slightly overdue, Just moved into a new house with a koi pond, but no plants besides grass, and no known history of chemical usage in the hard or pond >Is there anything interesting in the Family History Review of Systems: The node noted on the physical exam has been present for a week, and child has an appointment with her (? new) pediatrician already scheduled. Physical exam is positive for VS: Hypothermic at 95 F Rectal, o2: 90% room air RR: 8, very shallow and erratic, no gag reflex HR: 158, sinus arrhythmia, strong pulse BP: 98/56 Mental status: she is not responsive enough to answer questions or follow commands. Reaction to pain before RSI is NOT noted. HEENT: small abrasion on the chin, pupils are equal but very sluggish. mucosa is NOT pale. Gag Reflex is absent >What would be the effective Glasgow Coma Score of this patient? Neck: no nodes or obvious nuchal rigidity Chest and Abdomen findings are NOT reported. Extremities: a solid unilateral R inguinal/thigh node is noted. It is NOT a buboe. Skin: aside from the abrasion, there are no rashes or bruising noted. No evidence of arachnid bites or stings are noted. Neurologic: Babinski's reflex is normal. Deep tendon Reflexes are NOT reported. Working evaluation: Obtunded patient with ongoing seizures and ventilatory compromise, significant hypothermia. Treatment: Open Airway, apply oxygen, establish IV Access. IV ativan is given, and the seizures stop for less than one minute before tremors which progress to grand mal activity start. Core Body temp does NOT respond to environmental temperature and aggressive warming >note: WHY are you hanging around to try to warm this patient? Repeat VS: o2: 96% on 15 LPM NRB RR: 6, very shallow and erratic, no gag reflex HR: 164, sinus arrhythmia, strong pulse BP: 94/52 >At this point, more aggressive ventilatory support should be started. Question for the group: a: name *at least* two reasons for the decrease in ventilatory effort? b: name *at least* two methods for supporting ventilation? Further Treatment: The patient is set up for RSI- the seizures stop for 'a few minutes' under the influence of the paralytics. Phenobarbital is loaded, but is no more effective than Benzos at terminating the seizures, as they reported restart shortly after the loading drip is complete. >note: this is VERY unusual for seizures. question for the group: What is the next step in the treatment of the seizures *besides* transport. Active methods to support ventilation is NOT specified. Transport issues: You have one ER without so much as a dedicated pediatrician which is about 5-10 min northwest, and one which is a dedicated children's hospital 30-40 minutes in the opposite direction. The two closest flight teams are out on other calls, and consequently their ETA is worse than yours. >incidentally, this is a case where the patient needs a good EM doc, NOT your run of the mill pediatrician! I agree, there is significant internal derangement of this patient. As Ms. Wood has already noted that the diagnosis was difficult even in the ED, I doubt anyone will guess correctly at this point. What is next? ck Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 12, 2011 Report Share Posted July 12, 2011 Family history has nothing remarkable; nothing like this and nothing that had an onset in childhood. GCS 7 or 8 when you first sedate her with benzodiazepines. No verbal response, eye opening to pain, withdraws to pain (tested by sternal rub). No notable chest or abdomen findings. Pt is RSI'd and has a phenobarbital drip. We're not hanging around trying to warm her, but as we have a couple of extra hands, we've wrapped her thoroughly en route. Pt is not hyponatremic. I'll give you another hint -- this is an act of God, not man. Though man can fix it. Alyssa Woods, NREMT-B > OK, let's see if I can sum up the current findings of the last 40 odd > messages. My comments are in line at >: > > Chief Complaint: New Onset Seizure > > History of Present Illness: 5 yo WF previously in good health, noted to > have major convulsions after playing outside on a hot afternoon. Onset is un > certain as the parents were unpacking from the recent move. The convulsions > continued for at least 5 minutes, and recurred after appropriate initial > treatment. > > Past History: no medical or surgical history, no allergies, no medications. > > Social history is positive for a pregnant mother who is slightly overdue, > Just moved into a new house with a koi pond, but no plants besides grass, > and no known history of chemical usage in the hard or pond > > > >Is there anything interesting in the Family History > > Review of Systems: The node noted on the physical exam has been present > for a week, and child has an appointment with her (? new) pediatrician > already scheduled. > > Physical exam is positive for > > VS: Hypothermic at 95 F Rectal, o2: 90% room air > RR: 8, very shallow and erratic, no gag reflex > HR: 158, sinus arrhythmia, strong pulse > BP: 98/56 > > Mental status: she is not responsive enough to answer questions or follow > commands. Reaction to pain before RSI is NOT noted. > > HEENT: small abrasion on the chin, pupils are equal but very sluggish. > mucosa is NOT pale. Gag Reflex is absent > > > >What would be the effective Glasgow Coma Score of this patient? > > Neck: no nodes or obvious nuchal rigidity > > Chest and Abdomen findings are NOT reported. > > Extremities: a solid unilateral R inguinal/thigh node is noted. It is NOT > a buboe. > > Skin: aside from the abrasion, there are no rashes or bruising noted. No > evidence of arachnid bites or stings are noted. > > Neurologic: Babinski's reflex is normal. Deep tendon Reflexes are NOT > reported. > > Working evaluation: Obtunded patient with ongoing seizures and ventilatory > compromise, significant hypothermia. > > Treatment: Open Airway, apply oxygen, establish IV Access. IV ativan is > given, and the seizures stop for less than one minute before tremors which > progress to grand mal activity start. Core Body temp does NOT respond to > environmental temperature and aggressive warming > > >note: WHY are you hanging around to try to warm this patient? > > Repeat VS: > o2: 96% on 15 LPM NRB > RR: 6, very shallow and erratic, no gag reflex > HR: 164, sinus arrhythmia, strong pulse > BP: 94/52 > > >At this point, more aggressive ventilatory support should be started. > Question for the group: > a: name *at least* two reasons for the decrease in ventilatory effort? > b: name *at least* two methods for supporting ventilation? > > > Further Treatment: The patient is set up for RSI- the seizures stop for 'a > few minutes' under the influence of the paralytics. Phenobarbital is > loaded, but is no more effective than Benzos at terminating the seizures, as > they reported restart shortly after the loading drip is complete. > > >note: this is VERY unusual for seizures. question for the group: What is > the next step in the treatment of the seizures *besides* transport. > > Active methods to support ventilation is NOT specified. > > Transport issues: You have one ER without so much as a dedicated > pediatrician which is about 5-10 min northwest, and one which is a dedicated > children's hospital 30-40 minutes in the opposite direction. The two closest > flight teams are out on other calls, and consequently their ETA is worse than > yours. > > > >incidentally, this is a case where the patient needs a good EM doc, NOT > your run of the mill pediatrician! > > I agree, there is significant internal derangement of this patient. As Ms. > Wood has already noted that the diagnosis was difficult even in the ED, I > doubt anyone will guess correctly at this point. > > What is next? > > ck > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 12, 2011 Report Share Posted July 12, 2011 Family history has nothing remarkable; nothing like this and nothing that had an onset in childhood. GCS 7 or 8 when you first sedate her with benzodiazepines. No verbal response, eye opening to pain, withdraws to pain (tested by sternal rub). No notable chest or abdomen findings. Pt is RSI'd and has a phenobarbital drip. We're not hanging around trying to warm her, but as we have a couple of extra hands, we've wrapped her thoroughly en route. Pt is not hyponatremic. I'll give you another hint -- this is an act of God, not man. Though man can fix it. Alyssa Woods, NREMT-B > OK, let's see if I can sum up the current findings of the last 40 odd > messages. My comments are in line at >: > > Chief Complaint: New Onset Seizure > > History of Present Illness: 5 yo WF previously in good health, noted to > have major convulsions after playing outside on a hot afternoon. Onset is un > certain as the parents were unpacking from the recent move. The convulsions > continued for at least 5 minutes, and recurred after appropriate initial > treatment. > > Past History: no medical or surgical history, no allergies, no medications. > > Social history is positive for a pregnant mother who is slightly overdue, > Just moved into a new house with a koi pond, but no plants besides grass, > and no known history of chemical usage in the hard or pond > > > >Is there anything interesting in the Family History > > Review of Systems: The node noted on the physical exam has been present > for a week, and child has an appointment with her (? new) pediatrician > already scheduled. > > Physical exam is positive for > > VS: Hypothermic at 95 F Rectal, o2: 90% room air > RR: 8, very shallow and erratic, no gag reflex > HR: 158, sinus arrhythmia, strong pulse > BP: 98/56 > > Mental status: she is not responsive enough to answer questions or follow > commands. Reaction to pain before RSI is NOT noted. > > HEENT: small abrasion on the chin, pupils are equal but very sluggish. > mucosa is NOT pale. Gag Reflex is absent > > > >What would be the effective Glasgow Coma Score of this patient? > > Neck: no nodes or obvious nuchal rigidity > > Chest and Abdomen findings are NOT reported. > > Extremities: a solid unilateral R inguinal/thigh node is noted. It is NOT > a buboe. > > Skin: aside from the abrasion, there are no rashes or bruising noted. No > evidence of arachnid bites or stings are noted. > > Neurologic: Babinski's reflex is normal. Deep tendon Reflexes are NOT > reported. > > Working evaluation: Obtunded patient with ongoing seizures and ventilatory > compromise, significant hypothermia. > > Treatment: Open Airway, apply oxygen, establish IV Access. IV ativan is > given, and the seizures stop for less than one minute before tremors which > progress to grand mal activity start. Core Body temp does NOT respond to > environmental temperature and aggressive warming > > >note: WHY are you hanging around to try to warm this patient? > > Repeat VS: > o2: 96% on 15 LPM NRB > RR: 6, very shallow and erratic, no gag reflex > HR: 164, sinus arrhythmia, strong pulse > BP: 94/52 > > >At this point, more aggressive ventilatory support should be started. > Question for the group: > a: name *at least* two reasons for the decrease in ventilatory effort? > b: name *at least* two methods for supporting ventilation? > > > Further Treatment: The patient is set up for RSI- the seizures stop for 'a > few minutes' under the influence of the paralytics. Phenobarbital is > loaded, but is no more effective than Benzos at terminating the seizures, as > they reported restart shortly after the loading drip is complete. > > >note: this is VERY unusual for seizures. question for the group: What is > the next step in the treatment of the seizures *besides* transport. > > Active methods to support ventilation is NOT specified. > > Transport issues: You have one ER without so much as a dedicated > pediatrician which is about 5-10 min northwest, and one which is a dedicated > children's hospital 30-40 minutes in the opposite direction. The two closest > flight teams are out on other calls, and consequently their ETA is worse than > yours. > > > >incidentally, this is a case where the patient needs a good EM doc, NOT > your run of the mill pediatrician! > > I agree, there is significant internal derangement of this patient. As Ms. > Wood has already noted that the diagnosis was difficult even in the ED, I > doubt anyone will guess correctly at this point. > > What is next? > > ck > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 12, 2011 Report Share Posted July 12, 2011 Family history has nothing remarkable; nothing like this and nothing that had an onset in childhood. GCS 7 or 8 when you first sedate her with benzodiazepines. No verbal response, eye opening to pain, withdraws to pain (tested by sternal rub). No notable chest or abdomen findings. Pt is RSI'd and has a phenobarbital drip. We're not hanging around trying to warm her, but as we have a couple of extra hands, we've wrapped her thoroughly en route. Pt is not hyponatremic. I'll give you another hint -- this is an act of God, not man. Though man can fix it. Alyssa Woods, NREMT-B > OK, let's see if I can sum up the current findings of the last 40 odd > messages. My comments are in line at >: > > Chief Complaint: New Onset Seizure > > History of Present Illness: 5 yo WF previously in good health, noted to > have major convulsions after playing outside on a hot afternoon. Onset is un > certain as the parents were unpacking from the recent move. The convulsions > continued for at least 5 minutes, and recurred after appropriate initial > treatment. > > Past History: no medical or surgical history, no allergies, no medications. > > Social history is positive for a pregnant mother who is slightly overdue, > Just moved into a new house with a koi pond, but no plants besides grass, > and no known history of chemical usage in the hard or pond > > > >Is there anything interesting in the Family History > > Review of Systems: The node noted on the physical exam has been present > for a week, and child has an appointment with her (? new) pediatrician > already scheduled. > > Physical exam is positive for > > VS: Hypothermic at 95 F Rectal, o2: 90% room air > RR: 8, very shallow and erratic, no gag reflex > HR: 158, sinus arrhythmia, strong pulse > BP: 98/56 > > Mental status: she is not responsive enough to answer questions or follow > commands. Reaction to pain before RSI is NOT noted. > > HEENT: small abrasion on the chin, pupils are equal but very sluggish. > mucosa is NOT pale. Gag Reflex is absent > > > >What would be the effective Glasgow Coma Score of this patient? > > Neck: no nodes or obvious nuchal rigidity > > Chest and Abdomen findings are NOT reported. > > Extremities: a solid unilateral R inguinal/thigh node is noted. It is NOT > a buboe. > > Skin: aside from the abrasion, there are no rashes or bruising noted. No > evidence of arachnid bites or stings are noted. > > Neurologic: Babinski's reflex is normal. Deep tendon Reflexes are NOT > reported. > > Working evaluation: Obtunded patient with ongoing seizures and ventilatory > compromise, significant hypothermia. > > Treatment: Open Airway, apply oxygen, establish IV Access. IV ativan is > given, and the seizures stop for less than one minute before tremors which > progress to grand mal activity start. Core Body temp does NOT respond to > environmental temperature and aggressive warming > > >note: WHY are you hanging around to try to warm this patient? > > Repeat VS: > o2: 96% on 15 LPM NRB > RR: 6, very shallow and erratic, no gag reflex > HR: 164, sinus arrhythmia, strong pulse > BP: 94/52 > > >At this point, more aggressive ventilatory support should be started. > Question for the group: > a: name *at least* two reasons for the decrease in ventilatory effort? > b: name *at least* two methods for supporting ventilation? > > > Further Treatment: The patient is set up for RSI- the seizures stop for 'a > few minutes' under the influence of the paralytics. Phenobarbital is > loaded, but is no more effective than Benzos at terminating the seizures, as > they reported restart shortly after the loading drip is complete. > > >note: this is VERY unusual for seizures. question for the group: What is > the next step in the treatment of the seizures *besides* transport. > > Active methods to support ventilation is NOT specified. > > Transport issues: You have one ER without so much as a dedicated > pediatrician which is about 5-10 min northwest, and one which is a dedicated > children's hospital 30-40 minutes in the opposite direction. The two closest > flight teams are out on other calls, and consequently their ETA is worse than > yours. > > > >incidentally, this is a case where the patient needs a good EM doc, NOT > your run of the mill pediatrician! > > I agree, there is significant internal derangement of this patient. As Ms. > Wood has already noted that the diagnosis was difficult even in the ED, I > doubt anyone will guess correctly at this point. > > What is next? > > ck > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 12, 2011 Report Share Posted July 12, 2011 I found this artical while researching this: http://www.acep.org/content.aspx?id=31418 Section 7 has the most info about this Sent from my iPhone you've got a pretty sophisticated set up if you can confirm sodium levels in the field. Also, sodium disturbances are vanishingly rare in children who are otherwise healthy, on no medications, and who have free access to food and water. leading to two follow up questions: First, what two electrolytes MIGHT you be able to guess are out of whack in the field, and what findings would lead you to suspect those derangements? Second: what medication has hyponatremia as the most classic idiopathic side effect? ck In a message dated 07/12/11 20:21:51 Central Daylight Time, jeremydriver@... writes: Hyponutremia? Sent from my iPhone OK, let's see if I can sum up the current findings of the last 40 odd messages. My comments are in line at >: Chief Complaint: New Onset Seizure History of Present Illness: 5 yo WF previously in good health, noted to have major convulsions after playing outside on a hot afternoon. Onset is un certain as the parents were unpacking from the recent move. The convulsions continued for at least 5 minutes, and recurred after appropriate initial treatment. Past History: no medical or surgical history, no allergies, no medications. Social history is positive for a pregnant mother who is slightly overdue, Just moved into a new house with a koi pond, but no plants besides grass, and no known history of chemical usage in the hard or pond >Is there anything interesting in the Family History Review of Systems: The node noted on the physical exam has been present for a week, and child has an appointment with her (? new) pediatrician already scheduled. Physical exam is positive for VS: Hypothermic at 95 F Rectal, o2: 90% room air RR: 8, very shallow and erratic, no gag reflex HR: 158, sinus arrhythmia, strong pulse BP: 98/56 Mental status: she is not responsive enough to answer questions or follow commands. Reaction to pain before RSI is NOT noted. HEENT: small abrasion on the chin, pupils are equal but very sluggish. mucosa is NOT pale. Gag Reflex is absent >What would be the effective Glasgow Coma Score of this patient? Neck: no nodes or obvious nuchal rigidity Chest and Abdomen findings are NOT reported. Extremities: a solid unilateral R inguinal/thigh node is noted. It is NOT a buboe. Skin: aside from the abrasion, there are no rashes or bruising noted. No evidence of arachnid bites or stings are noted. Neurologic: Babinski's reflex is normal. Deep tendon Reflexes are NOT reported. Working evaluation: Obtunded patient with ongoing seizures and ventilatory compromise, significant hypothermia. Treatment: Open Airway, apply oxygen, establish IV Access. IV ativan is given, and the seizures stop for less than one minute before tremors which progress to grand mal activity start. Core Body temp does NOT respond to environmental temperature and aggressive warming >note: WHY are you hanging around to try to warm this patient? Repeat VS: o2: 96% on 15 LPM NRB RR: 6, very shallow and erratic, no gag reflex HR: 164, sinus arrhythmia, strong pulse BP: 94/52 >At this point, more aggressive ventilatory support should be started. Question for the group: a: name *at least* two reasons for the decrease in ventilatory effort? b: name *at least* two methods for supporting ventilation? Further Treatment: The patient is set up for RSI- the seizures stop for 'a few minutes' under the influence of the paralytics. Phenobarbital is loaded, but is no more effective than Benzos at terminating the seizures, as they reported restart shortly after the loading drip is complete. >note: this is VERY unusual for seizures. question for the group: What is the next step in the treatment of the seizures *besides* transport. Active methods to support ventilation is NOT specified. Transport issues: You have one ER without so much as a dedicated pediatrician which is about 5-10 min northwest, and one which is a dedicated children's hospital 30-40 minutes in the opposite direction. The two closest flight teams are out on other calls, and consequently their ETA is worse than yours. >incidentally, this is a case where the patient needs a good EM doc, NOT your run of the mill pediatrician! I agree, there is significant internal derangement of this patient. As Ms. Wood has already noted that the diagnosis was difficult even in the ED, I doubt anyone will guess correctly at this point. What is next? ck Quote Link to comment Share on other sites More sharing options...
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