I while back, I had an interesting call. This is the first part of two posts… Read the call below and see what diagnosis you come up with.
You were watching Emergency a tv series from the 1970s when the phone rang. Your partner went to pick up the phone as you turned off the tv and lugged yourself off the couch.
Partner: “We got a Code 3 for a seizure.”
So off you went, lights and sirens to the call. When you got there, you found an elderly gentleman on a chair, he looked rather flaccid and pale.
You: “Hi, what happened?”
Friend: “Well, we were having a meeting and he suddenly passed out on the ground and was having a seizure…”
You: “Can you describe the seizure to me?”
The patient’s friend imitated jerking movements of the whole body including the tonic-clonic and hypertonic phases. You find out the patient has been complaining of tremors in the right arm for the past several weeks (is new), has never had a seizure before, and had no recent falls. He did however have a stroke in the past. As for medications, he’s taking rabeprazole and plavix.
You: “Hi sir, do you know where you are?”
He can’t answer you properly and is confused…he appears postictal. You decide to get a quick set of vitals while your partner goes to get the stairchair.
- BP: 94/60
- HR: 118
- RR: 24
- SpO2: 97%
- Skin: Pale, cool, diaphoretic
- Temp: 37°C
- Pupils: PERL 3mm
- BG: 5.6 mmol/L
When you get him into the ambulance, you tell your partner to drive Code 3 and you place a nasal cannula on your pt at 4Lpm. Suddenly your patient starts to vomit without warning (he continued to vomit without warning throughout the trip to the hospital). The vomit is clear fluids with a tinge of yellow, no blood.
You notify the hospital then you do a quick neuro exam and found the following:
- Equal grip strength
- No arm drift
- Patient still confused and needs encouragement to respond to commands GCS 13 (4,4,5)
- Patient can look to the right, but needs encouragement and with difficulty can look to the left, cannot look up or down
- Patient has slightly droopy smile
You start a line of normal saline running at TKO en route to the hospital.
By the time you arrive at the hospital you had the patient in a gown and you are sweating like mad. You roll your patient into the trauma bay as a nurse greets you. You give her your hand off report as she comments how it’s so lovely that you got your patient in a gown! As you leave the hospital, you have a diagnosis in mind and look forward to following up with the doctor later to see if you were right.
Feel free to write your differential diagnosis in the comments section. What’s Your Differential Diagnosis Part II will reveal what the diagnosis is and the clues to coming to that conclusion based on information from this post.
My Paramedic Blog 
Hey M,
Someone who has a decrease in level of consciousness, repeated vomiting, and a recent seizure are all signs of diffuse injury to the CNS like from an increase in intracranial pressure from a bleed, tumor, or an abscess or infection. In an elderly person this makes you worry about a bleed in the brain like a subdural hematoma, and you would want to ask about any history of recent falls, although many of them can be spontaneous. The history of stroke puts the affected territory at risk of bleeding as well. The history of stroke also means you have to worry about a new CVA, and he does have what you call ‘lateralizing’ signs and symptoms like a droopy smile and some sort of problem with gaze (although that could be explained by a bleed too). With a history of tremor you do want to worry about injury to the midbrain either from a stroke, infection/abscess, tumor, or a degenerative disease like Parkinson’s or Huntington’s. Lastly, any oldsters who comes in with decrease in consciousness should have the simple stuff done like a blood sugar check, electrolytes, blood count, thyroid level, drug+alcohol screen, BUN/creatinine (for kidney function), liver function tests, ECG, troponin (in case he’s had a heart attack), and consider urine,blood,sputum cultures for infections.
Anyway, long story short I put my bet on a bleed in the brain, or a new stroke. He needs a CT scan of his head for sure! So what’s the diagnosis? Hopefully I’m not way off… 🙂
Lol woops i forgot to write in the bg for the vitals I’ll fix the post but bg came back as 5.6.
Good answers of course!! And no recent falls…. Guess you have to wait for the next post for the answers 😉
M
I absolutely LOVE this post. It has been driving me nuts in the last 24 hours.
So…
Hx of stroke puts this patient at a very high risk for another CVA. Eye movement deficits points to pressure on the Oculomotor nerve, which could be anything from a bleed to a tumor.
From the set of VS, he seems to be hypotensive (94/60 is QUITE low for an elderly gentleman, assuming he is not on meds for hypertension). He is a bit tachy, which could mean he’s compensating. This makes me think he is bleeding somewhere.
Plavix is an antiplatelet med that puts this patient at a pretty high risk for hemorrage as well.
Things I would like to know:
– Hx of TACOS = Tobacco, Alcohol, Caffeine, Over-the-counter, Street drugs. Probably impossible to get if the GCS was 13 al throughout the call and there was no significant others to provide it.
– More detail on the vomiting – you describe it as “clear fluids with a tinge of yellow”. That doesn’t sound like normal vomitus to me. If the vomit was clear because the stomach was empty, and the BG was 5.6 mmol/L, it could mean that the pt. has been vomiting prior to the seizure.
– Timeline on the onset of symptoms.
My DD:
Cerebral aneurysm, or intracerebral hemorrage (stroke).
This, to me, fits the Hx of stroke, the risks associated with Plavix, the VS (slightly shocky), and the neuro deficits caused by pressure to the brainstem and the Oculomotor cranial nerve.
I love these replies! Haha I’m glad I was successful at driving you crazy 😛
In terms of TACOS…wasn’t able to obtain that information. Pt was not vomiting prior to the seizure from bystander information…I’ve seen a lot of yellow tinged vomitus, either from food they’ve eaten before, or drinking apple juice, etc…nothing that pointed at anything abnormal so far from experience. As for onset, it started shortly after they called….so approx 10min ago.
Good thoughts. I’ve seen a few patients on plavix and blood thinners who had traumatic subarachnoid bleeds as well which is something to consider in addition to subdural and epidural bleeds (although subdural is most common in elderly). Also if someone has signs and symptoms of shock, this would not be from a bleed in the brain, as there is no room in the skull for that amount of blood loss to occur. Instead you get an increase in pressure which causes the nausea, vomiting, seizures that this patient is having. When the pressure gets high enough, it can cause the brain to physically herniate out of the skull through the hole at the bottom, which causes instant death. A common spot for this herniation is around the uncus of the brain, which compresses the oculomotor nerve. Oculomotor nerve damage usually causes the eye on the same side to be deviated down and out, and causes the pupil to dilate widely, which doesn’t fit with this patient’s presentation.
As for the blood pressure and heart rate, if it is shock, then this guy might have a bleed going on somewhere else in the body. If he fell from a stroke he may have broke his pelvis or another bone leading to bloodloss and shock. Usually when someone has both a bleed in the brain AND bleeding somewhere else leading to shock, the prognosis is really bad because the brain’s perfusion is attacked from multiple angles. I hope he turned out okay! Very interesting case. 🙂
yeah…..what Eze said! We discussed it when I saw him on Sunday. I can’t really argue with him on any points.
Todd’s paresis secondary to his seizure. Should resolve within 48 hours….. 🙂