21 yo male with seizure

[pbruss]

no multiple choice for this one. have shared with some of you in the ER so dont give it away.

21 yo male arives by EMS for a seizure. no history of seizures, had whitnesses 5 min tonic clonioc seizure while at Lowes. resolved by time EMS arives. they gave him no meds. on arival he is altered but not consistent with a post ictal state. he open his eyes to pain only moans and will move all 4 exts to pain and will not follow commands. full history and ROS is unobtainable.

PE - hr 160, bp 160/95, r 20, temp 98.6

general- ass above but is very warm to the touch.
cv - tachy but no MRG
lungs- tachynepic but CTA bilat
ABD - normal
EXTs - no CCE, no rash, no signs of trauma.

you decide to intubate, you have no labs or imaging. he gets more tachycardic. intubation is normal. while trying to figure out what is goin on EMS hand you a EKG that they did.

based on the limited histoyr, the exam and the EKG, what emergent meication is indicated ?

Attachments:

ekg.bmp (892.74 KB)

[kemple]

Well being as there is 1 medication to give, and there are EKG changes...I'm going with NaHCO3-. TCA Overdose? I say that because there doesn't appear to be hyperkalemia as not all T's are peaked and even then I don't have widening of the P, or lengthening of the PRI to suggest patient is having episodes of VTach causing his seizures. He is tachycardic with AMS but not post ictal which fits the anticholinergic effects of TCA overdose. Has a terminal R > 3mm in Lead AvR, and deep S in I and II but not as "slurred" as they call it (I looked that one up).

[jeanpaul1]

Kemple might be right on! But that will make the case too straight forward.

I am going to be a cowboy and go with Esmolol drip!
I am wandering if this patient is having some sort of catecholamine surge from potentially hydrocarbon poisoning from huffing. They usually present with tachyarrythmias usually V tach. They are much sicker and usually code. Tx is usually B blocker.

I am not sold on that EKG as that classic TCA overdose. I don't see that widened QRS or prolonged QT.

[kemple]

Out of curiosity how chocolate was (or wasn't) the blood when drawn?

[pbruss]

Blood not chocolate but I was looking for Bicarb. with his presentation and the large R wave in AVR greater the the S wave and the right axis very indicicative of an overdose on something that affects the sodium channels. we ended up pushing 5 amps of bicarb to get his ekg back to normal and put him on a bicarb drip.  turms out for him it was cocaine. i attached 2 more ekgs the first one was after the first dose of bicarb the secone one is 2 hours later on the bicarb drip.

here is some stuff for "The Fast Lane" for your review


The ECG is a vital tool in the prompt diagnosis of poisoning with sodium-channel blocking medications such as:



Tricyclic antidepressants (= most common)

Type Ia antiarrhythmics (quinidine, procainamide)

Type Ic antiarrhythmics (flecainide, encainide)

Local anaesthetics (bupivacaine, ropivacaine)

Antimalarials (chloroquine, hydroxychloroquine)

Dextropropoxyphene

Propranolol

Carbamazepine

Quinine

The two main adverse effects of sodium-channel blocker poisoning are seizures and ventricular dysrhythmias (due to blockade of sodium channels in the CNS and myocardium)

Electrocardiographic Features of Sodium-Channel Blockade

Features consistent with sodium-channel blockade are:


Interventricular conduction delay – QRS > 100 ms in lead II

Right axis deviation of the terminal QRS:

Terminal R wave > 3 mm in aVR

R/S ratio > 0.7 in aVR

The degree of QRS broadening on the ECG is correlated with adverse events:



QRS > 100 ms is predictive of seizures

QRS > 160 ms is predictive of ventricular arrhythmias (e.g. VT)

Patients need to be managed in a monitored area equipped for airway management and resuscitation.

Secure IV access, adminster high flow oxygen and attach monitoring equipment.

Administer IV sodium bicarbonate 100 mEq (1-2 mEq / kg); repeat every few minutes until BP improves and QRS complexes begin to narrow.

Intubate as soon as possible.

Hyperventilate to maintain a pH of 7.50 – 7.55.

Once the airway is secure, place a nasogastric tube and give 50g (1g/kg) of activated charcoal.

Treat seizures with IV benzodiazepines (e.g. diazepam 5-10mg).

Treat hypotension with a crystalloid bolus (10-20 mL/kg). If this is unsuccessful in restoring BP then consider starting vasopressors (e.g. noradrenaline infusion).

If arrhythmias occur, the first step is to give more sodium bicarbonate. Lidocaine (1.5mg/kg) IV is a third-line agent (after bicarbonate and hyperventilation) once pH is > 7.5.

Avoid Ia (procainamide) and Ic (flecainide) antiarrhythmics, beta-blockers and amiodarone as they may worsen hypotension and conduction abnormalities.

Admit the patient to the intensive care unit for ongoing management.

Attachments:

bicarb1ekg.TIF (475.72 KB)

bicarb2ekg.TIF (283.3 KB)