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You only live twice elsbecker

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You only live twice elsbecker

  1. 1. You Only Live Twice Steve Elsbecker D.O. 4/30/14
  2. 2. From UMC With Love • Interesting case from April 2nd 2014 • As with any great mystery, only the best detectives can solve the case
  3. 3. The Spy Who Stumped Me • 51 yo female BIBEMS after having a syncopal episode • From LVMH, per their report, weakness x 2 days, isolated syncope • No seizure-like activity per LVMH staff, did not strike head • EMS notes that she was bradycardic with a rate in the 30s-40s • Gave atropine, no response • Only records available are her L2K document and a med list • Olanzapine and Levothyroxine • Persistently altered since syncope,can’t answer any questions(moans)
  4. 4. The Spy Who Stumped Me • Pre Hospital Glucose 75 • Pre Hospital EKG
  5. 5. The Spy Who Stumped Me • IV, O2, Monitor….yada yada • HR 46 • RR 10 • BP 101/63 • SpO2 95% NRB • Temp (nurse “will get it soon”) • Patient is sick, moaning, no gross evidence of trauma, maybe seems post-ictal ?? • Maintaining airway, breathing slow, but sufficient, not hypotensive
  6. 6. The Spy Who Stumped Me • Physical • HEENT – NCAT, no echymoses or scalp hematoma, TMs clear, conjunctiva non- injected, no nystagmus, equal and reactive pupils (3mm2mm), nares patent, oropharynx very dry, mild periorbital edema • Neck – No JVD or bruit, placed in C Collar • Chest – CTAB, Regular rhythm, bradycardic, no MRG • Abdomen – Soft, ND, BS present • Skin – Normal color, dry, no ecchymosis, no rash • Extremities – Normal apprearance, no edema, normal pulses • Neuro – Drowsy but arouses with noxious stimuli, CNs unable to be tested thoroughly but no gross deficit, no gross motor or sensory deficit, no clonus, 1+ patellar reflexes, but slow
  7. 7. The Spy Who Stumped Me • Lets take a break and summarize • You have a very limited history • Temp 31.1C • CXR Slight LLL opacity, inflammatory vs infectious • What do you want to do next? (If you say “a CBC and a basic” you’re fired)
  8. 8. Quick Shot • When treating myxedema coma, the dose of levothyroxine is 200-500mcg IV
  9. 9. The Spy Who Stumped Me • Anything else? • Interventions • Labs • Imaging • Pericardiocentesis • Thoracotomy • IntraLipid • Lets get weird, its an interesting case
  10. 10. Doctor to Med 3, STAT Crit 7 Med 3
  11. 11. License To Ill • 43 yo male, started seizing 15 seconds before you walk in • EMS states they were called to his house by family who state he’s been having seizures all day • EMS noted an oozing lac to the back of his head, assumed it was from fall 2/2 seizure • Patient was non-verbal during their transfer and family members left the door unlocked and left prior to EMS arrival • Non verbal now
  12. 12. License To Ill • IV, O2, Monitor yada, yada… • HR 123 • RR 20 • BP 148/101 • SpO2 100% NRB • Temp 98.9 • Boarded and collared, seizing, obvious facial trauma, bloody gauze falling off back of head, no other external clues • Given 2mg Ativan IV, no break, 4mg Ativan IV, no break…
  13. 13. License To Ill • Induction: • Etomidate, Ketamine, Propofol, Versed, Ativan • Paralysis: • Succinylcholine, Rocuronium, Vecuronium • Sedation: • Propofol, Ativan, Versed, • Analgesia: • Fentanyl, Morphine, Dilaudid
  14. 14. License To Ill • Lets take a break and summarize • Even more limited history than last case • Re-eval vitals • What do you want to do now? • Interventions • Lab • Imaging • IntraLipid… • Define status epilepticus
  15. 15. Quick Shot • Define status epilepticus • Neuro Critical Care Society 2012 definition • Uninterupted seizure > 5 minutes or recurrent seizure activity without return to baseline
  16. 16. License To Ill Med 3 Crit 7
  17. 17. License To Ill • Wheeling patient to CT, you run into the patient’s family • They state that 24 hours prior he came home drunk from a bar, beat up • He had about 5 seizures throughout the day but did have a history of seizures • PMHx: Diverticulitis, “some liver problem” • PSHx: Unknown • Meds: Unknown • All: Unknown • SocHx: smoker, heavy daily drinker
  18. 18. License To Ill
  19. 19. License To Ill • Nuerosurgery on the way in • Trauma / TICU at bedside • Anything else you want to do?
  20. 20. The Spy Who Stumped Me • Re-eval of the bradycardic, hypothermic, hypotensive patient • Improved temp – 36C • HR 40s – 50s • BP 90s / 40s • Labs and Imaging pending • Interventions??
  21. 21. Quick Shot • Pacing • Variables • Mode • Sync vs Async • Rate • 60-70 • Amperage / Current • Average of 65 – 100 miliamperes (MA) for capture in adults
  22. 22. The Spy Who Stumped Me • IV Levothyroxine – FAIL • Solu-Cortef – FAIL • External Warming - FAIL • Warm Saline – FAIL • Transcutaneous Pacing – FAIL • Where are my labs ?!?!
  23. 23. The Spy Who Stumped Me • CBC – Normal • CMP – BUN 30, Cr 2.0 otherwise normal • Lactate – 1.3 • CT Brain and C Spine – Normal • TSH – 212.0 • T3 – Undetectable • T4 – Undetectable
  24. 24. The Spy Who Stumped Me • Given another 200mcg Levothyroxine • Admitted to ICU • Waking up with improving mental status prior to transfer to MICU
  25. 25. The Spy Who Stumped Me / License To Ill • Take Home Points • IV dose of Levothyroxine 200 – 500mcg for myxedema coma • Consider broad differential for persistent bradycardia • Sepsis, MI, AV block, Lyme, Thyroid Dz, Sick Sinus, Hypoxia • Pacing : Asynchronous vs Sync, average amperage required is 65-100 mA • Definition of status epilepticus = Uninterupted seizure > 5 minutes or recurrent seizure activity without return to baseline
  26. 26. References • Beran RG. An alternative perspective on the management of status epilepticus. Epilepsy Behav. 2008;12(3):349–53. • Seif-Eddeine H, Treiman DM. Problems and controversies in status epilepticus: a review and recommendations. Expert Rev Neurother. 2011;11(12):1747–58. • Rossetti AO, Lowenstein DH. Management of refractory status epilepticus in adults: still more questions than answers. Lancet Neurol. 2011;10(10):922–30. • Bledsole, B., Porter, R., and Cherry, R. "Paramedic Care: Principles & Practice: Volume 3". Third Edition, Pearson, 2009
  27. 27. UNTIL BOND’S NEXT ADVENTURE…

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