EM Forum Case #109 "A Lethal Status"
by Charlene Babcock Irvin, MD, FACEP  

A 52 y/o woman is brought in from home with altered mental status. Although her husband was able to get her to the car, she is unconscious now and is lifted from the car to a cot and brought immediately to the resuscitation suite.

My usual orders (one sentence) for sick people (six things all sick people get): “IV, oxygen, monitor, undress the patient, get me a set of vital signs, and draw some blood!” When I get to blood I always ask myself what do I need right now….

As the staff is doing this, I quickly perform an ABC evaluation. Patient clearly has facial seizure activity, and gurgling secretions in mouth with grunting respirations. Airway is suctioned (missing teeth allow this with her mouth shut tight from the seizure) and no gag is noted. She does have dark blood suctioned from her mouth. She has bounding pulses, and equal breath sounds. Extremities are tonic. No rashes or obvious abnormality besides the seizure.

2 mg of Lorazepam IV is ordered.

Her husband is at the bedside. Quick questions reveal she has likely been seizing for over one hour (He didn’t know she was seizing, just that she was gurgling a lot and breathing funny when he went to check her about one hour ago.) She had been feeling sick, and was very tired all day yesterday with multiple episodes of vomiting. She was also complaining of a stomachache. They both thought she had the stomach flu. She slept on the couch because of her vomiting during the night, and he got up about one hour ago and noted she was breathing loud. She wouldn’t wake up. Finally, after an hour of trying to wake her, he called his neighbor to help put her in the car to bring to the ED.

He now wants to know if it could be related to a new BP medication (Hydrochlorothiazide), which was added to Norvasc about one week ago. He denied her taking any extra. I told him I doubted it as neither of those medications are associated with seizures.

PMH: Only HTN per husband. No other significant hospitalizations or surgeries.

SH: Past smoker, social drinker.

ROS: Nausea and vomiting for last two days. Abdominal pain for the same time. No hemetemesis, coffee ground emesis, melena. No fevers, no cough. No complaints to him regarding bowel or bladder problems.

The 2 mg of Lorazepam does not stop the seizure activity.

Questions:

1. What is the first blood test to order?

2. Although nothing has even been sent, what is one diagnosis that you know she has?

3. What do you need to do to manage her?

 

Click here for answers and to respond