You Only Live TwiceSteve Elsbecker D.O.

4/30/14

From UMC With Love

• Interesting case from April 2nd 2014• As with any great mystery, only the best detectives can solve the case

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)

The Spy Who Stumped Me

• Pre Hospital Glucose 75• Pre Hospital EKG

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

The Spy Who Stumped Me

• Physical• HEENT – NCAT, no echymoses or scalp hematoma, TMs clear, conjunctiva non-

injected, no nystagmus, equal and reactive pupils (3mm2mm), 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

The Spy Who Stumped Me

• Lets take a break and summarize

• You have a very limited history

• Temp 31.1C

• CXR Slight LLL opacity, inflammatoryvs infectious

• What do you want to do next?(If you say “a CBC and a basic”you’re fired)

Quick Shot

• When treating myxedema coma, the dose of levothyroxine is 200-500mcg IV

The Spy Who Stumped Me

• Anything else?• Interventions• Labs• Imaging• Pericardiocentesis• Thoracotomy• IntraLipid

• Lets get weird, its an interesting case

Doctor to Med 3, STAT

Crit 7 Med 3

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

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…

License To Ill

• Induction:• Etomidate, Ketamine, Propofol, Versed, Ativan

• Paralysis:• Succinylcholine, Rocuronium, Vecuronium

• Sedation:• Propofol, Ativan, Versed,

• Analgesia:• Fentanyl, Morphine, Dilaudid

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

Quick Shot

• Define status epilepticus• Neuro Critical Care Society 2012 definition

• Uninterupted seizure > 5 minutes or recurrent seizure activity without return to baseline

License To Ill

Med 3 Crit 7

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

License To Ill

License To Ill

• Nuerosurgery on the way in• Trauma / TICU at bedside

• Anything else you want to do?

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??

Quick Shot

• Pacing• Variables

• Mode• Sync vs Async

• Rate• 60-70

• Amperage / Current• Average of 65 – 100miliamperes (MA) for capture in adults

The Spy Who Stumped Me

• IV Levothyroxine – FAIL• Solu-Cortef – FAIL• External Warming - FAIL• Warm Saline – FAIL• Transcutaneous Pacing – FAIL

• Where are my labs ?!?!

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

The Spy Who Stumped Me

• Given another 200mcg Levothyroxine• Admitted to ICU• Waking up with improving mental status prior to transfer to MICU

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

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

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