Bongy's Quiz No.4 Re-Assesment

[Bongy]

My dear colleagues!
Here is another case for your kind attention
Call received - 22:30(Just before you finish your shift)
Male,Unknown y/o,in a middle of the street,just fell down... Non responding...
You arrive 12 min later:
Appearance - male,look like 40-45 y/o,laying in the middle of the central bus station...Red sores in a both arms...
No response for voice,decerebration arm movement...
RR-20,Normal lung sounds,Pulse Ox 97%,HR100-120,Atrial Fibrillation,Multiply VPB's BP - 140/70,Glucose - 120,no medical history available.
After loading to the truck - start to move to the hospital with O2 via mask and NaCl 0.9% in slow drip... Airway inserted... After 10 min of transportation - just in the entrance to ER - Sudden cianocys,tonic-clonic convulsion....
So... What happened first,and what happened next...
Go Ahead!!

 

[RedZone]

Can you describe the sores a little? Is it like recent skin abrasions, or some sort of weeping wound?

Also, what do you mean by multiply VPB?

 

[KEVD18]

who cares. your at the hospital.

j/k

any other ill/injured parties from the same scene?

usual stuff o2 iv monitor, check a sugar, rapid trans. tx findings enroute

 

[RedZone]

who cares. your at the hospital.

j/k

Actually my very first thought as well.

He's not asking for treatment though. O2, IV, monitor, sugar are already done before the seizure. Since we have access.. preferred tx is Lorazepam 2 mg IVP.

He's asking for your presumptive dx here. I'll play a little:

any other ill/injured parties from the same scene?

I have Same Question.

Summary: Unknown Male in 40's, post-ictal phase of stat-ep on arrival, convulsions upon ED presentation. He is not hypoglycemic.

Assuming those sores on his arms are abrasions, I'd stick with epilepsy.

Vitals not indicative of increased intracranial pressure. Unless they changed en-route. If, on ED presentation, BP was higher, HR was lower, and maybe even some erratic respirations going on... then I'd go with head trauma or hemorrhagic CVA.

Otherwise... I'd say maybe those sores are indicative of an infection or even a route of toxic exposure. What are the venemous creatures inhabiting the area?

 

[Guardian]

Looks like we got a maladaptive urban sportsman who passed out secondary to inebriation and bumped his arms. Now he’s having a seizure because of his unregulated medical condition known as epilepsy.

Ok, just kidding…that’s what it would be where I work but I’m going to assume there is more to this one. So, is he a “normal looking person” or a homeless man ie has he been drinking? What do his pupils look like? My initial thoughts…either epilepsy, alcoholism, drugs, cva, or head injury.

 

[Bongy]

Ok... Some answers:
1. Sores look like... Sunburns... Very clear shape... Same size in both hands.
2.Man dressed as a construction worker - blue overall,metal protected boots
3.Multiply VPB's - in about every 4-5 sec - UNIFOCAL
4.No other injured around
5.Witnesses said that he looks like working on something before collapse.(toolbox found next to him)
Now about a being already in the hospital - the reason for convulsion ALMOST cause me to look like an idiot...:wacko:So..Any ideas?

 

[eggshen]

Electrical injury.....I would send him to detox.

Egg

 

[RedZone]

Electrical injury.....I would send him to detox.

Egg

Good one. I was going to ask what his skin temp/moisture was thinking maybe heat related injury... but I was still thrown off by the sores...

Now I agree with egg!

Electrocution..... detox it is.

 

[Bongy]

Egg and RedZone! Great! It was an electrical injury... In about 2000 volts!!... Now.. Why detox???!!! And try to guess what happened next? Sezures are NOT common complication of electrical injury... So what do you thing? I can give you a clue - in general - it was my missattention...

 

[eggshen]

Hypoxia I say.

 

[Guardian]

Egg and RedZone! Great! It was an electrical injury... In about 2000 volts!!... Now.. Why detox???!!! And try to guess what happened next? Sezures are NOT common complication of electrical injury... So what do you thing? I can give you a clue - in general - it was my missattention...

wow, that is surprising. I not sure what happened next but I'm eager to find out.

 

[Bongy]

Well... So let's make a conclusion and some learning features... At first,CNS abnormalities (like coma) are NOT common in high voltage AC electrical injures,so I should pay attention to this,but it somehow lost from my memory. I saw cardiac disturbances that common but wasn't life threating. In ADDITION most common complication is myoglobinemia that very fast can cause BRAIN EDEMA,especially when fluid given in large amount. I gave fluids - but without diuretics as needed and brain edema that starts to develop just after an injury,cause a seizures in an entrance to ED... So,FYI... In case of CNS disturbances due to electrical injury fluids SHOULD be given but with proper caution... Better with osmotic diuretic..(loop diuretic like furosemid(lasix) can be also used but with less effect.
BTW - In case that pt awake with no CNS troubles - give fluids - myoglobin HAS to be "washed" as soon as possible...Another point - if it was a DC injury - brain damage should be considered at a scene.
Bottom line - guy is alive an become awake after 24 hours in ICU... Mild HF due to myocardial damage,now lives normal life.