Differential Dx & Tx for seizure-like activity (scenario)

Qulevrius

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You respond to a call coming from a b&c/sober living facility. The pt is a 20 y.o. male who, per facility, has had seizure episodes in the past. A resident chart is N/A and the only medication the manager can remember is Keppra. The pt is found full Fowlers in his room, per facility has seized approx 10 min prior to your arrival, and is A+Ox1 but ambulatory with assistance. Vitals are 126/72, 106, 16, 98% on room air, normal skin signs, clear sclera x2 and PERRL. Once in the rig, pt goes into a stupor, starts drooling and, 30 sec into transport, seizes with full body rigor but non-synchronized, audible moaning, oral + nasal secretions, lateral head pull at nearly 90 deg. HR shoots up to 140+, tachypnea @ 40+, pupils are pinpoint @ 2mm and pink sclera x2. The ER is 10 min away.

What would be your differential diagnosis and treatment for this patient ?
 

VentMonkey

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What would be your differential diagnosis and treatment for this patient ?
R/O ICH. The ED is only 10 minutes away, so suction and protect the airway, keep HOB at 30-45 degrees, BGL, a lock, and have the benzo’s at the ready should another seizure ensue.

The sober living facility may increase my index of suspicion for past drug use (i.e., meth and/or speedballs), but aside from that there isn’t much else I would care to do, or know. He may simply be experiencing breakthrough seizures and need an adjustment on his Keppra, or a different seizure medication altogether.
 

VFlutter

Flight Nurse
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Hyponatremia, DT's, or withdrawal from Benzos or whatever illict drug they were addicted to contributing to their underlying seizure disorder.
 

EpiEMS

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Once in the rig, pt goes into a stupor, starts drooling and, 30 sec into transport,
I hope you kept the gift receipt. Hey, nurse? Yeah, I don't want him anymore.

What would be your differential diagnosis and treatment for this patient ?
BGL?

DDx:

1) Withdrawal-related...something
2) Needs a medication adjustment for his (longstanding?) seizure disorder
3) Trauma? Just throwing it out there, can't really rule it out
 
OP
Q

Qulevrius

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Thanks all for your input. On this call, I had very little say in terms of tx because it was an OCFA run. What threw me off, however, was the seizure presentation; there was no posturing, no teeth clenching and the convulsions were arrhythmic. Plus the pinpoint pupils which I specifically mentioned during a follow up assessment, and the medic ignored. I was also being able to calm the pt down during the 1st sz, which is very uncharacteristic. The medic decided not to suction (I already had the kit out), instead opting for Verced IM (pt got immediately knocked out) and BGL was 96, taken virtually in the ER bay. The medic’s DDx was pseudo seizures, my DDx was OD. ER doc agreed that it was OD, I did not have a chance to follow up.
 

VentMonkey

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I honestly thought you had some unheard of differential laid out since this thread was opened under the “Advanced Medical Discussions” subforum:).

I’m surprised no one else thought to throw out EPS as a differential. Completely not unheard of with the sober living crowds to over medicate themselves on what ever antipsychotic they may be consuming.

Also, I doubt the OCFA “medic” would have even thought twice himself, let alone recalled the reversal agent he may, or may not have learned in “paramedic school” at Saddleback College.
 

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