Not sure what happened to this one...

[NYMedic828]

78 female came in as unconscious called by son.

Patient was feeling fine and was about to take a bath. Son heard her collapse and went into bathroom to find her on floor with vomitus in the tub and she defecated.

Firefighters moved her to the living room before we go there.

Upon contact she responds only to pain and her skin was EXTREMELY hot. Probably the hottest I ever felt. Moist as well but I wouldn't say diaphoretic.

BP - 172/104
HR - 154
BGL - 115
RR - 20
Pupils - normal
Sat - 92% room air
3/12 ECG - textbook SVT @ 154 no ectopy.

Only history diabetes, HTN, HLD. Compliant with meds.

We start a peripheral line. She starts talking. Sometimes normal sometimes almost CVA like. Stays this way throughout transport.

Get to ER, temperature is 98.6 degrees, HR dropped to 104, BP 140/80


Totally lost as to what her deal was. We thought maybe a seizure or bleed but nothing explains her extremely hot to the touch temp. I swear you could of scrambled an egg on her head. Hypothalmic issues?

 

[VFlutter]

Was she filling the bathtub with hot water or was it empty? Decficated in the toilet or on herself? Description of the stool/vomit? Any noticeable head trauma? Current meds? Was the unresponsive period postictal?

The skin temp is interesting. At first I thought typical "fall down and get a boo-boo while taking a poo-poo" (Vasovagal syncope) with the SVT/Bp being a compensatory response but it sounds more complicated.

 

[NYMedic828]

Was she filling the bathtub with hot water or was it empty? Decficated in the toilet or on herself? Description of the stool/vomit? Any noticeable head trauma? Current meds? Was the unresponsive period postictal?

The skin temp is interesting. At first I thought typical "fall down and get a boo-boo while taking a poo-poo" (Vasovagal syncope) with the SVT/Bp being a compensatory response but it sounds more complicated.

We considered all the above but I've never seen such a strange rapid deviation in temperature which is why we thought maybe something more complex affecting the hypothalmus or something.

The thought of seizure was high on the list with her progression to higher mentation over time.

I think she was about to get into the bath tub and collapsed. Not on the toilet. The son was not a great historian but the patient was otherwise dry excluding sweat.

 

[VFlutter]

So she never actually got into the water? I was thinking like "hot tub" syncope when a rapid change in temp causes vasodilation. I suppose stream from extremely hot bath water could have a similar effect, like a sauna.

 

[NYMedic828]

So she never actually got into the water? I was thinking like "hot tub" syncope when a rapid change in temp causes vasodilation. I suppose stream from extremely hot bath water could have a similar effect, like a sauna.

Must be some kind of hot...tub...time machine.


The temperature thing is just so strange.

It was a bath I don't think there would be any substantial steam condition.

 

[VFlutter]

The temperature thing is just so strange.

Maybe she shot up some bath salts :huh:

 

[PaddyWagon]

A guess from out of the blue; TIA affecting the brain stem, per a CVA article this scenario prompted me to read:

If the stroke affects blood circulation in the brain stem, the regulation of temperature, blood pressure, and breathing may be affected since the brainstem controls these functions.

 

[mycrofft]

Brainstem sounds promising, but how about her thyroid? Does she take any meds, such as Synthroid (levothyroxine), a thyroid history?

 

[Aidey]

I've seen a few brain stem strokes and there was nothing transient about the symptoms. They were also significantly impaired and had a lot more going on than feeling hot.

 

[NYMedic828]

Brainstem sounds promising, but how about her thyroid? Does she take any meds, such as Synthroid (levothyroxine), a thyroid history?

She took a few meds but none of them looked familiar for thyroid. The son only reported HTN and DM but she had more meds than that. I forget with it being a few days later now.

We felt so stupid when we got into the ER and her temperature was 98.5... My parter, my boss on scene and myself all took a guess at the number thinking she would be 103.5-104.5 degrees.

And the ECG doesn't lie, she was in SVT at 160 whatever the cause may be. Obviously we didn't presume that to be treatable and thought it was a reflex tachycardia. That was 104 when we entered the ER.

She started talking fully in the ER as well and was mumbling answers to us on and off on the way like her social security number. I feel like the only thing that could cause that is an ischemia TIA affecting the diencephalon region or a being postictal but no one witnessed a seizure. I presume a thyroid disorder can also result in seizure so who knows.

I presume the thyroid being overactive would increase body temp through an overall increase in metabolism? I have never had a thyroid related emergency (that I know of).

I also forgot to get her chart number so I can't follow it up.

 

[PaddyWagon]

Long shot, maybe a new/weakening aneurysm bulging under the combined effects of the higher BP and leaning over for the bath, which would then un-bulge when the BP lowers.

Maybe some other "supplement" that people don't think of as "is she taking any medicines?"

Out of my depth now =)