2. From UMC With Love
• Interesting case from April 2nd 2014
• As with any great mystery, only the best detectives can solve the case
3. 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)
4. The Spy Who Stumped Me
• Pre Hospital Glucose 75
• Pre Hospital EKG
5. 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
6. 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
7. The Spy Who Stumped Me
• Lets take a break and summarize
• You have a very limited history
• Temp 31.1C
• CXR Slight LLL opacity, inflammatory
vs infectious
• What do you want to do next?
(If you say “a CBC and a basic”
you’re fired)
8. Quick Shot
• When treating myxedema coma,
the dose of levothyroxine is
200-500mcg IV
9. The Spy Who Stumped Me
• Anything else?
• Interventions
• Labs
• Imaging
• Pericardiocentesis
• Thoracotomy
• IntraLipid
• Lets get weird, its an interesting case
11. 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
12. 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…
14. 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
15. Quick Shot
• Define status epilepticus
• Neuro Critical Care Society 2012 definition
• Uninterupted seizure > 5 minutes
or recurrent seizure activity without
return to baseline
17. 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
19. License To Ill
• Nuerosurgery on the way in
• Trauma / TICU at bedside
• Anything else you want to do?
20. 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??
21. Quick Shot
• Pacing
• Variables
• Mode
• Sync vs Async
• Rate
• 60-70
• Amperage / Current
• Average of 65 – 100
miliamperes (MA) for
capture in adults
22. The Spy Who Stumped Me
• IV Levothyroxine – FAIL
• Solu-Cortef – FAIL
• External Warming - FAIL
• Warm Saline – FAIL
• Transcutaneous Pacing – FAIL
• Where are my labs ?!?!
23. 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
24. The Spy Who Stumped Me
• Given another 200mcg Levothyroxine
• Admitted to ICU
• Waking up with improving mental status prior to transfer to MICU
25. 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
26. 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
