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Case Number :  2 Chief Complaint : 37 y/o female with status epilepticus Presented by :  Phil Seidenberg
History of Present Illness 37 y/o female brought into the resuscitation room in the early am in status epilepticus.  According to the sister who is accompanying her, the patient has no previous history of seizure disorder but does have a history of significant alcohol dependence although no history of withdrawal seizures.  The sister also states that the patient occasionally smokes crack cocaine.  The sister denies any other history of medical problems.  According to the sister, the patient was last seen drinking alcohol with the family around midnight the night before.  She states that the patient hadn’t reported any recent headaches, fevers, neurologic abnormalities, vision changes, or other problems.  The sister had arrived at 0800 to find the patient still in bed.  Her eyes were wide open but the patient was unresponsive.  Within 2 minutes the sister witnessed a five minute generalized tonic-clonic seizure with drooling and no color changes.  The pt was found to have urinated on herself.  The seizure ended but was immediately followed by another tonic-clonic seizure lasting approx. 15 minutes.  At that stage the sister called EMS. As per EMS reports the patient was unresponsive, tachy to 140s, tachypic to 40s with O2 sat in low 90s upon arrival, BP 130/80 and no temperature taken.  An IV was established and pt was taken to the ER. Upon arrival in the ER the pt was obtunded, afebrile @ 36.7, with continued tachycardia.  A generalized tonic/clonic seizure was witnessed in the ER and lasted for 1 minute.  The pt was given 3 mg Ativan, CBG was taken and was 130, and the patient placed on oxygen.  An oral airway was attempted but the pt spit it out.  A nasal trumpet was then placed without complications.  1.5 gm fosphenytoin was given and a second IV established. Meds- unknown All- unknown PMH- previous c-section, depression FH- no hx of neulogic abnormalities
Physical Exam Vitals T 36.7 BP 130/80 HR 130s RR 40 O2 Sat 89%RA, 96% on FM Gen Pt open eyes, obtunded with gag reflex, GCS-6 HEENT NC/AT, no signs trauma Ears TMs-no hemotympanum bilat Eyes- proptotic, pupils- 5 mm bil, minimally reactive, unable to eval EOM Oral- mucosa dry, small tongue abrasion Neck- no JVD, no lan CV- RR, tachy, nl S1S2, no murmurs Lungs- slight upper airway noises, no rales/wheezing/rhonchi Abd- Soft, ND, no hepatomegaly, decreased BS Rectal- minimal tone, guiaiac neg Ext- no evidence of trauma Skin- diaphoretic, warm, no rashes/erythema/trackmarks Neuro- hyperreflexive DTRs bilat, non-extinguishing beats of clonus bilaterally
Head CT- nl, slight volume loss for age	Chest X-ray- ET-tube in place close to the carina, NG-placed in stomach, no infiltrate, nl cardiac silhouette
Differential Diagnosis CVA/Epidural/Subdural Infections- meningitis, encephalitis, neurocystercercosis, brain abscess Brain mass (tumor-primary or secondary) Electrolyte abnormality- hyper/hyponatremia/calcemia Overdose- sympathomimetic, theophyline, INH, other Vascultis Metabolic Abn Inherent seizure disorder ETOH Withdrawal
Laboratory Values WBC 15.7 HgB 13.6 Hct 42 Plts 369 Na 143 K 5.0 Cl 113 Bicarb 20 BUN 10 Cr 1.2 Glucose 114 LFTs- nl NH3- 6 CPK 1450 U/A- nl, PGU- neg ABG- 7.26/30/141/18 APAP- <1 ASA <1 ECG- sinus tach with nl QRS, slightly prolonged QTc Urine Drug Screen- pending
Clinical Course After the pt was taken to the CT-scanner and shown to have a normal CT, she was brought back to the resuscitation  room and the MICU was called.  An NG was placed which revealed pill fragments of unknown etiology.  The brother was sent to the home to look for any empty pill bottles.  The pt was paralyzed with rocuronium, intubated with 8-0 ETT, no complications.  The pt was then given 2 mg Ativan IV and started on a propofol gtt.  The brother returned with empty bottles of Buproprio (Wellbutrin), Celexa, Ateral.  The pt was admitted to the ICU, received charcoal, extubated after 72 hours with an uneventful recovery.
Final Diagnosis Wellbutrin OD Celexa OD Status Epilepticus Suicide Attempt
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