joel presented the case of a 25 year old Caucasian man with type I diabetes who had a witnessed seizures
there was some discussion of terminology (what is a funny turn?)
loss of consciousness was a key issue to establish
important categories of causes were neurological, cardiovascular and meto-toxic
features differentiating cardiogenic from neurogenic syncope are important - here is a bit table 18.21 from Davidson's - it's OK, but can you do better? neuro-cardiogenic is a fancy name for a faint
| 18.21 Typical features of cardiac syncope, vasovagal syncope and seizures |
| Cardiac syncope | Neuro-cardiogenic syncope | Seizures | |
| Premonitory symptoms | Often none | Nausea | Confusion |
| Lightheadedness | Lightheadedness | Hyperexcitability | |
| Palpitation | Sweating | Olfactory hallucinations | |
| Chest pain | 'Aura' | ||
| Breathlessness | |||
| Unconscious period | Extreme 'death-like' pallor | Pallor | Prolonged (> 1 min) unconsciousness |
| Motor seizure activity* | |||
| Tongue-biting | |||
| Urinary incontinence | |||
| Recovery | Rapid recovery (< 1 min) | Slow | Prolonged confusion (> 5 mins) |
| Flushing | Nausea | Headache | |
| Lightheadedness | Focal neurological signs | ||
*N.B. Cardiac syncope can also cause convulsions by inducing cerebral anoxia. |
in this chap the alcohol intake is important - it will decrease seizure threshold & also causes hypoglycaemia [why?]
if this is a recurrent phenomenon it would be nice/critical to find out why? - this issue may kill him soon - is he bothered? is it an education problem? is it insulin regimen related?
_ _ _
we then digressed into what would you do if this fitting person was in front of you in resus
we demonstrated the gaping hole between book/rote learning "I would assess ABCDE" and learning by doing "I would look, listen & feel for signs of respiratory effort" [of course easier to say than do often]
we talked about diazepam PR, lorazepam IV and the need for general anaesthesia
BM stands for Boehringer Mannheim, not Bayer
50mL of 50% glucose (or x) is around 25g glucose (or x)
one regular UK Mars bar weighs 58g
_ _ _
lessons/memories were:
- key questions around funny turns
- double check the timetable
- blood bottle colours x2
- the importance of starting on time
- DR ABCDE
homework generated was
- acute management of hypoglycaemia (including which blood tests to do)
- emergency pages cheese & onion fitting
- fitting look at local fitting guidelines
- emergency pages cheese & onion electrolytes Na & K
- read illustrated colour text of endo
- long term follow up epilepsy in cheese & onion
- read management of DM in taught course & K&C
_ _ _
my view on things to learn from the case:
- managing hypoglycaemia
- managing acute seizures
- managing alcohol withdrawal
- types of insulin & how to use them
- unusual, but important causes of LOC in young people (eg HCM, brain tumours eg astrocytoma)
_ _ _
we also touched on how governments kill people, focusing on the USA
interestingly some states are now switching from a 3-drug protocol, to a 1-drug protocol (5g of sodium thiopental)
here is how the state of Florida executes (3-drugs: barbiturate, ACh antagonist, KCl 120mmol)
here is a video of a discussion at NEJM
Salaam
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