25 year old diabetic with a grand mal seizure

after starting late ...

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