the case.
a 28 year old male presents to your Emergency Department with a 2-3 week history of increasing neck swelling. He is now spitting out frank purulent discharge from his mouth and reports fevers and night sweats.
a difficult airway…
The Case.
The ‘Batphone’ alerted us of a 68 year old female who is postictal following two seizures in rapid succession. She has a history of ‘a brain tumour’.
P 120. BP 176 systolic !! GCS 8/15. Afebrile. Sats 98% (15L NRB + guedel airway).
She arrives direct to your resus bay 4-5 minutes later and she is actively seizing.
A) Obstructed (Guedel on floor). Trismus ++.
- Bilateral nasopharyngeal airways inserted
- Two-handed jaw thrust
- Ventilating well on 100% BVM.
B) Bilateral air entry. Sats 99% on O2. No added sounds.
C) P 130 (sinus) BP 185 systolic. Diaphoretic. Warm peripheries.
- 2x IVC inserted
- 500mL N.Saline bolus
D) Actively seizing (GTCS with movement in all 4 limbs). Pupils 4mm (L+R).
- 2x 5mg IV Midazolam (seizure resolved)
- 1gram IV Phenytoin (loading commenced at cessation of seizure)
E) Temp 37*C. BSL 13. No rashes, contusions etc.
Impression:
Status Epilepticus (3x seizures with no return to normal mental state)
- ? secondary to ‘brain tumour’ or associated haemorrhage
- No other medical history available
- “Family are bringing in her medications”
Following resolution of her seizure she remains obtunded, GCS (E1V1M4) 6/15 and still obstructing her airway. A decision is made to RSI for airway control and prevention of secondary brain injury, followed by urgent CT. [Read more…]