Term 6 Case 4 (w/c 20/05/13)
You are taking your patient into the recovery unit. Everything seems fine. As you connect up the monitors the nurse in the next bed space pulls the emergency buzzer. She calls out her patient is fitting.
Tell us what you do next.
There is likely to be an agreed set of things to do but we also want you to think about what is really going on in your mind during this kind of event.
It is not a surprise that people want to set about abolishing the fit. So let’s say that 2 mg of Midazolam have been given with appropriate effect. The patient now appears sedated.
Answers suggested in the twitter feed include checking the notes for the operation.
It turns out that this is a 26 year old female who has been in theatre for a calcaneal bone grafting. She had a General Anaesthetic and a popliteal block. You note she had 150 mg Levo bupivicaine.
She isn’t fitting right now. But what are you thinking about?
We treat a bit more after next fit. More story is available. No past history of fits. Uncomplicated anaesthesia.
The patient was wide awake and pain free in recovery for 15 minutes prior to first episode.
Just write one diagnosis so that the class has a differential diagnosis.
Thanks everyone, lots of suggestions out there.
We are trying to construct a diagnostic sieve to direct our investigations. If we now consider in turn as a group that the results relevant to your thought process appear with an appropriate time frame.
Na 134 K 4.1 U 6.8 Cr 81
Hb 112 WCC 7.8 Plt 298
CT scan negative, no masses, no blood
The patient is now back in recovery unit and ready for discharge to ward. She seems fine.
Orthopaedics want to know what you would like them to do next?
Thanks for the safe suggestions. Of course, discussions like this may not turn up the answer because there is no actual patient to see. It is fictitious. However, in the back of my mind when thinking about the case I stumbled across an unusual differential. Well, its not that unusual because I have seen it a few times both in and out of theatre setting.
Check out http://bja.oxfordjournals.org/content/92/3/451.full and http://www.nature.com/bdj/journal/v208/n1/full/sj.bdj.2010.6.html
Can’t find a single thing: How about pseudo seizures??
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