Not sure what you're getting at here. Seems fairly straightforward here-
pass on management of your trauma cases to the surgical teams if you don't
have the staff to deal with both properly. Sort out whether this is
metabolic or surgical/ anatomical check usual BM, urine dip including SG,
bloods, ECG, try to control fits with phenytoin, look to anaesthetising and
CT scanning. Given the other cases, may need a bit of prioritising of CT and
anaesthetists. Wouldn't worry too much about the tox- fits due to drugs are
generally treated the same as other fits (OK, phenytoin doesn't work, but an
equivocal history of drug ingestion is not a reason for not trying it as
long as ECG is normal, then moving to GA with the anaesthetists' choice of
drug). Also, most drug related causes of fits usually cause pyrexia as well
to the extent that absence of pyrexia would make me question whether there
was another cause.
I'd probably scan earlier than Phil would- having taken ecstasy recently is
pretty common in the Spa towns and could easily be coincidental with a
bleed, tumour or abscess. Also, not sure what Phil's saying about the
temperature. I read it as apyrexial. If pyrexial, scan asap in case of
abscess; cool aggressively in the meantime in case of drugs; dantrolene
unlikely to be helpful.
Other than the surgical causes there's not much difference in treatment of
the different causes (except of course hepatic encephalopathy- which would
explain worsening of condition with diazemuls)
Work through the list of possible drug causes, but don't get too worked up
about them. Don't trust the history. All sorts of junk can get sold as
ecstasy, and most people who take ecstasy don't have any problems. Call the
RMO so he can suggest its eclampsia and ask for an obstetric opinion before
he gets involved etc.
Is the mention of a warm skin a clue to this having turned out to be an
anticholinergic OD? Still wouldn't give physostigmine etc. though.
Final possibility is pre- existing anisocoria (or contact lens in one eye)-
I wouldn't rely on a 1 mm difference being reliably reproduced- and faking
it.
Matt Dunn
Warwick
This email has been scanned for viruses by NAI AVD however we are unable to
accept responsibility for any damage caused by the contents.
The opinions expressed in this email represent the views of the sender, not
South Warwickshire General Hospitals NHS Trust unless explicitly stated.
If you have received this email in error, please notify the sender.
|