Often a problem when the first story is a bit sketchy, isn't it? I wasn't concerned about the other two
trauma calls (two lads full of ketamine being spiderman who fell 25' through a roof) as we were fine for
staff and I could peel people off as required.
I have to say I take 1mm size difference in a patient with decerebrate posturing very seriously.
Although the skin was warm and dry, her temperature (done by me) was normal at 36.9.
You must stop the fitting, whatever the cause, and I felt that tube and scan was going to be our
quickest way to gain control and exclude some important nasties. Fitting can be seen in water
intoxication (wet) ecstasy, tricyclic overdose, alcohol and so on - the list is almost endless. Fitting for
a considerable period of time will lead to hypoxia, hypercarbia, a fever and a mixed acidosis.
As other correspondents have rightly pointed out, treat the history with caution. Her boyfriend then
appears, very concerned, and admits that they haven't taken any E for a week. However, they had
drunk a bit the night before, and had a row. This had culminated in a bit of pushing and shoving, and
she had hit her head on a wall. She was knocked out for a few seconds, and he called an ambulance
and the Police. She recovered by the time they arrived, and sent them away. She goes to bed, he is in
the doghouse and sleeps on the patio. He is woken by the noise of her getting out of bed to clean
herself up at 5:30 as she has been doubly incontinent. He does not wake again until 8 am and finds
her fitting.
The story all now looks very different, so I go back while she is being tubed and lined and so on and
examine her carefully. The head is normal. There is no bruising, no swelling, no evidence of damage at
all anywhere. She has a pulse around 90 and a blood pressure of 117/60. This all seems to point away
from intracranial mischief, and there is a degree of difficulty in my mind pinning all this down. Blood
tests, including glucose, are unhelpful.
Is there anything significant now?
> > I agree, Matt. Warm skin, tachycardia, fitting, decerebrate posturing,
> > dilating pupils, all sounds suspiciously like the anticholinergic (and
> > other) effects of a tricyclic antidepressant overdose. And I don't
> > think
> > this causes pyrexia, does it? Anyway, incredibly difficult to treat
> > when it
> > reaches this stage...
> >
> >
>
> Yes Adrian, anticholinergics do cause elevated temperatures as well as
> flushed skin.
> Renee
>
Best wishes,
Rowley Cottingham
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http://www.emergencyunit.com
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