A young man with depressed conscious state and seizures

Published on 10/04/2015 by admin

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Last modified 10/04/2015

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Problem 39 A young man with depressed conscious state and seizures

Michelle Kiley

A young man is brought into the emergency department early one morning. He was found ‘unconscious’ in the street and an ambulance called. There were no witnesses. Immediate assessment shows that his airway is intact and patent, he has normal colour, respiratory rate and pulse oximetry. There is no circulatory compromise. There are no obvious injuries.
He is stuporose and responds with sluggish but purposeful limb movements to painful stimuli. He groans, but does not make any comprehensible sounds. His Glasgow coma score is 6 (E1, V2, M3). He has a temperature of 37°C and cardiorespiratory examination is normal. The pupils are mid-position, equal and reactive and the optic fundi are normal. The plantars are downgoing. He has no neck stiffness and Kernig’s sign is negative. No focal neurological abnormality can be elicited. The rest of the physical examination is normal.

Q.1

What test should immediately be performed on arrival in the emergency department and what else should be sought on examination?

The test does not help elucidate the cause of the patient’s collapse. The man is reasonably well kempt but there is a faint smell of alcohol on his breath. On closer inspection there is a superficial laceration over the occiput and bruising of the right lateral aspect of the tongue. The patient’s underpants are found to be damp with urine.

Before any further assessment is performed the patient suddenly lets out a grunt, all four limbs extend and his spine arches. He stops breathing and rapidly becomes cyanosed. After 30 seconds, violent rhythmic contractions of the limbs begin and persist for at least 5 minutes

Q.2

What is the diagnosis, and what should be done for the patient?

The seizure is aborted after 10 mg intravenous diazepam. At this stage a brother, who had been contacted by the nursing staff, arrives and provides further information. The patient is 24, has had epilepsy since his mid teens, and has been on regular anticonvulsant medication, although the brother is unsure as to the medication’s name.

Q.3

What are the causes of this condition? What are the likely causes in this patient?

The brother states that the patient has seizures every few months and his local doctor has told him that due to his poorly controlled epilepsy he is currently ineligible to drive and that it is the patient’s responsibility to inform the local licensing authorities. Over the last few days the patient has had several late nights, despite having an upper respiratory tract infection, including the previous night in which he had been out with his brother drinking until the early hours of the morning. He seemed reasonably well when he left the bar, saying that he would walk home.

The patient slowly regains consciousness over the next hour. His last recollection was leaving the bar with his brother the night before. He confirms his brother’s account and admits he has not taken his anticonvulsant medication (carbamazepine) for 2 days. In addition to occasional generalized tonic seizures the patient reports isolated myoclonic jerks of the arms and trunk, which usually occur first thing in the morning or later at night, particularly when tired.

Q.4

How will you manage this patient in the short term?

An electroencephalogram (EEG) is performed (Figure 39.1), as one had not been done since diagnosis many years ago. This shows 4–5 Hz paroxysmal generalized polyspike and wave discharges consistent with the diagnosis of primary generalized epilepsy.

image

Figure 39.1

Q.5

How are you going to manage his medications?

You counsel the patient about the medications you feel most appropriate for his needs, and spend some time talking to him about his illness.

Q.6

What other advice will you offer him?

Q.7

The patient asks you when he is likely to be able to stop taking anticonvulsant medication. What is your reply?

Answers

A.1 Hypoglycaemia should be promptly excluded by blood glucose estimation.

Further examination should be undertaken for evidence of:

• Drug abuse (needle tracks) and/or drugs or drug paraphernalia on his person.
• Seizure (tongue biting or incontinence).
• Medication usage (medical alert bracelet, personal details in pockets, any information about medications such as sedatives, antidepressants or illicit drugs).
• Signs of chronic liver disease.
• Head injury.
• Assess if the patient is kempt or unkempt and asssess the breath for the smell of alcohol.
• Look for a form of identification or any other personal items that will enable you to contact relatives or friends. Most importantly, these people may be able to give a history.

A.2

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