case 3 65 yr old male with acute onset of seizure

 

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Case discussion

65yr old male pt who was a farmer by occupation brought to casuality with
c/o 2 episodes of seizures 3hrs back.

Pt was apparently asymptomatic 6yrs back then he had a h/o trauma for which he went to a local hospital and CT brain was done which came out to be normal. At that hospital he was diagnosed to be hypertensive and was put on amlodipine but patient was not on regular medication.

Then 1yr back he started having symptoms such as forgetfulness, difficulty thinking and understanding. During this time,on one day while he was working in his farm he
had giddiness and went to a hospital in nalgonda where he was said to be having low bp and medication was given for it. The next day at 6am in the morning he was showing altered behavior. So his son took him to nalgonda hospital where CT brain was done. They were told that he was having an infarct in the brain. He was also diagnosed to be having alzheimers. By evening he had left side weakness, slurring of speech, deviation of mouth, altered behaviour. He was put on
1)Tab.Rosutor Gold 10/75
2) Tab.Topline forte
3)Tab.Donamen 5mg.

After using medication for 3days they went to a ayurvedic hospital and took treatment for 6months.
During those 6 months his left sided hemiplegia got better. But after few days he had right sided weakness in both upper and lower limbs. They continued the treatment in that 6months.

After 6 months as he was not getting any better, they visited another hospital in bhongiri where he was put on some (ayurvedic treatment along with peracetum and amlodipine from past 6months).

Then 3 hours before coming to our hospital, while he was made to walk for mins he had first episode of seizure activity lasted for about 10minutes associated with up rolling of eyes. After 10mins 2nd episode lasted for 30mins having generalized tonic clonic seizure of both upper limbs and lower limbs associated with up rolling of eyes and frothing.

History of alcohol intake occasionally for 30years. History of smoking chuttas 3-4per day for 30years.
On advice of doctor pt stopped consuming alcohol and smoking 6 years back.
History of toddy intake 500ml -1litre per day occasionally since 40years

No history of tb, diabetes, asthma,chronic kidney disease.

On presentation
GCS - 4/15
Febrile - 103°F
Pulse - 75bpm,regula
BP 140/100 mm of hg
RR 24 cpm
SpO2 94@5lit of o2
GRBS 136mg/dl


CNS examination
Power,sensory system and gait cannot be elicited

Tone :
UL LL
Right increased normal
Left increased normal

Power : rt UL 4/5, rt LL 3/5.


Reflexes:
                       Right                         left
Biceps              ++                            ++
Triceps            ++                            ++
Supinator       ++                            ++
Knee                 +                              +
Ankle               +                              +
Plantar        plantar              plantar
                     flexion                 flexion

Brain stem reflexes:

Corneal and conjunctiva reflex +
Doll's eye reflex +
Gag reflex - absent

RS : nvbs
CVS :S1S2 heard
No murmurs

Day 1

When pt was presented to casuality he has low saturation so oxygen was given 
@ 5 to 7 lits of O2 and the sp02 - 94 to 96%.
Inspite of fall in saturation the o2 was increased to 15litrs and the spo2 was 93-94% ; RR : 55 -58cpm

Rx:

1)Inj.levipil500mg iv BD

2) Inj. Piptaz 4.5gm iv TID
3)Inj. Pan 40mg OD
4)Tab. Atorvas 20mg h/s

Day 2

As RR was high 45 - 50 cpm and development of aspiration pneumonia
Further fall in saturation ( 86% --> 84 % --> 78%) pt was intubated in the afternoon @ 1:30 pm
Pt was in ACMV mode with Fio2 100% and RR 22 and spo2 : 97% -98% ; PEEP : 5cm of water

Breaths given by ventilator are 18 / min

Rx:

1)Inj.Ceftriaxone 2gm IV BD

2)Inj. Mannitol 100 mg TID

3)Inj.Neomal 1gm IV 

4)Tab.Telma 40 mg OD

5)Inj.Pan 40 mg IV BD

6)Inj.Loraz 2cc SOS

7)Inj. Levipil 500mg IV BD

8)Tab.Azithromycin 500 mg  OD

Day 3

Pt was on ACMV mode RR 12 - 15 cpm Fio2 - 60% and SpO2- 95% - 96% ; PEEP : 5cm of water

Breaths given by ventilator are 18 / min

in the evening pt was changed from ACMV to SIMV mode

Lp was done as to rule out the meningitis

Rx:

1)nj.Ceftriaxone 2gm IV BD

2)Inj. Mannitol 100 mg TID

3)Inj.Neomal 1gm IV 

4)Tab.Met xl 12.5mg OD

5)Inj.Pan 40 mg IV BD

6)Tab. Amlodipine 5mg OD 

7)Inj. Levipil 500mg IV BD

8)Inj.Metronidazole 100 ml IV TID

9) Neb. Budecort and mucomist 6th hrly

Day 4

Pt was continued to be on SIMV mode with RR 15cpm Fio2 30% - 50% and PEEP : 5cm of water

SpO2 97% - 99% 

In the night pt was again changed to ACMV mode because pt is tachyponeaic (60),tachycardia (145) and hypertensive (200/100) and started Atracurium 2ml/hr from 12:00am and slowly tapered in the morning @11:00am

Rx:

1))Inj.Ceftriaxone 2gm IV BD

2)Inj. Mannitol 100 mg TID

3)Inj.Neomal 1gm IV 

4)Tab.Met xl 12.5mg OD

5)Inj.Pan 40 mg IV OD

6)Tab. Amlodipine 5mg OD 

7)Inj. Levipil 500mg IV BD 

8)Inj.Metronidazole 100 ml IV TID

9) Neb. Budecort and mucomist 6th hrly

10)Tab.Amlodipine 10mg OD

11)Inj.Clexane 40mg s/c

12)Tab.Atorvas 20mg OD H/S

13)Tab.Ecosprin 75mg OD H/S

Day 5

In the morning pt was continued to be on ACMV mode with Fio2 - 40% ; PEEP : 5cm of water

Spo2 - 95% -97%

As the pt was showing respiratory effort justified by airway pressure graphs on ventilator screen we decided to give a trial of CPAP and shifted him to CPAP mode

In the afternoon @ 2:00pm pt was changed from ACMV mode to CPAP with Fio2 40%
Spo2 92% - 93%

Rx:

1))Inj.Ceftriaxone 2gm IV BD

2)Inj. Mannitol 100 mg TID

3)Inj.Neomal 1gm IV 

4)Tab.Met xl 12.5mg OD

5)Inj.Pan 40 mg IV OD

6)Tab. Amlodipine 5mg OD 

7)Inj. Levipil 500mg IV BD 

8)Inj.Metronidazole 100 ml IV TID

9) Neb. Budecort and mucomist 6th hrly

10)Tab.Amlodipine 10mg OD

11)Inj.Clexane 40mg s/c

12)Tab.Atorvas 20mg OD H/S

13)Tab.Ecosprin 75mg OD H/S

14)Inj.Optineuron 1amp in 100ml NS IV BD

Day 6

Pt is continued on CPAP with Fio2 40% ; 

Spo2 : 95% - 98% RR spontaneous 18 - 25cpm

Rx

1)Inj. Meropenem 1gm IV TID

2)Inj.Neomal 1gm IV 

3)Inj. Nicardia 10mg BD

4)Tab.Met xl 12.5mg OD

5)Inj.Pan 40 mg IV OD

6)Inj. Optineuron 1amp in 100ml of NS IV OD

7)Inj. Falcigo 120mg IV STAT

8)Tab.Doxycycline 100mg PO/BD/RT

9)Tab.Atorvas 20mg HS/RT

10)Tab. Met xl 25mg OD

11)Neb with Budecort and Muconist

12)Chest physiotherapy

Day 7

 Pt is continued to be on CPAP with Fio2 : 40% ,

Spo2 : 95% - 98%

Rx

1)Inj. Meropenem 1gm IV TID

2)Inj.Neomal 1gm IV 

3)Inj. Nicardia 10mg BD

4)Tab.Met xl 12.5mg OD

5)Inj.Pan 40 mg IV OD

6)Inj. Optineuron 1amp in 100ml of NS IV OD

7)Inj. Falcigo 120mg IV STAT

8)Tab.Doxycycline 100mg PO/BD/RT

9)Tab.Atorvas 20mg HS/RT

10)Tab. Met xl 25mg OD

11)Neb with Budecort and Muconist

12)Chest physiotherapy

Day 8

As pt respiratory effort is good pt is changed to

 T piece with 11 liters of O2

Rx

1)Inj. Meropenem 1gm IV TID

2)Inj.Neomal 1gm IV 

3)Inj. Nicardia 10mg BD

4)Tab.Met xl 12.5mg OD

5)Inj.Pan 40 mg IV OD

6)Inj. Optineuron 1amp in 100ml of NS IV OD

7)Inj. Falcigo 120mg IV STAT

8)Tab.Doxycycline 100mg PO/BD/RT

9)Tab.Atorvas 20mg HS/RT

10)Tab. Met xl 25mg OD

11)Neb with Budecort and Muconist

12)Chest physiotherapy

Day 9

Pt is on Tpiece with 11 litres of O2

Rx

1)Inj. Meropenem 1gm IV TID

2)Inj.Neomal 1gm IV 

3)Inj. Nicardia 10mg BD

4)Tab.Met xl 12.5mg OD

5)Inj.Pan 40 mg IV OD

6)Inj. Optineuron 1amp in 100ml of NS IV OD

7)Inj. Falcigo 120mg IV STAT

8)Tab.Doxycycline 100mg PO/BD/RT

9)Tab.Atorvas 20mg HS/RT

10)Tab. Met xl 25mg OD

11)Neb with Budecort and Muconist

12)Inj.Acyclovir 100mg IV TID

13)Chest physiotherapy

Patient was discharged after 2 days with power 4/5 in all limbs. 

1st follow up : 

All 4 limbs tone normal. Power 4/5 in al limbs. Able to do all his routine activities. Difficulty in getting up from squating position.