Triage: BIBM from school pt c/o syncopal episode. Pt lowered self to ground, unconscious for 3 mins, minor shaking episode.

History of Present Illness: This is a 15-year-old female who was brought in by ambulance for a witnessed 3-minute generalized tonic-clonic seizure around 930 this morning with postictal period of about 5 to 10 minutes. Patient has no known history of seizure no warning or prodrome. She did recently increase her Wellbutrin from 300 mg a day to 450 mg a day approximately 4 days ago and was also started on Remeron at that time. She does recall leaving the scene but does not recall ambulance arrival after her seizure.  Currently she feels tired but otherwise okay. She did have a stomach flu but that resolved about a week ago otherwise was feeling well earlier today.

Vital Signs: T: 36.9 °C (Oral)    HR: 115      RR: 20      BP: 111/69     SpO2: 99%

Physical Exam:  °EYES: Clear without discharge. No photophobia
°ENT: No oral trauma
°NECK: Supple
°HEART: Elevated rate. Regular.
°GENITOURINARY: No CVAT. No incontinence
°NEUROLOGIC: Normal speech. No focal weakness. Alert and oriented.
°PSYCHIATRIC: Normal mood. No SI

An ECG is done

Computer Read: Sinus Tach at 141 w/ 1st degree AV block, Right axis, Nonspecific ST abnormality

 

What is the most likely cause of ECG findings in this patient?

  • A) Normal
  • B) Electrolyte issue
  • C) Pulmonary embolism
  • D) Drug toxicity

SCROLL DOWN FOR THE EKG ANALYSIS & 1-MINUTE CONSULT

 

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ECG interpretation:

Interpretation: Computer read is accurate

QUIZ ANSWER:

    • A) Normal
    • B) Electrolyte issue
    • C) Pulmonary embolism – Right axis and tachycardia should absolutely make you worry about PE.  Even though the history was pretty clear that this was a seizure and not syncope and there was no chst pain or SOB, a D-dimer was sent, which was normal
    • D) Drug toxicity – CORRECT – She had seizure and has persistent tachycardia from Wellbutrin toxicity.  Other than Tramadol, Wellbutrin is probably the prescription medication most likely to cause seizure at usual doses.

     

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CASE CONCLUSION: CBC metabolic panel viral panel all essentially normal as was D-dimer, urinalysis and pregnancy test. Case discussed with children’s neurology who recommended no brain imaging. Patient remained persistently tachycardic with no definite cause even after IV fluids. Case discussed with poison control who recommended 24-hour admission.  She did well, had resolution of tachycardia and no further seizures.