History of Present Illness:
A man in his mid 60’s is brought in by ambulance after being given Narcan 4mg IN then 8 mg IV for pinpoint pupils after a single vehicle MVA on the highway. There was minimal vehicular damage. Medics says he started to wake up after Narcan but is still a bit out of it. Once he wakes up he denies any injury and says he does not use opiates, just marijuana and he used to be an alcoholic and occasionally use meth.
Vital Signs & Physical Exam:
Pulse 120, BP 158/89, otherwise normal. Exam is non focal with no evidence of trauma but medics did place him in a hard collar since he was altered
Workup:
- CT head and C-spine plus CXR normal
- Labs show WBC of 16, bicarb of 18 and lactate of 6.2
- Tox screen positive only for THC
What is the most likely diagnosis?
- A) Fentanyl OD
- B) Syncope
- C) Seizure
- D) Stroke
SCROLL DOWN FOR ANSWERS & 1-MINUTE CONSULT
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THE EMERGENCY MEDICINE POCKETBOOK TRIFECTA
- Emergency Medicine 1-Minute Consult, 5th edition
- A-to-Z EM Pharmacopoeia & Antibiotic Guide, 5th edition
- 8-in-1 Emergency Department Quick Reference, 5th edition
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ANSWER: What is the most likely diagnosis?
- A) Fentanyl OD
- B) Syncope
- C) Seizure – CORRECT
- D) Stroke
1-Minute EM Consult on the topic for this case from the Emergency Medicine 1-minute Consult Pocketbook
CASE CONCLUSION: Post ictal from seizure. Improvement after Narcan was likely a coincidence as tox screen negative for opiates. Tachycardia gradually resolved and was likely from Narcan. Lactic acidosis quickly resolved and was likely from seizure. Vitals stabilized. Patient treated for sepsis and observed though because CRP was 7.5. ID workup was negative. EEG and MRI were non-diagnostic