For Examiner Only
Case Cocaine Body packer – seizure, chest pain
Author: Larrisa Velez, MD
Revewer: Karen Jubanyik, MD
Approved 12/5/05
ORAL CASE SUMMARY
CONTENT AREA
NEUROLOGY
Status Epilepticus from cocaine body-packing
SYNOPSIS OF CASE
This case involves a 27 y/o woman brought in by ambulance from the airport after she started
acting strange and having seizures while at baggage claim at the airport. No one in the immediate
vicinity claimed to know the patient. She has no past medical history, is not pregnant, and had no
trauma, but this information is not readily available when patient arrives. The resident must
suspect cocaine body packing, treat aggressively with benzodiazepines and barbiturates; consider
whole bowel irrigation for decontamination; and call the surgeon for a laparotomy. The KUB will
show multiple packets.
SYNOPSIS OF HISTORY
The patient is a healthy 27 y/o who is traveling back from Colombia into the States (this is not
immediately volunteered – resident must ask paramedics to stay and will be able to get this
information if they ask paramedics). The plane had been flying for about 6 hours. During the flight,
she had complained of “not feeling well” according to flight attendants. Upon landing the patient
has a seizure in baggage claim. She has received 2 mg IV Ativan by EMS. She is post-ictal on
arrival to the ED.
SYNOPSIS OF PHYSICAL
The patient is post-ictal, with sonorous breathing, sweaty, tachycardic and hypertensive. The
pupils are large. There are no signs of trauma. There are no stigmata of drug use. There is a bite
mark on the tongue, but no incontinence. Sats are 87% at RA.
CRITICAL ACTIONS
1. Secure the airway early (PM, PS)
2. Treat the seizures with benzodiazepines +/- barbiturates (PM)
3. Follow vital signs (PM)
4. Initiate gastrointestinal decontamination (PM)
5. Call surgery for emergent laparotomy (PM)
SCORING GUIDELINES
(Critical Action No.)
1. Score down if delays airway management. Have patient have additional seizures and lower the
sats.
2. Dangerous action to treat with phenytoin only. Same as 1 (patient has more seizures and drops
sats if patient not treated with benzodiazepines or barbiturates.
For Examiner Only
Case
Case Summary - Page Two
4. Score down/dangerous action if initiates GI decontamination without managing the airway.
PLAY OF CASE GUIDELINES
(Critical Action No.)
1. Have patient have additional seizures and lower the sats if resident delays airway
management. Patient codes if airway management is further delayed.
1. Ask resident how to perform a RSI. Ensure that only short acting paralytics are used.
Dangerous to paralyze the patient since unable to monitor for seizure activity/seizure control.
2. Seizures continue and patient deteriorates if treated with phenytoin only. Same as 1 (patient
has more seizures and drops sats if patient not treated with benzodiazepines or barbiturates).
Patient eventually codes if status epilepticus is not identified and correctly treated.
2. If resident uses adequate doses of benzodiazepines, vital signs improve.
3. If resident uses beta blockers to control hypertension and tachycardia, blood pressure
increases.
4. If resident initiates GI decontamination without managing the airway, the patient has a seizure,
vomits, and aspirates. Nurse can warn once, saying “the patient started having another seizure as
I was placing the nasogastric tube. Do you still want it, doctor?”.
FOR EXAMINER ONLY
For Examiner Only
Critical Actions
1.
Secure the airway early (PM, PS)
This critical action is met by the candidate doing early airway management and describing
the proper sequence for RSI.
Cueing Guideline:
2. Treat the seizures early with benzodiazepines +/barbiturates (PM)
This critical action is met by the candidate treating with proper drugs and doses and
reassessing patient for resolution of the seizure activity and improvement of the vital signs.
Cueing Guideline:
3.
Follow vital signs (PM)
This critical action is met by the candidate requesting repeat vital.
Cueing Guideline: Nurse may tell resident that patient’s vitals are “worse”.
4.
Initiate gastrointestinal decontamination (PM)
This critical action is met by the candidate initiating GI decontamination after airway has
been secured.
Cueing Guideline:
5.
Call surgery for emergent laparotomy (PM)
This critical action is met by the candidate consulting general surgery before end of case.
Cueing Guideline: If totally lost about reason for seizures, have airline representative call on
phone to ED and want to speak to candidate about patient’s condition and mention that
“patient frequently flies from Colombia to the USA”.
For Examiner Only
History Data Panel
Onset of Symptoms: About 1 hour ago
Description of Complaint: Seizures for about 30 minutes.
Past Medical History
Surgical: Unknown
Medical: Unknown
Injuries: Unknown
Allergies: None. No Medic Alert bracelets noted (must ask)
Last menstrual period: unknown
Habits
Smoking: Unknown
Drugs: Unknown
Alcohol: Unknown
Family Medical History
Father: Unknown
Mother: Unknown
Siblings: Unknown
Social History
Married: No
Children: None
Employed: Unknown
Education: Unknown
For Examiner Only
Physical Data Panel
Patient: 27 y/o woman
Patient Name: Unidentified female
General Appearance: Post-ictal, sonorous breathing. In ambulance stretcher.
Vital Signs:
BP : 214/121
P : 136
R : 23
T : 38.3 (tympanic)
Sats (upon request only): 87%
D stick (upon request only): 123 mg/dl
Head: No trauma. No nystagmus or gaze. No perforated septum.
Eyes: Dilated pupils, sluggish and symmetric, to 6 mm.
Ears: Normal
Mouth: Normal, except for tongue bite mark. Pooling of secretion in posterior throat.
Neck: Normal
Skin: Diaphoretic. No rashes, no needle tracks.
Chest: No signs of trauma. Normal breasts. Hyperdynamic precordium.
Heart: Tachycardic and regular. No murmurs, rubs, or gallops.
Abdomen: Decreased bowel sounds. No trauma, not distended. No masses.
Extremities: Diaphoresis noted. No signs of trauma. Symmetric pulses.
Rectal: Heme negative stools. Decreased tone (if done after intubation)
Pelvic: Normal
Neurological: Normal cranial nerves except for mydriasis. Normal reflexes. Eyes closed.
Withdraws to pain (if not seizing). Noisy breathing and non-verbal.
Mental Status: Post-ictal. See above.
For Examiner Only
Lab Data Panel
Stimulus #2 - Hematology
Complete Blood Count
WBC
23,000/mm3
Hgb
11.9 g/dL
Hct
35 %
Platelets
240,000/mm3
Differential
Segs
90%
Bands
1%
Lymphs
5%
Monos
2%
Eos
2%
Stimulus #5 - Arterial Blood Gases (right
after intubation)
pH
7.14
pCO2
pO2
O2 Sat
30 mm Hg
305 mm Hg
100%
Stimulus #6 - CK 4,304
Stimulus #7 – see KUB
Stimulus #8 – CRX, portable: adequately
placed ETT, normal otherwise
Stimulus #3 - Chem-7
Na+
K+
CO2
Cl-
140 mEq/L
4.1 mEq/L
12 mEq/L
109 mEq/L
Glucose
BUN
Creatinine
135 mg/dL
24 mg/dL
1.4 mg/dL
Stimulus #4 - Urinalysis
Color yellow
Sp gravity 1.035
Glucose negative
Protein negative
Ketone positive
Leuk. Est. none
Nitrite neg
WBC 0-1/HPF
RBC 2-4/HPF
VERBAL REPORTS
Monitor shows sinus tachycardia at 136/minute.
12 lead ECG shows sinus tachycardia at
140/minute. Intervals are normal. QRS is
normal. There is no ectopy.
Initial sats: 87%
If applies oxygen: 92%
After intubation: 100%
D-stick: 123 mg/dl. Must ask for this. Can make
hypoglycemic if resident does not ask for it.
Pregnancy test: negative
Note: hold all labs until seizures are managed.
This case does not need labs in general.
Mock Oral Feedback Form
Date:
Examiner:
Examinee:
Data acquisition
Worst
1
NOTES
2
3
4
5
6
7
8
Best
Problem solving
Worst
1
NOTES
2
3
4
5
6
7
8
Best
Patient management
Worst
1
2
NOTES
3
4
5
6
7
8
Best
Resource utilization
Worst
1
2
NOTES
3
4
5
6
7
8
Best
Health care provided
Worst
1
2
NOTES
3
4
5
6
7
8
Best
4
5
6
7
8
Best
Comprehension of path physiology
Worst
1
2
3
4
NOTES
5
6
7
8
Best
Clinical competence (overall)
Worst
1
2
3
NOTES
5
6
7
8
Best
Patient Interpersonal relations
Worst
1
2
3
NOTES
4
Critical Actions
Dangerous actions
Secure the airway early (PM, PS)
 and omissions
Treat the seizures with benzodiazepines +/-

Follow vital signs (PM)

Initiate gastrointestinal decontamination (PM)

Call surgery for emergent laparotomy (PM)

For Examiner Only
Stimulus Inventory
#1
Emergency Admitting Form
#2
CBC
#3
BMP
#4
Urinalysis
#5
ABG
#6
Creatinine Kinase level
#7
KUB showing multiple radio-opaque drug packets
#8
Chest X ray
#9
#10
FOR EXAMINER ONLY
Stimulus #1
ABEM General Hospital
Emergency Admitting Form
Name
:
Unidentified Female
Age
:
27
Sex
:
F
Method of Transportation
:
EMS
Person giving information
:
EMS
Presenting complaint
:
seizures
Background: 27 y/o woman s/p seizure, which EMS treated with Ativan, 2 mg.
Vital Signs
BP : 214/121
P
: 136
R
: 23
T
: 38.3 (tympanic)
Stimulus #2
CBC
Complete Blood Count
WBC
23,000/mm3
Hgb
11.9 g/dL
Hct
35 %
Platelets
240,000/mm3
Differential
Segs
90%
Bands
1%
Lymphs
5%
Monos
2%
Eos
2%
Stimulus #3
Electrolytes
Na+
K+
CO2
ClGlucose
BUN
Creatinine
140 mEq/L
4.1 mEq/L
12 mEq/L
109 mEq/L
135 mg/dL
24 mg/dL
1.4 mg/dL
Stimulus #4
Urinalysis
Color yellow
Sp gravity 1.035
Glucose negative
Protein negative
Ketone positive
Leuk. Est. none
Nitrite neg
WBC 0-1/HPF
RBC 2-4/HPF
Stimulus #5
Arterial Blood Gases (right after intubation)
pH
7.14
pCO2
pO2
O2 Sat
Stimulus #6
Creatine Kinase
CK 4,304
30 mm Hg
305 mm Hg
100%
Stimulus # 7
KUB film