“A 34-year-old woman in otherwise good health suffers a first grand mal seizure, and during her postictal state begins to experience hypoxemia, tachypnea, tachycardia, and frothy sputum. Auscultation reveals diffuse rales. How does seizure activity cause this presentation? How does this differ from ARDS?”
HEALTHCASTS COMMUNITY RESPONSE
This patient case was posted to the Healthcasts peer-to-peer community. 78 unique opinions were contributed from October 19, 2019 to November 2, 2019. The following is a synopsis of their treatment plan recommendation.
Presentation of Symptoms
Aspiration pneumonia due to decreased airway protection as a result from impaired level of consciousness post-seizure
Opinions were split between aspirational pneumonia, pulmonary edema, and Acute Respiratory Distress Syndrome (ARDS) resulting from the seizure. 60% of respondents agreed that this patient likely aspirated during the seizure and is also experiencing aspirational pneumonia as a result. 24% of respondents said that this patient is experiencing a pulmonary edema as a result of her grand mal seizure. Another 6% of the respondents thought this patient was suffering from ARDS, also as a result of the grand mal seizure.
Aspiration of gastric contents can cause ARDS as well as a pulmonary source
It is possible that acute respiratory distress syndrome is a result of the seizure. “She probably aspirated during the seizure,” said one respondent. “Aspiration of gastric contents can cause ARDS as well as a pulmonary source.” Many pointed out that the patient was in good health until the seizure, so it is possible that the patient aspirated on saliva.
Neurogenic pulmonary edema (NPE) may be the result of grand mal seizure
Acute pulmonary edema following significant injury to the central nervous system is known as neurogenic pulmonary edema (NPE). While the pathophysiology is not well understood, one respondent explained, “NPE may be the result of grand mal seizure and is an increase in pulmonary interstitial and alveolar fluid.”
ARDS vs. Pulmonary Edema
ARDS is pathophysiologically different and has a different prognosis. Its time of onset is also not as acute as NPE
Many respondents said that is it possible the patient will develop acute respiratory distress syndrome over time, but she does not have it yet. A few users mentioned that the time of onset for ARDS is typically 6 to 17 hours, so it is unlikely that a patent would experience ARDS during her postictal state. A neurologic pulmonary edema is different from ARDS because with ARDS fluid collects in alveoli. Additionally, seizures typically impact the left lower lobe whereas ARDS is diffuse or bilateral.
This patient may need further examination to rule out any underlying health conditions that would have led to her seizure. She should have a CT scan to determine if she has a traumatic brain bleed. Another respondent said, “I would still get a brain MRI to ensure there’s nothing structural that could have caused the seizure.” If the patient’s stats continue to stay above 90%, she may need oxygenation and intubation. The patient may need to stay in the ICU for monitoring and supportive care.
Her seizure was a manifestation of her underlying medical disorder
Based on her reaction to the seizure, the patient may have pre-existing conditions, including heart disease, that she was not aware of before the seizure. An echocardiogram may help her team learn more.