Hyperexcitability and Abnormal Movements

The 84 year old woman, who lives at home, says she is light-headed, feels shaky and is seeing white spots, but she really doesn’t want to go to the hospital.

“Well, if you are light-headed, feeling shaky and seeing white spots, you need to go to the hospital,” I say.

“Okay,” she says.

That was easy.

We get her in a Johnny top and on the stretcher. Out in the ambulance, I do a 12 lead and a full assessment. She has a sinus rhythm with occasional PACs and a right bundle branch block. No ST elevations. Her lungs are slightly decreased, but it could just be that my hearing is slightly decreased. Her skin is warm now, although she says she felt sweaty earlier. Her abdomen is soft, her grip strengths are equal.

Her blood pressure is 180/100. Her heart rate is in the 90’s. She is Satting at 95% so I put her on a cannula at 2 lpm.

I try to get a history, but she is 84, partially deaf and a poor historian.

On the way to the hospital, I notice that she seems uncomfortable.

I ask her is she is in pain and she says her back hurts. Is this new pain or old pain?

I have arthritis, she says.

So you have had this pain before?

What?

The pain.

She is holding her belly and looks like she is trying to sit up more, so I undo the belt and slide her up, but it doesn’t seem to help. She seems very anxious.

I am starting to get concerned, but no matter what I ask, I can’t get a good answer.

I’m going to throw up, she says.

I quickly grab an emesis basin, and while she belches, I take out the med kit and pull out an ampule of Phenergan. I draw up 12.5 mg and dilute it in 10 cc of NS. I tell her I am giving her something for her nausea as I push it slowly through the saline lock I put in her arm.

We are just a few minutes from the hospital now so I tell her I am going to call the hospital and tell them we are coming.

My patch starts out routine. “I’m four minutes out with an 84 year old female complaining of light-headedness, shakiness and seeing white spots…” But as I am talking she is changing in front of my eyes. She gets a crazy unfocused look. She seems like she is trying to come off the stretcher, but doesn’t seem to have control of her left side. She arches her back and is grasping at her chest with her right arm.

I don’t remember what I say on the rest of the patch, something about the patient is going nuts and I’m not certain what is going on.

When we get to triage the patient cannot follow commands, her left side is weak, she is moving strangely, almost spastically, and she is still nauseous. If I ask her a question, I get a nonsensical answer. She is completely altered. Her skin is also diaphoretic and she looks quite pale.

We get her into a room and the nurse gets a doctor and as I relate the history, he assesses her. He runs through the same diagnostic possibilities I had thought of – everything from throwing a clot to MI to AAA.

I did give her some Phenergan – 12.5 for her nausea, I say.

Phenergan? He says.

Yeah. Phenergan 12.5

Was she like this before you gave her the Phenergan?

No, she was a little crazy, something was going on, but she wasn’t like this. She could talk to me at least.

It could be the Phenergan, he says – it’ll make them do this.

Really? I’ve seen it makes them very lethargic, and I know it can produce a produce a dystonic reaction, but nothing like this.

***

I see the nurse the next day. I ask her about the patient. The CAT scan was clean. As soon as the Phenergan wore off, she was alert and oriented with equal neuros. Still, they admitted her for observation. She did after all have that problem about being light-headed, feeling shaky and seeing white spots.

***

I check the drug appendix for Phenergan at the back of my protocol book.

Under side effects, it says: “May impair mental and physical ability.”

Under contraindications, it reads “Hx of prior idiosyncratic/hypersensitivity reactions to Phenergan.”

I hope they tell her to remind any future paramedics who offer her Phenergan that she now apparently is one of those people who have had an idiosyncratic/hypersensitivity reaction to Phenergan.

I talk to some other medical people who have witnessed the same phenomenon in patients, particularly elderly. Phenergan can make them go crazy, they say.

The link below on Phenergan side effects mentions “Hyperexcitability and abnormal movements.”

***

Next time, I give Zofran.

(Or if I am out of Zofran, for the elderly at least start with 6.25 mg of Phenergan instead of the full 12.5 mg.)

10 Comments

  • Anonymous says:

    When we had phenergan I use to see the medic chase it with Benadryl, don’t know if there is any evidence in doing that just speaking from observation. We have Zofran now and the three or four times I gave it in school I never had a problem with it.

  • Jeremy Pope says:

    I was just reading one of the other medical blogs 2 days ago, and they were mentioning the phenergen phenomenon as well. Benadryl was what they gave for it too. They mentioned a couple of other meds that could cause that reaction, but I don’t remember them. They seemed to only do it in cases of weird abreactions, though, not every time.

  • Anonymous says:

    Maybe the Benadryl was just to knock the person down for a while?

  • Anonymous says:

    Well, actually Benadryl is an antihistamine too. It can suppress nausea also. I never had thought to use it like that, but when I saw an M.D. give it in the ER. (Well, MD ordered and I administered.) I was sold on the idea.As to Phenergan, it’s a dirty drug with lots of side effects, and there is really no way to tell how the pt will react until they have had the drug before. I tend to go with Zofran on a regular basis.

  • New Medic says:

    This is one of the reasons that my system switched from the 12.5mg dose to 6.25mg dose. There are rumors of acquiring Zofran, which would be nice. I’ve called for IV Benadryl before in the case of an allergy/aversion to Phenergan. It can work, but it is not as dramatic as Zofran can be.Eric

  • fiznat says:

    Peter do you know if this was treated as dystonic in the ED? I’d be interested to hear if they tried to treat it, or if they decided to just let the drug wear off.Do you have Zofran in your trucks yet? We *just* got the LMAs yesterday.

  • PC says:

    Thanks for the comments.From all I hear and from the patient I had, I can see how phenergan can be an unpredicatble drug, or as anynomous says, a dirty drug with lots of side effects. Fortunately, we just got Zofran in, so in most cases that will be my first choice, or if the patient is particularly anxious and I want phenergan’s sedative effects, I will give it in the 6.25 dose to start, particularly for the elderly.As for Benadryl. I know it is used for the dystonic, extrapyrmadial raactions, but my patient wasn’t having a dystonic reaction. (My experience with dystonic reactions has been patients who are alert, but who have trouble moving some muscles particlarly in face and tongue and they tend to present almost like a physically handicapped person.) Whether or not Benadryl works for the “hyperexcitability and abnormal movements” I don’t know. The patient wasn’t given it at the hospital.

  • Ambulance Driver says:

    I’ve had a few patients hallucinate and/or show hyperexcitability after having received Phenergan, and all of them were elederly patients. Around the ERs, it is considered a no-no among the ER nurses to give the old folks Phenergan, so it appears to be a fairly common phenomenon.Now that Zofran is available as a generic (Odansetron) at a tiny fraction of it’s former price, it may become more popular.Still not as effective as Phenergan for motion-induced nausea, though.

  • Anonymous says:

    Cost was a HUGE issue with Zofran when it first came out. The generic is really new. I don’t recall the cost difference but it was an order of several magnitudes between phenergan and Zofran. Like $1 for a dose vs. $60.Zofran is still a lot more expensive, and it has some differences in who it works for. Some types of n/v respond better to one drug, vs the other. We don’t have an antiemetic protocol for some reason, so it’s not an issue for me. It’s not always something to ponder, but when you possible, I try to think about the cost to the patient, and cost to our system in my treatments. For instance, how quick are you to pop with Glucagon IM when you can’t find an IV in a diabetic?Cost-wise, you’re talking about $5 for an amp of D50 and an IV. You’ll likely be doing an IV anyway, so just look at the cost of D50 amp vs. Glucagon. D50 is about $3 (all prices will vary with your system, but this is a rough ballpark for discount internet retail prehospital places) vs. >$100 for a dose of Glucaon.So, maybe spending an extra minute or two finding that IV site will save both the patient and your service $97 dollars. There’s a lot of little things you can do in your daily work that will add up to a lot of savings.My coworkers cringe when I mention cost savings, but less than 50% of our patients pay their bill. So our service eats over half the cost of patient transports.Which means, indirectly, I eat the cost of 50% of our transports. If I can still treat a patient effectively and fully, but save the service and the patient some money, I’m going to do it whenver possible. Lidocaine vs amiodarone is a good example if your service carries both. Same with epi vs vasopressin. Big cost difference in these drugs. And there is no proven difference in patient outcomes from either. So why not stick with the lidocaine or epi when you have the choice?

  • PC says:

    Valid points on the cost. Fortunately zofran is down to about $25 a dose. I have heard of some services getting it even cheaper.While I am a big proponent of capnography, I am sparing now in my use of the capnography cannula for the non-intubated patients unless I think it will tell me something I wouldn’t otherwise know.The glucagon/D50 example is excellent. I agree look for the vein unless absolutely neccessary. The other issue besides cost is a brittle diabetic who gets glucagon today and drops their sugar again tomorrow may not have any glycogen stores left for the glucagon to work the second time. I only use it as a last resort.As far as cost to the patient here in this state they are charged a flat BLS or ALS rate independent of what drugs are used.We have a protocol for betablocker overdose that calls for 5 mg of glucagon. The cost of 5 mgs of glucagon to the service is probably more than the total bill to the patient.Thanks for the comments.

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