Download Q - Calgary Emergency Medicine

Case Presentation
Dave Choi
PGY-5 ER
Edmonton
Learning Goals
• Present an interesting case
• Discuss Ddx and management issues
• Briefly review relevant material
Case
• 74 yo asian female from assisted living
• Fever, feeling unwell x 2-3 days
• Found by nurse on floor ++confused
• ?falls recently?
EMS
• Found patient lying on floor, confused
• 185/60 - 117 - 40 - 93%RA
• GCS E4V3M6 (language barrier?)
• Diaphoretic
• Room was very warm
5th and 6th vital signs
• Temp 40.1
• C/S 8.2
HPI
• Was last seen walking / talking
yesterday by family
• No new URTI symptoms
• No travels / sick contacts
• No new med changes
PmHx / Meds
• Parkinson’s
• Alzheimers
• DM
• HTN
• Chol
• ?Asthma
• Osteoporosis
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Sinemet (carbo/levodopa)
Mirapex (pramipexole)
Aricept (donepezil)
Metformin
Atacand (candesartan)
Norvasc (amlodipine)
Lipitor (atorvastatin)
Singulair (montelukast)
Didrocal (etidronate)
Physical Exam
• Airway intact
• AE = AE, clear
• PPPx4, bounding pulses
• GCS14/15, PERL 3mm
• No focal deficits
• Warm extremities
Physical Exam
• T40.2 HR120 BP179/67 RR36
Sat99%on5L
• No obvious signs of head injury
• No skin rash
• Weird limb movements
• Increased tone vs irritable
What was that?
• Choreoathetoid movements
• How would you like to proceed?
Ddx
• Infectious
• Heat illness
• Trauma
• Neuroleptic malignant syndrome
• Serotonin syndrome
• Malignant hyperthermia
• Toxicological
Investigations
• Bloodwork / VBG
• Urine
• CXR
• CT?
• LP?
Treatment
• IV NS 500cc bolus
• Cool patient: ice packs, cool IV saline,
fan, mist
• Tylenol?
• Sedation?
• Antibiotics?
Feels Warm
•FEVER
•Hypothalamus controls temperature:
sets theromostat
•Skin, lungs, liver
•HYPERTHERMIA
•Normal set point, but increased body
temp via endogenous/exogenous
mechanism
Antipyretics
• Work by inhibiting COX (which is
responsible for PGE2 synthesis)
• Decrease PGE2
• PGE2 is responsible for fever
Case cont’d
• Sedation with cautious IV Ativan
• Patient settles with 0.5mg IV Ativan
• T / BP / HR / RR normalizes with
sedation / cooling
• Started on Ceftriaxone and Vancomycin
Bloodwork
• Hgb118 Plt193 WBC11.5 (no bands)
• Na131 K3.2 Cl95 Bicarb26
• Cr88 Urea5.6
• Mg0.75 Ca2.13
• CK2305
• Coags N, Liver enzymes N
Other Investigations
• Urine - non-contributory
• CT head - nil acute
• LP - WBC2 RBC0 Glucose5.5
Protein0.32
Diagnosis?
•Neuroleptic Malignant Syndrome
•vs
•Heat Stroke
NMS
• 0.02 – 2.4% of patients on neuroleptics
• Onset: days to weeks (slower than SS)
• Risk highest first 2 weeks of initiation or
dose escalation
• Previous to 1976, mortality up to 76%,
now ~10%
Pathophysiology
• Too much blockage of dopaminergic
(D2) receptors
• Brain/spinal cord (muscle rigidity,
tremor via EPS)
• Hypothalamus (reset temp set point)
Risk Factors for NMS
• Rapid initiation/increase dose
• Rapid withdrawal antiparkinson drugs
• Dehydration
• Previous hx NMS
• Hot weather
Drugs
• Dopamine antagonists: more with
higher potency agents (Haldol)
• Some non-antipsychotics can cause it
(maxeran, lithium)
• Withdrawal of dopamine agonists
(antiparkinson drugs)
• Others (Aricept)? - maybe
Diagnosis
1. Development of severe muscle rigidity
and elevated temperature associated
with use of neuroleptic/antipsychotic
medication
2. TWO or more of: diaphoresis,
dysphagia, tremor, incontinence,
change in LOC, mutism, tachycardia,
elevated/labile BP, leukocytosis, lab
evidence of muscle injury
3. Symptoms in 1 or 2 not caused by other
causes
NMS
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•
•
•
•
Altered LOC (97%) (agitated delirum to catatonia to
stupor/coma)
Increased muscle tone (lead pipe rigidity 97%):
akinesia, choreathetosis, myoclonus, dystonia,
dyskinesia, opisthotonus
Hyperthermia (98%)
Autonomic instability (tachycardia (88%), tachypnea, BP
labile (61%), sweats, arrhythmias)
Death: from uncontrolled hyperthermia and muscular
rigidity, but can be from cardioresp failure, arrhythmia,
etc
Treatment
• Stop the drug (or start if Parkinsons)
• Active cooling: ice packs, ice bath, fans
with mist, cold IV
• Sedation / muscle relaxation: benzo’sparalyze if cannot cool (rare)
• Supportive (rhabdo, vital signs, etc)
Cooling
• Conduction: direct physical contact
• Convection: heat loss to air/water vapor
around body (windchill)
• Radiation: electromagnetic waves
• Evaporation: conversion of liquid to gas
Medications
•Bromocriptine
•- central dopaminergic agonist
•Dantrolene
•- decrease Ca release from SR(more for
MH)
•Amantadine
•- dopaminergic / anticholinergic
Case cont’d
• Admitted to internal medicine
• IV fluid rehydration with cooling
• All cultures neg - antibiotics d/c’d
• Mentation slowly cleared
• Discharged home 10 days later
Key Points
• Broad Ddx for hyperthermia and altered
LOC
• Initiate empiric treatment
• Cooling is key for most hyperthermic
illnesses