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Case Presentation

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

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Case Presentation

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  1. Case Presentation • Dave Choi • PGY-5 ER • Edmonton

  2. Learning Goals • Present an interesting case • Discuss Ddx and management issues • Briefly review relevant material

  3. Case • 74 yo asian female from assisted living • Fever, feeling unwell x 2-3 days • Found by nurse on floor ++confused • ?falls recently?

  4. EMS • Found patient lying on floor, confused • 185/60 - 117 - 40 - 93%RA • GCS E4V3M6 (language barrier?) • Diaphoretic • Room was very warm

  5. 5th and 6th vital signs • Temp 40.1 • C/S 8.2

  6. HPI • Was last seen walking / talking yesterday by family • No new URTI symptoms • No travels / sick contacts • No new med changes

  7. PmHx / Meds • Sinemet (carbo/levodopa) • Mirapex (pramipexole) • Aricept (donepezil) • Metformin • Atacand (candesartan) • Norvasc (amlodipine) • Lipitor (atorvastatin) • Singulair (montelukast) • Didrocal (etidronate) • Parkinson’s • Alzheimers • DM • HTN • Chol • ?Asthma • Osteoporosis

  8. Physical Exam • Airway intact • AE = AE, clear • PPPx4, bounding pulses • GCS14/15, PERL 3mm • No focal deficits • Warm extremities

  9. 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

  10. What was that? • Choreoathetoid movements • How would you like to proceed?

  11. Ddx • Infectious • Heat illness • Trauma • Neuroleptic malignant syndrome • Serotonin syndrome • Malignant hyperthermia • Toxicological

  12. Investigations • Bloodwork / VBG • Urine • CXR • CT? • LP?

  13. Treatment • IV NS 500cc bolus • Cool patient: ice packs, cool IV saline, fan, mist • Tylenol? • Sedation? • Antibiotics?

  14. Feels Warm • FEVER • Hypothalamus controls temperature: sets theromostat • Skin, lungs, liver • HYPERTHERMIA • Normal set point, but increased body temp via endogenous/exogenous mechanism

  15. Antipyretics • Work by inhibiting COX (which is responsible for PGE2 synthesis) • Decrease PGE2 • PGE2 is responsible for fever

  16. 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

  17. 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

  18. Other Investigations • Urine - non-contributory • CT head - nil acute • LP - WBC2 RBC0 Glucose5.5 Protein0.32

  19. Diagnosis? • Neuroleptic Malignant Syndrome • vs • Heat Stroke

  20. 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%

  21. Pathophysiology • Too much blockage of dopaminergic (D2) receptors • Brain/spinal cord (muscle rigidity, tremor via EPS) • Hypothalamus (reset temp set point)

  22. Risk Factors for NMS • Rapid initiation/increase dose • Rapid withdrawal antiparkinson drugs • Dehydration • Previous hx NMS • Hot weather

  23. 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

  24. Diagnosis • Development of severe muscle rigidity and elevated temperature associated with use of neuroleptic/antipsychotic medication • TWO or more of: diaphoresis, dysphagia, tremor, incontinence, change in LOC, mutism, tachycardia, elevated/labile BP, leukocytosis, lab evidence of muscle injury • Symptoms in 1 or 2 not caused by other causes

  25. NMS • 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

  26. Treatment • Stop the drug (or start if Parkinsons) • Active cooling: ice packs, ice bath, fans with mist, cold IV • Sedation / muscle relaxation: benzo’s-paralyze if cannot cool (rare) • Supportive (rhabdo, vital signs, etc)

  27. Cooling • Conduction: direct physical contact • Convection: heat loss to air/water vapor around body (windchill) • Radiation: electromagnetic waves • Evaporation: conversion of liquid to gas

  28. Medications • Bromocriptine • - central dopaminergic agonist • Dantrolene • - decrease Ca release from SR(more for MH) • Amantadine • - dopaminergic / anticholinergic

  29. 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

  30. Q

  31. Key Points • Broad Ddx for hyperthermia and altered LOC • Initiate empiric treatment • Cooling is key for most hyperthermic illnesses

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