ROS: all remaining ROS negative

Transcription

1 Case # 1

2 CC: altered mental status HPI: 13 yo male presents with altered metal status. Child`s mother was called by the school nurse to pick her child up from school today due to child`s unusual behavior. The child`s teacher found the child drowsy, with his head down, drooling during class. Speech was slurred, and response to questions was slower than usual. His movements were slow. He was having difficulty writing down class notes and writing took longer than usual. No medications were given by the school nurse. The school nurse called the child`s mother. Child was able to eat his breakfast as usual earlier that morning. Child has chronic behavioral issues including ADHD. Patient has recently been more moody and more agitated. Patient was recently evaluated by his psychiatrist for the agitation and his medication was increased. ROS: all remaining ROS negative

3 PMHx: ADHD, depression, behavioral problems PSHx:none Family Hx: ADHD in child`s father Social Hx: child lives with his mother. child`s mother is divorced from his father. Child has no history of substance abuse. Attends school. Has difficulty making friendships and interpersonal relationships. Allergies:NKDA Medications: Quietiapine, Fluoxetine

4 VS: 99.1, 140, 130/82, 99% oxygen sat RA Physical exam: general: Alert, NAD, sitting with head down, makes poor eye contact, slow response to verbal command. HEENT: NCAT, PERLA, EOMI, no JVD distention, no neck mass, oral mucus membranes dry. cardiac:rrr, s1 s2, no murmurs respiratory: CTA abdomen: normal bowel sounds, soft, nontender Neurological: alert and oriented. Responds to questions slowly. Poor attention span. Cogwheel rigidity in both upper extremities. CN II-XII intact. Gait is slow and walks in small steps. Strength 5/5. sensation: intact

5 DDX: medication overdose neurolept malignant syndrome Serotonin syndrome alcohol, drug effect metabolic disorder Infection malingering child abuse

6 Labs and diagnostics: fingerstick glucose CBC, CMP, CK, Urinalysis, ethanol level, salicylate level, acetaminophen level, urine toxicology EKG consult : poison control center

7 Results: CBC:normal CMP: BUN elevated, otherwise normal CK: within normal range Urinalysis:normal Urine toxicology: normal acetaminophen level, salicylate level, ethanol: normal.

8 Fingerstick glucose : 80 EKG: RRR, no Qtc prolongation, no ST or T changes

9 Assessment: 13 yo male on atypical antipsychotics presenting with extrapyramidal signs likely due to medication side effect Treatment provided: - Benadryl reevaluated after 30 minutes no improvement -another dose of Benadryl -Valium -IV NS -observation -psychiatry referal

10 Current guidelines for evaluation and management of atypical antipsychotic toxicity: Labs and diagnostics: fingerstick glucose CBC BMP LFT if abdominal pain acetaminophen and salicylate levels pregnancy test for females EKG Urine myoglobin and serum CK (rhabdomyolysis) LP for CSF if AMS due to unknown factor

11 Typical EKG findings: sinus tachycradia, Qtc prolongation, ST depression and flattening of T wave

12 Recommended Treatment: admit for observation (at least 4 hrs) ABC continuous cardiac monitoring frequent neurological exams IV access and NS hydration if hypotensive contact poison control center activated charcoal with sorbitol (cathardic). Avoid if sedated and unable to protect the airway Anticholinergics such as diphenhydramine or benztropine to help with EPS (dystonia)

13 Benzodiazepines for agitation or altered mental status psychiatry consult

14 If neurolept malignant syndrome: Symptoms: fever, rigidity, altered mental status, autonomic instability Physical exam: Hyperthermia, tachycardia, tachypnea, labile blood pressure Increased muscle tone, rigidity, tremor, diaphoresis, sialorhea, dystonia, opisthotonus, chorea, dyskinesia, trismus, agitation, delirium, cataonic mutism. In wort cases see stupor and coma.

15 Labs: Ck > 1,000 (can be as high as 100, 000) Leukocytosis, left shift possible Elevated LDH, ALP, LFT Hypocalcemia, hypomagnesemia, hyponatremia, hypernatremia, hyperkalemia, metabolic acidosis ARF from rhabdomyolysis U/A: myoglobin

16 Treatment: Discontinue the medication Cardiac monitor, neural exams IV fluids Cooling blankets Clonidine, Nitroprusside for BP control Benzodiazapines (Lorazepam, clonazepam) for agitation Supportive care VS Dantrolene

17 Dantrolene: skeletal muscle relaxant Reduces CK, rigidity, hyperthermia, speeds up resolution of symptoms, lower mortality Evidence for use is limited but there is no better alternative treatment and use has shown to decrease mortality when compared to receiving supportive care alone mg/kg IV for adults Maximum 10 mg/kg/day for adult Effects noted in minutes

18 Continue treatment for 10 days. Then slowly taper down Monitor for relapse symptoms Contraindicated if markedly elevated LFT

19 Other agents: Bromocriptine: Dopamine agonist. 2.5 mg q 6-8 hrs. Continue for 10 days and then taper Amantadine: Dopamine agonist and anticholinergic agent. 100 mg Q 12 hrs ECT: reduces catatonia and Parkinson like symptoms. Treatment decreases mortality compared to supportive care complications of cardiac arrythmia (v fib), anoxic brain injury, have to use anesthesia which may worsen initial NMS symptoms

20 Symptoms resolve in 2 weeks Outcome Mortality rate high (5-20 %) if untreated When to resume medications Two weeks after symptoms resolve Low dose and low potency Avoid using with Lithium Keep well hydrated

21 Pediatric patients: Experience similar symptoms as adults Are at a higher risk of toxicity due to faster metabolism, lower protein binding, lower adipose. This means higher bioavailability of the drug. Lower threshold for admitting. Must be observed at least 6 hrs. Treat same way as adults Outcome is good in most cases Low mortality reported from toxicity (0.1%)

22 Thank You