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Dr. Idaly Hidalgo and Jenny Luo 8.31.2012. Case #1  AH 3108356  7 yo male with hx of ADHD presents with excessive sleepiness x 1 day with one episode.

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Presentation on theme: "Dr. Idaly Hidalgo and Jenny Luo 8.31.2012. Case #1  AH 3108356  7 yo male with hx of ADHD presents with excessive sleepiness x 1 day with one episode."— Presentation transcript:

1 Dr. Idaly Hidalgo and Jenny Luo 8.31.2012

2 Case #1  AH 3108356  7 yo male with hx of ADHD presents with excessive sleepiness x 1 day with one episode of “throwing up and turning blue” while sleeping. What would you like to know?

3 Case #1  HPI Patient was noted to be more tired than usual, slept until 10am this morning. During the day he was playful and interacting appropriately with his siblings. Throughout the day he complained of tiredness and nausea but was able to tolerate food and took his usual medication. Went to bed at 6pm because he felt nauseous and tired.

4 Case #1  HPI cont. Around 11pm, family noticed patient vomiting in his sleep and “turning blue”. Patient was not responding to verbal or tactile stimulation. Brother threw water on patient’s face, after which he awoke but remained lethargic.

5 Case #1  Denied abnormal movement or incontinence recent trauma fever headache sick contact  ROS otherwise negative

6 Case #1  PMHx ADHD ODD Immunizations UTD  Meds Ritalin (10mg at 7am, 10mg at 12pm, 5mg at 4pm) Refilled medication two days ago, no change in dosage but these pills are “made by a different company”  No known allergies

7 Case #1  FHx Brother- ADHD Mother- Asthma  SHx Lives with mother and three older brothers No one else in the household takes medication No history of child abuse

8 Case #1  Physical Exam v/s: T 100.1F HR115 BP109/73 RR28 O2 95%RA General: patient observed walking into ED and climbing onto stretcher in NAD. Falls asleep minutes later, arousable but lethargic. HEENT: NCAT, Pupils equal ~2mm, EOMI, MMM, nares patent, TMs nl, no tonsil erythema or exudate Neck: supple, no LAD Lungs: slow and shallow, RR 12. CTAB CV: HR 60, s1s2 nl Abd: Soft, NT/ND, +BS Neuro: lethargic, orientedx3, CNs II-XII intact, motor 5/5 upper and lower extremities, steady narrow based gait Skin: no rash or lesions What would you like to do next?

9 Case #1  During the exam patient was placed on the monitor repeat vitals HR 58 BP 110/65 RR 10 @86% patient lethargic, arousable by painful stimuli only complaining of being tired O2, IV access and labs, EKG in progress  Obtained medication bottle from mom, it is labeled methylphenidate hydrochloride 5mg.

10 Case #1  Labs?  Imaging?  EKG?

11 Case #1  Labs CBC: 13.7>12.1/37.6<323 BMP: 136/3.9-100/26.8-6/0.5<103 Ca 9.8 PT10.4 INR1.1 PTT24.8 UA: Yellow, turbid; SpGrav 1.025; unremarkable  EKG- sinus brady 56

12 Case #1  Differential Diagnosis for AMS in Children  Medical  Hypoxemia  Hypoglycemia  Hypo/Hyperthermia  DKA  Sepsis  Inborn errors of metabolism  Intussusception  Meningitis and encephalitis  Exogenous toxins  Electrolyte abnormality  Psychogenic  Postictal  Uremia  Structural  CVA  Cerebral venous thrombosis  Trauma- cerebral edema, mass lesion  Hydrocephalus

13 Case #1 Methadone Hydrochloride 5mg What would you do next?

14 Opioid OD  Signs Decreased mental status, respiratory rate, tidal volume, bowel sounds and pupil size  Treatment ABC Naloxone ○ competitive antagonist to all opioid receptors. ○ onset of IV naloxone is 1-2min, duration of action 20-90min.

15 Opioid OD  Naloxone dosing Opioid-dependent with depressed mental status but minimal respiratory depression – 0.05mg IV Non-opioid-dependent with depressed mental status but minimal respiratory depression – 0.4mg IV Apnea or near apnea- 2mg IV Q3min until maximum dose of 10mg or improved respiratory status Due to short duration of action, multiple does or continuous infusion may be necessary. ○ Infusion rate= (2/3 x wake up dose)/hr

16 Methadone  Onset of action 0.5-1 hour  Peak effect for continuous dosing 3-5 days  Half-life 8-59 hours  QTc prolongation, torsades

17 Case #1 ED course ○ Naloxone 2mg IVP x1 Patient became very agitated, but his v/s improved ○ Poison control notified recommend observation for 24hours and at least 4 hours after stopping continuous infustion ○ Hospital administration notified ○ Admit to PICU for airway monitor and naloxone drip.

18 Case #1  Hospital Course Naloxone drip started at 0.5mg/hr and monitored for changes in mental status, respiratory depression and cardiac abnormalities. Drip weaned off over 16hrs Transferred to floor Discharged on HD#3

19 Case #1  Take Home Point Trust no one!

20 Case #2  TH 03573339  34 yo F presents to ED with headache and AMS. What would you like to know?

21 Case #2  HPI Patient complaining of generalized HA for past 2-3 days, not improving with her BP medication. S/P c-section 8 days ago, discharged from OSH one day PTA. Denies nausea, vomiting, photophobia, fever, chills, neck stiffness, sick contact or trauma. ROS otherwise negative Per friend, patient is more confused and forgetful today. Also noted slurred speech.

22 Case #2  PMHx Gestational HTN  PSHx C-section x2  Meds Labetalol 300mg PO Iron supplements  SHx Denies tobacco, alcohol and illicit drug use  FHx Noncontributory What would you like to know on PE?

23 Case #2  Physical Exam V/S: T97.9 BP188/117 HR72 RR16 O2 100% General: NAD, AAOx3 HEENT: PERRL ~3cm, EOMI, no nystagmus, no icterus Neck: supple, no stiffness Lungs: CTAB CV: RRR, s1s2 nl Abd: Soft, NT/ND, +BS, c/s incision d/c/I Ext: 2+ b/l LE pitting edema Neuro: AAOx3, follow commends, able to recall 2/3 objects after 5 minutes. Slow speech with word finding difficulties. Able to name items/read/write. CN II-XII intact. Motor and sensory intact. Skin: intact, no rash What would you like to do next?

24 Case #2  Labs CBC: 9.1>8.7/26.6<265 BMP: 140/3.6-104/24-11/0.8<80 LFT: WNL Trop <0.01, CPK 174 UA: trace protein  Imaging CTH: normal, no acute hemorrhage, hydrocephalus, sulcal effacement, midline shift or mass effect. CXR: normal, no cardiomegaly

25 Case #2  Differential Diagnosis Encephalitis Hemorrhagic/ ischemic stroke TIA CVA SAH Subdural hematoma Migraine HA Tension HA Hyperthyroidism (thyroid storm) Toxicity Metabolic disease Seizure disorder Postpartum depression/psychosis Postpartum preeclampsia

26 Hypertensive disorders of pregnancy  Chronic hypertension- BP>140/90 on two occasions before 20 wks of gestation or persisting beyond 12 wks postpartum  Gestational hypertension- BP>140/90 without proteinuria after 20 wks of gestation  Preecalmpsia- BP>140/90 WITH proteinuria after 20 wks of gestation

27 Severe Preeclampsia  Diagnostic Criteria BP≥ 160 systolic or 110 diastolic on two occasions at least six hours apart during bed rest Proteinuria ≥ 5 g in a 24-hour urine specimen or 3+ or greater on two random urine specimens collected at least four hours apart  Any of the following associated signs and symptoms:  Cerebral or visual disturbances  Epigastric or right upper quadrant pain  Fetal growth restriction  Impaired liver function  Oliguria < 500 mL in 24 hours  Pulmonary edema  Thrombocytopenia

28 Severe Preeclampsia- Management

29  ABC  Magnesium Sulfate- first line treatment/prevention for eclamptic seizures. 4-6gm IV over 5-10minutes followed by 1-2gm/h for 24 hours. additional 2gm bolus for recurrent seizures lorazepam and phenytoin are second line  Hydralazine- first line antihypertensive in pregnancy 5-10mg IV bolus, then Q20min to max of 30mg onset of action 20min  Labetalol 20mg IV with q10min to max of 300mg onset of action 5min  Nifedipine 10mg PO Q15-20min, max of 3 doses commonly used postpartum  Nitroprusside last resort, can cause severe rebound hypertension and cyanide poisoning in fetus

30 Case #2  ED course Patient received Labetalol 20mg IV, Labetalol gtt at 2mg/min, hydralazine 5mg IV x2 and Mg 6mg IV BP improved to 167/106, HA improved but neuro exam unchanged. GYN, Neuro and ICU consult Patient admitted to MICU

31 Case #2  Hospital Course HD#1: Mild HA, neuro intact. No sign of HELLP. Continued labetalol drip and 2g Mg infused over 24hrs. HD#2: HA resolved, neuro intact. Transitioned to PO labetalol 500mg PO q8h. MRI, MRA, MRV head all normal, MRA brain normal. HD#3: patient eloped without prescription.

32 Case #2  Take home point Pre-eclampsia can occur postpartum Patients will elope no matter how sick they are

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