Nms...

Specialties Neuro

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Specializes in Neuro, Critical Care.

Anyone ever taken care of a pt. that has neuroleptic malignant syndrome??? I had one the other day for the first time...very rare apparently. What was the outcome for your pt.? My pt. has been cataonic for almost 3 weeks.....I was having major issues with him and the docs just didnt know what to do with him, hes not waking up, he's getting worse. We had him on all the standard treatments according to the literature....

Id love to hear your experiences with these pts. I had a heck of a time keeping him sedated, he would have periods (without warning..going from exremely sedated to sitting up, extremely rigid, trying to extubate) of extreme rigidy where his sats would drop into the low 80's, HR into the 140;s and BP over 200 systolic. The docs ordered Ativan drip, morphine drip, pushing versed q10mins. It was awful. I didnt know what to do with him. He was a huge guy and im not so huge and def. not that strong. It took 4 of us to hold him (bc he was so rigid) just so i could push more versed so that he wouldnt extubate and his BP would come down...ugh..as soon as he was sedated properly, his vitals returned to WNL. There was just nothing left to sedate him with. We had him on propofol for 10 days!!!!! I fought so hard to get his sedation switched bc his lipids were through the roof, his urine was the darkest GREEN id ever seen and well he was on 80mcgs/kg/hr and 5 of morphine. Finally after he almost self extubated at the end of my shift I was able to get one of the MDs to switch his propolol to versed and we titrated and titrated and maxed ourselves out and he was worse!!!!!!! By the middle of my 3rd shift he was now on an ativan drip of 10/hr, morph 10/hr and getting versed 5mg IVP q10mins. It was awful. I called every MD in the house by the time my shift was over.

Sorry so long. I really felt at a loss that night. I couldnt find very much literature on this condition and the other nurses on my floor were just as stumped...as were the MDs! We all felt as though we were grasping at straws. So any info would be greatly appreciated!!!!!!!!!!!!!! Thanks for letting me vent.

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I don't have any great words of wisdom for you, but can sympathize.....these patients can change quickly, and tend to be resistant to treatment. I had one last night who jumped out of the back of a rolling pickup truck....huge epidural hematoma with a 3 cm midline shift, pupils fixed and dilated....family made him a DNR and were going to deescalate in the morning.

About 4 this morning his temp went up to 105.7.....Dantrolene didn't touch him. He had been a 3T, but started responding to pain, even with his pupils like they were.

Anyway, I read an article back a few months ago which you might find helpful, if you get Critical Care Nurse; here's the info.

Sympathetic Storming After Severe Traumatic Brain Injury

Crit. Care Nurse, Feb 2007

I am in a combined MICU/SICU/Neuro/Trauma unit, and would love to read more of other people's particular experiences with neuro patients.

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Specializes in PICU, surgical post-op.

We had a kid in our PICU with NMS. I think he was less severe than what you're describing, though. He was a quad following an MVA, and would get extremely hypertensive and diaphoretic with noxious stimuli. Usually, though, the only thing needed was a good straight cath or some ativan and things would be back to normal.

Those kids are tough though ... something like a wrinkle in the sheet can set them off, and it's often quite the hunt to find out and fix what's bothering them.

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Specializes in Neuro, Critical Care.
I don't have any great words of wisdom for you, but can sympathize.....these patients can change quickly, and tend to be resistant to treatment. I had one last night who jumped out of the back of a rolling pickup truck....huge epidural hematoma with a 3 cm midline shift, pupils fixed and dilated....family made him a DNR and were going to deescalate in the morning.

About 4 this morning his temp went up to 105.7.....Dantrolene didn't touch him. He had been a 3T, but started responding to pain, even with his pupils like they were.

Anyway, I read an article back a few months ago which you might find helpful, if you get Critical Care Nurse; here's the info.

Sympathetic Storming After Severe Traumatic Brain Injury

Crit. Care Nurse, Feb 2007

I am in a combined MICU/SICU/Neuro/Trauma unit, and would love to read more of other people's particular experiences with neuro patients.

Thanks for the reply! I actually read that article just two days ago and printed it out. Im wondering if he was some sort of TBI and we just dont know it? I mean i know if he had a SD or SAH wed see it but we arent positive that he took anything to cause the NMS? We can't really ask him. We doubled his dantrolene and didnt touch him either. We also used bromocriptine. Thanks for the replies!

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Specializes in Neuro, Critical Care.
I don't have any great words of wisdom for you, but can sympathize.....these patients can change quickly, and tend to be resistant to treatment. I had one last night who jumped out of the back of a rolling pickup truck....huge epidural hematoma with a 3 cm midline shift, pupils fixed and dilated....family made him a DNR and were going to deescalate in the morning.

About 4 this morning his temp went up to 105.7.....Dantrolene didn't touch him. He had been a 3T, but started responding to pain, even with his pupils like they were.

Anyway, I read an article back a few months ago which you might find helpful, if you get Critical Care Nurse; here's the info.

Sympathetic Storming After Severe Traumatic Brain Injury

Crit. Care Nurse, Feb 2007

I am in a combined MICU/SICU/Neuro/Trauma unit, and would love to read more of other people's particular experiences with neuro patients.

what type of pt.? i work strictly neurosurg/neruology ICU w/some traumas MOst of the time we get SAH/SDH, malformations...mostly bleeds. We don't see that many CVAs, alothough depending, some of them may go to CICU.

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Specializes in Almost everywhere.
We had a kid in our PICU with NMS. I think he was less severe than what you're describing, though. He was a quad following an MVA, and would get extremely hypertensive and diaphoretic with noxious stimuli. Usually, though, the only thing needed was a good straight cath or some ativan and things would be back to normal.

Those kids are tough though ... something like a wrinkle in the sheet can set them off, and it's often quite the hunt to find out and fix what's bothering them.

I am confused. This sounds like autonomic dysreflexia. Is it different in kids? I mostly care for adults.

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Specializes in PICU, surgical post-op.
I am confused. This sounds like autonomic dysreflexia. Is it different in kids? I mostly care for adults.

WOW. Thank you for the tact in not just laughing me out of the park on that one! I knew there was a reason I don't usually post after a busy day. Total brain fart there. (And I'm looking for an embarrassed smiley, but can't find one, so that's par for the course.) =)

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Specializes in Almost everywhere.
WOW. Thank you for the tact in not just laughing me out of the park on that one! I knew there was a reason I don't usually post after a busy day. Total brain fart there. (And I'm looking for an embarrassed smiley, but can't find one, so that's par for the course.) =)

Hey, not a problem. I just wanted to be sure I was clear because I am full of the brain toots! :lol2: So don't feel bad. ;)

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Specializes in PICU, surgical post-op.
Hey, not a problem. I just wanted to be sure I was clear because I am full of the brain toots! :lol2: So don't feel bad. ;)

aaaand, as of right now, i'll forever be calling them "the brain toots." it's official. =)

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Anyone ever taken care of a pt. that has neuroleptic malignant syndrome??? I had one the other day for the first time...very rare apparently. What was the outcome for your pt.? My pt. has been cataonic for almost 3 weeks.....I was having major issues with him and the docs just didnt know what to do with him, hes not waking up, he's getting worse. We had him on all the standard treatments according to the literature....

Id love to hear your experiences with these pts. I had a heck of a time keeping him sedated, he would have periods (without warning..going from exremely sedated to sitting up, extremely rigid, trying to extubate) of extreme rigidy where his sats would drop into the low 80's, HR into the 140;s and BP over 200 systolic. The docs ordered Ativan drip, morphine drip, pushing versed q10mins. It was awful. I didnt know what to do with him. He was a huge guy and im not so huge and def. not that strong. It took 4 of us to hold him (bc he was so rigid) just so i could push more versed so that he wouldnt extubate and his BP would come down...ugh..as soon as he was sedated properly, his vitals returned to WNL. There was just nothing left to sedate him with. We had him on propofol for 10 days!!!!! I fought so hard to get his sedation switched bc his lipids were through the roof, his urine was the darkest GREEN id ever seen and well he was on 80mcgs/kg/hr and 5 of morphine. Finally after he almost self extubated at the end of my shift I was able to get one of the MDs to switch his propolol to versed and we titrated and titrated and maxed ourselves out and he was worse!!!!!!! By the middle of my 3rd shift he was now on an ativan drip of 10/hr, morph 10/hr and getting versed 5mg IVP q10mins. It was awful. I called every MD in the house by the time my shift was over.

Sorry so long. I really felt at a loss that night. I couldnt find very much literature on this condition and the other nurses on my floor were just as stumped...as were the MDs! We all felt as though we were grasping at straws. So any info would be greatly appreciated!!!!!!!!!!!!!! Thanks for letting me vent.

I've taken care of several NMS patient's. The treatment of choice is Dantrolen, the same as for malignant hypothermia. I am curious why the doc's aren't giving your guys this?

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Specializes in Neuro, Critical Care.
I've taken care of several NMS patient's. The treatment of choice is Dantrolen, the same as for malignant hypothermia. I am curious why the doc's aren't giving your guys this?

they did, the max dose and bromocriptine. Wasnt helping. Poor kid never came out of it. Started following eventually but thats about it.

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