Case Study #3

[emtb2rn]

30ish male wheeled to room from triage. Slumped over in wheelchair. Able to move to stretcher with a lot of assistance from 2 staff members. Per parent, pt was "fine today". However, pt went to bathroom, came out, "was not himself, he was lethargic and keeps zoning out, so I brought him in".

Pt responds to touch but cannot or will not answer questions, skin flushed, warm and dry, hr 160, bp 90/50, rectal temp 102.6, rr 28, pulse ox 95. Hx is psych and etoh. Per parent, pt saw psychiatrist this afternoon and was recently released from rehab.

Nu? Whatcha gonna do? Whatcha thinking? Whatcha wanna know and what're your priorities?

Have at it.....

[Esme12, ASN, BSN, RN]

You are on the right track...I think ....with the meds. That alcohol med is antabuse which the patient is on. What about the other meds mentioned?

suboxone, antabuse & seroquel

But even before considering the meds...what is the fist thing we should do with periods of apnea and a low O2 sat?

[Lev, MSN, RN, NP]

CPAP and maybe intubation for the periods of apnea/low o2 sat.

[Lev, MSN, RN, NP]

The suboxone is for opioid dependency and has narcan in it. Maybe the patient didn't take his suboxone? Seroquel is an antipsychotic which can have nasty side effects. Maybe he is having side effects to the seroquel. Are any of these meds new for the patient?

[Roman1]

I am thinking seroquel overdose d/t the anticholinergic effects... Tachycardia, hypotension, flushed, warm dry skin (Dr. Google).

[Esme12, ASN, BSN, RN]

But what should be done?

Fluids of course. O2 of course. Consider intubation. Consider overdose. I would consider neuroleptic syndrome or they drank with the Antabuse.

The temp makes me lean towards NMS neuroleptic malignant syndrome is a rare, but life-threatening, idiosyncratic reaction to a neuroleptic medication. The syndrome is characterized by fever, muscular rigidity, altered mental status, and autonomic dysfunction.

Since I mentioned it what is the drug used for NMS with hyperthermia?

[Lev, MSN, RN, NP]

But what should be done?

Fluids of course. O2 of course. Consider intubation. Consider overdose. I would consider neuroleptic syndrome or they drank with the Antabuse.

The temp makes me lean towards NMS neuroleptic malignant syndrome is a rare, but life-threatening, idiosyncratic reaction to a neuroleptic medication. The syndrome is characterized by fever, muscular rigidity, altered mental status, and autonomic dysfunction.

Since I mentioned it what is the drug used for NMS with hyperthermia?

Would the muscular rigidity make his BP go up, not down?

[emtb2rn, BSN, RN, EMT-B]

cpap with possible ams? Might not end so well, but intubation, now that's a good move.

Sinus tach in the 120's to 130's is the rhythm after a hefty fluid bolus through those 18's in the ac.

[scottaprn]

Sat of 89 and periods of apnea- intubate

Pan culture, cbc, cmp, troponin, lactate, acetamenophin, salacitic. A CK level to help rule in or out NMS.

A full head to toe looking for track marks, signs of infection, and assess for purpura and tissue perfusion.

Fluids- 30 ML/KG over 30-60 minutes to start and see the response-more fluids if hypotension improves but have vasopressors ready if not.

Lets gets CVP monitoring going with a goal of 8-12.

Fever- external cooling blanket and ice packs in axilla.

Emperic Antibiotics- Start within the first hour.

[AmyRN303, BSN, RN]

But what should be done?

Fluids of course. O2 of course. Consider intubation. Consider overdose. I would consider neuroleptic syndrome or they drank with the Antabuse.

The temp makes me lean towards NMS neuroleptic malignant syndrome is a rare, but life-threatening, idiosyncratic reaction to a neuroleptic medication. The syndrome is characterized by fever, muscular rigidity, altered mental status, and autonomic dysfunction.

Since I mentioned it what is the drug used for NMS with hyperthermia?

Dantrolene. I remembered it then googled to check :)

[libran1984, ASN, RN]

Omg! This was so much fun!!!

[LadyFree28, BSN, LPN, RN]

Dantrolene. I remembered it then googled to check :)

Thank YOU!!

That's what I was thinking about earlier!

[emtb2rn, BSN, RN, EMT-B]

We addressed the fever with tylenol 650mg pr. Pt was tubed to protect airway. And the doc was real interested in what csf might look like.... So what do think happened after tubing?