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Follow Up Rounds

Dr. Idaly Hidalgo and Jenny Luo 8.31.2012. Follow Up Rounds. 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 ?. Case #1. HPI

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Follow Up Rounds

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  1. Dr. Idaly Hidalgo and Jenny Luo 8.31.2012 Follow Up Rounds

  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 soundsand 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 • QTcprolongation, 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. Severe Preeclampsia- Management • 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, Labetalolgtt 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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