Dr. Idaly Hidalgo and Jenny Luo 8.31.2012. Case #1 AH 3108356 7 yo male with hx of ADHD presents...

FOLLOW UP ROUNDS

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 of “throwing up and turning blue” while sleeping.

What would you like to know?

Case #1

HPIPatient 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.

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.

Case #1

Deniedabnormal movement or incontinencerecent traumafeverheadachesick contact

ROS otherwise negative

Case #1

PMHxADHDODDImmunizations UTD

MedsRitalin (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

Case #1

FHxBrother- ADHDMother- Asthma

SHxLives with mother and three older brothersNo one else in the household takes

medicationNo history of child abuse

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 LADLungs: slow and shallow, RR 12. CTABCV: HR 60, s1s2 nlAbd: Soft, NT/ND, +BSNeuro: lethargic, orientedx3, CNs II-XII intact, motor 5/5 upper

and lower extremities, steady narrow based gaitSkin: no rash or lesions

What would you like to do next?

Case #1 During the exam patient was placed on the

monitorrepeat vitals HR 58 BP 110/65 RR 10 @86%patient lethargic, arousable by painful stimulionly complaining of being tiredO2, IV access and labs, EKG in progress

Obtained medication bottle from mom, it is labeled methylphenidate hydrochloride 5mg.

Case #1

Labs?

Imaging?

EKG?

Case #1

LabsCBC: 13.7>12.1/37.6<323BMP: 136/3.9-100/26.8-6/0.5<103 Ca 9.8PT10.4 INR1.1 PTT24.8UA: Yellow, turbid; SpGrav 1.025;

unremarkable

EKG- sinus brady 56

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

Case #1

Methadone Hydrochloride 5mg

What would you do next?

Opioid OD Signs

Decreased mental status, respiratory rate, tidal volume, bowel sounds and pupil size

TreatmentABCNaloxone

○ competitive antagonist to all opioid receptors. ○ onset of IV naloxone is 1-2min, duration of

action 20-90min.

Opioid OD

Naloxone dosingOpioid-dependent with depressed mental status but

minimal respiratory depression – 0.05mg IVNon-opioid-dependent with depressed mental status

but minimal respiratory depression – 0.4mg IVApnea or near apnea- 2mg IV Q3min until maximum

dose of 10mg or improved respiratory statusDue to short duration of action, multiple does or

continuous infusion may be necessary. ○ Infusion rate= (2/3 x wake up dose)/hr

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

Case #1ED course

○ Naloxone 2mg IVP x1Patient became very agitated, but his v/s improved

○ Poison control notifiedrecommend observation for 24hours and at least 4

hours after stopping continuous infustion

○ Hospital administration notified○ Admit to PICU for airway monitor and

naloxone drip.

Case #1

Hospital CourseNaloxone drip started at 0.5mg/hr and

monitored for changes in mental status, respiratory depression and cardiac abnormalities.

Drip weaned off over 16hrsTransferred to floorDischarged on HD#3

Case #1

Take Home PointTrust no one!

Case #2

TH 03573339

34 yo F presents to ED with headache and AMS.

What would you like to know?

Case #2

HPIPatient 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.

Case #2 PMHx

Gestational HTN PSHx

C-section x2 Meds

Labetalol 300mg POIron supplements

SHxDenies tobacco, alcohol and illicit drug use

FHxNoncontributory What would you like to know on PE?

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?

Case #2 Labs

CBC: 9.1>8.7/26.6<265BMP: 140/3.6-104/24-11/0.8<80LFT: WNLTrop <0.01, CPK 174 UA: trace protein

ImagingCTH: normal, no acute hemorrhage,

hydrocephalus, sulcal effacement, midline shift or mass effect.

CXR: normal, no cardiomegaly

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

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

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

Severe Preeclampsia- Management

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

Case #2

ED coursePatient 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 consultPatient admitted to MICU

Case #2

Hospital CourseHD#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.

Case #2

Take home pointPre-eclampsia can occur postpartum Patients will elope no matter how sick they

are