RnR Rounds Podcast

Air transport

Takeaways:
☙ Remain objective
☙ Risk associated with transport medicine when untrained.

Advocate for optimal patient care—Sometimes, this can be the opposite of advice given by a specialist.
- Have open and constructive communication.
- Question if there are dose differences to make sure there isn’t a communication error

Generalist opinions are not inferior to specialist opinions—they are collaborative, so raise concerns if something doesn’t fit.
“The first one to plead his cause is right until his neighbour examines him.”

CASE
20yo with TBI moved to tertiary centre 900km (2.5h flight away)

☙ First consult – neurosurgeon requests patient not intubated and keep that way if possible. ---Stated that intubation will increase ICP.

I picked up the patient and explained to the ED physician about the plan – the patient was on propofol and midazolam. Pt fought sedation the whole time.
- The flight was through a thunderstorm. Unable to monitor pt properly.
- Intubation at this point is impossible due to turbulence
- Ran out of propofol – had to change medications.

The nurse and RT at the receiving hospital questioned why the patient was not intubated and was preparing to intubate before leaving.

With gaining experience over the years would have questioned the orders better.

**Understand your knowledge gaps and find ways to improve education.
☙ Some provinces do not have transport services that support patients. Sometimes, you might think you should go on the transport, but use caution.
☙ If you go on a transport, you are entering an unknown environment, have no idea where any supplies are, and are not working with the typical team you are used to. This causes a safety hazard to the patient with not fully understanding the environment.
- Best to wait and stay in your environment and wait for the proper transport team to arrive.

Case

EMS brought in 62yo male post-arrest hooked up to monitors in the ED. Sudden collapse found by a bystander and 7min EMS response – worked patient for 10 min for an estimated total downtime of 17 min.
BMI 21 weight - 60kg
No significant med history
Acting normally before collapse.

Vitals
☙ BP - 110/90
☙ Pulse - 92
☙ Temp - 36.4
☙ Igel – resp BVM -12
☙ SPO2 -100 on 10l
☙ ETCO – 25 good waveform

Pupils fixed and dilated @ 10mm with no reaction
Agonal resp no purposeful movement
Consult to move patient to tertiary hospital – receiving physician asking for intubation for transport.

Anatomical airway checks – good

Induction medication
- Ketamine (reduced dose) 1mg/kg – 60mg
- Rocuronium – no concerns with prolonged paralyzation (60mg)
- Succinocholine – unknown what potassium and renal function is – not used.

Not a time-sensitive urgent intubation. No anatomic or physiologic contraindications
- Patient pre oxygenated
- Position on the stretcher is good
A – Direct look
B – video look
C – fallback to supraglottic airway
D – cricothyrotomy

☙ Post intubation, Ketamine and Rocuronium will provide a 30-40-minute window to start infusion or prep ongoing boluses.
☙ If a ventilator is present its good to have it on standby if transport is not readily available

Have airway equipment checklist – use your own that you are familiar with and have modified based on experience.
Equipment:*
- Suction
- BVM
- Ventilator
- Ongoing sedation plan
- O2 source
- Syringe for inflating ET tube
- Lyrigoscope – proper blade and functioning light
- Backup airway – iGel, oral airways
- ET tube holder
- ET tube

NIBP – now dropped 62/30
Pulse check – unknown
EMS is still on scene

POCUS – to confirm cardiac functioning. Clearly beating. LV beating well and squeezing well. Good stroke volume. Mitral valve, not a full excursion. EPSS – Ejection fraction around 40%
- Don’t start CPR in this case it will hinder pt care
- BP likely due to EF of 40%

Intubation is no longer a priority at this point – Cardiac stabilization is now the priority.
- Need to improve Mean Arterial Pressure (MAP) to neuroprotective levels

MAP target – min of 65 for adults at risk to protect the heart. Min MAP of 70 to protect the brain.
MAP of 70 target for this patient.

Neuro –In closed head injury, cerebral perfusion pressure (CPP) equals MAP - ICP. normal ICP is 7 -15 mmHg. This pt could have a head injury (with blown and fixed pupils bilaterally) with increased ICP. If the patient had ICP of 40 – 70-40=30

Current MAP 41 – use POCUS to rule out inferior vena cava – no collapsing completely – no preload dependent. IVC is not fully distended – not obstructive shock
- No clinical signs of bleeding or fluid loss – FAST scan

Consider cardiogenic shock (known element in this case) and neurogenic shock
Neurogenic shock – depressed brain stem - dilated pupils – consider vaso pelagic and blood pooling in legs and not returning to heart as well as could be.

Do you want crystalloid? (pt received only 200ml Lactated ringers at this point)
- No signs of overload (can use ultrasound to check lungs for pulmonary edema) reasonable for 1L bolus of LR and reassess
- Cardiogenic shock management – assists the heart in returning to normal parameters of function. HR and BP within normal ranges. Target into the normal range

Think about heart function in 4 steps.
1. Preload – want preload optimized – meaning plenty of fluid upstream for heart
2. Chronotropy – how quick is the heart beating optimal 60-80bpm
3. Inotropy – how much is heart squeezing (Frank Stirling) – can use vasopressor
4. Afterload – MAP of 70 – don’t want excessive as heart is having to work harder to overcome resistance.

Vasopressors
- Norepi – good choice - more alpha effects improve preload. Also has beta effects, which increases inotropy through actin myosin troponin system. Good for supporting cardiac activity. Does take time to mix and get running.
- Phenylephrine – pure alpha 1 agonist. Help with preload. 200mcg bolus (large dose)
- Repeat BP – Map improved 41 – 62

If critical BP, start with a larger dose. If BP/MAP ok then start with lower dose (norepi starting dose started at .05mcg/kg/min). The MAP doesn’t improve with the initial nor-epi dose and after 3 min MAP still at 62 – increased norepi dose by doubling the dose to 0.1mcg/kg.min and MAP increase to 67 - let BP recycle over the next few min and MAP decrease to 64. Double nor-epi dose again to 0.2mcg/kg/min – MAP improved and maintained at this dose.

Intubation now that BP stabilized
- Ketamine – SIVP that can sometimes destabilize cardiac function
- Rocuronium

Tube confirmation
- Tube misting
- Auscultate bilateral apex
- ETCO2
- Secure tube

Sent Janelle went with EMS and premade syringes of ketamine 50mg/ml – 1ml q 5 min if needed and phenylephrine 100mcg/ml q 5 while titrating nor-epi.

Try to catch changes early and manage with smaller doses versus having big swings in patient stability and struggling to catch up

https://www.ahajournals.org/doi/full/10.1161/circulationaha.107.728840

Discussion of what it is like being a rural physician with limited resources.

Objectives:
- Challenges in low-resource settings
- What is a resource-setting
- Lessons learned working in low-resource settings
- Review and compare the management of cases in resource-abundant and limited settings
- Discuss different cases
- ED peer-to-peer programs

What is a low-resource setting?

- It means different things based on where you are. One site might have different options compared with another site.
- There can be a lack of staff, high turnover, locums coming and going, challenges to continuity of care, and a lack of equipment, imaging, medications, specialists, and experienced practitioners. This is not just for remote areas. Consider urgent care centers in Calgary, AB – run by GPs with some imaging capabilities (x-ray), limited lab, no specialists, but still considered an emergency department.
- Rural vs. Remote: Rural areas refer to areas with a lower population and less infrastructure and might be more accessible with clear routes to urban sites. Remote areas are distant or hard to reach due to geographical challenges with less clear routes to urban sites.

Challenges working in low-resource settings

- The main problem is that it is lonely, with no colleagues nearby to lean on for support -No elbow support.
- No PT or OT, no RT. Your managing intubation and supporting pt aftwars. Huge reliance/dependence on transport and at the mercy of weather as well as transport crew schedules (pilot timeout). No imaging support.
- Wearing multiple hats – ED doc to hospitalist if you are the only physician on and need to admit a patient. Learn to test wisely vs sending them out – consider admitting and observing over night vs transport.

Lessons Learned while living in low resource settings

- Learn to live with uncertainty but realize that help is only a phone call away
- POCUS skills are paramount.
- Rules of care and standard of care change based on location.
- Changing practice and location – helps with burnout.
- Know where you are transporting to. Depending on where you are in remote settings closest ICU may be hours away and require multiple modes of transport.
- Might have to use a community pager – where other allied health care call looking to consult for support.

Review and compare management

- Tylenol OD with no labs – draw the blood and send the patient out to a level 1 facility. start the treatment you are not going to be able to wait for the labs to come back because they have to be flown out – likely with the patient.
- Diverticulitis or renal colic with no imaging without an acute abdomen. Bring the patient back the next day to reassess. If the patient's condition worsens, then transport.
- Appendicitis – used POCUS – sent photo to the surgeon to consult and recommended patient transported.
- Compartment syndrome – fasciotomy with ortho consult and permission on the phone and through video.
- Airway management – learn ventilator and know settings. You will miss RTs
- Sepsis – start antibiotics, blood work and cultures – come back in a couple of days.
- Form 1 – Consult psychiatry to determine if the form can be lifted or maintained.

Discuss different cases (see photo below)

- Medivac vs schedivac
o Medivac needs to happen ASAP.
o Schedivac – scheduled appointment.
- prioritize patients transports and bypass to more definitive care if needed.

ED Peer-to-Peer
- Call another ED colleague to receive collaborative support.
- The challenge is that rural practice is lonely. Recognized the need for 24/7 support and that more practitioners might be willing to take rural shifts.
- Two heads are better than one, and it is nice to have someone not directly involved in the case providing feedback.
- Helped to keep people in the community and avoid unnecessary travel.
- Consults can vary in complexity and sometimes can be just a simple review of a case.
- There is an increase in the uptake of locums, and practitioners report feeling more supported in the community.

EMS brought in a 62-year-old female with altered LOC from a motel room surrounded by pill bottles, blister packs, and a bottle of helium. It is thought to have been ingested within the last two hours. The patient had previously admission to the hospital for suicidal ideation. EMS and police brought all medications, and the staff was able to identify 10 of them.

☙Perindopril, primidone, sertraline, rosuvastatin, trazadone, b12 quetiapine, aspirin, bisoprolol, and Ativan.

Bisoprolol - most concerning.
☙ HR 70
☙ BP 110/65
☙ R – 16-18
☙ Sp02 – normal – no supplemental O2 given at this time.
☙ T – normal
☙ BGL – normal

Patient initially protecting airway, answering 1-2 words, but increasingly became drowsy.
☙ ECG, IV, Fluids

Estimate tablets were taken and consult with poison control.

HR and BP did start to decrease. Lactated Ringers bolus given vasopressors drawn up. Intubation due to increasing drowsiness, and vitals trending wrong way and suicide note left and intentional overdose. Narcan was given to rule out possible narcotics.

Poison Control – Priority treatment for bisoprolol (21 tablets at 105mg each estimated to be ingested) and concern for hemodynamic consequences.
- Suggested decontamination with charcoal via NG tube due to believing pt ingestion was around two hours before arrival. 125g activated charcoal to start.
- Bolus of IV fluid, and if BP continued to decrease, to give norepinephrine.
- Calcium Gluconate – two amps.
- If Norepinephrine is ineffective - start with high-dose insulin therapy – giving a bolus of 1unit/kg of regular insulin and following up with a continuous infusion of 1unit/kg/hour if no improvement in hemodynamic stability titrate up a unit/kg/hour, every 20-30min to a max of 10units/kg/hour. Given with dextrose as well (rare to see glucose drop precipitously – monitor glucose and serum potassium)
Insulin used to treat heart metabolic problems not glucose in this case – has positive inotropic effects and stimulates myocardial glucose metabolism and lactate intake
- Primidone, trazadone, Ativan – sedatives – concerns for respiratory status – managed with intubation.
- Aspirin – monitor for toxicity – in this case, initial and repeat serum aspirin levels were negligible.
The patient was not on high-dose insulin for long – DC in ICU.
Poison Control algorithm on website. https://www.ontariopoisoncentre.ca/siteassets/pdfs/english/beta-blockertreatmentalgorithm.pdf

Initial management of patient considered in steps:
1. IV, O2, monitor, glucose, ECG, IV fluids
2. Decontamination with charcoal
3. Starting Vasopressors
4. High dose insulin
5. Lipid emulsion therapy – did not get to steps 5 & 6
6. ECMO

Learning Points
1. Many drugs can produce low and slow toxidrome (bradycardia and hypotension) – Beta-blockers, calcium channel blockers, digoxin, opioids, clonidine, and drugs that fall into the sodium channel blockers category. If seeing a patient with bradycardia and hypotension without concerns of toxin consider – hypothyroid, hypothermia, post MI, spinal injury, hyperkalemia.
2. Activated charcoal is advised with beta-blocker OD if it is within 1-2 hours of ingestion.
3. Specific treatment - Calcium is recommended for cardiac membrane stabilization and high-dose insulin. Insulin bolus is given in tandem with D50W then 1 unit/kg/hour. Continue to monitor glucose and potassium.
4. Vasopressors may be indicated. If you can do POCUS and notice decreased heart contractility, consider epinephrine. If contractility is normal, consider norepinephrine.
5. Lipid emulsion therapy – on poison control website
6. ECMO – last step consider transport options early if not located close to site with capabilities

CASE:
30yo female brought in by EMS seizing. 39 weeks pregnant – Eclamptic seizure till proven otherwise.
The roommate heard a thump and witnessed the patient size – approx. 30s tonic activity, no clonic activity.

EMS – semi combative – 5mg midazolam given. The patient vomited – 4mg ondansetron was given.

ED – partly sedated and partially agitated.
Unable to obtain NIBP due to patient agitation
P - 123
SPO2 -98%

Magnesium 2g over 5 min using syringe due to poor IV site. While attempting other access managed to obtain 4 more sites.

CBC, lytes, creatine, LFT, INR
Consult obstetrician – LDH, urate, fibrinogen, haptoglobin
2g magnesium was administered again

Total 4g mag

Still agitated and requiring restraint.

30mg ketamine given – with minor effect
20mg ketamine given – Patient settled down – NIBP 125/95

Put in foley catheter
Obtained fetal HR – 160
NST machine brought down – good baseline with slightly decreased variability, which is not unexpected with giving the magnesium.

Ankle clonus when compressing ankle 6-12 beats
Patient starts to come around and is more responsive – confirms no prenatal care sought out.
Patient not found in provincial records. Family physician at site was helping and able to find some records of her coming with concerns of being pregnant (which were positive) and no further follow up of any further care found.
24 hours later, patient delivered.

Medscape review
☙ The main priority is to stop seizures
o First-line drug - Magnesium 2-4g given over 2-5 min
o Benzos (midazolam or lorazepam) 2-5mg IV over 2-5 min
o Phenytoin – if mag is contraindicated (hypermagnesemia), benzos and phenytoin become the main drugs
☙ Second priority control hypertension
o Systolic over 160 or diastolic over 110
o Hydralazine 5-10mg over 2 min or labetalol IV 20mg
o Goal is to maintain BP systolic 140-160 and diastolic 90-110
☙ Supportive care
o Consider the need for intubation – especially if given lots of benzos
☙ Definitive care for pre-eclampsia or eclampsia – is Delivery if not managed medically
☙ Consider steroids for preterm deliveries, BUT consult before giving as there is a narrow window to deliver the baby after the medication has been administered.
Consult with the obstetrician
☙ Do not want to give more than one dose of steroids, and delivery should happen within 24 hours of steroids.
- Small window of opportunity to delivery
 o Betamethasone 12mg IM q24 hours x 2 doses – ideal
 o Dexamethasone 6mg IM q12 hours x 4 doses
☙ Premature rupture of membranes – Give steroids. Still, consult with OBGYN

Laura Dunkin

Two patients arrived both approx. 20yo. One male on female by EMS

Decreased LOC. Respirations ok. No obstruction. Unknown how long they were presenting like this. Mom found them sleeping in the basement and couldn’t be roused

Soft BP around 100 systolic and lower HR in the 50s

Priority is to triage

Female resp rate decreased 8-9

Male resp 12-14

Narcan by EMS – no effect

BGL – normal

Pupils normal

GCS 7 – female.

Afebrile

Repeat Narcan – no response

☙ IVs established and some fluids given due to soft BPs

☙ Labs – VBG, septic workup, serum and urine

Male – more stable GCS, not as severe, with good respirations.

Female intubated – set up transport.

☙ Intubated with roc and ketamine – airway clear

No indications for narcotics or alcohol use

Friend talked to pt mom and informed them they took GHB and mom called hospital. Transport in timely manor

Outcome for female – extubated later that night and had a good outcome

GHB – used to increase intoxication feeling.

- Less calories. Common in bodybuilders to enhance intoxication without additional calories of alcohol.

Patient - young man brought in by EMS CPR in progress (during COVID). PEA on monitor – no vitals. Appeared pale and cyanotic – EMS had a suicide note and a bottle of sodium nitrate from the patient's residence.

Staff were able to contact a colleague who was a toxicologist specialist for advice. It took an extended period to get poison control on the phone. The patient was intubated, and multiple lines started.

Recommended starting Methylene blue started (color of blue ink) started running right away and continued with CPR. The patient started turning blue as infusion began circulating. Redosed q 5 min (5-6 doses total) – after 45 min of CPR patient remained in PEA and time of death was called.

Concerns for how the patient was able to obtain it and suspect possible online purchase? Unknown how patient was able to obtain sodium nitrate

☙ Sodium Nitrate (nitrates) causes methemoglobinemia. The Fe2+ (healthy) atom in hemoglobin is oxidized to Fe3+ rendering the molecule unable to carry oxygen efficiently. Methemoglobinemia turns RBCs a chocolatey brown colour but seen through the skin, appears as a profound cyanosis
☙ Methylene Blue treats methemoglobinemia by reducing the Fe ion back to 2+. Thus despite being a richly blue colour itself, it actually helps to resolve cyanosis in this context.

What is Resuscitation – making clinical decisions based on limited time and information – gambling essentially.

☙ The sicker and more unstable they become, the greater their risk.
Be comfortable with making important decisions with limited information and accepting the risks you may make the wrong decision and that sometimes there is harmful outcomes
- Know that failure to act and decide is also a choice and has its own consequences.

☙ Be aggressive when resuscitating – especially pre-arrest patients
- Delay in treatment and loss of pulse results in damage control and trying to recover with minimal brain damage if possible.
- There are no black-and-white recommendations in pre-arrest patients
- there is a risk of having underlying causes that lead to death based on the treatment given.
- Identifying anything time-sensitive - don’t delay
Ex:
☙ Anaphylaxis or sepsis – once identified or high suspicion – treat!
☙ Toxicology – treat with activated charcoal if possible
☙ Toxic shock – remove (replace if needed with clean dressing), use caution with abx in this case.
☙ Critical Bradycardia – give atropine.
☙ Critical hypotension – start a vasopressor (whatever you have or are comfortable with to start) to stabilize and switch to a different pressor afterwards if needed
☙ Look at H’s and T’s for initial diagnosis and treat quickly in ACLS

Slower decline patients in delirium
- Small dose of ketamine to help sedate
Phoning a friend – causes delays of min 5 and greater – attribute the harm that comes with delays.

Protocols of resuscitation
IV fluid – 2 L of fluid – much time spent on what fluid to give and how fast to run it in – Don’t delay other treatments on fluid. Other times, there are other more effective treatments than just fluid.

☙ Think ahead to be ahead – while waiting for transport, think about what is coming next – transport. Try to be two steps ahead of where the patient is at. What might the patient need next – set up for airway, set up for vasopressors and pump programmed ready to go, get d-fib pads on if cardiac issues arise (ex. STEMI or arrhythmia patients)

☙ Think about barriers to transport!
- What can you do to expedite the process? Team arrival is not the saviour.
- It’s the destination the patient is going to.
- The goal is to help the transport team as much as possible.
- Delaying basic interventions can be detrimental to patient care and delay transport to definitive care.
Ex. What drugs are the patient going to need and get them going prior to transport? If you can give them meds before transport and reduce the amount needed in transport, that would be better.
- If IV is not reliable, then start another. Consider a central line or IO.
- Heavier sedation during transport is normal due to the amount of stimulation experienced during transport.

Resuscitation is rarely black and white where you know 100% what to do. Get comfortable with having a limited picture and play the odds and probability of the patient's best interests.

☙ Analysis Paralysis is how you lose at the resuscitation game.

☙ Get comfortable with being uncomfortable

Case

55yo male previously diagnosed with major depressive disorder (MDD) being treated with fluoxetine and going through marital problems with worsening mood.
- Took 10 -15 tablets immediate release Asprin 325mg – no co-ingestion

Time to assessment is 2 hours post-ingestion and feeling at baseline during the exam. Vitals normal. Physical exam normal. No activated charcoal was given due to the time elapsed.

☙ Toxic ASA levels 150mg/kg – pt toxic dose is 12,000mg. Pts reported dose is 3000mg based on the 10-15 tablets reported.

Patients Serum level - 3.65mmol/L reported back from the lab – Critical value.

☙ Management
- If no toxicological level is available but the patient is presenting with s/s of:
- OD (ex., tinnitus, hyperventilation, vomiting, seizures, respiratory distress, hyperthermia), these are good clinical clues.
- ASA level of greater than 3.5mmol/L
- Presence of metabolic acidosis

Endpoints of therapy (3 points that all have to be met)
- ASA level of less than 2.2mmol/L
- Two consecutive ASA levels of declining trend
- Clinically patient must be doing well

ASA OD – thinking ahead
- If you think it is serious – start arranging for dialysis ASAP
Call Poison Control – alkalinization process of urine
- Prepare bicarb drip – take 1L D5W and remove 150ml and use 3 amps of 50ml bicarb to replace fluid then run at 1.5 times fluid maintenance rate up to a max of 200ml/h.
- Monitor urine output of 2-3 ml/kg/H – TARGET output
- Insert a foley – empty urine in the bladder for a baseline for patient's physiology and monitor exact volume and urine testing.
o Check urine q2h for pH and serum blood gas, potassium, and salicylate levels.

Specific targets are harder to get the more serious the cases (which is why dialysis consideration is so important)

☙ Targets
 Urine pH >7.5
 Serum Potassium < 3.5-5 role is for the urine alkalinization process.
 Serum pH <7.56
 Serum salicylate aims for <2.2 with two continuously declining levels

At the 5–6-hour mark, the repeated serum level was 3.92, and the patient started getting nauseous, diaphoretic, tachypnea, and tinnitus, and resp alkalosis (at worst presentation)
Within 36-48 hours, the patient was treated effectively and resolved all levels. No dialysis was required.

Buffalo Attack

It is a very remote site, a 5-hour drive to tertiary care. Patient is two hours further away from the site.

Buffalo throws the patient to the ground, and the patient lands on his back, the buffalo hits him in the chest with his head, then gores the patient to the left chest (around the 6th rib midclavicular). The patient also gets gored in the back of their legs.
- Large open chest around 20cm x 10cm following along the rib with lots of red subcutaneous tissue exposed (no sucking chest wound). Concerned for femur fracture in the left leg.

Pt has minimal pain with minimal analgesic (100mcg fentanyl over 2 hours). Spo2 95% HR and BP with in normal limits – no signs of early shock

50yo male with a higher BMI of around 33 and otherwise healthy.
- ABCs normal. No head or neck pain. Only pain to central chest (not the gaping chest wound) and back pain and pain to the legs

Priorities – transport to greater care.
- Concern for pneumothorax – ultrasound had no lung slide but doesn’t necessarily mean pneumothorax when you can’t see the two plural lines moving opposite each other.
- Ultrasound is sensitive to pneumothorax - look for lung point – on ultrasound you can see one side apposition of plura and see it sliding and the other side where you see the absence of sliding. Looking where the visceral pleura is peeling off the parietal pleura. Tracing out the margins of that, you can see how large the air bubble is.
- He does have a small pneumo – so consider treatment – does patient really need large chest tube? Used small pigtail in this case.

Central chest pain – ultrasound used to look at bony context – found sternal fracture.
Concern for internal bleeding – placed patient in Trendelenburg to see if there was any fluid in the abdomen. It would be caught in the area of the diaphragm to see early detection – nothing major found.
Long bone fracture – linear probe used to follow the cortex of the bone. Not superior to X-rays in long bones. No fracture was noted.
Heart – able to look in subxiphoid and parasternal – no pericardial effusion or mechanical issue. No signs of obstructive or hypovolemic shock.
Within a short period of time, ultrasound was able to rule out very dangerous concerns
CT scan available – verified all found on ultrasound.

Take home points
1. Stay away from wild animals! Fatalities typically come from species that don’t get the attention. It’s typically from the “cute and fuzzy” animals.
2. Consider the amount of force that these animals can cause.
3. ABCs, ATLS and getting pt set up for transport most important.

CASE - 28yo female brought in via EMS with GCS 3 who was at a bar with friends and family, she went outside to have a smoke and was found unresponsive (unwitnessed) in the middle of the afternoon. No suspected foul play.

No meds or med hx
Vitals with EMS
P – 88, Spot 98% on RA, T – 36.8, BP – 120/80, R – 16

No known risk factors – no drug use, was out with friends and family had some alcohol.
Well dressed, well groomed, no track marks

Exam: No muscle tone, pupils slightly miotic (but not obvious) but reactive. Full breath sounds, no snoring resp or vomitus. Strong pulses, chest auscultation unremarkable. Abdo is soft, the neck is supple, no obvious trauma, and moist mucous membranes. No spinal concern – no step-off concerns. Good rectal tone. No discernible reflexes

Appears to be in a deep sleep.

Review ABC’s, IV access, airway stable at present.
BGL – normal, empiric Naloxone – started with .4mg and increased to 1mg up to 2mg no response.

CT scan – normal - Patient intubated after scan
Labs – VBG lactate, extended electrolytes – all normal. Tox screen came back after patient intubated with Ethanol 118mmol/L

Consulted with ICU – review of common issues - hypoglycemia, intracranial issues, opioid overdose? None found.

Collateral history - Sister reported to EMS that patient had only been drinking alcohol with no other substances. Reports that patient is a heavy drinker (family unaware)

Sedated with low doses of propofol and fentanyl – patient started waking up quickly and decided to increase sedation while figuring out story. Patient later extubated in ICU once no other concerns cleared and story continued to check out.

Toxic Alcoholism typical concerns:
- Tachypnea – underlying metabolic acidosis – till VBG comes back
- Seizures, especially if serum tox can confirm.
- Serum tox screen ethanol and serum osmolality.
- If no CT - need transport to rule out.

Case - 32yo male with a history of Major Depressive Disorder(MDD) and taking Sertraline and bupropion.
- Referred to ED from PCP presenting with loose diarrhea for last 10-12 days – concern for electrolyte abnormalities
- No complaints of fever, vomiting, abdominal pain, appetite intact, jaundice. No recent travel or sick contacts.
- Lost a few pounds from having loose stool.
- Cognitive fog for 2-3 weeks. Vitals normal with heart rate on the higher end around 94bpm.

Agitated and slightly tremulous. Dilated pupils and cranial nerves are normal. Skin normal. Has hyperreflexia - No clonus or rigidity

Differentials
Toxidrome, sympathomimetic? Opioid or ETOH withdrawal? Medications? Encephalitis? Hyperthyroidism, any overt electrolyte abnormalities with concern for hypercalcemia *Rhyme Bones, stones, abdominal groans, and psychiatric overtones

Labs – normal, urine drug screen normal.

Looked like he was hopped up on coffee. Similar presentation to a patient who was on venlafaxine who had a dose change and had serotonin syndrome

This patient's medications were stable with long-term use and no recent changes.

Categorize serotonin syndrome based on spectrum and adjust treatment accordingly.
- Mild to moderate presentation – agitated, appears heavily caffeinated, has brisk reflexes, and can have GI involvement.
- Severe presentation – Hunter Criteria – Hyperthermia, unstable vitals, altered LOC, increased tone in muscles, Clonus. Requires Benzodiazepines

Antidote – Cyproheptadine
Have a multidisciplinary approach to treatment - Call poison control, ICU, psychiatry

Recreational drug use – cocaine can be a big precipitation, and opioids (tramadol/fentanyl) can also contribute use caution when doing procedural sedation
MDMA or any other serotoninergic agents
Ondansetron, cyclobenzaprine, and dextromethorphan can interact

Patient Management – conservative measures, small dose of benzodiazepines, decreased medications to ½ dosages and ensured good follow-up afterwards. Didn’t want to stop meds completely as they helped with his mental health

Clinical diagnosis – no labs or imaging to confirm.
- Keep alternative pathology in mind
- Anticholinergic, EtOH, recreational drugs, hyperthyroidism
- Hunter Criteria
- Distinguishing from other etiology’s such as neuroleptic malignant syndrome (NMS) or malignant hyperthermia
NMS – more ridged type presentation vs serotonin syndrome being hopped up on coffee appearance with brisk reflexes and jumpy.
Malignant hyperthermia – typically from recent anesthetic meds in history.

Volume 04:

Quick Links:

Volume 04: #076 - present

087 - TBI @ 18,000 Feet

086 - Post ROSC Resuscitation

085 - Cases from the Great White North

084 - Beta Blocker OD

083 - Eclamptic Seizure

082 - OD with unknown downer

Laura Dunkin

081 - Sodium Nitrate Overdose

080 - How to become a better Rural Resuscitationist

079 - ASA Overdose

078 - Buffalos and Benzos

077 - Alcohol Toxicity - Tox 3 Mini-series

076 - Serotonin Syndrome - Tox 2 miniseries

Description: 30 Minute Video from UBC-CPD's GPA Refresher Course (2021)

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