Not another patient with seizures.

[AnthonyM83]

Ah, you posted while I was typing up my post.

Okay, well, I guess it's back to those ice packs at the joints, dressing him down, cool wet towel on the forehead. Watch his airway and continue with assisted high flow O2 ventilations. It's my understanding it just resolves itself usually, but I'd start transport to the ER so they can give him anti-pyretics or other drugs and an IV (altered LOC). Since there's a history of violence, I'd consider having a police unit follow or restraints, depending local procedures. Constantly monitor ABCs.

[chbare]

AnthonyM83, Good, we are working on getting his temp down. Unfortunately, a severe episode of NMS like this is going to need definitive care. There is a high possibility that he may develop a problem that is usually associated with severe dehydration and crush injuries. Your driver takes a wrong turn and now we are in the land of OZ. You have a magic ambulance with all of the ALS supplies and meds you could ever think about giving. In addition you have full laboratory capabilities. What do you want to do about his airway, and what other treatments and tests would you like?

Take care,

chbare.

[AZCEP]

Secure an airway. First and foremost. Bilateral IV's with enough fluid to maintain perfusion. Since we have all the toys here at Land of Oz EMS, I want a Chem panel including BGL, CBC, ABG with and without O2, CXR, and while we're at it a tox screen. It would probably also be a good idea to find out how well his liver is working.

That should keep the lab busy a while.

[AnthonyM83]

Well first off, I'd thank my driver and ask if he could try making a wrong turn into the land of Available Supermodels...but while he find that turn:

I'd start an TKO IV of dextrose. This should help with the hypotension.

For the fever, I'd say acetaminophen or ASA by IV (but I had trouble finding dosing info for IV)...would this change if there were other drugs on-board b/c of liver?

My Google Guide says a dopamine agonists such as oral bromocriptine (2.5mg) and a muscle relaxant such as Dantrolene by IV (2-3mg/kg) until I start seeing symptoms resolve.

You'd want to watch out for rhabdomyolysis (have bicarbonate IV handy).

Lab workup would include CBC, blood cultures, nitrogen, CPK, myoglobin, blood gases, prothrombin/coagulation tests, and toxicology screen for drug use. And a CT to be thorough?

Do we have electroconvulsant therapy on this magic rig?

Also, I would retract my suggestion for restraints because of the fever.

[chbare]

AZCEP, the patient is given etomidate and vercronium iv and intubated with a 8.0 ETT 23 cm at the lip. No epigastric sounds and bilateral lung sounds with good rise and fall. You use capnometry and an esophageal intubation detector as secondary confirmation devices. His sats increase to 100% with PPV and you notice is is much easier to bag now that he patient is paralyzed. IV fluids are bolused and his B/P remains around 110/50, pulse decreases to 105-110 and strong. You also give a benzo of your choice for ongoing sedation. ( why did we not use succnyl... during the intubation?)

CBC-normal except a WBC of 13.8 & neutrophils of 9, SMA 12; Potassium- 5.9, Sodium-133, Chloride- 92, BUN 35, Creat 2.1, BGL 129, and all others WNL. ABG indicates metabolic acidosis. Tox screen is negative. You also decide to run a Ck & myoglobin- Both are very elevated and UA indicates myoglobinuria. CXR is clear with proper ETT placement noted.

What do you think.

Take care,

chbare.

[chbare]

AnthonyM83, no ECT available, but you have your labs. The patient is recieving NS via IV and per a prior post he was given a bolus to increase his B/P. You have got you labs per above and the CT is negative. Dopamine agonist meds are on board. This is a tough case. In fact this was the first thing I experienced during my first day of my first psych rotation in nursing school.

Take care,

chbare.

[TechMedic05]

No succs due to the possibility of hyperkalemia due to the NMS?

Airway = good.

Cooling = good.

I'd err on the side of fluids, possibly even a diuretic, in an attempt at keeping good urine production to help prevent renal failure from the rhabdo. I've heard conflicting stories on whether or not that's actually useful or not, but it's worth a shot.

[AZCEP]

I'll agree with Techmedic. No Sux because of the hyper-K+, and maintain renal function with fluid boluses. Probably a good idea to place a foley and monitor urine output as well.

Any indication of liver failure? Another item that would be useful to keep an eye on.

What does the ECG look like? If there is any widening of the QRS's, we would need to start thinking about treating the K+ level. Depending on the degree of acidosis, it might be reasonable to use some bicarb.

Have to get these deck chairs arranged just so.

[chbare]

Nice job everybody!! He does need IV fluids and his renal status needs close monitoring. His labs and UA indicate Rhabo.., a complication of NMS. He needs a foley, fluids, and diuretics to prevent renal failure. 12 lead shows sinus tachycardia. Good job on catching the sux A potential side effect of sux in addition to hyperkalemia (especially with renal failure) is malignant hyperthermia. I hope everybody had fun with this scenario.

Take care,

chbare.

[TechMedic05]

thanks, chbare! Good scenario!