Posted: 9/12/2016 8:18:25 AM EDT
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39M brought in by EMS, found unconscious/unresponsive on a street corner, no response to narcan. He kept clenching when EMS attempted to intubate, for which they gave him versed (probably 5mg IM) which did nothing. He arrives... N: GCS 3, pupils 6mm, non reactive CV: HR 160-190, BP 50s/30s on scene, 70/40s on arrival P: poor insp effort, not protecting his own airway, RSI on arrival GI: 500ml green nonbilious output via OG (slushy... or listerine?) GU: 130-150ml uop after 3L chilled crystalloid, Tcore 41.9 (!). Utox (-) MSK: Gastroc clonus before rsi and sedation ENDO: FSBG 143 ID: urine was clean, cxr was clean, no stool, no murmur, no wounds. I think Tylenol finally broke the temp. Initial lactate was 16, 3.5 after fluids. Everything else was surprisingly unremarkable. He was on CRRT last I saw.
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Originally Posted By TheGrayMan:
Serotonin syndrome would not be my first thought on that patient. Mine neither, unless I was suspicious he ODed on an SSRI or SNRI. You are kind of saying that you are going to offer supportive care when you call it Serotonin Syndrome. I'd want to makes sure there was nothing else going on first. I did have a case of NMS on my unit this week. Resolved shortly after stopping Haldol. Don't see NMS too often anymore. |
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Originally Posted By TheGrayMan: Serotonin syndrome would not be my first thought on that patient. No? We had some collateral information and a med list from one of our county mental health agencies that showed access to serotonergics. That, along with the clonus, pupils, and temperature moved it higher up on our list, and as I recall much of the rest of his workup wasn't turning up much re: labs or imaging. |
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Originally Posted By AGW:
No? We had some collateral information and a med list from one of our county mental health agencies that showed access to serotonergics. That, along with the clonus, pupils, and temperature moved it higher up on our list, and as I recall much of the rest of his workup wasn't turning up much re: labs or imaging. Originally Posted By AGW:
Originally Posted By TheGrayMan:
Serotonin syndrome would not be my first thought on that patient. No? We had some collateral information and a med list from one of our county mental health agencies that showed access to serotonergics. That, along with the clonus, pupils, and temperature moved it higher up on our list, and as I recall much of the rest of his workup wasn't turning up much re: labs or imaging. No. I can recall a handful of Serotonin Syndromes in 20 years. I've seen about the same number of Neuroleptic Malignant Syndromes. I like a good zebra-hunt as much as the next guy, but SS isn't seen much. That said, faced with that patient, I would do as you did: give them a critical-care full-court-press, paralyze, intubate, etc. I would probably assume it was a sympathomimetic overdose. |
Everything you are doing is wrong, and it is my sworn duty to resist you.
