Pearls From Wednesday Lecture (7/30/2014)

Tony’s Take-Home Memo, Wed Conference 7/30/14, Altered Mental Status

10a – Thyroid Disease (Kruse)
Follicular (T3,T4) & Parafollicular Cells (Calcitonin)… TSH, T3, freeT4 recommended for screening. Thyrotoxicosis ~80% Graves, then toxic multinodular goiter & thyroiditis (subacute, hashimoto, postpartum). Temperature sensation alterations, tachy, wt loss… avoid Iodinated contrast dt Iodine effects on thyroid conditions. Propylthiouracil(PTU) & Methimazole for thyrotoxicosis. Propranolol for Sx Trx. 2 main emergencies: thyroid storm (hyper) & myxedema coma (hypo). Thyroid Storm give: PTU, Lugol’s solution (inorganic Io) or Lithium, steroids, Propranolol, supportive care & search for cause, Adm ICU… Hypothyroid most common dt Hashimotos sp Tx, then treat c Synthroid/Levothyroxine, start 50 to 75 mcg/day. Myxedema hyponatremia can cause Sz! Hypoglycemia & hypothermia also dangerous (passive > active rewarming prn)… check cortisol Lv (steroids prn)… IV synthroid & basic supportive care. Mortality 15 to 30% for myxedema coma! Thyroid nodules can cause mechanical occlusion. Thyroid conditions can mimic multiple other conditions, & often comorbid.

1030a – Bites & Envenomations (Jennings)
especially aquatic animals, hyperbarics context… Surf & Turf (snakes & spiders, then: jellyfish, sea snakes, sting rays, octopus, scorpion fish…) Venom is injected toxin by animal.

Locally, timber rattlesnake (more local) & northern copperhead (NYC area of NYS & south…)

CroFab antitoxin binds venom, but many bites are dry. Most antivenom is horse or sheep serum. Anaphylaxis risk.

Most venomous snakes all Australian.

Brown recluse (violin pattern, woodpiles & dark basements, delayed bite pain, hemolytic toxin causes ischemic necrosis, debridement, tetanus; Dapsone…doesn’t work) centered around Alabama, very far South…

Black Widow is here (N, W, S variants). Hourglass pattern on back in females, much more aggressive! Painful, rigid abdomen mimics Appy, common rxn. Tx c tetanus, CaGluconate? There is antivenom for severe cases. No local antivenom availability. Often, no distinctive bite marks dt small size.

Jellyfish, ManOWar, Anemones, Corals (Cnidarians) have stinging barbs (nematocysts from cnidocytes). Toxins have mixed effects, catecholamines & multiple toxicity, sometimes continuous release after sting! (Vinegar ~acid may help c some?). Remove source! Analgesics & Antihistamines…

True jellyfish (Scyphozoans) rarely lethal, but can cause recurrent dermatitis.

Blue Bottle/Portuguese ManOWar is a colony of smaller organisms that look like a Jellyfish bubble, potentially very deadly! StringofPearls rash.

Box Jellyfish is MOST POISONOUS venom known. Usually in shallow waters (mostly Asian Pacific, but also California occasionally). Sheepbased antivenom… Vinegar ok, may help.

Stingrays physically dangerous, but also toxic…
Sea snakes have paddle shaped tail & normally NOT aggressive, but ALL venomous, small mouths normally can’t penetrate wetsuit. Cholinomimetic toxin c ascending paralysis & myoglobinuria.

Scorpion Fish ~ Stone Fish on bottom, stepped on 13 spines (most toxic scorpionfish), Lion Fish

Octopus ~ Blue Ringed Octopus Dangerous! Tetrodotoxin deadly. “Never give an Octopus a ride”.

11a – Small Groups (ERod, Sarsfield)
*Sim Case1: AMS… Septic in Pregnancy c Diarrhea, febrile, tachy, HTN, 29F… hallucinating… Pheochromocytoma? Sympathomimetic Toxidrome? Cocaine? Thyroid Storm: TSH abnormality, Fever & AMS! (Mortality up to 30% if untreated). Formal scoring system in Tintinalli, somewhat coomplicated & sensitive, but not superspecific… Beta blockers give, c consideration of hydralazine for alpha block, PTU given to prevent T3 conversion… SSKI (super saturated Potassium Iodide), steroids also block conversion of T4 to T3. APAP good antipyretic, but no ASA (may exacerbate hyperthyroid?). Fever & AMS, consider LP & urgent Abx! Vanc, Ceftri, Acyclovir… Pregnancy as trigger? HCG in molar pregnancy can trigger TSH release; additional stressors can trigger hormone release… Off/stopped Methimazole in pregnancy…

*Case2 (Haldipur, 1130a): 56M confusion & weak 2 days, L face & extrem twitching (synchronous), EMS arrival… lethargic, arousable to pain stimulus, suspected Sz… Glucose high, other VSS except HR 110… Sepsis? DKA? Sz? Syncope workup… CThead (wnl), IVF bolus, Labs, EKG, VBG lactate (.03 to .04 pH difference from ABG?)… Pt has glucose 1100, but no Anion gap, HHS (no longer HHNK dt small ketosis likely). Na corrected from 137, plus (1100 minus 100 eq 1000, div by 100 is 10)x1.5, plus15, gives corrected Na of 142. Check Ammonia? TSH? “MI until proven otherwise”…

12:30p – J/Sr Sessions, Head CT Reading (Paolo)
*Schwartz’s Radiology Textbook, recommended. Online?

*Artifacts & Anatomy: beam hardening artifact adjacent to dense bone; streak artifact from fillings, density scatter or motion; partial volume (averaging) artifact dt avg volume of structures causing intermediate signals (less with subdural window view). Anatomy orientation of slice is ANGLED lower in posterior, higher anterior. Temporal horns of lateral ventricles important; Cisterns (interpeducular[between cerebellar peduncles], quadrigeminal[smiley face], & supracellar[pentagonal, circle of Willis]) also important. “Dense MCA sign” [obvious CVA] in hyperacute stroke, as well as loss of gray & white matter differentiation [“effacement of sulci”]…

*SAH: 4th ventricle open in SAH, communicating hydrocephalus (Juan Valdez mustache, not good <;), found with dilation of temporal horns. Look at interhemispheric fissure to confirm blood away from hardening artifacts anterior & posterior. Pineal gland looks calcified, wnl, not blood…

*VThromb: young females who smoke on BCP with coagulopathy…& Clinton… Look for hyperattenuation, but can be wnl in up to 60% of ppl! …but with clinical suspicion, follow c CTv or MRv… Not usually b/L, usually unilateral. “Empty Delta sign” is clot in sinus confluence.

*Hydrocephalus & LP: know the ventricles… most hydrocephalus not suble, but know communicating v noncommunicating… & old ppl hydrocephalus “ex vacuo” ~ brain loss. 4th ventricle loss in NC~hydrocephalus! …means compression somewhere (could be in 3rd ventricle). Meningitis & SAH most common causes for communicating hydroccephalus, failure of reabsorption. *Focal Neuro exam, papilledema, Sz, & immune compromise are reasons to confirm CThead prior to LP. No LP if midline shift, obstructive hydrocephalus, compressed cisterns or compressed 4th ventricle.
1) Symmetry/Midline Shift?
2) SAH?
3) Ventricles Enlarged? Small or wnl ventricles? (communicating?)
4) Brain Parenchymal Lesions…

1:30p – Meningitis/Encephalitis (Johnson)
CSF studies: Culture, Gram Stain, Cell Count (1&3, 1&4, 2&4), Protein, Glucose

…Viral PCR, HSV, Antigen tests

Abx: Gent/Cefotax/Ceftri (GramNEG), Vanco (GramPOS), Acyclovir (HSV)

*Amp (Listeria) for Neonates & Elderly…

IV, O2, Monitor, H&P, Abx&Cxs with Steroids!!! …better CSF penetration & outcomes, VBGlactate, Labs… CT?&LP… CT first if Focal Neuro deficits, Papilledema, Seizures, or Immune Compromise. Then LP! If NEG, aseptic meningitis still require hospitalization!

*Meningitis Risks: Immunosuppression, Uncooked food, College & EtOH…, DM2, ENT/nasal dsx

*Encephalitis can be very complex. Recognize HSV (treatable), but EEE, WNV, enterovirus, other arboviruses supportive care. Ceftriaxone 2g (>1g) normal dose. Acyclovir 10mg/kg. Amphotericin for Fungal?! DON’T FORGET AMPICILLIN & DEXAMETHASONE!!!

*Consider Fungus & Tuberculosis!

*Cryptococcal Ag >> India Ink stain for Cryptococcus in Immune compromised pt.

>5WBCs in tap (no more than 1WBC:1000RBC) is bad.

ICU brain support, glucose & fever monitoring.

PPx for meningococcemia: Rifampin &…

10 to 20% of bacterial meningitis may have Leukocytic predominance!

Encephalitis needs Acyclovir, Steroids, IgG?

2:00p – Adrenal Dsx (Siegler)
Epinephrine (Adrenal) Gland Disorders

Cortex 3 zones: Salt(Aldosterone), Sugars(CCS), & Sex(DHEA) from ACTH(Ant.Pit)…
& Medulla(Epi, NorEpi)

HPA Axis c stress response… Primary(Adrenal), Secondary(Ant.Pit, ACTH), Tertiary(Hypothal)

*Primary: severe electrolyte abnormalities…high K, low Na…

*Secondary: dt exogenous CCS, drugs, Sheehans syndrome (pituitary infarct)…

*Tertiary: exogenous CCS, brain tumors… similar to 2* Adrenal failure… hypotension, shock, may be refractory to pressors.

*Pheochromocytoma: Rule of 10s: 10% bilateral, 10% Malignant, 10% extraadrenal, 10% familial. Weight Loss, fever, arrhythmia & tachycardia, seizure, tremors, NET syndromes… Dx c plasma metanephrin testing or 24hr urine collection(cortisol). AbdCT, MRI both good for localization… Treat c alpha/beta blockers, CCB, angiotensinRBs, Magnesium? (preoperatively). For incidentalomas, followup c PCP is usually adequate, for repeat CT in [time]…

2:30p – Exposures (Joslin) “Heat & Photography”
Alaska chasing grizzly bears last week 🙂 Approach bears slowly & predictably…Wilderness Med.

*Case: No air connditioner, obese 24yoF at 42*C, AMS, heat stroke, done?

Delirium, disoriented, confused, decreased mentation…

HR not predictive in BetaBlocked pts. (May be tachy otherwise?)

BP LOW! (vasodilation peripherally in skin, flushed).

Temp:HeatStroke::BP:HTN Emergency… #, itself does not define automatic pathology.

Labs: BMP, CK [likely wnl], EKG, UA, CBC/infxn?, Coags, LFTs, Troponin, CXR, Lactate/VBG…

Abx not unreasonable dt gut bacterial translocation…

Ice Bath in Body Bag, Cool/Cold water immersion… Arctic Sun, Shower, Mist & Fan [easiest]…

*Case2: <; Mountain Goat Race May3rd: Awake & speaking pig latin only[AMS], HR 121, oral 39*C, glucose & Na wnl. No med hx, still sweating. …still heat stroke! (mental status change in context of heat stress). “Brain boils first.” Heat stroke needs admission. Discharge instructions must include special precautionary instructions.

Heat stroke DOES NOT MEAN pt is necessarily dehydrated.

Correct pt down ~0.1*C per minute, goal.

*Heat cramps/syncope/exhausion “fake terms” (v exercise associated collapse, heat intolerance…)

3p – Pediatric AMS (KNacca)
12moM P2, AMS… slow to wake… “lethargic” is BAD ~ think “unresponsive”.

Neuro, Tox, Intuss(GI), Infxn, …

*Modified GCS in children… APVU?

ABC Dextrose! & FULLY EXPOSE KIDS! (bruises, patches, rashes…)

Moro reflex up to 9mo… infant sucking reflex…

Peds milestones, know: 2mo support head, 4mo flips over, 7mo sits, 1yr walk & one word, 18mo stiff running…

GLUCOSE, GLUCOSE, GLUCOSE. Neonates need >40.

Rule of 50s: [glucose bolus]
*5cc/kg of D10 is 50…[neonate]
*2cc/kg of D25 is 50…[infant]
*1cc/kg of D50 is 50…[can use in child/adolescent]

Ask how formula is prepared. Pure water is not for infants. HypoNatremia can be Sz problem!

TOX! <; Call PCC 1 800 222 1222.

UDS can be used in undifferentiated peds OD. Comprehensive screens need drug specific tests as sendouts. Flumazenil may be used in naiive Benzo ODs, such as Peds Tox!

Suspect Abuse! Low threshold for LP! Consider Intussusception!

Random Tumors & Intracranial bleeds do happen too… consider CT if necessary.


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