Critical Care

Question 1

SSRI Syndrome

Answer 1

• Serotonin Syndrome: Typical features are shivering, hyperreflexia, myoclonus, and ataxia (not often seen in NMS); Nausea, vomiting, and diarrhea are also a common part of the prodrome in serotonin syndrome (rarely described in NMS). Rigidity and hyperthermia, when present, are less severe than in patients with NMS.

Question 2

Neuroleptic Malignant Syndrome

Answer 2

Defn: Due to massive dopamine blockade; risk factors neuroleptics, antiemetics [high-dose or rapid dose increase], concurrent illness dehydration\exhaustion\poor nutrition

Sx: FARM (24-72 hours) fever (>39), autonomic hyperreactivity, rigidity, MSE

Findings: elevated CK, LDH, AST, leukocytosis, myoglobinuria

Mgmt: discontinued drug ( results in 1-2 weeks), aggressive hydration, cooling measures, dantrolene

Note:

• Central dopamine receptor blockade in the hypothalamus may cause hyperthermia and other signs of dysautonomia
• Bromocriptine is a dopamine agonist, and thought to restore lost dopaminergic tone. 2.5mg q6-8 hours to a max of 40mg/day. Continue 10 days after NMS controlled, taper slowly.
• Dantrolene – direct muscle relaxant. Effective within minutes.
• Amantadine has dopaminergic and anticholinergic effects, can be used as an alternate agent.

Question 3

Refeeding Syndrome

Answer 3

The refeeding syndrome is defined as the clinical complications that occur as a result of fluid and electrolyte shifts during nutritional rehabilitation of malnourished patients

The refeeding syndrome can be avoided by limiting the amount of calories and fluid provided, avoiding rapid increases in the amount of daily calories ingested, and monitoring the patient during the first few weeks of the refeeding process. If the refeeding syndrome occurs, clinicians should immediately slow nutritional replenishment and correct hypophosphatemia, hypokalemia, and hypomagnesemia while evaluating the cardiovascular system.

Question 4

MDMA intoxication

Answer 4

• Acute intoxication cocaine and ecstasy (3,4-methylenedioxymethamphetamine, MDMA): - psychomotor agitation, delirium, and even psychosis. Hyperthermia and rhabdomyolysis can develop, usually in association with increased physical exertion and ambient temperature. Rigidity is not common in these cases. MDMA use can also cause a serotonin syndrome

Question 5

Central anticholinergic Syndrome

Answer 5

• Central anticholinergic syndromes - encephalopathy and elevated body temperatures (usu. not as severe as NMS). Other features seen in NMS - diaphoresis, rigidity, and elevated CK levels – absent. Atypical features of NMS (flushing, mydriasis, bladder distension) are common.

Question 6

Intoxication (Acute management)

Answer 6

2) Non-drug related ddx:

• Central nervous system infection (eg, meningitis, encephalitis)/ Systemic infections (eg, pneumonia, sepsis)
• Seizures
• Acute hydrocephalus
• Acute spinal cord injury
• Heat stroke (neuroleptics predispose to heat stroke by impairing thermoregulation)
• Acute dystonia
• Tetanus
• Central nervous system vasculitis
• Thyrotoxicosis
• Pheochromocytoma
• Drug intoxication, toxicity (eg, phencyclidine, ecstasy, cocaine, amphetamines, lithium)
• Withdrawal states
• Acute porphyria

Rx Supportive Care for Following Complications:

Dehydration

Maintain Euvolemia, ++insensible loss from fever. Treat Hyperthermia

Electrolyte Imbalance

ARF assoc. with Rhabdo

IVF, consider urine alkalinization

MI/Cardiomyopathy/Cardiac Arrhythmias (TdP)

MV, antiarrhythmics, Pacemaker

Lower BP if very high. Clonidine effective. Nitroprusside may help cool (Cut. Vasodil)

Respiratory Failure from CW rigidity, Aspiration, PE

DVT, Thrombocytopenia, DIC

DVT Prophylaxis

Seizures/Agitation

Clonaz/Lorazepam

Liver Failure