Sickle Cell pain treatment

Pain triggers

• inflammation
• hemolysis
• organ damage
• deoxygenation status
• dehydration
• infection
• stress

Diagnositc criteria

• pain onset within 10ndays of presentation lasting >2 hrs
• At least one: focal tenderness, focal pain w movement or regional pain causing decreased ROM,
• lab evidence of hemolysis
• pain not explained by another diagnosis

Management points:

• treat pain first: IN fentanyl if available, intranasal fentanyl instead of oral d/t bioavailability
• Individualized pain plan
• Explore social determinants
• If self-dc likely, plan oral step-down and follow-up within 48-72 hrs

Pharmacy lecture

• Renal colic
  • first line: ketorolac 15mgIV once, tyelnol 1000mg PO once
  • Second line: mag sulfate 2g IV, lidocaine 1.5mg/kg over 15 mins, ketamine
  • DC: ibuprofen 400mg PO Q4-6H, naproxen 500mg BID, ketorolac 10mg PO Q6H

Myasthenic Crisis

• anti-AChR auto antibodies
• ocular bulbar, limb symptoms, weakness worsens with muscle use
• Many meds can cause exacerbation i.e. macrolides, fluoroquinolones, levophed, laxatives etc.
• most on pyridostigmine at home
• infection/pregnancy common precipitants
• Bedside PFT, basic labs, tsh, hcg, cxr, r.o CVA
• 20-30-40 rule> FCV below 20, MIP below 30, MEP 40 consider intubation; NIF <30
• Will need increased dose of succinylcholine about double (depolarizing), less of roccuronium about half
• Treatment IvIG vs. plasmapharesis

Febrile seizure

• H and P
  • seizure characteristics
  • duration
  • recorded? video? can they act it out?
  • sick symptoms/contaqcts
  • PMHx, developmental hx IUTD, seizure hx
  • Fever causes that can be treated with ABX
• Seizure education/precautions
• Rescue meds> consider nasal vs rectal
• treat benzo x2> keppra load
• Consider intubation IF going on a drip

Pharmacology

• Status epilepticus
• SE neurocritical care society: 5 minutes or more of continuous clinical or electrical seizure activity or recurrent seizure without return to baseline
• refractory SE with highest mortality
• Treatment approach:
  • Consider levels
  • POC labs/EKG/Blood gas/valproate level/carbamazepime/phenytoin levels (all can run in house) keppra is a send out
  • Benzos: diazepam ( IV: 0.15-0.2 mg/kg max 10mg, Rectal: 0.2-0.5 mg/kg max 20mg, rapid onset, long half life, major hepatic clearance), lorazepam ( IV 0.1mg/kg max 4mg, may repeat once, fast onset, moderate half life, limited hepatic clearance) Midazolam ( IV 0.2mg/kg max 10mg can repeat once, IM 5mg, 10mg for >40kg, single dose, IN 5mg one nostril, may repeat once, rapid onset, very lipophilic)
  • IM midazolam non-inferior to IV lorazepam
  • lorazepam> faster seizure cessation
  • Midaz> faster time to administer
  • Sodium channel agonists: prevent further propagation for action potential between neurons, phenytoin ( max 50mg/min, need inline filter, high protein binding, cardio/hepato toxic, extrav (purple glove syndrome) and derm reactions) Fosphenytoin (converted to phenytoin w/in 15 min IV admin, 20mgPE/kg max 1500, infuse max 150mgPE/min no inline filter, decreased cardiotoxicity and extrav problems, still do therapeutic drug monitoring like phenytoin) valproic acid blocks na/ca/ channels, potentiates GABA( 40mg/kg max 3g, hepatotoxic, thrombocytopenia, hyperammonemia, derm reactions, dose dependent) Lacosamide (400mg single IV dose, arrhythmia, diplopia, derm reactions, renally excreted, EKG before administering)
  • Racatems (levetiracetam) Keppra blocks Ca and AMPA receptors, 60mg/kg max 4.5g, psych disturbances
  • Barbs: direct GABA-A agonists, some glutamate antagonism at high doses Phenobarbital (IV 15mg/kg, rapid onset, very long half life up to 120hrs, hepatic clearance avoid in liver pts) Pentobarbital ( 15mg/kg cumulative bolus, maintenance 0.5-5mg/kg/hr, drug monitoring, long half life, cardiac dysfunction,, hypotension, propylene glycol toxicity, severe ileus, hepatotoxicity)
• Tips: best agent is the one most readily available, consider avoiding phenytoin/phospheny, consider alternative from home reg, consider avoiding valproic acid and pheny/fospheny, avoid valproic acid in pregnancy, remember drug interactions.
• RSI considerations: ketamine/propofol for induction, succs is preferred d/t quick on and off, rocc not preferred d/t duration bc might suppress seizure activity
• Myasthenia Gravis
• RSI considerations: Succinylcholine 2mg/kg 2x normal dose, must overcome antibodies, rocuronium 0.6 mg/kg (about half), preferred for RSI since does not act on receptors.

Stroke prehospital

• should be dispatched high priority
• CSTAT- intended to identify LVO, Gaze Arm weakness, LOC
• Must determine LKN

TBI EMS

• EPIC study
• aggressively prevent and treat “three H bombs of TBI” hypoxemia, hypotension, hyperventilation
• EPIC studies showed increase survival in all groups

Central Venous thrombosis

• Female predominance/postpartum/pregnancy/OCP/thrombophilia
• HA/stroke like symptoms/N/V/Encephalopathy
• Most common in sup.sag. sinus> transverse sinus> sigmoid sinus
• Cord sign https://radiopaedia.org/articles/cord-sign-dural-sinus-thrombosis
• Triangle sign https://radiopaedia.org/articles/empty-delta-sign-dural-venous-sinus-thrombosis?lang=us
• Heparin? Yes please. Then OAc

Guillain- Barre

• Autoimmune mediated polyradiculoneuropathy
• Ascending symmetric, bilateral weakness
• Red flags: bulbar weakness/resp. distress/autonomic instability
• Preceded by recent illness/vaccination
• IVIg or plasmapheresis

Acute dizziness

• Must differentiate between pre-syncope and dizziness
• Vertiginous: Acute vestibular syndrome, triggered episodic vestibular syndrome, spontaneous vestibular syndrome, vestibular neuritis, BPPV
• Dangerous Ds: diplopia, dysarthria, dysphonia, dysphagia, dysmetria > r/o CVA
• Do a HINTS exam: head impulse test, nystagmus, test of skew
• HINTS https://www.youtube.com/watch?v=1q-VTKPweuk
• Dix hallpiike https://www.youtube.com/watch?v=Ey7TlLJUErY&pp=0gcJCfwAo7VqN5tD
• Epley maneuver https://www.youtube.com/watch?v=F_2GpR4HtkY

Functional Neurologic Disorder

• Functional neurologic abnormality without evidence of structural abnormality
• Always rule out structural causes i.e. CVA
• Can see abnormalities on fMRI
• Involuntary is a key aspect, absence of conscious secondary gain
• Hoover sign