Handling Medical Emergencies

First Response:

• When you are called for an emergency, ASK FOR VITAL SIGNS IMMEDIATELY.
• Call CODE BLUE (dial #36) if patient is in medical extremis with exam indicating no pulse, no respirations, or both.
• Call RAPID RESPONSE (dial 77480) for patients requiring urgent care who are not in cardiac arrest or respiratory failure, but who require immediate attention (e.g., a patient who has just seized and is now post-ictal and apneic)
• Call a CONSULT for concerning medical issues that can be safely managed within 24 hours.

Common Medical Emergencies:

• Brief Loss of Consciousness (LOC)
  • Get orthostatics (lying/sitting/standing, each 3 min apart; specifically request all three positions); POC glucose if diabetic pt; and obtain history, including any trauma with fall, specifically head trauma
  • Based on HPI and medical history, attempt to rule out:
    • Cardiac arrhythmia
    • Vasovagal episode
    • Seizure (witnessed movements, urinary or bowel incontinence during episode)
    • Hypoglycemia
    • Orthostasis secondary to medication induced, poor intake, fluid loss (diabetes insipidus secondary to lithium, diarrhea, vomiting).
  • Review medications and timing of administration, along with any potential side effects
  • With narrowed differential, consider ordering:
    • EKG (consult cardiology to review)
    • POC glucose, CBC, CMP, electrolytes
    • IVFs
    • NCHCT (if fall where pt hit head)
• Seizures
  • Call Rapid Response (dial 77480) and consult neurology after immediate stabilization (or ask someone to consult neurology for you while you manage RR)
  • While awaiting RR team, assess airway, breathing, circulation, and obtain vital signs. Also:
    • Look for airway obstruction or impaired ventilation. If needed, suction, begin O2 supplementation, perform bag-mask ventilation if needed, prepare for rapid sequence intubation
    • Obtain IV access.
    • Place pulse ox and cardiorespiratory monitors.
    • Obtain rapid bedside glucose. Correct with IV dextrose 0.25-0.5 gm/kg 110
    • Assess for signs of head trauma.
    • If concerns for sepsis, obtain STAT labs including CBC, BMP, blood cultures, urine culture
    • Order lithium, valproic acid, or AED levels as applicable
  • Within 0 – 5 minutes of suspected seizure, begin medical treatment with benzodiazepine, with example procedures below:
    • Administer lorazepam 0.05 to 0.1 mg/kg IV or IO (NTE 4 mg with first administration)
    • If unable to gain IV or IO access, administer:
      • Rectal diazepam (Diastat® gel or injection solution given rectally) 0.5 mg/kg, maximum 20mg OR
      • Buccal midazolam 0.2 mg/kg, maximum 10 mg OR
      • IM midazolam 0.1-0.2 mg/kg, maximum 10 mg
    • At 5 – 10 minutes, continue treatment by:
      • Giving second dose of benzodiazepine
      • Giving broad spectrum antibiotics if signs of sepsis
      • Maintaining monitoring and respiratory support

Psychiatric Medication-Induced Emergencies

• Neuroleptic Malignant Syndrome
  • This is an emergency that can lead to death if untreated. NMS has a 10-20% overall mortality.
  • Characterized by hyperthermia, muscle rigidity, autonomic instability and altered mental status. More common with high potency typical antipsychotics (haldol, fluphenazine). 90% of cases occur within 10 days of starting the neuroleptic. NMS is more common in younger males. Other risk factors: dehydration, rapid titration, parenteral administration, concomitant use of lithium, and comorbid medical illness (trauma, surgery, infection).
  • If suspected,
    • STOP offending agents (including lithium, anticholinergics, if possible and serotonergic agents (note: meperidine is a serotonergic agent).
    • START IV hydration (cooled if possible) and aggressive cooling (remove clothing, cover patient with ice packs and fanning).
    • Immediate transfer to ICU.
    • Draw CPK (levels typically >1000-100,000), urine myoglobin (elevated), chemistry panel (metabolic acidosis), and CBC (leukocytosis).
    • Discuss with attending prior to starting:
      • Bromocriptine (dopamine agonist) at 2.5mg PO [NG tube] Q6 to 8hrs NTE 40mg/24hrs
      • Dantrolene (muscle relaxant) at 0.25mg – 2mg/kg IV Q6 to q12h NTE 10mg/kr/24hrs).
    • May manage acute agitation with lorazepam 0.5 to 1mg.
    • May manage hypertension with clonidine.
• Serotonin Syndrome
  • This is also an emergency that can lead to death if untreated. Serotonin syndrome is a clinical diagnosis, so take a good history and do a physical exam!
  • Characterized by autonomic manifestations (increased Temp, HR and BP, diaphoresis, diarrhea), altered mental status, neuromuscular hyperactivity (tremors, muscle rigidity, clonus, hyperreflexia, +babinski). Generally occurs days to one week after the addition of a new serotonergic agent, particularly in medically ill patients who may be on medications that interfere with serotonin pharmacokinetics, or after the dose of a serotonergic agent is increased.
  • If suspected,
    • STOP offending agents (serotonergic agents such as SSRIs, SNRIs, TCAs, tramadol, meperidine, etc AND agents that interfere with serotonin metabolism, such as linezolid)
    • START IV hydration and aggressive cooling (remove clothing, cover patient with ice packs and fanning)
    • Immediately transfer to ICU if autonomically unstable, including Temp > 41.1oC
    • No pathognomonic laboratory studies, but basic labs can help rule out medical illness.
    • Discuss with attending prior to starting:
      • Benzodiazepines for acute agitation, seizures and myoclonus.
      • Cryptoheptadine for second line treatment. Dosing varies depending on age of child 2mg to 4mg q8 to q12hrs. NTE 12mg to 16mg per day.
    • QTc Prolongation
      • Many medications, and all antipsychotics, can cause prolongation of the QT interval, increasing a patient’s risk of arrhythmia. The correct QT (QTc) is considered prolonged if greater than 450 msec (in males and prepubescent females) or 460 msec (in postpubescent females); however our colleagues in cardiology typically do not recommend changes in medication management unless the QTc reaches above 500 msec. The most concerning possible outcome is torsades de pointes, where patients lose cardiac contractions and quickly become unresponsive, requiring immediate defibrillation and magnesium.
      • If QTc is in borderline range (above 450 – 460 mec):
        • Confirm that there is no history of syncope (especially with activity), and no family history of arrhythmia or sudden death under age 40. You should also look at prior EKGs for comparison. If there is a history of syncope or family history of cardiac conditions, consult cardiology to make sure that it really is acquired QT prolongation from medications as opposed to a genetic prolonged QT syndrome.
      • If QTc is above 460 msec with no symptoms and with a potentially prolonging medication:
        • Consult peds cardiology – ask them to review the EKG, curbside vs formal consult