I’m Seeing Double Scott E. Rudkin, MD, MBA, FAAEM Department of Emergency Medicine University of...
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Transcript of I’m Seeing Double Scott E. Rudkin, MD, MBA, FAAEM Department of Emergency Medicine University of...
![Page 1: I’m Seeing Double Scott E. Rudkin, MD, MBA, FAAEM Department of Emergency Medicine University of California, Irvine.](https://reader036.fdocuments.us/reader036/viewer/2022062515/56649cb85503460f9497f270/html5/thumbnails/1.jpg)
I’m Seeing DoubleI’m Seeing Double
Scott E. Rudkin, MD, MBA, FAAEM
Department of Emergency Medicine
University of California, Irvine
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Scott E. Rudkin, MD, MBA
Teaching points to be addressedTeaching points to be addressed
• When should a CNS toxin be considered highly in the differential of weakness?
• When is the optimal timing of imaging, procedures, and therapy in patient with a suspected CNS toxin ingestion?
• What empiric therapy should be initiated in patients with suspected CNS toxin ingestion?
![Page 3: I’m Seeing Double Scott E. Rudkin, MD, MBA, FAAEM Department of Emergency Medicine University of California, Irvine.](https://reader036.fdocuments.us/reader036/viewer/2022062515/56649cb85503460f9497f270/html5/thumbnails/3.jpg)
Scott E. Rudkin, MD, MBA
Case PresentationCase Presentation
• 43-year-old female with upper respiratory tract symptoms for a week
• Now has complaints of diplopia, dysarthria and dysphagia
• Patient’s eyelids are noted to be “droopy”
• Patient is able to answer all questions appropriately
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Scott E. Rudkin, MD, MBA
Past Medical History & Social HistoryPast Medical History & Social History
• No past medical history• No chronic medications• No history of surgery• Admits to “social” use of subcutaneous
heroin
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Scott E. Rudkin, MD, MBA
Physical ExamPhysical Exam
• VS: 37.1, 125/90 (93/70 standing), 105, 18, sat 98%
• Awake and alert• Cooperative with exam• Pulmonary, cardiac,
abdomen: Normal• No cutaneous findings on
arms or legs• Pupils 7mm, reactive; Ptosis
noted• Upper extremities weaker
than lower extremities; DTR’s also decreased
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Your Differential Diagnosis?Your Differential Diagnosis?
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Scott E. Rudkin, MD, MBA
Differential DiagnosisDifferential Diagnosis
• Metabolic• Endocrine• Toxicologic• Tick paralysis• Aminoglycoside toxicity• Botulism
• Neurologic• Stroke• Myasthenia• Lambert-Eaton
• Infectious etiologies• Meningitis• Poliomyelitis
• Metabolic
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Scott E. Rudkin, MD, MBA
ED CourseED Course
• What should be done and in what order?
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Scott E. Rudkin, MD, MBA
ED Course-what occurredED Course-what occurred
• Verify A,B,C’s
• IV access, labs, blood cultures
• Early assessment of ventilatory function; our patient required intubation
• Non-contrast cranial CT
• Lumbar puncture
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• Midline structures appear normal
• No gross abnormalities
Non-contrast Non-contrast Cranial CTCranial CT
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Scott E. Rudkin, MD, MBA
Lumbar punctureLumbar puncture
• Normal Protein/glucose
• 0 RBC/WBC
• Normal opening pressure
• Gram stain - no bacteria
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Scott E. Rudkin, MD, MBA
Lab ResultsLab Results
• WBC = 7
• Hct =42
• Platelets = 263
• Chemistry = wnl
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Scott E. Rudkin, MD, MBA
• What is the next step in this patient’s management?
ED CourseED Course
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Scott E. Rudkin, MD, MBA
Case courseCase course
• Patient was given botulinum antitoxin for presumptive diagnosis of botulism
• Antitoxin obtained from California Department of Heath Services• Also helped with wound culture
• Blood/stool cultures obtained, but of little help• Penicillin given to help eradicate spores• Admission to ICU after intubation• Prolonged stay (one month intubated, three months for
rehabilitation)
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Scott E. Rudkin, MD, MBA
Risk FactorsRisk Factors
• Wound botulism can happen in any patient
• Identified risk factors• Traumatic wounds• Work near farm equipment• Injection of black tar heroin
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Scott E. Rudkin, MD, MBA
Presentation-4 D’sPresentation-4 D’s
• Dysphagia, Diplopia, Dysarthria, Dry mouth—the four classic findings in botulism
• Symptoms start 18 to 36 hours after exposure
• Over 90% of affected patients have these symptoms
• Sensorium is intact
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Scott E. Rudkin, MD, MBA
Anatomy and PathophysiologyAnatomy and Pathophysiology
• Wound botulism caused by gram positive, anaerobic, spore-forming bacteria (C. botulinum)
• Germinates in areas of high pH (>4.6) or local oxygen concentrations
• After toxin absorption, the toxin binds irreversibly to the presynaptic nerve endings and prevent the transmission of acetylcholine through the neuromuscular junction; effectively denervates muscles by preventing acetylcholine transmission
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Scott E. Rudkin, MD, MBA
Lab studiesLab studies
• CBC, chemistries
• Coagulation studies
• Blood/stool/urine cultures
• Other cultures as appropriate
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Scott E. Rudkin, MD, MBA
ProceduresProcedures
• Lumbar puncture• Normal protein helps to exclude Guillain- Barré• Glucose and protein normal
• Electromyelography (EMG) demonstrates potentiation • Repetitive testing at 50 Hz should demonstrate
potentiation from this supramaximal stimulation with jitter and blocking
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Scott E. Rudkin, MD, MBA
Emergency Department CareEmergency Department Care
• Prompt recognition
• Prompt intervention• Give antitoxin early• Do not delay pending diagnostic
interventions in high-suspicion cases• Antibiotics
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Scott E. Rudkin, MD, MBA
ConsultationsConsultations
• Will depend upon institution
• Ill patients - ICU admission
• General surgery for any signs of trauma
• Infectious disease, neurology, or others might be helpful
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Scott E. Rudkin, MD, MBA
SummarySummary
• Wound botulism may present only ptosis or the other extreme of autonomic dysregulation• Think of the 4 D’s: Diplopia, Dysarthria, Dry mouth,
Dysphagia
• Acute intervention may limit morbidity and mortality
• Antibiotics (PCN) and antitoxin• Avoid aminoglycosides (neuromuscular
junction blockade)
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Scott E. Rudkin, MD, MBA
Teaching pointsTeaching points
• When should CNS toxin be considered highly in the differential of weakness?
• When is the optimal timing of imaging, procedures, and therapy in patient with a suspected CNS toxin ingestion?
• What empiric therapy should be initiated in patients with suspected CNS toxin ingestion?
![Page 25: I’m Seeing Double Scott E. Rudkin, MD, MBA, FAAEM Department of Emergency Medicine University of California, Irvine.](https://reader036.fdocuments.us/reader036/viewer/2022062515/56649cb85503460f9497f270/html5/thumbnails/25.jpg)
Scott E. Rudkin, MD, MBA
Teaching pointsTeaching points
• When should a CNS toxin be considered highly in the differential of weakness?
• Any patient with a descending paralysis with a history of injection drug abuse should raise suspicion for wound botulism
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Scott E. Rudkin, MD, MBA
Teaching pointsTeaching points
• When is the optimal timing of imaging, procedures, and therapy in patient with a suspected CNS toxin ingestion?
• Early. Obtain CT/LP early and start therapy before confirmatory testing returns
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Scott E. Rudkin, MD, MBA
Teaching pointsTeaching points
• What empiric therapy should be initiated in patients with suspected CNS toxin ingestion?
• Start with penicillin, preferably before the I&D; reduces toxin burden
• Initiation of antitoxin reduces Morbidity/mortality