History & Physical
38M, unknown medical history, brought in after being found unresponsive next to an empty bottle of Seroquel. Presenting vital signs notable for blood pressure of 96/43, heart rate 103. Examination reveals tentatively protected airway (GCS E2 M5 V3, SpO2 100%, RR 14), normal pupil diameter and reactivity, dry mucous membranes with thick vomitus in oral cavity.
Laboratory evaluation was unremarkable, and there was no evidence of aspiration on chest radiography. ECG showed sinus tachycardia without QT prolongation. Blood pressure increased to normal range with fluid resuscitation. The patient’s mental status progressively improved and he was discharged after six hours of uneventful continuous cardiac monitoring.
|Class ||Vital Signs ||Mental Status ||Pupils ||Skin ||Other ||Examples |
|Anti-cholinergic || T |
|Mydriasis ||Dry ||Urinary retention |
|Sympathomimetic || T |
|Mydriasis ||Diaphoresis ||Tremor |
|Opioid/Sedative || HR |
|CNS depression |
|Miosis || ||Hyporeflexia |
- POC Glucose
- ECG (QT interval)
- Serum acetaminophen, salicylate, EtOH level
- Serum drug levels if known (anti-epileptics)
- Urine toxicology screen
- Chemistry (metabolic acidosis, electrolytes, renal function)
- LFT (hepatotoxicity)
- CK (rhabdomyolysis)
- Serum osmolarity (osmolar gap)
- UA with microscopy (crystals in ethylene glycol poisoning)
- ABG (carboxyhemoglobin, methemoglobin)
Pharmacology, Toxicity and Management of Second Generation Antipsychotic (SGA) Overdose3
- Kulig, K. (2013). General Approach to the Poisoned Patient. In Rosen’s Emergency Medicine – Concepts and Clinical Practice (8th ed., Vol. 1, pp. 1954-1959). Elsevier Health Sciences.
- Wittler, M., & Lavonas, E. (2013). Antipsychotics. In Rosen’s Emergency Medicine – Concepts and Clinical Practice (8th ed., Vol. 1, pp. 2047-2051). Elsevier Health Sciences.
- Levine M, Ruha A-M. Overdose of atypical antipsychotics: clinical presentation, mechanisms of toxicity and management. CNS Drugs. 2012;26(7):601–611.
- WikEM: Antipsychotic toxicity
1yo M, ex-term, previously healthy, with 8d tactile fever/diarrhea, initially watery, presenting now due to bloody diarrhea x1d. Mother reports 8-10 episodes/day, decreased PO intake and urine output x4d and changes in behavior (lethargy, irritability). No vomiting, no e/o abdominal pain, no cough, no seizures, no weight loss, no known sick contacts.
- Full term
- No perinatal complications
- Vaccination history unknown
- Meeting all developmental milestones
- No sick contacts
- VS: HR 135 BP 86/60 RR 24 T N/A Wt 11kg (60%)
- General: Patient was initially examined after initial rehydration with IVF. Well-appearing child, interactive and smiling.
- HEENT: NC/AT, PERRL, MMM no lesions, no nuchal rigidity
- CV: RRR, normal S1/S2
- Lungs: CTAB
- Abd: +BS, soft, NT/ND, no rebound/guarding
- Ext: Warm, well-perfused, 2+ peripheral pulses (radial, DP, PT), capillary refill <2s
- Skin: No visible skin lesions
- Neuro: Alert and responsive
1yo healthy male with fever, bloody diarrhea and history consistent with dehydration. Most likely cause of acute diarrhea in this patient is infectious, particularly Shigella spp given presence of blood. Other concerning causes of diarrhea in this patient with reports of fever and changes in mental status include a serious bacterial illness (meningitis, pneumonia, UTI), however, these are less likely given the predominant, voluminous diarrhea and absence of symptoms associated with each. Other considerations include appendicitis, volvulus, intussusception, however again copious diarrhea in association with a benign abdominal exam makes these causes less likely. Early presentation of chronic diarrhea cannot be ruled out, however unlikely given association with fever and local prevalence of infectious causes.
Management included IV rehydration, followed by maintenance with PO ORS, early nutritional support, and ciprofloxacin 15mg/kg IV q12h.
Types and causes of acute diarrhea: 1, 2
Assessment of Hydration Status
| || |
|Variable/Sign ||Mild (3-5%) ||Moderate (6-9%) ||Severe (>10%) |
|General appearance ||Restless, alert ||Drowsy, postural hypotension ||Limp, cold, sweaty, cyanotic extremities |
|Radial pulse ||Normal rate, strength ||Rapid, weak ||Rapid, thready, sometimes impalpable |
|Respiration* ||Normal ||Deep ||Deep and rapid |
|Anterior fontanelle ||Normal ||Sunken ||Very sunken |
|SBP ||Normal ||Normal or low ||Low |
|Capillary refill* ||Normal (<2s) ||Prolonged (2-4s) ||Markedly prolonged (>4s) |
|Skin turgor* ||Normal ||Pinch retracts slowly ||Pinch retracts very slowly |
|Eyes ||Normal ||Sunken ||Grossly sunken |
|Tears ||Present ||Absent ||Absent |
|Mucous membranes ||Moist ||Dry ||Very Dry |
* = sensitivity > 70% 3,4
Management of Acute Diarrhea: 5,6
Pathogens causing diarrhea: 6
|Pathogen ||Epidemiology/Transmission ||Comments ||Incubation ||Fever ||Abd. pain ||N/V ||Bloody stool ||Stool WBC ||Stool Heme |
|S. aureus, B. cereus ||Food poisoning with preformed toxin ||Vomiting > diarrhea ||1-6h ||X ||– ||✓ ||X ||X ||X |
|C. perfringens ||Spores germinate in meats, poultry || ||6-24h ||X ||– ||✓ ||X ||X ||X |
|Norovirus ||Winter outbreaks in schools, nursing homes, cruise ships ||Adults: diarrhea |
|1-2d ||– ||✓ ||– ||X ||X ||X |
|Rotavirus ||#1 MCC children ||Vaccine available ||1-2d ||– ||✓ ||– ||X ||X ||X |
|Campylobacter ||#1 MCC invasive enterocolitis in US |
|GBS ||2-5d ||✓ ||✓ ||– ||– ||✓ ||– |
|Salmonella ||#2 MCC enterocolitis in US Outbreaks |
Undercooked egg, dairy, poultry
| ||1-3d ||✓ ||✓ ||– ||– ||✓ ||– |
|Shigella ||Community-acquired, person-to-person || ||1-3d ||✓ ||✓ ||✓ ||– ||✓ ||– |
|EIEC ||Outbreaks |
Undercooked beef, raw seed sprouts
|Produces Shiga toxin ||1-8d ||– ||✓ ||– ||✓ ||– ||✓ |
|C. difficile ||Nosocomial ||Leukocytosis || ||– ||– ||X ||– ||✓ ||– |
|E. histolytica ||Travel to tropical regions || || ||– ||– ||– ||– ||– ||✓ |
|Giardia ||Day care, waterborne transmission || ||1-3d ||X ||✓ ||– ||X ||X ||X |
|Vibrio ||Contaminated water, seafood || ||1-3d ||– ||– ||– ||– ||– ||– |
|Yersinia ||Foodborne transmission ||Mesenteric lympadenitis (simulates acute appendicitis) ||1-3d ||✓ ||✓ ||– ||– ||– ||– |
- Huilan, S., Zhen, L. G., Mathan, M. M., Mathew, M. M., Olarte, J., Espejo, R., Khin Maung, U., et al. (1991). Etiology of acute diarrhoea among children in developing countries: a multicentre study in five countries. Bulletin of the World Health Organization, 69(5), 549–555.
- Navaneethan, U., & Giannella, R. A. (2008). Mechanisms of infectious diarrhea. Nature clinical practice. Gastroenterology & hepatology, 5(11), 637–647. doi:10.1038/ncpgasthep1264
- Steiner, M. J., DeWalt, D. A., & Byerley, J. S. (2004). Is this child dehydrated? JAMA : the journal of the American Medical Association, 291(22), 2746–2754. doi:10.1001/jama.291.22.2746
- Gorelick, M. H., Shaw, K. N., & Murphy, K. O. (1997). Validity and reliability of clinical signs in the diagnosis of dehydration in children. Pediatrics, 99(5), E6.
- Harris, JB, Pietroni M. Approach to the child with acute diarrhea in developing countries. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA, 2013.
- Thielman, N. M., & Guerrant, R. L. (2004). Clinical practice. Acute infectious diarrhea. The New England journal of medicine, 350(1), 38–47. doi:10.1056/NEJMcp031534
29F BIB family after patient was found down at home, near opened bottle of Gastosin in presumed suicide attempt. On arrival to ED, patient was awake, but unresponsive, groaning and clutching stomach. GCS was E3-V2-M5, HR 110, BP 60/palp, RR 24.
Upon arrival, placed two large-bore IV w/rapid infusion of 2L NS and given DA 2g IV x2. NG tube placed, initiated lavage of gastric contents with NS. Patient’s mental status continued to deteriorate, became unresponsive.
History of alcohol abuse and depression per family.
- VS: 110bpm, 60/palp, 24 R/min, no temp/O2sat available
- General: Ill-appearing female, laying on bed in considerable distress, groaning and clutching stomach, diaphoretic
- HEENT: NC/AT, PERRL (4-3mm), EOMI, MMM no lesions, no tongue lacerations, breath with foul odor, TM’s clear b/l.
- CV: RRR, normal S1/S2, tachycardia, faint heart sounds, JVP elevated though patient supine
- Lungs: CTAB, no crackles/wheezes
- Abdomen: +BS, soft, non-distended, no guarding, no ecchymosis
- GU: Normal external genitalia, loss of stool noted.
- Neuro: Patient confused, initially responsive to sternal rub, moving all 4 extremities spontaneously/equally, EOMI without nystagmus, gag reflex present, DTR 2+ and symmetric throughout with toes downgoing.
- Extremities: Cool, peripheral pulses 0 (radial, PT, DP), 1+ (femoral, brachial, carotid)1, capillary refill 3sec
- Skin: No visible skin lesions
Assessment & Plan:
29F, unknown PMH, ċ ingestion of unknown amount of “Gastosin”. Patient presenting in likely cardiogenic shock given hypotension with reflex sympathetic activation (evidenced by peripheral vasoconstriction à cool extremities, diaphoresis) and no evidence of hemorrhage. Gastosin is a pesticide used in the storage of maize2, and is well-known locally as a common agent in self-poisonings. Chemically composed of aluminum phosphide, and liberates phosphine gas on exposure to moisture which is rapidly absorbed by inhalation, transdermally or gastrointestinally. Toxicity results from free radical damage and inhibition of enzymes of metabolism (particularly affecting cardiac myocytes). Clinical features include vomiting, resistant hypotension and metabolic acidosis.3
Patient’s symptoms and presentation are consistent with cardiogenic shock secondary to Gastosin ingestion. Management included fluid resuscitation and inotropic support with dopamine, as well as gastric lavage. Resuscitation efforts were unsuccessful and patient remained hypotensive with worsening of mental status, and eventual death.
Differential Diagnosis for Shock:
A System for the Management of Aluminum Phosphide Poisoning:4,5
The Glasgow Coma Scale:
| ||Eye Opening ||Best Motor Response ||Best Verbal Response |
|1 ||None ||None ||None |
|2 ||Pain ||Extension ||Groans |
|3 ||Verbal ||Flexion ||Unintelligible |
|4 ||Open ||Withdraws ||Disoriented |
|5 || ||Localizes ||Oriented |
|6 || ||Obeys commands || |
- Hill RD, Smith RB III. Examination of the Extremities: Pulses, Bruits, and Phlebitis. In: Walker HK, Hall WD, Hurst JW, editors. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Boston: Butterworths; 1990. Chapter 30. Available from: http://www.ncbi.nlm.nih.gov/books/NBK350/
- Udoh, J., Ikotun, T., & Cardwell, K. (n.d.). Storage systems for maize (zea mays l.) in nigeria from five agro-ecological zones. Proceedings of the 6th International Working Conference on Stored-product Protection, 2, 960-965.
- Bogle, R. G., Theron, P., Brooks, P., Dargan, P. I., & Redhead, J. (2006). Aluminium phosphide poisoning. Emergency medicine journal : EMJ, 23(1), e3. doi:10.1136/emj.2004.015941
- Gurjar, M., Baronia, A. K., Azim, A., & Sharma, K. (2011). Managing aluminum phosphide poisonings. Journal of Emergencies, Trauma, and Shock, 4(3), 378–384. doi:10.4103/0974-2700.83868
- Jones, A. L., & Volans, G. (1999). Management of self poisoning. BMJ (Clinical research ed.), 319(7222), 1414–1417.