Differentiating Thyroid Storm from Sepsis

[Veneficus]

54 female, volunteered that she thought she was having a reaction to a new antibiotic she had taken shortly before calling. I briefly asked her a few more questions to clear up what exactly had happened, she had abdominal cramps and had just had diarrhoea.

This is indicative of the side effects of clindamycin and an resultant overgrowth of C. Difficile not anaphylaxis.

It also commonly causes UTIs in females.

Severely short of breath, obvious erythema on the neck, face. Extremely anxious, BP was 90/I forget, Pulse 110, RespRar - 12 (I took that to mean that she was in such profound resp distress that her RR was trending down), speaking only in single words, Sinus Tach, Loud expiratory wheeze, GCS 15. Tried some 100% through the closed circuit, wouldn't tolerate it, so back to simple face mask..

All of this respiratory difficulty would be helped by epinephrine. The pulse could go either way, depending on beta stimulation vs. response to increased perfusion. Depending on history, this might be normal for a 54 y/o female.

I called for intensive care early, and had my partner draw up adrenaline while I did the vitals after I saw the erythema and SOB. There was a pause after obs for my explanation of the situation to the examiner (exam technique), I got nebulised Salbutamol and Ipratropium setup took another pressure and took HR off the monitor, no change in BP, HR now 120. Got the adrenaline on board. Partner to get the bed. Took meds and hx, spoke with intensive care, decided it would be quicker to go to the nearest ED and went, obs 5 minutely.

Sounds like you were really worried about the airway and breathing and went for the nuclear option. About the only way to further crush the inflammatory response would be some steroids and some malox.

In my best arm chair quarterbacking, I think I would have tried either the nebs first with some Diphenhydramine or went with the Epi and saw how that worked out.

I got canned for giving the adrenaline too early and not eliciting a proper history first..

That sounds like BS to me. It was an aggresive approach, certainly not improper by any measure I have ever been held to.

I replied that I thought the threat to her airway was paramount and that no information I elicited would change my management in anyway. He didn't agree, saying that I hadn't taken enough of an event history to show that it was anaphylaxis, and other information like a temp could have been helpful...."what if she had a chest infection and the wheeze was from that?" At that point I didn't argue further because I didn't want him in a bad mood when he referred it to the subject head, but that seemed like a :censored::censored::censored::censored: reason to me. Looking back on it now, I feel like I could have got the adrenaline on board earlier.

What if it was Feb 29th during the full moon, low tide, and a comet was visible in the sky?

I really can't find fault in the Epi. Not treating conservatively is not wrong, it is just another way. Appeal to a doctor.

What do you think? This thread should be titled, "Help Melclin as he stresses through exam period".

No worries, I know exactly how you feel.

 

[Aidey]

This is indicative of the side effects of clindamycin and an resultant overgrowth of C. Difficile not anaphylaxis.

It also commonly causes UTIs in females.

Wouldn't the likelihood of this depend on the time line of symptoms? Diarrhea and upset stomach within 15-30 minutes of taking the antibiotic would make me more suspicious of a systemic allergic reaction. Diarrhea 3 days into a course of the antibiotic makes me more suspicious that it's a side effect and not an allergic reaction.

 

[Veneficus]

Wouldn't the likelihood of this depend on the time line of symptoms? Diarrhea and upset stomach within 15-30 minutes of taking the antibiotic would make me more suspicious of a systemic allergic reaction. Diarrhea 3 days into a course of the antibiotic makes me more suspicious that it's a side effect and not an allergic reaction.

The post says shortly before, it doesn't really specify how many times it was taken before, there would have had to be a prior sensitization.

But you are right, if she had the same or similar ab before, she could have prior sensitization and it would point more towards an allegric rxn.

The information is just not given.

 

[MrBrown]

A helicopter doctor swanning down in his orange suit would have fixed it up for ya

As we talked about, I dont find fault in your logic but I could not resist plugging my beloved orange jumpsuit

 

[Melclin]

This is indicative of the side effects of clindamycin and an resultant overgrowth of C. Difficile not anaphylaxis.

It also commonly causes UTIs in females.

I don't disagree with you, but our scenarios are not that involved and we have often been given cramps, nausea or diarrhoea as symptoms of anaphylaxis, its out guidelines as "GIT disturbance" so I'm quite sure that is was that. Whether or not that is realistic, I can 't say. I have to confess its not an area I've done a lot of reading in (We sort of have to learn the uni version of reality and then go an check if that's right for actual practice :wacko: ). I forget the antibiotic but it was for a chest infection...started with a "B" I think.

All of this respiratory difficulty would be helped by epinephrine. The pulse could go either way, depending on beta stimulation vs. response to increased perfusion. Depending on history, this might be normal for a 54 y/o female.

Again, our prac exams aren't that complicated. No distracting elements, just straight up cases we were told. In that way they are quite unrealistic but they are just a hurdle to make sure we are not completely incompetent

Sounds like you were really worried about the airway and breathing and went for the nuclear option. About the only way to further crush the inflammatory response would be some steroids and some malox.



In my best arm chair quarterbacking, I think I would have tried either the nebs first with some Diphenhydramine or went with the Epi and saw how that worked out.

We don't carry Diphen, in fact I don't think anyone does here in Aus. Steroids are a MICA issue.

That sounds like BS to me. It was an aggresive approach, certainly not improper by any measure I have ever been held to.

The issue was never going to be whether or not it was anaphylaxis. It would be ana, stroke, some kind of fairly benign abdo pain (to test our pain management skills), hypo G, hyper G, seizure, sepsis (ceft).

What if it was Feb 29th during the full moon, low tide, and a comet was visible in the sky?

I really can't find fault in the Epi. Not treating conservatively is not wrong, it is just another way. Appeal to a doctor.

Oh I don't really need to appeal, the issue was, I think that the assessor is very "get ALL the info before treatment" where as the subject head is very much the "get the RELEVANT info before treatment" type so I think I'll be fine passing wise, I just wanted to present it make sure I hadn't ACTUALLY done anything TOO wrong

No worries, I know exactly how you feel.

Wouldn't the likelihood of this depend on the time line of symptoms? Diarrhea and upset stomach within 15-30 minutes of taking the antibiotic would make me more suspicious of a systemic allergic reaction. Diarrhea 3 days into a course of the antibiotic makes me more suspicious that it's a side effect and not an allergic reaction.

She had taken the antibiotic "last night" and she was presenting about an hour after taking a morning dose, having experienced the symptoms for about 20mins.

 

[MonkeySquasher]

We don't carry Diphen, in fact I don't think anyone does here in Aus. Steroids are a MICA issue.

You don't... carry... diphenhydramine.... ?? :wacko:

 

[Aidey]

She had taken the antibiotic "last night" and she was presenting about an hour after taking a morning dose, having experienced the symptoms for about 20mins.

So it's plausible that dose 1 sensitized her, and dose 2 set off the reaction.

You don't... carry... diphenhydramine.... ?? :wacko:

This x 2!

 

[Melclin]

No service that I'm aware of in Australia carries diphenhydramine.

I know Queensland, Victoria and New South Wales state ambulance services don't. The others I can't check but I suspect not. NSW and QLD carry Promethazine, mostly for nausea, but indicated for mild localised allergic reactions and absolutely contraindicated in moderate to severe allergic reactions/anaphylaxis.

I suppose the idea is that if its serious enough to warrant ambulance intervention then its adrenaline (and we are fairly liberal with handing out the adrenaline), if not then it can wait until hospital. It seems sort of overly simplistic to me, but like I said, I'm not really read in on the subject and I haven't the time at the moment (I've had my med exam, now its time for the nearly dead, the newly bred and those off their head- obstets, geri and psych). Can someone explain why we should carry diphen? That'll give me something else to complain loudly about in tutes

 

[MrBrown]

DPH is benadryl, an anti histamine.

We (like you) carry steroids.

 

[Aidey]

I suppose the idea is that if its serious enough to warrant ambulance intervention then its adrenaline (and we are fairly liberal with handing out the adrenaline), if not then it can wait until hospital.

Uhhh...negative.

Someone correct me if I'm wrong. An allergic reaction sets off a cascade in the body. An antihistamine can short circuit that cascade preventing the reaction from progressing. As far as I'm aware, the epi just treats the side effects of the reaction, it doesn't actually do anything to stop the reaction itself. Thus, prompt administration of an antihistamine can reduce the severity of the reaction and how much treatment and misery your patient has to go through.

I personally am not a huge fan of being liberal with epi. In a healthy young adult it isn't likely to cause an adverse reaction. But in older people or people with medical conditions the epi can be quite the strain and cause some problems.

 

[Smash]

Uhhh...negative.

Someone correct me if I'm wrong. An allergic reaction sets off a cascade in the body. An antihistamine can short circuit that cascade preventing the reaction from progressing. As far as I'm aware, the epi just treats the side effects of the reaction, it doesn't actually do anything to stop the reaction itself. Thus, prompt administration of an antihistamine can reduce the severity of the reaction and how much treatment and misery your patient has to go through.

I personally am not a huge fan of being liberal with epi. In a healthy young adult it isn't likely to cause an adverse reaction. But in older people or people with medical conditions the epi can be quite the strain and cause some problems.

Ok, I will.

Anaphylaxis does indeed trigger a cascade. Mast cell degranulation releases a very wide range of inflammatory mediators: histamine is only one of them, there are leukotrienes, bradykinins, all sorts of bits and pieces.
Diphenhydramine competitively antagonizes Histamine receptors, essentially knocking the histamine off and minimizing the adverse effects of the histamine. Think of it as naloxone but for histamine receptors instead of opiod receptors. What it doesn't do is reduce in any way the production of histamine, nor any of the other inflammatory mediators.

Epi on the other hand binds to beta receptors on mast cells, increasing the production of cAMP and reducing the production of all the inflammatory mediators as well as treating all aspects of the syndrome through alpha and beta stimulation. So basically, the opposite of your statement holds true.

Diphenhydramine may still be an appropriate drug to carry both as an adjunct to the cornerstones of epi, fluid and steroids for anaphylaxis and for allergic reactions as opposed to anaphylaxis. However I can see the logic of the 'wait until hospital' idea (not that I necessarily agree with it).

 

[mycrofft]

I'm not good with epi.

Even the epi in local anesthetics would give me chest tightness and SOB. I went on to develop atrial fibrillation. Epi would have, and might still, cause me to go into a worse arrrythmia.
Nothing to do with thyroid and sepsis though.

 

[MonkeySquasher]

That's the thing, I've always been taught that diphen- was more to halt the reaction, where as Epi- was more to act on Beta to bronchodilate.

What about someone with a cardiac Hx, or someone on a Beta blocker? Those would both cause a problem where diphen- wouldn't, right? But then again, if the person is on a sedative, it'd mix poorly with the diphen-, so it's a double-edged sword.

Also, what about Mag Sulfate as a smooth muscle relaxer to ease the respiratory distress? Would that work?

 

[Aidey]

That's the thing, I've always been taught that diphen- was more to halt the reaction, where as Epi- was more to act on Beta to bronchodilate.

What about someone with a cardiac Hx, or someone on a Beta blocker? Those would both cause a problem where diphen- wouldn't, right? But then again, if the person is on a sedative, it'd mix poorly with the diphen-, so it's a double-edged sword.

Also, what about Mag Sulfate as a smooth muscle relaxer to ease the respiratory distress? Would that work?

^^^ That has been what I was always taught too. It may just be that the common paramedic texts don't go into the pathophys in that much detail.

The gist of what I know about what epi does in anaphylaxis is that it decreases vascular permeability, causes vasoconstriction, causes increased contractility, and also causes bronchodilation. I double checked my book and it doesn't mention anything about cAMP.

Even the epi in local anesthetics would give me chest tightness and SOB. I went on to develop atrial fibrillation. Epi would have, and might still, cause me to go into a worse arrrythmia.
Nothing to do with thyroid and sepsis though.

It does have to do with sepsis in a remote way....epi is sometimes used to treat sepsis induced DIC isn't it? ^_^

I discussed using Epi with one of the ER docs the other day after I used it on a 26 year old status asthmaticus patient. I had followed my protocols so he didn't blame me, but he was quite surprised that it was still in the protocol. His opinion of epi was pretty low because of the number of people that ended up having reactions to the epi because of the stress it puts on the heart.

 

[got_shoes]

Okay, I am a bit confused by the statement epi is used to treat DIC sometimes. wouldn't the treatment of DIC induced by sepsis, be treating the underlying condition? and if some one is septic, why would epi be used? wouldn't epi potentially cause some unwanted side effects?

please excuse my ignorance

 

[Veneficus]

Okay, I am a bit confused by the statement epi is used to treat DIC sometimes. wouldn't the treatment of DIC induced by sepsis, be treating the underlying condition? and if some one is septic, why would epi be used? wouldn't epi potentially cause some unwanted side effects?

please excuse my ignorance

I think (don't want to speak for them) they are refering to using an epi drip as the vasoconstrictor of choice in the later stage of DIC after the clotting factors are exhausted.

Many pathologies can result in DIC, you do have to try to treat the underlying cause if possible, but the condition itself is lethal, so you must also do something to support the body too.

 

[got_shoes]

Vene

thanks for the info. I realize that DIC is a fatal condition, I was under the impression that vasopressin was indicated rather then epi. and i thought that epi was maybe useful in DIC, further more I thought that activated protein C was indicated in sepsis induced DIC. I realize the apC is not available in EMS and is potentially very dangerous.

 

[Veneficus]

Vene

thanks for the info. I realize that DIC is a fatal condition, I was under the impression that vasopressin was indicated rather then epi. and i thought that epi was maybe useful in DIC, further more I thought that activated protein C was indicated in sepsis induced DIC. I realize the apC is not available in EMS and is potentially very dangerous.

APC is for the Coag Phase.

http://emedicine.medscape.com/article/786058-treatment

here, norepi is the first line, but every doc has their favorite flavour of pressor and reasons why.

 

[Aidey]

Okay, I am a bit confused by the statement epi is used to treat DIC sometimes. wouldn't the treatment of DIC induced by sepsis, be treating the underlying condition? and if some one is septic, why would epi be used? wouldn't epi potentially cause some unwanted side effects?

please excuse my ignorance

I think (don't want to speak for them) they are refering to using an epi drip as the vasoconstrictor of choice in the later stage of DIC after the clotting factors are exhausted.

Many pathologies can result in DIC, you do have to try to treat the underlying cause if possible, but the condition itself is lethal, so you must also do something to support the body too.

Yup, exactly. Also, once DIC has developed the treatment for the underlying condition may not work fast enough to help the patient much.

Vene

thanks for the info. I realize that DIC is a fatal condition, I was under the impression that vasopressin was indicated rather then epi. and i thought that epi was maybe useful in DIC, further more I thought that activated protein C was indicated in sepsis induced DIC. I realize the apC is not available in EMS and is potentially very dangerous.

Pre-hospital it is very very very unlikely that we would use any meds to treat DIC. Like Ven said, every doc has their favorite meds to use, and in late stage DIC there are a lot of medications that can be used to try and control the DIC. The last DIC pt I had I believe they used norepi on him, but I'm not 100% sure.

There was also a small degree of humor to my post, since I was trying to connect anaphylaxis to sepsis after mycrofft pointed out our topic jump.

 

[8jimi8]

Yup, exactly. Also, once DIC has developed the treatment for the underlying condition may not work fast enough to help the patient much.



Pre-hospital it is very very very unlikely that we would use any meds to treat DIC. Like Ven said, every doc has their favorite meds to use, and in late stage DIC there are a lot of medications that can be used to try and control the DIC. The last DIC pt I had I believe they used norepi on him, but I'm not 100% sure.

There was also a small degree of humor to my post, since I was trying to connect anaphylaxis to sepsis after mycrofft pointed out our topic jump.

Sometimes the treatment is heparin and then FFPs. Don't some agencies carry heparin drips?