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1. ABDULMUNIM AL FARSI I CAN NOT HOLD A GLASS CASE PRESENTATION CME JULY. 13 th , 2010
2. CASE SCENARIO DIFFERENTIAL DIAGNOSIS ? MANAGEMENT PITFALLS TAKE HOME MASSAGE OBJECTIVES OUTLINE
3. 10.07.2010 60+ yrs old gentleman .. presented with h/o tremor in his hands for > 1 month, associated with slurred speech CASE SCENARIO TRIAGE
4. A irway: Patent B reathing: [spontaneous, RR:16/min, SPO2:99 % in RA] C irculation: [BP: 108/66 mmhg, P: 86/min, regular] D isability: [GCS:15 , reflo: 10.7 mmol, T: 37C] E xposure: NAD CASE SCENARIO PRIMARY SURVEY
5. CASE SCENARIO HISTORY The pt was seen in LHC for this tremor .. Told to have Parkinson disease Known to have - DM type II on insulin - HTN on medication - LV systolic dysfunction , EF=35% - Mild renal impairment - Known psychiatric problem .. f/u in Ibn Sina hospital
6. CASE SCENARIO HISTORY No h/o trauma, headache or blurred vision No h/o vomiting or fever Ex-smoking, No alcohol consumption, No h/o drug abuse h/o incoherent speech, and sleepiness No h/o chest pain , no SOB, No bowel or urine compliant
7. CVS : s1, s2, no murmur, no carotid bruits CHEST : b/l basal minimal ABDOMEN : soft, non tender. no organomegaly CASE SCENARIO SECONDARY SURVEY
8. CNS : No meningeal sign Alert , oriented to time place and person Lt eye cataract . Rt eye pupil reacting to light , no nystagmus facial asymmetry Rt angle mouth drop UL: Tone: cogwheel rigidity, Power: 4/5 b/l, Reflexes: 1+, Sensation: intact. LL: Right/Left sided, Power 4+, Reflexes b/l 1+, Sensation: intact Gait ataxic,finger nose incoordination with significant knee - heel incoordination. Romberg’s sign positive .. Planter reflex eqivocal CASE SCENARIO SECONDARY SURVEY
16. CASE SCENARIO MANAGEMENT in A/E NEPHROLOGY CONSULTATION LITHIUM LEVEL 3.2 mEq/l Neuromuscular excitability, irregular coarse tremors, fascicular twitching, rigid motor agitation, muscle weakness, ataxia, sluggishness, delirium, nausea, vomiting, diarrhea, leukocytosis, sinus bradycardia, and hypotension. Can lead to seizures, stupor, coma, and a 10% risk of permanent neurologic sequelae (such as dementia and ataxia) Severec > 3.5 mEq/L Moderate 2.5 - 3.5 mEq/L Mild 1.5 - 2.5 mEq/L TOXICITY PLASMA LITHIUM LEVEL
17. Nephrology Impression: ARF secondary to LITHIUM TOXICITY CASE SCENARIO MEDICAL CONSULTATION » What are the indication of HD in this pt ? » Plan: HEMODIALYSIS Lithium is the most dialyzable toxin due to its: - low molecular weight - negligible protein binding - volume of distribution similar to that of water
18. ADMISSION UNDER NEPHROLOGY TEAM CASE SCENARIO DISPOSITION Indications of Hemodialysis HD is indicated if one or more of the following is present: - A plasma lithium level is >4 mEq/L, regardless of the clinical status of the patient. - A plasma lithium concentration >2.5 mEq/L in a patient who is markedly symptomatic or who has renal insufficiency or other conditions that can limit urinary lithium excretion (such as congestive heart failure or cirrhosis) - If the plasma lithium level is between 2.5 - 4 mEq/L in an asymptomatic patient and is not anticipated to be less than 0.6 mEq/L within 36 hours.
19. There is relatively slow equilibration between extracellular and intracellular As a result, there is a rebound increase in plasma lithium levels after the cessation of dialysis as intracellular lithium diffuses into the extracellular fluid. Recommend extending the duration of dialysis to 8-12 hrs to minimize rebound and to repeat dialysis as necessary until the plasma lithium level remains at less than 1 mEq/L for 6 to 8 hours after dialysis CASE SCENARIO FOLLOW-UP
20. LITHIUM CLEARANCE 70 - 170 ml/min in hemodialysis 10 - 40 ml/min in the urine (due to extensive proximal reabsorption) 15 ml/min with peritoneal dialysis (because of the low blood flow associated with this procedure) CASE SCENARIO FOLLOW-UP
