S-LAMS for suspected acute strokes

The red phone in resus rings and the nurse tells you: “r/o LVO (large vessel occlusion), LAMS is 5”.

Here in NYC, our EMS uses the Stratified Los Angeles Motor Scale or S-LAMS in the field to help determine where to transport potential stroke patients.

FACIAL DROOP: Absent 0, Present +1

ARM DRIFT: Absent 0, Drifts down +1, Falls rapidly +2

SPEECH DEFICIT: Absent 0, Present +1

GRIP STRENGTH: Normal 0, Weak grip +1, No grip +2

If the score is < 3, the patient should go to the closest primary stroke center.

If the score is > 4, they will call online medical control (OLMC) for a transport decision, often to the closest thrombectomy stroke center (Maimonides is one!). This is because in LVO, endovascular mechanical thrombectomy is the treatment of choice. EMS has to call OLMC to discuss the patient because sometimes there are exclusion criteria for transport to a thrombectomy center.

Time is brain and the S-LAMS scoring system helps get our most concerning patients to the center most suitable to care for them.

Neuroleptic Malignant Syndrome/Serotonin Syndrome

Let's talk about hyperthemia today, the weird kind. NMS and SS - I often get confused between the two, so this is as much as I can remember:

NMS is SLOW, it happens slowly and takes forever to resolve. Fever + rigidity.

SS is FAST, hyper reflexive and agitated, quick on and relatively quick off. Fever + clonus.

Both have fever/elevated temp. Treat both with benzos. For NMS, add on bromocriptine (SLOW down BRO). For SS, just use the other weird-sounding drug (cyproheptadine).

I think it's also important to learn to recognize potential offending agents when you are doing med recs on patients.

Definitely not a comprehensive list but here are some our patients might be taking (or you are giving them):

NMS

typical antipsychotics > atypicals. Classically, haldol, droperidol, thorazine, pheneragan. Metoclopramide. Less rare but atypicals like clozapine, olanzapine, risperidone, quetiapine, ziprasidone.

SS

sertraline, fluoxetine, citalopram, paroxetine, trazadone, buspirone, venlafaxine, valproate, tramadol, fentanyl, meperidine, ondansetron, metoclopramide, sumatriptan, linezolid, dextromethorphan, MDMA, LSD, St. John’s wort, ginseng.

Check this out for more details and some of the more nitty gritty:

http://www.emdocs.net/toxcard-differentiating-serotonin-syndrome-neuroleptic-malignant-syndrome/

Drowning and Submersion Injuries

For today's POTD, we're going to talk about drowning/submersion injuries. Hopefully you don't have to take care of a jet-skiier that gets pulled out of the East river this weekend, but in case you do, here's some tips to prepare you!

Epidemiology: 20% of deaths involve children < 14 yo, a leading cause of death in children < 5yo, typically in swimming pools, bathtubs, buckets. 

History of seizures and cardiac disease increases the risk of drowning.

Bimodal distribution with second peak usually (80%) in males 15-25 yo, alcohol involved in up to 70% of cases. Typically rivers, lakes, beaches.

Pathophys: Fluid aspiration => loss of surfactant, pulmonary edema, hypoxemia from V/Q mismatch

ED Management: ACLS if in cardiac arrest, it is usually a respiratory arrest. Remove wet clothing and use rewarming techniques. Initial CXR often normal. Assess for signs of trauma. C-spine injuries are uncommon (<5%) but still evaluate for trauma especially if unwitnessed event. Intubate if O2 sat < 90% despite supplemental O2, PaO2 < 60, or PaCO2>50 as hypoxemia is the major issue. If able to protect airway, BIPAP for positive pressure.

Fresh water vs. salt water drowning distinctions do not matter much because you need to aspirate more than 11mL/kg of body weight to get blood volume changes and even more to get electrolyte changes. Most nonfatal drowning victims aspirate at most 3-4 mL/kg.

Meds: none really helpful, it is supportive care. Steroids and antibiotics have not been shown to help.

Dispo: admit if any symptoms on arrive to hospital, at least for monitoring. If asymptomatic after a near drowning, monitor for at least 4-6 hours.  

Sources

https://www.nuemblog.com/blog/drowning

https://www.saem.org/cdem/education/online-education/m4-curriculum/group-m4-environmental/drowing