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/

POTD: How to Treat Cellulitis...and Leishmaniasis

You diagnose a patient with cellulitis and you reach the old, familiar mental roadblock: which antibiotic do I use? Sure, you treated your last cellulitis patient with Keflex, but this patient has a small, mild abscess — do we use a different antibiotic?

UptoDate is tedious, and you’ve called the ED pharmacy 15 billion times today already for other med recommendations. Is there a better way?

B  E  H  O  L  D :  The IDSA Practice Guidelines

https://www.idsociety.org/practiceguidelines#/name_na_str/ASC/0/+/

From treating cellulitis to combat-related infections to leishmaniasis, the IDSA has the most current recommendations for you, the practitioner.

Back to our patient's skin infection. A quick search will yield this handy chart:

Our patient is young, with no comorbidities, and he has a mild, superficial, purulent infection with no systemic symptoms. According to this chart, we could treat with I & D and NO ANTIBIOTICS AT ALL. However, the same patient with a more deep-seated infection, systemic symptoms, or any risk factors would warrant empiric treatment with doxy or bactrim.

IN SUM: The IDSA practice guidelines exist. Use them.