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Poster 203: Life Threatening Serotonin Syndrome Associated With the Use of Trazodone: A Case Report
E86
ACADEMY ANNUAL ASSEMBLY ABSTRACTS
tionnaire was administered by the residents in PM&R to assess the 2 methods (theoretical or interactive classes). Main Outcome Measures: This questionnaire evaluated learning, clinical skills, acquisition of knowledge, and usefulness for clinical practice. Results: A total of 183 questionnaires were completed for the evaluation of 95 theoretical and 94 interactive classes. We found no association between learning and class methods. A relationship exists between clinical skills and interactive classes (91.3% disagree vs 8.7%, 56.1% partially disagree vs 43.9%, 50.3% agree vs 61.5%). We found a relationship between knowledge and interactive classes (90.9% disagree vs 9.1%, 64.4% partially disagree vs 35.6%, 37.7% agree vs 62.3%). A relationship exists between useful clinical practice and interactive classes (18.2% disagree vs 81.8%, 70.9% partially disagree vs 29.1%, 33.9% agree vs 66.1%). Conclusions: The interactive method gave the best results for the acquisition of clinical skills, knowledge, and usefulness for our clinical practice, but we found no differences in learning. Key Words: Education, medical; Rehabilitation; Residency. Poster 202 Leech Therapy as an Innovative Tool in the Healing of Grafts for Traumatic Amputations: A Case Report. John Santa Ana, DO (Walter Reed Army Medical Center, Washington, DC); Allison Franklin, DO; Brandon J. Goff, DO; William J. Kroski, DO. Disclosure: A. Franklin, none; B.J. Goff, none; W.J. Kroski, none; J. Santa Ana, none. Setting: Inpatient rehabilitation unit. Patient: A 40-year-old man (military service member) with a right traumatic thumb amputation at the metacarpal joint. Case Description: The patient was injured from an improvised explosive device. He sustained a traumatic amputation of the right thumb at the metacarpal joint, a transected left distal superficial femoral artery, a left open distal femoral fracture, and multiple extremity soft tissue injuries. A surgical bypass graft of his left superficial femoral artery was done and the left femur was repaired via intermedullary nailing. He subsequently underwent a posterior interosseous artery rotation flap to cover the soft tissue defect over the right thumb amputation site. Leech therapy was initiated to relieve the venous congestion of the flap repair. This therapy consisted of placing leeches on the flap site for 2 hours per day for 1 week. At this point the flap showed significant improvements in wound healing, with excellent blood flow. The patient continued to participate in occupational therapy for the right upper extremity and was also fit for a thumb prosthesis. At the time of discharge, the flap site was clean and dry with healthy cutaneous tissue and his hand demonstrated excellent range of motion, strength and function. Assessment/Results: The patient developed venous congestion in his flap secondary to a repaired arterial blood flow with an un-established venous flow. After 1 week of 2-hour daily leech therapy, the accumulation of blood from the flap site was relieved, allowing the flap to heal. He was able to participate in therapies for the affected hand, to include grasping objects, activities of daily living, assisting with transfers, and was also able to be fitted with a thumb prosthesis. All these functions would have been delayed if the flap had not healed due to congestion. Conclusions: Leech therapy has been around for thousands of years and is still useful today in surgical reattachment of appendages and tissues. It enables adequate blood flow to the tissues for enhanced healing. Further studies are warranted to explore leech therapy’s full potential, especially for the specialized tissue flaps and grafts needed to cover devastating traumatic amputation sites and other soft tissue injuries. Key Words: Amputation; Leeches; Rehabilitation. Arch Phys Med Rehabil Vol 89, November 2008
Poster 203 Life Threatening Serotonin Syndrome Associated With the Use of Trazodone: A Case Report. Angela Stillwagon, DO (University of Cincinnati College of Medicine, Cincinnati, OH); Mary McMahon, MD; Austin I. Nobunaga, MD, MPH. Disclosure: M. McMahon, none; A.I. Nobunaga, none; A. Stillwagon, none. Setting: Skilled nursing facility. Patient: A 24-year-old man admitted to skilled nursing facility 8 days following a MVC resulting in C3 American Spinal Association on grade A tetraplegia. Case Description: Patient had a history of intermittent fevers without clear source on admission. On day 2, the patient was started on trazodone 50mg at bedtime for sleep. His fevers continued up to 103.5° on day 3 and he was started on augmentin for presumed otitis media. On day 4, the patient was started on amitriptyline, 10mg at bedtime, for neuropathic pain. On day 6, the patient’s temperature rose to 108.8° and he was noted to have lethargy, diaphoresis, tachycardia, and hypotension requiring fluid resuscitation and transfer to an acute care hospital. Work-up revealed an UTI, small infiltrate on CXR, elevated serum aminotransferase, and CPK and he was started on broad-spectrum antibiotics and dantrium. Assessment/Results: The patient’s degree of hyperthermia was felt to be unlikely due solely to an infectious process. The symptoms were felt to be most consistent with a diagnosis of serotonin syndrome resulting from the combined use of trazodone and amitriptyline. Following the withdrawal of these medications, symptoms resolved over 1 to 2 days. Discussion: Excess serotonin classically produces a triad of clinical findings, which include mental status changes, neuromuscular excitation, and autonomic stimulation. The presentation, however, can be variable and is not always dose related. As the use of serotonergic agents increases, it is likely that the incidence of serotonin syndrome will rise as well. Because many physicians are unfamiliar with its clinical presentation there is the potential for symptoms to go unrecognized. Conclusion: Life-threatening serotonin syndrome may occur with doses of serotonergic drugs that are commonly used by rehabilitation physicians. Physiatrists should be aware of this syndrome and be able to recognize the signs and symptoms. Key Words: Rehabilitation; Serotonin Syndrome; Trazodone. Poster 204 Median Nerve High-Resolution Ultrasonographic Measures: Correlates With Median Nerve Conduction Studies in Normal Subjects. Christina M. Marciniak, MD (McGaw Medical Center of Northwestern University, Northwestern Medical School/Rehabilitation Institute of Chicago, Chicago, IL); Eric M. Feldman, MD; Jean Lai, MD; Paul H. Lento, MD; Chris Plastaras, MD; Heather Sered, MD. Disclosure: E.M. Feldman, none; J. Lai, none; P.H. Lento, Disaboom. com, stock options or bond holdings; C.M. Marciniak, Allergan, Inc, research grants; C. Plastaras, none; H. Sered, none. Objective: To study relationships between median wrist and forearm ultrasonographic measurements and median nerve conduction studies (NCS). Design: Prospective, convenience sample of healthy adults. Setting: Outpatient clinic of an academic center. Participants: Healthy subjects replying to flyer advertisements. Interventions: Following subject screening, median motor NCS and sensory NCS to the index finger were performed using standard published techniques. A second examiner blinded to NCS results used a high-frequency lineararray transducer to measure the cross-sectional area (CSA) of the median nerve at the distal volar wrist crease (carpal tunnel outlet) and forearm (4cm proximally), measured in the transverse plane on static sonographic images. The outer margin of the median nerve was traced at the junction of the hypoechoic fascicles and adjacent outer connec-
ACADEMY ANNUAL ASSEMBLY ABSTRACTS
tionnaire was administered by the residents in PM&R to assess the 2 methods (theoretical or interactive classes). Main Outcome Measures: This questionnaire evaluated learning, clinical skills, acquisition of knowledge, and usefulness for clinical practice. Results: A total of 183 questionnaires were completed for the evaluation of 95 theoretical and 94 interactive classes. We found no association between learning and class methods. A relationship exists between clinical skills and interactive classes (91.3% disagree vs 8.7%, 56.1% partially disagree vs 43.9%, 50.3% agree vs 61.5%). We found a relationship between knowledge and interactive classes (90.9% disagree vs 9.1%, 64.4% partially disagree vs 35.6%, 37.7% agree vs 62.3%). A relationship exists between useful clinical practice and interactive classes (18.2% disagree vs 81.8%, 70.9% partially disagree vs 29.1%, 33.9% agree vs 66.1%). Conclusions: The interactive method gave the best results for the acquisition of clinical skills, knowledge, and usefulness for our clinical practice, but we found no differences in learning. Key Words: Education, medical; Rehabilitation; Residency. Poster 202 Leech Therapy as an Innovative Tool in the Healing of Grafts for Traumatic Amputations: A Case Report. John Santa Ana, DO (Walter Reed Army Medical Center, Washington, DC); Allison Franklin, DO; Brandon J. Goff, DO; William J. Kroski, DO. Disclosure: A. Franklin, none; B.J. Goff, none; W.J. Kroski, none; J. Santa Ana, none. Setting: Inpatient rehabilitation unit. Patient: A 40-year-old man (military service member) with a right traumatic thumb amputation at the metacarpal joint. Case Description: The patient was injured from an improvised explosive device. He sustained a traumatic amputation of the right thumb at the metacarpal joint, a transected left distal superficial femoral artery, a left open distal femoral fracture, and multiple extremity soft tissue injuries. A surgical bypass graft of his left superficial femoral artery was done and the left femur was repaired via intermedullary nailing. He subsequently underwent a posterior interosseous artery rotation flap to cover the soft tissue defect over the right thumb amputation site. Leech therapy was initiated to relieve the venous congestion of the flap repair. This therapy consisted of placing leeches on the flap site for 2 hours per day for 1 week. At this point the flap showed significant improvements in wound healing, with excellent blood flow. The patient continued to participate in occupational therapy for the right upper extremity and was also fit for a thumb prosthesis. At the time of discharge, the flap site was clean and dry with healthy cutaneous tissue and his hand demonstrated excellent range of motion, strength and function. Assessment/Results: The patient developed venous congestion in his flap secondary to a repaired arterial blood flow with an un-established venous flow. After 1 week of 2-hour daily leech therapy, the accumulation of blood from the flap site was relieved, allowing the flap to heal. He was able to participate in therapies for the affected hand, to include grasping objects, activities of daily living, assisting with transfers, and was also able to be fitted with a thumb prosthesis. All these functions would have been delayed if the flap had not healed due to congestion. Conclusions: Leech therapy has been around for thousands of years and is still useful today in surgical reattachment of appendages and tissues. It enables adequate blood flow to the tissues for enhanced healing. Further studies are warranted to explore leech therapy’s full potential, especially for the specialized tissue flaps and grafts needed to cover devastating traumatic amputation sites and other soft tissue injuries. Key Words: Amputation; Leeches; Rehabilitation. Arch Phys Med Rehabil Vol 89, November 2008
Poster 203 Life Threatening Serotonin Syndrome Associated With the Use of Trazodone: A Case Report. Angela Stillwagon, DO (University of Cincinnati College of Medicine, Cincinnati, OH); Mary McMahon, MD; Austin I. Nobunaga, MD, MPH. Disclosure: M. McMahon, none; A.I. Nobunaga, none; A. Stillwagon, none. Setting: Skilled nursing facility. Patient: A 24-year-old man admitted to skilled nursing facility 8 days following a MVC resulting in C3 American Spinal Association on grade A tetraplegia. Case Description: Patient had a history of intermittent fevers without clear source on admission. On day 2, the patient was started on trazodone 50mg at bedtime for sleep. His fevers continued up to 103.5° on day 3 and he was started on augmentin for presumed otitis media. On day 4, the patient was started on amitriptyline, 10mg at bedtime, for neuropathic pain. On day 6, the patient’s temperature rose to 108.8° and he was noted to have lethargy, diaphoresis, tachycardia, and hypotension requiring fluid resuscitation and transfer to an acute care hospital. Work-up revealed an UTI, small infiltrate on CXR, elevated serum aminotransferase, and CPK and he was started on broad-spectrum antibiotics and dantrium. Assessment/Results: The patient’s degree of hyperthermia was felt to be unlikely due solely to an infectious process. The symptoms were felt to be most consistent with a diagnosis of serotonin syndrome resulting from the combined use of trazodone and amitriptyline. Following the withdrawal of these medications, symptoms resolved over 1 to 2 days. Discussion: Excess serotonin classically produces a triad of clinical findings, which include mental status changes, neuromuscular excitation, and autonomic stimulation. The presentation, however, can be variable and is not always dose related. As the use of serotonergic agents increases, it is likely that the incidence of serotonin syndrome will rise as well. Because many physicians are unfamiliar with its clinical presentation there is the potential for symptoms to go unrecognized. Conclusion: Life-threatening serotonin syndrome may occur with doses of serotonergic drugs that are commonly used by rehabilitation physicians. Physiatrists should be aware of this syndrome and be able to recognize the signs and symptoms. Key Words: Rehabilitation; Serotonin Syndrome; Trazodone. Poster 204 Median Nerve High-Resolution Ultrasonographic Measures: Correlates With Median Nerve Conduction Studies in Normal Subjects. Christina M. Marciniak, MD (McGaw Medical Center of Northwestern University, Northwestern Medical School/Rehabilitation Institute of Chicago, Chicago, IL); Eric M. Feldman, MD; Jean Lai, MD; Paul H. Lento, MD; Chris Plastaras, MD; Heather Sered, MD. Disclosure: E.M. Feldman, none; J. Lai, none; P.H. Lento, Disaboom. com, stock options or bond holdings; C.M. Marciniak, Allergan, Inc, research grants; C. Plastaras, none; H. Sered, none. Objective: To study relationships between median wrist and forearm ultrasonographic measurements and median nerve conduction studies (NCS). Design: Prospective, convenience sample of healthy adults. Setting: Outpatient clinic of an academic center. Participants: Healthy subjects replying to flyer advertisements. Interventions: Following subject screening, median motor NCS and sensory NCS to the index finger were performed using standard published techniques. A second examiner blinded to NCS results used a high-frequency lineararray transducer to measure the cross-sectional area (CSA) of the median nerve at the distal volar wrist crease (carpal tunnel outlet) and forearm (4cm proximally), measured in the transverse plane on static sonographic images. The outer margin of the median nerve was traced at the junction of the hypoechoic fascicles and adjacent outer connec-