**Table 3.**

*Trauma and Emergency Surgery - The Role of Damage Control Surgery*

vaginal foreign body [38].

**2.8 Indwelling devices**

and cultured [39–41].

**3. Hyperthermia**

(**Table 3**).

**3.1 Neuroleptic malignant syndrome (NMS)**

cholangitis, ruptured hollow viscus, or infection of the gastrointestinal tract. While abdominal sources for sepsis are common in the ED, the diagnosis may be hampered by examination difficulties secondary to the patient's mental status or body habitus. Altered consciousness can impede a patient's ability to localize their discomfort, and many abdominal pathologies have no manifestations on external visual examination. As such, a thorough abdominal examination is of vital importance in altered patients. Although these patients may be unable to verbalize discomfort, absent bowel sounds, abdominal distention, or abdominal rigidity on examination can be clues to the presence of intraabdominal pathology [36–38]. Additionally, grimacing, guarding, or reflex tachycardia can be useful indicators of pain in patients are altered or obtunded [36–38]. Pelvic examination should be done if a pelvic source is suspected or if there is concern for toxic shock syndrome secondary to a retained

Indwelling devices such as urinary catheters, ports, pacers, and long-term intravenous access are associated with an increased risk of infection. Examination of these devices is an important part of the physical examination of the septic patient. Erythema or purulence at the exit site is specific for infection but these signs of not sensitive for the presence of device-associated infection. In fact, less than 5% of dialysis line-associated bacteremia was found to have associated purulent exit site drainage [39]. Because physical examination findings are often absent, it is important to keep device-associated infection in the differential in septic patients. If infection is suspected, the device should be removed as soon as clinically possible

While a reflexive diagnosis of sepsis is tempting for the ill-appearing patient with an elevated temperature, it is important to consider conditions that mimic sepsis which are often both life-threatening and reversible. Unlike the fever associated with sepsis, the majority of these sepsis mimics have elevated temperature as a result of hyperthermia, which occurs secondary to dysfunction of the hypothalamic thermoregulatory system [1]. If an infectious source cannot be found in a seemingly septic patient or the patient is not improving with antibiotics and fluids, it is important to broaden the differential to conditions that cause hyperthermia

NMS is a life-threatening syndrome of altered mental status, autonomic instability, hyperthermia, and muscle rigidity associated with the use of dopaminergic antagonists. "Lead pipe" rigidity is the hallmark physical examination finding in NMS and can be severe enough to precipitate rhabdomyolysis. Most commonly, NMS occurs with the use of dopaminergic antagonists used in the treatment of psychiatric disorders and nausea, but NMS can also be precipitated by may be caused withdrawal from dopaminergic medications, such as those used in the treatment of Parkinson's disease [42, 43]. First generation antipsychotic medications are the most commonly implicated in NMS, with haloperidol and fluphenazine having the highest risk [42]. Risk factors for the development of NMS include higher medication doses, recent or rapid dose escalation, and parenteral medication administration [42].

**24**

*Hyperthermic sepsis mimics, their presentation, and their management.*

The highest risk of NMS is within two weeks of medication initiation but this syndrome develop at any time during the treatment timeline [44]. A review of the patient's medications is typically needed to make the diagnosis. The cornerstone of management of NMS is supportive, with discontinuation of the suspected offending agent, support of the cardiopulmonary system, maintenance of normothermia and euvolemia, and prevention of complications including deep venous thrombosis, acute renal failure, and cardiac dysrhythmias [42–44]. In cases of severe muscle rigidity not responding to supportive treatment, intravenous dantrolene sodium or oral bromocriptine mesylate should be considered [44].

#### **3.2 Serotonin syndrome (SS)**

SS is a syndrome of altered mentation, neuromuscular abnormalities, and autonomic hyperactivity caused by excess serotonin levels [45]. The most commonly implicated medications in SS include linezolid, fentanyl, and selective serotonin reuptake inhibitor (SSRIs) [46]. The neuromuscular abnormalities associated with SS can include hyperreflexia, clonus, or muscle rigidity, and, as with NMS, these may be severe enough to which may lead to rhabdomyolysis [45, 46]. SS is a clinical diagnosis based on patient presentation, and there is no laboratory test or imaging study to confirm the diagnosis [45]. The Hunter criteria for serotonin syndrome is one outline the clinical criteria needed to make the diagnosis [47]. Like NMS, management of SS is primarily supportive. If this is insufficient or ineffective, use of cyproheptadine can be used under the consultation of a toxicologist [45]. If neuromuscular paralysis is need to control neuromuscular rigidity or facilitate intubation, only nondepolarizing agents should be used, as depolarizing agents may exacerbate the hyperkalemia precipitated by the neuromuscular abnormalities of SS [45, 46].


#### **Table 4.**

*Hunter criteria for serotonin syndrome [47].*

Suspect serotonin syndrome if the patient has taken a serotonergic agent and has one of the symptom complexes outlined below (**Table 4**).
