Case Based for February

The patient is a 58 y/o male who was driving in a stolen pickup when the police pulled him over.  Police noted that he had a bag of an unknown substance sitting on the seat next to him and he was quickly eating from a bag as they walked to the truck.  He was arrested and placed in the police car.  For the first 10 or 15 minutes with the police he appeared mildly agitated and was talking.  He then very quickly decompensated and became unresponsive, with multiple quick generalized tonic-clonic movements and “twitchiness” that he showed on arrival to the emergency department.  In my experience this appeared unlikely to represent true seizures, but made it very difficult to get vital signs, or appropriately evaluate him.  Staff was initially reluctant to obtain vital signs, worrying about possible personal injury.  He was foaming from the mouth, unresponsive, mouth clamped down and with a mediocre waveform appeared to have room air oxygen saturations about 90%.

Past medical history: Unknown.  There is no history on file in epic.

Allergies: Unknown

Medications: Unknown

Social and family history: Unknown

Physical examination:
General: Obvious distress, mouth clamped down and moving moderate to poor air although with adequate respiratory rate, very agitated and unresponsive to painful and verbal stimuli
Head: Atraumatic, normocephalic
Eyes: Extraocular muscles appear to be intact with a difficult exam, pupils fully dilated bilaterally.
ENT: No obvious nasal congestion.  Difficult exam initially.
Neck:  Supple
Lungs: Clear bilaterally with shallow breaths, noisy breath sounds from oral secretions
Heart: Tachycardic and irregularly irregular
Abdomen: Soft without obvious tenderness
Extremities: No obvious trauma
Neurologic: Awake and extremely agitated, unable to respond to verbal or painful stimuli.  Diffuse tonic-clonic movements and twitching that seemed unlikely represent true seizure, though of course status epilepticus remained possible.  He was moving all 4 extremities more or less equally.

Emergency Department course: I asked that police hold him down for an IV to be started.  He was moved to the trauma room.  Thankfully an IV was possible and he was given Ativan 4 mg IV.  No change was noted over several minutes.  Ketamine and rocuronium were then given and he was intubated.  A small plastic bag with unknown substance was found in his mouth once he was relaxed enough to intubate.  Propofol drip was started at this point.  His initial monitor showed an irregularly irregular tachycardic rhythm in the 130s.  This settled down after intubation, and we were able to obtain full vital signs.  This revealed blood pressure of 185/101, pulse 105, temperature 36.4, respiratory rate 20, and saturations rose to the high 90s.  Chest x-ray showed no acute change.  The patient initially was hypertensive for approximately the first 15 minutes and then dropped his blood pressure.  He was reexamined at this point and found to have equal breath south, and no abnormality noted.  No difficulty with the ventilator.  Chest x-ray was repeated and was negative.  Fluids had been running open.  Narcan was given without change.  A norepi drip was then started.  At this point laboratories were returning.  Unremarkable CBC.  CMP normal other than a creatinine of 1.32 and glucose 120.  Lactate was 3.1.  Troponin, acetaminophen and salicylate levels negative.  CT of the head and abd/pelvis was about to be done when the helicopter arrived to transport the patient to ICU care.  Therefore, CT was postponed to be done at the receiving hospital.  Later the tox screen returned positive for methamphetamine and benzodiazepines (the latter was given in the ED).

Sympathomimetic toxicity and poisoning:

Sympathomimetic toxicity does not generally affect respiratory drive.  However, respiratory depression needs to be monitored for, considering the risk of mixed overdose.  Benzodiazepines are generally first-line treatment.  IV fluids are recommended to reduce the risk of rhabdomyolysis effects.  If the patient needs to be intubated, a nondepolarizing agent is recommended considering the risk of hyperkalemia related to rhabdomyolysis.  Beta-blockers are generally not recommended because of the risk of unopposed alpha agonist effect.  Wide-complex tacky dysrhythmias are a risk related to sodium channel blockade and can be treated effectively with sodium bicarbonate.  Hyperthermia needs to be treated aggressively, as it is associated with increased morbidity and mortality.  Aggressive use of benzodiazepines and external cooling is recommended.  CT scanning of the brain is recommended with any seizure activity or mental status change, to rule out intracranial hemorrhage.  Complaints of chest pain, even in younger patients, indicates a need for investigation of possible cardiac cause.  Inhalation use may cause lung injury, such as “crack lung”, which includes fever, cough, hemoptysis, dyspnea and hypoxemia, often with CXR showing infiltrates.  Suspect body packing in cases of large-volume ingestion.  Obtain abdominal imaging and consider activated charcoal (rarely useful), whole bowel irrigation or surgical consultation.

References:

Sympathomimetic Toxicity and Poisoning | CorePendium

Methamphetamine: Acute intoxication – UpToDate

Discussion:

Perhaps the most difficult part of this patient’s management is deciding to take control of the situation and intubate the patient.  Sometimes it is easy to think for too long that you can do it in another way.  It can be even more difficult to make this decision in a rural area where you are alone, and especially if an IV is not possible.  If it is impossible to obtain an IV, an IO or ketamine IM is very helpful.  This issue can be even more difficult in a patient who is still somewhat purposeful with his/her movements.

It remained uncertain to me why the patient dropped his blood pressure, when I was expecting the opposite.  The first things I felt important to rule out were ventilator related issues, including tension pneumothorax.  Of course, propofol effect is likely, when other issues have been ruled out.  At that point the decision is whether to back off on the propofol or start a pressor.  Considering the horror of potentially being paralyzed and aware of the situation, I favor adding a pressor.

The question of whether the patient was potentially having a seizure, made it all the more important to take control of the situation, and move expeditiously.  Several medications were used to hopefully halt any seizure, though transfer to a location where they could do EEG monitoring was also important.

There is a wide variety of opinions on when to use Narcan, especially in a mixed or unknown overdose situation.  My personal preference is to usually wait until vital signs push me to act, though arguing points can be made for otherwise.  Some opiate effect can be your friend at times and reversing it too much can potentially bring a more difficult situation.

Written by Gordon Luther, MD

ERx Clinical Partners Physician and Medical Director at Locations in Washington

This is for informational purposes only. For medical advice or diagnosis, consult a physician