cpc discussion
DESCRIPTION
CPC Discussion. Anne-Michelle Ruha, MD Department of Medical Toxicology Good Samaritan Regional Medical Center Phoenix, Arizona. History. 24 year old man with altered mental status Found on bed, fully clothed History of depression Use of weight loss supplement. HR= 179 bpm RR= 24/min - PowerPoint PPT PresentationTRANSCRIPT
CPC Discussion
Anne-Michelle Ruha, MD
Department of Medical Toxicology
Good Samaritan Regional Medical Center Phoenix, Arizona
History• 24 year old man with altered
mental status
• Found on bed, fully clothed
• History of depression
• Use of weight loss supplement
Physical Exam
• HR= 179 bpm
• RR= 24/min
• BP= 90/60 mmHg
• Temp 103ºF (core)
Physical Exam• Awake, but confused and agitated
• Non-verbal, not following commands
• Dilated pupils (4-5 mm)
• Slight diaphoresis
• Active bowel sounds
Physical Exam
• Pertinent negative findings
–Not comatose
–Not rigid
–Not hyperreflexic
Tachycardic, hypotensive, and hyperthermic man who is awake but exhibits an agitated delirium.
AMS and Hyperthermia: ‘Tox’
• Sympathomimetics– “Amines” – Cocaine–MAOIs
• Anticholinergics• Dissociatives• Hallucinogens• Lithium• Neuroleptics
• Neuroleptic Malignant Syndrome
• Sedative Hypnotic Withdrawal
• Serotonin Syndrome• Strychnine• Thyroid hormone• Uncouplers– Dinitrophenol– Salicylates
ECG #1
Intervention
• 3 ampules of sodium bicarbonate IV
ECG #2
Possibilities…
• Wide QRS secondary to sodium channel blockade
• Wide QRS secondary to hyperkalemia
• Ventricular tachycardia
Toxins that produce Sodium Channel Blockade• Amantadine• Antihistamines• Beta blockers• Carbamazepine• Chloroquine• Class IA antiarrhythmics• Class IC antiarrhythmics• Cocaine
• Cyclic Antidepressants
• Local anesthetics• Orphenadrine• Phenothiazines• Propoxyphene• Quinine• Verapamil
Toxins that produce Sodium Channel Blockade• Amantadine• Antihistamines• Beta blockers• Carbamazepine• Chloroquine• Class IA antiarrhythmics• Class IC antiarrhythmics
• Cocaine
• Cyclic Antidepressants
• Local anesthetics• Orphenadrine• Phenothiazines• Propoxyphene• Quinine• Verapamil
Course
• Mild hyperglycemia (160 mg/dL)
• Worsening agitation
• APAP, IV droperidol, IV lorazepam
• Blood and urine then collected
Labs148 102 23
5.4 26 2.7150 15 245
34
AST = 148 IU/L
ALT = 36 UY.K
Total Bili = 0.6 mg/dL
INR = 1.0
PTT = 35 sec
UA = large blood
0-2 RBC
no ketones
“UDS” = + amphetamines
neg barbs/benzos/cocaine opiates/PCP
neg APAP / EtOH
Interpretation of labs
• Hypovolemia/dehydration
• Renal insufficiency
• Rhabdomyolysis
• Hyperkalemia
• Salicylate level not reported
+ amphetamine screen• Amphetamine (l,d)• Amphetaminil • Benzedrine• Benzphetamine• Biphetamine• Clobenzorex • Desoxyn• Dexedrine• Dimethylamphetamine• Ephedrine• Ethylamphetamine• Famprofazone• Fencamine• Fenethylline
• Fenproporex• Furfenorex• 3,4-MDMA • 3,4-MDA• Methamphetamine (l,d)• Mefenorex• Mesocarb• Paramethoxyamphetamine• Phentermine• Phenylpropanolamine• Prenylamine• Pseudoephedrine• Selegiline
Weight Loss Agents• Bitter Orange extract • Carnitine• Chitosan • Chromium• Clobenzorex• Dessicated thyroid• Dexfenfluramine• Dinitrophenol• Fenfluramine• Gamma linoleic acid • Ginkgo biloba
• Ginseng• Guarana• Hydroxycitrate • Ma Huang - ephedrine
alkaloids• Orlistat • Phentermine • Phenylpropanolamine• Pyruvate• Sibutramine • Starch blocker
Weight Loss Agents• Bitter Orange extract • Carnitine• Chitosan • Chromium• Clobenzorex• Dessicated thyroid• Dexfenfluramine• Dinitrophenol• Fenfluramine• Gamma linoleic acid • Ginkgo biloba
• Ginseng• Guarana• Hydroxycitrate • Ma Huang - ephedrine
alkaloids• Orlistat • Phentermine • Phenylpropanolamine• Pyruvate• Sibutramine • Starch blocker
Further Course
• Rapid Sequence Intubation–lidocaine, etomidate,
succinylcholine• Activated charcoal• IVF at 200 cc/hr• CT brain: no acute changes• CXR: no acute disease
• Worsening agitation
• Temperature = 105ºF (core)
• Vecuronium, rapid cooling
measures
• Temperature = 109ºF
• ABG = 7.09 / 40 / 517
• serum K = 6.7
Final course
• Hyperventilation
• Treatment of hyperkalemia
• Fatal cardiac arrest
Etiology?• Primary toxin responsible for
continued deterioration and death
• Intervention contributed to worsening hyperthermia and subsequent death
AMS and Hyperthermia: ‘Tox’
• Sympathomimetics– “Amines” – Cocaine–MAOIs
• Anticholinergics• Dissociatives• Hallucinogens• Lithium• Neuroleptics
• Neuroleptic Malignant Syndrome
• Sedative Hypnotic Withdrawal
• Serotonin Syndrome• Strychnine• Thyroid hormone• Uncouplers– Dinitrophenol– Salicylates
AMS and Hyperthermia: ‘Tox’
• Sympathomimetics– “Amines” – Cocaine–MAOIs
• Anticholinergics• Dissociatives• Hallucinogens• Lithium• Neuroleptics
• Neuroleptic Malignant Syndrome
• Sedative Hypnotic Withdrawal
• Serotonin Syndrome• Strychnine• Thyroid hormone• Uncouplers– Dinitrophenol– Salicylates
Sympathomimetic Amines• Support:
–Symptoms, renal failure, severe hyperthermia
–Positive urine screen
–History of use of weight loss agent
• Against:
–No reported cases of QRS widening secondary to sodium channel blockade
Which Agent?• Weight loss agents:–Ma Huang / ephedrine alkaloids–Phenylpropanolamine–Clobenzorex
• Illicit drugs:–Methylenedioxymethamphetamine –Paramethoxyamphetamine–Methamphetamine
Ripped Fuel Xenedrine Metabolife
MAOIs• MAOI overdose or drug interaction with
serotonergic weight loss agent or antidepressant
• Support:
–Tachycardia, agitation, diaphoresis
–Selegiline, an antiparkinson drug, is metabolized to methamphetamine
• Against:
–Lack of neuromuscular findings (rigidity, hyperreflexia, tremor)
Dinitrophenol• Support:
–Uncouples oxidative phosphorylation and would be expected to produce hyperthermia despite paralysis
–Tachypnea, diaphoresis, tachycardia consistent with poisoning
–Recent experimentation with this agent documented on the internet
Dinitrophenol• Against:
–Would expect more acidosis early on in presentation
Salicylate• Support:
–Agitated delirium, tachypnea, tachycardia, diaphoresis
–May produce severe hyperthermia
• Against:
–Not initially acidotic (CO2=26)
–No ketones in urine
Why did the patient deteriorate following paralysis?
• Amphetamines and uncouplers can both produce hyperthermia independent of increased motor activity
? Succinylcholine
–Malignant hyperthermia
–Hyperkalemia
–Rigidity and hyperthermia in salicylates
Most likely culprits…
1. Amphetamine – like agent
2. MAOI (selegiline)
3. Dinitrophenol
4. Salicylate
Final Answer….
• Overdose of a weight loss supplement detected on UDS as an amphetamine
Ma Huang – Ephedrine alkaloids