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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

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Cpc discussion

CPC Discussion

Anne-Michelle Ruha, MD

Department of Medical Toxicology

Good Samaritan Regional Medical Center Phoenix, Arizona


History
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


Physical exam1
Physical Exam

  • Awake, but confused and agitated

  • Non-verbal, not following commands

  • Dilated pupils (4-5 mm)

  • Slight diaphoresis

  • Active bowel sounds


Physical exam2
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’ awake but exhibits an agitated delirium.

  • 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 awake but exhibits an agitated delirium.


Intervention
Intervention awake but exhibits an agitated delirium.

  • 3 ampules of sodium bicarbonate IV


ECG #2 awake but exhibits an agitated delirium.


Sodium Bicarbonate awake but exhibits an agitated delirium.


Possibilities
Possibilities… awake but exhibits an agitated delirium.

  • Wide QRS secondary to sodium channel blockade

  • Wide QRS secondary to hyperkalemia

  • Ventricular tachycardia


Toxins that produce sodium channel blockade

Amantadine awake but exhibits an agitated delirium.

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


Toxins that produce Sodium Channel Blockade awake but exhibits an agitated delirium.

  • Amantadine

  • Antihistamines

  • Beta blockers

  • Carbamazepine

  • Chloroquine

  • Class IA antiarrhythmics

  • Class IC antiarrhythmics

  • Cocaine

  • Cyclic Antidepressants

  • Local anesthetics

  • Orphenadrine

  • Phenothiazines

  • Propoxyphene

  • Quinine

  • Verapamil


Course
Course awake but exhibits an agitated delirium.

  • Mild hyperglycemia (160 mg/dL)

  • Worsening agitation

  • APAP, IV droperidol, IV lorazepam

  • Blood and urine then collected


Labs awake but exhibits an agitated delirium.

148 102 23

15 245

150

5.4 26 2.7

34

AST = 148 IU/L

ALT = 36 UY.K

Total Bili = 0.6 mg/dL

INR = 1.0

PTT = 35 sec

“UDS”= + amphetamines

neg barbs/benzos/cocaine opiates/PCP

neg APAP / EtOH

UA = large blood

0-2 RBC

no ketones


Interpretation of labs
Interpretation of labs awake but exhibits an agitated delirium.

  • Hypovolemia/dehydration

  • Renal insufficiency

  • Rhabdomyolysis

  • Hyperkalemia

  • Salicylate level not reported


Amphetamine screen

Amphetamine ( awake but exhibits an agitated delirium.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

+ amphetamine screen


Weight Loss Agents awake but exhibits an agitated delirium.

  • 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 awake but exhibits an agitated delirium.

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


Further course
Further Course awake but exhibits an agitated delirium.

  • Rapid Sequence Intubation

    • lidocaine, etomidate, succinylcholine

  • Activated charcoal

  • IVF at 200 cc/hr

  • CT brain: no acute changes

  • CXR: no acute disease


  • Worsening agitation awake but exhibits an agitated delirium.

  • Temperature = 105ºF (core)

  • Vecuronium, rapid cooling measures

  • Temperature = 109ºF

  • ABG = 7.09 / 40 / 517

  • serum K = 6.7


Final course
Final course awake but exhibits an agitated delirium.

  • Hyperventilation

  • Treatment of hyperkalemia

  • Fatal cardiac arrest


Etiology
Etiology? awake but exhibits an agitated delirium.

  • Primary toxin responsible for continued deterioration and death

  • Intervention contributed to worsening hyperthermia and subsequent death


AMS and Hyperthermia: ‘Tox’ awake but exhibits an agitated delirium.

  • 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’ awake but exhibits an agitated delirium.

  • 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
Sympathomimetic Amines awake but exhibits an agitated delirium.

  • 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
Which Agent? awake but exhibits an agitated delirium.

  • Weight loss agents:

    • Ma Huang / ephedrine alkaloids

    • Phenylpropanolamine

    • Clobenzorex

  • Illicit drugs:

    • Methylenedioxymethamphetamine

    • Paramethoxyamphetamine

    • Methamphetamine

Ripped Fuel Xenedrine Metabolife


Maois
MAOIs awake but exhibits an agitated delirium.

  • 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
Dinitrophenol awake but exhibits an agitated delirium.

  • 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


Dinitrophenol1
Dinitrophenol awake but exhibits an agitated delirium.

  • Against:

    • Would expect more acidosis early on in presentation


Salicylate
Salicylate awake but exhibits an agitated delirium.

  • 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
Why did the patient deteriorate following paralysis? awake but exhibits an agitated delirium.

  • Amphetamines and uncouplers can both produce hyperthermia independent of increased motor activity

    ? Succinylcholine

    • Malignant hyperthermia

    • Hyperkalemia

    • Rigidity and hyperthermia in salicylates


Most likely culprits
Most likely culprits… awake but exhibits an agitated delirium.

  • Amphetamine – like agent

    2. MAOI (selegiline)

    3. Dinitrophenol

    4. Salicylate


Final answer
Final Answer…. awake but exhibits an agitated delirium.

  • Overdose of a weight loss supplement detected on UDS as an amphetamine


Ma Huang – Ephedrine alkaloids awake but exhibits an agitated delirium.


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