TY  - CHAP
M1  - Book, Section
TI  - Case Study 1
A1  - Nelson, Lewis S.
A1  - Howland, Mary Ann
A1  - Lewin, Neal A.
A1  - Smith, Silas W.
A1  - Goldfrank, Lewis R.
A1  - Hoffman, Robert S.
PY  - 2019
T2  - Goldfrank's Toxicologic Emergencies, 11e
AB  - HistoryPolice  were  called  to  a  public  area  where  a  young  man  was  shirtless  and  acting  bizarrely.  It  was  a  hot  summer  day  with  a  temperature  of  92°F  (33°C)  and  a  dew  point  of  75°F  (24°C).  The  man,  who  appeared  confused,  was  pacing  and  gesturing  as  if  he  was  hallucinating.  When  the  police  approached  him,  he  began  to  run  away,  but  after  a  struggle,  he  was  subdued.  The  paramedics  were  called  because  of  his  behavior.  When  they  arrived,  they  found  an  agitated  and  confused  man  whose  arms  and  legs  were  restrained  and  in  a  full-body  bag.  He  was  diaphoretic  with  6  to  7  mm  pupils,  and  he  was  breathing  rapidly  and  had  a  pulse  of  180  beats/min.  Because  of  the  restraints,  no  other  vital  signs  were  obtained,  and  the  patient  was  transported  to  the  emergency  department  (ED).Physical  ExaminationOn  arrival  to  the  ED,  a  team  of  physicians,  nurses,  and  hospital  security  personnel  removed  the  patient  from  the  body  bag,  restrained  him,  and  transfered  him  to  a  hospital  stretcher.  An  arm  was  held  in  place,  and  an  intravenous  (IV)  line  was  administered.  Blood  was  obtained  for  analysis,  and  midazolam  (10  mg  IV)  was  given.  Within  a  few  moments,  the  patient  became  calmer,  and  the  following  vital  signs  were  obtained:  blood  pressure,  198/122  mm  Hg;  pulse,  188  beats/min;  respiratory  rate,  38  breaths/min;  tympanic  temperature,  104.6°F  (40.3°C);  oxygen  saturation,  98%  on  room  air;  and  glucose,  187  mg/dL.  Physical  examination  revealed  a  diaphoretic  young  man  who  was  mumbling  incoherently  and  was  hot  to  the  touch.  There  were  no  signs  of  trauma,  and  his  pupils  were  7  mm  and  reactive  to  light.  His  chest  was  clear,  and  his  heart  rate  was  regular  and  tachycardic  without  extra  sounds.  His  abdomen  was  soft  and  nontender  with  normal  bowel  sounds.  A  complete  neurologic  assessment  could  not  be  performed,  as  he  was  disoriented,  distracted,  and  unable  to  follow  commands.  His  pupils  were  reactive,  and  oculocephalic  reflexes  were  present.  Muscle  tone  was  increased  symmetrically,  and  reflexes  were  brisk,  with  three  to  four  beats  of  clonus  noted  at  both  ankles.  His  toes  were  downgoing.What  Is  the  Toxicologic  Differential  Diagnosis?This  patient  presents  with  agitation,  tachycardia,  hypertension,  hyperthermia,  diaphoresis,  mydriasis,  and  disorientation.  Although  this  presentation  is  fairly  characteristic  of  a  sympathomimetic  toxic  syndrome  (Chaps.  3,  73,  and  75)  additional  considerations  must  include  alcohol  and  sedative–hypnotic  withdrawal  (Chaps.  14  and  77),  hallucinogens  (Chap.  79),  and  phencyclidine  (Chap.  83).  These  and  other  etiologies  for  the  hyperthermia  are  listed  in  Table  CS1–1.Initial  ManagementA  rectal  probe  was  inserted,  and  the  patient’s  core  temperature  was  noted  to  be  109.2°F  (42.9°C).  This  single  vital  sign  abnormality  takes  precedence  over  the  others  and  requires  emergent  intervention,  regardless  of  the  etiology.  An  additional  5  mg  of  IV  midazolam  was  administered  (Antidotes  in  Depth:  A26)  to  further  control  the  agitation,  and  the  patient  was  placed  in  an  ice-water  bath  (Chap.  29).  While  in  the  bath,  another  5  mg  of  midazolam  was  needed  to  control  his  behavior.  One  liter  of  0.9  sodium  chloride  was  infused  through  the  peripheral  IV  line,  and  a  Foley  catheter  was  inserted,  which  ...
SN  - 
PB  - McGraw-Hill Education
CY  - New York, NY
Y2  - 2024/04/18
UR  - accesspharmacy.mhmedical.com/content.aspx?aid=1163016807
ER  -