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CPC Discussion

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

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  1. CPC Discussion Anne-Michelle Ruha, MD Department of Medical Toxicology Good Samaritan Regional Medical Center Phoenix, Arizona

  2. History • 24 year old man with altered mental status • Found on bed, fully clothed • History of depression • Use of weight loss supplement

  3. HR= 179 bpm RR= 24/min BP= 90/60 mmHg Temp 103ºF (core) Physical Exam

  4. Physical Exam • Awake, but confused and agitated • Non-verbal, not following commands • Dilated pupils (4-5 mm) • Slight diaphoresis • Active bowel sounds

  5. Physical Exam • Pertinent negative findings • Not comatose • Not rigid • Not hyperreflexic

  6. Tachycardic, hypotensive, and hyperthermic man who is awake but exhibits an agitated delirium.

  7. 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

  8. ECG #1

  9. Intervention • 3 ampules of sodium bicarbonate IV

  10. ECG #2

  11. Sodium Bicarbonate

  12. Possibilities… • Wide QRS secondary to sodium channel blockade • Wide QRS secondary to hyperkalemia • Ventricular tachycardia

  13. 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

  14. 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

  15. Course • Mild hyperglycemia (160 mg/dL) • Worsening agitation • APAP, IV droperidol, IV lorazepam • Blood and urine then collected

  16. Labs 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

  17. Interpretation of labs • Hypovolemia/dehydration • Renal insufficiency • Rhabdomyolysis • Hyperkalemia • Salicylate level not reported

  18. 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 + amphetamine screen

  19. 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

  20. 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

  21. Further Course • Rapid Sequence Intubation • lidocaine, etomidate, succinylcholine • Activated charcoal • IVF at 200 cc/hr • CT brain: no acute changes • CXR: no acute disease

  22. Worsening agitation • Temperature = 105ºF (core) • Vecuronium, rapid cooling measures • Temperature = 109ºF • ABG = 7.09 / 40 / 517 • serum K = 6.7

  23. Final course • Hyperventilation • Treatment of hyperkalemia • Fatal cardiac arrest

  24. Etiology? • Primary toxin responsible for continued deterioration and death • Intervention contributed to worsening hyperthermia and subsequent death

  25. 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

  26. 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

  27. 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

  28. Which Agent? • Weight loss agents: • Ma Huang / ephedrine alkaloids • Phenylpropanolamine • Clobenzorex • Illicit drugs: • Methylenedioxymethamphetamine • Paramethoxyamphetamine • Methamphetamine Ripped Fuel Xenedrine Metabolife

  29. 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)

  30. 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

  31. Dinitrophenol • Against: • Would expect more acidosis early on in presentation

  32. Salicylate • Support: • Agitated delirium, tachypnea, tachycardia, diaphoresis • May produce severe hyperthermia • Against: • Not initially acidotic (CO2=26) • No ketones in urine

  33. 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

  34. Most likely culprits… • Amphetamine – like agent 2. MAOI (selegiline) 3. Dinitrophenol 4. Salicylate

  35. Final Answer…. • Overdose of a weight loss supplement detected on UDS as an amphetamine

  36. Ma Huang – Ephedrine alkaloids

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