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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
Physical Exam
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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
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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
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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
Labs
148 102 23
5.4
26 2.7
150
AST = 148 IU/L
ALT = 36 UY.K
Total Bili = 0.6 mg/dL
15
245
34
INR = 1.0
PTT = 35 sec
“UDS” = + amphetamines
UA = large blood
0-2 RBC
no ketones
neg barbs/benzos/cocaine
opiates/PCP
neg APAP / EtOH
Interpretation of labs
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Hypovolemia/dehydration
Renal insufficiency
Rhabdomyolysis
Hyperkalemia
Salicylate level not reported
+ amphetamine screen
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Amphetamine (l,d)
Amphetaminil
Benzedrine
Benzphetamine
Biphetamine
Clobenzorex
Desoxyn
Dexedrine
Dimethylamphetamine
Ephedrine
Ethylamphetamine
Famprofazone
Fencamine
Fenethylline
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Fenproporex
Furfenorex
3,4-MDMA
3,4-MDA
Methamphetamine (l,d)
Mefenorex
Mesocarb
Paramethoxyamphetamine
Phentermine
Phenylpropanolamine
Prenylamine
Pseudoephedrine
Selegiline
Weight Loss Agents
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Bitter Orange extract
Carnitine
Chitosan
Chromium
Clobenzorex
Dessicated thyroid
Dexfenfluramine
Dinitrophenol
Fenfluramine
Gamma linoleic acid
Ginkgo biloba
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Ginseng
Guarana
Hydroxycitrate
Ma Huang - ephedrine
alkaloids
Orlistat
Phentermine
Phenylpropanolamine
Pyruvate
Sibutramine
Starch blocker
Weight Loss Agents
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Bitter Orange extract
Carnitine
Chitosan
Chromium
Clobenzorex
Dessicated thyroid
Dexfenfluramine
Dinitrophenol
Fenfluramine
Gamma linoleic acid
Ginkgo biloba
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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
Ripped Fuel
– Clobenzorex
Xenedrine
Metabolife
• Illicit drugs:
– Methylenedioxymethamphetamine
– Paramethoxyamphetamine
– Methamphetamine
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.
2.
3.
4.
Amphetamine – like agent
MAOI (selegiline)
Dinitrophenol
Salicylate
Final Answer….
• Overdose of a weight loss
supplement detected on UDS
as an amphetamine
Ma Huang –
Ephedrine
alkaloids