Updated: 5/17/2019

Substance Intoxication and Withdrawal

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Questions
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Evidence
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Overview
  • General
    • most addictive drugs act on the dopamine mesolimbic-reward pathway
    • withdrawal symptoms are often the opposite of intoxication
      • e.g., mydraisis and miosis - opioid intoxication
    • depressant withdrawal generally more life-threatening than stimulant withdrawal 
    • substance use typically denied or underreported
      • check urine drug immunoassay to screen for substance use
      • if urine drug test is positive, will need follow-up gas chromatography / mass spectrometry assessment to confirm and quantiy drug use
      • collect collateral info from friends/family
  • Drug classes
    • depressants
      • opioids (mu agonist)
      • barbiturates (GABAa channel opening duration increased)
      • benzodiazepines (GABAa channel opening frequency increased)
      • alcohol
    • stimulants
      • amphetamine
      • MDMA
      • cocaine
      • caffeine
      • nicotine
    • hallucinogens
      • PCP
      • LSD
      • marijuana
  • General complications 
    • injection drug users at risk for
      • right-sided endocarditis
      • hepatitis and abscesses
      • overdose
      • hemorrhoids
      • AIDS
Snapshot
  • A young male is brought into the ED by his friends who say he is not responding to them.  The patient seems extremely drowsy and has slurred speech.  On physical exam he has pinpoint pupils and his respiratory rate is 4/min.
Opioids
  • Mechanism
    • mu receptor agonist
  • Examples
    • morphine, heroin, methadone
  • Intoxication
    • presentation
      • constipation - no tolerance to this side effect
      • respiratory depression - life threatening
      • pupillary constriction (pinpoint pupils) 
      • seizures (overdose is life-threatening)
      • for heroin use, look for track marks (needle injections)
    • treatment 
      • pharmacologic  
        • naloxone
          • opioid receptor antagonist
          • opioid withdrawal is NOT fatal - it is just unpleasant
        • symptomatic treatment
  • Withdrawal
    • presentation
      • anxiety, insomnia, anorexia, sweating, dilated pupils, piloerection ("cold turkey"),
      • fever, rhinorrhea, nausea, stomach cramps, diarrhea ("flulike" symptoms)
      • yawning 
        • unpleasant but not life-threatening
    • treatment of withdrawal
      • clonidine
        • α2 agonist that decreases NE and sympathetic output making autonomic symptoms less intense
      • methadone (long-acting) 
      • buprenorphine + naloxone
        • can precipitate withdrawal if given too soon (partial mu agonist)
    • treatment of addiction
      • pharmacologic  
        • methadone 
          • typically oral
          • long-acting IV opiate
          • used for heroin detoxification or long-term maintenance
        • suboxone (buprenorphine + naloxone)
          • long-acting oral administration with fewer withdrawal symptoms than methadone
          • naloxone + buprenorphine (partial opioid agonist) 
          • naloxone is not active when taken orally, so withdrawal symptoms occur only if injected
            • intended to prevent overdose when suboxone is injected
        • naltrexone
          • opioid antagonist used to assist in blocking cravings for both opioids (and alcohol)
          • should not be used for opioid overdose as it takes longer to take effect as compared to naloxone
Snapshot
  • A patient presents to the ED with impaired memory, poor concentration and extreme drowsiness.  Pupils are not dilated on exam and the patient is minimally responsive.  Of greatest concern is the patient's respiratory rate of 5/min.
Barbiturates
  • Mechanism
    • GABAa channel - increased duration of opening
  • Intoxication
    • presentation
      • respiratory/CNS depression - can be fatal
      • does not have a depression "ceiling" in contrast to benzodiazepines
    • treatment 
      • pharmacologic 
        • symptom management
        • support BP
      • non-pharmacologic
        • assist respiration
        • intubate if necessary
  • Withdrawal
    • presentation
      • anxiety, seizures, delirium
      • similar to alcohol
      • life-threatening cardiovascular collapse 
      • additive affects with alcohol
    • treatment
      • pharmacologic
        • long-acting benzodiazepines with taper
        • could also use long-acting barbiturates (phenobarbital)
Snapshot
  • A patient with a past medical history of panic attacks and anxiety is brought into the ED by her husband as she has been stuporous and has been minimally responsive and extremely drowsy.  The patient's husband mentions that his wife did have a panic attack today.
Benzodiazepines
  • Mechanism
    • GABAa channel - increased frequency of opening
  • Intoxication
    • presentation 
      • amnesia, ataxia, stupor/somnolence, minor respiratory depression
      • has a depression "ceiling"
      • additive affects with alcohol
    • treatment 
      • pharmacologic
        • flumazenil
          • competitive GABAa antagonist
      • DO NOT treat benzodiazepine overdose with flumazenil
        • in general it is benign and the patient can "sleep off" the overdose
        • offer respiratory support if needed
        • flumazenil can precipitate seizures particularly if the patient is benzodiazepine dependent
  • Withdrawal 
    • presentation
      • rebound anxiety
      • seizures (life-threatening) and tremor
        • most commonly from short-acting benzos (e.g. alprazolam) 
      • insomnia
    • treatment 
      • pharmacologic
        • long-acting benzodiazepine to taper off dose
          • e.g., clonazepam 
        • symptomatic treatment
Snapshot
  • A 25-year-old male is brought into the ED by his own volition as he has been unable to sleep for the past 5 nights and is concerned.  He says he feels as if he doesn't need to sleep but came in at the request of his friend.  He has been studying all night for finals and says he has been, "in the zone," and been unable to stay up all night with no need for sleep.
Amphetamines
  • Mechanism
    • simulates biogenic amine (DA, NE, 5HT) release + decreases reuptake (high dose)
  • Intoxication
    • presentation 
      • mental status changes
        • euphoria, impaired judgment, delusions, hallucinations, prolonged wakefulness/attention
      • sympathetic activation
        • psychomotor agitation, pupillary dilation, hypertension, tachycardia, fever, cardiac arrhythmias 
    • treatment
      • pharmacologic
        • antipsychotics (haloperidol)
        • benzodiazepines
        • vitamin C (promotes excretion)
        • antihypertensives
        • propranolol (BP + tachycardia control)
      • non-pharmacologic
        • do not restrain patients
          • may result in rhabdomyolysis
Snapshot
  • A 23-year-old female is brought into the ED by her friends as they are concerned about her behavior.  She seems more energetic than usual and this has gone on well past the end of the rave.  On exam, you see a young female in neon clothing, consumed with the colors of her outfit, and very affectionate towards you.
MDMA (Ecstasy)
  • Mechanism
    • similar to amphetamines
    • effects 5-HT more than dopamine
      • may damage serotonergic neurons
  • Intoxication
    • presentation
      • hyperthermia and social closeness
        • "club drug"
      • hyponatremia
        • due to increased fluid intake or antidiuretic hormone (ADH) secretion
    • treatment
      • no specific treatment
        • symptomatic treatment only 
  • Withdrawal
    • presentation
      • mood offset for several weeks
    • treatment
      • no specific treatment
        • symptomatic treatment only
Snapshot
  • A 21-year-old male is brought into the ED by the police for an altercation.  Last night, the patient was at a party and seemed much more active than usual according to his girlfriend.  He punched another male at the party in the face claiming that he was hitting on his girlfriend.  On exam, you see an agitated young male with dilated pupils, and his pulse is 128/min.
Cocaine
  • Mechanism
    • block biogenic amine (DA, NE, 5HT) reuptake
  • Intoxication
    • presentation
      • mental status changes
        • euphoria, psychomotor agitation, grandiosity, hallucinations (including tactile), paranoid ideations
      • sympathetic activation
        • ↓ appetite, tachycardia, pupillary dilation, hypertension, angina
        • can cause severe vasospasm 
          • MI - coronary vasospasm
          • placental infarction - vasospasm of placental vessels
          • nasal septum perforation - Kiesselbach's plexus vasospasm
          • stroke - CVA
      • stereotyped behavior
        • repetitive motions (eg. digging through trash)
    • treatment
      • pharmacologic
        • antipsychotics (haloperidol)
        • benzodiazepines
        • antihypertensives (labetalol - need alpha-1 blockade)
        • vitamin C - promotes excretion
      • non-pharmacologic
        • do not restrain patients
          • may result in rhabdomyolysis
  • Withdrawal
    • presentation
      • severe depression and suicidality
      • hyperphagia, hypersomnolence, fatigue, malaise
      • severe psychological craving
    • treatment
      • pharmacologic
        • bupropion
        • bromocriptine
        • SSRI's for depression
  • Chronic/long-term treatment
    • individual and group psychotherapy 
Snapshot
  • A 22-year-old college student has been studying for finals but came into the emergency department because of a strange sensation in her chest and a feeling of palpitations.  She has been studying every night consuming copious amounts of energy drinks and is unsure what is going on but is afraid that she is, "having a heart attack from all the stress."  A segment of the girl's EKG is pointed out to you by the on call cardiologist.
Caffeine
  • Mechanism
    • adenosine antagonist → decreased GABA activity (wakefulness)
  • Intoxication
    • presentation
      • restlessness, insomnia
      • diuresis
      • muscle twitching
      • cardiac arrhythmias
    • treatment
      • no specific treatment
        • symptomatic treatment only
  • Withdrawal
    • presentation
      • headache, lethargy, depression, weight gain
    • treatment
      • no specific treatment
        • symptomatic treatment only
Snapshot
  • A patient comes to his primary care physician because he has felt more anxious and irritable lately.  He states that he has been very stressed out at work lately and thinks that his symptoms are attributable to the stress.  He smokes 1 pack per day, but lately has found himself smoking up to 4 packs per day to ease his stress.  Upon further counseling he says he is interested in quitting and wants your help.
Nicotine
  • Intoxication
    • presentation
      • restlessness, insomnia, anxiety, arrhythmias
    • treatment
      • no specific treatment
        • symptomatic treatment only
  • Withdrawal
    • presentation
      • irritability, headache, anxiety, weight gain, craving
    • treatment for cessation
      • pharmacologic
        • bupropion
          • can lower seizure threshhold (for exam purposes)
        • varenicline
          • partial nicotine receptor agonism
          • mediates partial reward of nicotine yet blocks reward of nicotine
          • highest success rate of other anti-smoking drugs, particularly when stacked with nicotine patches
        • nicotine administration via other routes
        • bromocriptine
Snapshot
  • A young man is brought into the ED and has attempted to assault a nurse several times.  He is extremely aggressive and becomes enraged when sudden movements or loud sounds are made.  The patient is escorted to a dimly lit, quiet exam room where he becomes much calmer.  On physical exam, the patient is agitated and has nystagmus.  His blood pressure in the ED is 180/100 mmHg.
PCP
  • Mechanism
    • NMDA receptor antagonist
    • ketamine is a similar drug
  • Intoxication
    • presentation 
      • belligerence, impulsiveness, fear, homicidality, psychosis, delirium, seizures, psychomotor agitation, vertical and horizontal nystagmus, tachycardia, ataxia 
    • treatment
      • pharmacologic
        • benzodiazepines
        • antipsychotics (haloperidol) if benzodiazepines are not adequately sedating patient
      • further management
        • low stimulus environment
        • restraints if needed to prevent patient from hurting self/others
  • Withdrawal
    • presentation
      • depression, anxiety, irritability, restlessness, anergia, disturbances of thought and sleep
    • treatment
      • no specific treatment
        • symptomatic treatment only
Snapshot
  • A 23-year-old male is brought into the ED by his friends at 1 a.m.  They are afraid that he is going to hurt himself.  They say that he has "been freaking out" and seeing things that are not there.  At one point, he tried to ride a bike off the roof of a house.  On exam, you see a young man who appears to be in a panic.  His gait is abnormal, he has diffuse tremors and his pupils are dilated.
LSD
  • Mechanism
    • action at 5-HT receptor
  • Intoxication
    • presentation
      • visual hallucinations and synesthesias (e.g., seeing sound as color)
      • marked anxiety or depression, delusions, pupillary dilation
      • "bad trip" panic
    • treatment
      • pharmacologic
        • antipsychotics (e.g., haloperidol)
        • benzodiazepines
        • talking down, supportive counseling
  • Withdrawal
    • presentation
      • largely no withdrawal because it does not effect dopamine
      • flashbacks can occur years later
    • treatment
      • no specific treatment
        • symptomatic treatment only
Snapshot
  • A 17-year-old male is brought to his family physician by his parents due to his behavior - increased appeptite, lack of motivation, and paranoia.  When interviewing the patient, the physician notes a slowed speech and conjunctival injection.
Marijuana (Cannabis)
  • Mechanism
    • binds to CB1/CB2 cannabinoid receptors
  • Intoxication
    • presentation  
      • euphoria, anxiety, disinhibition, paranoid delusions, perception of slowed time, conjunctival injection, impaired judgment, social withdrawal, ↑ appetite, dry mouth, hallucinations
        • largely psychological effects
      • amotivational syndrome
      • cyclical vomiting syndrome 
    • treatment
      • no specific treatment
        • symptomatic treatment only
  • Withdrawal
    • presentation
      • mild symptoms
        • irritability, depression, insomnia, nausea, anorexia
      • most symptoms peak in 48 hours and last for 5 - 7 days
      • can be detected in urine up to 1 month after last use
      • hyperemesis syndrome
        • in chronic canabis users, individuals can experience chronic severe emesis due to downregulation of CNS cannabinoid receptors and upregulation of gut cannabinoid receptors
        • treatment: stop smoking marijuana, anti-emetics (ondansetron, metoclopramide)
    • treatment
      • no specific treatment
        • symptomatic treatment only
Snapshot
  • A 15-year-old male is brought to the ED for aggressive behavior.  This patient has been admitted to the ED many times, last time for abusing bath salts.  He comes from a foster home and is largely unsupervised.
Inhalants
  • Mechanism
    • unknown
  • Intoxication
    • presentation
      • belligerence, assaultiveness
      • apathy, impaired judgement
      • blurred vision, coma
    • treatment
      • no specific treatment
      • antipsychotics (haloperidol) if severe aggression
  • Withdrawal
    • not well characterized, no treatment
    • abuse of other drugs commonly seen in these patients often from a low socioeconomic background
Snapshot
  • A 69-year-old male presents to the emergency department with sudden, severe onset epigastric pain that began while he was watching television.  On physical exam is an unkempt male with pain upon palpation of the epigastric region.  Labs are drawn and the patient has an elevated amylase and lipase.  The patient is made NPO, an NG tube is placed, and the patient is given IV fluids.  The patient is noted to be experiencing hallucinations.  On his second hospital day, the patient has a seizure.
Alcohol
 
  Minor Withdrawal Alcoholic Hallucinosis Withdrawal Seizure Delirium Tremens
Time Since Last Drink
6 hours 12 - 24 hours 48 hours 48 - 96 hours
Symptoms
  • Trembling
  • Irritability
  • Anxiety
  • Headache
  • Tachycardia
  • Insomnia
  • Visual, auditory, and in some cases tactile hallucinations
  • Tonic-clonic seizures
  • Autonomic instability
  • Disorientation
  • Hallucinations
  • Agitation
Management
  • Thiamine
  • Folate
  • Multivitamin
  • Dextrose
  • IV Fluids
  • Begin benzodiazepine taper to avoid seizures
  • Benzodiazepine taper
  • Head CT
  • Suspect in patient with unknown history follwed by DT symptoms 2 days later
  • Benzodiazepine taper
 
  • Mechanism (seizure)
    • alcohol is a depressant - increases GABAa channel opening
      • long term use leads to downregulation of GABA channels (inhibitory) and upregulation of NMDA (excitatory)
  • Intoxication
    • presentation
      • wide and varied - talkative, flirtatious, aggressive, moody, disinhibited
    • treatment
      • secure airway
      • thiamine, magnesium, multivitamin, dextrose (particularly if chronic alcoholism)
      • benzodiazepines (if withdrawal)
      • addiction medications
        • disulfiram - inhibits acetaldehyde dehydrogenase, aversive conditioning
        • naltrexone - decreases desire
        • gabapentin - decreases desire
 

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Questions (12)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M2.PY.4867) A 25-year-old man is brought to the emergency department by police. He was found at a local celebration acting very strangely and was reported by other patrons of the event. The patient is very anxious and initially is hesitant to answer questions. He denies any substance use and states that he was just trying to have a good time. The patient's responses are slightly delayed and he seems to have difficulty processing his thoughts. The patient tells you he feels very anxious and asks for some medication to calm him down. The patient has a past medical history of psoriasis which is treated with topical steroids. His temperature is 99.5°F (37.5°C), blood pressure is 120/75 mmHg, pulse is 110/min, respirations are 15/min, and oxygen saturation is 99% on room air. On physical exam, you note an anxious young man. HEENT exam reveals a dry mouth and conjunctival injection. Neurological exam reveals cranial nerves II-XII as grossly intact with normal strength and sensation in his upper and lower extremities. Cardiac exam reveals tachycardia, and pulmonary exam is within normal limits. Which of the following is the most likely intoxication in this patient? Review Topic

QID: 109591
1

Alcohol

0%

(0/45)

2

Benzodiazepines

0%

(0/45)

3

Marijuana

96%

(43/45)

4

Cocaine

4%

(2/45)

5

Phencyclidine

0%

(0/45)

M2

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(M2.PY.4) A 17-year-old white male is brought to the emergency department after being struck by a car. He complains of pain in his right leg and left wrist, and slowly recounts how he was hit by a car while being chased by a lion. In between sentences of the story, he repeatedly complains of dry mouth and severe hunger and requests something to eat and drink. His mother arrives and is very concerned about this behavior, noting that he has been withdrawn lately and doing very poorly in school the past several months. Notable findings on physical exam include conjunctival injection bilaterally and a pulse of 107. What drug is this patient most likely currently abusing? Review Topic

QID: 105614
1

Cocaine

0%

(0/16)

2

Phencylidine (PCP)

0%

(0/16)

3

Benzodiazepines

0%

(0/16)

4

Marijuana

94%

(15/16)

5

Heroin

0%

(0/16)

M2

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

(M2.PY.81) A 46-year-old anesthesiologist is found placing several syringes of amobarbital in his backpack prior to leaving the hospital. When confronted, the anesthesiologist admits that he began abusing the medication the previous year, after his divorce was finalized. He has been using it on a daily basis since then, and his most recent usage was 8 hours ago. Which of the following is the most life-threatening complication of amobarbital withdrawal? Review Topic

QID: 106921
1

Internal bleeding

0%

(0/33)

2

Respiratory depression

12%

(4/33)

3

Hypothermia

6%

(2/33)

4

Cardiovascular collapse

64%

(21/33)

5

Self-inflicted violence

12%

(4/33)

M2

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

(M2.PY.22) Mr. Z is a 62-year-old male with poorly controlled diabetes mellitus, chronic back pain, and a history of prescription drug abuse. He was admitted overnight following an emergency appendectomy. When you round on Mr. Z in the morning, he complains of severe abdominal pain in his RLQ, severe back pain from the hospital bed, nausea, and constipation. The team decides to increase the dose and frequency of his hydromorphone and docusate is added. Later that afternoon, the rapid response team is called to Mr. Z's room because he was found unresponsive in bed. Examination of his eyes is shown in Figure A. His vitals are as follows: T 38.1 C, BP 132/86 mm Hg, HR 71/min, RR 6/min, SpO2 85% on room air. Fingerstick glucose is 137 mg/dl. Following administration of oxygen via a mask or nasal cannula, what is the most appropriate next step in management? Review Topic

QID: 105632
FIGURES:
1

Oral glucose bolus

0%

(0/14)

2

Urine Toxicology

14%

(2/14)

3

Insulin Aspart

0%

(0/14)

4

Naloxone

79%

(11/14)

5

Initiate CPR

0%

(0/14)

M2

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

(M2.PY.6) A 19-year-old man is brought to the emergency department by the police. The officers indicate that he was acting violently and talking strangely. In the ED, he becomes increasingly more violent. On exam his vitals are: Temp 101.1 F, HR 119/min, BP 132/85 mmHg, and RR 18/min. Of note, he has vertical nystagmus on exam. What did this patient most likely ingest prior to presentation? Review Topic

QID: 105643
1

Marijuana

0%

(0/0)

2

Phencyclidine

0%

(0/0)

3

Ketamine

0%

(0/0)

4

Dextromethorphan

0%

(0/0)

5

Mescaline

0%

(0/0)

M2

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

(M3.PY.4) A 20-year-old college student is brought to the ED after a motor vehicle accident. Primary and secondary surveys reveal no significant compromise to his airway, his cardiovascular system, or to his motor function. However, his conjunctiva appear injected and he maintains combative behavior towards staff. What test will confirm potential substance use? Review Topic

QID: 102945
1

Polymerase chain reaction

0%

(0/0)

2

Urine immunoassay

0%

(0/0)

3

Western blot

0%

(0/0)

4

Gas chromatography / mass spectrometry (GC/MS)

0%

(0/0)

5

Breath alcohol test

0%

(0/0)

M2

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PREFERRED RESPONSE 4
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