A 22-year-old college student is brought to the emergency department by his roommate due t… — USMLE Step 2 CK

A $22$ -year-old college student is brought to the emergency department by his roommate due to severe agitation and bizarre behavior. The roommate reports that for the past $2$ weeks, the patient has barely slept, paced the room continuously, and claimed that government agents are monitoring his thoughts. The roommate found empty plastic baggies containing residual white powder on the patient's desk. The patient has a history of major depressive episodes and is currently prescribed sertraline. His family history is notable for a mother with bipolar disorder. In the emergency department, the patient is combative, diaphoretic, and uncooperative. Temperature is $38.2^\circ \text{C}$ ( $100.8^\circ \text{F}$ ), blood pressure is $165/100 \text{ mmHg}$ , pulse is $128/\text{min}$ , and respirations are $22/\text{min}$ . Physical examination reveals bilaterally dilated pupils and a fine resting tremor. Which of the following is the most appropriate next step in the management of this patient?

Administer intravenous lorazepamAnswer
B
Diagnose schizophreniform disorder and initiate risperidone
C
Increase the current dosage of sertraline
D
Add phenelzine to the current medication regimen
E
Disclose the substance use to the university administration

Answer

Administer intravenous lorazepam

The correct action is to administer intravenous lorazepam. This patient presents with a classic sympathomimetic toxidrome resulting from acute stimulant intoxication (likely cocaine or amphetamines, given the white powder). The presentation includes severe psychomotor agitation, paranoia, hyperthermia, hypertension, tachycardia, diaphoresis, and mydriasis. The immediate priority in severe stimulant intoxication is to control agitation and sympathetic hyperactivity to prevent life-threatening complications such as myocardial infarction, arrhythmias, or seizures. Benzodiazepines (e.g., lorazepam, diazepam) are the first-line agents because they safely sedate the patient, reduce central sympathetic outflow, decrease heart rate and blood pressure, and increase the seizure threshold.

Step-by-Step Solution

Identify the patient's toxidrome from the clinical presentation.

The combination of severe psychomotor agitation, paranoia, hyperthermia, hypertension, tachycardia, diaphoresis, and mydriasis indicates sympathomimetic toxicity (e.g., cocaine or amphetamine intoxication).

Recognizing the pattern of vital sign abnormalities and physical exam findings is essential to differentiate stimulant intoxication from primary psychiatric disorders or other ingestions.

Determine the immediate medical priorities.

The primary goal is to safely sedate the patient, lower the cardiovascular demand, and raise the seizure threshold.

Uncontrolled sympathetic overdrive can lead to fatal arrhythmias, myocardial infarction, intracranial hemorrhage, or status epilepticus.

Select the appropriate pharmacotherapy.

Benzodiazepines, such as lorazepam, are administered to achieve the management goals.

Benzodiazepines enhance GABA-ergic inhibition in the central nervous system, effectively reversing the stimulant-induced agitation and sympathetic excess.

Key Concept

The first-line treatment for acute stimulant (sympathomimetic) intoxication with severe agitation is the administration of benzodiazepines.

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