Law enforcement officers transport an unidentified young male to the emergency department.… — USMLE Step 2 CK

Law enforcement officers transport an unidentified young male to the emergency department. He was apprehended while running through a busy intersection, violently striking passing vehicles, and screaming about extraterrestrial entities. In the resuscitation bay, he exhibits extreme combativeness, vertical nystagmus, profuse diaphoresis, and flushed skin. Vital signs reveal a heart rate of $152$ /min, blood pressure of $188/112$ mm Hg, and a core temperature of $39.6^\circ\text{C}$ ( $103.3^\circ\text{F}$ ). The patient requires physical restraint by multiple staff members to prevent immediate harm to himself and others.

Arrange the following clinical interventions in the most appropriate chronological order for managing this patient's acute presentation and subsequent care.

1Administer intravenous lorazepam to rapidly control psychomotor agitation and reduce sympathetic outflow.
2Initiate active external cooling measures and aggressive intravenous crystalloid resuscitation.
3Obtain serum creatine kinase levels and a basic metabolic panel to assess for rhabdomyolysis and renal dysfunction.
4Provide motivational interviewing and refer the patient to a comprehensive outpatient substance use treatment program.

Answer

The correct sequence prioritizes immediate staff and patient safety via chemical sedation, followed by stabilization of life-threatening hyperthermia, subsequent diagnostic evaluation for complications like rhabdomyolysis, and finally, long-term psychiatric rehabilitation.

In the emergency management of severe psychomotor agitation due to substance intoxication (e.g., phencyclidine, synthetic cathinones, or cocaine), the strict chronological priority is safety and stabilization. The patient must first be chemically sedated with benzodiazepines to prevent harm to staff and themselves. Only after sedation can interventions like active cooling and fluid resuscitation be safely and effectively implemented. Once the patient is physiologically stabilized, diagnostic tests (e.g., creatine kinase to check for rhabdomyolysis) are obtained. Finally, psychiatric interventions and substance use counseling are deferred until the patient is fully sober and cognitively intact.

Step-by-Step Solution

Chemically sedate the severely agitated patient.

Intravenous benzodiazepine administration.

Controls extreme agitation, stops excessive heat generation from muscle hyperactivity, reduces sympathetic drive, and allows staff to safely approach the patient for further medical care.

Address life-threatening physiologic derangements.

External cooling and intravenous fluids.

High core temperatures (

>39.5^\circ\text{C}

) and profound diaphoresis are life-threatening and require immediate correction once the patient can be safely managed.

Evaluate for systemic end-organ complications.

Check creatine kinase and renal function.

Extreme physical exertion against restraints combined with hyperthermia puts the patient at high risk for rhabdomyolysis and subsequent acute kidney injury.

Address the underlying substance use disorder.

Motivational interviewing and outpatient referral.

Ensures long-term recovery and prevents recurrent episodes; this can only occur after acute delirium has resolved.

Key Concept

Management of acute phencyclidine (PCP) or sympathomimetic intoxication prioritizes chemical sedation before medical workup, followed by cooling/fluids, complication screening, and psychiatric care.

Estimated Time:1m 0s

Question

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Topics

More questions from this topic