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Zorluk: OrtaSubstance-Related and Addictive Disorders

Emergency medical services personnel bring a 29-year-old man to the emergency department after he was found shouting erratically outside a nightclub. The patient is highly agitated, pacing the room, and repeatedly scratching his forearms, claiming that "insects are trying to burrow into my veins." His medical history includes bipolar I disorder, for which he is prescribed lithium. Vital signs are temperature 38.1°C (100.6°F), blood pressure 172/108 mm Hg, pulse 128/min, and respirations 20/min. Physical examination reveals mydriasis, profuse diaphoresis, and multiple linear excoriations on both upper extremities. The patient is uncooperative with a detailed neurological examination but moves all extremities spontaneously. Which of the following is the most appropriate initial step in the management of this patient?

  1. A
    Administer intravenous propranolol
  2. B
    Diagnose schizophreniform disorder and admit to psychiatry
  3. Administer intravenous lorazepamCevap
  4. D
    Initiate citalopram therapy for suspected comorbid depression
  5. E
    Notify local law enforcement regarding the illicit drug use

Cevap

The correct answer is to administer intravenous lorazepam.
The correct answer is the administration of intravenous lorazepam. This patient's presentation of severe agitation, paranoia, tactile hallucinations (formication, often described as 'meth mites' or 'cocaine bugs'), mydriasis, diaphoresis, and marked sympathetic overactivity (hypertension, tachycardia, hyperthermia) is the classic toxidrome of acute stimulant intoxication (e.g., methamphetamine or cocaine). The first-line treatment for both the psychomotor agitation and the cardiovascular toxicity associated with stimulant overdose is the administration of benzodiazepines. Benzodiazepines reduce central sympathetic outflow, which helps lower blood pressure and heart rate, decreases agitation, and raises the seizure threshold.

Adım Adım Çözüm

1
Analyze the patient's clinical presentation and vital signs.
The patient exhibits severe agitation, paranoia, tactile hallucinations (formication), mydriasis, and sympathetic overactivity (tachycardia, hypertension, hyperthermia).
Identifying the specific toxidrome is the critical first step in determining the appropriate acute management.
2
Determine the most likely diagnosis based on the toxidrome.
The findings are highly characteristic of acute stimulant intoxication, likely methamphetamine or cocaine.
The combination of profound sympathetic stimulation and stimulant-induced psychosis (specifically the sensation of bugs crawling under the skin) distinguishes this from primary psychiatric episodes or other toxicities.
3
Select the most appropriate initial pharmacological intervention.
Intravenous lorazepam (or another benzodiazepine) is selected as the initial management.
Benzodiazepines enhance GABA-ergic inhibition, effectively decreasing sympathetic outflow, controlling psychomotor agitation, and reducing the risk of seizures and cardiovascular complications in stimulant toxicity.

Anahtar Kavram

Acute management of stimulant intoxication
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Konular

Substance-Related and Addictive Disorders

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