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Zorluk: OrtaSubstance-Related and Addictive Disorders

A 32-year-old man is brought to the emergency department by emergency medical services after he was found violently striking parked cars and yelling that "aliens are trying to abduct me." The patient's medical records indicate a history of bipolar I disorder and opioid use disorder. He is currently prescribed lithium and phenelzine. Vital signs are temperature 38.3°C (101.0°F), pulse 132/min, respirations 22/min, and blood pressure 165/100 mm Hg. Physical examination reveals prominent horizontal and vertical nystagmus, diaphoresis, and a lack of pain response when minor lacerations on his hands are examined. The patient is physically restrained for staff safety but continues to struggle aggressively. Which of the following is the most appropriate next step in the management of this patient?

  1. Administer intravenous lorazepamCevap
  2. B
    Diagnose schizophrenia and admit to the psychiatric inpatient unit
  3. C
    Initiate sertraline monotherapy for mood stabilization
  4. D
    Administer intravenous meperidine to manage pain from his lacerations
  5. E
    Contact the patient's employer to warn them of his violent behavior

Cevap

The most appropriate next step is to administer intravenous lorazepam.
The patient's presentation of severe agitation, bizarre and violent behavior, autonomic instability, decreased pain perception, and characteristic horizontal and vertical nystagmus strongly points to phencyclidine (PCP) intoxication. In the acute setting, PCP intoxication is a medical emergency due to the high risk of trauma, seizures, and severe rhabdomyolysis resulting from prolonged muscle contractions. The first-line management for severe agitation and aggression associated with PCP is the administration of parenteral benzodiazepines, such as lorazepam. Benzodiazepines effectively provide chemical restraint, raise the seizure threshold, and promote muscle relaxation without interacting dangerously with his current medications.

Adım Adım Çözüm

1
Identify the primary toxidrome based on the clinical presentation.
The patient exhibits severe agitation, psychosis, autonomic hyperactivity, analgesia, and prominent horizontal/vertical nystagmus.
These findings are the classic triad of acute phencyclidine (PCP) intoxication.
2
Determine the priority in acute management.
The immediate goal is to safely control the patient's severe agitation and aggressive behavior.
Agitation in PCP intoxication can lead to hyperthermia, seizures, and severe rhabdomyolysis, posing a direct threat to the patient's life and staff safety.
3
Select the appropriate pharmacological intervention while avoiding contraindicated drug interactions.
Parenteral benzodiazepines (e.g., lorazepam) are chosen as the first-line treatment.
Benzodiazepines rapidly sedate the patient, raise the seizure threshold, and relax muscles. Other agents, such as meperidine, are avoided due to the patient's concurrent phenelzine use.

Anahtar Kavram

The primary acute management for phencyclidine (PCP) intoxication involves ensuring safety and administering benzodiazepines to control severe agitation and prevent systemic complications.
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Substance-Related and Addictive Disorders

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