Runaway Heart – treating an unidentified drug overdose patient at a hospital

Pamela Grim

Quick, before this kid dies: figure out what he’s taken

I was writing up a chart when a message blared over the intercom: “There’s a drive-by in the parking lot.” A drive-by is a patient dropped off at the emergency room doorstep by someone making a quick getaway A car flows. The driver pushes our next patient out and takes off in a cloud of exhaust and burning rubber. A drive-by can be a victim of anything: a drug overdose, gunshots, a stabbing, even a cardiac arrest.

I rounded up Matt Tang, a first-year resident, and Omar Veniciano, a nurse, and quickly headed for the parking lot. There we found a kid, no more than 18 or 19 years old, dressed only in underpants and wearing a leather hat with a feather in it. He looked around, confused and terrified, as we prepared to move him onto a gurney.

“Hey kid,” I said. “What’s your name?”

He mumbled a name that sounded like Raphael.

“Raphael, what happened?”

He grabbed my arm. “You’ve got to help me,” he said. “The leprechauns, are everywhere,

By the time we got Raphael to the ER and hooked him up to an IV and monitor, he was incoherent.

In emergency medicine, a case like this falls under the category Change in Mental Status of Unknown Etiology. The patient has no available history. The only clues come from the physical exam, laboratory tests, and the physician’s best guesses. Given the mental challenge such cases present, it’s not surprising that Arthur Conan Doyle, himself a physician, modeled Sherlock Holmes after a medical professor.

We usually begin the detective work by looking through the patient’s clothes for a wallet or miscellaneous contents. In Raphael’s case, we didn’t have any pockets to turn out, so the resident and I started with the physical exam. Raphael’s skin was red, but there was no sign of injury. His lungs were clear, his belly soft. The most obvious abnormality was his pupils; they were so dilated that the irises had all but disappeared. He had the eyes of a cartoon character–two blank black saucers.

Raphael was muttering incessantly and began pushing us away. He scrambled off the end of the bed and then stopped. He just stood there, stark naked, looking around in fear and bewilderment.

“Security!” I shouted, reaching for the boy.

It took five of us to restrain him. We finally strapped him down and reattached him to the monitor. His heart rate was even faster than before–145 beats per minute and climbing. His skin was flushed.

I quizzed Matt: “Can you tell me the differential diagnosis in this case?”

“Encephalitis.” (Inflammation of the brain.)

“Drug overdose.

Intracranial bleeding. Hypoglycemia. Electrolyte abnormalities.”

“Psychosis,” Omar added.

Although anything on the list was possible, I had a strong suspicion Raphael was whacked out. But which drug? The most likely answer was cocaine, a lot of cocaine. Why else would someone with an overdose have a pulse this high?

The symptom profile of a patient with a drug overdose is called a toxidrome. A cocaine toxidrome includes a fast heart rate, high blood pressure, and profuse sweating.

But Raphael was dry as a bone. And the dilated pupils–you don’t see that with a cocaine overdose.

There were, of course, other possibilities. Raphael could have been smoking PCP–an animal tranquilizer-cum-hallucinogen sold on the street. PCP can make you awfully confused and agitated, but it usually doesn’t make your heart race.

“So what tests do you want to order?” I asked Matt.

“Glucose, chemistries, urine drug screen …,” he replied.

The urine drug screen would tell us whether Raphael had cocaine in his system, but the results wouldn’t be available for an hour or two, at least.

Meanwhile, Raphael’s heart rate kept climbing. It was now 158, and he was even redder than before and more agitated. He looked the way patients look just before they seize.

“I think we need to call for a pharmacological backup,” I said. “Let’s consult Seamus.”

Seamus Herzog, an intensive-care specialist, had done a two-year toxicology fellowship. He had become our walking poison control center and a brilliant medical detective.

“Yo!” Seamus said when he answered his page. “I’ll be down just like that!” In a few minutes he ambled into the ER, coffee cup in hand.

Matt presented the case. It was hard to concentrate as I watched Raphael’s heart rate rising: 160… 168. After the presentation, Seamus glanced over the patient, peeking into his eyes and tapping gently at his belly.

“This doesn’t really sound like cocaine,” he said. “Sounds like an anticholinergic overdose.”

Anticholinergic overdose. A different toxidrome. Cocaine operates on the sympathetic nervous system, which mobilizes us for emergency action. An anticholinergic drug acts on the parasympathetic nervous system, which regulates activities when the body is at rest. The classic anticholinergic drug, atropine, is often used in the ER to treat a slow heart rate. The symptoms of an anticholinergic overdose include dry mouth, tachycardia, and fever. If the dose is high enough, the patient will also exhibit confusion. Other classes of drugs–antipsychotics, antidepressants, and even over-the-counter cold medications–can produce similar actions and symptoms. But I had never seen a patient with an anticholinergic overdose who was this sick.

“Do you know the nursery rhyme for the anticholinergic toxidrome?” Seamus asked Matt.

The resident looked startled. “What do you mean, nursery rhyme?”

“It lists the way patients present: red as a beet, blind as a bat, dry as a bone, mad as a hatter, hotter than hell.”

We all looked down at Raphael. That description pretty much fit the way he looked.

“What else do you see with anticholinergic overdoses?” Matt asked just as Raphael began seizing.

“Seizures,” Seamus said, while Omar scrambled for some Valium.

We rolled Raphael over on his side and got the Ambu bag ready to give him oxygen.

“You’d have to take a lot of cold tablets to overdose this bad,” I said.

“Maybe he took a lot of antipsychotics,” Seamus said.

Omar gave Raphael the Valium. Nothing happened. He continued to seize. We gave him a little more Valium and still he seized.

“How about giving him some physostigmine?” Seamus said.

I shook my head. While physostigmine will block the effects of an anticholinergic drug, it has many side effects–bad side effects like seizures and slowed heart rate. The word itself made me shiver. It was not a drug to fool around with.

“What would happen with physostigmine?” the resident asked.

Seamus steepled his hands and peered over them wisely. “If this is an anticholinergic overdose, he’ll stop seizing.”

“And if it’s cocaine?” I asked.

Seamus nodded. “He’ll seize worse.”

I gazed down at Raphael. His head was arched back, eyes twitching, froth on his lips. Maybe we were missing something big. Maybe this wasn’t an overdose. But I felt in my bones that this was a kid looking to get high.

“We need to paralyze and intubate him,” I told Omar, but as we pulled the intubation cart over and began to get ready, Raphael suddenly stopped seizing and lay still.

“Thank God,” I said.

Seamus shook his head. “He’s going to seize again.”

“I don’t want to give this kid physostigmine. It’s a terrible drug.”

Seamus looked down at Raphael. “Okay, let’s start over. Tell me about it from the beginning.”

I went back through the drop-off, the underwear, and the hat. “He said his name was Raphael, and that’s about all. He was hallucinating.”

“Did he say what he saw?”

“Well, it didn’t make any sense, but he said he was seeing leprechauns everywhere.”

Seamus grabbed my arm. “That’s it!” he said. “That’s the key! Lilliputian syndrome!”

“Lilliputian syndrome?”

“It’s when you hallucinate and you see tiny …,” Seamus waved his hands, searching for the words, “tiny people. Lilliputians, like in Gulliver’s Travels. There’s only one drug that does that: stramonium, the psychoactive substance in jimsonweed.”

“Jimsonweed,” I repeated.

“What’s jimsonweed?” the resident wanted to know.

“Jimsonweed is locoweed is Datura stramonium. The active ingredient is scopolamine, an alkaloid much like atropine. Same effect.” Seamus raised his finger and assumed a teacher’s pose. “The plant’s name comes from the 1680s, when the English were invading America. Soldiers in Jamestown, Virginia, had a feast where they made a salad from a local plant, the datura plant. After they ate it, they hallucinated for hours and were completely, totally out of it. People called the plant Jamestown weed, and the name was eventually corrupted to jimsonweed. The stuff grows wild on the western plains. When cattle get into it, they pretty much look like the Jamestown soldiers must have looked. Plumb loco. Occasionally some idiot smokes it or eats it. Usually some stupid kid.”

“Look! The patient’s seizing again,” the resident said.

We all looked down. I groaned.

Seamus put a hand on my arm. “What this kid needs is some physostigmine.”

I shook my head. “Are you absolutely sure about this?”

He gave me a withering look. “Have I ever been wrong?”

Okay, I thought to myself. I’m going to give someone physostigmine because he told me he saw leprechauns.

Omar drew up the drug and gave it. Then we all stood there helplessly watching Raphael seize.

It went on and on. I started racking my brains for other causes. Maybe the boy’s problem was a ruptured blood vessel in the brain, or herpes encephalitis, or something else. Something that left a clue we somehow missed or misinterpreted.

Then, as suddenly as he started, Raphael lay still. Dead still.

“He’s not breathing,” Matt said. As I reached for the Ambu bag, Raphael turned his face to the side, gagged twice, catlike, and vomited vegetable matter all over the floor.

“No!” Seamus cried as I leaped forward. “That’s a good sign.”

Raphael sat up and looked around, dazed. “Who am I?”

“I was rather hoping you could tell us,” I said.

Raphael kept looking around. “Wow, man, like everyone’s looking at me. Hey, where’s my hat? I think someone stole my hat.”

Eventually Raphael confessed that he and two friends had smoked the seeds from several jimsonweed plants. They had heard somebody say it was just like marijuana.

“Well, looks like you heard wrong,” Seamus told him.

Raphael hung his head.

I could see Matt wanted to ask Seamus something.

“I know about anticholinergic effects and all that,” he said, “but can you tell me how you put all this together to figure it out?”

Seamus smiled at him. “It’s very elementary,” he said, patting the resident’s back, “you just have to follow the clues.”

Pamela Grim is an emergency physician who lives in Cleveland. She grew up on the West Coast, went to college and medical school at the University of Washington, then headed to the University of Chicago to train in emergency medicine. She says she decided on that field because “1 have a short attention span.” Grim has published scientific papers in the Journal of the American Medical Association, American Journal of Cardiology, and the Annals of Emergency Medicine. She has also participated in medical missions to Nigeria, Haiti, and Bosnia. Her first book, a collection of essays entitled Just Here Trying to Save a Few Lives, will be published next year.

COPYRIGHT 1999 Discover

COPYRIGHT 2000 Gale Group

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