Altered Mental Status in a Young Man Picked Up On the Street

Andréa B. Lese, MD, MA; Rick G. Kulkarni, MD


October 05, 2018

Physical Examination and Workup

Upon physical examination, he is extremely diaphoretic and, soon after arrival, the patient begins convulsing. His pupils are dilated but equal and reactive to light. His vital signs are notable for a blood pressure of 80/40 mm Hg, a heart rate of 180-190 beats/min, a respiratory rate of 32 breaths/min, and an oxygen saturation of 63% while using a nonrebreather mask. The patient's rectal temperature is measured at 108.1°F (42.3°C).

While preparations are made to intubate the patient, his blood pressure drops to 60/40 mm Hg. Cardiac monitoring reveals the patient to be in a wide-complex tachycardia indicative of ventricular tachycardia vs supraventricular tachycardia with aberrancy. Because he is unstable, Advanced Cardiac Life Support (ACLS) guidelines are followed, and he is defibrillated with 50 Joules biphasic, without response. The initial defibrillation attempt is followed by a second attempt at 100 Joules, also without resolution of the tachycardia. A 3-lead rhythm strip is then obtained (Figure 1) that demonstrates a narrow-complex tachycardia.

Figure 1.

Rapid-sequence intubation is initiated with 20 mg intravenous (IV) etomidate and 10 mg IV vecuronium. Once the endotracheal tube is successfully placed and the position confirmed, 4 mg IV lorazepam is administered for ongoing sedation.

A presumptive diagnosis of heatstroke caused by cocaine toxicity is made. Ice packs are applied to the patient's groin and axillae, and a cooling blanket is placed on the patient. Cooled IV saline is infused, and a Foley catheter with a temperature probe is placed. The patient's temperature drops to 102°F (38.9°C). After sedation, intubation, aggressive cooling measures, and IV hydration have been initiated, the patient's heart rate is noted to slow to around 130 beats/min, and his blood pressure and oxygen saturation both normalize. The patient is admitted to the medical intensive care unit (ICU).


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