Case of the Month
January 2008

26-year-old male – decreased LOC, bizarre behavior

Dispatch
Your BLS unit is dispatched with an ALS unit to a 26-year-old male who cannot be awaken.

While en route the dispatcher notifies you that the patient is in the living room and a friend is trying to awaken him.

En route your crew discusses the following considerations:

• Reasons decreased level of consciousness
• Scene safety

Scene Size-up
As you roll up to the house a young woman runs out to meet you. She states the patient is her housemate, but she doesn’t really know him well. He came home a little while ago and then “kinda passed out on the couch.” She leads you into the house where you find a male lying face up on the sofa. On arm is at his side and the other across his abdomen. There appears to be no weapons or drugs around the patient. You ask the woman and she confirms there are none.

Initial Assessment
You approach the patient and check his radial pulse. It is strong and very fast (rough estimate of 160). He feels very warm to the touch. A pinch of the earlobe produces no reaction. His eyes are closed and you see what appears to be an occasional chewing motion. It is initially somewhat difficult for you to move his arm, but an initial blood pressure of 186/P is obtained. You determine this is a SICK patient.

Initial Treatment
Your first move is to update the ALS unit and administer oxygen via non-rebreathing mask and standing by with a BVM. You open his eyes and observe the pupils for size (dilated), symmetry (equal), and reactivity (sluggish and reactive to light) — they move together and sweep slowly from one side to the other. The sporadic chewing continues. A blood sugar is sampled and the reading is 96.

Vital Signs

• Respirations                          24
• Pulse                                  168
• Mental status                       Unconscious/unresponsive to pain
• Pulse oximetry                      98% on NRM
• Blood sugar                          96 mg/dl
• Blood pressure                      186/Palp

Further Evaluation and Treatment
You continue to evaluate the patient and find that he has a temperature of 101.4 degrees Fahrenheit, utilizing a skin thermometer. Your partner interviews the roommate and finds out the patient has a history of depression and cocaine use. He takes Celexa for his depression and she believes he has not used cocaine for a long time. He went to a party earlier in the evening and came back acting drunk. Then he passed out on the sofa.

You decide to load the patient for transport with the expectation of meeting the ALS unit en route to the hospital. As you prepare to load the patient on the stretcher, he suffers a two-minute generalized tonic/clonic seizure, followed by a postictal phase. The patient is placed into the recovery position and you monitor his airway.

The ALS unit arrives and initiates an IV line. Your crew assists the medics with packaging and you accompany the ALS crew during transport. En route to the hospital medical control gives the medics permission to administer 5 mg of diazepam IV and to intubate if necessary. The remainder of the transport is uneventful and the patient is discharged to the emergency department. After evaluation in the ED a preliminary diagnosis of cocaine intoxication with accompanying serotonin syndrome. The patient is admitted to the ICU for monitoring.

Cocaine Overdose
Cocaine is a street drug that is usually sniffed or injected and has extremely strong effects on the nervous system producing a euphoric high. Crack is a slightly altered version of cocaine that is often smoked producing a similar high. In any dose these drugs can be fatal. In “normal” doses, their use can lead to a rapid heart rate, heart attack, stroke, hypertensive crisis, or aortic dissection, just to name a few. When taken in overdose amounts a cocaine or crack user might also encounter seizures, profound hyperthermia, rhabdomyolysis, decreased level of consciousness, among other potentially fatal medical conditions.

The field treatment for cocaine or crack overdose is largely supportive, providing oxygen, cardiac monitoring, airway management, and in the case of hyperthermia, cooling. ALS interventions might include benzodiazepines (valium family of drugs), nitrates and beta-blockers for hypertension control, and benzodiazepines may also be used to control seizures.

Serotonin Syndrome
Serotonin syndrome is sometimes seen in overdoses that involve cocaine, methamphetamine, and other stimulant drugs. It has also been seen in patients who use ecstasy and LSD. This condition can also occur in persons who are prescribed selective serotonin reuptake inhibitors (SSRI) antidepressants or, more rarely, use dextromethorphan or pseudoephedrine without the introduction of any illicit drugs.
 
Some common observations of serotonin syndrome are a rapid heart rate, sweating, confusion, lack of coordination, muscle spasms, hyper reflexivity, muscle rigidity, and occasionally bruxism (subconscious teeth grinding). The most common treatment for serotonin syndrome is the use of benzodiazepines (Valium-like drugs).

Cocaine
National Institutes of Health (external website)

Cocaine Toxicity
eMedicine (external website)

Serotonin Syndrome
Mayo Clinic (external website)