Lumbar puncture to rule out a central nervous system infection Which of the following is the most important initial investigation for this patient with a depressed level of consciousness due to a suspected overdose?Ībdominal radiograph to identify radio-opaque toxinsīlood work to identify acid–base disturbances and calculate anion and osmole gaps (blood gas, electrolytes, glucose, urea, osmolality, ethanol level)
1 Anticholinergic toxicity presents with agitated delirium, hyperthermia, mydriasis, dry skin and mucous membranes, and urinary retention. 1 Serotonin syndrome is characterized by acute onset, hyperreflexia and myoclonus, while NMS occurs over days, classically with lead-pipe rigidity. 1 Serotonin syndrome and neuroleptic malignant syndrome (NMS) can both present with altered mental status and autonomic instability. Although several features of opioid toxicity overlap with sedative or hypnotic toxicity, the former typically causes pinpoint pupils, which we did not see in this patient. Her physical examination suggested a sedative or hypnotic overdose, compatible with the collateral history of benzodiazepine, zopiclone and doxylamine ingestion. This patient presented with a decreased level of consciousness, without characteristic features to suggest another toxidrome ( Table 1). Which toxidrome best describes this patient? She had normal tone with no rigidity, hyperreflexia or clonus. Her pupils were 3 mm bilaterally and reactive to light. Her capillary blood glucose was 14.6 (normal 3.8–7.0) mmol/L.
She had a decreased level of consciousness, with a Glasgow Coma Scale score of 3T, and no agitation or excited delirium. On arrival, her temperature was 35.7✬, blood pressure 74/33 mm Hg, heart rate 115 beats/min, respiratory rate 8 breaths/min and oxygen saturation 98% on 100% FiO 2. History from her partner raised concern that she may have ingested about ninety 0.5-mg tabs of lorazepam, seventy 1-mg tabs of alprazolam, forty-eight 1-mg tabs of clonazepam, twenty-four 50-mg tabs of quetiapine, ten 7.5-mg tabs of zopiclone and 1 bottle of NyQuil, which contains acetaminophen, dextromethorphan and doxylamine.īefore arrival at the emergency department the patient had been intubated by paramedics to protect her airway. Her medical history included bipolar I disorder and 2 previous suicide attempts. Her partner had spoken to her on the phone 5 hours earlier, when she was reportedly well. A 53-year-old woman was brought to the emergency department after being found unresponsive at home, surrounded by empty pill bottles.
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