Did he get injury?

Dr. Law chi yin

PYNEH

One Saturday afternoon

• young man age 32

• Sent to AED by ambulance

• Fixed by spinal board and neck collar

• Claimed back pain after jumping from the second floor of a building,

• He was chased by 30 persons

One Saturday afternoon

• He called ambulance in a MTR station after quarreling with his girl friend

• Accompanied with a girl who could provide only limited information

In the triage station

• He was alert

• Bp 145/100 mmHg

• Pulse rate 104 bpm

• Temp 36o C

• RR 16

• SpO2 100% room air

Seen by MO 10 minutes later

• GCS E4V4-5M6

• Agitated with confused words

• No alcoholic smell

• Denied taking drugs

Seen by MO 10 minutes later

• With history of trauma and altered mental status

• Transported to resuscitation room– Set drip– Trauma series X-ray with lumbar spine– FAST scan

In Resuscitation room

• Agitated

• Struggling around

• No external wounds

• PERL 4 mm

• ABC was good,

In Resuscitation room

• Chest, abdomen, pelvis and limbs were normal

• No spinal tenderness

• No focal neurological signs

In Resuscitation room

• Sugar 6.8

• ECG sinus VR 110 bpm, QRS 90ms

• X-ray, trauma series, L-spine all normal

• US abdomen showed no fluid

In Resuscitation room

• He was agitated and uncooperative during examination and X-ray taking

• 5 mg valium was given intravenously in order to calm him down

In Resuscitation room

• Did he get injury?

• What caused his agitation?

In Resuscitation room

• Foley was inserted

• Urine was tested for toxicology

• It showed positive for amphetamine

• With this evidence

• He then admitted that he had taken “ICE” before quarreling with his girl friend

He was admitted medical ward

• CT brain was normal

• Blood tests were normal

• Mental status was improved after admission

• Psychiatrist was consulted

• Put on haldol and ativan

• Home after 3 days admission

History reviewed

• Known ex-IVDA

• Amphetamines and heroin abuser

• Took 3 tablets of “ICE” before quarrelling with his girl friend

• He really had back injury 2 days before he attended AED

Learning points

• CNS stimulants causes hyper-alert, agitation, confusion, seizure and coma

• It depends on the severity of overdose

• Light overdose may be difficult to recognize and diagnose

Learning points

• Sympathomimetic toxidrome may not be evidenced, especially for chronic abuser in light overdose

• Substance abuser may deny taking drugs

Learning points

• Common amphetamines– Methamphetamine (Ice)– MDMA (Ecstasy)

Learning points

• Methamphetamine – name: crystal, ice, tina or meth– Route:

• insufflation (inhale powder)• inhalation (smoke), • IV or PO

• MDMA– Ecstasy in tablet form

Learning points

• Common features for amphetamine overdose– CNS stimulation: agitation, insomnia,

confusion, fit, psychosis.– CVS: high BP, fast pulse, tachypnoea, – Hyperthermia, sweating, dehydration

Learning points

• methamphetamine overdose

• Tweaking – psychomotor agitation– psychiatric symptoms

• mimic schizophrenia

• Strange history may be caused by delusion and hallucination

Leaning points

• DDx for abnormal agitation– body packer or stuffers – CNS stimulants overdose

• Cocaine• Amphetamine (Ice or Ecstasy)• Ketamine

– Drugs withdrawal• Alcohol• Benzodiazepine

Leaning points– Non toxic causes

• Hypoglycemia• Hypoxia• Shock• Thyrotoxicosis• Head injury, SAH or meningitis• Psychiatric disorder