Case Conference: agitated delirium from snorting “bath salts”

This article is part of the New England Journal of Medicine‘s “Case Records of the Massachusetts General Hospital” series. There is a very good discussion of the initial approach and differential diagnosis for a patient who presents with “agitation, delirium abnormal vital signs, and reports he had taken a toxic substance.” However, I find some of the management decisions puzzling. The patient was initially treated with fomepizole and sodium thiosulfate. Although toxic alcohols and cyanide are certainly in the differential for metabolic acidosis, that seems to me a case of treating the lab values, not the patient. In his discussion of managing cathinone-induced delirium, Dr. Shamim Nejad of the Mass General Department of Psychiatry reports that when the patient was admitted to the intensive care unit: The administration of midazolam and propofol was quickly stopped, and dexmedetomidine, an α2-adrenergic agonist that can ameliorate excess noradrenergic activity, was begun. Low-dose haloperidol administered as a continuous infusion to treat excess mesolimbic dopaminergic transmission was also initiated. To avoid administering a dopamine antagonist alone after dexmedetomidine had been discontinued, phenobarbital was administered because it targets GABAA, α-amino-3-hydroxy-5-methyl-4-isoxazole propionic acid (AMPA), and kainate receptors . . . I don’t know about you, but I’m always very concerned about α-amino-3-hydroxy-5-methyl-4-iso...
Source: The Poison Review - Category: Toxicology Authors: Tags: Medical agitated delirium bath salts case records of the massachusetts general hospital methcathinone Source Type: news