This patient presents to the Emergency Department with a depressed mental status and normal sized pupils after an unknown toxic ingestion. Many different agents can act as Central Nervous System depressants and cause this clinical presentation. Some examples include ethanol, toxic alcohols (methanol, ethylene glycol, isopropyl alcohol), benzodiazepines, barbiturates, opioids, and muscle relaxants.
Of the choices listed, Heroin (Choice A) and Alprazolam (Choice B) are the most likely. Heroin is an opioid, and Alprazolam is a benzodiazepine (a sedative-hypnotic agent). The clinical presentation caused by overdoses of opioids versus sedative-hypnotic agents overlaps in many areas, but the pupillary exam can help the most in differentiating the type of ingestion. Opioids will can constricted, pinpoint pupils, while benzodiazepines should not cause change in pupillary size. See the chart below for a review of the most common toxidromes (toxic syndromes).
*Treatment of all toxic ingestions should include general supportive care and management of the airway, breathing, and circulation of the patient. Examples include administration of supplemental oxygen in hypoxia, IV fluids in hypotension, cooling measures in hyperthermia, etc. **Flumazenil is the antidote for benzodiazepine overdose, but it is rarely used clinically as it can trigger benzodiazepine-refractory seizures.
Cocaine (Choice C) is a sympathomimetic with a CNS excitatory effect, not a CNS depressant effect as in this patient. A large ingestion of paracetamol (Choice D) is often accompanied with little to no symptoms in the first 24hours. Later in the ingestion timeline, liver failure and its associated sequalae can occur if no antidote is given. Correct Answer: B
Joey Ciano, DO, MPH is an Emergency Medicine Physician from New York, USA. He completed his Emergency Medicine Residency in Brooklyn, NY and a Fellowship in Global Emergency Medicine in the Northwell-LIJ Health System. He is interested in building the educational infrastructure of EM in countries where EM is not yet recognized as a field and in countries that are in the early stages of this process. He has partnered with international NGOs in EM educational projects and works as a visiting EM faculty member in West Bengal, India. He is excited to collaborate with the other authors of the iEM Education Project to contribute to world of FOAM-ed.
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