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MODULE 19 EMQs
Match each toxidrome to the likely clinical agent.
Cocaine toxicity
Neuroleptic malignant syndrome
Sympathomimmetic toxicity
Anticholinergic Toxicity
Redback spider bite
Organophosphate poisoning
Cholinergic toxicity
Funnel Web spider bite
Serotonin syndrome
Gamma-Hydroxybutyrate overdose
Heroin overdose
Cocaine toxicity
Neuroleptic malignant syndrome
Sympathomimmetic toxicity
Anticholinergic Toxicity
Redback spider bite
Organophosphate poisoning
Cholinergic toxicity
Funnel Web spider bite
Serotonin syndrome
Gamma-Hydroxybutyrate overdose
Heroin overdose
EMQ 1.
A 45 year old male presents after an overdose of an unknown medication. He is red and flushed with smooth dry skin and has significant tremor and mydriasis. He is acutely confused and complaining of lower abdominal pain.
His vital signs are:
HR 140 /min
BP 134/86 mmHg
RR 24
Sats 99% RA
T 38.7 oC
Answer: this is anticholinergic toxicity.
Comment: the dry flushed skin differentiates this from the very similar sympathomimetic toxidrome, which is associated with diaphoresis.
EMQ 2.
An 18 year old man presents with severe pain in his left hand. He had been working in his garden shed at dusk and was concerned he had been bitten by something. He is complaining of excessive salivation, dyspnoea and chest pain, as well as significant perioral paraesthesia.
His vital signs are:
HR 132 /min
BP 167/91 mmHg
RR 29 /min
T 37.1 oC
Answer: funnel web spider envenomation
Comment: the history suggests envenomation, and the similar syndrome to cholinergic toxicity is characteristic of funnel web spider bites.
EMQ 3.
A 40 year old female with a history of paranoid schizophrenia presents complaining of severe muscle pain. A week prior she had an admission to the psychiatric ward where she was started on sertraline and changed from risperidone to haloperidol.
She is complaining of difficulty speaking, and the inability to straighten her arms. She is quite agitated and complaining of dizziness. On examination she has no clonus.
Her vital signs are:
HR 112 /min
BP 147/93 mmHg
RR 22 /min
T 39.1 oC
Answer: neuroleptic malignant syndrome.
Comment: the triad of fever, muscle rigidity and altered mental status are characteristic of NMS. The absence of clonus makes serotonin syndrome extremely unlikely.
.
EMQ 4.
A 19 year old man presents from a local nightclub. His friends admit that he had bought drugs, but are unsure exactly what. The ambulance reports that he has an extremely fluctuant conscious state, with periods of apnoea interspersed with periods of extreme agitation. On arrival in the emergency department he has notable myoclonus and is unconscious.
His vital signs are:
HR 112 /min
BP 112/73 mmHg
RR 6 /min
T 37.1 oC
GCS E1V2M4 (7)
Answer: Gamma-hydroxybutyrate toxicity (GHB)
Comment: the fluctuant conscious state, myoclonus and bradycardia with respiratory depression are characteristic of intoxication with GHB (“Fantasy” or “Grievous bodily harm”)
A 45 year old male presents after an overdose of an unknown medication. He is red and flushed with smooth dry skin and has significant tremor and mydriasis. He is acutely confused and complaining of lower abdominal pain.
His vital signs are:
HR 140 /min
BP 134/86 mmHg
RR 24
Sats 99% RA
T 38.7 oC
Answer: this is anticholinergic toxicity.
Comment: the dry flushed skin differentiates this from the very similar sympathomimetic toxidrome, which is associated with diaphoresis.
EMQ 2.
An 18 year old man presents with severe pain in his left hand. He had been working in his garden shed at dusk and was concerned he had been bitten by something. He is complaining of excessive salivation, dyspnoea and chest pain, as well as significant perioral paraesthesia.
His vital signs are:
HR 132 /min
BP 167/91 mmHg
RR 29 /min
T 37.1 oC
Answer: funnel web spider envenomation
Comment: the history suggests envenomation, and the similar syndrome to cholinergic toxicity is characteristic of funnel web spider bites.
EMQ 3.
A 40 year old female with a history of paranoid schizophrenia presents complaining of severe muscle pain. A week prior she had an admission to the psychiatric ward where she was started on sertraline and changed from risperidone to haloperidol.
She is complaining of difficulty speaking, and the inability to straighten her arms. She is quite agitated and complaining of dizziness. On examination she has no clonus.
Her vital signs are:
HR 112 /min
BP 147/93 mmHg
RR 22 /min
T 39.1 oC
Answer: neuroleptic malignant syndrome.
Comment: the triad of fever, muscle rigidity and altered mental status are characteristic of NMS. The absence of clonus makes serotonin syndrome extremely unlikely.
.
EMQ 4.
A 19 year old man presents from a local nightclub. His friends admit that he had bought drugs, but are unsure exactly what. The ambulance reports that he has an extremely fluctuant conscious state, with periods of apnoea interspersed with periods of extreme agitation. On arrival in the emergency department he has notable myoclonus and is unconscious.
His vital signs are:
HR 112 /min
BP 112/73 mmHg
RR 6 /min
T 37.1 oC
GCS E1V2M4 (7)
Answer: Gamma-hydroxybutyrate toxicity (GHB)
Comment: the fluctuant conscious state, myoclonus and bradycardia with respiratory depression are characteristic of intoxication with GHB (“Fantasy” or “Grievous bodily harm”)