# Overdose?



## NomadicMedic (Aug 16, 2011)

I had a pt yesterday that was dispatched as an overdose. On arrival, pt is conscious and alert, but confused. Airway patent, no work of breathing. Resp rate 18, Rapid HR, brisk cap refill. Sinus tach at 130, SpO2 99% on room air.  Sugar 107. Pupils 5mm and reactive. 

She was trembling, restless and having difficulty speaking. 

Hx of anxiety and a fx foot 2 weeks ago. 

Meds: Xanax, wellbutrin and percocet. 

My thought was a dystonic reaction. I got orders for 25mg benadryl. No change. What do you all think?

I can provide more details if you need 'em.


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## abckidsmom (Aug 16, 2011)

Posting from my phone, but my first thought is PE vs anxiety.  Has she been immobile?  What happened tonight?

Did she have any symptoms of acute dystonia? You didn't mention any...you might want to look it up so you'll recognize it next time.


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## NomadicMedic (Aug 16, 2011)

She did have signs of dystonia. The broken/stuttering speech, the muscle rigidity, the uncontrollable tremors, the restlessness. 

She has not been immobile, and her spo2 was 99% on room air with no shortness of breath, air hunger or other complaint. 

She had an argument with her boyfriend a few hours prior to the event.


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## NomadicMedic (Aug 16, 2011)

Here was a decent little blurb in dystonic reactions... 
http://www.emsvillage.com/articles/article.cfm?id=1137


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## mgr22 (Aug 16, 2011)

Any chance she was seizing? A Wellbutrin OD could lead to that.

I don't think any of those meds are known to cause dystonic reactions.


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## usafmedic45 (Aug 16, 2011)

> Any chance she was seizing? A Wellbutrin OD could lead to that.



Hell, Wellbutrin at therapeutic levels can do that, although I doubt that it's the case if she was talking.

She likely had other things on board that she didn't disclose. 



> I don't think any of those meds are known to cause dystonic reactions.



Wellbutrin:
Bupropion-related parkinsonism and dystonia.

Cheng WC, Liu CM, Hsieh MH, Hwang TJ.

J Clin Psychopharmacol. 2009 Dec;29(6):616-8. No abstract available. 

PMID:19910737[PubMed - indexed for MEDLINE] 
Related citations 

3.Prolonged oro-facial dystonia in a 58 year old female following therapy with bupropion and St John's Wort.

Milton JC, Abdulla A.

Br J Clin Pharmacol. 2007 Nov;64(5):717-8. Epub 2007 Jun 19. No abstract available. 

PMID:17578477[PubMed - indexed for MEDLINE] Free PMC Article
Free full text Related citations 

4.Acute dystonia resulting from abrupt bupropion discontinuation.

Wang HY, Chou WJ, Huang TY, Hung CF.

Prog Neuropsychopharmacol Biol Psychiatry. 2007 Apr 13;31(3):766-8. Epub 2007 Jan 10.

PMID:17218049[PubMed - indexed for MEDLINE] 
Related citations 

5.Bupropion-induced acute dystonia.

Detweiler MB, Harpold GJ.

Ann Pharmacother. 2002 Feb;36(2):251-4.

PMID:11847943[PubMed - indexed for MEDLINE] 
Related citations 

6.[Dystonia associated with bupropion].

Hernanz Hernanz P, Ortega Inclán M, Sainza Rúa T, Hernández Matías P.

Aten Primaria. 2001 Oct 31;28(7):507-8. Spanish. No abstract available. 

PMID:11718649[PubMed - indexed for MEDLINE] Free Article
Related citations 

7.Acute delirium and parkinsonism in a bupropion-treated liver transplant recipient.

Strouse TB, Salehmoghaddam S, Spar JE.

J Clin Psychiatry. 1993 Dec;54(12):489-90. No abstract available. 

PMID:8276742[PubMed - indexed for MEDLINE]


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## abckidsmom (Aug 16, 2011)

n7lxi said:


> She did have signs of dystonia. The broken/stuttering speech, the muscle rigidity, the uncontrollable tremors, the restlessness.
> 
> She has not been immobile, and her spo2 was 99% on room air with no shortness of breath, air hunger or other complaint.
> 
> She had an argument with her boyfriend a few hours prior to the event.



Then my vote is on anxiety.  Or drama.  Sorry I missed a couple of things from your first post, but typically I'm going with the horses, not the zebras.  

When I'm thinking about letting anxiety ride as what I think the primary problem is, I usually consider PE as a possibility because the anxiety can be the only manifestation of that hypoxia, aside from the tachycardia, restlessness, etc that you describe.

The more details you provide, the more I vote anxiety.


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## NomadicMedic (Aug 16, 2011)

Nope. Not a seizure. She was awake and alert. Never postictal. 

I read that dystonia can also be triggered by anxiety and stress, so if it wasn't a med/illicit substance on board, it may have just been a physical manifestation of her anxiety. 

I tried to follow up, with no luck.


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## Farmer2DO (Aug 16, 2011)

Any chance she had been using anything else?  You say she's on xanax and percocet; I'm just wondering if she's in withdrawal from something.


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## mgr22 (Aug 16, 2011)

usafmedic45 said:


> Hell, Wellbutrin at therapeutic levels can do that, although I doubt that it's the case if she was talking.
> 
> She likely had other things on board that she didn't disclose.
> 
> ...



Didn't the OP say the pt was having trouble speaking?

As for Wellbutrin causing dystonia, I'll meet you halfway: Yes, I see that there have been instances of dystonia likely caused by Wellbutrin. However, one of the studies you mentioned involves dystonia secondary to withdrawal from Wellbutrin, and another speculates that a dystonic reaction was caused by a combination of Wellbutrin and buspirone. The prescribing info for Wellbutrin lists dystonia as a very rare side-effect.


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## usafmedic45 (Aug 16, 2011)

mgr22 said:


> Didn't the OP say the pt was having trouble speaking?
> 
> As for Wellbutrin causing dystonia, I'll meet you halfway: Yes, I see that there have been instances of dystonia likely caused by Wellbutrin. However, one of the studies you mentioned involves dystonia secondary to withdrawal from Wellbutrin, and another speculates that a dystonic reaction was caused by a combination of Wellbutrin and buspirone. The prescribing info for Wellbutrin lists dystonia as a very rare side-effect.



How do we know she's actually taking it as prescribed?  A lot of folks are hit and miss on their dosing schedules as you're likely well aware.


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## NomadicMedic (Aug 16, 2011)

The PTs husband was not aware of her taking anything other than her prescribed meds, but he wasn't with her at every moment. 

While I'm not the most experienced provider, it didn't look like a typical panic attack or hyperventilation. It also wasn't seizure activity. While I do think it was dystonia, I don't believe it was an extrapyramidal effect from medication. 

They did have an argument prior and the pt was agitated.


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## usalsfyre (Aug 16, 2011)

What were your chances of adding a little lorazepam to the diphenhydramine?


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## NomadicMedic (Aug 16, 2011)

usalsfyre said:


> What were your chances of adding a little lorazepam to the diphenhydramine?



We don't carry it. Versed is it, and I doubt I would have been able to get orders. I actually should have asked for 50mg of benadryl. If she wasn't having an extrapyramidal reaction, the sedative effect might have been helpful.


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## usalsfyre (Aug 16, 2011)

Versed woulda worked, sucks you have a hard time getting orders for sedation.


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## NomadicMedic (Aug 16, 2011)

I think if I had a longer transport, I could have painted a clinical picture where I might have been able to justify some versed orders... But I was 10 minutes away from the ED and the Benadryl was what I thought first. I'm actually surprised I was granted those orders.


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## firetender (Aug 16, 2011)

I'm having trouble seeing any evidence of OD except that the Dispatcher called it an OD. I don't see the patient as needing anything more than psychological/emotional support. Why the wild goose chase in search of something that really caused nothing?


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## Sasha (Aug 16, 2011)

Why do you say she was confused? Was she acting out of it, or like legitimately confused? She could have been faking for attention, you never know!


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## NomadicMedic (Aug 16, 2011)

She seemed legitimately confused. 

And yeah, it was reported as an overdose, but as I said, I didn't think it actually was. The benadryl was used as a rule out. Her husband said when I walked in, "I think she may have overdosed on her meds"

It's a hard thing to describe. It fits the S/S of dystonia. She had severy muscle rigidity, tremors, a very strange, distorted speech... Think of a stuttering CD. I've seen fakers. If she was faking, she was good. 

And frankly, I don't care if she was faking or not... I'll always treat patients appropriately.


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## firetender (Aug 16, 2011)

n7lxi said:


> And frankly, I don't care if she was faking or not... I'll always treat patients appropriately.


 
I agree. If need treat, treat. If no need treat, no treat.


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## aclsjax (Aug 16, 2011)

It was anxiety. All v/s were good.


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## systemet (Aug 17, 2011)

The symptoms being anxiety / psychogenic has to be considered, but can't be the first assumption.  From what you described, dystonia seems a reasonable concern.  I think benadryl was probably appropriate.

What was the skin condition?  She's taching along at 130 bpm with dilated pupils.  Is she diaphoretic?  What's the temperature?  With the muscle rigidity is there a possibility that we're seeing a presentation of serotonin syndrome?

Or, if the skin's dry, have we considered an anticholinergic overdose?  A lot of people get pretty messed up taking meds like gravol (dramamine) in excess.  

ECG's narrow right?  This isn't an early / mild TCA OD presentation?  Because you can see stuttering and ticks with these (I assume due to the anticholinergic properties).

What happened with the patient?


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## NomadicMedic (Aug 17, 2011)

No diaphoresis, skin temp was normal. Narrow sinus tach with no ectopy. 

I attempted to follow up with no results.


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## hyperlyeman1 (Aug 18, 2011)

I wasn't there so it would be hard to totally judge. Any Hx of illegal drugs, that almost sounds like it could be. Also, from my experience, the two dystonic patients I have had both had their heads turned to the side and were smacking their lips violently. Were confused, alert and oriented to name, age and time but nothing else. Sounds to me like anxiety? possibly HP?h34r:


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## NomadicMedic (Aug 19, 2011)

Could be illicit drugs. I hate to stereotype, but the surroundings would lead me down that path. If she had a hx, nobody was telling me about it. 

I've seen a dystonic reaction from haldol, and it was a lot more severe than this presentation. 

I am also going down the anxiety road, but again... Without follow up info, which I was unable to obtain, I'm in the dark, too. 


---
- Sent from my iPhone.


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## systemet (Aug 19, 2011)

n7lxi said:


> C
> I am also going down the anxiety road, but again... Without follow up info, which I was unable to obtain, I'm in the dark, too.



This is a huge problem, isn't it?  You take a patient to the hospital, you want to know a little bit more about their status, and their clinical course, and yet often no one's willing to give out that information.  It's a wasted opportunity to learn. Too bad.


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## lawndartcatcher (Aug 19, 2011)

*How 'bout serotonin syndrome?*

Could be early onset of Serotonin storm - irritability, jerking movements, anxiety. She's on an SSRI and the benzos could have pushed her down that path. Only thing missing is high temp (later sign). Of course, you need a full lab and hospital to really diagnose that.


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## abckidsmom (Aug 19, 2011)

systemet said:


> This is a huge problem, isn't it?  You take a patient to the hospital, you want to know a little bit more about their status, and their clinical course, and yet often no one's willing to give out that information.  It's a wasted opportunity to learn. Too bad.



I just met a medic who had personal business cards made up at vistaprint.com that she hands out to patients and asks them to contact her and let her know what ever happened. 

She's pretty smart and on her game, so I'm thinking it probably helps.  And with so many patients having her first and last name and the department phone number, it keeps her customer service skills crisp too.  All she has are good write-ups in her personnel file...an odd phenomenon.


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## the_negro_puppy (Aug 19, 2011)

I'd guess at anxiety/emotion mixed with perhaps some drugs/meds shes not mentioning. Either way I would be transporting and a keeping a close eye for any changes. There's nothing we could giver her here.


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## systemet (Aug 20, 2011)

abckidsmom said:


> I just met a medic who had personal business cards made up at vistaprint.com that she hands out to patients and asks them to contact her and let her know what ever happened.
> 
> She's pretty smart and on her game, so I'm thinking it probably helps.  And with so many patients having her first and last name and the department phone number, it keeps her customer service skills crisp too.  All she has are good write-ups in her personnel file...an odd phenomenon.



That a great idea, at least, in theory.  I think, in practice, I'd be a little too nervous to give out any personal information or encourage my patients to contact me after the event.  I've just heard too many bad stories.


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## Ramathorn90 (Sep 7, 2011)

All V/s stable, hx of anxiety, recent argument with boyfriend. It appears the lights are shining on anxiety in this case. I would snag etco2, a 12 lead, and monitor her sat while making an attempt at coaching her to relax and calm down.

Sent from my T-Mobile myTouch 3G using Tapatalk


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## NomadicMedic (Sep 7, 2011)

Turned out to dystonia related to her severe anxiety issues. Not an extrapyramidal reaction from her meds. 


Sent from my iPhone.


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