Overdose?

NomadicMedic

NomadicMedic

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

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.
Click to expand...

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]
 
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.
Click to expand...

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.
 
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.
 
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.
 
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.



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]
Click to expand...

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.
 
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.
Click to expand...

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.
 
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.
 
What were your chances of adding a little lorazepam to the diphenhydramine?
 
usalsfyre said:
What were your chances of adding a little lorazepam to the diphenhydramine?
Click to expand...

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. ;)
 
Versed woulda worked, sucks you have a hard time getting orders for sedation.
 
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.
 
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?
 
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!
 
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.
 
n7lxi said:
And frankly, I don't care if she was faking or not... I'll always treat patients appropriately.
Click to expand...

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